Below is a list of failure codes that can be assigned to a claim on the Remittance Advice along with an explanation of the code and evidence required for a covered entity to dispute the payment determination for the claim.
|
Failure Reason |
Explanation |
Evidence Required to Dispute |
|
"Non-compliant stacked discount", code: "01-STA" |
A Medicaid Drug Rebate program rebate has already been paid. Payment of a 340B price on the same unit would cause a 340B duplicate discount. |
An email received from the state’s Medicaid office agreeing to credit the Medicaid rebate to the manufacturer. |
|
"Duplicate request", code: "02-DUP" |
MFR already paid a 340B rebate via 340B Pay for this exact claim |
The original paid rebate must be reversed by the covered entity before a new rebate can be requested. |
|
"Units exceed the allowable range per day", code: "03-XDA" |
The units requested exceed the maximum allowed for the NDC per day as set by the manufacturer. |
Evidence verifying the units dispensed were correct. This may include screenshots from pharmacy management software. |
|
"Units exceed the allowable range per script", code: "04-XRX" |
The units requested exceed the maximum allowed for the NDC per script as set by the manufacturer |
Evidence verifying the units dispensed were correct. This may include screenshots from pharmacy management software. |
|
"Covered entity not eligible for discount", code: "08-ENT" |
This code can show for 3 reasons: (1) Covered entity is not shown as participating as of the date of service in the HRSA OPAIS database. (2) Covered entity type is not eligible for 340B prices for Orphan Drugs (3) No contract pharmacy relationship found between covered entity and contract pharmacy per HRSA’s OPAIS database for the submitted date of service. |
(1) Screenshot of OPAIS showing the CE is active for date of service (2) Screenshot of OPAIS showing dates of CE eligible to purchase Orphan drugs (3) Screenshot of OPAIS indicating Pharmacy was active and registered on DOS. |
|
"Pharmacy NPI missing or invalid", code: "09-PHR" |
The pharmacy ID does not match a valid “business” NPI per the NPPES database. |
Re-submit with a valid business NPI or provide a screenshot showing NPI is valid from NPPES Registry. |
|
"Date of service missing or invalid", code: "10-DOS" |
DOS submission does not match manufacturer contract configuration in 340B Pay |
Screenshot from pharmacy system showing accurate DOS |
|
"Rx ID missing or invalid", code: "11-RXI" |
RX ID format appears invalid or is inconsistent . |
Screenshot from pharmacy system showing Rx ID. |
|
"Prescriber NPI missing or invalid", code: "15-PRE" |
The prescriber ID does not matc h a valid “professional” NPI per the NPPES database. |
Re-submit with a valid professional NPI or provide a screenshot showing NPI is valid from NPPES Registry. |
Below is a list of adjustment codes that can be assigned to a claim on the Remittance Advice along with an explanation of the code and evidence required for a covered entity to dispute the payment determination for the claim.
|
Adjustment Reason |
Use Case(s) |
Evidence required |
|
Adjusted: 70-DPU Requested Discount/Unit was invalid |
340B rebate per unit has been adjusted based on the correct WAC and 340B price. |
Screenshot of official WAC and 340B prices (need to WAC prices would be found in a wholesalers catalog and 340B pricing is available at OPAIS pricing program |
|
Adjusted: 51-UOM Units adjusted due to incorrect unit of measure |
Rebate quantity adjusted to be in the correct unit of measure (for example, package units corrected to equal dispensing units per package). |
Screenshot from pharmacy management software showing actual dispense units. |
|
Adjusted: 52-UDA Units adjusted to be within allowable range per day |
Units adjusted to equal the maximum allowable units per transaction. |
Screenshot from pharmacy management software showing actual dispense units. |
|
Adjusted: 53-URX Units adjusted to be within allowable range per script |
Units adjusted to equal the maximum allowable units per transaction |
Screenshot from pharmacy management software showing actual dispense units |