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WV MMIS MedicaidHealth PAS-Rx Help Desk HintsWest Virginia Medicaid Health PAS-RxHelp Desk HintsDate of Publication: 02/24/2022Document Version: 1.77
WV MMIS MedicaidHealth PAS-Rx Help Desk HintsPrivacy and Security RulesThe Health Insurance Portability and Accountability Act of 1996 (HIPAA – Public Law 104191) and the HIPAA Privacy Final Rule1 and the American Recovery and Reinvestment Act(ARRA) of 2009 requires that covered entities protect the privacy and security of individuallyidentifiable health information.Protected health information (PHI) includes demographic information and other healthinformation and confidential information, whether verbal, written, or electronic, created,received, or maintained by Gainwell Technologies about members and patients. It is healthcaredata plus identifying information that would allow the data to tie the medical information to aparticular person. PHI relates to the past, present, and future physical or mental health of anyindividual or recipient; the provision of healthcare to an individual; or the past, present, or futurepayment for the provision of healthcare to an individual. Claims data, prior authorizationinformation, and attachments such as medical records and consent forms are all PHI.145 CFR Parts 160 and 164, Standards for Privacy of Individually Identifiable Health Information; Final RuleProprietary and ConfidentialPage 2 of 74 2020 Gainwell Technologies. All rights reserved.
WV MMIS MedicaidHealth PAS-Rx Help Desk HintsDisclaimerThis document and information contains proprietary information.Authorization is hereby provided to you to copy documents published by Gainwell Technologieson the Health PAS-OnLine portal provided such copies are used for non-commercial purposesand solely for use within your organization. This authorization is specifically conditioned uponincluding all legends, copyright, proprietary, and other notices that appear herein on all copiesyou make of such documents whether they pertain to Gainwell Technologies or another party.No license is granted herein expressly, impliedly, by estoppel or otherwise under any patent or touse any trademark of any party. No other rights under any copyrights are granted herein, exceptas expressly stated above.The documents herein may refer to products and/or services that are neither available norplanned for availability in your particular locality. In referring to such products and/or services,Gainwell Technologies incurs no obligation to subsequently make them available in yourlocality.DOCUMENTS PUBLISHED HEREIN ARE FURNISHED TO YOU “AS IS.” THERE ARENO WARRANTIES, EXPRESS, OR IMPLIED, BY OPERATION OF LAW OR OTHERWISE.GAINWELL TECHNOLOGIES DISCLAIMS THE IMPLIED WARRANTIES OFMERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND NONINFRINGEMENT AS TO BOTH GAINWELL TECHNOLOGIES AND NON-GAINWELLTECHNOLOGIES DOCUMENTS FURNISHED HEREIN.Some states or territories do not allow the exclusion of implied warranties and the foregoingexclusions may not be applicable to you. Any communication provided by you to GainwellTechnologies relating to the documents furnished herein by Gainwell Technologies will bereceived only on a non-confidential basis. There shall be no obligation on the part of GainwellTechnologies with respect to use or disclosure of any information in such communication.Gainwell Technologies shall have the unrestricted right to copy, use, and distribute anyinformation you communicate including but not limited to any ideas, concepts, know-how,techniques, software, documentation, diagrams, schematics, or blueprints.Additionally, Gainwell Technologies may use all such information in any manner or for anypurpose including but not limited to developing products or providing services.The documents furnished herein by Gainwell Technologies are subject to change without notice.All brand names and product names are acknowledged to be the trademarks or registeredtrademarks of their respective owners.Proprietary and ConfidentialPage 3 of 74 2020 Gainwell Technologies. All rights reserved.
WV MMIS MedicaidHealth PAS-Rx Help Desk HintsRevision HistoryVersionDateAuthorN/AAction/Summary of ChangesInitial 4.7 SubmissionStatus1.0N/A1.105/08/2006 K. OlsonMinor certification changes – CR327Draft1.209/01/2006 K. WolffUpdate translator edits – CR334Draft1.303/21/2007 K. OlsonAdded edit 7232 – CR436Draft1.404/04/2007 K. OlsonAdded NPI updates – CR461Draft1.505/07/2007 K. OlsonAdded edit 7235 – CR420Draft1.610/23/2007 K. OlsonRetire edits 7500 and 7145;updates to edits 7095 and 7216.Draft1.703/11/2008 K. OlsonAdded edit 7236 – CR543Draft1.806/03/2008 K. OlsonAdded edits 7237 & 7238 –CR607Draft1.908/13/2008 D. ThomasDelivered to BMSDraft1.1011/12/2008 K. OlsonEdits 7237 & 7238 to Deny –DT600Draft1.1112/10/2008 K. OlsonAdded edit 7239 – CR545Draft1.1212/15/2008 K. OlsonAdded edit 7240 – CR62Draft1.1312/15/2008 K. OlsonAdded edit 7241 – CR666Draft1.1406/08/2009 K. OlsonUpdate to edit 7236 – CR723Draft1.1506/24/2009 K. OlsonAdded edit 7242 – CR625Draft1.1606/24/2009 K. OlsonAdded edit 7243 – CR645Draft1.1706/30/2009 K. OlsonUpdate refill count for edit7095/7216 – CR738Draft1.1809/02/2009 K. OlsonNew/revised DUR compoundedits – CR727Draft1.1909/16/2009 K. OlsonNew/revised DUR PG edits –CR702Draft1.2009/29/2009 K. OlsonAdded edit 7253 – CR756Draft1.2103/31/2010 K. OlsonNew compound edits – CR499Draft1.2206/14/2010 W. EballarMolina BrandingDraft1.2306/17/2010 K. OlsonUpdate to edit 7011 – CR829Draft1.2407/20/2010 K. OlsonNew/updated TPL edits – CR567 DraftProprietary and ConfidentialApprovalPage 4 of 74 2020 Gainwell Technologies. All rights reserved.
WV MMIS MedicaidHealth PAS-Rx Help Desk HintsVersionDateAuthorAction/Summary of ChangesStatus1.2507/20/2010 K. OlsonAdd edit 217 – CR817Draft1.2607/21/2010 K. OlsonAdd edit 7257 – CR792Draft1.2708/23/2010 K. OlsonUpdate edit 7231 – CR842Draft1.2809/13/2010 K. OlsonNew edit 7262 – CR843Draft1.2911/08/2010 K. OlsonUpdate edit 7235 – CR860Draft1.3011/08/2010 K. OlsonUpdate edit 199 – CR856Draft1.3111/08/2010 K. OlsonAdd edits 7248 and 7249 – CR856 Draft1.3203/10/2011 R. ObispoUpdates for D.0Draft1.3308/16/2011 A. BellUpdate edit 7097 – CR918Draft1.3408/10/2012 M. ParentAdd edits 7263-7279 – CR925Draft1.3511/27/2012 M. ParentUpdate edit 7045, 7189-90, 7258Draft1.3602/01/2013 M. ParentUpdate edit 7240Draft1.3704/22/2013 M. ParentAdd edits 7281 & 7283Draft1.3805/31/2013 M. ParentAdd edit 7282Draft1.3908/09/2013 M. ParentUpdate edit 7258, add edits 7284& 7285Draft1.4009/13/2013 M. ParentBack out previous update to edit7258Draft1.4108/31/2015 David RoyseUpdated for 5.0Draft1.4209/02/2015 Susan Savage-McGuckin QA Mgmt. Review1.4308/12/2016 Kim StoudenmireUpdated based on comment logfrom the StateDraft1.4409/08/2016 Dave ThomasUpdated based on comment logfrom the StateDraft1.4509/09/2016 Kim StoudenmireQA review of updatesDraft1.4610/25/2016 Dave ThomasRQMS6724: Added edits 7286 – Draft7290 and 7501 – 7512.1.4710/25/2016 Kim StoudenmireQA review of updates for CR6724Draft1.4804/10/2017 David ThomasRQMS6724 –Updated thedescription and hint to includereactivation logic for edits 7107and 7161.DraftProprietary and ConfidentialDraftPage 5 of 74 2020 Gainwell Technologies. All rights reserved.
WV MMIS MedicaidHealth PAS-Rx Help Desk HintsVersionDateAuthorAction/Summary of ChangesStatus1.4908/01/2017 David ThomasRQMS6724 and RQMS15206 –Change the description of Edits7155 and 7241Draft1.5008/01/2017 Luigi BalducciQA review of descriptions andhints for edits 7107, 7161, 7155and 7241Draft1.5108/24/2017 David ThomasRQMS6724 and RQMS15206 –Change the description of Edit7155Draft1.5208/25/2017 Luigi BalducciQA review of edit 7155description change per RQMS6724 and 15206Draft1.5310/23/2017 David ThomasRQMS6724 – Add Edit 7513 and Draft75141.5410/23/2017 Luigi BalducciQA Review of RQMS6724 –Added Edit 7513 and 75141.5512/06/2017 David ThomasRQMS17420 and RQMS17171 – DraftAdded Edits 7515 and 75161.5612/07/2017 Luigi BalducciQA review of RQMS17420 andDraftRQMS17171 – Added Edits 7515and 75161.5712/14/2017 David ThomasRQMS17420 and RQMS17171 – DraftModify description of edits 7018and 7169.1.5812/15/2017 Luigi BalducciQA of RQMS17420 andDraftRQMS17171 –Modify descriptionof edits 7018 and 7169.1.5901/15/2018 David ThomasRQMS17171 and RQMS17172 – DraftChange age of edit 7287 and adddrug classes to edit 75161.6001/17/2018 Luigi BalducciQA of RQMS17171 andDraftRQMS17172 – Change age of edit7287 and add drug classes to edit75161.6105/01/2018 David ThomasRQMS17524 – Added edit 7517Draft1.6205/09/2018 Luigi BalducciQA Review of RQMS17524 –Added edit 7517Draft1.6308/14/2018 David ThomasRQMS17219 – Added sentence to Draft7240. Changed title to 7517Proprietary and ConfidentialDraftPage 6 of 74 2020 Gainwell Technologies. All rights reserved.
WV MMIS MedicaidHealth PAS-Rx Help Desk HintsVersionDateAuthorAction/Summary of ChangesStatus1.6408/15/2018 Kim StoudenmireQA review of updates forCR17219.Draft1.6511/26/2018 Katie BanikGAINWELL RebrandingDraft1.6611/27/2018 Kim StoudenmireQA of GAINWELL RebrandingDraft1.6702/08/2019 Kim StoudenmireFixed some Rebranding issuesDraft1.6806/03/2020 David ThomasRQMS 30648 – Added edits 7518 Draftand 75201.6906/08/2020 Tisjauna PalmerQA review of updates for CR306481.7008/21/2020 David ThomasRQMS 31363 – Added edits 7521 Draft– 7527.1.7108/27/2020 Kim StoudenmireQA review of updates for CR313631.7209/21/2020 David ThomasRQMS 30648 – Updated theDraftlanguage of edit 7006 because edit7503 we only allow 3 3-dayemergency fills1.7309/21/2020 Kim StoudenmireQA review of updates for CR306481.7401/27/2021 David ThomasRQMS 34976 – Added Edits 7533 Draft- 75431.7501/27/2021 David ThomasGainwell Rebranding – ReplacedDXC with Gainwell, logoincluded.1.7602/10/2022 David ThomasRQMS 37913 – Added edits 7546 Draft– 7550, and 7370.DraftDraftDraftDraftRQMS 34249 – Added edits 7528– 7532, and 75441.7702/24/2022 Kim StoudenmireQA review of changes andrebrandingProprietary and ConfidentialDraftPage 7 of 74 2020 Gainwell Technologies. All rights reserved.
WV MMIS MedicaidHealth PAS-Rx Help Desk HintsTable of Contents1. INTRODUCTION . 182. EDIT RULES/DESCRIPTION/HELP DESK HINTS . 18Edit 101 – No Active Provider Contract . 18Edit 104 – Incomplete Provider . 18Edit 108 – Un-credentialed Provider . 18Edit 149 – Benefit does NOT meet date criteria on claim . 18Edit 150 – No Contract Term Found for Service . 18Edit 152 – Provider Type Does Not Match Required Type Required by Benefit . 18Edit 155 – Benefit Has Age Restriction . 18Edit 156 – Provider Type Does Not Match Type Required by Contract Term . 19Edit 172 – Term Does Not meet the Date Criteria of the Claim. 19Edit 199 – Benefit Rider Not Valid for Member DOS . 19Edit 202 – No Benefit for Service. 19Edit 205 – Benefit Requires Authorization . 19Edit 217 – Member May Be Incarcerated . 19Edit 272 – No Benefit For Service . 19Edit 7001 – No Copay for Children . 19Edit 7002 – No Copay for Pregnant Member . 20Edit 7004 – No Copay for Member in Nursing Home or ICF . 20Edit 7005 – No Copay for Family Planning . 20Edit 7006 – No Copay for 3 Day Emergency Supply . 20Edit 7007 – Medicare eligible; file Medicare first . 20Edit 7009 – Date Written is After Date Filled . 20Edit 7010 – Usual and Customary Charge Missing/Invalid format . 21Edit 7011 – Submit to Other Payer First . 21Edit 7012 – Claim Too Old to File . 21Edit 7013 – Claim Too Old to Reverse . 21Edit 7018 – Need Therapeutically Equivalent Generic Drug – for Non-Compound Drug . 21Edit 7019 – Date Prescription Written Missing or Invalid . 22Edit 7020 – Claim is Post-Dated . 22Proprietary and ConfidentialPage 8 of 74 2020 Gainwell Technologies. All rights reserved.
WV MMIS MedicaidHealth PAS-Rx Help Desk HintsEdit 7021 – No Product ID on Transaction . 22Edit 7024 – Missing or Invalid Days Supply . 22Edit 7025 – Missing or Invalid Quantity Dispensed . 22Edit 7026 – Quantity Dispensed Exceeds Maximum Allowed . 22Edit 7028 – Compound Indicated but no Compound Segment . 23Edit 7032 – Missing or Invalid Compound Route of Administration . 23Edit 7034 – Compound Ingredient Component Count Exceeds Maximum . 23Edit 7035 – Missing or Invalid Claim Segment. 23Edit 7039 – Missing or Invalid Compound Product ID Qualifier . 23Edit 7040 – Missing or Invalid Compound Product ID . 23Edit 7041– Invalid Other Coverage Code . 24Edit 7043 – Missing or Invalid Prescriber ID Qualifier . 24Edit 7044 – Missing or Invalid Coordination of Benefits/Other Payment Counts . 24Edit 7045 – Missing or Invalid Other Payer Coverage Type. 24Edit 7046 – Verify Other Payer Reject Code is Valid NCPDP Code . 25Edit 7047 – Missing Prescriber ID. 25Edit 7048 – Missing or Invalid Other Payer Amount Paid . 25Edit 7050 – Other Payer Reject Count Does not match Number of Repetitions . 25Edit 7051 – Missing or Invalid Other Payer Date. 26Edit 7054 – COB - Hospice Patient, so Hospice is primary payer . 26Edit 7056–Invalid Transaction Count for Compounds . 26Edit 7057–Missing or Invalid Transaction Count . 26Edit 7060 – Missing or Invalid Compound Ingredient Drug Cost. 26Edit 7062– Non-Matched Unit of Measure to NDC – for Non-Compound Drug . 27Edit 7064– Non Matching Birth Date . 27Edit 7067 – Rx DUR DD Severity 1 . 27Edit 7068 – Rx DUR DD Severity 3 thru 5 . 27Edit 7069 – Rx DUR TD Severity 1 . 28Edit 7070 – Rx DUR TD Severity 3 thru 5 . 28Edit 7071 – Rx DUR ID Severity 1 . 28Edit 7072 – Rx DUR ID Severity 3 thru 5 . 29Edit 7073 – Rx DUR ER Severity 1 . 29Edit 7074 – Rx DUR ER Severity 3 thru 5 . 29Proprietary and ConfidentialPage 9 of 74 2020 Gainwell Technologies. All rights reserved.
WV MMIS MedicaidHealth PAS-Rx Help Desk HintsEdit 7075 – Rx DUR LR Severity 1 . 29Edit 7076 – Rx DUR LR Severity 3 thru 5 . 30Edit 7077 – Rx DUR PG Severity 1 – Member is Pregnant . 30Edit 7078 – Rx DUR SX Severity 1 thru 3 . 30Edit 7079 – Rx DUR HD Event . 31Edit 7080 – Rx DUR LD Event . 31Edit 7081 – Rx DUR MX Event . 31Edit 7082 –Invalid DUR/PPS Code Counter . 31Edit 7085 –Missing or Invalid Version Number. 32Edit 7086 –Missing or Invalid Transaction Code . 32Edit 7087 –Missing or Invalid Processor Control Code . 32Edit 7091 –Prescribing physician is not on file . 32Edit 7092 –Product/Service Not Covered – DESI – for Non-Compound Drug . 32Edit 7093 – Non Numeric DUR/PPS Code Counter . 33Edit 7094 – Invalid Step Therapy NDC . 33Edit 7095 – Invalid Number of Refills . 33Edit 7096– Invalid Product/Service ID Qualifier for Pharmacy . 33Edit 7097– Days Supply Exceeds Max for 3 Day Emergency Supply . 34Edit 7100 – Original Claim Not Found for Reversal . 34Edit 7101 – Dispensing fee for Nursing Home . 34Edit 7102 – Date of Service less than (LT) Date of Birth . 34Edit 7103 – Date of Service greater than (GT) Date of Death. 35Edit 7106 – Product/Service Not Covered – Categorically Removed – for Non-CompoundDrug . 35Edit 7107– Product/Service Not Covered – Lot Terminated – for Non-Compound Drug . 35Edit 7109– Product/Service Not Covered – NDC Not Activated – for Non-Compound Drug 35Edit 7111–Product/Service Not Covered –Gender Check . 36Edit 7112 – Processing cannot be Completed. 36Edit 7116– Pre-Natal Vitamin Checks . 36Edit 7117– Missing DUR/PPS segment for DUR Override . 36Edit 7118 – Invalid Product/Service ID value for DUR Override . 36Edit 7119 – Limited Pharmacy Services - Claim Too Old to File . 37Edit 7121 –Recipient is Locked In. 37Proprietary and ConfidentialPage 10 of 74 2020 Gainwell Technologies. All rights reserved.
WV MMIS MedicaidHealth PAS-Rx Help Desk HintsEdit 7122– No Copay for Diabetic Supplies. 37Edit 7124 – Missing or Invalid Prescriber Segment . 37Edit 7125 – Invalid Product/Service ID value for Compound Drug . 37Edit 7126– Invalid Product/Service ID Qualifier value for Compound Drug . 37Edit 7127 – Medicare eligible; not enrolled . 38Edit 7130–Partial Fill Transaction Not Supported. 38Edit 7131 –Provider not active for Plan on DOS . 38Edit 7134 – Scheduled Drug Claim Refill Too Old to File . 38Edit 7135– Invalid Service Provider ID Qualifier . 38Edit 7136 – Claim Date Written is Post-Dated . 39Edit 7137 – Member not eligible on DOS . 39Edit 7138 – No Product ID Qualifier on Transaction for DUR Override . 39Edit 7139 – Invalid Professional Service Code – DUR OVR . 39Edit 7140– Invalid Reason for Service Code – DUR OVR . 39Edit 7141– Invalid Result of Service Code – DUR OVR . 40Edit 7142– Days Supply Exceeds Max for 3-Day Emergency Supply for Compound Drug . 40Edit 7143– Invalid Time Span for Refills . 40Edit 7146 – Scheduled Drug Claim Too Old to File for Compound Drugs . 40Edit 7147 – For Non-Compound Drug Claim – No Vacation Supply allowed for ScheduledDrugs (IGNORE) . 41Edit 7148 – For Non-Compound Drug Claim – No Lost Script Supply allowed for ScheduledDrugs . 41Edit 7149– Invalid Product/Service ID Qualifier for Reversals . 41Edit 7151 – For Compound Scheduled Drug Claim – No Vacation Supply allowed (IGNORE). 41Edit 7152 – For Compound Scheduled Drug Claim – No Lost Script Supply allowed(IGNORE) . 42Edit 7154 – For Non-Compound Drug Claim, Invalid Vacation Supply for Non-Scheduleddrugs (IGNORE) . 42Edit 7155 – For All Drug Claims, MaxRxDays limitation of Days Supply check . 42Edit 7156 – Missing or Invalid Ingredient Cost Submitted . 42Edit 7157 – Compound Drug requires 1 Legend NDC. 42Edit 7158 – No Copay for Limited Pharmacy Services . 43Edit 7159 –Compound Drug requires more than 1 Ingredient . 43Proprietary and ConfidentialPage 11 of 74 2020 Gainwell Technologies. All rights reserved.
WV MMIS MedicaidHealth PAS-Rx Help Desk HintsEdit 7160 – Product/Service Not Covered – Categorically Removed on Compound DrugIngredient . 43Edit 7161 – Product/Service Not Covered – Lot Terminated for Compound Drug . 43Edit 7162 – Product/Service Not Covered – NDC Not Activated for Compound Drug . 43Edit 7166 – No Drug Rebate Agreement exists for this NDC – for Compound Drug . 44Edit 7167 – Product/Service Not Covered – DESI – for Compound Drug . 44Edit 7169 – Need Therapeutically Equivalent Generic Drug – for Compound Drug . 44Edit 7170 – Rx DUR DD Severity 1 or 2 – for Compound Secondary Occurrences . 44Edit 7171 – Rx DUR TD Severity 1 – for Compound Secondary Occurrences . 45Edit 7172 – Rx DUR ID Severity 1 – for Compound Secondary Occurrences . 45Edit 7173 – Rx DUR ER Severity 1 – for Compound Secondary Occurrences . 45Edit 7174 – Rx DUR LR Severity 1 or 2 – for Compound Secondary Occurrences . 45Edit 7175 – Rx DUR HD Event – for Compound Secondary Occurrences . 46Edit 7176 – For Non-Scheduled Compound Drug, Invalid Vacation Supply (IGNORE). 46Edit 7178 – Member not found . 46Edit 7179 – Rx DUR Stopped Processing so Not Performed . 46Edit 7180 – Secondary DESI Ingredient Reimburse at zero for Compound Drug . 46Edit 7181 – Non-Rebateable Secondary Ingredient Reimburse at zero for Compound Drug . 46Edit 7184 – Refill not allowed as too soon (IGNORE) . 47Edit 7185 – Missing or Invalid Birth Date. 47Edit 7187 –User Max Units limitation Exceeded . 47Edit 7189 – Submission Clarification Code so turn off Rx DUR processing (Ignore) . 47Edit 7190 – No price available on NDC tables for drug . 47Edit 7191 – After COB calculation reimbursement amount is 0.00 . 48Edit 7192 – Lost/Stolen Prescriptions - Exceeds Days Supply Allowed (IGNORE) . 48Edit 7193 – Batch Claim Verification . 48Edit 7194 – Medicare eligible; file Medicare first – For compound drugs . 48Edit 7195 – Missing Prior Authorization Number Submitted . 49Edit 7196 –User Sum of quantity dispensed within script time span exceeds limits . 49Edit 7197 – Submission of Claim on Paper is required . 49Edit 7198 – No units remaining on PA . 49Edit 7199 – Insufficient units remaining on PA . 49Edit 7200 – Claim DOS too old to file . 50Proprietary and ConfidentialPage 12 of 74 2020 Gainwell Technologies. All rights reserved.
WV MMIS MedicaidHealth PAS-Rx Help Desk HintsEdit 7202 – Rx DUR DD Severity 2 . 50Edit 7203– Rx DUR TD severity 2 . 50Edit 7204– Rx DUR ID severity 2 . 50Edit 7205– Rx DUR ER severity 2 . 51Edit 7206 – Rx DUR LR severity 2 . 51Edit 7208 – Insulin User Max Units limitations .
WV MMIS Medicaid Health PAS-Rx Help Desk Hints West Virginia Medicaid Health PAS-Rx Help Desk Hints Date of Publication: 02/24/2022
