Data Pkg 22 - Paid Claims and Rejects - Retail.xlsx

XLSX spreadsheet 57 KB Posted Dec 2, 2019

Attached to: DRAFT RFP TRICARE Pharmacy Services, 5th Generation (TPharm5) Federal contract opportunity
Solicitation number: HT940220R0002
Issued by: Defense Health Agency

About this file

Written by GovTribe AI · Dec 28, 2023

This document provides a draft request for proposals for the TRICARE Pharmacy Services, 5th Generation contract. The Defense Health Agency is seeking pharmacy services through a new stand-alone contract with fixed unit pricing and a potential total period of performance of 9 years including transition periods. Services will include retail pharmacy networks, specialty pharmacy, care coordination, and quality control programs. Interested vendors are invited to review the draft RFP sections and provide feedback on requirements and approach by January 17, 2020. The agency estimates a formal solicitation may be issued in mid-2020. An information session on the draft RFP was held on December 11, 2019 and materials are posted. The contract will support pharmacy benefits for TRICARE beneficiaries.

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Other files for this federal contract opportunity

Other files attached to DRAFT RFP TRICARE Pharmacy Services, 5th Generation (TPharm5), newest first.
File	Type	Posted
QA CAS Applicability Specific Clauses (May 15 2020).pdf	PDF	May 15, 2020
TPharm5 Section C Draft RFP2 2020-4-6.docx	DOCX document	Apr 6, 2020
DHA Responses to Industry on Draft RFP 20200318.pdf	PDF	Mar 18, 2020
Data Pkg 7 Specialty Drug Utilization, Retail and Mail.xlsx	XLSX spreadsheet	Dec 2, 2019
Data Pkg 14 Retail Claims with COB.xlsx	XLSX spreadsheet	Dec 2, 2019
Attachment J-5 TPharm5 Award Fee Plan 20191122.docx	DOCX document	Dec 2, 2019
Data Pkg 5 MOP Utilization by Drug.xlsx	XLSX spreadsheet	Dec 2, 2019
Data Pkg 23 - Paid Claims and Rejects - MHS GENESIS.xlsx	XLSX spreadsheet	Dec 2, 2019
Data Pkg 24 - CHCBP Volume.xlsx	XLSX spreadsheet	Dec 2, 2019
Attachment L-9.6 Self-Admin Injectables List.xlsx	XLSX spreadsheet	Dec 2, 2019
Attachment L-9.7 Expanded Use of MTF and TMOP List.xlsx	XLSX spreadsheet	Dec 2, 2019
Attachment L-18 CDRL Supplemental Bid Schedule.xlsx	XLSX spreadsheet	Dec 2, 2019
Attachment L-1 Ordering Instructions for Data Files not on SAM.gov.docx	DOCX document	Dec 2, 2019
TPharm5 Draft Section L 20191202.docx	DOCX document	Dec 2, 2019
Data Pkg 25 - OHI Development.xlsx	XLSX spreadsheet	Dec 2, 2019
Attachment L-9.5 Non-Formulary List.xlsx	XLSX spreadsheet	Dec 2, 2019
Data Pkg 9 Customer_Service_Volume.xlsx	XLSX spreadsheet	Dec 2, 2019
Data Pkg 16 VA_VA CHDR Volume.xlsx	XLSX spreadsheet	Dec 2, 2019
Data Pkg 17 - TRICARE Beneficiaries by Zip Code.xlsx	XLSX spreadsheet	Dec 2, 2019
Attachment L-1.3 Business Associate Agreement.docx	DOCX document	Dec 2, 2019
Attachment L-9.2 Retail Vaccine List.docx	DOCX document	Dec 2, 2019
Attachment L-9.1 Non-FCP Compliant List.xlsx	XLSX spreadsheet	Dec 2, 2019
Data Pkg 1 Retail Utilization by Pharmacy.xlsx	XLSX spreadsheet	Dec 2, 2019
Data Pkg 4 - Clinical Review Volume.xlsx	XLSX spreadsheet	Dec 2, 2019
Attachment L-6 Client Authorization.docx	DOCX document	Dec 2, 2019
TPharm5 Draft Section K 20191120.docx	DOCX document	Dec 2, 2019
HT940220R0002 SF33 and Section B 20191202.pdf	PDF	Dec 2, 2019
Attachment J-4 MTF Sites.xlsx	XLSX spreadsheet	Dec 2, 2019
Data Pkg 8 Mail and Retail Monthly Utilizers.xlsx	XLSX spreadsheet	Dec 2, 2019
TPharm5 Draft Section J 20191127.docx	DOCX document	Dec 2, 2019
Attachment L-10 Small Business Participation Plan.docx	DOCX document	Dec 2, 2019
Data Pkg 2 - Retail Utilization by Drug.xlsx	XLSX spreadsheet	Dec 2, 2019
Attachment J-1 Definitions.DOCX	DOCX document	Dec 2, 2019
TPharm5 Draft Section M 20191202.docx	DOCX document	Dec 2, 2019
Data Pkg 13 - MTF Claims Volumes by Site.xlsx	XLSX spreadsheet	Dec 2, 2019
Attachment L-3 Specialty Reimbursement for Use in Determining Incentiv....docx	DOCX document	Dec 2, 2019
Attachment L-9 Benefit Design Document_TPharm5.xlsx	XLSX spreadsheet	Dec 2, 2019
Attachment L-2 Retail Network Reimbursement Table.docx	DOCX document	Dec 2, 2019
TPharm5 Draft RFP READ FIRST 20191202.docx	DOCX document	Dec 2, 2019
Tpharm5 Draft Section G 20191202.docx	DOCX document	Dec 2, 2019
Attachment L-8 MMC Sample File.xlsx	XLSX spreadsheet	Dec 2, 2019
Attachment L-9.8 PA_ST_QL List.XLSX	XLSX spreadsheet	Dec 2, 2019
Attachment L-4 Negotiated Specialty Retail Replenished Dispensing Fees.docx	DOCX document	Dec 2, 2019
Attachment L-9.9 Fluoride Products List.xlsx	XLSX spreadsheet	Dec 2, 2019
Attachment L-12 IHS_Pharmacy_Listing_2019.xlsx	XLSX spreadsheet	Dec 2, 2019
Data Pkg 15 IHS_Pharmacy_Claims_Volume_2017_&_2018.xlsx	XLSX spreadsheet	Dec 2, 2019
TPharm5 Draft Section E 20191120.docx	DOCX document	Dec 2, 2019
TPharm5 Draft Section D 20191120.docx	DOCX document	Dec 2, 2019
Attachment L-1.1 List of Data Packages.docx	DOCX document	Dec 2, 2019
Attachment L-19 Past Performance Questionnaire Template Tab F 20191120.docx	DOCX document	Dec 2, 2019

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Paid & Reject by 1st Rej 2017

FOR OFFICIAL USE ONLY
Title: Retail Paid and Reject (1st position only) Claim Volume
Date Range: 1/1/2017 - 12/31/2017
		Claim Status
Service Category (Claim)	Rej1 Definition	Paid	Rejected
Retail		44,005,449
Retail	04 - M/I Processor Control Number		153,337
Retail	13 - M/I Other Coverage Code		5
Retail	19 - M/I Days Supply		189
Retail	1R - Version/Release Value Not Supported		27
Retail	1V - Multiple Transactions Not Supported		347
Retail	1W - Multi-Ingredient Compound Must Be A Single Transaction		257
Retail	1Y - Claim Segment Required For Adjudication		12
Retail	20 - M/I Compound Code		2
Retail	21 - M/I Product/Service ID		31
Retail	23 - M/I Ingredient Cost Submitted		4,079
Retail	25 - M/I Prescriber ID		9,233
Retail	26 - M/I Unit Of Measure		6
Retail	28 - M/I Date Prescription Written		4,588
Retail	2N - M/I Prescriber State/Province Address		54
Retail	33 - M/I Prescription Origin Code		126
Retail	40 - Pharmacy Not Contracted With Plan On Date Of Service		579,093
Retail	41 - Submit Bill To Other Processor Or Primary Payer		1,670,805
Retail	4W - Must Fill Through Specialty Pharmacy		5,805
Retail	50 - Non-Matched Pharmacy Number		22,921
Retail	54 - Non-Matched Product/Service ID Number		140,785
Retail	60 - Product/Service Not Covered For Patient Age		7,986
Retail	61 - Product/Service Not Covered For Patient Gender		723
Retail	62 - Patient/Card Holder ID Name Mismatch		1
Retail	64 - Claim Submitted Does Not Match Prior Authorization		19,778
Retail	65 - Patient Is Not Covered		1,117,205
Retail	67 - Filled Before Coverage Effective		1,996
Retail	6G - Coordination Of Benefits/Other Payments Segment Required For Adjudication		50
Retail	6P - Pricing Segment Required For Adjudication		1
Retail	6Z - Provider Not Eligible To Perform Service/Dispense Product		2,155
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion		2,006,915
Retail	71 - Prescriber ID Is Not Covered		3,381
Retail	73 - Refills Are Not Covered		6,910
Retail	75 - Prior Authorization Required		1,652,691
Retail	76 - Plan Limitations Exceeded		348,495
Retail	77 - Discontinued Product/Service ID Number		138,778
Retail	78 - Cost Exceeds Maximum		168,018
Retail	79 - Refill Too Soon		3,818,201
Retail	7B - Service Provider ID Qualifier Value Not Supported For Processor/Payer		153
Retail	7D - Non-Matched DOB		82,429
Retail	7V - Duplicate Refills,		86,916
Retail	7W - Refills Exceed allowable Refills		9,550
Retail	7X - Days Supply Exceeds Plan Limitation		379,450
Retail	81 - Claim Too Old		21,970
Retail	82 - Claim Is Post-Dated		901
Retail	83 - Duplicate Paid/Captured Claim		115,501
Retail	88 - DUR Reject Error		1,038,237
Retail	8E - M/I DUR/PPS Level Of Effort		102,305
Retail	8K - DAW Code Value Not Supported		26,893
Retail	8R - Submission Clarification Code Value Not Supported		54,244
Retail	8Z - Product/Service ID Qualifier Value Not Supported		3
Retail	92 - System Unavailable/Host Unavailable		5,407
Retail	9E - Quantity Does Not Match Dispensing Unit		44,795
Retail	9G - Quantity Dispensed Exceeds Maximum Allowed		3,064
Retail	9T - Prior Authorization Type Code Submitted Not Covered		475
Retail	A1 - ID Submitted is associated with a Sanctioned Prescriber		802
Retail	AB - Date Written Is After Date Filled		13
Retail	AC - Product Not Covered Non-Participating Manufacturer		153
Retail	AG - Days Supply Limitation For Product/Service		11,558
Retail	BB - Diagnosis Code Qualifier Submitted Not Covered		20
Retail	CA - M/I Patient First Name		171,015
Retail	DN - M/I Basis Of Cost Determination		2
Retail	DQ - M/I Usual And Customary Charge		1,271
Retail	DU - M/I Gross Amount Due		195
Retail	DV - M/I Other Payer Amount Paid		44
Retail	E1 - M/I Product/Service ID Qualifier		4
Retail	E3 - M/I Incentive Amount Submitted		5,269
Retail	E5 - M/I Professional Service Code		491
Retail	E7 - M/I Quantity Dispensed		2
Retail	EE - M/I Compound Ingredient Drug Cost		8
Retail	EU - M/I Prior Authorization Type Code		24
Retail	EV - M/I Prior Authorization Number Submitted		486
Retail	EW - M/I Intermediary Authorization Type ID		2
Retail	EZ - M/I Prescriber ID Qualifier		1,454
Retail	G1 - M/I Compound Type		6
Retail	GE - M/I Percentage Sales Tax Amount Submitted		19
Retail	M2 - Recipient Locked In		8,500
Retail	NQ - M/I Other Payer-Patient Responsibility Amount		286
Retail	PE - M/I Request Coordination Of Benefits/Other Payments Segment		19
Retail	R9 - Value In Gross Amount Due Does Not Follow Pricing Formulae		3
Retail	18		525
Retail	XK		31
	Grand Totals	44,005,449	14,059,481

Paid & Reject by 1st Rej 2018

FOR OFFICIAL USE ONLY
Title: Retail Paid and Reject (1st position only) Claim Volume
Date Range: 1/1/2018 - 12/31/2018
		Claim Status
Service Category (Claim)	Reject 1 Definition	Paid	Rejected
Retail		43,818,103
Retail	04 - M/I Processor Control Number		101,253
Retail	13 - M/I Other Coverage Code		4
Retail	19 - M/I Days Supply		140
Retail	1R - Version/Release Value Not Supported		7
Retail	1V - Multiple Transactions Not Supported		404
Retail	1W - Multi-Ingredient Compound Must Be A Single Transaction		307
Retail	1Y - Claim Segment Required For Adjudication		8
Retail	21 - M/I Product/Service ID		36
Retail	23 - M/I Ingredient Cost Submitted		5,920
Retail	25 - M/I Prescriber ID		8,057
Retail	26 - M/I Unit Of Measure		21
Retail	28 - M/I Date Prescription Written		2,833
Retail	2N - M/I Prescriber State/Province Address		38
Retail	33 - M/I Prescription Origin Code		139
Retail	40 - Pharmacy Not Contracted With Plan On Date Of Service		98,587
Retail	41 - Submit Bill To Other Processor Or Primary Payer		1,449,743
Retail	4W - Must Fill Through Specialty Pharmacy		5,362
Retail	50 - Non-Matched Pharmacy Number		22,963
Retail	52 - Non-Matched Cardholder ID		79
Retail	54 - Non-Matched Product/Service ID Number		133,261
Retail	60 - Product/Service Not Covered For Patient Age		5,190
Retail	61 - Product/Service Not Covered For Patient Gender		566
Retail	64 - Claim Submitted Does Not Match Prior Authorization		22,774
Retail	65 - Patient Is Not Covered		1,388,359
Retail	67 - Filled Before Coverage Effective		2,307
Retail	6G - Coordination Of Benefits/Other Payments Segment Required For Adjudication		45
Retail	6Z - Provider Not Eligible To Perform Service/Dispense Product		2,067
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion		2,014,167
Retail	71 - Prescriber ID Is Not Covered		3,453
Retail	73 - Refills Are Not Covered		5,200
Retail	75 - Prior Authorization Required		1,803,872
Retail	76 - Plan Limitations Exceeded		337,539
Retail	77 - Discontinued Product/Service ID Number		144,608
Retail	78 - Cost Exceeds Maximum		178,018
Retail	79 - Refill Too Soon		4,038,996
Retail	7B - Service Provider ID Qualifier Value Not Supported For Processor/Payer		170
Retail	7D - Non-Matched DOB		86,366
Retail	7V - Duplicate Refills,		88,033
Retail	7W - Refills Exceed allowable Refills		7,804
Retail	7X - Days Supply Exceeds Plan Limitation		406,211
Retail	81 - Claim Too Old		39,752
Retail	82 - Claim Is Post-Dated		805
Retail	83 - Duplicate Paid/Captured Claim		82,383
Retail	87 - Reversal Not Processed		1,308
Retail	88 - DUR Reject Error		1,074,932
Retail	89 - Rejected Claim Fees Paid		137
Retail	8E - M/I DUR/PPS Level Of Effort		94,508
Retail	8K - DAW Code Value Not Supported		27,547
Retail	8R - Submission Clarification Code Value Not Supported		21,683
Retail	8Z - Product/Service ID Qualifier Value Not Supported		3
Retail	92 - System Unavailable/Host Unavailable		35,414
Retail	9E - Quantity Does Not Match Dispensing Unit		77,800
Retail	9G - Quantity Dispensed Exceeds Maximum Allowed		3,026
Retail	9T - Prior Authorization Type Code Submitted Not Covered		573
Retail	A1 - ID Submitted is associated with a Sanctioned Prescriber		844
Retail	AB - Date Written Is After Date Filled		8
Retail	AG - Days Supply Limitation For Product/Service		17,678
Retail	BB - Diagnosis Code Qualifier Submitted Not Covered		13
Retail	CA - M/I Patient First Name		455,848
Retail	DN - M/I Basis Of Cost Determination		3
Retail	DQ - M/I Usual And Customary Charge		3,933
Retail	DU - M/I Gross Amount Due		303
Retail	DV - M/I Other Payer Amount Paid		27
Retail	E1 - M/I Product/Service ID Qualifier		12
Retail	E3 - M/I Incentive Amount Submitted		7,962
Retail	E5 - M/I Professional Service Code		1,613
Retail	E7 - M/I Quantity Dispensed		2
Retail	ED - M/I Compound Ingredient Quantity		6
Retail	EE - M/I Compound Ingredient Drug Cost		14
Retail	EU - M/I Prior Authorization Type Code		28
Retail	EV - M/I Prior Authorization Number Submitted		533
Retail	EZ - M/I Prescriber ID Qualifier		4,535
Retail	G1 - M/I Compound Type		5
Retail	GE - M/I Percentage Sales Tax Amount Submitted		9
Retail	JE - M/I Percentage Sales Tax Basis Submitted		1
Retail	M2 - Recipient Locked In		7,332
Retail	NQ - M/I Other Payer-Patient Responsibility Amount		208
Retail	PE - M/I Request Coordination Of Benefits/Other Payments Segment		42
Retail	R0 - Professional Service Code of “MA” required for Vaccine Incentive Fee Submitted		2
Retail	R3 - Procedure Modifier Code Count Does Not Match Number Of Repetitions		1
Retail	R9 - Value In Gross Amount Due Does Not Follow Pricing Formulae		7
Retail	18		404
Retail	XK		48
	Grand Totals	43,818,103	14,326,199

Paid & Reject (all) 2017

FOR OFFICIAL USE ONLY
Title: Retail Paid and Rejected Claim Volume
Date Range: 1/1/2017 - 12/31/2017
				Claim Status
Service Category (Claim)	Reject 1 Definition	Reject 2 Definition	Reject 3 Definition	Paid	Rejected
Retail				44,005,449
Retail	04 - M/I Processor Control Number	04 - M/I Processor Control Number	(blank)		278
Retail	04 - M/I Processor Control Number	60 - Product/Service Not Covered For Patient Age	(blank)		6
Retail	04 - M/I Processor Control Number	61 - Product/Service Not Covered For Patient Gender	(blank)		2
Retail	04 - M/I Processor Control Number	70 - Product/Service Not Covered – Plan/Benefit Exclusion	(blank)		3,842
Retail	04 - M/I Processor Control Number	70 - Product/Service Not Covered – Plan/Benefit Exclusion	70 - Product/Service Not Covered – Plan/Benefit Exclusion		338
Retail	04 - M/I Processor Control Number	71 - Prescriber ID Is Not Covered	(blank)		19
Retail	04 - M/I Processor Control Number	81 - Claim Too Old	(blank)		9
Retail	04 - M/I Processor Control Number	M2 - Recipient Locked In	(blank)		26
Retail	04 - M/I Processor Control Number	(blank)	(blank)		148,817
Retail	13 - M/I Other Coverage Code	1V - Multiple Transactions Not Supported	(blank)		5
Retail	19 - M/I Days Supply	04 - M/I Processor Control Number	(blank)		2
Retail	19 - M/I Days Supply	21 - M/I Product/Service ID	85 - Claim Not Processed		2
Retail	19 - M/I Days Supply	23 - M/I Ingredient Cost Submitted	54 - Non-Matched Product/Service ID Number		20
Retail	19 - M/I Days Supply	23 - M/I Ingredient Cost Submitted	50 - Non-Matched Pharmacy Number		5
Retail	19 - M/I Days Supply	41 - Submit Bill To Other Processor Or Primary Payer	85 - Claim Not Processed		3
Retail	19 - M/I Days Supply	50 - Non-Matched Pharmacy Number	(blank)		1
Retail	19 - M/I Days Supply	54 - Non-Matched Product/Service ID Number	(blank)		62
Retail	19 - M/I Days Supply	70 - Product/Service Not Covered – Plan/Benefit Exclusion	(blank)		6
Retail	19 - M/I Days Supply	81 - Claim Too Old	54 - Non-Matched Product/Service ID Number		3
Retail	19 - M/I Days Supply	(blank)	(blank)		52
Retail	19 - M/I Days Supply	(blank)	23 - M/I Ingredient Cost Submitted		15
Retail	19 - M/I Days Supply	(blank)	85 - Claim Not Processed		14
Retail	19 - M/I Days Supply	(blank)	54 - Non-Matched Product/Service ID Number		3
Retail	19 - M/I Days Supply	(blank)	81 - Claim Too Old		1
Retail	1R - Version/Release Value Not Supported	(blank)	(blank)		27
Retail	1V - Multiple Transactions Not Supported	65 - Patient Is Not Covered	(blank)		1
Retail	1V - Multiple Transactions Not Supported	(blank)	(blank)		346
Retail	1W - Multi-Ingredient Compound Must Be A Single Transaction	21 - M/I Product/Service ID	(blank)		1
Retail	1W - Multi-Ingredient Compound Must Be A Single Transaction	65 - Patient Is Not Covered	(blank)		1
Retail	1W - Multi-Ingredient Compound Must Be A Single Transaction	9Z - Duplicate Product ID In Compound	9Z - Duplicate Product ID In Compound		3
Retail	1W - Multi-Ingredient Compound Must Be A Single Transaction	DN - M/I Basis Of Cost Determination	DN - M/I Basis Of Cost Determination		16
Retail	1W - Multi-Ingredient Compound Must Be A Single Transaction	E2 - M/I Route of Administration	(blank)		13
Retail	1W - Multi-Ingredient Compound Must Be A Single Transaction	E2 - M/I Route of Administration	6T - Compound Segment Required For Adjudication		4
Retail	1W - Multi-Ingredient Compound Must Be A Single Transaction	E2 - M/I Route of Administration	65 - Patient Is Not Covered		1
Retail	1W - Multi-Ingredient Compound Must Be A Single Transaction	(blank)	(blank)		218
Retail	1Y - Claim Segment Required For Adjudication	6P - Pricing Segment Required For Adjudication	23 - M/I Ingredient Cost Submitted		12
Retail	20 - M/I Compound Code	21 - M/I Product/Service ID	(blank)		1
Retail	20 - M/I Compound Code	(blank)	(blank)		1
Retail	21 - M/I Product/Service ID	85 - Claim Not Processed	(blank)		8
Retail	21 - M/I Product/Service ID	(blank)	(blank)		23
Retail	23 - M/I Ingredient Cost Submitted	19 - M/I Days Supply	54 - Non-Matched Product/Service ID Number		4
Retail	23 - M/I Ingredient Cost Submitted	40 - Pharmacy Not Contracted With Plan On Date Of Service	(blank)		3
Retail	23 - M/I Ingredient Cost Submitted	41 - Submit Bill To Other Processor Or Primary Payer	(blank)		2
Retail	23 - M/I Ingredient Cost Submitted	50 - Non-Matched Pharmacy Number	(blank)		5
Retail	23 - M/I Ingredient Cost Submitted	50 - Non-Matched Pharmacy Number	54 - Non-Matched Product/Service ID Number		5
Retail	23 - M/I Ingredient Cost Submitted	54 - Non-Matched Product/Service ID Number	(blank)		998
Retail	23 - M/I Ingredient Cost Submitted	65 - Patient Is Not Covered	(blank)		35
Retail	23 - M/I Ingredient Cost Submitted	67 - Filled Before Coverage Effective	65 - Patient Is Not Covered		1
Retail	23 - M/I Ingredient Cost Submitted	70 - Product/Service Not Covered – Plan/Benefit Exclusion	(blank)		24
Retail	23 - M/I Ingredient Cost Submitted	70 - Product/Service Not Covered – Plan/Benefit Exclusion	70 - Product/Service Not Covered – Plan/Benefit Exclusion		12
Retail	23 - M/I Ingredient Cost Submitted	70 - Product/Service Not Covered – Plan/Benefit Exclusion	54 - Non-Matched Product/Service ID Number		3
Retail	23 - M/I Ingredient Cost Submitted	70 - Product/Service Not Covered – Plan/Benefit Exclusion	77 - Discontinued Product/Service ID Number		1
Retail	23 - M/I Ingredient Cost Submitted	77 - Discontinued Product/Service ID Number	(blank)		193
Retail	23 - M/I Ingredient Cost Submitted	7D - Non-Matched DOB	(blank)		2
Retail	23 - M/I Ingredient Cost Submitted	81 - Claim Too Old	(blank)		56
Retail	23 - M/I Ingredient Cost Submitted	81 - Claim Too Old	85 - Claim Not Processed		30
Retail	23 - M/I Ingredient Cost Submitted	81 - Claim Too Old	54 - Non-Matched Product/Service ID Number		4
Retail	23 - M/I Ingredient Cost Submitted	81 - Claim Too Old	70 - Product/Service Not Covered – Plan/Benefit Exclusion		4
Retail	23 - M/I Ingredient Cost Submitted	85 - Claim Not Processed	(blank)		35
Retail	23 - M/I Ingredient Cost Submitted	8E - M/I DUR/PPS Level Of Effort	(blank)		2
Retail	23 - M/I Ingredient Cost Submitted	8K - DAW Code Value Not Supported	(blank)		1
Retail	23 - M/I Ingredient Cost Submitted	8R - Submission Clarification Code Value Not Supported	(blank)		2
Retail	23 - M/I Ingredient Cost Submitted	92 - System Unavailable/Host Unavailable	81 - Claim Too Old		14
Retail	23 - M/I Ingredient Cost Submitted	92 - System Unavailable/Host Unavailable	(blank)		10
Retail	23 - M/I Ingredient Cost Submitted	92 - System Unavailable/Host Unavailable	85 - Claim Not Processed		1
Retail	23 - M/I Ingredient Cost Submitted	9E - Quantity Does Not Match Dispensing Unit	(blank)		3
Retail	23 - M/I Ingredient Cost Submitted	CA - M/I Patient First Name	(blank)		6
Retail	23 - M/I Ingredient Cost Submitted	DQ - M/I Usual And Customary Charge	(blank)		133
Retail	23 - M/I Ingredient Cost Submitted	DQ - M/I Usual And Customary Charge	54 - Non-Matched Product/Service ID Number		28
Retail	23 - M/I Ingredient Cost Submitted	DQ - M/I Usual And Customary Charge	65 - Patient Is Not Covered		15
Retail	23 - M/I Ingredient Cost Submitted	DQ - M/I Usual And Customary Charge	77 - Discontinued Product/Service ID Number		9
Retail	23 - M/I Ingredient Cost Submitted	DQ - M/I Usual And Customary Charge	CA - M/I Patient First Name		1
Retail	23 - M/I Ingredient Cost Submitted	DU - M/I Gross Amount Due	DQ - M/I Usual And Customary Charge		467
Retail	23 - M/I Ingredient Cost Submitted	DU - M/I Gross Amount Due	(blank)		108
Retail	23 - M/I Ingredient Cost Submitted	DU - M/I Gross Amount Due	54 - Non-Matched Product/Service ID Number		29
Retail	23 - M/I Ingredient Cost Submitted	DU - M/I Gross Amount Due	40 - Pharmacy Not Contracted With Plan On Date Of Service		3
Retail	23 - M/I Ingredient Cost Submitted	DU - M/I Gross Amount Due	70 - Product/Service Not Covered – Plan/Benefit Exclusion		3
Retail	23 - M/I Ingredient Cost Submitted	DU - M/I Gross Amount Due	9E - Quantity Does Not Match Dispensing Unit		1
Retail	23 - M/I Ingredient Cost Submitted	DU - M/I Gross Amount Due	8R - Submission Clarification Code Value Not Supported		1
Retail	23 - M/I Ingredient Cost Submitted	DU - M/I Gross Amount Due	65 - Patient Is Not Covered		1
Retail	23 - M/I Ingredient Cost Submitted	DV - M/I Other Payer Amount Paid	(blank)		6
Retail	23 - M/I Ingredient Cost Submitted	DV - M/I Other Payer Amount Paid	41 - Submit Bill To Other Processor Or Primary Payer		2
Retail	23 - M/I Ingredient Cost Submitted	(blank)	(blank)		1,804
Retail	23 - M/I Ingredient Cost Submitted	(blank)	81 - Claim Too Old		7
Retail	23 - M/I Ingredient Cost Submitted	(blank)	92 - System Unavailable/Host Unavailable		2
Retail	23 - M/I Ingredient Cost Submitted	(blank)	19 - M/I Days Supply		1
Retail	23 - M/I Ingredient Cost Submitted	(blank)	50 - Non-Matched Pharmacy Number		1
Retail	23 - M/I Ingredient Cost Submitted	(blank)	DV - M/I Other Payer Amount Paid		1
Retail	25 - M/I Prescriber ID	04 - M/I Processor Control Number	(blank)		1
Retail	25 - M/I Prescriber ID	19 - M/I Days Supply	(blank)		251
Retail	25 - M/I Prescriber ID	19 - M/I Days Supply	54 - Non-Matched Product/Service ID Number		36
Retail	25 - M/I Prescriber ID	19 - M/I Days Supply	85 - Claim Not Processed		4
Retail	25 - M/I Prescriber ID	19 - M/I Days Supply	23 - M/I Ingredient Cost Submitted		1
Retail	25 - M/I Prescriber ID	23 - M/I Ingredient Cost Submitted	(blank)		24
Retail	25 - M/I Prescriber ID	23 - M/I Ingredient Cost Submitted	54 - Non-Matched Product/Service ID Number		4
Retail	25 - M/I Prescriber ID	23 - M/I Ingredient Cost Submitted	DU - M/I Gross Amount Due		3
Retail	25 - M/I Prescriber ID	23 - M/I Ingredient Cost Submitted	70 - Product/Service Not Covered – Plan/Benefit Exclusion		3
Retail	25 - M/I Prescriber ID	23 - M/I Ingredient Cost Submitted	81 - Claim Too Old		3
Retail	25 - M/I Prescriber ID	23 - M/I Ingredient Cost Submitted	92 - System Unavailable/Host Unavailable		2
Retail	25 - M/I Prescriber ID	23 - M/I Ingredient Cost Submitted	85 - Claim Not Processed		1
Retail	25 - M/I Prescriber ID	23 - M/I Ingredient Cost Submitted	19 - M/I Days Supply		1
Retail	25 - M/I Prescriber ID	23 - M/I Ingredient Cost Submitted	67 - Filled Before Coverage Effective		1
Retail	25 - M/I Prescriber ID	2N - M/I Prescriber State/Province Address	(blank)		2
Retail	25 - M/I Prescriber ID	41 - Submit Bill To Other Processor Or Primary Payer	(blank)		117
Retail	25 - M/I Prescriber ID	41 - Submit Bill To Other Processor Or Primary Payer	23 - M/I Ingredient Cost Submitted		94
Retail	25 - M/I Prescriber ID	41 - Submit Bill To Other Processor Or Primary Payer	85 - Claim Not Processed		38
Retail	25 - M/I Prescriber ID	41 - Submit Bill To Other Processor Or Primary Payer	70 - Product/Service Not Covered – Plan/Benefit Exclusion		21
Retail	25 - M/I Prescriber ID	41 - Submit Bill To Other Processor Or Primary Payer	19 - M/I Days Supply		11
Retail	25 - M/I Prescriber ID	41 - Submit Bill To Other Processor Or Primary Payer	50 - Non-Matched Pharmacy Number		4
Retail	25 - M/I Prescriber ID	41 - Submit Bill To Other Processor Or Primary Payer	81 - Claim Too Old		1
Retail	25 - M/I Prescriber ID	50 - Non-Matched Pharmacy Number	(blank)		220
Retail	25 - M/I Prescriber ID	50 - Non-Matched Pharmacy Number	85 - Claim Not Processed		9
Retail	25 - M/I Prescriber ID	50 - Non-Matched Pharmacy Number	54 - Non-Matched Product/Service ID Number		6
Retail	25 - M/I Prescriber ID	50 - Non-Matched Pharmacy Number	6G - Coordination Of Benefits/Other Payments Segment Required For Adjudication		2
Retail	25 - M/I Prescriber ID	50 - Non-Matched Pharmacy Number	19 - M/I Days Supply		1
Retail	25 - M/I Prescriber ID	50 - Non-Matched Pharmacy Number	65 - Patient Is Not Covered		1
Retail	25 - M/I Prescriber ID	54 - Non-Matched Product/Service ID Number	(blank)		93
Retail	25 - M/I Prescriber ID	64 - Claim Submitted Does Not Match Prior Authorization	81 - Claim Too Old		1
Retail	25 - M/I Prescriber ID	67 - Filled Before Coverage Effective	65 - Patient Is Not Covered		156
Retail	25 - M/I Prescriber ID	67 - Filled Before Coverage Effective	(blank)		15
Retail	25 - M/I Prescriber ID	67 - Filled Before Coverage Effective	19 - M/I Days Supply		3
Retail	25 - M/I Prescriber ID	67 - Filled Before Coverage Effective	41 - Submit Bill To Other Processor Or Primary Payer		2
Retail	25 - M/I Prescriber ID	67 - Filled Before Coverage Effective	50 - Non-Matched Pharmacy Number		1
Retail	25 - M/I Prescriber ID	6G - Coordination Of Benefits/Other Payments Segment Required For Adjudication	(blank)		12
Retail	25 - M/I Prescriber ID	70 - Product/Service Not Covered – Plan/Benefit Exclusion	(blank)		113
Retail	25 - M/I Prescriber ID	70 - Product/Service Not Covered – Plan/Benefit Exclusion	41 - Submit Bill To Other Processor Or Primary Payer		3
Retail	25 - M/I Prescriber ID	70 - Product/Service Not Covered – Plan/Benefit Exclusion	70 - Product/Service Not Covered – Plan/Benefit Exclusion		2
Retail	25 - M/I Prescriber ID	81 - Claim Too Old	(blank)		138
Retail	25 - M/I Prescriber ID	81 - Claim Too Old	85 - Claim Not Processed		33
Retail	25 - M/I Prescriber ID	81 - Claim Too Old	70 - Product/Service Not Covered – Plan/Benefit Exclusion		7
Retail	25 - M/I Prescriber ID	81 - Claim Too Old	50 - Non-Matched Pharmacy Number		4
Retail	25 - M/I Prescriber ID	81 - Claim Too Old	54 - Non-Matched Product/Service ID Number		1
Retail	25 - M/I Prescriber ID	85 - Claim Not Processed	(blank)		283
Retail	25 - M/I Prescriber ID	85 - Claim Not Processed	70 - Product/Service Not Covered – Plan/Benefit Exclusion		47
Retail	25 - M/I Prescriber ID	85 - Claim Not Processed	50 - Non-Matched Pharmacy Number		10
Retail	25 - M/I Prescriber ID	85 - Claim Not Processed	54 - Non-Matched Product/Service ID Number		9
Retail	25 - M/I Prescriber ID	85 - Claim Not Processed	6G - Coordination Of Benefits/Other Payments Segment Required For Adjudication		8
Retail	25 - M/I Prescriber ID	85 - Claim Not Processed	85 - Claim Not Processed		4
Retail	25 - M/I Prescriber ID	92 - System Unavailable/Host Unavailable	(blank)		117
Retail	25 - M/I Prescriber ID	92 - System Unavailable/Host Unavailable	81 - Claim Too Old		20
Retail	25 - M/I Prescriber ID	92 - System Unavailable/Host Unavailable	41 - Submit Bill To Other Processor Or Primary Payer		16
Retail	25 - M/I Prescriber ID	92 - System Unavailable/Host Unavailable	19 - M/I Days Supply		11
Retail	25 - M/I Prescriber ID	92 - System Unavailable/Host Unavailable	85 - Claim Not Processed		8
Retail	25 - M/I Prescriber ID	92 - System Unavailable/Host Unavailable	70 - Product/Service Not Covered – Plan/Benefit Exclusion		3
Retail	25 - M/I Prescriber ID	92 - System Unavailable/Host Unavailable	50 - Non-Matched Pharmacy Number		2
Retail	25 - M/I Prescriber ID	92 - System Unavailable/Host Unavailable	54 - Non-Matched Product/Service ID Number		1
Retail	25 - M/I Prescriber ID	92 - System Unavailable/Host Unavailable	DV - M/I Other Payer Amount Paid		1
Retail	25 - M/I Prescriber ID	9E - Quantity Does Not Match Dispensing Unit	(blank)		1
Retail	25 - M/I Prescriber ID	AC - Product Not Covered Non-Participating Manufacturer	41 - Submit Bill To Other Processor Or Primary Payer		4
Retail	25 - M/I Prescriber ID	AC - Product Not Covered Non-Participating Manufacturer	(blank)		1
Retail	25 - M/I Prescriber ID	DV - M/I Other Payer Amount Paid	41 - Submit Bill To Other Processor Or Primary Payer		4
Retail	25 - M/I Prescriber ID	(blank)	(blank)		6,406
Retail	25 - M/I Prescriber ID	(blank)	85 - Claim Not Processed		395
Retail	25 - M/I Prescriber ID	(blank)	54 - Non-Matched Product/Service ID Number		178
Retail	25 - M/I Prescriber ID	(blank)	23 - M/I Ingredient Cost Submitted		121
Retail	25 - M/I Prescriber ID	(blank)	19 - M/I Days Supply		75
Retail	25 - M/I Prescriber ID	(blank)	50 - Non-Matched Pharmacy Number		33
Retail	25 - M/I Prescriber ID	(blank)	70 - Product/Service Not Covered – Plan/Benefit Exclusion		12
Retail	25 - M/I Prescriber ID	(blank)	92 - System Unavailable/Host Unavailable		9
Retail	25 - M/I Prescriber ID	(blank)	81 - Claim Too Old		6
Retail	25 - M/I Prescriber ID	(blank)	67 - Filled Before Coverage Effective		2
Retail	26 - M/I Unit Of Measure	GE - M/I Percentage Sales Tax Amount Submitted	(blank)		2
Retail	26 - M/I Unit Of Measure	(blank)	(blank)		4
Retail	28 - M/I Date Prescription Written	7W - Refills Exceed allowable Refills	(blank)		72
Retail	28 - M/I Date Prescription Written	(blank)	(blank)		4,516
Retail	2N - M/I Prescriber State/Province Address	EZ - M/I Prescriber ID Qualifier	(blank)		44
Retail	2N - M/I Prescriber State/Province Address	EZ - M/I Prescriber ID Qualifier	EZ - M/I Prescriber ID Qualifier		1
Retail	2N - M/I Prescriber State/Province Address	(blank)	(blank)		9
Retail	33 - M/I Prescription Origin Code	(blank)	(blank)		126
Retail	40 - Pharmacy Not Contracted With Plan On Date Of Service	(blank)	(blank)		579,093
Retail	41 - Submit Bill To Other Processor Or Primary Payer	19 - M/I Days Supply	(blank)		35
Retail	41 - Submit Bill To Other Processor Or Primary Payer	19 - M/I Days Supply	70 - Product/Service Not Covered – Plan/Benefit Exclusion		4
Retail	41 - Submit Bill To Other Processor Or Primary Payer	19 - M/I Days Supply	23 - M/I Ingredient Cost Submitted		2
Retail	41 - Submit Bill To Other Processor Or Primary Payer	23 - M/I Ingredient Cost Submitted	(blank)		2,223
Retail	41 - Submit Bill To Other Processor Or Primary Payer	23 - M/I Ingredient Cost Submitted	81 - Claim Too Old		244
Retail	41 - Submit Bill To Other Processor Or Primary Payer	23 - M/I Ingredient Cost Submitted	70 - Product/Service Not Covered – Plan/Benefit Exclusion		77
Retail	41 - Submit Bill To Other Processor Or Primary Payer	23 - M/I Ingredient Cost Submitted	85 - Claim Not Processed		66
Retail	41 - Submit Bill To Other Processor Or Primary Payer	23 - M/I Ingredient Cost Submitted	50 - Non-Matched Pharmacy Number		33
Retail	41 - Submit Bill To Other Processor Or Primary Payer	25 - M/I Prescriber ID	(blank)		31
Retail	41 - Submit Bill To Other Processor Or Primary Payer	50 - Non-Matched Pharmacy Number	(blank)		40
Retail	41 - Submit Bill To Other Processor Or Primary Payer	54 - Non-Matched Product/Service ID Number	(blank)		17
Retail	41 - Submit Bill To Other Processor Or Primary Payer	54 - Non-Matched Product/Service ID Number	70 - Product/Service Not Covered – Plan/Benefit Exclusion		3
Retail	41 - Submit Bill To Other Processor Or Primary Payer	60 - Product/Service Not Covered For Patient Age	(blank)		401
Retail	41 - Submit Bill To Other Processor Or Primary Payer	61 - Product/Service Not Covered For Patient Gender	(blank)		14
Retail	41 - Submit Bill To Other Processor Or Primary Payer	64 - Claim Submitted Does Not Match Prior Authorization	(blank)		571
Retail	41 - Submit Bill To Other Processor Or Primary Payer	64 - Claim Submitted Does Not Match Prior Authorization	50 - Non-Matched Pharmacy Number		1
Retail	41 - Submit Bill To Other Processor Or Primary Payer	64 - Claim Submitted Does Not Match Prior Authorization	70 - Product/Service Not Covered – Plan/Benefit Exclusion		1
Retail	41 - Submit Bill To Other Processor Or Primary Payer	70 - Product/Service Not Covered – Plan/Benefit Exclusion	70 - Product/Service Not Covered – Plan/Benefit Exclusion		4,579
Retail	41 - Submit Bill To Other Processor Or Primary Payer	70 - Product/Service Not Covered – Plan/Benefit Exclusion	(blank)		1,515
Retail	41 - Submit Bill To Other Processor Or Primary Payer	71 - Prescriber ID Is Not Covered	(blank)		110
Retail	41 - Submit Bill To Other Processor Or Primary Payer	81 - Claim Too Old	(blank)		1,049
Retail	41 - Submit Bill To Other Processor Or Primary Payer	81 - Claim Too Old	70 - Product/Service Not Covered – Plan/Benefit Exclusion		124
Retail	41 - Submit Bill To Other Processor Or Primary Payer	81 - Claim Too Old	85 - Claim Not Processed		113
Retail	41 - Submit Bill To Other Processor Or Primary Payer	81 - Claim Too Old	50 - Non-Matched Pharmacy Number		2
Retail	41 - Submit Bill To Other Processor Or Primary Payer	85 - Claim Not Processed	(blank)		312
Retail	41 - Submit Bill To Other Processor Or Primary Payer	85 - Claim Not Processed	70 - Product/Service Not Covered – Plan/Benefit Exclusion		70
Retail	41 - Submit Bill To Other Processor Or Primary Payer	85 - Claim Not Processed	50 - Non-Matched Pharmacy Number		39
Retail	41 - Submit Bill To Other Processor Or Primary Payer	M2 - Recipient Locked In	(blank)		192
Retail	41 - Submit Bill To Other Processor Or Primary Payer	(blank)	(blank)		1,658,812
Retail	41 - Submit Bill To Other Processor Or Primary Payer	(blank)	23 - M/I Ingredient Cost Submitted		72
Retail	41 - Submit Bill To Other Processor Or Primary Payer	(blank)	81 - Claim Too Old		46
Retail	41 - Submit Bill To Other Processor Or Primary Payer	(blank)	70 - Product/Service Not Covered – Plan/Benefit Exclusion		6
Retail	41 - Submit Bill To Other Processor Or Primary Payer	(blank)	85 - Claim Not Processed		1
Retail	4W - Must Fill Through Specialty Pharmacy	(blank)	(blank)		5,805
Retail	50 - Non-Matched Pharmacy Number	19 - M/I Days Supply	23 - M/I Ingredient Cost Submitted		1
Retail	50 - Non-Matched Pharmacy Number	23 - M/I Ingredient Cost Submitted	(blank)		9
Retail	50 - Non-Matched Pharmacy Number	23 - M/I Ingredient Cost Submitted	DQ - M/I Usual And Customary Charge		1
Retail	50 - Non-Matched Pharmacy Number	41 - Submit Bill To Other Processor Or Primary Payer	23 - M/I Ingredient Cost Submitted		109
Retail	50 - Non-Matched Pharmacy Number	41 - Submit Bill To Other Processor Or Primary Payer	(blank)		43
Retail	50 - Non-Matched Pharmacy Number	41 - Submit Bill To Other Processor Or Primary Payer	81 - Claim Too Old		2
Retail	50 - Non-Matched Pharmacy Number	41 - Submit Bill To Other Processor Or Primary Payer	85 - Claim Not Processed		1
Retail	50 - Non-Matched Pharmacy Number	41 - Submit Bill To Other Processor Or Primary Payer	50 - Non-Matched Pharmacy Number		1
Retail	50 - Non-Matched Pharmacy Number	41 - Submit Bill To Other Processor Or Primary Payer	92 - System Unavailable/Host Unavailable		1
Retail	50 - Non-Matched Pharmacy Number	50 - Non-Matched Pharmacy Number	(blank)		2
Retail	50 - Non-Matched Pharmacy Number	54 - Non-Matched Product/Service ID Number	(blank)		39
Retail	50 - Non-Matched Pharmacy Number	54 - Non-Matched Product/Service ID Number	85 - Claim Not Processed		1
Retail	50 - Non-Matched Pharmacy Number	62 - Patient/Card Holder ID Name Mismatch	(blank)		1
Retail	50 - Non-Matched Pharmacy Number	6G - Coordination Of Benefits/Other Payments Segment Required For Adjudication	(blank)		2
Retail	50 - Non-Matched Pharmacy Number	70 - Product/Service Not Covered – Plan/Benefit Exclusion	41 - Submit Bill To Other Processor Or Primary Payer		1
Retail	50 - Non-Matched Pharmacy Number	81 - Claim Too Old	(blank)		16
Retail	50 - Non-Matched Pharmacy Number	81 - Claim Too Old	85 - Claim Not Processed		4
Retail	50 - Non-Matched Pharmacy Number	85 - Claim Not Processed	(blank)		17
Retail	50 - Non-Matched Pharmacy Number	DQ - M/I Usual And Customary Charge	(blank)		22
Retail	50 - Non-Matched Pharmacy Number	(blank)	(blank)		22,648
Retail	54 - Non-Matched Product/Service ID Number	54 - Non-Matched Product/Service ID Number	(blank)		96
Retail	54 - Non-Matched Product/Service ID Number	54 - Non-Matched Product/Service ID Number	54 - Non-Matched Product/Service ID Number		33
Retail	54 - Non-Matched Product/Service ID Number	70 - Product/Service Not Covered – Plan/Benefit Exclusion	70 - Product/Service Not Covered – Plan/Benefit Exclusion		29
Retail	54 - Non-Matched Product/Service ID Number	70 - Product/Service Not Covered – Plan/Benefit Exclusion	(blank)		10
Retail	54 - Non-Matched Product/Service ID Number	77 - Discontinued Product/Service ID Number	(blank)		15
Retail	54 - Non-Matched Product/Service ID Number	85 - Claim Not Processed	(blank)		3
Retail	54 - Non-Matched Product/Service ID Number	9E - Quantity Does Not Match Dispensing Unit	(blank)		3
Retail	54 - Non-Matched Product/Service ID Number	(blank)	(blank)		140,596
Retail	60 - Product/Service Not Covered For Patient Age	(blank)	(blank)		7,986
Retail	61 - Product/Service Not Covered For Patient Gender	(blank)	(blank)		723
Retail	62 - Patient/Card Holder ID Name Mismatch	(blank)	(blank)		1
Retail	64 - Claim Submitted Does Not Match Prior Authorization	41 - Submit Bill To Other Processor Or Primary Payer	(blank)		37
Retail	64 - Claim Submitted Does Not Match Prior Authorization	70 - Product/Service Not Covered – Plan/Benefit Exclusion	(blank)		28
Retail	64 - Claim Submitted Does Not Match Prior Authorization	85 - Claim Not Processed	(blank)		1
Retail	64 - Claim Submitted Does Not Match Prior Authorization	(blank)	(blank)		19,712
Retail	65 - Patient Is Not Covered	25 - M/I Prescriber ID	67 - Filled Before Coverage Effective		6
Retail	65 - Patient Is Not Covered	65 - Patient Is Not Covered	65 - Patient Is Not Covered		4,404
Retail	65 - Patient Is Not Covered	67 - Filled Before Coverage Effective	65 - Patient Is Not Covered		51
Retail	65 - Patient Is Not Covered	67 - Filled Before Coverage Effective	41 - Submit Bill To Other Processor Or Primary Payer		1
Retail	65 - Patient Is Not Covered	(blank)	(blank)		1,112,743
Retail	67 - Filled Before Coverage Effective	19 - M/I Days Supply	65 - Patient Is Not Covered		1
Retail	67 - Filled Before Coverage Effective	23 - M/I Ingredient Cost Submitted	65 - Patient Is Not Covered		4
Retail	67 - Filled Before Coverage Effective	41 - Submit Bill To Other Processor Or Primary Payer	65 - Patient Is Not Covered		212
Retail	67 - Filled Before Coverage Effective	41 - Submit Bill To Other Processor Or Primary Payer	23 - M/I Ingredient Cost Submitted		12
Retail	67 - Filled Before Coverage Effective	65 - Patient Is Not Covered	(blank)		1,380
Retail	67 - Filled Before Coverage Effective	65 - Patient Is Not Covered	81 - Claim Too Old		289
Retail	67 - Filled Before Coverage Effective	65 - Patient Is Not Covered	85 - Claim Not Processed		59
Retail	67 - Filled Before Coverage Effective	65 - Patient Is Not Covered	70 - Product/Service Not Covered – Plan/Benefit Exclusion		15
Retail	67 - Filled Before Coverage Effective	65 - Patient Is Not Covered	50 - Non-Matched Pharmacy Number		4
Retail	67 - Filled Before Coverage Effective	65 - Patient Is Not Covered	54 - Non-Matched Product/Service ID Number		3
Retail	67 - Filled Before Coverage Effective	70 - Product/Service Not Covered – Plan/Benefit Exclusion	(blank)		2
Retail	67 - Filled Before Coverage Effective	70 - Product/Service Not Covered – Plan/Benefit Exclusion	65 - Patient Is Not Covered		2
Retail	67 - Filled Before Coverage Effective	(blank)	65 - Patient Is Not Covered		13
Retail	6G - Coordination Of Benefits/Other Payments Segment Required For Adjudication	(blank)	(blank)		50
Retail	6P - Pricing Segment Required For Adjudication	23 - M/I Ingredient Cost Submitted	DU - M/I Gross Amount Due		1
Retail	6Z - Provider Not Eligible To Perform Service/Dispense Product	6Z - Provider Not Eligible To Perform Service/Dispense Product	(blank)		1,993
Retail	6Z - Provider Not Eligible To Perform Service/Dispense Product	6Z - Provider Not Eligible To Perform Service/Dispense Product	6Z - Provider Not Eligible To Perform Service/Dispense Product		162
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	04 - M/I Processor Control Number	(blank)		262
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	23 - M/I Ingredient Cost Submitted	(blank)		1
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	25 - M/I Prescriber ID	(blank)		38
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	25 - M/I Prescriber ID	70 - Product/Service Not Covered – Plan/Benefit Exclusion		1
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	25 - M/I Prescriber ID	23 - M/I Ingredient Cost Submitted		1
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	25 - M/I Prescriber ID	41 - Submit Bill To Other Processor Or Primary Payer		1
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	41 - Submit Bill To Other Processor Or Primary Payer	(blank)		14,224
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	41 - Submit Bill To Other Processor Or Primary Payer	23 - M/I Ingredient Cost Submitted		51
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	41 - Submit Bill To Other Processor Or Primary Payer	81 - Claim Too Old		12
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	41 - Submit Bill To Other Processor Or Primary Payer	85 - Claim Not Processed		9
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	41 - Submit Bill To Other Processor Or Primary Payer	19 - M/I Days Supply		2
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	41 - Submit Bill To Other Processor Or Primary Payer	71 - Prescriber ID Is Not Covered		1
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	50 - Non-Matched Pharmacy Number	(blank)		2
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	54 - Non-Matched Product/Service ID Number	(blank)		14,220
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	54 - Non-Matched Product/Service ID Number	54 - Non-Matched Product/Service ID Number		1,440
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	54 - Non-Matched Product/Service ID Number	77 - Discontinued Product/Service ID Number		157
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	61 - Product/Service Not Covered For Patient Gender	(blank)		1
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	70 - Product/Service Not Covered – Plan/Benefit Exclusion	70 - Product/Service Not Covered – Plan/Benefit Exclusion		105,139
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	70 - Product/Service Not Covered – Plan/Benefit Exclusion	(blank)		1,264
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	71 - Prescriber ID Is Not Covered	(blank)		76
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	77 - Discontinued Product/Service ID Number	(blank)		8,238
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	77 - Discontinued Product/Service ID Number	77 - Discontinued Product/Service ID Number		576
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	77 - Discontinued Product/Service ID Number	54 - Non-Matched Product/Service ID Number		355
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	7X - Days Supply Exceeds Plan Limitation	70 - Product/Service Not Covered – Plan/Benefit Exclusion		2
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	81 - Claim Too Old	(blank)		22
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	81 - Claim Too Old	85 - Claim Not Processed		1
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	85 - Claim Not Processed	(blank)		1
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	8R - Submission Clarification Code Value Not Supported	70 - Product/Service Not Covered – Plan/Benefit Exclusion		6
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	8R - Submission Clarification Code Value Not Supported	77 - Discontinued Product/Service ID Number		2
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	92 - System Unavailable/Host Unavailable	(blank)		1
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	AG - Days Supply Limitation For Product/Service	70 - Product/Service Not Covered – Plan/Benefit Exclusion		1
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	M2 - Recipient Locked In	(blank)		10
Retail	70 - Product/Service Not Covered – Plan/Benefit Exclusion	(blank)	(blank)		1,860,798
Retail	71 - Prescriber ID Is Not Covered	70 - Product/Service Not Covered – Plan/Benefit Exclusion	70 - Product/Service Not Covered – Plan/Benefit Exclusion		7
Retail	71 - Prescriber ID Is Not Covered	(blank)	(blank)		3,374
Retail	73 - Refills Are Not Covered	73 - Refills Are Not Covered	73 - Refills Are Not Covered		2,171
Retail	73 - Refills Are Not Covered	73 - Refills Are Not Covered	(blank)		198
Retail	73 - Refills Are Not Covered	79 - Refill Too Soon	79 - Refill Too Soon		71
Retail	73 - Refills Are Not Covered	79 - Refill Too Soon	(blank)		4
Retail	73 - Refills Are Not Covered	9T - Prior Authorization Type Code Submitted Not Covered	9T - Prior Authorization Type Code Submitted Not Covered		1
Retail	73 - Refills Are Not Covered	(blank)	(blank)		4,465
Retail	75 - Prior Authorization Required	75 - Prior Authorization Required	(blank)		1,094
Retail	75 - Prior Authorization Required	75 - Prior Authorization Required	75 - Prior Authorization Required		213
Retail	75 - Prior Authorization Required	85 - Claim Not Processed	(blank)		1
Retail	75 - Prior Authorization Required	(blank)	(blank)		1,651,383
Retail	76 - Plan Limitations Exceeded	76 - Plan Limitations Exceeded	76 - Plan Limitations Exceeded		414
Retail	76 - Plan Limitations Exceeded	76 - Plan Limitations Exceeded	(blank)		12
Retail	76 - Plan Limitations Exceeded	(blank)	(blank)		348,069
Retail	77 - Discontinued Product/Service ID Number	(blank)	(blank)		138,778
Retail	78 - Cost Exceeds Maximum	78 - Cost Exceeds Maximum	78 - Cost Exceeds Maximum		469
Retail	78 - Cost Exceeds Maximum	(blank)	(blank)		167,549
Retail	79 - Refill Too Soon	79 - Refill Too Soon	79 - Refill Too Soon		9,849
Retail	79 - Refill Too Soon	(blank)	(blank)		3,808,352
Retail	7B - Service Provider ID Qualifier Value Not Supported For Processor/Payer	8E - M/I DUR/PPS Level Of Effort	(blank)		1
Retail	7B - Service Provider ID Qualifier Value Not Supported For Processor/Payer	(blank)	(blank)		152
Retail	7D - Non-Matched DOB	7D - Non-Matched DOB	7D - Non-Matched DOB		689
Retail	7D - Non-Matched DOB	(blank)	(blank)		81,740
Retail	7V - Duplicate Refills,	(blank)	(blank)		86,916
Retail	7W - Refills Exceed allowable Refills	79 - Refill Too Soon	(blank)		8
Retail	7W - Refills Exceed allowable Refills	(blank)	(blank)		9,542
Retail	7X - Days Supply Exceeds Plan Limitation	7X - Days Supply Exceeds Plan Limitation	(blank)		486
Retail	7X - Days Supply Exceeds Plan Limitation	7X - Days Supply Exceeds Plan Limitation	7X - Days Supply Exceeds Plan Limitation		16
Retail	7X - Days Supply Exceeds Plan Limitation	(blank)	(blank)		378,948
Retail	81 - Claim Too Old	04 - M/I Processor Control Number	(blank)		20
Retail	81 - Claim Too Old	50 - Non-Matched Pharmacy Number	(blank)		78
Retail	81 - Claim Too Old	50 - Non-Matched Pharmacy Number	54 - Non-Matched Product/Service ID Number		3
Retail	81 - Claim Too Old	54 - Non-Matched Product/Service ID Number	(blank)		68
Retail	81 - Claim Too Old	64 - Claim Submitted Does Not Match Prior Authorization	70 - Product/Service Not Covered – Plan/Benefit Exclusion		1
Retail	81 - Claim Too Old	70 - Product/Service Not Covered – Plan/Benefit Exclusion	(blank)		141
Retail	81 - Claim Too Old	70 - Product/Service Not Covered – Plan/Benefit Exclusion	70 - Product/Service Not Covered – Plan/Benefit Exclusion		57
Retail	81 - Claim Too Old	85 - Claim Not Processed	(blank)		451
Retail	81 - Claim Too Old	85 - Claim Not Processed	70 - Product/Service Not Covered – Plan/Benefit Exclusion		26
Retail	81 - Claim Too Old	85 - Claim Not Processed	50 - Non-Matched Pharmacy Number		10
Retail	81 - Claim Too Old	85 - Claim Not Processed	54 - Non-Matched Product/Service ID Number		3
Retail	81 - Claim Too Old	8R - Submission Clarification Code Value Not Supported	(blank)		3
Retail	81 - Claim Too Old	(blank)	(blank)		21,109
Retail	82 - Claim Is Post-Dated	DQ - M/I Usual And Customary Charge	(blank)		1
Retail	82 - Claim Is Post-Dated	(blank)	(blank)		900
Retail	83 - Duplicate Paid/Captured Claim	83 - Duplicate Paid/Captured Claim	83 - Duplicate Paid/Captured Claim		213
Retail	83 - Duplicate Paid/Captured Claim	(blank)	(blank)		115,288
Retail	88 - DUR Reject Error	88 - DUR Reject Error	(blank)		1,690
Retail	88 - DUR Reject Error	88 - DUR Reject Error	88 - DUR Reject Error		209
Retail	88 - DUR Reject Error	(blank)	(blank)		1,036,338
Retail	8E - M/I DUR/PPS Level Of Effort	81 - Claim Too Old	(blank)		2
Retail	8E - M/I DUR/PPS Level Of Effort	8K - DAW Code Value Not Supported	(blank)		18
Retail	8E - M/I DUR/PPS Level Of Effort	8R - Submission Clarification Code Value Not Supported	(blank)		12
Retail	8E - M/I DUR/PPS Level Of Effort	EV - M/I Prior Authorization Number Submitted	(blank)		1
Retail	8E - M/I DUR/PPS Level Of Effort	(blank)	(blank)		102,272
Retail	8K - DAW Code Value Not Supported	8R - Submission Clarification Code Value Not Supported	(blank)		57
Retail	8K - DAW Code Value Not Supported	(blank)	(blank)		26,836
Retail	8R - Submission Clarification Code Value Not Supported	8R - Submission Clarification Code Value Not Supported	(blank)		1
Retail	8R - Submission Clarification Code Value Not Supported	(blank)	(blank)		54,243
Retail	8Z - Product/Service ID Qualifier Value Not Supported	65 - Patient Is Not Covered	(blank)		1
Retail	8Z - Product/Service ID Qualifier Value Not Supported	(blank)	(blank)		2
Retail	92 - System Unavailable/Host Unavailable	04 - M/I Processor Control Number	81 - Claim Too Old		1
Retail	92 - System Unavailable/Host Unavailable	19 - M/I Days Supply	(blank)		6
Retail	92 - System Unavailable/Host Unavailable	19 - M/I Days Supply	21 - M/I Product/Service ID		1
Retail	92 - System Unavailable/Host Unavailable	19 - M/I Days Supply	81 - Claim Too Old		1
Retail	92 - System Unavailable/Host Unavailable	19 - M/I Days Supply	23 - M/I Ingredient Cost Submitted		1
Retail	92 - System Unavailable/Host Unavailable	19 - M/I Days Supply	41 - Submit Bill To Other Processor Or Primary Payer		1
Retail	92 - System Unavailable/Host Unavailable	23 - M/I Ingredient Cost Submitted	81 - Claim Too Old		5
Retail	92 - System Unavailable/Host Unavailable	23 - M/I Ingredient Cost Submitted	(blank)		1
Retail	92 - System Unavailable/Host Unavailable	23 - M/I Ingredient Cost Submitted	54 - Non-Matched Product/Service ID Number		1
Retail	92 - System Unavailable/Host Unavailable	41 - Submit Bill To Other Processor Or Primary Payer	81 - Claim Too Old		222
Retail	92 - System Unavailable/Host Unavailable	41 - Submit Bill To Other Processor Or Primary Payer	(blank)		203
Retail	92 - System Unavailable/Host Unavailable	41 - Submit Bill To Other Processor Or Primary Payer	23 - M/I Ingredient Cost Submitted		172
Retail	92 - System Unavailable/Host Unavailable	41 - Submit Bill To Other Processor Or Primary Payer	70 - Product/Service Not Covered – Plan/Benefit Exclusion		22
Retail	92 - System Unavailable/Host Unavailable	41 - Submit Bill To Other Processor Or Primary Payer	85 - Claim Not Processed		21
Retail	92 - System Unavailable/Host Unavailable	41 - Submit Bill To Other Processor Or Primary Payer	M2 - Recipient Locked In		1
Retail	92 - System Unavailable/Host Unavailable	41 - Submit Bill To Other Processor Or Primary Payer	19 - M/I Days Supply		1
Retail	92 - System Unavailable/Host Unavailable	50 - Non-Matched Pharmacy Number	(blank)		24
Retail	92 - System Unavailable/Host Unavailable	50 - Non-Matched Pharmacy Number	85 - Claim Not Processed		1
Retail	92 - System Unavailable/Host Unavailable	54 - Non-Matched Product/Service ID Number	(blank)		16
Retail	92 - System Unavailable/Host Unavailable	6G - Coordination Of Benefits/Other Payments Segment Required For Adjudication	(blank)		2
Retail	92 - System Unavailable/Host Unavailable	70 - Product/Service Not Covered – Plan/Benefit Exclusion	(blank)		39
Retail	92 - System Unavailable/Host Unavailable	70 - Product/Service Not Covered – Plan/Benefit Exclusion	41 - Submit Bill To Other Processor Or Primary Payer		4
Retail	92 - System Unavailable/Host Unavailable	70 - Product/Service Not Covered – Plan/Benefit Exclusion	81 - Claim Too Old		1
Retail	92 - System Unavailable/Host Unavailable	81 - Claim Too Old	(blank)		1,137
Retail	92 - System Unavailable/Host Unavailable	81 - Claim Too Old	85 - Claim Not Processed		56
Retail	92 - System Unavailable/Host Unavailable	81 - Claim Too Old	70 - Product/Service Not Covered – Plan/Benefit Exclusion		13
Retail	92 - System Unavailable/Host Unavailable	81 - Claim Too Old	54 - Non-Matched Product/Service ID Number		12
Retail	92 - System Unavailable/Host Unavailable	81 - Claim Too Old	50 - Non-Matched Pharmacy Number		5
Retail	92 - System Unavailable/Host Unavailable	85 - Claim Not Processed	(blank)		90
Retail	92 - System Unavailable/Host Unavailable	85 - Claim Not Processed	50 - Non-Matched Pharmacy Number		11
Retail	92 - System Unavailable/Host Unavailable	85 - Claim Not Processed	70 - Product/Service Not Covered – Plan/Benefit Exclusion		7
Retail	92 - System Unavailable/Host Unavailable	85 - Claim Not Processed	54 - Non-Matched Product/Service ID Number		5
Retail	92 - System Unavailable/Host Unavailable	(blank)	(blank)		3,318
Retail	92 - System Unavailable/Host Unavailable	(blank)	81 - Claim Too Old		5
Retail	92 - System Unavailable/Host Unavailable	(blank)	54 - Non-Matched Product/Service ID Number		1
Retail	9E - Quantity Does Not Match Dispensing Unit	41 - Submit Bill To Other Processor Or Primary Payer	(blank)		1
Retail	9E - Quantity Does Not Match Dispensing Unit	81 - Claim Too Old	70 - Product/Service Not Covered – Plan/Benefit Exclusion		1
Retail	9E - Quantity Does Not Match Dispensing Unit	(blank)	(blank)		44,793
Retail	9G - Quantity Dispensed Exceeds Maximum Allowed	7W - Refills Exceed allowable Refills	(blank)		1

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Dec 2, 2019.