Procella HelpdeskThe Override Edit enables a claim to not reject for certain reasons. The most common application is for a Refill Too Soon, Vacation Override.
Edit Name is the unique name for the edit.
Administrative
Reject Code
The selected NCPDP reject code the Override EDIT can bypass.
Internal Error Code
The specific internal error code that can be overridden with this EDIT. The option of ALL will allow an override of all internal codes.
Message Group is the assigned Message group to be captured each time the edit is used.
Deny Override
The Deny Override enables an Adjudication Rule to ignore any override codes.
Clarifications
The Clarifications switch allows the ability to select how the claim is qualified for the override edit. The fields for this qualification are as follows:
Code Type
The following code types are based on the NCPDP values on the claim.
Prior Auth Type is the value submitted Prior Authorization field. Values are 0 through 0.
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Note on Prior Auth Type When Prior Auth Type is selected, a field (just below Clarifications heading) will present. This allows this specific value to be matched from the claim submitted prior authorization number. Submission Clarification Code is the code indicating that the pharmacist is clarifying the submission. Eligibility Clarification Code is the code indicating that the pharmacy is clarifying eligibility for a patient. Professional Service Code is the code identifying pharmacist intervention when a conflict code has been identified or service has been rendered. Result of Service Code reflects the action taken by a pharmacist or prescriber in response to a conflict or the result of a pharmacist's professional service. Reason for Service Code is the code identifying the type of utilization conflict detected by the prescriber or the pharmacist or the reason for the pharmacist's professional service. CodesThe codes are the codes available for use for the Code Type. Each Code Type has its own list and are standard NCPDP codes. Each override rule can have one or more combinations (Code Type plus Code). If these are within one override rule, each must be satisfied by the claim. Additional Clarifications can be added to the one Override Edit. In those scenarios, the claim need only match one Clarification Override Rule. Add Clarification
Enables multiple clarification override rule setups.
Accumulation LimitationsThe Accumulation Limitations allow control of the number of occurrences, or uses, of the override for a member. Number of OccurrencesHow many times for this member will this Override Edit be eligible. Every X Days
The frequency for the number of occurrences. For instance, 3 occurrences every 30 days.
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