Learning Objectives
In this module, you will learn how to identify and resolve:
- Transaction Rejected at Switch or Intermediary
- Coverage No Longer Active rejections
- Days Supply Exceeds Plan Limitation issues
Rejection Type 1: Transaction Rejected at Switch or Intermediary
Transaction Rejected at Switch or Intermediary
What it means: The claim was stopped at the insurance processor's switching system before reaching the actual insurance plan. This often indicates an issue with the insurance card or plan setup.
Common scenario: Patient needs to activate a savings card or there's an issue with how the pharmacy is set up with the processor.
Example of Transaction Rejected rejection showing Bausch savings card activation requirement
Resolution Steps:
- Check if the patient needs to activate their savings card
- Many manufacturer savings cards require online or phone activation
- Patient must register before first use
- Verify card information is entered correctly
- Double-check BIN, PCN, Group, and ID numbers
- Ensure all fields match the physical card exactly
- Read processor message carefully
- Example: "*WAG*Bausch savings card avail. instore or online (order savings cards via StoreNet>Patient Care>Pharma Partner/Consignment). Patient must activate savings card."
- Messages often tell you exactly what needs to happen
- For manufacturer savings cards:
- Direct patient to manufacturer website or phone number to activate
- Some cards activate immediately, others take 24 hours
- Once activated, retry the claim
- If savings card needs to be ordered:
- Access StoreNet > Patient Care > Pharma Partner/Consignment
- Order the appropriate savings card
- May need to process via PDQ (Pharma Partner) instead
- Check for override instructions:
- Some rejections require "Override 9998 with COB"
- Follow specific processor instructions in the message
- If card is activated and still rejecting:
- Wait 15-30 minutes and retry (activation may need time to process)
- Call the help desk number provided in the rejection message
- Have claim reference number and card details ready
Rejection Type 2: Coverage No Longer Active
Coverage No Longer Active - Use New Plan/Cash
What it means: The patient's insurance coverage has been terminated or is no longer effective. This typically occurs when employment ends, insurance is not renewed, or coverage dates have lapsed.
Additional message often includes: "Coverage Terminated - [date]"
Example: "Coverage Terminated - 02/28/22"
Example of "Coverage No Longer Active-Use new plan / Cash" rejection showing "Coverage Terminated - 02/28/22" in Additional Messages
Resolution Steps:
- Review the termination date
- Check the additional messages for the exact date coverage ended
- Verify this matches patient's understanding of their coverage
- Ask patient about new insurance
- "I see your [insurance name] coverage ended on [date]. Do you have new insurance?"
- If yes, request the new insurance card
- Enter new insurance information into patient profile
- If patient recently changed employers:
- New coverage may not be in system yet
- Ask if they've received new insurance cards
- If waiting for new cards, offer to process as cash and submit later for reimbursement
- If patient states they still have coverage:
- Ask patient to contact their insurance to verify active status
- Employer may not have paid premiums
- Patient may be in grace period or have lapse in coverage
- If no active coverage available:
- Offer to process as cash/self-pay
- Quote the cash price to patient
- Check if patient qualifies for discount programs
- Suggest manufacturer savings cards if available for the medication
- Update patient profile:
- Mark the terminated insurance as inactive
- Add new insurance if provided
- Document termination date for future reference
- If patient will get new insurance soon:
- Offer to hold prescription until new insurance is active
- Or process small quantity as cash to tide them over
- Schedule callback when new insurance is available
Rejection Type 3: Days Supply Exceeds Plan Limitation
Days Supply Exceeds Plan Limitation
What it means: The quantity being dispensed exceeds the maximum days supply allowed by the insurance plan. Many plans limit prescriptions to 30, 34, or 90-day supplies.
Common scenario: Attempting to fill a 90-day supply when plan only allows 34 days, or plan has specific maximum days supply limits.
Example message: "MAXIMUM DAYS SUPPLY OF 34"
Example showing "Days Supply Exceeds Plan Limitation" with "MAXIMUM DAYS SUPPLY OF 34" in Additional Messages
Resolution Steps:
- Check the "Additional Messages" for maximum allowed days
- Look for text like "MAXIMUM DAYS SUPPLY OF 34"
- Note the exact number of days allowed
- Calculate the adjusted quantity:
- Determine the daily usage from the sig
- Multiply by the maximum allowed days supply
- Example: If max is 34 days and sig is "take 1 tablet daily" → 34 tablets
- Example: If max is 34 days and sig is "take 1 tablet twice daily" → 68 tablets
- Adjust the prescription:
- Return to RxEntry
- Update the quantity to match the maximum days supply
- Verify days supply field reflects the plan's maximum
- Update refills if necessary (more refills may be needed for smaller quantities)
- If patient needs more than the allowed days supply:
- Process the maximum allowed amount through insurance
- For the remainder, consider these options:
- Bill to secondary insurance if patient has COB
- Process remainder as cash
- Check if plan has mail-order option for 90-day supplies
- Communicate with patient:
- Explain the plan's days supply limitation
- "Your insurance limits prescriptions to [X] days supply. I can fill [quantity] tablets which is your maximum."
- If patient wants more: "For the additional amount, you could pay cash for $[amount], or use mail-order through your insurance."
- Resubmit the claim
- After adjusting quantity and days supply
- Verify claim processes successfully
- Document the limitation:
- Note in patient profile that plan limits days supply
- Helps prevent future rejections
- Inform patient of limitation for future fills
Key Takeaways
- Transaction rejected at switch usually means savings card needs activation
- Coverage terminated requires getting new insurance or processing as cash
- Days supply limitations require quantity adjustments to match plan rules
- Always read processor and additional messages completely for specific instructions
- Communicate clearly with patients about limitations and options