Pharmacy reject codes: meanings and next checks.

Compare the submitted BIN with the current card or eligibility response.

Medi-Cal Rx Appendix D · April 1, 2026. The code description is published here; program-specific values and comments apply to Medi-Cal Rx, not every payer. The next check is a verification step, not an override instruction.

Check the transaction version configured in the pharmacy software against the payer sheet.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check whether the intended action is billing, reversal, rebilling or eligibility, and compare the transmitted transaction type.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the exact PCN, including leading zeros and casing, against the current payer route.

Medi-Cal Rx Appendix D · April 1, 2026. The code description is published here; program-specific values and comments apply to Medi-Cal Rx, not every payer. The next check is a verification step, not an override instruction.

Compare the submitted service-provider identifier with the payer sheet; Medi-Cal Rx specifies the pharmacy NPI.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the current member group and the payer’s group-field requirements.

Medi-Cal Rx Appendix D · April 1, 2026. The code description is published here; program-specific values and comments apply to Medi-Cal Rx, not every payer. The next check is a verification step, not an override instruction.

The submitted member ID is blank, malformed, or does not match the plan's record.

Compare the value and any alpha prefix with the current card, then recheck eligibility before resubmitting.

Compare the person code with the current member record, especially when several family members share a policy.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the recorded date and transmitted format against the patient and eligibility records.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the submitted field against the payer’s eligibility record and accepted values; do not change patient information simply to clear a reject.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Verify the patient’s relationship to the cardholder and the payer’s accepted relationship values.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

The submitted Other Coverage Code is blank, invalid, or inconsistent with the other payer's result.

Review the primary payer response, then use the secondary payer's current OCC and COB instructions for that result.

Check the actual service date and how the software transmitted it.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the prescription/service reference number on the transaction and the intended prescription record.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Compare the fill number with the prescription’s fill history; do not change it merely to bypass a refill restriction.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

The submitted days supply is missing or fails the payer's edit, including a mismatch with quantity or directions.

Recompute it from the dispensed quantity and maximum use permitted by the directions, then follow the payer's rounding rule.

Verify that the compound indicator describes the preparation being billed.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

The product or service identifier is absent or invalid for the submitted claim.

Verify the reimbursement-format NDC and its padding against the package actually dispensed.

The payer reported field 408-D8 as missing or invalid under its claim rules.

Use the code that documents the actual selection decision, then follow the payer's additional message and current instructions.

Review the transmitted ingredient-cost value and the applicable payer billing instructions.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

The prescriber identifier or qualifier is absent, malformed, inactive, or not the identifier the payer expects.

Validate the prescriber's current individual NPI and the submitted qualifier against the payer's instructions.

Compare the submitted unit with the product and quantity being billed. Keep units distinct from package size.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Compare the date written with the original prescription documentation.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the authorized refill count against the prescription record, separately from the number already dispensed.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the submitted clarification code against the documented circumstance and the payer sheet. This reject does not tell you which replacement code to use.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

The submitted diagnosis code is blank, malformed, or not accepted for the claim as submitted.

Confirm whether the payer requires a diagnosis and submit only a code supported by the prescription or prescriber documentation.

The processor does not recognize the pharmacy as contracted for this plan on the submitted date of service.

Confirm the intended benefit and date of service, then verify the pharmacy's current network or enrollment status with the processor.

The response indicates that another payer must adjudicate the claim first.

Bill the primary payer, then use the secondary payer's current OCC and COB instructions with the primary response.

The processor cannot match the submitted pharmacy service-provider identifier to its records for this transaction.

Verify the submitted pharmacy identifier and qualifier, then confirm enrollment or routing with the processor before resubmitting.

Compare the submitted group with the member’s current plan record.

Medi-Cal Rx Appendix D · April 1, 2026. The code description is published here; program-specific values and comments apply to Medi-Cal Rx, not every payer. The next check is a verification step, not an override instruction.

Check the member identifier against the current card and eligibility response.

Medi-Cal Rx Appendix D · April 1, 2026. The code description is published here; program-specific values and comments apply to Medi-Cal Rx, not every payer. The next check is a verification step, not an override instruction.

The processor cannot match the submitted product or service identifier.

Compare the NDC with the dispensed package and the payer's response or current product data.

Verify the submitted pharmacy identifier and ask the payer to clarify the sanction record. Do not switch identifiers to evade the restriction.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Compare the transmitted prescriber identifier and qualifier with the documented prescriber and payer requirements; distinguish this from a coverage restriction under 71.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Caremark’s December 1, 2022 reject list, page 18, publishes this notice-related description. It does not identify the underlying coverage issue by itself.

Read the accompanying reject and current plan instructions. CMS publishes the Medicare Drug Coverage and Your Rights notice (CMS-10147) and instructions. Use those instructions for the notice workflow; this code is not an override or a coverage approval.

Verify the patient’s date of birth, product and service date, then read the plan’s age-specific coverage message.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the exact product/NDC requested by the payer and the prescription’s selection requirements. This code does not itself authorize substitution or a different DAW value.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the submitted patient field and exact product against the response. Resolve a record discrepancy with the payer rather than changing accurate information to obtain coverage.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Compare the submitted name and member identifier with the payer’s eligibility record.

Medi-Cal Rx Appendix D · April 1, 2026. The code description is published here; program-specific values and comments apply to Medi-Cal Rx, not every payer. The next check is a verification step, not an override instruction.

Check the member’s Part D coverage and the accompanying routing message. “May be covered” is not confirmation of payment.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the recorded patient setting and the benefit’s instructions for that setting.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Compare the claim with the approved authorization and its dates and conditions.

Medi-Cal Rx Appendix D · April 1, 2026. The code description is published here; program-specific values and comments apply to Medi-Cal Rx, not every payer. The next check is a verification step, not an override instruction.

Verify the package NDC actually dispensed and the payer’s contract-specific product restriction.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

The member data does not establish active coverage for this claim.

Verify current eligibility and plan information before changing or resubmitting the claim.

Verify the date of birth and date of service, then identify the applicable age limit in the plan’s response.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the actual service date and the plan’s coverage start date.

Medi-Cal Rx Appendix D · April 1, 2026. The code description is published here; program-specific values and comments apply to Medi-Cal Rx, not every payer. The next check is a verification step, not an override instruction.

Check coverage for the actual service date; do not change a date merely to obtain payment.

Medi-Cal Rx Appendix D · April 1, 2026. The code description is published here; program-specific values and comments apply to Medi-Cal Rx, not every payer. The next check is a verification step, not an override instruction.

The date of service falls after the coverage termination date in the payer's record.

Confirm whether the patient has a current plan and bill the coverage active for the fill date.

The other payer's reject code is absent, invalid, or inconsistent with the submitted COB detail.

Compare the primary response with the secondary payer's required other-payer fields and submit only the returned reject information it accepts.

Check which provider identifier the response concerns and the payer’s eligibility requirements for this service or product.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

The current benefit does not cover the submitted product or service in this context.

Use the payer's message to determine whether a covered NDC, alternative, exception, or authorization path exists.

Verify the prescriber identifier and ask the payer to distinguish an identifier problem from an enrollment or coverage restriction.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Compare the fill history and submitted fill number, then review the benefit’s refill restriction.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

The plan requires authorization review before it may cover the drug.

Follow the plan's authorization process and coordinate required information with the prescriber. Approval is not guaranteed.

The claim exceeds a quantity, days-supply, network, or other limit applied by the plan.

Determine which limit fired and whether the payer permits another dispensing path, clarification, or authorization.

The submitted NDC is no longer active in the processor's product data.

Confirm the NDC on the stock actually dispensed and use the payer's current product instructions.

Review the transmitted cost fields and the specific limit named by the payer; do not alter an accurate amount solely to pass the edit.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

The plan's refill threshold has not been reached, sometimes because the prior fill carried an incorrect days supply.

Verify the prior fill first. If it is correct, follow the payer's documented override, help-desk, clarification-code, or waiting process.

Check whether the benefit covers the preparation and whether the payer offers a documented review path.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Compare the transmitted ingredient count and ingredient records with the actual preparation.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Compare the documented diagnosis with the payer’s clinical criteria. Unlike 39, this response concerns coverage criteria, not simply a missing or invalid field. Do not select a different diagnosis to obtain payment.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the service date and the payer’s filing or exception process.

Medi-Cal Rx Appendix D · April 1, 2026. The code description is published here; program-specific values and comments apply to Medi-Cal Rx, not every payer. The next check is a verification step, not an override instruction.

Identify the excluded benefit and the payer’s next instruction. Medi-Cal Rx’s note addresses physician-administered drugs under the medical benefit; do not generalize that instruction to every payer or product.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Verify the actual service date and correct a genuine entry error.

Medi-Cal Rx Appendix D · April 1, 2026. The code description is published here; program-specific values and comments apply to Medi-Cal Rx, not every payer. The next check is a verification step, not an override instruction.

The processor found a previously paid or captured claim that matches the submitted transaction.

Check claim history for the same patient, product, prescription, refill, and date of service before retransmitting or reversing anything.

Check the original transaction’s final status before attempting another transaction.

Medi-Cal Rx Appendix D · April 1, 2026. The code description is published here; program-specific values and comments apply to Medi-Cal Rx, not every payer. The next check is a verification step, not an override instruction.

Retain the full response and establish the claim’s status with the processor before deciding whether to resubmit.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Match the reversal to the original paid claim and confirm its status before retrying.

Medi-Cal Rx Appendix D · April 1, 2026. The code description is published here; program-specific values and comments apply to Medi-Cal Rx, not every payer. The next check is a verification step, not an override instruction.

The response identifies a DUR edit, with the detailed conflict supplied in the accompanying response fields.

Evaluate and document the clinical issue, then submit only the intervention and outcome values the payer accepts when warranted.

Verify the pharmacy identifier and enrollment for the named state program and service date.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Verify whether the product was used in a compound and whether the transmitted claim represents the actual preparation.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the software’s transaction status and processor response before retrying; the interruption alone does not establish whether another submission is appropriate.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Retain the response and have the software vendor or processor review the transaction; separate this from a coverage denial.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the processor’s availability and the transaction status before following its retry instructions.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

The processor reported an internal host error rather than a specific claim-field or coverage edit.

Confirm whether the original transaction reached a final status before resubmitting, then follow the processor's outage or help-desk instructions.

The dispensed quantity is above the maximum the payer applies to this product or claim.

Verify quantity and days supply, then determine whether the payer permits a smaller covered fill, an exception, or authorization.

Compare the transmitted ingredient count with the payer’s supported limit. Medi-Cal Rx names a 25-ingredient limit; other payer requirements need their own source.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the product and submitted route against the prescription and the payer’s coverage message.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Compare the submitted authorization type with the payer’s instructions and the authorization actually issued.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Verify the prescriber identifier and have the payer clarify the sanction record; do not substitute another prescriber’s identifier.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the submitted identifier for a mismatch and have the payer resolve the record discrepancy before further billing.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Read the exact exclusion and current plan instructions. Distinguish this response from a formulary restriction or a missing authorization.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Verify the product, documented use and applicable benefit requirements. This response does not guarantee Part B coverage.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the member’s eligibility and spenddown status with the applicable program; the code alone does not establish the amount still owed.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Verify the member’s managed-care plan and date-specific pharmacy routing rather than assuming the fee-for-service route applies.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check that the qualifier matches the type of pharmacy identifier submitted and the payer sheet.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Verify enrollment in the Medicare Prescription Payment Plan and the sponsor receiving the secondary claim.

NCPDP Medicare Part D FAQ · August 2026, section 3.8. These codes concern the payment-plan secondary claim response. They are not general drug-coverage rejects. The verification prompt is an editorial checklist.

Check that the corresponding Part D transaction exists and matches the payment-plan submission.

NCPDP Medicare Part D FAQ · August 2026, section 3.8. These codes concern the payment-plan secondary claim response. They are not general drug-coverage rejects. The verification prompt is an editorial checklist.

Read the eligibility response for this claim and the plan’s instructions. Payment-plan eligibility is a separate question from Part D drug coverage.

NCPDP Medicare Part D FAQ · August 2026, section 3.8. These codes concern the payment-plan secondary claim response. They are not general drug-coverage rejects. The verification prompt is an editorial checklist.

Review the transmitted patient-paid amount and the payer’s definition of that field; do not confuse it with another payment or responsibility amount.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Verify the member’s eligibility category and the program’s coverage for the service date.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Read the additional message to distinguish a prescription-reference issue from the applicable time limit.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

The submitted product is not on the plan's formulary for this claim.

Use the payer's message to identify a covered alternative, formulary exception, or authorization path; do not substitute without appropriate authorization.

Compare the submitted patient identifiers and demographics with the current eligibility record.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.

Check the unit against the exact product and quantity. Distinguish a mismatch from a missing or invalid unit under 26.

Medi-Cal Rx Appendix D · April 1, 2026. The heading summarizes the published code meaning. The verification prompt is an editorial checklist, not a payer-approved resolution or override.