P-5.5. Edits

Following an online claim transmission by a pharmacy, the system will return a response to indicate the outcome of processing.  If the claim passes all edits, a “paid” response will be returned with VDP's allowed amount for the paid claim.  A “rejected” response will be returned when a claim fails one or more edits.  Pharmacy staff should consult with their software provider for a list of NCPDP standard reject codes.

5.1. Timely Filing Limits

While most claims are generally submitted at the time of dispensing, there may be mitigating reasons requiring a claim be submitted after being dispensed.  The pharmacy’s software should allow the transmission of claims with past service dates.

  • The timely filing limit from the date of service is 90 days for all original claims. 

  • The timely filing limit from the date of service is 720 days for all reversals.

  • Transmission of claims using the current date for a past service date is a violation of program policy and could result in an audit exception.

  • The inability of a pharmacy's software to submit past service dates is not an acceptable reason for the submission of paper claims.

Claims exceeding the timely filing limit will reject with NCPDP code "81" (“Claim Too Old”).  Claims for people certified with retroactive Medicaid eligibility will process online for 90 days after the certification date of retroactive eligibility regardless of the date of service.