Stream: CARIN IG for Blue Button®
Topic: Pharmacy Reject Claims
Jason Teeple (Aug 21 2020 at 19:17):
@Amol Vyas @Pat Taylor Is it the intention of the EOB Pharmacy mapping to represent rejected claims?
Rejected claims in the pharmacy world are different from rejected claims in the Medical world. Medical claims are typically submitted after the service is completed; pharmacy claims are submitted before the medication is dispensed. As a result, if a claim is rejected in the medical world, it represents something that happened to the patient, but the insurer decided not to pay for. On the other hand, if a pharmacy claim is rejected, it represents a dispensing event that did not occur.
Pat Taylor (Aug 22 2020 at 13:33):
Jason, you ask a good question. I'm verifying but at first glance, we don't receive rejected pharmacy claims. And, to your point, the NCPDP reject code field, #511-FB is used when transactions cannot be completed. Would you be willing to speak to this on the CARIN WG call Monday? @Ryan Howells @Mark Roberts May this be added as an agenda item? @Amol Vyas are you ok if we clarify that pharmacy data does not include rejected transactions?
Last updated: Apr 12 2022 at 19:14 UTC
