Handle Common NCPDP Reject Codes with a Seasoned Specialty Pharmacy Billing Company

Claims rejections are part of everyday life for specialty pharmacies, just like any other medical field. According to reports from Specialty Pharmacy Continuum, specialty pharmacies face initial claim rejection rates around 52%. As per the report, rejection mostly varies by payer, drug class and complexity of utilization management.

A seasoned specialty pharmacy billing company processes claims and routinely addresses rejections as part of their regular work routine. They understand how a rejected claim hinders or rather slows down specialty pharmacy revenue cycle management. And as a result, working capital gets reduced further delaying patient access to expensive medication.

This is why an expert specialty pharmacy billing company keeps itself updated on NCPDP reject codes. Such awareness is central to specialty pharmacy revenue protection, as each code denotes the reason for the claim rejection.

How NCPDP Reject Codes Work in Specialty Pharmacy Claims

Telecommunication Standard Version D.0 is the HIPAA-named format mainly for pharmacy benefits claims, published by the National Council for Prescription Drug Programs. While the compliance date for Version D.0 was January 1, 2012, the CMS has set April 14, 2028, for compliance with the replacement F6 standard, following a transition beginning August 14, 2027.

So once the claim is submitted, the processor replies instantly and if rejected, provides a code in Field 511-FB. The corresponding explanation follows in Field 504-F4, often indicating the requirement that made the claim fail.

A specialty claim is costlier than a retail one given the expensive nature of the medicine, limited distribution network, and stringent clinical criteria. This honestly results in many more possible reasons for rejection.

Related Reading: How a Specialty Pharmacy Billing Company Supports Value-Based Care

The Reject Codes That Most Often Disrupt Specialty Claims

Pharmacy Reject Code 75 Stands For: Prior Authorization Required

Rejection Code 75 can be given in response to a treatment request that is missing, expired, or invalid authorization for the service performed and corresponding billing. Resolution will require checking the record for the authorization and the submission of the prior authorization number in 462-EV. Additionally, step therapy edit errors can also cause a reject code 75 or may apply separate step therapy coding.

Pharmacy Reject Code 76 Stands For: Plan Limitations Exceeded

Reject code 76 signals where days’ supply or quantity is greater than plan maximums, thus the claim needs to be verified using fields 405-D5 and 442-E7. The errors associated with specialty medications include metric quantity (mL, grams or each) and package conversion which does not correlate with NDC number being billed.

Pharmacy Reject Code 79 Stands For: Refill Too Soon

Reject Code 79 is activated when the claim is received before the utilization threshold as established by the insurance company. This often happens when there is a modification in dosage, change of location, absence of medicine, or the switch from one pharmacy to another. Pre-emptive refills can be exempted through the usage of a submission clarification code in field 420-DK. Herein, code 3 denotes a vacation supply, whereas code 4 indicates a lost prescription. On the other hand, code 5 reflects a therapy change.

Pharmacy Reject Code 70 Stands for: Product or Service Not Covered

Reject code 70 represents either a formulary exclusion or inclusion error. An error in the NDC number or a drug billed under pharmacy benefit rather than patient’s medical benefit (wherever applicable) can also trigger it. The billers need to check the billed NDC number and make sure the package size is correct.

Pharmacy Reject Code 80 Stands For: Drug and Diagnosis Mismatch

Rejection Code 80 is applicable when the ICD-10 code does not meet the diagnosis-related coverage criteria of the plan despite the prescription being correct. An expert specialty pharmacy billing company will first verify the ICD-10 code. They will also follow up and submit the claim again.

Pharmacy Reject Code 41 Stands for: Submit Bill to Other Processor or Primary Payer

If reject 41 occurs, there is other coverage, and the claim should be billed to the primary insurer first before the secondary insurer processes it. When processing secondary claims, it requires an Other Coverage Code in 308-C8 field, primary payment in 431-DV field, and rejection information in 472-6E field, when available. The code 2 represents a payment received, while the code 3 indicates a denial from the primary.

Common Triggers for Reject Code 88: DUR Reject Error

The reject code 88 reflects a Drug Utilization Review disagreement, like duplicative therapy, which requires pharmacist resolution instead of resubmission. The documented results are submitted using the reason for service field, 439-E4; professional service field, 440-E5; and result of service field, 441-E6.

Related Reading: Why Specialty Pharmacies Need a Billing Company for Claim Accuracy

A Structured Workflow for Resolving Rejections

The rectification process led by a specialty pharmacy billing company, in general, segregates true coverage denials from recoverable rejections. This helps to prevent recurrence of mistakes.

1. Examine the complete rejection notification first. The next process starts with identifying the exact field, payer or authorization requirement that the processor stated before rectifying the claims.
2. Confirm eligibility, BIN, PCN, group number, and other certainties.
3. Each declined claim should be rectified, and all overrides and correction codes utilized should be documented before resubmission made timely.
4. Appeal against recurring denials, including 75 and 70 as soon as possible attaching medical notes and lab reports as well as previous pharmacological history.
5. Monitor the rejection codes rejection by payer, medication, and prescriber to find recurring underlying problems and rectify the intake, authorization, and NDC mapping process.

Why Practices Rely on a Specialty Pharmacy Billing Company

A proficient specialty pharmacy billing company scrubs claims, reviews claims against payer-specific rules and even conducts thorough eligibility verification for preventing unnecessary claim rejections. When a claim gets denied, these professionals try to resolve issues that same day.

They follow up with prescribers to get the required information and submit an amended claim supported by the necessary paperwork. Analytics use rejection data to derive process improvements. This allows them to reduce denial rate, improve accounts receivable turn-around time, and make sure costly therapies remain profitable.

Turn Reject Codes into Recovered Revenue with SunKnowledge

An unresolved rejection can delay payment and increase the time staff spends obtaining authorization, correcting claim information or contacting the payer. And practices do incur losses, money sits idle and so on. Detecting and resolving these complicated issues is what SunKnowledge offers as an expert specialty pharmacy billing company.

Some of our most noteworthy KPIs include:

• A first-pass collection rate of 97%
• 99.7% accuracy in coding and data entry
• A reimbursement cycle reported as 30% faster
• Cost reductions of up to 80% for partner practices

If pharmacy owners have doubts that claims rejections may harm revenue, they should contact us and schedule a no-obligation consultation.

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