...
| Code Block |
|---|
{
"id": "5c34979c-30dc-496c-8cd3-6eb9925862c1",
"type": "eligibility.checked",
"created": 1546950556,
"account_code": "vclinic",
"data": {
"eligibility_id": "28540",
"member_id": "60610",
"eligibility_response": "Invalid/Missing subscriber/insured ID",
"external_member_id": 1111
}
} |
Rejection reason and codes
| Code Block |
|---|
'04' => 'Authorized quantity exceeded',
'15' => 'Required application data missing',
'33' => 'Input Errors',
'35' => 'Out of Network',
'41' => 'Authorization/Access restrictions',
'42' => 'Unable to respond at current time.',
'43' => 'Invalid/Missing provider information',
'44' => 'Invalid/Missing provider name',
'45' => 'Invalid/Missing provider speciality',
'46' => 'Invalid/Missing provider phone number',
'47' => 'Invalid/Missing provider state',
'48' => 'Invalid/Missing referring provider identification number',
'49' => 'Provider is not primary care physician',
'50' => 'Provider ineligible for inquiries',
'51' => 'Provider not on file',
'52' => 'Service dates not within provider plan enrollment',
'53' => 'Inquired benefit inconsistent with provider type',
'56' => 'Inappropriate date',
'57' => 'Invalid/Missing dates of service',
'58' => 'Invalid/Missing date of birth',
'60' => 'Date of birth follows date of service',
'61' => 'Date of death preceeds dates of service',
'62' => 'Date of service not within allowable inquiry period',
'63' => 'Date of service in future',
'64' => 'Invalid/Missing patient ID',
'65' => 'Invalid/Missing patient name',
'66' => 'Invalid/Missing patient gender code',
'67' => 'Patient not found',
'69' => 'Inconsistent with patient age.',
'70' => 'Inconsistent with patient gender.',
'71' => 'Patient birth date does not match that for the patient in the database',
'72' => 'Invalid/Missing subscriber/insured ID',
'73' => 'Invalid/Missing subscriber/insured name',
'74' => 'Invalid/Missing subscriber/insured gender code',
'75' => 'Subscriber/Insured not found',
'76' => 'Duplicate Subscriber/Insured ID number',
'77' => 'Subscriber found, patient not found',
'78' => 'Subscriber/Insured not in Group/Plan identified',
'79' => 'Invalid participant identification',
'97' => 'invalid or missing provider address',
'T4' => 'Payer name or identifier missing',
'T5' => 'Certification Information Missing',
'80' => 'No response received by clearinghouse',
'98' => 'Expiremental service or procedure.',
'AA' => 'Authorization number not found.',
'AE' => 'Requires primary care physician authorization.',
'AF' => 'Invalid/Missing diagnosis codes.',
'AG' => 'Invalid/Missing procedure codes.',
'AO' => 'Additional patient condition information required.',
'CI' => 'Certification information does not match patient.',
'E8' => 'Requires medical review.',
'IA' => 'Invalid authorization number format.',
'MA' => 'Missing authorization number.' |
Eligibility Responses List
...