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