There were some other threads on this, so I'll copy and revise what I wrote there:
http://forums.studentdoctor.net/threads/how-the-heck-do-you-learn-inurance-computer-systems.1028848/
http://forums.studentdoctor.net/threads/common-insurance-rejections-and-insurance-cards.1048847/
Techs can handle most insurance issues but there are some that the pharmacist is supposed to do.
Disclaimer: inappropriate use of these codes could result in third-party chargebacks to your store.
PPS Professional Pharmacy Services Codes
Sometimes the insurance will identify a DUR issue like a drug-drug (DD) interaction or therapeutic duplication (TD) that the pharmacist will have to override. Copy each DUR code (DD, TD, etc) from the message to the input box in your software, then for each one enter an intervention such as "R0 Pharmacist reviewed" and the outcome such as "1B Filled as is".
Some insurances only accept "M0 Prescriber consulted" and "1G Filled with prescriber approval" so you are meant to call or "call" the prescriber and document in case you get audited. Plans that need the M0/1G override include: Medco, Coventry, Florida Blue Cross
EnvisionCare, Advantage Medicare Part D, Health Choice of Arizona Medicaid, require the MR (Medication Review)/1B code.
Benecard PBF requires DE (Dosing evaluation)/1B.
Catalyst requires a call to them to override every single DUR.
Submission Clarification: 02 Other override
Medco has a lot of these rejects where the message says for example, the dose is too high on a pediatric script, zolpidem 10mg qhs is too much for a geriatric patient, or verify the CrCl is okay or adjust the dose. Call or "call" the prescriber and document, then enter the 02 override code.
Dosage change override
If the rejection is for an early refill but you review the history and there was a dosage change, sometimes you can override it with one of the following Prior Authorization Type 1 codes depending on which insurance it is:
00000000003
45645645641
22222222222
