Enhanced claim validation system with comprehensive alerts to improve first-pass claim acceptance rates:
Vaccine coverage rejections - Identifies vaccines not typically covered by Medicare Part B
Diagnosis code required notifications - Ensures proper coding compliance
Refill too soon alerts - Prevents premature refill submissions
Quantity supply limits - Validates diabetic supply quantities against coverage rules
Medicare prior authorization flags - Highlights claims requiring prior auth
These intelligent edits help reduce claim rejections and streamline the billing process by catching potential issues before submission. All edits come with the ability to override the rejection by entering specific DUR codes. Look to the message section of the claim for the appropriate codes to override the rejection.
In this example, the claim is rejected because the pharmacy is attempting to bill Medicare Part B for the Abrysvo vaccine, which is not typically covered by Medicare. The message clearly states this as the reason for the rejection, but also provides DUR override codes in the event of a special circumstance and the pharmacy does in fact need to bill Medicare for this vaccine.
Most rejection messages will include the three-segment DUR override. Enter these two-digit codes in the DUR fields in order, then reprocess the claim to push it to DocStation.