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Copy pathSQLCreate_tbl_PDE_Edit.sql
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SQLCreate_tbl_PDE_Edit.sql
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SET ANSI_NULLS ON
GO
SET QUOTED_IDENTIFIER ON
GO
SET ANSI_PADDING ON
GO
CREATE TABLE [dbo].[tbl_PDE_Edit](
[Edit Code] [varchar](50) NULL,
[IAP] [varchar](50) NULL,
[Edit Category] [varchar](50) NULL,
[Data Element to be Edited] [varchar](64) NULL,
[Explanation] [varchar](512) NULL,
[Edit Resolution] [varchar](512) NULL,
[Detailed Resolution] [varchar](max) NULL
) ON [PRIMARY] TEXTIMAGE_ON [PRIMARY]
GO
SET ANSI_PADDING OFF
GO
/* Populate the table */
Insert Into dbo.tbl_PDE_Edit "126", "", "", "", "Record ID is missing or invalid", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "127", "", "", "", "HDR record is out of sequence. HDR record is not first record in file or does not follow a TLR record.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "128", "", "", "", "Check file has a Submitter ID in the header", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "129", "", "", "", "Submitter ID is not on file", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "130", "", "", "", "Submitter ID is not certified to submit Production data.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "131", "", "", "", "Check file has File ID in the header", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "132", "", "", "", "The file ID is a duplicate of another file that was accepted in the last 12 months.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "133", "", "", "", "Check file has transaction ID and is not in the future in the header", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "134", "", "", "", "File type must be PROD/TEST/CERT and not be missing in the header", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "176", "", "", "", "Check that TLR record is not out of sequence. TLR record does not follow a BTR record", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "177", "", "", "", "Submitter ID is missing from the trailer", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "178", "", "", "", "Submitter ID is not equal to the Submitter ID in the HDR record.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "179", "", "", "", "File ID is missing in the trailer", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "180", "", "", "", "File ID is not equal to the file ID in the HDR record", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "181", "", "", "", "TLR record total does not match the total number of batches in the file", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "182", "", "", "", "DET record total on the TLR record is missing or does not match the computed number", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "184", "", "", "", "Production file cannot exceed 3,000,000 records", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "226", "", "", "", "BHD record is out of sequence. BHD record does not follow either a HDR or BTR record.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "227", "", "", "", "Sequence number is missing or invalid. Sequence number cannot be blank or zero. Sequence number must start with a 0000001.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "228", "", "", "", "Sequence number is invalid. Sequence number is out of order.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "229", "", "", "", "Contract number is missing in header.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "230", "", "", "", "Contract number does not match number assigned by CMS.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "231", "", "", "", "Contract number is not active.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "232", "", "", "", "Submitter not authorized to submit for this contract.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "233", "", "", "", "PBP ID is missing.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "234", "", "", "", "PBP is not valid for the contract ID.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "235", "", "", "", "PBP ID is not active. Not authorized to submit production data.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "276", "", "", "", "BTR record is out of sequence. BTR record does not follow a DET record.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "277", "", "", "", "Sequence number is missing or invalid. Sequence number is not numeric.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "278", "", "", "", "Sequence number is not equal to the BHD sequence number.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "279", "", "", "", "Contract number is missing or invalid.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "280", "", "", "", "Contract number does not match the contract number in the BHD record.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "281", "", "", "", "PBP ID is missing.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "282", "", "", "", "PBP ID does not match the PBP in the BHD record.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "283", "", "", "", "DET record on the BTR is missing.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "284", "", "", "", "BTR record does not match the total number of DET records.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "003", "", "", "", "Member Number Was Truncated To Fit Pde.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "601", "", "", "", "DET Record Is Out Of Sequence. Det Record Does Not Follow A BHD Or Another Det Record.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "602", "", "", "", "Sequence Number Is Invalid. Det Sequence Number Is Not Numeric Or Not Equal To The Computed Sequence Number.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "603", "Y", "M/I", "Health Insurance Claim (HIC) Number", "The HICN is missing. Must not be blank", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "604", "Y", "M/I", "Cardholder ID", "The Cardholder ID is missing.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "605", "Y", "M/I", "Patient Date of Birth (DOB)", "The DOB is an invalid date. Dates must be in CCYYMMDD format. DOB is optional. If Plans choose to report DOB, the format must be correct. Matching is done on Month and Year only, Day is disregarded. If no DOB is to be provided, zeros or spaces should be used to populate this field.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "606", "Y", "M/I", "Patient Gender", "The Gender is missing or invalid. The Gender must be either '1' or '2'.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "607", "Y", "M/I", "Date of Service (DOS)", "The DOS is missing or invalid. DOS must be in CCYYMMDD format and be a valid date.", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "608", "Y", "M/I", "Date of Service (DOS)", "The DOS must be on/after 1/1/2006", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "609", "Y", "M/I", "Date of Service (DOS)", "DOS must be on or before today's date.", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "610", "Y", "M/I", "Paid Date", "The Paid Date is missing. Must not be blank for Fallback Plans. Paid Date is optional for non-Fallback Plans. If Paid Date is not provided, zeros or spaces should be used to populate this field.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "611", "Y", "M/I", "Paid Date", "The Paid Date is an invalid date in CCYYMMDD format. If non-Fallback Plans choose to report Paid Date, format must be correct. DDPS will reject all date fields with invalid date format.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "612", "Y", "M/I", "Prescription/ Service Reference Number", "The Prescription Number/Service Reference Number is missing or invalid. Prescription Number/Service Reference Number must be numeric. ", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "613", "Y", "M/I", "Product/ Service ID", "The NDC code is missing.", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "614", "Y", "M/I", "Service Provider ID Qualifier", "The Service Provider ID Qualifier is missing or invalid. Service Provider ID Qualifier must be equal to '01' - NPI or '06' - UPIN or '07' - NCPDP or '08' - State License or '11' - TIN or '99' - Other. Service Provider ID Qualifier must be '01' - NPI or '07' - NCPDP on standard claim.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "615", "Y", "M/I", "Service Provider ID", "The Service Provider ID is missing or invalid. Both NPI and NCPDP numbers are validated", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "616", "Y", "M/I", "Fill Number", "The Fill Number is missing or invalid. The Fill Number must be equal to a value between 0 and 99.", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "617", "Y", "M/I", "Dispensing Status", "The Dispensing Status is invalid. For DOS prior to 1/1/2011, the Dispensing Status must be either a blank or 'P' or 'C'. For DOS 1/1/2011 and forward, the Dispensing Status must be blank.", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "618", "Y", "M/I", "Compound Code", "Compound Code is missing or invalid. The Compound Code must be equal to 0, 1 or 2.", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "619", "Y", "M/I", "DAW/Product Selection Code", "The DAW/Product Selection Code is missing or invalid. The DAW/Product Selection Code must be equal to a value between ‘0’ and ‘9’.", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "620", "Y", "M/I", "Quantity Dispensed", "The Quantity Dispensed is missing or invalid. The Quantity Dispensed must be >=0.001.", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "621", "Y", "M/I", "Days Supply", "The Days Supply is missing or invalid. The value must be a value between 0 and 999 days.", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "622", "Y", "M/I", "Prescriber ID Qualifier", "Prescriber ID Qualifier is missing. Applies only to standard format claims", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "623", "Y", "M/I", "Prescriber ID Qualifier", "Prescriber ID Qualifier is invalid. The Prescriber ID Qualifier must be equal to '01' - NPI or '06' - UPIN or '08' - State License or '12' - DEA. If present, must be a valid value", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "624", "Y", "M/I", "Prescriber ID", "The Prescriber ID is missing. Must not be blank. Applies on all standard format claims and on non-standard format claims when Prescriber ID Qualifier is present and valid.", "Plan provides correct Prescriber ID", ""
Insert Into dbo.tbl_PDE_Edit "625", "Y", "M/I", "Drug Coverage Status Code", "The Drug Coverage Status Code is missing or invalid. Valid values are ‘C’, ‘E’, ‘O’.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "626", "Y", "M/I", "Adjustment/ Deletion Code", "The Adjustment Code is invalid. Valid Values are ‘A’ for Adjustment and ‘D’ for Deletion, or 'blank'.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "627", "Y", "M/I", "Non-Standard Format Code", "The Non-Standard Format Code is invalid. Valid values are ‘blank’, ‘B’, 'C' ‘X’, or ‘P’. Effective November 2011, S (state to plan) is no longer a valid value.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "628", "Y", "M/I", "Pricing Exception Code", "The Pricing Exception Code is invalid. Valid values are ‘blank’, ‘O’, or ‘M’.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "629", "Y", "M/I", "Catastrophic Coverage Code", "The Catastrophic Coverage Code is invalid. Must be Blank, ‘A’, or ‘C’.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "630", "Y", "M/I", "Ingredient Cost Paid", "The Ingredient Cost Paid is missing or invalid. The Ingredient Cost Paid must be >= zero. Total drug cost must always be greater than zero. This requirement also applies to OTC drugs funded by administrative costs.", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "631", "Y", "M/I", "Dispensing Fee Paid", "Dispensing Fee Paid is missing or invalid. Must be >= zero.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "632", "Y", "M/I", "Total Amount Attributed to Sales Tax", "Sales Tax is missing or invalid. Must be >= zero.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "633", "Y", "M/I", "Gross Drug Cost Below Out-Of-Pocket Threshold (GDCB)", "GDCB is missing or invalid. Must be >= zero.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "634", "Y", "M/I", "Gross Drug Cost Above Out-Of-Pocket Threshold (GDCA)", "GDCA is missing or invalid; must be >= zero.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "635", "Y", "M/I", "Patient Pay Amount", "The Patient Pay Amount is missing or invalid. Must be >= zero.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "636", "Y", "M/I", "Other TrOOP Amount", "Other TrOOP Amount is missing or invalid; must be >= zero.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "637", "Y", "M/I", "Low Income Cost-sharing Subsidy Amount (LICS)", "The LICS value is missing or invalid. Must be >= zero.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "638", "Y", "M/I", "Patient Liability Reduction due to Other Payers (PLRO)", "PLRO is missing or invalid. Must be numeric.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "639", "Y", "M/I", "Covered D Plan Paid Amount (CPP)", "CPP is missing or invalid. Must be >= zero. ", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "640", "Y", "M/I", "Non-covered Plan Paid Amount (NPP)", "NPP is missing or invalid. Must be numeric.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "641", "Y", "M/I", "Filler Fields, positions 128-129, 181-182, and 378-512.", "Filler Fields must be blank. Change from filler field positions 125-126 and 308-512 to 128-129, 181-182, and 378-512. Effective for all PDEs submitted 1/1/2011 and forward.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "642", "Y", "M/I", "Non-Standard Format Code, Date of Service", "State-to-Plan PDEs are not allowed with dates of service after March 31, 2006", "State-to-plan editing discontinued in November 2011; edit is obsolete.", ""
Insert Into dbo.tbl_PDE_Edit "643", "Y", "M/I", "Non-Standard Format Code, Date of Service", "State-to-Plan PDEs are not allowed with non-covered drugs.", "State-to-plan editing discontinued in November 2011; edit is obsolete.", ""
Insert Into dbo.tbl_PDE_Edit "644", "Y", "M/I", "Non-Standard Format Code, Service Provider ID Qualifier", "Service Provider ID Qualifier must be '07' for State-to-Plan PDEs.", "State-to-plan editing discontinued in November 2011; edit is obsolete.", ""
Insert Into dbo.tbl_PDE_Edit "645", "Y", "M/I", "Non-Standard Format Code, Service Provider ID Qualifier, Servic", "Service Provider ID '5300378' allowed only for State-to-Plan PDEs.", "State-to-plan editing discontinued in November 2011; edit is obsolete.", ""
Insert Into dbo.tbl_PDE_Edit "646", "Y", "M/I", "Estimated Rebate at Point of Sale", "Estimated Rebate at Point of Sale amount is missing or invalid. For DOS effective January 1, 2008 and forward, must be >= zero. For DOS prior to January 1, 2008, must be zero or spaces.", "N/A", ""
Insert Into dbo.tbl_PDE_Edit "647", "Y", "M/I", "Vaccine Administration Fee", "Vaccine Administration Fee Amount is missing or invalid. For DOS effective January 1, 2008 and forward, must be >= zero. For DOS prior to January 1, 2008, must be zero or spaces.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "648", "Y", "M/I", "Prescription Origin Code", "The Prescription Origin Code is invalid. Valid values are blank, 0, 1, 2, 3, and 4. Edit effective January 2009. For DOS effective January 1, 2010 and forward. This edit only applies to non-standard format PDEs and standard format PDEs for refills (Fill Number not = '00').", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "649", "Y", "M/I", "Prescription Origin Code", "The Prescription Origin Code is invalid. Valid values for original fill standard formats are “1”, “2”, “3”, and “4”. Original fill PDEs are identified as having Fill Number ='00'. This edit only applies to PDEs with DOS effective January 1, 2010 and forward.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "650", "Y", "M/I", "Date Original Claim Received", "The Date Original Claim Received is missing or invalid. For DOS 1/1/2011 and forward, must be a valid date in CCYYMMDD format. Cannot be a future date or less than the Date of Service. For DOS prior to 1/1/2011, must be zeros or spaces. Required on all LI NET PDEs, for any DOS.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "651", "Y", "M/I", "Claim Adjudication Began Timestamp", "The Claim Adjudication Began Timestamp is missing or invalid. For DOS 1/1/2011 and forward, must be a valid timestamp in the CCYY-MM-DD- HH.MM.SS.MMMMMM format. Cannot be a future date or < DOS. For DOS prior to 1/1/2011, must be zeros or spaces.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "652", "Y", "M/I", "Total Gross covered Drug Cost Accumulator", "The Total Gross Covered Drug Cost Accumulator is missing or invalid. For DOS 1/1/2011 and forward, must be >= zero. For DOS prior to 1/1/2011, must be zeros or spaces. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "653", "Y", "M/I", "True Out-of-Pocket Accumulator", "The True Out-of-Pocket Accumulator is missing or invalid. For DOS 1/1/2011 and forward, must be >= zero. For DOS prior to 1/1/2011, must be zeros or spaces. Cannot exceed the program level OOP Threshold. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "654", "Y", "M/I", "Brand/Generic Code", "The Brand/Generic Code is missing or invalid. Valid values are 'B' for brand or 'G' for generic. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "655", "Y", "M/I", "Beginning Benefit Phase", "The Beginning Benefit Phase is missing or invalid. For DOS 1/1/2011 and forward, valid values are 'D' for Deductible, 'N' for Initial Coverage Period, 'G' for Coverage Gap or 'C' for Catastrophic. For DOS prior to 1/1/2011, must be blank. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "656", "Y", "M/I", "Ending Benefit Phase", "The Beginning Benefit Phase is missing or invalid. For DOS 1/1/2011 and forward, valid values are 'D' for Deductible, 'N' for Initial Coverage Period, 'G' for Coverage Gap or 'C' for Catastrophic. For DOS prior to 1/1/2011, must be blank. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "657", "Y", "M/I", "Reported Gap Discount", "The Reported Gap Discount is missing or invalid. Must be >=zero. Conditionally required on PDEs with DOS 1/1/2011 and forward. On PDEs with DOS prior to 1/1/2011, or on PDEs where the Gap Discount does not apply, must be zeros or spaces. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "658", "Y", "M/I", "Tier", "The Tier is missing or invalid. For DOS 1/1/2011 and forward, must be blank or a numeric value from 1-6. For DOS prior to 1/1/2011, must be blank. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "659", "Y", "M/I", "Gap Discount Plan Override Code", "The Gap Discount Plan Override Code is invalid. Must be blank. Future use. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "660", "", "Adj/Del", "Adjustment/ Deletion Code, Contract Number, Plan Benefit Packag", "The Adjustment/Deletion PDE does not match the existing PDE record. Please check the Contract No, PBP ID, HICN, Service Provider ID Qualifier, Service Provider ID, Prescription/Service Reference Number, DOS, Fill Number, and Dispensing Status. All nine (9) fields noted must match the existing PDE record.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "661", "", "Adj/Del", "Adjustment/ Deletion Code, Contract Number, Plan Benefit Packag", "Cannot adjust a deleted record. Existing PDE has already been deleted.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "662", "", "Adj/Del", "Adjustment/ Deletion Code, Contract Number, Plan Benefit Packa", "Existing PDE has already been deleted.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "663", "Y", "Adj/Del", "Adjustment/ Deletion Code, Contract Number, Plan Benefit Packag", "Value of Dispensing Status on adjustment record and the record to be adjusted must be the same. ", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "664", "Y", "Adj/Del", "Adjustment/ Deletion Code, Contract Number, Plan Benefit Packag", "For adjustment or deletion LI-NET PDEs submitted 1/1/2011 and forward, the Date Original Claim Received must equal the Date Original Claim Received submitted on the original. Applies to LI NET only.", "", ""
Insert Into dbo.tbl_PDE_Edit "670", "Y", "Cat Cov", "GDCB, Catastrophic Coverage, True Out-of-Pocket Accumulator", "For DOS prior to 1/1/2011, if Catastrophic Coverage Code = 'blank', GDCB must be greater than zero. For DOS 1/1/2011 and forward, if True Out-of-Pocket Accumulator < OOP Threshold, GDCB must be greater than zero. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "671", "Y", "Cat Cov", "GDCA, Catastrophic Coverage Code, True Out-of-Pocket Accumulato", "For DOS prior to 1/1/2011, if Catastrophic Coverage Code = 'blank', GDCA must be zero. For DOS 1/1/2011 and forward, if (True Out-of-Pocket Accumulator + Patient Pay + Other TrOOP + Reported Gap Discount + LICS ) <= OOP Threshold, GDCA must be zero. Eff 2/24/12 allows GDCA on PDEs in which the TrOOP Accumulator + Patient Pay + Other TrOOP + Reported Gap Discount + LICS = OOP maximum and NPP > 0 and/or PLRO > 0.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "672", "Y", "Cat Cov", "GDCB, Catastrophic Coverage Code", "For DOS prior to 1/1/2011, if Catastrophic Coverage Code is 'A', GDCB must be greater than zero. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "673", "Y", "Cat Cov", "GDCA, Catastrophic Coverage Code", "For DOS prior to 1/1/2011, if Catastrophic Coverage Code is 'C', GDCA must be greater than zero. For DOS 1/1/2011 and forward, if True Out-of-Pocket Accumulator = OOP Threshold, GDCA must be greater than zero. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "674", "Y", "Cat Cov", "GDCB, Catastrophic Coverage Code", "For DOS prior to 1/1/2011, if Catastrophic Coverage Code is 'C', GDCB must be zero. For DOS 1/1/2011 and forward, if True Out-of-Pocket Accumulator = OOP Threshold, GDCB must be zero. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "675", "Y", "Cat Cov", "True Out-of-Pocket Accumulator, Patient Pay, Other TrOOP, Gap D", "On PDE that straddles the Out-of-Pocket threshold where LICS is > than zero, CPP must be 95% of GDCA. Effective for PDEs with a DOS => 1/1/2011. Applies to plans that apply the Defined Standard benefit in Catstrophic. Applies to catastrophic PDEs with co-insurance (for example, GDCA > $126 in 2011). Does not apply to MSP PDEs.", "", ""
Insert Into dbo.tbl_PDE_Edit "690", "Y", "Cost", "Ingred Cost, Disp Fee, Sales Tax, Vaccine Administration Fee, P", "For DOS prior to 1/1/2011, Sum of Cost Fields > Sum of Payment Fields +/- Rounding Error and Dispensing Status is 'blank' or 'P'. For DOS 1/1/2011 and forward, Sum of Cost Fields > Sum of Payment Fields +/- Rounding Error and Dispensing Status is 'blank. System allows $.05 margin of error because some fields are calculated fields (i.e. CPP, NPP and LICS).", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "691", "Y", "Cost", "GDCB, GDCA, Ingred Cost, Disp Fee, Sales Tax, Vaccine Administr", "The sum of GDCB and GDCA is not equal to the sum of Ingred Cost + Disp Fee + Sales Tax + Vaccine Administration Fee and Medicare is primary. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "692", "Y", "Cost", "Ingred Cost, Disp Fee Paid, Sales Tax, Vaccine Administration F", "Sum of Cost Fields < Sum of Payment Fields +/- Rounding Error and Dispensing Status is 'blank For PDEs with DOS prior to 5/15/2010, the original edit logic applies: Sum of Cost Fields < Sum of Payment Fields +/- Rounding Error and Dispensing Status is 'blank' and CPP + NPP > 0. This edit version does not apply to MSP PDEs. For PDEs with DOS on or after 5/15/2010, CPP + NPP > 0 is no longer a condition for the edit. This edit version applies to all PDEs including MSP PDEs. The edit is bypassed when a non-Me", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "693", "Y", "Cost", "Ingred Cost, Disp Fee Paid, Sales Tax, Vaccine Administration F", "Sum of Cost Fields < Sum of Payment Fields +/- Rounding Error and Dispensing Status is 'C'", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "694", "Y", "Cost", "Ingredient Cost, Dispensing Fee, Vaccine Administration Fee", "The sum of Ingredient Cost, Dispensing Fee, and Vaccine Administration Fee must be > zero. This requirement also applies to OTC drugs funded by adminstrative costs.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "695", "", "Cost", "Submitting Contract, Submitting PBP, NPP Amount", "NPP Amount must be zero for LI NET PDEs.", "", ""
Insert Into dbo.tbl_PDE_Edit "696", "Y", "Cost", "True Out-of-Pocket Accumulator ,Total Gross Covered Drug Cost A", "True Out-of-Pocket Accumulator cannot be greater than Total Gross Covered Drug Cost Accumulator. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "", ""
Insert Into dbo.tbl_PDE_Edit "698", "Y", "Cost", "Gap discount amount, remaining TrOOP", "The reported gap discount amount cannot be greater than the remaining TrOOP.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "699", "Y", "Cost", "Accumulated TrOOP, GDCA, out of pocket treshhold, benefit phase", "The true out of pocket cost is greater than the out of pocket threshold, the entire PDE falls within the catastrophic coverage phase and submitted GDCA is not greater than 0.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "700", "Y", "Elig", "HICN", "The HICN does not match an existing Beneficiary.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "701", "Y", "Elig", "Patient Date of Birth (DOB)", "The DOB provided does not match the DOB on MBD", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "702", "Y", "Elig", "Patient Gender", "The Gender does not match the value on MBD", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "703", "", "Elig", "Date of Service (DOS)", "The DOS cannot be less than the DOB.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "704", "", "Elig", "Date of Service (DOS)", "The DOS cannot be greater than the date of death (DOD) + 32 days.", "Plan verifies plan end date. ", ""
Insert Into dbo.tbl_PDE_Edit "705", "", "Elig", "Date of Service (DOS)", "The Beneficiary must be enrolled in Part D on the DOS.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "706", "", "Elig", "Date of Service (DOS)", "This DOS does not fall in a valid P2P period. The Beneficiary must be enrolled in this Contract on the DOS. This edit is bypassed for POS plans.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "707", "", "Elig", "Date of Service (DOS)", "The Beneficiary must be enrolled in this Part D Plan Benefit Package on the DOS. If the contract on MBD matches the contract on the PDE, then the PBP on MBD must match the PBP on the PDE.", "Plan updates eligibility file.", ""
Insert Into dbo.tbl_PDE_Edit "708", "", "Elig", "Date of Service (DOS) Contract Drug Coverage Status Code", "Submitting Contract differs from contract of record; this PDE is subject to plan to plan reconciliation. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'.", "Informational", ""
Insert Into dbo.tbl_PDE_Edit "709", "", "Elig", "Date of Service (DOS) Contract Drug Coverage Status Code", "Even though the Submitting Sontract does not equal the contract of record, this PDE is not subject to plan-to-plan reconciliation. PDEs with drug coverage status of 'E' or 'O' are not eligible for plan-to-plan reconciliation. Applies to non-covered drugs (enhanced and over-the-counter).", "Informational", ""
Insert Into dbo.tbl_PDE_Edit "710", "", "Elig", "HICN", "The beneficiary HICN has changed according to CMS records; use the corrected HICN for future submissions. See the Corrected HICN field (positions 446-465) in the return file for the correct HICN.", "Informational", ""
Insert Into dbo.tbl_PDE_Edit "711", "", "Elig", "Submitting Contract Contract of Record", "PACE plans cannot submit plan-to-plan PDEs.", "Plan verifies the submitting contract/ contract of record", ""
Insert Into dbo.tbl_PDE_Edit "712", "", "Elig", "Date of Service (DOS), Submitting Contract", "Submitting Contract was not prior Contract of Record for this P2P period. Submitting plan should check their records and determine if they need to update their enrollment information for the beneficiary.", "Informational_ Applies to Covered drugs. Edit effective in May 2007", ""
Insert Into dbo.tbl_PDE_Edit "713", "", "Elig", "Submitting Contract and PBP, Date of Service", "The Submitting Contract/PBP does not offer Part D on Date of Service. Compared to the HPMS extract data", "Plan compares with the HPMS extract data. Edit effective in December 2006 ", ""
Insert Into dbo.tbl_PDE_Edit "714", "", "Elig", "Date of Service (DOS) ", "The DOS is greater than the date of death (DOD), but is within the 32 day allowable margin.", "Informational - Plan confirms that Date of Service is correct. Edit effective May 2007", ""
Insert Into dbo.tbl_PDE_Edit "715", "", "LICS", "Low Income Cost-sharing Subsidy Amount (LICS)", "Dollars reported in LICS are greater than zero. However, Beneficiary is not eligible for LICS subsidy. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'. This edit is bypassed for 2006 dates of service.", "Plan verifies beneficiary's LICS eligibility and updates LICS data.", ""
Insert Into dbo.tbl_PDE_Edit "716", "Y", "LICS", "Patient Pay Amount Other TrOOP Amount ", "Patient Liability exceeds the statutorily defined maximum for Institutionalized (LICS3) Low Income beneficiary. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'. Institutionalized Low-Income beneficiaries have zero cost-sharing. This edit is bypassed for POS plans. ", "Plan verifies beneficiary's LICS level and updates LICS data.", ""
Insert Into dbo.tbl_PDE_Edit "717", "Y", "LICS", "Patient Pay Amount, Other TrOOP Amount, Catastrophic Coverage C", "Patient liability exceeds the statutorily defined pre-catastrophic maximum for Category 2 Low Income beneficiary. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'. Non-catastrophic cost-sharing maximum is determined by benefit year. ", "Plan verifies beneficiary's LICS level and updates LICS data.", ""
Insert Into dbo.tbl_PDE_Edit "718", "Y", "LICS", "Patient Pay Amount, Other TrOOP Amount, PLRO, Catastrophic Cove", "Patient liability exceeds the statutorily defined pre-catastrophic maximum for Category 1 Low Income beneficiary. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'. Non-catastrophic cost-sharing maximum is determined by benefit year.", "Plan verifies beneficiary's LICS level and updates LICS data.", ""
Insert Into dbo.tbl_PDE_Edit "719", "", "LICS", "Patient Pay Amount, Other TrOOP Amount, PLRO,Catastrophic Cover", "Patient liability exceeds the statutorily defined pre-catastrophic maximum for Category 4 Low Income beneficiary who has met deductible. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'. Non-catastrophic cost-sharing maximum is determined by benefit year.", "Informational", ""
Insert Into dbo.tbl_PDE_Edit "720", "Y", "LICS", "Patient Pay Amount, Other TrOOP Amount, PLRO, Catastrophic Cove", "Patient Liability exceeds the statutorily defined catastrophic maximum for Category 1 or Category 2 Low Income beneficiary. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'. Applies to beneficiaries who have reached the out-of-pocket threshold.", "Plan verifies beneficiary's LICS level and updates LICS data.", ""
Insert Into dbo.tbl_PDE_Edit "721", "Y", "LICS", "Patient Pay Amount, Other TrOOP Amount, PLRO, Catastrophic Cove", "Patient liability exceeds the statutorily defined catastrophic maximum for Category 4 Low Income beneficiary who has reached the out-of-pocket threshold. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'. Catastrophic cost-sharing maximum is determined by benefit year.", "Plan verifies beneficiary's LICS level and updates LICS data.", ""
Insert Into dbo.tbl_PDE_Edit "722", "", "LICS", "Low Income Cost-sharing Subsidy Amount (LICS), Drug Coverage St", "Dollars reported in LICS are greater than zero. However, beneficiary is not eligible for LICS subsidy in CMS systems. Plans must have documented evidence to substantiate LICS. ", "Plan verifies beneficiary's LICS eligibility and updates LICS data.", ""
Insert Into dbo.tbl_PDE_Edit "735", "", "NDC", "Product/ Service ID", "The NDC Code does not match a valid code on the NDC database.", "MI conducts research to determine root cause of rejection. MI researches internally with FMT and externally with CMS. Resolution responsibility could ultimately reside with CMS or MedImpact.", ""
Insert Into dbo.tbl_PDE_Edit "736", "", "NDC", "Product/ Service ID", "DOS < NDC effective date. ", "This edit code is disabled.", ""
Insert Into dbo.tbl_PDE_Edit "737", "", "NDC", "Drug Coverage Status Code, Product/Service ID", "Inappropriate Drug Coverage. Drug Coverage is O although the drug is on the OTC list. ", "This edit code is disabled.", ""
Insert Into dbo.tbl_PDE_Edit "738", "", "NDC", "Drug Coverage Status Code, Product/Service ID", "The NDC identifies a Part D Non-coverable Drug.", "MI conducts research to determine root cause of rejection. MI researches internally with FMT and externally with CMS. Resolution responsibility could ultimately reside with CMS or MedImpact.", ""
Insert Into dbo.tbl_PDE_Edit "739", "", "NDC", "Drug Coverage Status Code, Product/Service ID", "This NDC is for a drug that is usually covered under Part B. If Plan determines that this drug is Part B covered, submit deletion record. ", "This edit code is disabled.", ""
Insert Into dbo.tbl_PDE_Edit "740", "", "NDC", "Product/Service ID", "NDC is DESI drug. ", "This edit code is disabled.", ""
Insert Into dbo.tbl_PDE_Edit "741", "", "NDC", "Product/ Service ID", "The drug is always excluded from Part D; the drug is always covered by Part B. ", "This edit code is disabled.", ""
Insert Into dbo.tbl_PDE_Edit "742", "", "NDC", "Product/Service ID, Vaccine Administration Fee", "If the amount in the Vaccine Administration Fee field is >0, then the NDC Code must qualify as a valid Part D vaccine.", "MI conducts research to determine root cause of rejection. MI researches internally with FMT and externally with CMS. Resolution responsibility could ultimately reside with CMS or MedImpact.", ""
Insert Into dbo.tbl_PDE_Edit "743", "", "NDC", "Submitting Contract, Submitting PBP, Drug Coverage Status Code", "Drug Coverage Status Code must be 'C' for LI NET PDEs.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "744", "Y", "NDC", "Product/ Service ID", "For DOS 1/1/2011 and forward, this drug is not covered under Part D because the FDA-assigned Marketing Category is NDA or BLA, and no Medicare Coverage Gap Discount Program agreement is on file for the manufacturer responsible for this labeler code. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'. Edit bypassed for PDEs with compound drugs.", "MI conducts research to determine root cause of rejection. MI researches internally with FMT and externally with CMS. Resolution responsibility could ultimately reside with CMS or MedImpact.", ""
Insert Into dbo.tbl_PDE_Edit "745", "", "NDC", "NDC, Quantity, DS", "Medicare does not pay for this drug for this strength and/or daily supply.", "Plan adjusts strength or DS.", ""
Insert Into dbo.tbl_PDE_Edit "746", "Y", "NDC", "Product Service ID ", "This NDC is not found on the current FDA NDC SPL Data Element file.", "MI conducts outreach to the manufacturers to request that NDCs be listed on the NSDE file. Plan Sponsors are also encouraged to conduct outreach. ", ""
Insert Into dbo.tbl_PDE_Edit "747", "Y", "NDC", "Product Service ID, Date of Service ", "This NDC is found on the current FDA NDC SPL Data Element file, but is not effective for the given Date of Service.", "When appropriate, MI will reach out to manufacturers to research marketing start and end date discrepancies. Plan Sponsors are also encouraged to conduct outreach. ", ""
Insert Into dbo.tbl_PDE_Edit "755", "", "Non Cov Drug", "Drug Coverage Status Code, Catastrophic Coverage Code", "If Drug Coverage Status Code equals E or O, Catastrophic Coverage Code must not equal 'A' or 'C'", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "756", "", "Non Cov Drug", "Drug Coverage Status Code, CPP", "If Drug Coverage Status Code is 'E' or 'O', then the Covered D Plan Paid Amount must be zero.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "757", "", "Non Cov Drug", "Drug Coverage Status Code, Other TrOOP Amount", "If Drug Coverage Status Code is 'E' or 'O', then Other TrOOP Amount must be zero.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "758", "", "Non Cov Drug", "Drug Coverage Status Code, LICS", "If Drug Coverage Status Code is 'E' or 'O', then LICS must be zero.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "759", "", "Non Cov Drug", "Drug Coverage Status Code, GDCB", "If Drug Coverage Status Code is 'E' or 'O', then GDCB must be zero", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "760", "", "Non Cov Drug", "Drug Coverage Status Code, GDCA", "If Drug Coverage Status Code is 'E' or 'O', then GDCA must be zero.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "761", "", "Non Cov Drug", "Drug Coverage Status Code, GDCA", "If Drug Coverage Status Code is 'O' and Pricing Exception Code <> ‘M’, then Patient Pay Amount, LICS, Other TrOOP, PLRO, and CPP must each equal zero. There cannot be a covered plan paid amount for OTC PDEs. Plans cannot charge beneficiaries for OTC drugs. Patient liability can be reported in as many as 4 fields: Patient Pay Amount, LICS, Other TrOOP Amount and/or PLRO.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "762", "", "Non Cov Drug", "Drug Coverage Status Code, Part D Benefit Type Code", "If Drug Coverage Status Code is 'E', the contract type must be Enhanced Alternative.", "E' drugs should report only on Enhanced Alternative plans", ""
Insert Into dbo.tbl_PDE_Edit "763", "", "Non Cov Drug", "Drug Coverage Status Code, Vaccine Administration Fee", "If Drug Coverage Status Code is ‘E’ or ‘O’ then the Vaccine Administration Fee must be zero.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "764", "", "Non Cov Drug", "Drug Coverage Status Code, Total Gross Covered Drug Cost Accumu", "If Drug Coverage Status Code is ‘E’ or ‘O’, then the Total Gross Covered Drug Cost Accumulator must be blanks or zeros.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "765", "", "Non Cov Drug", "Drug Coverage Status Code, True Out-of-Pocket Accumulator", "Code is ‘E’ or ‘O’, then the True Out-of-Pocket Accumulator must be blanks or zeros.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "766", "", "Non Cov Drug", "Drug Coverage Status Code, Beginning Benefit Phase", "If Drug Coverage Status Code is ‘E’ or ‘O’, then the Beginning Benefit Phase must be blank.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "767", "", "Non Cov Drug", "Drug Coverage Status Code, Ending Benefit Phase", "If Drug Coverage Status Code is ‘E’ or ‘O’, then the Ending Benefit Phase must be blank.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "768", "", "Non Cov Drug", "Drug Coverage Status Code, Reported Gap Discount", "If Drug Coverage Status Code is ‘E’ or ‘O’, then the Reported Gap Discount must be blanks or zeros.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "769", "", "Non Cov Drug", "Drug Coverage Status Code, Gap Discount Plan Override Code", "If Drug Coverage Status Code is ‘E’ or ‘O’, then the Gap Discount Plan Override Code must be blank.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "770", "", "Non Cov Drug", "Drug Coverage Status Code, Tier", "If Drug Coverage Status Code is ‘E’ or ‘O’, then the Tier must be blank.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "771", "", "Non Cov Drug", "Drug Coverage Status Code, Formulary Code", "If Drug Coverage Status Code is ‘E’ or ‘O’, then the Formulary Code must be blank.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "772", "", "Non Cov Drug", "Drug Coverage Status Code, Brand/Generic Code", "If Drug Coverage Status Code is ‘E’ or ‘O’, then the Brand/Generic Code must be blank.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "775", "", "Misc", "Dispensing Status - record incompatibility", "Status (blank cannot follow 'C' or 'P'). Record for a Partl ('P') or Compl ('C') fill is on file for this disp event. DDPS cannot accept another record with Disp Status = blank for the same dispensing event. Applies to DOS prior to January 1, 2011.", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "776", "", "Misc", "Dispensing Status - record incompatibility", "Incompatible Dispensing Status ('C' or 'P' cannot follow 'blank' ). Record with unspecified fill status (blank) is on file for this same dispensing event. DDPS cannot accept another record with Partl ('P') or Compl ('C') fill for the same dispensing event. Applies to DOS prior to January 1, 2011.", "MI works with pharmacy to correct.", ""
Insert Into dbo.tbl_PDE_Edit "777", "", "Misc", "Service Provider, Prescription/Service Reference Number, Date o", "Duplicate PDE record. Duplicate PDE record exists in DDPS data warehouse. Applies only if adjustment/deletion code is blank on the PDE record. Added match against the PDE file for duplicates and incompatible status. See edit 784 for associated edit.", "MI conducts research to determine root cause of duplicate. Resolution responsibility could ultimately reside with the plan or MedImpact.", ""
Insert Into dbo.tbl_PDE_Edit "778", "", "Misc", "Paid Date", "Paid Date < DOS Applies only if paid date is present. Zeros or spaces are allowed.", "Paid date not reported", ""
Insert Into dbo.tbl_PDE_Edit "779", "Y", "Misc", "Covered D Plan Paid Amount", "Submitting Plan cannot report NPP for Covered Part D Drug. The following Plan types are excluded: EA, Employer-only, Flexible Capitated Payment Demo, Fixed Capitated Payment Demo. ", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "780", "Y", "Misc", "Service Provider ID Quaifier", "Service Provider ID Qualifier must be '01' - NPI or '07' - NCPDP on standard claim. Does not apply to X12, Paper, or Beneficiary Submitted claims", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "781", "Y", "Misc", "Service Provider ID ", "Service Provider ID is not on master provider file. If Service Provider ID = 01, then validate as an NPI number. If Service Provider ID = 07, then validate as an NCPDP number. Effective April 24, 2011, bypassed if NDC is a vaccine.", "MI works with pharmacy to submit valid NPI", ""
Insert Into dbo.tbl_PDE_Edit "782", "", "Misc", "N/A", "Record had no error, but was submitted as part of a rejected batch. DDPS rejects batches with error rates exceeding 50%. ", "This edit has been disabled.", ""
Insert Into dbo.tbl_PDE_Edit "783", "Y", "Misc", "Service Provider was not an active pharmacy on DOS ", "Service provider was not an active pharmacy on DOS. Edit was re-established as of 4/24/2011 for all DOS. Applies when DOS less than or equal to the store closing date plus six months. ", "MI works with NCPDP to resolve.", ""
Insert Into dbo.tbl_PDE_Edit "784", "", "Misc", "Service Provider, Prescription/Service Reference Number, Date o", "Duplicate PDE record, originally submitted by different contract. Applies only if adjustment/deletion code is blank on the PDE record. Replaces Edit #777 when Contract Number differs from the original PDE that this record is duplicating. Original Submitting Contract is indicated in Return File.", "Plan verifies the submitting contract/ contract of record and work with original submitted contract for reconciliation.", ""
Insert Into dbo.tbl_PDE_Edit "785", "", "Misc", "Service Provider ID Qualifier, Service Provider ID, Prescriptio", "Duplicate PDE record exists on this file. This PDE is not saved. Applies only if a duplicate PDE is found on the same submitter file.", "MI conducts research to determine root cause of duplicate. Resolution responsibility could ultimately reside with the plan or MedImpact.", ""
Insert Into dbo.tbl_PDE_Edit "786", "Y", "Misc", "Beginning Benefit Phase, Ending Benefit Phase", "Beginning and Ending Benefit Phase combination is invalid. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'. Effective for DOS 1/1/2011 and forward.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "787", "", "Misc", "Beginning Benefit Phase, Ending Benefit Phase, Total Gross Cove", "Beginning and Ending Benefit Phase combination does not match the True Out-of-Pocket Accumulator and/or Total Gross Covered Drug Cost Accumulator. Applies to Covered Drugs only. Drug Coverage Status Code = 'C'. Effective for DOS 1/1/2011 and forward. Bypassed for EGWP plans.", "Informational. ", ""
Insert Into dbo.tbl_PDE_Edit "788", "", "Misc", "", "DDPS no longer accepts PDEs with dates of service before 1/1/08. CMS will update annually to close the DDPS databas 37 months following the end of each contract year. Eff 2/24/12 DDPS no longer accepts PDEs with dates of service before 1/1/09. Bypassed for LI NET. ", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "789", "", "Misc", "Prescriber ID", "The Prescriber ID is listed on the Office of Inspector General?s List of Excluded Individuals and Entities.", "Informational", ""
Insert Into dbo.tbl_PDE_Edit "790", "", "Misc", "Service Provider ID Qualifier, Service Provider ID", "The Service Provider ID is listed on the Office of Inspector General’s List of Excluded Individuals and Entities.", "Informational", ""
Insert Into dbo.tbl_PDE_Edit "791", "", "Misc", "Date Original Claim Received", "The Date Original Claim Received cannot be more than 6 months after the PBP expiration date. ", "For LI NET plans only", ""
Insert Into dbo.tbl_PDE_Edit "800", "Y", "PACE", "Catastrophic Coverage Code", "The Catastrophic Coverage Code is invalid. Must be Blank in PDEs submitted by PACE Programs. ", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "801", "Y", "PACE", "Patient Pay Amount", "The Patient Pay Amount is invalid. Must equal zero in PDEs submitted by PACE Programs.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "802", "Y", "PACE", "Other TrOOP Amount", "Other TrOOP Amount is invalid. Must equal zero in PDEs submitted by PACE Programs.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "803", "Y", "PACE", "Low Income Cost-sharing Subsidy Amount (LICS)", "The LICS value is not a valid value. Must equal zero in PDEs submitted by PACE Programs.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "804", "Y", "PACE", "Patient Liability Reduction due to Other Payers (PLRO)", "The PLRO must equal zero in PDEs submitted by PACE Programs.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "805", "Y", "PACE", "Non-covered Plan Paid Amount (NPP), Drug Coverage Status Code", "When Drug Coverage Status Code = 'C' the Non-covered Plan Paid Amount must equal zero in PDEs submitted by PACE Programs.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "806", "Y", "PACE", "Gross Drug Cost Below Out-Of-Pocket Threshold (GDCB)", "GDCB is invalid; must equal zero in PDEs submitted by PACE Programs.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "807", "Y", "PACE", "Gross Drug Cost Above Out-Of-Pocket Threshold (GDCA)", "GDCA is invalid; must equal zero in PDEs submitted by PACE Programs. ", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "808", "Y", "PACE", "Drug Coverage Status Code, Ingredient Cost Paid, Dispensing Fe", "For a Covered Drug, sum of Ingredient Cost Paid, Dispensing Fee Paid, Total Amount Attributed to Sales Tax and Vaccine Administration Fee must equal covered D Plan Paid Amount in PDE submitted by a PACE Program.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "809", "", "PACE", "Drug Coverage Status Code, Ingredient Cost Paid, Dispensing F", "For a Non-Covered Drug, sum of Ingredient Cost Paid, Dispensing Fee Paid, Total Amount Attributed to Sales Tax and Vaccine Administration Fee must equal Non-Covered Plan Paid Amount in PDE submitted by a PACE Program.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "810", "Y", "PACE", "Rebate Pass Through at POS", "The Estimated Rebate at Point of Sale amount is invalid. Must equal zero in PDEs submitted by PACE Programs.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "811", "Y", "PACE", "Total Gross covered Drug Cost Accumulator", "The Total Gross Covered Drug Cost Accumulator is missing or invalid. Must be equal to zeros or spaces in PDEs submitted by PACE Programs.", "", ""
Insert Into dbo.tbl_PDE_Edit "812", "Y", "PACE", "True Out-of-Pocket Accumulator", "The True Out-of-Pocket Accumulator is invalid. Must be equal to zeros or spaces in PDEs Submitted by PACE Programs.", "", ""
Insert Into dbo.tbl_PDE_Edit "813", "Y", "PACE", "Beginning Benefit Phase", "The Beginning Benefit Phase is invalid. Must be equal to blank in PDEs submitted by PACE Programs. ", "", ""
Insert Into dbo.tbl_PDE_Edit "814", "Y", "PACE", "Ending Benefit Phase", "The Ending Benefit Phase is invalid. Must be equal to blank in PDEs submitted by PACE Programs. ", "", ""
Insert Into dbo.tbl_PDE_Edit "815", "Y", "PACE", "Reported Gap Discount", "The Reported Gap Discount is invalid. Must be equal to zeros or spaces in PDEs submitted by PACE Programs.", "", ""
Insert Into dbo.tbl_PDE_Edit "816", "Y", "PACE", "Tier", "The Tier is invalid. Must be equal blank in PDEs Submitted by PACE Programs.", "", ""
Insert Into dbo.tbl_PDE_Edit "817", "Y", "PACE", "Gap Discount Plan Override Code", "The Gap Discount Plan Override Code is invalid. Must be blank in PDEs submitted by PACE Programs.", "", ""
Insert Into dbo.tbl_PDE_Edit "818", "Y", "PACE", "Formulary Code", "The Formulary Code is invalid. Must be equal to blank in PDEs submitted by PACE Programs.", "", ""
Insert Into dbo.tbl_PDE_Edit "819", "Y", "PACE", "Brand/Generic Code", "The Brand/Generic Code is invalid. Must Be equal to blank in PDEs submitted by PACE Programs.", "", ""
Insert Into dbo.tbl_PDE_Edit "831", "Y", "M/I", "Formulary Code", "The Formulary Code is missing or invalid. For DOS 1/1/2011 and forward, valid values are 'F' for Formulary or 'N' for Non-Formulary. For DOS prior to 2011, must be blank. Applies to Covered Drugs only. Drug Coverage Status Code = 'C' . Required on PDEs with service dates effective January 1, 2011 forward. On PDEs with DOS prior to 1/1/2011, must be spaces.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "832", "Y", "M/I", "Prescriber ID", "NPI number not found on CMS NPI table; however it contains a valid check digit. Applies to Covered drugs with DOS on or after January 1, 2012.", "Informational.", ""
Insert Into dbo.tbl_PDE_Edit "833", "Y", "M/I", "Prescriber ID", "The submitted Prescriber ID is not found on CMS NPI table. Applies to Covered drugs with DOS on or after January 1, 2012.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "834", "Y", "M/I", "Prescriber ID", "The submitted Prescriber ID is not active on the CMS NPI table for given DOS. Applies to Covered drugs with DOS on or after January 1, 2012. ", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "835", "", "M/I", "Pharmacy Service Type", "The Pharmacy Service Type code is missing or invalid. Must be 01, 02, 03, 04, 05, 06, 07, 08, or 99 on PDEs with DOS on or after 2/28/2013. Must be blank, 01, 02, 03, 04, 05, 06, 07, 08, or 99 on PDEs with DOS before 2/28/2013.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "836", "", "M/I", "Patient Residence Code", "The Patient Residence code is missing or invalid. Must be 00, 01, 03, 04, 06, 09, or 11 on PDEs with DOS on or after 2/28/2013. Must be blank, 00, 01, 03, 04, 06, 09, or 11 on PDEs with DOS before 2/28/2013.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "837", "", "M/I", "Submission Clarification Code, Patient Residence Code", "The Submission Clarification Code is invalid. For DOS on or after 2/28/2013, the field must be blank, 16, or 21 through 36. If the Patient Residence Code is '03', the SCC, if applicable, must be a valid value. ", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "851", "", "P2P Phase III Retro Enrollment", "Submitting Contract/PBP, Original Contract/PBP, Updated Contrac", "The Contract of Record has been updated, a P2P condition now exists. Identifies P2P Phase III condition # 1", "This informational edit only appears on the Phase III P2P special file and will not appear on a production DDPS file", ""
Insert Into dbo.tbl_PDE_Edit "852", "", "P2P Phase III Retro Enrollment", "Submitting Contract/PBP, Original Contract/PBP, Updated Contrac", "Submitting Contract/PBP is now the Contract/PBP of Record, a P2P condition no longer exists. Identifies P2P Phase III condition # 2", "This informational edit only appears on the Phase III P2P special file and will not appear on a production DDPS file", ""
Insert Into dbo.tbl_PDE_Edit "853", "", "P2P Phase III Retro Enrollment", "Submitting Contract/PBP, Original Contract/PBP, Updated Contrac", "PBP of Record has been updated. This PDE continues to be a non-P2P PDE. Identifies P2P Phase III condition # 3", "This informational edit only appears on the Phase III P2P special file and will not appear on a production DDPS file", ""
Insert Into dbo.tbl_PDE_Edit "854", "", "P2P Phase III Retro Enrollment", "Submitting Contract/PBP, Original Contract/PBP, Updated Contrac", "The Contract of Record and PBP of Record have been updated. A new P2P condition is established. Identifies P2P Phase III condition # 4", "This informational edit only appears on the Phase III P2P special file and will not appear on a production DDPS file", ""
Insert Into dbo.tbl_PDE_Edit "855", "", "P2P Phase III Retro Enrollment", "Submitting Contract/PBP, Original Contract/PBP, Updated Contrac", "The Submitting Contract is now the Contract of Record but the updated PBP of Record is different from the Submitting PBP. A P2P condition no longer exists. Identifies P2P Phase III condition # 5", "This informational edit only appears on the Phase III P2P special file and will not appear on a production DDPS file", ""
Insert Into dbo.tbl_PDE_Edit "865", "Y", "Gap Discount", "Reported Gap Discount, Low Income Cost-sharing Subsidy Amount (", "Beneficiaries eligible for the low income cost sharing subsidy on the date of service are not eligible to receive a coverage gap discount. LICS eligibility is evaluated in MBD.", "Plan verifies beneficiary's LICS eligibility and updates LICS data.", ""
Insert Into dbo.tbl_PDE_Edit "866", "Y", "Gap Discount", "Pricing Exception Code, Non-Standard Format Code, Reported Ga", "MSP and COB claims are not eligible for the coverage gap discount.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "867", "Y", "Gap Discount", "NDC, Reported Gap Discount.", "FDA does not designate this drug as NDA or BLA; therefore it is ineligible for the coverage gap discount.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "868", "Y", "Gap Discount", "Service Provider Qualifier Code, Reported Gap Discount.", "Service Provider ID Qualifier cannot be '99' when PDE reports the coverage gap discount.", "MI conducts research to determine root cause. Resolution responsibility could ultimately reside with the plan or MedImpact.", ""
Insert Into dbo.tbl_PDE_Edit "869", "Y", "Gap Discount", "Beginning Benefit Phase, Ending Benefit Phase, Total Gross Cov", "No portion of the claim is in the coverage gap, therefore the coverage gap discount does not apply.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "870", "Y", "Gap Discount", "Reported Gap Discount, Ingredient Cost Paid, Total Amount Attr", "Reported Gap Discount <> CMS Calculated Gap Discount+/- 0.05.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "871", "", "Gap Discount", "See Edit 870", "Reported Gap Discount exceeds amount estimated by CMS +/- 0.05. ", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "872", "", "Gap Discount", "See Edit 870", "Reported Gap Discount is less than or equal to amount estimated by CMS. This PDE may be subject to additional scrutiny. Estimation necessary because the accumulator amounts did not agree with the benefit phase values. Excludes EGWPs.", "Informational. ", ""
Insert Into dbo.tbl_PDE_Edit "873", "Y", "Gap Discount", "Reported Gap Discount, GDCB", "For DOS 1/1/2011 forward, if Drug Coverage Status Code is 'C' and GDCB is zero, Reported Gap Discount must be zero.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "874", "Y", "Gap Discount", "Reported Gap Discount, Low Income Cost-sharing Subsidy Amount ", "Reported Gap Discount is > zero. The sponsor provided LICS based on Best Available Evidence. Low income beneficiaries are not eligible to receive a Coverage Gap Discount.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "875", "Y", "Gap Discount", "Reported Gap Discount, Compound Code", "Claims submitted with compound drugs are not eligible to receive the coverage gap discount.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "876", "", "Gap Discount", "See Edit 870", "Reported Gap Discount (minus rounding error) is less than the discount amount estimated by CMS, provided that Non-Covered Plan Paid (NPP) includes supplemental benefits in the Coverage Gap. This PDE may be subject to additional scrutiny.", "Informational", ""
Insert Into dbo.tbl_PDE_Edit "877", "", "Gap Discount", "See Edit 870", "Reported Gap Discount +/- rounding error equals the discount amount estimated by CMS, provided that Non-Covered Plan Paid Amount (NPP) reports supplemental benefits in other benefit phases excluding the coverage gap. This PDE may be subject to additional scrutiny.", "Informational", ""
Insert Into dbo.tbl_PDE_Edit "878", "", "Gap Discount", "See Edit 870", "Reported Gap Discount is zero. No Gap discount applies when a PDE straddles two adjoining co-pay benefit phases and the second benefit phase is the coverage gap. This PDE may be subject to additional scrutiny.", "Informational", ""
Insert Into dbo.tbl_PDE_Edit "879", "Y", "Gap Discount", "See Edit 870", "Reported coverage gap discount is zero and generic cost sharing is reported for gap discount eligible PDE. Edit bypassed for EGWPs.", "MI reviews/researches to determine corrective action.", ""
Insert Into dbo.tbl_PDE_Edit "998", "", "Misc", "Contract/PBP of Record", "Internal CMS issue regarding Contract/PBP of Record encountered Compares data returned from MBD against the HPMS extract.", "Compares data returned from MBD against the HPMS extract. Edit effective in December 2006.", ""
Insert Into dbo.tbl_PDE_Edit "999", "", "Misc", "Various", "Internal CMS system issue encountered. Beneficiary has overlapping enrollment information in MBD. This is the system error edit code we will default to when we experience MBD issues where data is not returned for us to properly continue editing.", "CMS will correct.", ""
Insert Into dbo.tbl_PDE_Edit "001", "", "", "", "Actual Error Ratio Is Over The Set Ratio Limit", "", ""