Pharmacy Adjudication Rejections Vocabulary

Vocabulary flashcards covering common pharmacy adjudication rejections, insurance requirements, and specific diagnosis codes for diabetes supplies.

Refill Too Soon

Inform patient of issue, offer to fill it out of pocket, or wait until the current day supply expires; pharmacies cannot fill controlled medications (CII - CV) more than $3$ days early.

Missing Origin Code

A rejection indicating that an origin code is missing; this code is required for all Medicare–D claims submitted.

Prior Authorization

A process where the insurance company requires the doctor to declare a medication as medically necessary

• Inform patient of issue, explain that these typically take a week or so to resolve.

• The patient has the option of paying for the medication out of pocket

Invalid Cardholder ID

A rejection indicating updated insurance information is needed; the pharmacy should fill the prescription as cash and request the information at pickup.

Missing/Invalid Prescriber

A rejection where the prescriber profile is incomplete, typically missing NPI or DEA numbers.

Medication Not Covered

A rejection stating the insurance will not pay for the drug; patient options include paying out of pocket or contacting the doctor for a change in therapy.

• Occasionally the insurance company will indicate which medication they prefer for a specific condition. Follow the previous step for resolution.

Missing/Invalid Diagnosis Code

All Medicare–B claims involving diabetic supplies require a diagnosis code with every claim.

• Type 1 Diabetes – those requiring insulin • 250.00

• Type 2 Diabetes – those on an oral glucose replacement therapy • 250.01

Diagnosis Code $250.00$

The specific diagnosis code used for Type 1 Diabetes (those requiring insulin) in Medicare–B claims.

Diagnosis Code $250.01$

The specific diagnosis code used for Type 2 Diabetes (those on an oral glucose replacement therapy) in Medicare–B claims.

Therapeutic Duplication

A situation where a patient is taking multiple prescriptions for the same condition

• Call insurance company for override, inform pharmacist of duplication of therapy