Appendix A—Response Codes

Adjudication Response Codes

Standard Canadian Pharmacists Association response codes are attached to a claim when it is returned by PharmaNet, providing information on the status of the claim.

Although the list below can be used as a guide, pharmacists should refer to the latest version of the Canadian Pharmacists Association (CPhA) Pharmacy Claim Standard for the most up-to-date and authoritative listing of adjudication response codes. Note: The series of codes in bold text (MA to NE) are not error codes. These codes are returned in the Drug Use Evaluation (DUE) response status field.

Response Codes

Response Code	Meaning
01	IIN error
02	Version number error
03	Transaction code error
04	Provider software ID error
05	Provider software version error
07	Active device ID error
08	PC terminal language error
09	Test indicator error
10	Invalid MMI code
11	Invalid MMI/clinical service code
12	MMI maximum exceeded
13	Invalid clinical service code
14	Invalid RBRVS parameter count
15	Invalid original Rx date
16	Drug not eligible for service
17	Prescriber must be a pharmacist
18	Field keyword contains invalid value
19	Practitioner ID not found
20	No service agreement identified
21	Pharmacy ID code error
22	Provider transaction date error
23	Trace number error
24	Service not eligible for veterinary Rx
25	Invalid dispense reference
26	"Refusal to fill" claim was paid
27	MMF claims exceed insurer limit
28	Clinical service claims exceed insurer limit
30	Carrier ID error
31	Group number error
32	Client ID # error
33	Patient code error
34	Patient DOB error
35	Cardholder identity error
36	Relationship error
37	Patient first name error
38	Patient last name error
39	Provincial healthcare # error
40	Patient gender error
41	Duplicate MMI event
42	Duplicate clinical service
43	Invalid dispense details submitted
44	Invalid MMF claim contact type
45	Patient not eligible for service reported
46	Too many same Rx references submitted
47	Too many same dispense references
50	Medical reason reference error
51	Medical condition/reason code error
52	New/refill code error
53	Original prescription number error
54	Refill/repeat authorization error
55	Current Rx # error
56	DIN/GP #/PIN error
57	SSC error
58	Quantity error
59	Days supply error
5A	Supply source error
5B	Designated pharmacy error
5C	Source package size error
5D	Prescription validity date error
60	Invalid prescriber ID reference code
61	Prescriber ID error
62	Product selection code error
63	Unlisted compound code error
64	Special authorization #/code error
65	Intervention/exception code error
66	Drug cost/product value error
67	Cost upcharge error
68	Professional fee error
70	Compounding charge error
71	Compounding time error
72	Special services fee error
75	Previously paid error
76	Pharmacist ID code error/missing
77	Adjudication date error
80	Service code & number of DINs do not match
81	Primary drug product is not insured
82	Product duplicated in this claim for payment
83	DIN is not allowed for the indicated condition
84	Authorization for this treatment has expired
85	Therapy (product) is not repeatable
86	Confirm provincial drug coverage for DIN
87	Exceeds max. # of prof. fees for this drug
90	Adjudication date error
91	Beginning of record error
92	End of record error
99	No claims for specified parameters
A1	Claim is too old
A2	Claim is post-dated
A3	Identical claim has been processed
A4	Claim has not been captured
A5	Claim has not been processed
A6	Submit manual claim
A7	Submit manual reversal
A8	No reversal made - orig. claim missing
A9	Reversal processed previously
AA	Duplicate of claim adjudication
AB	Swipe benefit card for payment
B1	Pharmacy not authorized to submit claims
B2	Return to first pharmacy requested
B3	Invalid PharmaNet Rx ID
B4	PharmaNet Rx ID does not match patient
B5	Prescriber differs from Rx
B6	Date of service is less than Rx date
B7	Date of service is less than disp. start date
B8	Prescription has expired
B9	Prescription has been adapted
BA	Chronic disease costs are not a benefit
C1	Patient age over plan maximum
C2	Service provided before effective date
C3	Coverage expired before service
C4	Coverage terminated before service
C5	Plan maximum exceeded
C6	Patient has other coverage
C7	Patient must claim reimbursement
C8	No record of this beneficiary
C9	Patient not covered for drugs
CA	Needles not eligible - insulin gun used
CB	Only enrolled for single coverage
CC	This spouse not enrolled
CD	Patient not entitled to drug claimed
CE	35 day maximum allowed for welfare client
CF	Quantity exceeds maximum days of treatment
CG	Drug not eligible for LTC facility
CH	Good faith coverage has expired
CI	Program not eligible for good faith
CJ	Patient not covered by this plan
CK	Health card version code error
CL	Exceeds good faith limit
CM	Patient is nearing quantity limit
CN	Patient has attained quantity limit
CO	Patient is over quantity limit
CP	Eligible for special authorization
CQ	Date not covered by premiums paid
CR	Patient is exceeding dosage safety limit
CS	Patient exclusion prevents payment
CT	Beneficiary not eligible to use provider
CU	Beneficiary not eligible to use prescriber
CV	No record of client ID number
CW	No record of group number or code
CX	No record of patient data
CY	No record of patient code
CZ	No record of authorization number
D1	DIN/PIN/GP #/SSC not a benefit
D2	DIN/PIN/GP # is discontinued
D3	Prescriber is not authorized
D4	Refills are not covered
D5	Co-pay exceeds total value
D6	Maximum cost is exceeded
D7	Refill too soon
D8	Reduced to generic cost
D9	Call adjudicator
DA	Adjusted to interchangeable - prov. reg.
DB	Adjusted to interchangeable - gen. plan
DC	Pharmacist ID requested
DD	Insufficient space for all DUR warnings
DE	Fill/refill too late - non-compliant
DF	Insufficient space for all warnings
DG	Duplicate prescription number
DH	Professional fee adjusted
DI	Deductible not satisfied
DJ	Drug cost adjusted
DK	Cross-selection pricing
DL	Collect difference from patient
DM	Days supply exceeds plan limit
DN	Alternate product is a benefit
DO	Future refills require prior approval
DP	Quantity exceeds maximum per claim
DQ	Quantity is less than minimum per claim
DR	Days supply lower than minimum allowable
DS	Reduced to cost upcharge maximum
DT	Reduced to compounding charge maximum
DU	Maximum compounding time exceeded
DV	Reduced to special service fee maximum
DW	Return to first prescriber requested
DX	Drug must be authorized
DY	Intervention/exception code missing
DZ	Days supply limited due to benefit yr end
E1	Host processing error
E2	Claim coordinated with govt plan
E3	Claim coordinated with other carrier
E4	Host timeout error
E5	Host processing error - please resubmit
E6	Host processing error - do not resubmit
E7	Host processor is down
E8	Patient must remit cash receipt to Trillium
E9	Reduced to reference-based price
EA	Benefits coordinated internally
EB	Limited use drug. Time has expired
EC	Limited use drug. Approaching time limit
ED	Concurrent therapy required
EE	Questionable concurrent therapy
EF	Inappropriate concurrent therapy
EG	No record of trying first-line therapy
EH	Claim cost reduced to days supply limit
EI	Reverse original claim and resubmit
EJ	Calculated renewal date is CCYYMMDD*
EK	Extended prescription term for XXX** days
EL	Prior to pro-rated start date
EM	ODB pricing - TDP deductible reached
EN	Insurer requires provincial plan enrolment
EO	Failure to enroll may suspend payment
EP	Last claim, must enroll with prov. plan
EQ	Reject, prov. plan enrolment required
ER	Program coverage validation is down
ES	Call service already paid (see field E-20)***
ET	Submit invoice for price verification
EU	Quantity &/or days supply not permitted
EV	Claim exceeds ODB legislated pricing
EW	Prof. fee exceeds ODB legislated pricing
EX	Handicap authorization is required
EY	Max cost/upcharge paid, do not claim balance
EZ	Allowed amount paid from an HSA****
FA	Conversion successful cognitive fee paid
FB	Invalid prescription status
FC	Dispensed medication differs from Rx
FD	Dispensed device differs from Rx
FE	Prescription is not an adaptation
FF	Must provide brand ordered - no sub. allowed
FG	Drug cost paid as per provider agreement
FH	Exceeds maximum special service fee allowed
FP	Dosage form not allowed for service claimed
FQ	Medical reason reference is not eligible
FR	Condition or risk factor is not eligible
GA	Preferred provider network fee paid
GB	Preferred provider network claim
GC	Quantity max. approval is 40 days supply
GD	Not eligible for a quantity authorization
GE	Drug is not a benefit
HA	Cardholder date of birth is required
HB	Cardholder is over coverage age limit
HC	Require cardholder province of residence
HD	Patient may qualify for govt program
HE	Coverage suspended - refer to employer
HF	Patient authorization expired CCYYMMDD
HG	Client has provided consent
HH	Client has not provided consent
HI	Client consent required
HJ	Client consent required in future
HK	Confirm patient status, contact insurer
I1	Beneficiary street address error
I2	City or municipality error
I3	Province or state code error
I4	Postal/zip code error
I5	Country code error
I6	Address type error
J1	Invalid PharmaNet Rx ID
J2	PharmaNet Rx ID does not match patient
J3	Prescriber ID does not match Rx info
J4	Rx filled prior to issue of Rx
J5	Rx filled before medication start date
J6	Requirement for medication has expired
J7	Rx has been adapted by the pharmacist
J8	Prescription status is no longer valid
J9	Medication issued differs from Rx
K1	Dispensed device differs from Rx
K2	Rx submitted is not an adaption Rx
K6	Parental relationship and age do not match
KA	Does not match patient information
KB	Does not match cardholder information
KC	Patient product dollar maximum exceeded
KD	Patient product deductible not satisfied
KE	Authorization dollar maximum exceeded
KF	Authorization quantity maximum exceeded
KG	Authorization refills exceeded
KH	Authorization costs allowed exceeded
KI	Prior to authorization eligible period
KJ	Authorization eligible period expired
KK	Not eligible for COB
KL	Age/relationship discrepancy
KM	Exceeds days supply limit for this drug
KN	Days supply limit for period exceeded
KO	Good faith code was used previously
KP	Obtained at other pharmacy - refill too soon
KQ	Good faith not valid
KR	Patient not eligible for product
KS	Client is deceased
KT	Assess patient SDP eligibility
KU	Patient at $... of a $... max.
KV	Patient has met max. of $...
KW	Patient exceeds max of $...
KX	Patient now eligible for maintenance supply
KY	Dependent covered by spouse's insurer
KZ	Student eligibility to be confirmed
LA	Adjudicated to $0.00 as requested
LB	Use generic - patient has generic plan
LC	Reduced to generic cost - no exceptions
LD	Do not collect co-pay - item is exempt
LE	Trial Rx second fee not allowed
LF	Prescriber ID reference is missing
LG	Lowest cost equivalent pricing
LH	Authorization required - call adjudicator
LI	Select network fee paid
LJ	Resubmit to WCB with DE intervention code
LK	Claim processed - net payable is $0.00
LL	Drug covered by RAMQ
LM	AIA - upcharge adjusted
LN	Check potential benefit criteria
LO	Benefit maximum exceeded
LP	Lifetime plan maximum exceeded
LQ	Exceeds NRT time limit
LR	Exceeds NRT reimbursement period
LS	Exceeds NRT XX day use limit*****
LT	See trace # XXXXXX, exceeds NRT use period******
LU	Other pharmacy trace # exceed NRT use period*******
LV	Exceeds annual NRT product limit
LW	Authorization for drug expires CCYYMMDD*******
LX	Predetermination - drug is eligible
LY	Claim EC drug in separate transaction
LZ	Claim adjusted to plan type fee cap
MA	Avoidance of alcohol indicated
MB	Avoidance of tobacco indicated
MC	Drug/lab interaction potential
MD	Drug/food interaction potential
ME	Drug/drug interaction potential
MF	May be exceeding Rx dosage
MG	May be using less than Rx dosage
MH	May be double doctoring
MI	Polypharmacy use indicated
MJ	Dose appears high
MK	Dose appears low
ML	Drug incompatibility indicated
MM	Prior ADR on record
MN	Drug allergy recorded
MP	Duration of therapy may be insufficient
MQ	Duration of therapy may be excessive
MR	Potential drug/disease interaction
MS	Potential drug/pregnancy concern
MT	Drug/gender conflict indicated
MU	Age precaution indicated
MV	Additive effect possible
MW	Duplicate drug
MX	Duplicate therapy
MY	Duplicate drug other pharmacy
MZ	Duplicate therapy other pharmacy
NA	Duplicate ingredient same pharmacy
NB	Duplicate ingredient other pharmacy
NC	Dosage exceeds maximum allowable
ND	Dosage is lower than minimum allowable
NE	Potential overuse/abuse indicated
NF	Quantity - treatment period discrepancy
NG	Product - form prescribed do not match
NH	Quantity error - indicate package size
NI	Only one service code is allowed
NJ	Request is inconsistent with other service
NK	Service requires compounding
NL	Service and compound type do not match
NM	Service and medication type do not match
NN	Intervention inconsistent with service
NO	Service requires controlled use drug
NP	Services to beneficiary are restricted
NQ	Drug not eligible for trial Rx
NR	Drug not suitable for dosette packaging
NS	Refusal and opinion claimed on same date
NT	Not suitable - similar item on recent trial Rx
NU	Too soon after previous therapy
NV	Potential duplicate claim
NW	Quantity - trial Rx days do not match
NX	Quantity exceeds trial days period
NY	Insufficient quantity for trial days period
NZ	Trial balance given too late
OA	Trial balance given too soon
OB	Reject trial Rx - days supply exceeded
OC	Quantity reduction required
OD	No trial Rx on record, balance rejected
OE	Trial balance already dispensed
OF	Initial Rx days supply exceeded
OG	Duration exceeds high DOT - no max. available
OH	Duration exceeds high DOT but not max.
OI	Claim precedes start of current period
OJ	Claim begins new limited supply period
OK	Maximum allowable AIA exceeded
OL	Max. allowable dispensing fee exceeded
OM	Special services fee not allowed
ON	Compounding fee not valid in this field
OP	Last supply (NCE) issued in pillbox
OQ	Special auth. eligible under other cvg
OR	Exception drug, submit to provincial plan
OS	Submit future claims to provincial plan
OT	Maximum fee paid - do not claim balance
OU	Refill is X days early
OV	Verbal prescription not permitted
OW	Verbal renewal not permitted
OX	Total claimed exceeds prescription price
OY	Special services fee has been adjusted
OZ	Patient now covered by successor payor
PA	Prescriber restriction for this drug
PB	No match to prescriber ID and name found
PC	Not a benefit for this prescriber type
PD	Cost reduced - pt. elected therapeutic option
QA	Matches health spending account funds
QB	Nearing health spending account funds max.
QC	Exceeds health spending account funds
QD	Prior health spending account
QE	Health spending account period expired
QF	Monthly maximum has been reached
QG	Drug not allowed by this program
QH	Calculated product price is too high
QI	Claim processed previously is cancelled
QJ	Deferred payment - patient to pay pharmacist
QK	Sent to insurer to reimburse $999.99
QL	Patient consultation suggested
QM	No record of required prior therapy
QN	Agency restriction for this drug
QO	Preference or step drug available
QP	Drug ineligible - funded by hospital budget
QQ	Drug ineligible - specialty program drug
QR	Maximum allowable cost (MAC) paid
QS	Claim over $9999.99, send as 2 claims
QT	Reduced to quantity limit maximum
QU	Reduced to $ limit maximum
QV	Patient has reached category $ limit
QW	Special authorization - long term
QX	Conditional eligibility period exceeded
QY	Exception drug - submit claim to insurer
QZ	Renewal denied
RA	Exceeds max. number of Rx per day
RB	Exceeds max. number of active Rx allowed
RC	Transmitted to insurer
RD	Eligible for prior approval
RE	Will pay insured if covered by drug plan
RF	Consideration to add drugs is in progress
RG	Plan will advise client of benefit status
RH	Not presently an eligible benefit
RI	DIN removed from market/discontinued
RJ	Herbal, homeo, naturo products not covered
RK	This product is not covered by VAC
RL	This formulation not covered
RM	Exceeds daily limit
RN	Exceeds annual limit
RO	LRB, future fills require spec auth
RP	LRB, max. exceeded, required spec auth
RQ	Call VAC for spec auth
RR	Residual amount based on annual limit
RS	Annual limit reached with current claim
RT	Annual limit reached with previous claim
RU	Special COB, refers to plan pays amount only
RV	Non-designated phys future fills need spec auth
RW	Spec auth required
RX	Spec auth needed after transition period D
RZ	Request for coverage logged
SA	Preferred or step drug must be submitted
SB	Preferred drug or step drug processed
SC	Prof. fee for preferred/step drug exceeds max.
SD	Days supply exceeds quantity authorized
TA	Balance of trial was processed previously
TB	Trial claim already sent and processed
TC	Patient declined trial, bal. claim invalid
TD	Drug cost on trial exceeds MAC
TE	Upcharge on trial exceeds limit
TF	Professional fee on trial exceeds limit
TG	Quantity does not match ref. quantity
TH	Current claim for unfilled bal. processed
TI	Balance reversal pending
TJ	Trial claim processed
TK	Days supply does not match reference days supply
TL	No trial or reporting claim found
TM	More than one matching claim found
TN	Trial portion already claimed
TO	No matching claim found
TP	Patient is eligible for trial Rx
TQ	Trial quantity claimed exceeds limit
TT	Trial not processed, bal. claim invalid
TU	Patient has declined trial Rx program
TV	Upcharge adjusted
TX	Trial Rx reporting claim already exists
TY	Co-pay to collect adjusted
UA	Stolen special authorization #/code
UB	Optional special authorization required
UC	Void special authorization #/code
UE	Duplicate special authorization #/code
UF	Inactive special authorization #/code
UG	Missing special authorization #/code
UH	Original special authorization #/code not found
UJ	Pharmacy not authorized under program
UK	Pharmacist is not authorized
UL	Zero dispensing fee - monthly limit exceeded
UM	Please document adherence counselling
VA	Days supply lower than minimum allowable of 7
Z3	1st fill of trial drug > 7 days supply
Z4	2nd fill of trial drug > 23 days supply
ZA	Unable to resolve code
ZB	DIN does not resolve to a drug product
ZC	Cancel date cannot be future-dated
ZD	Cannot process claim - internal order
ZE	Transaction date cannot be future dated
ZF	Quantity error - must be one or more
ZG	Days supply error - must be one or more
ZH	Cannot find Rx with physician's Rx #
ZI	Physician's Rx # is for another patient
ZJ	Provider software is non-conformant
ZK	Cannot cancel another pharmacy's record
ZL	Compound PIN Rx already exists
ZM	Cannot cancel non-pharmacy batch record
ZN	No further payment for program period
ZO	Patient must call adjudicator re coverage

*Re. EJ: May be expressed as EJCCYYMMDD (i.e. max field length) if EJ is only code sent. Otherwise expiry date should be shown in Field E.20.03

**Re. EK: May be expressed as EK_XXX (i.e. 6 of max field length) if only EK and two (or less) other codes are sent. Otherwise "XXX" should be shown in Field E.20.03

***Re. ES: Message in Field E.20.03 refers to a Trace Number

****Re. EZ - HSA refers to health spending account

*****Re. LS: May be expressed as LSnn (i.e. up to max field length of 10). Otherwise day use limit should be defined in Field E.20.03

******Re. LT and LU: Trace number may be expressed as LTnnnnnnnn or LUnnnnnnnn (i.e. up to a max field length). Otherwise trace numbers should be indicated in Field E.20.03

*******Re. LW: May be expressed as LWccyymmdd (i.e. max field length) if LW is the only code sent. Otherwise trace numbers should be indicated in Field E.20.03