Question on DAW codes, submission clarification codes and other coverage codes in retail.

[justjoe]

DAW 4 - Substitution Allowed - Generic Drug Not in Stock

Does this mean that you just don't have the generic drug in the pharmacy that day? What if you can order the generic drug in the next day? Is it okay to use this code if you are just out of stock that day and the patient needs it today?

DAW 5 - Substitution Allowed - Brand Drug Dispensed as Generic

Can someone give me an example of when to use this one? Thanks.

DAW 8 - Substitution Allowed - Generic Drug Not Available in Marketplace

I'm guessing that you use this code if your wholesaler is out of stock, correct? What if other wholesalers can supply the generic drug? Is it okay to use if only your wholesaler can't supply the medication?

SCC 3 - Vacation Supply

You use this when the patient requests a refill and it's too soon for insurance. They say that they are leaving on vacation before insurance will pay for it. Correct?

What about if you are transferring in a prescription for an out of state patient on vacation and you get a refill too soon reject. Okay to use it here?

Other Coverage Code 4 Other coverage exists - payment not collected

Has anyone ever used this one before? I've only used OCC 2 and 8.

Thanks!

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[LoveWillSaveTheDay]

DAW 4 - Substitution Allowed - Generic Drug Not in Stock

Does this mean that you just don't have the generic drug in the pharmacy that day? What if you can order the generic drug in the next day? Is it okay to use this code if you are just out of stock that day and the patient needs it today?

DAW 5 - Substitution Allowed - Brand Drug Dispensed as Generic

Can someone give me an example of when to use this one? Thanks.

DAW 8 - Substitution Allowed - Generic Drug Not Available in Marketplace

I'm guessing that you use this code if your wholesaler is out of stock, correct? What if other wholesalers can supply the generic drug? Is it okay to use if only your wholesaler can't supply the medication?

SCC 3 - Vacation Supply

You use this when the patient requests a refill and it's too soon for insurance. They say that they are leaving on vacation before insurance will pay for it. Correct?

What about if you are transferring in a prescription for an out of state patient on vacation and you get a refill too soon reject. Okay to use it here?

Other Coverage Code 4 Other coverage exists - payment not collected

Has anyone ever used this one before? I've only used OCC 2 and 8.

Thanks!

Can't help you with the DAW codes, I've only ever used 1,2&6

For OCC 4, I constantly use it for Texas Medicaid patients when Medicaid rejects for other coverage exists even when the patient has no primary ins. I've never used it for any other ins types.

 

[JustAnotherRph]

This is the OCC codes per NCPDP. OCC 1 and 2 means claims are primary and usually not accepted for COB claims. OCC 2 means primary paid and they are billing secondary for balance. OCC 3 means primary did not pay. If this is a Medicare plan, usually the Medicaid secondary will only cover if the drug is Part D=N. OCC 8 is copay only submission to secondary. Used when Medicare is primary.

As far as DAW 5, I've only seen it used when brand and generic are covered and pharmacies want to be reimbursed the generic rate. In cases of Medicaid, where brand is preferred and generic is non-preferred, no DAW needs to be selected and the pharmacy will be paid the brand reimbursement rate.