Define ValueSet NCPDP Reject Reason

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    • Type: Change Request
    • Resolution: Persuasive with Modification
    • Priority: Highest
    • US CARIN Blue Button (FHIR)
    • 0.1 [deprecated]
    • Financial Mgmt
    • (NA)
    • Terminology
    • Hide

      While some payers do not receive rejected retail pharmacy claims, other payers do.  The Value Set and Code System will be defined as requested for payers that do receive this information to provide it to the Patient Access API.   Additionally, Payers provide payer specific reason codes for accepted claim that are partially rejected, i.e., meeting  a maximum, etc..? The IG will capture these reasons as text.  

      Define Value Set

      Defining URL: http://hl7.org/fhir/us/carin-bb/ValueSet/NCPDPRejectCode
      Name: NCPDPRejectCode
      Title: NCPDP Reject Code
      Definition: Contains exception definitions for use when transaction processing cannot be completed. NCPDP field # 511-FB (Reject Code)
      Copyright: NCPDP codes are available by subscription at ncpdp.org.  As HL7 is working with the owning authority to finalize the url, this url is subject to change
      Logical Definition: This value set includes codes from the following code systems:
      ·       Include all codes defined in https://www.ncpdp.org/RejectCode

       

      Bind with binding strength Required to the slice denialReason, data element item.adjudication in the Pharmacy profile.

       

      Define Code System

      Defining URL: https://www.ncpdp.org/RejectCode
      Name: NCPDPRejectCode
      Title: NCPDP Reject Code
      Definition: Contains exception definitions for use when transaction processing cannot be completed. NCPDP field # 511-FB (Reject Code)
      Copyright: NCPDP codes are available by subscription at ncpdp.org.  As HL7 is working with the owning authority to finalize the url, this url is subject to change.

       

      Show
      While some payers do not receive rejected retail pharmacy claims, other payers do.  The Value Set and Code System will be defined as requested for payers that do receive this information to provide it to the Patient Access API.   Additionally, Payers provide payer specific reason codes for accepted claim that are partially rejected, i.e., meeting  a maximum, etc..? The IG will capture these reasons as text.   Define Value Set Defining URL: http://hl7.org/fhir/us/carin-bb/ValueSet/NCPDPRejectCode Name: NCPDPRejectCode Title: NCPDP Reject Code Definition: Contains exception definitions for use when transaction processing cannot be completed. NCPDP field # 511-FB (Reject Code) Copyright: NCPDP codes are available by subscription at ncpdp.org .  As HL7 is working with the owning authority to finalize the url, this url is subject to change Logical Definition: This value set includes codes from the following code systems: ·       Include all codes defined in https://www.ncpdp.org/RejectCode   Bind with binding strength Required to the slice denialReason, data element item.adjudication in the Pharmacy profile.   Define Code System Defining URL: https://www.ncpdp.org/RejectCode Name: NCPDPRejectCode Title: NCPDP Reject Code Definition: Contains exception definitions for use when transaction processing cannot be completed. NCPDP field # 511-FB (Reject Code) Copyright: NCPDP codes are available by subscription at ncpdp.org .  As HL7 is working with the owning authority to finalize the url, this url is subject to change.  
    • Mark Roberts/Pat Taylor: 10-0-2
    • Enhancement
    • Compatible, substantive

      Ballot feedback was that the Terminology Section of the IG requires a major overall, renaming the Value Sets and Code Systems and updating links. Following is a recommended resolution for the Pharmacy Reject Code.

      1) Define a Value Set NCPDPRejectCode

      2) Title: NCPDP Reject Code

      3) Description: NCPDP field # 511-FB (Reject Code)

      4) Value Set: http://hl7.org/fhir/us/ValueSet/ncpdp-rejectcode

      5) Code System URI (new): http://www.ncpdp.org/reject-code. Submit a request to define an OID named ncpdp-RejectCode-cs

      6) Code System Definition for Reject Code: Code indicating the error encountered. NCPDP field # 511-FB (Reject Code). NCPDP codes are available by subscription at https://www.ncpdp.org/members/pdf/versiond.editorial.pdf

      7) Bind the Value Set with binding strength required to the slice denialreason.EOB.item.adjudication.reason in the Pharmacy Profile

            Assignee:
            Unassigned
            Reporter:
            Patricia Taylor
            Patricia Taylor
            Watchers:
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              Created:
              Updated:
              Resolved: