PistonFan531

10+ Year Member
Jun 23, 2008
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Does anyone know of any good sources or books out there that list the most common insurance rejections and how to resolve them? Also, does anyone know of any good sources or books out there that instruct you on how to input the different kinds of insurance cards into the computer system? Like the BIN number, ID number and all of that? Some of them are easy to process but some like the straight medicaid cards are tricky because very little info is on the card. Any assistance would be greatly appreciated. Thanks
 

zelman

7+ Year Member
Nov 27, 2009
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Does anyone know of any good sources or books out there that list the most common insurance rejections and how to resolve them? Also, does anyone know of any good sources or books out there that instruct you on how to input the different kinds of insurance cards into the computer system? Like the BIN number, ID number and all of that? Some of them are easy to process but some like the straight medicaid cards are tricky because very little info is on the card. Any assistance would be greatly appreciated. Thanks
There is no such thing.
 

zelman

7+ Year Member
Nov 27, 2009
3,390
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Pharmacist
So there is nothing out there?
Correct.

You might be able to get some sort of information from each PBM and Medicaid provider separately on how to interpret cards, but fixing rejections is another story. If you ask Medco how to override a high dose rejection, they'll tell you to check the FDA approved dosing regimen and consult with the physician and document on the hardcopy and do a million other steps. If you ask a pharmacist how to override a high dose rejection, they'll tell you "put a number two in this field and reprocess".
 
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WVUPharm2007

imagine sisyphus happy
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Born: Parkersburg, WV | Now: Montgomery TWP, PA
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M0/1G

Fixes it most of the time...
 

Muse600

10+ Year Member
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May 24, 2008
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this time of the year sucks, everyone's stupid insurance expired and they claim nothing has changed

there is no book...and I think the rejects possibly vary per state...

1.) read the reject and try to decipher it: day supply issue? insurance terminated?
2.) ask a friend - same pharmacy, or different one
3.) call the ins company and ask them
4.) if they don't see the claim, you have to get it supported through your software vendor
 

Ackj

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Nov 25, 2008
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M0 is claiming to have consulted the prescriber. R0 is "consulted other source" which seems like less liability to me.
1G is "filled with prescriber approval" also, 1B is "filled as is" so R0/1G probably doesn't make sense if you think about it.

But I agree with you, I would prefer to use R0/1B but those don't always work, M0/1G seem to work in more instances.

For the OP's question, the rejects are just something you get the hang of after a while. Ask your techs/other pharmacists about them, call the PBM's help desk if necessary, and eventually you'll just see the same rejects and know what took care of it last time. For the inputting of the cards, that's something else you'll learn with time, because in a given area there are fairly limited number of plans that you'll see over and over. Govt plans like Medicare B, Tricare, your state's medicaid, you can usually do a search and find out what the BIN/PCN/group is.
 
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pezdispenser

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Dec 14, 2006
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Some plans need the M0/1G override such as Medco, Coventry, Florida Blue Cross, but if you use it, it implies that you contacted the prescriber so you should document it in case you get audited.

Other plans will take R0/1B such as United OptumRx, Express Scripts, Florida Medicaid, so I prefer to use R0 because it does not require documentation that you contacted the prescriber.

One plan, EnvisionCare, actually requires the MR/1B (Medication Review) code.
 
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sosoo

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search by bin and pcn should do for the most part to help you find the right insurance. sometimes the card will have it in tiny prints on the back so you have to look hard for it. sometimes the patient gives you a medical insurance card, it won't have bin n pcn, so you give it back to them and ask for the right one. if you still can't find the right insurance, or bin search n nothing comes up like carefirst bluechoice, then you call helpdesk. they wont be able to help you but at least they'll give you a reference number.

as for insurance rejections, make sure you read the reject message. it usually tells you how to fix it. if it doesn't, call that insurance and ask.
 
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Mar 2, 2014
180
80
Los Angeles
Status
Pharmacist
Does anyone know of any good sources or books out there that list the most common insurance rejections and how to resolve them? Also, does anyone know of any good sources or books out there that instruct you on how to input the different kinds of insurance cards into the computer system? Like the BIN number, ID number and all of that? Some of them are easy to process but some like the straight medicaid cards are tricky because very little info is on the card. Any assistance would be greatly appreciated. Thanks
Give us the state you work in, region of state, and which company you work for. You will get more specific answer. If you want to be anonymous, make a new account and post that information.
 
Mar 2, 2014
180
80
Los Angeles
Status
Pharmacist
Give us the state you work in, region of state, and which company you work for. You will get more specific answer. If you want to be anonymous, make a new account and post that information.
I can only share about California, Los Angeles County, so hopefully this will help some friends out there....
For example:
For ID,
In California,
Medicaid: Main Plan (Straight Medicaid): Use all of ID: 14 digits total.
Medicaid: Sub plan: Use most of ID: 9 digits total: start with number, up to and include the letter.
Issue date is important in some cases, so, always type in.

+++++++++++++++++++++++++++++++++++++++++++++++++
If Medicaid: If Green Card for Family Planning Program:
Use all ID, 10 digits total, start with number, include letter, and the last digit.
+++++++++++++++++++++++++++++++++++++++++++++++++
If Medicaid: Temporary Paper Card for Pregnant Women:
For ID: Ignore the dash.
Must set expiration date in your computer so you don't give out free medication after card expires and get audit later.
+++++++++++++++++++++++++++++++++++++++++++++++++
Within the company software, how to input the insurance is different. Just putting the BIN will show you over 20 different plans that will confuse you. Picking randomly 1 of that 20 plans and try while patient waiting is not acceptable.
That's why I ask to please tell us the company you work for and the region and we will guide you specifically which common plan to pick.
+++++++++++++++++++++++++++++++++++++++++++++++++
For commercial insurance:
Example: you see ID on card, what do you do?
ABC123456789-01

For ID:
Case 1: 95% of cases: Ignore the first 3 letters and ignore the dash and the number after dash.
ID is: number after first 3 letters.
ID is: 123456789

Case 2: 5% of cases: Use all of ID, still ignoring the dash and number after dash.
ID is: ABC123456789

Ending of ID:
Case 1: 95% of cases: Ignore the relationship code at the end of ID.
ID is: 123456789

Case 2: 5% of cases: Use the relationship code at the end of ID
ID is: 12345678901

+++++++++++++++++++++++++++++++++++++++++++++++++

BIN: Must have.
PCN: NOT Must have.
GROUP: NOT Must have (ignore all dash in any field.)
ID: Must have (ignore all dash in any field.)
Person Code: often, pick: Card Holder

Relationship code: (I use blank space in many cases.)

Often,
Card Holder: 01 (But have seen 00 zero zero).
Spouse: 02 (have seen 01).
Child: 03 (have seen 02).

Nowadays,
+++++++++++++++++++++++++++++++++++++++++++++++++
Wrong Birth Date: common problem. If insurance hiccup, always double check this. You must match birth date with whatever birth date the plan has, then, payment will go through. Patient will argue that my birth date is wrong. Your answer: Please fix with your plan. If I fix in my computer to the way you like, payment will not go through and you have to pay your own money.
+++++++++++++++++++++++++++++++++++++++++++++++++
Wrong Gender: common problem. If insurance hiccup, always double check this.
Name of card holder: have seen cases where wrong name of card holder does not matter.
Relationship Code: have seen cases where Relationship Code does not matter (I use blank space in many cases.)
+++++++++++++++++++++++++++++++++++++++++++++++++
Rejection:
Day supply:
As pharmacist, you may see rejection in billing with the message indicating because of Day Supply Problem while tech can not see that message.
Example: 9 pills of Imitrex, instruction is: 1 or 2 a day as needed.
Tried day supply as 4 days, not going through.
Tried day supply as 15 days, not going through.
Tried day supply as 20days, not going through.
Tried day supply as 25 days, not going through.
Tried day supply as 30 days, YES: going through.
Tried day supply as 29 days, not going through.
+++++++++++++++++++++++++++++++++++++++++++++++++
Rejection:
Too soon:
As pharmacist, you may see rejection in billing with the message indicating because of Too Soon Problem while tech can not see that message.
+++++++++++++++++++++++++++++++++++++++++++++++++
Too soon can be fixed by:
If previous fill was at your pharmacy and if previous setting of day supply was wrong, you can edit old script, mark as sold, fill new script.
For example:
Itch Cream (Hydrocortisone 2.5%) was filled, previous script was set to be 30 days.
Patient used all cream and showed up at pharmacy on day 20, you try to fill. Rejection: Too Soon to fill.
Fix: edit last script, set date to be 20 days (seems reasonable for 1 tube of 28 grams), finalize script, mark as sold, fill new script. Will go through.
+++++++++++++++++++++++++++++++++++++++++++++++++
If Too Soon because of different pharmacy, you may or may not know where, depending on insurance. I have seen message from insurance telling me the name of pharmacy and the phone of pharmacy. I have seen message from insurance simply telling me it was filled at Other Pharmacy.
Case: Script was sent to different pharmacy last week, somewhere out there. Now, script is sent to you. You try to bill. Rejection: Too Soon.
Fix: Call insurance. Ask phone of Other Pharmacy. Call that Pharmacy.
+++++++++++++++++++++++++++++++++++++++++++++++++
Duplicate Claim? Even after you are sure you reversed the claim at your own pharmacy?
Try:
PA field: 01
PA code field: 9991
Helped me in 50 percent of cases. Learned from a tech support specialist at my company.
+++++++++++++++++++++++++++++++++++++++++++++++++
.............
Los Angeles County Medicaid:
At this time, you have at least 5 sub plans:
Anthem.
Blue Cross.
L.A. Care.
Kaiser (You can not bill if you are not inside Kaiser.)
Health Net.
Care1st.
Medimpact Medcare Network.
Molina (sometimes.)

Orange County Medicaid:
CalOptima.

If both Medicare and Medicaid: for Medicaid, you then have to pick:
CalWrap.

You see...certain county has certain trick of trade. If you really want to master the insurance of your area in a short time, somehow relay the message here about the area you work at. Someone will help.
 
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