United States Health Information Knowledgebase

 

File Submission Comparison

Selected Items
Item Name Version State Type Organization
Pharmacy Claims File Submission August 12, 2009 - v1.3 Utah File Specification Utah Department of Health, Office of Health Care Statistics (UDH - OHCS)
Pharmacy Claims File Submission December 5, 2013 - v2.0 Utah File Specification Utah Department of Health, Office of Health Care Statistics (UDH - OHCS)
File Specification: Pharmacy Claims File Submission - August 12, 2009 - v1.3 (Utah) Pharmacy Claims File Submission - December 5, 2013 - v2.0 (Utah)
[Shared] Responsible Organization:
Utah Department of Health, Office of Health Care Statistics Utah Department of Health, Office of Health Care Statistics
[Shared] Definition:
Not Provided Not Provided
File Specification: Pharmacy Claims File Submission - August 12, 2009 - v1.3 (Utah) Pharmacy Claims File Submission - December 5, 2013 - v2.0 (Utah)
1
[Unshared] Name: Payer Name
[Unshared] Type: Not Provided
[Unshared] Length: 80
Data Element: 1
not present in this file submission.
2
[Unshared] Name: Insured Group or Policy Number
[Unshared] Type: Not Provided
[Unshared] Length: 30
Data Element: 2
not present in this file submission.
3
[Unshared] Name: Subscriber Last name
[Unshared] Type: Not Provided
[Unshared] Length: 35
Data Element: 3
not present in this file submission.
4
[Unshared] Name: Subscriber First name
[Unshared] Type: Not Provided
[Unshared] Length: 25
Data Element: 4
not present in this file submission.
5
[Unshared] Name: Subscriber Middle Name
[Unshared] Type: Not Provided
[Unshared] Length: 25
Data Element: 5
not present in this file submission.
6
[Unshared] Name: Subscriber Primary Identifier
[Unshared] Type: Not Provided
[Unshared] Length: 80
Data Element: 6
not present in this file submission.
7
[Unshared] Name: Subscriber Address
[Unshared] Type: Not Provided
[Unshared] Length: 55
Data Element: 7
not present in this file submission.
8
[Unshared] Name: Subscriber Address 2
[Unshared] Type: Not Provided
[Unshared] Length: 55
Data Element: 8
not present in this file submission.
9
[Unshared] Name: Subscriber City
[Unshared] Type: Not Provided
[Unshared] Length: 30
Data Element: 9
not present in this file submission.
10
[Unshared] Name: Subscriber State
[Unshared] Type: Not Provided
[Unshared] Length: 2
Data Element: 10
not present in this file submission.
11
[Unshared] Name: Subscriber Zipcode
[Unshared] Type: Not Provided
[Unshared] Length: 15
Data Element: 11
not present in this file submission.
12
[Unshared] Name: Subscriber Phone
[Unshared] Type: Not Provided
[Unshared] Length: 10
Data Element: 12
not present in this file submission.
13
[Unshared] Name: Subscriber Date of Birth
[Unshared] Type: Not Provided
[Unshared] Length: 8
Data Element: 13
not present in this file submission.
14
[Unshared] Name: Subscriber Gender
[Unshared] Type: Not Provided
[Unshared] Length: 1
Codes:
F
Female
M
Male
Data Element: 14
not present in this file submission.
15
[Unshared] Name: Subscriber Secondary Identification Qualifier
[Unshared] Type: Not Provided
[Unshared] Length: 2
Codes:
1W
Member Identification Number If NM108 = MI, this qualifier cannot be used.
23
Client Number
IG
Insurance Policy Number
SY
Social Security Number
Data Element: 15
not present in this file submission.
16
[Unshared] Name: Subscriber Secondary Identification
[Unshared] Type: Not Provided
[Unshared] Length: 30
Data Element: 16
not present in this file submission.
17
[Unshared] Name: Patients Relationship to Insured
[Unshared] Type: Not Provided
[Unshared] Length: 2
Codes:
01
Spouse
04
Grandfather or Grandmother
05
Grandson or Granddaughter
07
Nephew or Niece
09
Adopted Child
10
Foster Child
15
Ward
17
Stepson or Stepdaughter
18
Self
19
Child
20
Employee
21
Unknown
22
Handicapped Dependent
23
Sponsored Dependent
24
Dependent of a Minor Dependent
29
Significant Other
32
Mother
33
Father
34
Other Adult
36
Emancipated Minor
39
Organ Donor
40
Cadaver Donor
41
Injured Plaintiff
43
Child Where Insured Has No Financial Responsibility
53
Life Partner
G8
Other Relationship
Data Element: 17
not present in this file submission.
18
[Unshared] Name: Patient Last name
[Unshared] Type: Not Provided
[Unshared] Length: 35
Data Element: 18
not present in this file submission.
19
[Unshared] Name: Patient First name
[Unshared] Type: Not Provided
[Unshared] Length: 25
Data Element: 19
not present in this file submission.
20
[Unshared] Name: Patient Middle Name
[Unshared] Type: Not Provided
[Unshared] Length: 25
Data Element: 20
not present in this file submission.
21
[Unshared] Name: Patient Primary Identifier
[Unshared] Type: Not Provided
[Unshared] Length: 80
Data Element: 21
not present in this file submission.
22
[Unshared] Name: Patient Address
[Unshared] Type: Not Provided
[Unshared] Length: 55
Data Element: 22
not present in this file submission.
23
[Unshared] Name: Patient Address 2
[Unshared] Type: Not Provided
[Unshared] Length: 55
Data Element: 23
not present in this file submission.
24
[Unshared] Name: Patient City
[Unshared] Type: Not Provided
[Unshared] Length: 30
Data Element: 24
not present in this file submission.
25
[Unshared] Name: Patient State
[Unshared] Type: Not Provided
[Unshared] Length: 2
Data Element: 25
not present in this file submission.
26
[Unshared] Name: Patient ZipCode
[Unshared] Type: Not Provided
[Unshared] Length: 15
Data Element: 26
not present in this file submission.
27
[Unshared] Name: Patient Phone
[Unshared] Type: Not Provided
[Unshared] Length: 10
Data Element: 27
not present in this file submission.
28
[Unshared] Name: Patient Date of Birth
[Unshared] Type: Not Provided
[Unshared] Length: 8
Data Element: 28
not present in this file submission.
29
[Unshared] Name: Patient Gender
[Unshared] Type: Not Provided
[Unshared] Length: 1
Codes:
F
Female
M
Male
Data Element: 29
not present in this file submission.
30
[Unshared] Name: Patient Secondary Identification Qualifier
[Unshared] Type: Not Provided
[Unshared] Length: 3
Codes:
1W
Member Identification Number If NM108 = MI, this qualifier cannot be used.
23
Client Number
IG
Insurance Policy Number
SY
Social Security Number
Data Element: 30
not present in this file submission.
31
[Unshared] Name: Patient Secondary Identification
[Unshared] Type: Not Provided
[Unshared] Length: 30
Data Element: 31
not present in this file submission.
32
[Unshared] Name: RxClaimNo
[Unshared] Type: Not Provided
[Unshared] Length: 30
Data Element: 32
not present in this file submission.
33
[Unshared] Name: RxClaimNoCrossRef
[Unshared] Type: Not Provided
[Unshared] Length: 30
Data Element: 33
not present in this file submission.
34
[Unshared] Name: RxNo
[Unshared] Type: Not Provided
[Unshared] Length: 10
Data Element: 34
not present in this file submission.
35
[Unshared] Name: PBMMebID
[Unshared] Type: Not Provided
[Unshared] Length: 40
Data Element: 35
not present in this file submission.
36
[Unshared] Name: RXClaimTxnType
[Unshared] Type: Not Provided
[Unshared] Length: 1
Codes:
0
Original Claim
1
Adjustment
3
Reversal
4
Replacement
5
Dummy Claim
Data Element: 36
not present in this file submission.
37
[Unshared] Name: RxType
[Unshared] Type: Not Provided
[Unshared] Length: 1
Codes:
0
Unknown
1
Retail
2
Mail Order
9
Other
Data Element: 37
not present in this file submission.
38
[Unshared] Name: RxClaimXrefNo
[Unshared] Type: Not Provided
[Unshared] Length: 30
Data Element: 38
not present in this file submission.
39
[Unshared] Name: RxAdjType
[Unshared] Type: Not Provided
[Unshared] Length: 2
Codes:
00
Original claim
01
Partial positive adjustment ($ or qty)
02
Partial negative adjustment ($ or qty)
03
Full reversal (delete)
Data Element: 39
not present in this file submission.
40
[Unshared] Name: SubscriberSfx
[Unshared] Type: Not Provided
[Unshared] Length: 4
Data Element: 40
not present in this file submission.
41
[Unshared] Name: RxPrescriberID
[Unshared] Type: Not Provided
[Unshared] Length: 80
Data Element: 41
not present in this file submission.
42
[Unshared] Name: RxPrescriberNoType
[Unshared] Type: Not Provided
[Unshared] Length: 1
Codes:
0
NPI
1
UPIN
2
DEA
3
TIN
4
State license no
8
PBM assigned
9
Other
Data Element: 42
not present in this file submission.
43
[Unshared] Name: RxPrescriberName
[Unshared] Type: Not Provided
[Unshared] Length: 80
Data Element: 43
not present in this file submission.
44
[Unshared] Name: RxPharmacyNo
[Unshared] Type: Not Provided
[Unshared] Length: 20
Data Element: 44
not present in this file submission.
45
[Unshared] Name: MembMcareSTatus
[Unshared] Type: Not Provided
[Unshared] Length: 1
Codes:
0
Non-Medicare
1
Medicare primary
2
Medicare eligible
3
Unknown
Data Element: 45
not present in this file submission.
46
[Unshared] Name: RxWrittenDt
[Unshared] Type: Not Provided
[Unshared] Length: 8
Data Element: 46
not present in this file submission.
47
[Unshared] Name: RxFilledDt
[Unshared] Type: Not Provided
[Unshared] Length: 8
Data Element: 47
not present in this file submission.
48
[Unshared] Name: Reject Code 1
[Unshared] Type: Not Provided
[Unshared] Length: 3
Codes:
*95
Time out
*96
Scheduled downtime
*97
Payer unavailable
*98
Connection to payer is down
1C
Missing\invalid smoker/non smoker code
1E
Missing\invalid prescriber location code
2C
Missing\invalid pregnancy indicator
2E
Missing\invalid primary care provider id qualifier
3A
Missing\invalid request type
3B
Missing\invalid request period date begin
3C
Missing\invalid request period date end
3D
Missing\invalid basis of request
3E
Missing\invalid authorized representative first name
3F
Missing\invalid authorized representative last name
3G
Missing\invalid authorized representative street address
3H
Missing\invalid authorized representative city address
3J
Missing\invalid authorized representative state/province address
3K
Missing\invalid authorized representative zip/postal zone
3M
Missing\invalid prescriber phone number
3N
Missing\invalid prior authorized number assigned
3P
Missing\invalid authorization number
3R
Prior authorization not required
3S
Missing\invalid prior authorization supporting documentation
3T
Active prior authorization exists resubmit at expiration of prior authorization
3W
Prior authorization in process
3X
Authorization number not found
3Y
Prior authorization denied
4C
Missing\invalid coordination of benefits/other payments count
4E
Missing\invalid primary care provider last name
5C
Missing\invalid other payer coverage type
5E
Missing\invalid other payer reject count
6C
Missing\invalid other payer id qualifier
6E
Missing\invalid other payer reject code
7C
Missing\invalid other payer id
7E
Missing\invalid dur/pps code counter
8C
Missing\invalid facility id
8E
Missing\invalid dur/pps level of effort
00
No Reject Code Applies
01
Missing\invalid bin
02
Missing\invalid version number
03
Missing\invalid transaction code
04
Missing\invalid processor control number
05
Missing\invalid pharmacy number
06
Missing\invalid group number
07
Missing\invalid cardholder id number
08
Missing\invalid person code
09
Missing\invalid birth date
10
Missing\invalid patient gender code
11
Missing\invalid patient relationship code
12
Missing\invalid patient location
13
Missing\invalid other coverage cod
14
Missing\invalid eligibility clarification code
15
MISSING\INVALID Date of Service
16
Missing\invalid prescription/service reference number
17
Missing\invalid fill number
19
Missing\invalid days supply
20
Missing\invalid compound code
21
Missing\invalid product/service id
22
Missing\invalid dispense as written (daw)/product selection code
23
Missing\invalid ingredient cost submitted
25
Missing\invalid prescriber id
26
Missing\invalid unit of measure
28
Missing\invalid date prescription written
29
Missing\invalid number refills authorized
32
Missing\invalid level of service
33
Missing\invalid prescription origin code
34
Missing\invalid submission clarification code
35
Missing\invalid primary care provider id
38
Missing\invalid basis of cost
39
Missing\invalid diagnosis code
40
Pharmacy not contracted with plan on date of service
41
Submit bill to other processor or primary payer
50
Non matched pharmacy number
51
Non matched group id
52
Non matched cardholder id
53
Non matched person code
54
Non matched product/service id number
55
Non matched product package size
56
Non matched prescriber id
58
Non matched primary prescriber
60
Product/service not covered for patient age
61
Product/service not covered for patient gender
62
Patient/card holder id name mismatch
63
Institutionalized patient product/service id not covered
64
Claim submitted does not match prior authorization
65
Patient is not covered
66
Patient age exceeds maximum age
67
Filled before coverage effective
68
Filled after coverage expired
69
Filled after coverage terminated
70
Product/service not covered
71
Prescriber is not covered
72
Primary prescriber is not covered
73
Refills are not covered
74
Other carrier payment meets or exceeds payable
75
Prior authorization required
76
Plan limitations exceeded
77
Discontinued product/service id number
78
Cost exceeds maximum
79
Refill too soon
80
Drug diagnosis mismatch
81
Claim too old
82
Claim is post dated
83
Duplicate paid/captured claim
84
Claim has not been paid/captured
85
Claim not processed
86
Submit manual reversal
87
Reversal not processed
88
Dur reject error
89
Rejected claim fees paid
90
Host hung up
91
Host response error
92
System unavailable/host unavailable
99
Host processing error
000
No Reject Code Applies
A9
Missing\invalid transaction count
AA
Patient spenddown not met
AB
Date written is after date filled
AC
Product not covered non participating manufacturer
AD
Billing provider not eligible to bill this claim type
AE
Qmb (qualified medicare beneficiary) bill medicare
AF
Patient enrolled under managed care
AG
Days supply limitation for product/service
AH
Unit dose packaging only payable for nursing home recipients
AJ
Generic drug required
AK
Missing\invalid software vendor/certification id
AM
Missing\invalid segment identification
B2
Missing\invalid service provider id qualifier
BE
Missing\invalid professional service fee submitted
CA
Missing\invalid patient first name
CB
Missing\invalid patient last name
CC
Missing\invalid cardholder first name
CD
Missing\invalid cardholder last name
CE
Missing\invalid home plan
CF
Missing\invalid employer name
CG
Missing\invalid employer street address
CH
Missing\invalid employer city address
CI
Missing\invalid employer state/province address
CJ
Missing\invalid employer zip postal zone
CK
Missing\invalid employer phone number
CL
Missing\invalid employer contact name
CM
Missing\invalid patient street address
CN
Missing\invalid patient city address
CO
Missing\invalid patient state/province address
CP
Missing\invalid patient zip/postal zone
CQ
Missing\invalid patient phone number
CR
Missing\invalid carrier id
CW
Missing\invalid alternate id
CX
Missing\invalid patient id qualifier
CY
Missing\invalid patient id
CZ
Missing\invalid employer id
DC
Missing\invalid dispensing fee submitted
DN
Missing\invalid basis of cost determination
DQ
Missing\invalid usual and customary charge
DR
Missing\invalid prescriber last name
DT
Missing\invalid unit dose indicator
DU
Missing\invalid gross amount due
DV
Missing\invalid other payer amount paid
DX
Missing\invalid patient paid amount submitted
DY
Missing\invalid date of injury
DZ
Missing\invalid claim/reference id
E1
Missing\invalid product/service id qualifier
E3
Missing\invalid incentive amount submitted
E4
Missing\invalid reason for service code
E5
Missing\invalid professional service code
E6
Missing\invalid result of service code
E7
Missing\invalid quantity dispensed
E8
Missing\invalid other payer date
E9
Missing\invalid provider id
EA
Missing\invalid originally prescribed product/service code
EB
Missing\invalid originally prescribed quantity
EC
Missing\invalid compound ingredient component count
ED
Missing\invalid compound ingredient quantity
EE
Missing\invalid compound ingredient drug cost
EF
Missing\invalid compound dosage form descriptin code
EG
Missing\invalid compound dispensing unit form indicator
EH
Missing\invalid compound route of administration
EJ
Missing\invalid originally prescribed product/service id qualifier
EK
Missing\invalid scheduled prescription id number
EM
Missing\invalid prescription/service reference number qualifier
EN
Missing\invalid associated prescription/service reference number
EP
Missing\invalid associated prescription/service date
ER
Missing\invalid procedure modifier code
ET
Missing\invalid quantity prescribed
EU
Missing\invalid prior authorization type code
EV
Missing\invalid prior authorization number submitted
EW
Missing\invalid intermediary authorization type id
EX
Missing\invalid intermediary authorization id
EY
Missing\invalid provider id qualifier
EZ
Missing\invalid prescriber id qualifier
FO
Missing\invalid plan id
GE
Missing\invalid percentage sales tax amount submitted
H1
Missing\invalid measurement time
H2
Missing\invalid measurement dimension
H3
Missing\invalid measurement unit
H4
Missing\invalid measurement value
H5
Missing\invalid primary care provider location code
H6
Missing\invalid dur co agent id
H7
Missing\invalid other amount claimed submitted count
H8
Missing\invalid other amount claimed submitted qualifier
H9
Missing\invalid other amount claimed submitted
HA
Missing\invalid flat sales tax amount submitted
HB
Missing\invalid other payer amount paid count
HC
Missing\invalid other payer amount paid qualifier
HD
Missing\invalid dispensing status
HE
Missing\invalid percentage sales tax rate submitted
HF
Missing\invalid quantity intended to be dispensed
HG
Missing\invalid days supply intended to be dispensed
J9
Missing\invalid dur co agent id qualifier
JE
Missing\invalid percentage sales tax basis submitted
KE
Missing\invalid coupon type
M1
Patient not covered in this aid category
M2
Recipient locked in
M3
Host pa/mc error
M4
Prescription/service reference number/time limit exceeded
M5
Requires manual claim
M6
Host eligibility error
M7
Host drug file error
M8
Host provider file error
ME
Missing\invalid coupon number
MZ
Error overflow
NE
Missing\invalid coupon value amount
NN
Transaction rejected at switch or intermediary
P1
Associated prescription/service reference number not found
P2
Clinical information counter out of sequence
P3
Compound ingredient component count does not match number of repetitions
P4
Coordination of benefits/other payments count does not match number of repetitions
P5
Coupon expired
P6
Date of service prior to date of birth
P7
Diagnosis code count does not match number of repetitions
P8
Dur/pps code counter out of sequence
P9
Field is non repeatable
PA
Pa exhausted/not renewable
PB
Invalid transaction count for this transaction code
PC
Missing\invalid claim segment
PD
Missing\invalid clinical segment
PE
Missing\invalid cob/other payments segment
PF
Missing\invalid compound segment
PG
Missing\invalid coupon segment
PH
Missing\invalid dur/pps segment
PJ
Missing\invalid insurance segment
PK
Missing\invalid patient segment
PM
Missing\invalid pharmacy provider segment
PN
Missing\invalid prescriber segment
PP
Missing\invalid pricing segment
PR
Missing\invalid prior authorization segment
PS
Missing\invalid transaction header segment
PT
Missing\invalid workers' compensation segment
PV
Non matched associated prescription/service date
PW
Non matched employer id
PX
Non matched other payer id
PY
Non Matched Unit Form/Route of Administration
PZ
Non matched unit of measure to product/service id
R1
Other amount claimed submitted count does not match number of repetitions
R2
Other payer reject count does not match number of repetitions
R3
Procedure modifier code count does not match number of repetitions
R4
Procedure modifier code invalid for product/service id
R5
Product/service id must be zero when product/service id qualifier equals 06
R6
Product/service not appropriate for this location
R7
Repeating segment not allowed in same transaction
R8
Syntax error
R9
Value in gross amount due does not follow pricing formulae
RA
Pa reversal out of order
RB
Multiple partials not allowed
RC
Different drug entity between partial & completion
RD
Mismatched cardholder/group id partial to completion
RE
Missing\invalid compound product id qualifier
RF
Improper order of 'dispensing status' code on partial fill transaction
RG
MISSING\INVALID Associated Prescription/service Reference Number On Completion Transaction
RH
Missing\invalid associated prescription/service date on completion transaction
RJ
Associated partial fill transaction not on file
RK
Partial fill transaction not supported
RM
Completion transaction not permitted with same 'date of service' as partial transaction
RN
Plan limits exceeded on intended partial fill values
RP
Out of sequence 'p' reversal on partial fill transaction
RS
Missing\invalid associated prescription/service date on partial transaction
RT
Missing\invalid associated prescription/service reference number on partial transaction
RU
Mandatory data elements must occur before optional data elements in a segment
SE
Missing\invalid procedure modifier code count
TE
Missing\invalid compound product id
UE
Missing\invalid compound ingredient basis of cost determination
VE
Missing\invalid diagnosis code count
WE
Missing\invalid diagnosis code qualifier
XE
Missing\invalid clinical information counter
ZE
Missing\invalid measurement date
Data Element: 48
not present in this file submission.
49
[Unshared] Name: Reject Code 2
[Unshared] Type: Not Provided
[Unshared] Length: 3
Codes:
*95
Time out
*96
Scheduled downtime
*97
Payer unavailable
*98
Connection to payer is down
1C
Missing\invalid smoker/non smoker code
1E
Missing\invalid prescriber location code
2C
Missing\invalid pregnancy indicator
2E
Missing\invalid primary care provider id qualifier
3A
Missing\invalid request type
3B
Missing\invalid request period date begin
3C
Missing\invalid request period date end
3D
Missing\invalid basis of request
3E
Missing\invalid authorized representative first name
3F
Missing\invalid authorized representative last name
3G
Missing\invalid authorized representative street address
3H
Missing\invalid authorized representative city address
3J
Missing\invalid authorized representative state/province address
3K
Missing\invalid authorized representative zip/postal zone
3M
Missing\invalid prescriber phone number
3N
Missing\invalid prior authorized number assigned
3P
Missing\invalid authorization number
3R
Prior authorization not required
3S
Missing\invalid prior authorization supporting documentation
3T
Active prior authorization exists resubmit at expiration of prior authorization
3W
Prior authorization in process
3X
Authorization number not found
3Y
Prior authorization denied
4C
Missing\invalid coordination of benefits/other payments count
4E
Missing\invalid primary care provider last name
5C
Missing\invalid other payer coverage type
5E
Missing\invalid other payer reject count
6C
Missing\invalid other payer id qualifier
6E
Missing\invalid other payer reject code
7C
Missing\invalid other payer id
7E
Missing\invalid dur/pps code counter
8C
Missing\invalid facility id
8E
Missing\invalid dur/pps level of effort
00
No Reject Code Applies
01
Missing\invalid bin
02
Missing\invalid version number
03
Missing\invalid transaction code
04
Missing\invalid processor control number
05
Missing\invalid pharmacy number
06
Missing\invalid group number
07
Missing\invalid cardholder id number
08
Missing\invalid person code
09
Missing\invalid birth date
10
Missing\invalid patient gender code
11
Missing\invalid patient relationship code
12
Missing\invalid patient location
13
Missing\invalid other coverage cod
14
Missing\invalid eligibility clarification code
15
MISSING\INVALID Date of Service
16
Missing\invalid prescription/service reference number
17
Missing\invalid fill number
19
Missing\invalid days supply
20
Missing\invalid compound code
21
Missing\invalid product/service id
22
Missing\invalid dispense as written (daw)/product selection code
23
Missing\invalid ingredient cost submitted
25
Missing\invalid prescriber id
26
Missing\invalid unit of measure
28
Missing\invalid date prescription written
29
Missing\invalid number refills authorized
32
Missing\invalid level of service
33
Missing\invalid prescription origin code
34
Missing\invalid submission clarification code
35
Missing\invalid primary care provider id
38
Missing\invalid basis of cost
39
Missing\invalid diagnosis code
40
Pharmacy not contracted with plan on date of service
41
Submit bill to other processor or primary payer
50
Non matched pharmacy number
51
Non matched group id
52
Non matched cardholder id
53
Non matched person code
54
Non matched product/service id number
55
Non matched product package size
56
Non matched prescriber id
58
Non matched primary prescriber
60
Product/service not covered for patient age
61
Product/service not covered for patient gender
62
Patient/card holder id name mismatch
63
Institutionalized patient product/service id not covered
64
Claim submitted does not match prior authorization
65
Patient is not covered
66
Patient age exceeds maximum age
67
Filled before coverage effective
68
Filled after coverage expired
69
Filled after coverage terminated
70
Product/service not covered
71
Prescriber is not covered
72
Primary prescriber is not covered
73
Refills are not covered
74
Other carrier payment meets or exceeds payable
75
Prior authorization required
76
Plan limitations exceeded
77
Discontinued product/service id number
78
Cost exceeds maximum
79
Refill too soon
80
Drug diagnosis mismatch
81
Claim too old
82
Claim is post dated
83
Duplicate paid/captured claim
84
Claim has not been paid/captured
85
Claim not processed
86
Submit manual reversal
87
Reversal not processed
88
Dur reject error
89
Rejected claim fees paid
90
Host hung up
91
Host response error
92
System unavailable/host unavailable
99
Host processing error
000
No Reject Code Applies
A9
Missing\invalid transaction count
AA
Patient spenddown not met
AB
Date written is after date filled
AC
Product not covered non participating manufacturer
AD
Billing provider not eligible to bill this claim type
AE
Qmb (qualified medicare beneficiary) bill medicare
AF
Patient enrolled under managed care
AG
Days supply limitation for product/service
AH
Unit dose packaging only payable for nursing home recipients
AJ
Generic drug required
AK
Missing\invalid software vendor/certification id
AM
Missing\invalid segment identification
B2
Missing\invalid service provider id qualifier
BE
Missing\invalid professional service fee submitted
CA
Missing\invalid patient first name
CB
Missing\invalid patient last name
CC
Missing\invalid cardholder first name
CD
Missing\invalid cardholder last name
CE
Missing\invalid home plan
CF
Missing\invalid employer name
CG
Missing\invalid employer street address
CH
Missing\invalid employer city address
CI
Missing\invalid employer state/province address
CJ
Missing\invalid employer zip postal zone
CK
Missing\invalid employer phone number
CL
Missing\invalid employer contact name
CM
Missing\invalid patient street address
CN
Missing\invalid patient city address
CO
Missing\invalid patient state/province address
CP
Missing\invalid patient zip/postal zone
CQ
Missing\invalid patient phone number
CR
Missing\invalid carrier id
CW
Missing\invalid alternate id
CX
Missing\invalid patient id qualifier
CY
Missing\invalid patient id
CZ
Missing\invalid employer id
DC
Missing\invalid dispensing fee submitted
DN
Missing\invalid basis of cost determination
DQ
Missing\invalid usual and customary charge
DR
Missing\invalid prescriber last name
DT
Missing\invalid unit dose indicator
DU
Missing\invalid gross amount due
DV
Missing\invalid other payer amount paid
DX
Missing\invalid patient paid amount submitted
DY
Missing\invalid date of injury
DZ
Missing\invalid claim/reference id
E1
Missing\invalid product/service id qualifier
E3
Missing\invalid incentive amount submitted
E4
Missing\invalid reason for service code
E5
Missing\invalid professional service code
E6
Missing\invalid result of service code
E7
Missing\invalid quantity dispensed
E8
Missing\invalid other payer date
E9
Missing\invalid provider id
EA
Missing\invalid originally prescribed product/service code
EB
Missing\invalid originally prescribed quantity
EC
Missing\invalid compound ingredient component count
ED
Missing\invalid compound ingredient quantity
EE
Missing\invalid compound ingredient drug cost
EF
Missing\invalid compound dosage form descriptin code
EG
Missing\invalid compound dispensing unit form indicator
EH
Missing\invalid compound route of administration
EJ
Missing\invalid originally prescribed product/service id qualifier
EK
Missing\invalid scheduled prescription id number
EM
Missing\invalid prescription/service reference number qualifier
EN
Missing\invalid associated prescription/service reference number
EP
Missing\invalid associated prescription/service date
ER
Missing\invalid procedure modifier code
ET
Missing\invalid quantity prescribed
EU
Missing\invalid prior authorization type code
EV
Missing\invalid prior authorization number submitted
EW
Missing\invalid intermediary authorization type id
EX
Missing\invalid intermediary authorization id
EY
Missing\invalid provider id qualifier
EZ
Missing\invalid prescriber id qualifier
FO
Missing\invalid plan id
GE
Missing\invalid percentage sales tax amount submitted
H1
Missing\invalid measurement time
H2
Missing\invalid measurement dimension
H3
Missing\invalid measurement unit
H4
Missing\invalid measurement value
H5
Missing\invalid primary care provider location code
H6
Missing\invalid dur co agent id
H7
Missing\invalid other amount claimed submitted count
H8
Missing\invalid other amount claimed submitted qualifier
H9
Missing\invalid other amount claimed submitted
HA
Missing\invalid flat sales tax amount submitted
HB
Missing\invalid other payer amount paid count
HC
Missing\invalid other payer amount paid qualifier
HD
Missing\invalid dispensing status
HE
Missing\invalid percentage sales tax rate submitted
HF
Missing\invalid quantity intended to be dispensed
HG
Missing\invalid days supply intended to be dispensed
J9
Missing\invalid dur co agent id qualifier
JE
Missing\invalid percentage sales tax basis submitted
KE
Missing\invalid coupon type
M1
Patient not covered in this aid category
M2
Recipient locked in
M3
Host pa/mc error
M4
Prescription/service reference number/time limit exceeded
M5
Requires manual claim
M6
Host eligibility error
M7
Host drug file error
M8
Host provider file error
ME
Missing\invalid coupon number
MZ
Error overflow
NE
Missing\invalid coupon value amount
NN
Transaction rejected at switch or intermediary
P1
Associated prescription/service reference number not found
P2
Clinical information counter out of sequence
P3
Compound ingredient component count does not match number of repetitions
P4
Coordination of benefits/other payments count does not match number of repetitions
P5
Coupon expired
P6
Date of service prior to date of birth
P7
Diagnosis code count does not match number of repetitions
P8
Dur/pps code counter out of sequence
P9
Field is non repeatable
PA
Pa exhausted/not renewable
PB
Invalid transaction count for this transaction code
PC
Missing\invalid claim segment
PD
Missing\invalid clinical segment
PE
Missing\invalid cob/other payments segment
PF
Missing\invalid compound segment
PG
Missing\invalid coupon segment
PH
Missing\invalid dur/pps segment
PJ
Missing\invalid insurance segment
PK
Missing\invalid patient segment
PM
Missing\invalid pharmacy provider segment
PN
Missing\invalid prescriber segment
PP
Missing\invalid pricing segment
PR
Missing\invalid prior authorization segment
PS
Missing\invalid transaction header segment
PT
Missing\invalid workers' compensation segment
PV
Non matched associated prescription/service date
PW
Non matched employer id
PX
Non matched other payer id
PY
Non Matched Unit Form/Route of Administration
PZ
Non matched unit of measure to product/service id
R1
Other amount claimed submitted count does not match number of repetitions
R2
Other payer reject count does not match number of repetitions
R3
Procedure modifier code count does not match number of repetitions
R4
Procedure modifier code invalid for product/service id
R5
Product/service id must be zero when product/service id qualifier equals 06
R6
Product/service not appropriate for this location
R7
Repeating segment not allowed in same transaction
R8
Syntax error
R9
Value in gross amount due does not follow pricing formulae
RA
Pa reversal out of order
RB
Multiple partials not allowed
RC
Different drug entity between partial & completion
RD
Mismatched cardholder/group id partial to completion
RE
Missing\invalid compound product id qualifier
RF
Improper order of 'dispensing status' code on partial fill transaction
RG
MISSING\INVALID Associated Prescription/service Reference Number On Completion Transaction
RH
Missing\invalid associated prescription/service date on completion transaction
RJ
Associated partial fill transaction not on file
RK
Partial fill transaction not supported
RM
Completion transaction not permitted with same 'date of service' as partial transaction
RN
Plan limits exceeded on intended partial fill values
RP
Out of sequence 'p' reversal on partial fill transaction
RS
Missing\invalid associated prescription/service date on partial transaction
RT
Missing\invalid associated prescription/service reference number on partial transaction
RU
Mandatory data elements must occur before optional data elements in a segment
SE
Missing\invalid procedure modifier code count
TE
Missing\invalid compound product id
UE
Missing\invalid compound ingredient basis of cost determination
VE
Missing\invalid diagnosis code count
WE
Missing\invalid diagnosis code qualifier
XE
Missing\invalid clinical information counter
ZE
Missing\invalid measurement date
Data Element: 49
not present in this file submission.
50
[Unshared] Name: Reject Code 3
[Unshared] Type: Not Provided
[Unshared] Length: 3
Codes:
*95
Time out
*96
Scheduled downtime
*97
Payer unavailable
*98
Connection to payer is down
1C
Missing\invalid smoker/non smoker code
1E
Missing\invalid prescriber location code
2C
Missing\invalid pregnancy indicator
2E
Missing\invalid primary care provider id qualifier
3A
Missing\invalid request type
3B
Missing\invalid request period date begin
3C
Missing\invalid request period date end
3D
Missing\invalid basis of request
3E
Missing\invalid authorized representative first name
3F
Missing\invalid authorized representative last name
3G
Missing\invalid authorized representative street address
3H
Missing\invalid authorized representative city address
3J
Missing\invalid authorized representative state/province address
3K
Missing\invalid authorized representative zip/postal zone
3M
Missing\invalid prescriber phone number
3N
Missing\invalid prior authorized number assigned
3P
Missing\invalid authorization number
3R
Prior authorization not required
3S
Missing\invalid prior authorization supporting documentation
3T
Active prior authorization exists resubmit at expiration of prior authorization
3W
Prior authorization in process
3X
Authorization number not found
3Y
Prior authorization denied
4C
Missing\invalid coordination of benefits/other payments count
4E
Missing\invalid primary care provider last name
5C
Missing\invalid other payer coverage type
5E
Missing\invalid other payer reject count
6C
Missing\invalid other payer id qualifier
6E
Missing\invalid other payer reject code
7C
Missing\invalid other payer id
7E
Missing\invalid dur/pps code counter
8C
Missing\invalid facility id
8E
Missing\invalid dur/pps level of effort
00
No Reject Code Applies
01
Missing\invalid bin
02
Missing\invalid version number
03
Missing\invalid transaction code
04
Missing\invalid processor control number
05
Missing\invalid pharmacy number
06
Missing\invalid group number
07
Missing\invalid cardholder id number
08
Missing\invalid person code
09
Missing\invalid birth date
10
Missing\invalid patient gender code
11
Missing\invalid patient relationship code
12
Missing\invalid patient location
13
Missing\invalid other coverage cod
14
Missing\invalid eligibility clarification code
15
MISSING\INVALID Date of Service
16
Missing\invalid prescription/service reference number
17
Missing\invalid fill number
19
Missing\invalid days supply
20
Missing\invalid compound code
21
Missing\invalid product/service id
22
Missing\invalid dispense as written (daw)/product selection code
23
Missing\invalid ingredient cost submitted
25
Missing\invalid prescriber id
26
Missing\invalid unit of measure
28
Missing\invalid date prescription written
29
Missing\invalid number refills authorized
32
Missing\invalid level of service
33
Missing\invalid prescription origin code
34
Missing\invalid submission clarification code
35
Missing\invalid primary care provider id
38
Missing\invalid basis of cost
39
Missing\invalid diagnosis code
40
Pharmacy not contracted with plan on date of service
41
Submit bill to other processor or primary payer
50
Non matched pharmacy number
51
Non matched group id
52
Non matched cardholder id
53
Non matched person code
54
Non matched product/service id number
55
Non matched product package size
56
Non matched prescriber id
58
Non matched primary prescriber
60
Product/service not covered for patient age
61
Product/service not covered for patient gender
62
Patient/card holder id name mismatch
63
Institutionalized patient product/service id not covered
64
Claim submitted does not match prior authorization
65
Patient is not covered
66
Patient age exceeds maximum age
67
Filled before coverage effective
68
Filled after coverage expired
69
Filled after coverage terminated
70
Product/service not covered
71
Prescriber is not covered
72
Primary prescriber is not covered
73
Refills are not covered
74
Other carrier payment meets or exceeds payable
75
Prior authorization required
76
Plan limitations exceeded
77
Discontinued product/service id number
78
Cost exceeds maximum
79
Refill too soon
80
Drug diagnosis mismatch
81
Claim too old
82
Claim is post dated
83
Duplicate paid/captured claim
84
Claim has not been paid/captured
85
Claim not processed
86
Submit manual reversal
87
Reversal not processed
88
Dur reject error
89
Rejected claim fees paid
90
Host hung up
91
Host response error
92
System unavailable/host unavailable
99
Host processing error
000
No Reject Code Applies
A9
Missing\invalid transaction count
AA
Patient spenddown not met
AB
Date written is after date filled
AC
Product not covered non participating manufacturer
AD
Billing provider not eligible to bill this claim type
AE
Qmb (qualified medicare beneficiary) bill medicare
AF
Patient enrolled under managed care
AG
Days supply limitation for product/service
AH
Unit dose packaging only payable for nursing home recipients
AJ
Generic drug required
AK
Missing\invalid software vendor/certification id
AM
Missing\invalid segment identification
B2
Missing\invalid service provider id qualifier
BE
Missing\invalid professional service fee submitted
CA
Missing\invalid patient first name
CB
Missing\invalid patient last name
CC
Missing\invalid cardholder first name
CD
Missing\invalid cardholder last name
CE
Missing\invalid home plan
CF
Missing\invalid employer name
CG
Missing\invalid employer street address
CH
Missing\invalid employer city address
CI
Missing\invalid employer state/province address
CJ
Missing\invalid employer zip postal zone
CK
Missing\invalid employer phone number
CL
Missing\invalid employer contact name
CM
Missing\invalid patient street address
CN
Missing\invalid patient city address
CO
Missing\invalid patient state/province address
CP
Missing\invalid patient zip/postal zone
CQ
Missing\invalid patient phone number
CR
Missing\invalid carrier id
CW
Missing\invalid alternate id
CX
Missing\invalid patient id qualifier
CY
Missing\invalid patient id
CZ
Missing\invalid employer id
DC
Missing\invalid dispensing fee submitted
DN
Missing\invalid basis of cost determination
DQ
Missing\invalid usual and customary charge
DR
Missing\invalid prescriber last name
DT
Missing\invalid unit dose indicator
DU
Missing\invalid gross amount due
DV
Missing\invalid other payer amount paid
DX
Missing\invalid patient paid amount submitted
DY
Missing\invalid date of injury
DZ
Missing\invalid claim/reference id
E1
Missing\invalid product/service id qualifier
E3
Missing\invalid incentive amount submitted
E4
Missing\invalid reason for service code
E5
Missing\invalid professional service code
E6
Missing\invalid result of service code
E7
Missing\invalid quantity dispensed
E8
Missing\invalid other payer date
E9
Missing\invalid provider id
EA
Missing\invalid originally prescribed product/service code
EB
Missing\invalid originally prescribed quantity
EC
Missing\invalid compound ingredient component count
ED
Missing\invalid compound ingredient quantity
EE
Missing\invalid compound ingredient drug cost
EF
Missing\invalid compound dosage form descriptin code
EG
Missing\invalid compound dispensing unit form indicator
EH
Missing\invalid compound route of administration
EJ
Missing\invalid originally prescribed product/service id qualifier
EK
Missing\invalid scheduled prescription id number
EM
Missing\invalid prescription/service reference number qualifier
EN
Missing\invalid associated prescription/service reference number
EP
Missing\invalid associated prescription/service date
ER
Missing\invalid procedure modifier code
ET
Missing\invalid quantity prescribed
EU
Missing\invalid prior authorization type code
EV
Missing\invalid prior authorization number submitted
EW
Missing\invalid intermediary authorization type id
EX
Missing\invalid intermediary authorization id
EY
Missing\invalid provider id qualifier
EZ
Missing\invalid prescriber id qualifier
FO
Missing\invalid plan id
GE
Missing\invalid percentage sales tax amount submitted
H1
Missing\invalid measurement time
H2
Missing\invalid measurement dimension
H3
Missing\invalid measurement unit
H4
Missing\invalid measurement value
H5
Missing\invalid primary care provider location code
H6
Missing\invalid dur co agent id
H7
Missing\invalid other amount claimed submitted count
H8
Missing\invalid other amount claimed submitted qualifier
H9
Missing\invalid other amount claimed submitted
HA
Missing\invalid flat sales tax amount submitted
HB
Missing\invalid other payer amount paid count
HC
Missing\invalid other payer amount paid qualifier
HD
Missing\invalid dispensing status
HE
Missing\invalid percentage sales tax rate submitted
HF
Missing\invalid quantity intended to be dispensed
HG
Missing\invalid days supply intended to be dispensed
J9
Missing\invalid dur co agent id qualifier
JE
Missing\invalid percentage sales tax basis submitted
KE
Missing\invalid coupon type
M1
Patient not covered in this aid category
M2
Recipient locked in
M3
Host pa/mc error
M4
Prescription/service reference number/time limit exceeded
M5
Requires manual claim
M6
Host eligibility error
M7
Host drug file error
M8
Host provider file error
ME
Missing\invalid coupon number
MZ
Error overflow
NE
Missing\invalid coupon value amount
NN
Transaction rejected at switch or intermediary
P1
Associated prescription/service reference number not found
P2
Clinical information counter out of sequence
P3
Compound ingredient component count does not match number of repetitions
P4
Coordination of benefits/other payments count does not match number of repetitions
P5
Coupon expired
P6
Date of service prior to date of birth
P7
Diagnosis code count does not match number of repetitions
P8
Dur/pps code counter out of sequence
P9
Field is non repeatable
PA
Pa exhausted/not renewable
PB
Invalid transaction count for this transaction code
PC
Missing\invalid claim segment
PD
Missing\invalid clinical segment
PE
Missing\invalid cob/other payments segment
PF
Missing\invalid compound segment
PG
Missing\invalid coupon segment
PH
Missing\invalid dur/pps segment
PJ
Missing\invalid insurance segment
PK
Missing\invalid patient segment
PM
Missing\invalid pharmacy provider segment
PN
Missing\invalid prescriber segment
PP
Missing\invalid pricing segment
PR
Missing\invalid prior authorization segment
PS
Missing\invalid transaction header segment
PT
Missing\invalid workers' compensation segment
PV
Non matched associated prescription/service date
PW
Non matched employer id
PX
Non matched other payer id
PY
Non Matched Unit Form/Route of Administration
PZ
Non matched unit of measure to product/service id
R1
Other amount claimed submitted count does not match number of repetitions
R2
Other payer reject count does not match number of repetitions
R3
Procedure modifier code count does not match number of repetitions
R4
Procedure modifier code invalid for product/service id
R5
Product/service id must be zero when product/service id qualifier equals 06
R6
Product/service not appropriate for this location
R7
Repeating segment not allowed in same transaction
R8
Syntax error
R9
Value in gross amount due does not follow pricing formulae
RA
Pa reversal out of order
RB
Multiple partials not allowed
RC
Different drug entity between partial & completion
RD
Mismatched cardholder/group id partial to completion
RE
Missing\invalid compound product id qualifier
RF
Improper order of 'dispensing status' code on partial fill transaction
RG
MISSING\INVALID Associated Prescription/service Reference Number On Completion Transaction
RH
Missing\invalid associated prescription/service date on completion transaction
RJ
Associated partial fill transaction not on file
RK
Partial fill transaction not supported
RM
Completion transaction not permitted with same 'date of service' as partial transaction
RN
Plan limits exceeded on intended partial fill values
RP
Out of sequence 'p' reversal on partial fill transaction
RS
Missing\invalid associated prescription/service date on partial transaction
RT
Missing\invalid associated prescription/service reference number on partial transaction
RU
Mandatory data elements must occur before optional data elements in a segment
SE
Missing\invalid procedure modifier code count
TE
Missing\invalid compound product id
UE
Missing\invalid compound ingredient basis of cost determination
VE
Missing\invalid diagnosis code count
WE
Missing\invalid diagnosis code qualifier
XE
Missing\invalid clinical information counter
ZE
Missing\invalid measurement date
Data Element: 50
not present in this file submission.
51
[Unshared] Name: Reject Code 4
[Unshared] Type: Not Provided
[Unshared] Length: 3
Codes:
*95
Time out
*96
Scheduled downtime
*97
Payer unavailable
*98
Connection to payer is down
1C
Missing\invalid smoker/non smoker code
1E
Missing\invalid prescriber location code
2C
Missing\invalid pregnancy indicator
2E
Missing\invalid primary care provider id qualifier
3A
Missing\invalid request type
3B
Missing\invalid request period date begin
3C
Missing\invalid request period date end
3D
Missing\invalid basis of request
3E
Missing\invalid authorized representative first name
3F
Missing\invalid authorized representative last name
3G
Missing\invalid authorized representative street address
3H
Missing\invalid authorized representative city address
3J
Missing\invalid authorized representative state/province address
3K
Missing\invalid authorized representative zip/postal zone
3M
Missing\invalid prescriber phone number
3N
Missing\invalid prior authorized number assigned
3P
Missing\invalid authorization number
3R
Prior authorization not required
3S
Missing\invalid prior authorization supporting documentation
3T
Active prior authorization exists resubmit at expiration of prior authorization
3W
Prior authorization in process
3X
Authorization number not found
3Y
Prior authorization denied
4C
Missing\invalid coordination of benefits/other payments count
4E
Missing\invalid primary care provider last name
5C
Missing\invalid other payer coverage type
5E
Missing\invalid other payer reject count
6C
Missing\invalid other payer id qualifier
6E
Missing\invalid other payer reject code
7C
Missing\invalid other payer id
7E
Missing\invalid dur/pps code counter
8C
Missing\invalid facility id
8E
Missing\invalid dur/pps level of effort
00
No Reject Code Applies
01
Missing\invalid bin
02
Missing\invalid version number
03
Missing\invalid transaction code
04
Missing\invalid processor control number
05
Missing\invalid pharmacy number
06
Missing\invalid group number
07
Missing\invalid cardholder id number
08
Missing\invalid person code
09
Missing\invalid birth date
10
Missing\invalid patient gender code
11
Missing\invalid patient relationship code
12
Missing\invalid patient location
13
Missing\invalid other coverage cod
14
Missing\invalid eligibility clarification code
15
MISSING\INVALID Date of Service
16
Missing\invalid prescription/service reference number
17
Missing\invalid fill number
19
Missing\invalid days supply
20
Missing\invalid compound code
21
Missing\invalid product/service id
22
Missing\invalid dispense as written (daw)/product selection code
23
Missing\invalid ingredient cost submitted
25
Missing\invalid prescriber id
26
Missing\invalid unit of measure
28
Missing\invalid date prescription written
29
Missing\invalid number refills authorized
32
Missing\invalid level of service
33
Missing\invalid prescription origin code
34
Missing\invalid submission clarification code
35
Missing\invalid primary care provider id
38
Missing\invalid basis of cost
39
Missing\invalid diagnosis code
40
Pharmacy not contracted with plan on date of service
41
Submit bill to other processor or primary payer
50
Non matched pharmacy number
51
Non matched group id
52
Non matched cardholder id
53
Non matched person code
54
Non matched product/service id number
55
Non matched product package size
56
Non matched prescriber id
58
Non matched primary prescriber
60
Product/service not covered for patient age
61
Product/service not covered for patient gender
62
Patient/card holder id name mismatch
63
Institutionalized patient product/service id not covered
64
Claim submitted does not match prior authorization
65
Patient is not covered
66
Patient age exceeds maximum age
67
Filled before coverage effective
68
Filled after coverage expired
69
Filled after coverage terminated
70
Product/service not covered
71
Prescriber is not covered
72
Primary prescriber is not covered
73
Refills are not covered
74
Other carrier payment meets or exceeds payable
75
Prior authorization required
76
Plan limitations exceeded
77
Discontinued product/service id number
78
Cost exceeds maximum
79
Refill too soon
80
Drug diagnosis mismatch
81
Claim too old
82
Claim is post dated
83
Duplicate paid/captured claim
84
Claim has not been paid/captured
85
Claim not processed
86
Submit manual reversal
87
Reversal not processed
88
Dur reject error
89
Rejected claim fees paid
90
Host hung up
91
Host response error
92
System unavailable/host unavailable
99
Host processing error
000
No Reject Code Applies
A9
Missing\invalid transaction count
AA
Patient spenddown not met
AB
Date written is after date filled
AC
Product not covered non participating manufacturer
AD
Billing provider not eligible to bill this claim type
AE
Qmb (qualified medicare beneficiary) bill medicare
AF
Patient enrolled under managed care
AG
Days supply limitation for product/service
AH
Unit dose packaging only payable for nursing home recipients
AJ
Generic drug required
AK
Missing\invalid software vendor/certification id
AM
Missing\invalid segment identification
B2
Missing\invalid service provider id qualifier
BE
Missing\invalid professional service fee submitted
CA
Missing\invalid patient first name
CB
Missing\invalid patient last name
CC
Missing\invalid cardholder first name
CD
Missing\invalid cardholder last name
CE
Missing\invalid home plan
CF
Missing\invalid employer name
CG
Missing\invalid employer street address
CH
Missing\invalid employer city address
CI
Missing\invalid employer state/province address
CJ
Missing\invalid employer zip postal zone
CK
Missin