00

M/I means Missing/Invalid

01

M/I BIN

02

M/I Version Number

03

M/I Transaction Code

04

M/I PCN

05

M/I Pharmacy Number

06

M/I Group Number

07

M/I Cardholder ID Number

08

M/I Person Code

09

M/I DOB

10

M/I Patient Gender Code

11

M/I Patient Relationship Code

12

M/I Patient Location

13

M/I Other Coverage Code

14

M/I Eligibility Clarification Code

15

M/I DOS

16

M/I Prescription/Service Reference Number

17

M/I Fill Number

18

M/I Metric Quantity

19

M/I Days’ Supply

1C

M/I Smoker/Non-Smoker Code

1E

M/I Prescriber Location Code

20

M/I Compound Code

21

M/I NDC Number

22

M/I DAW Code/Product Selection Code

23

M/I Ingredient Cost Submitted

24

M/I Sales Tax

25

M/I Prescriber ID

26

M/I Unit of Measure

27

(Future Use) M/I Amount Due (V1.0 only)

28

M/I Date Prescription Written

29

M/I Number Refills Authorized

2C

M/I Pregnancy Indicator

2E

M/I Primary Care Provider

30

M/I PA/MC Code and Number

31

(Future Use)

32

M/I Level of Service

33

M/I Prescription Origin Code

34

M/I Submission Clarification Code

35

M/I Primary Care Provider ID

36

M/I Clinic ID

37

(Future Use)

38

M/I Basis of Cost

39

M/I Diagnosis Code

3A

M/I Request Type

3B

M/I Request Period Date-Begin

3C

M/I Request Period Date-End

3D

M/I Basis of Request

3E

M/I Authorized Representative First Name

3F

M/I Authorized Representative Last Name

3G

M/I Authorized Representative Street Address

3H

M/I Authorized Representative City Address

3J

M/I Authorized Representative State/Province Address

3K

M/I Authorized Representative Zip/Postal Zone

3M

M/I Prescriber Phone Number

3N

M/I Prior Authorized Number Assigned

3P

M/I Authorization Number

3R

Prior Authorization Not Required

3S

M/I Prior Authorization Supporting Documentation

3T

Active Prior Authorization Exists Resubmit an Expiration of PA

3W

Prior Authorization in Process

3X

Authorization Number Not Found

3Y

Prior Authorization Denied

40

Pharmacy not contracted with plan on DOS

41

Submit bill to other processor or primary payer

42 – 49

(Future Use)

4C

M/I COB/Other Payments Count

4E

M/I Primary Care Provider Last Name

50

Non-Matched Pharmacy Number

51

Non-Matched Group Number

52

Non-Matched Cardholder ID

53

Non-Matched Person Code

54

Non-Matched Product/Service ID Number

55

Non-Matched Product Package Size

56

Non-Matched Prescriber ID

57

Non-Matched PA/MC Number

58

Non-Matched Primary Prescriber

59

Non-Matched Clinic ID

5C

M/I Other Payer Coverage Type

5E

M/I Other Payer Reject Count

60

Product/Service Not Covered For Patient Age

61

Product/Service Not Covered For Patient Gender

62

Patient/Card Holder ID Name Mismatch

63

Institutionalized Patient Product/Service ID Not Covered

64

Claim Submitted Does Not Match Prior Authorization

65

Patient is Not Covered

66

Patient Age Exceeds Maximum Age

67

Filled Before Coverage Effective

68

Filled After Coverage Expired

69

Filled After Coverage Terminated

6C

M/I Other Payer ID Qualifier

6E

M/I Other Payer Reject Code

70

Product/Service Not Covered

71

Prescriber is Not Covered

72

Primary Prescriber is Not Covered

73

Refills are Not Covered

74

Patient Pays Exceeds Payable

75

Prior Authorization Required

76

Plan Limitations Exceeded

77

Discontinued Product/Service ID Number

78

Cost Exceeds Maximum

79

Refill-Too-Soon

7C

M/I Other Payer ID

7E

M/I DUR/Prospective Payment System (PPS) Code Counter

80

Drug-Diagnosis Mismatch

81

Claim Too Old

82

Claim is Post-Dated

83

Duplicate Paid/Captured Claim

84

Claim Has Not Been Paid/Captured

85

Claim Not Processed

86

Submit Manual Reversal

87

Reversal Not Processed

88

DUR Reject Error

89

Rejected Claim Fees Paid

8C

M/I Facility ID

8E

M/I DUR/PPS Level of Effort

90

Host Hung Up (Host disconnected before session completed)

91

Host Response Error (Response not in appropriate format to be displayed)

92

System Unavailable/Host Unavailable (Processing host did not accept transaction/did not respond within time-out period)

93

Planned Unavailable (Transmission occurred during scheduled down time)

94

Invalid Message (Transaction not decipherable)

95

Time-Out

96

Scheduled Downtime

97

Payer Unavailable

98

Connection to Payer is Down

99

Host Processing Error

A9

M/I Transaction Count

AA

Patient Spenddown Not Met

AB

Date Written Is After Date Filled

AC

Product Not Covered Non-Participating Manufacturer

AD

Billing Provider Not Eligible to Bill This Claim Type

AE

OMB (Qualified Medicare Beneficiary) – Bill Medicare

AF

Patient Enrolled Under Managed Care

AG

Days’ Supply Limitation For Product/Service

AH

Unit Dose Packaging Only Payable for Nursing Home Recipients

AJ

Generic Drug Required

AK

M/I Software Vendor/Certification ID

B2

M/I Service Provider ID Qualifier

BE

M/I Professional Service Fee Submitted

CA

M/I Patient’s First Name

CB

M/I Patient’s Last Name

CC

M/I Cardholder’s First Name

CD

M/I Cardholder’s Last Name

CE

M/I Home Plan

CF

M/I Employer Name

CG

M/I Employer Street Address

CH

M/I Employer City Address

CI

M/I Employer State/Province Address

CJ

M/I Employer Zip/Postal Zone

CK

M/I Employer Phone Number

CL

M/I Employer Contact Name

CM

M/I Patient Street Address

CN

M/I Patient City Address

CO

M/I Patient State/Province Address

CP

M/I Patient Zip/Postal Zone

CQ

M/I Patient Phone Number

CR

M/I Carrier ID

CT

M/I Patient Social Security Number

CW

M/I Alternate ID

CX

M/I Patient ID Qualifier

CY

M/I Patient ID

CZ

M/I Employer ID

DC

M/I Dispensing Fee Submitted

DN

M/I Basis Of Cost Determination

DP

M/I Drug Type Override

DQ

M/I U&C

DR

M/I Prescriber Last Name

DS

M/I Postage Amount Claimed

DT

M/I Unit Dose Indicator

DU

M/I Gross Amount Due

DV

M/I Other Payer Amount Paid

DW

M/I Basis of Days’ Supply Determination

DX

M/I Patient Paid Amount Submitted

DY

M/I Date of Injury

DZ

M/I Claim/Reference ID Number

E1

M/I Product/Service ID Qualifier

E2

M/I Alternate Product Code

E3

M/I Incentive Amount Submitted

E4

M/I Reason For Service Code

E5

M/I Professional Service Code

E6

M/I Result of Service Code

E7

M/I Quantity Dispensed

E8

M/I Other Payer Date

E9

M/I Provider ID

EA

M/I Originally Prescribed Product/Service Code

EB

M/I Originally Prescribed Quantity

EC

M/I Compound Ingredient Component Count

ED

M/I Compound Ingredient Quantity

EE

M/I Compound Ingredient Drug Cost

EF

M/I Compound Dosage Form Description Code

EG

M/I Compound Dispensing Unit Form Indicator

EH

M/I Compound Route of Administration

EJ

M/I Originally Prescribed Product/Service ID Qualifier

EK

M/I Scheduled Prescription ID Number

EM

M/I Prescription/Service Reference Number

EN

M/I Associated Prescription/Service Reference Number

EP

M/I Associated Prescription Service Date

ET

M/I Quantity Prescribed

EU

M/I Prior Authorization Type Code

EV

M/I Prior Authorization Number Submitted

EW

M/I Intermediary Authorization Type ID

EX

M/I Intermediary Authorization ID

EY

M/I Provider ID Qualifier

EZ

M/I Prescriber ID Qualifier

FO

M/I Plan ID

GE

M/I Percentage Sales Tax Amount Submitted

H1

M/I Measurement Time

H2

M/I Measurement Dimension

H3

M/I Measurement Unit

H4

M/I Measurement Value

H5

M/I Primary Care Provider Location Code

H6

M/I DUR Co-Agent ID

H7

M/I Other Amount Claimed Submitted Count

H8

M/I Other Amount Claimed Submitted Qualifier

H9

M/I Other Amount Claimed Submitted

HA

M/I Flat Sales Tax Amount Submitted

HB

M/I Other Payer Amount Paid Count

HC

M/I Other Payer Amount Paid Qualifier

HD

M/I Dispensing Status

HE

M/I Percentage Sales Tax Rate Submitted

HF

M/I Quantity Intended To Be Dispensed

HG

M/I Days’ Supply Intended To Be Dispensed

J9

M/I DUR Co-Agent ID Qualifier

JE

M/I Percentage Sales Tax Basis Submitted

KE

M/I Coupon Type

M1

Patient Not Covered in this Aid Category

M2

Recipient Locked In

M3

Host PA/MC Error

M4

Prescription Number/Tune Limit Exceeded

M5

Requires Manual Claim

M6

Host Eligibility Error

M7

Host Drug File Error

M8

Host Provider File Error

ME

M/I Coupon Number

MZ

Error Overflow

NE

M/I Coupon Value Amount

NN

Transaction Rejected at Switch or Intermediary

P1

Associated prescription/Service Reference Number Not Found

P2

Clinical Information Counter Out of Sequence

P3

Compound Ingredient Component Count Does Not Match Number of Repetitions

P4

COB/Other Payments Count Does Not Match Number of Repetitions

P5

Coupon Expired

P6

DOS Prior to DOB

P7

Diagnosis Code Count Does Not Match Number of Repetitions

P8

DUR/PPS Code Counter Out of Sequence

P9

Filed is Non-Repeatable

PA

PA Exhausted/Not Renewable

PB

Invalid Transaction Count For This Transaction Code

PV

Non-Matched Associated Prescription/Service Date

PW

Non-Matched Employer ID

PX

Non-Matched Other Payer ID

PY

Non-Matched Unit Form/Route of Administration

PZ

Non-Matched Unit Of Measure to Product/Service ID

R1

Other Amount Claimed Submitted Count Does Not Match Number of Repetitions

R2

Other Payer Reject Count Does Not Match Number of Repetitions

R3

Procedure Modifier Code Count Does Not Match Number of Repetitions

R4

Procedure Modifier Code Invalid For Product/Service ID

R5

Product/Service ID Must Be Zero When Product/Service ID Qualifier Equals 06

R6

Product/Service Not Appropriate For This Location

R9

Value in Gross Amount Due Does Not Follow Pricing Formula

RA

PA Reversal Out of Order

RB

Multiple Partials Not Allowed

RC

Different Drug Entity Between Partial and Completion

RD

Mismatched Cardholder/Group ID-Partial to Completion

RE

M/I Compound Product ID Qualifier

RF

Improper Order of “Dispensing Status” Code on Partial Fill Transaction

RG

M/I Associated Prescription/Service Reference Number on Completion Transaction

RH

M/I Associated Prescription/Service Date on Completion Transaction

RJ

Associated Partial Fill Transaction Not on File

RK

Partial Fill Transaction Not Supported

RM

Completion Transaction Not Permitted With Same “Date of Service” As Partial Transaction

RN

Plan Limits Exceeded on Intended Partial Fill Values

RP

Out of Sequence ‘P’ Reversal on Partial Fill Transaction

RS

M/I Associated Prescription/Service Date on Partial Transaction

RT

M/I Associated Prescription/Service Reference Number on Partial Transaction

RU

Mandatory Data Elements Must Occur Before Optional Data Elements in a Segment

SE

M/I Procedure Modifier Code Count

TE

M/I Compound Product ID

UE

M/I Compound Ingredient Basis of Cost Determination

VE

M/I Diagnosis Code Count

WE

M/I Diagnosis Code Qualifier

XE

M/I Clinical Information Counter

ZE

M/I Measurement Date