Insurance

[ZakMeister]

Hello, i have just started working as a tech and would like to knw if there is a website or resource from where I can learn the common insurance rejection codes?

Also, i just had to deal with a DUR rejection but my pharmacist took over and solved it. Can anyone tell me what it is? Thanks!

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[romaniangirl]

What company do you work for? Lots of us on SDN can give you some guidelines for insurance reject codes depending on which company you work for.

DUR stands for drug utilization review. In pretty much all cases, pharmacists will have to take care of these rejections. These are often things like drug interactions, higher than normal doses, etc. So these will have to be looked at and resolved by the rph.

 

[ZakMeister]

What company do you work for? Lots of us on SDN can give you some guidelines for insurance reject codes depending on which company you work for.

DUR stands for drug utilization review. In pretty much all cases, pharmacists will have to take care of these rejections. These are often things like drug interactions, higher than normal doses, etc. So these will have to be looked at and resolved by the rph.

Target, just started out few weeks ago.

 

[SClENCE]

Sometimes DUR rejection simply means refill to early. Other times it has to do with dosage and the pharmacist will need to submit an override/clarification code to the insurance stating that the MD was consulted.

 

[BidingMyTime]

prior auth or PA is a common rejection. In this case, depending on the drug and ins, the doctor will usually have to be contacted to change the drug to something on the insurances formulary. Or if the patient has failed the therapies on the insurances formulary, or can't take those drugs for some reason, then the doctor will need to be contacted to let him know he needs to do a PA with the ins.

 

[SClENCE]

prior auth or PA is a common rejection. In this case, depending on the drug and ins, the doctor will usually have to be contacted to change the drug to something on the insurances formulary. Or if the patient has failed the therapies on the insurances formulary, or can't take those drugs for some reason, then the doctor will need to be contacted to let him know he needs to do a PA with the ins.

These are always fun. I usually explain it to the customer and when I stop talking they just stand there starting at me awkwardly

 

[BidingMyTime]

These are always fun. I usually explain it to the customer and when I stop talking they just stand there starting at me awkwardly

Yes, because no matter how clear or simple you try to be in explaining it, the person will walk away muttering to their companion about how the pharmacy "won't give my medicine."

 

[SClENCE]

Yes, because no matter how clear or simple you try to be in explaining it, the person will walk away muttering to their companion about how the pharmacy "won't give my medicine."

Or after you explain it they say "Call my insurance company. I'll wait here since I had a 15 minute drive"

Then you realize that they can't comprehend the fact that doctor has to approve it, it's a Sunday, and Medicaid probably isn't going to approve of their nearly expired prescription for a blood pressure monitor anyways.

 

[Ackj]

Yes, because no matter how clear or simple you try to be in explaining it, the person will walk away muttering to their companion about how the pharmacy "won't give my medicine."

I'd be happy to fill it for you today, but it will cost you $786. If you'd like to wait a few days, the insurance may cover part of that cost. I would recommend waiting, but it's up to you if you want it today.

 

[BidingMyTime]

I'd be happy to fill it for you today, but it will cost you $786. If you'd like to wait a few days, the insurance may cover part of that cost. I would recommend waiting, but it's up to you if you want it today.

Oh, if only it were that simple. Believe me, I am quite upfront that I am happy to fill their prescription, but it will cost them $786 and there is no guarantee that insurance will reimburse them. They still blame think its my fault that I'm not giving them their med at whatever their normal co-pay is.

 

[SClENCE]

But last time it was 5 dollars. Re-run it.

 

[ZakMeister]

But last time it was 5 dollars. Re-run it.

Hey, you seem to be a pro at these insurance rejection stuff. Do you happen to know if anyone at this network can help me with the Target rejection codes?

 

[SClENCE]

I personally don't know anything about Target or anyone who works there 🙁

 

[PharFromNormal]

Hey, you seem to be a pro at these insurance rejection stuff. Do you happen to know if anyone at this network can help me with the Target rejection codes?

I would actually pay money to see people say this back to customers who responded "but last time it was $5. Rerun it"

 

[Ackj]

The insurance rejects shouldn't vary by chain, although you do have to know where to put them in your software. Really you just have to look at what the rejection is telling you. An override of "02" fixes tons of issues (high dose, drug interaction, etc) with no further effort required. If there's a dose change, and you're getting "refill too soon" as a result, it's "05" instead. Not all plans will accept that, you may need to call the help desk for an override. Really, if there's anything you can't solve, the insurance help desk should be able to walk you through it. It will be time consuming if you have to do this, but after you've run into an issue 1-2 times, you should remember how to fix it.

 

[HelpfulPharmer1]

if there is a website or resource from where I can learn the common insurance rejection codes?

Can anyone tell me what it is? Thanks!

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Rejections
Online adjudication is fast-usually taking from a few seconds to a few minutes. Sometimes problems come up during the online billing process which prevent a customer's prescription from being billed off to their insurance when they want it to be.

The most common rejection that techs receive is a refill too soon rejection..........

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http://www.pharmacy-tech-resources.com/prior-authorization.html
http://www.pharmacy-tech-resources.com/medicare-part-d.html
http://www.pharmacy-tech-resources.com/days-supply.html


NOT SELLING, JUST SHARING.....
NOT SELLING, JUST SHARING.....
NOT SELLING, JUST SHARING.....

 

[greenwoodmedbilling]

Hello, i have just started working as a tech and would like to knw if there is a website or resource from where I can learn the common insurance rejection codes?

Also, i just had to deal with a DUR rejection but my pharmacist took over and solved it. Can anyone tell me what it is? Thanks!

Hi. My name is Tiffany and I am the owner of Greenwood Medical Billing. I have attached a list of common insurance rejection codes and their descriptions for your review. Hope this helps!

 

[ZakMeister]

Hi. My name is Tiffany and I am the owner of Greenwood Medical Billing. I have attached a list of common insurance rejection codes and their descriptions for your review. Hope this helps!

Thanks for sharing Tiffany!

 

[PharFromNormal]

Medical billing codes are a little different than NCPDP prescription transaction codes. You might be able to find some on google if you search the right thing...