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Revised January, 2010 CONFIDENTIAL AND PROPRIETARY - page 13 / 31





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Outcome Codes Result of Service Code Field E441-E6

Outcome Codes Result of Service Code Field E441-E6

1A 1B 1C 1D 1E 1F 1G 1H 1J 1K 2A 2B 3A 3B 3C 3D 3E 3F 3G 3H 3J 3K 3M 3N

Filled As Is, False Positive Filled Prescription As Is Filled, With Different Dose Filled, With Different Directions Filled, with Different Drug Filled, With Different Quantity Filled, With Prescriber Approval Brand-to-Generic Change Rx-to-OTC Change Filled with Different Dosage Form Prescription Not Filled Not Filled, Directions Clarified Recommendation Accepted Recommendation Not Accepted Discontinued Drug Regimen Changed Therapy Changed Therapy Changed-Cost Increased Drug Therapy Unchanged Follow up Report Patient Referral Instructions Understood Compliance Aid Provided Medication Administered

When the network pharmacy encounters a denial due to drug safety edits and has confirmed the safety edit can be overridden, should enter the reason for service code/conflict code in field 439-E4, the professional service rendered code/intervention code in field 440-E5, and the result of service code/outcome code in field 441-E6.

Please note: These general override rules may not apply to every plan. If you receive instructions for a specific plan, please use those instructions as directed by that plan sponsor.

Payor Sheet

Walgreens Health Initiatives supplies the pharmacies, through the Walgreens Health Initiatives website and upon request, a payor sheet that lists each field in the POS claims transaction and the requirements for each field. Please refer to this document if you are experiencing difficulty with point-of-sale transmissions.

NCPDP Standard Universal Claim Form (UCF)

There are two types of forms as listed below—handwritten and computer generated. When forms are completed by hand, the last copy is sent to the claims processor at the address below. For computer generated, submit only the original (top) copy. The continuous form paper used by computers when printing claims on Universal Claim Forms (UCFs) should be separated (burst) and the tractor strips must be removed from the edges prior to sending to the claim processor. The member’s signature in a prescription log should be noted as “Signature on File” in the appropriate space on the UCF. There may be a fee reduction per claim for processing UCFs. All UCFs must be legible, accurate, and complete. Please type or neatly print all the UCF information. Claims and corrections to prior claims must be forwarded to Walgreens Health Initiatives via first-class mail within 90 days of original service date.

Walgreens Health Initiatives – Pharmacy Manual


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