After a Pharmacy claim is submitted, Beacon Rebate Model applies back-end validations to evaluate the claim against applicable claim, entity, provider, network, and manufacturer policy requirements.
Validation | Description | Fields Examined |
ACA Orphan Drug | Appears when a claim is submitted for an orphan drug and the manufacturer does not offer 340B pricing to this Entity Type. | NDC-11, 340B ID, Date Of Service |
Not in Network | Appears when a claim is submitted for an NDC belonging to an LDN and the dispensing pharmacy NPI is not part of the configured network. | NDC-11, Date Of Service, Service Provider ID |
Aberrant Quantity | Appears when a claim quantity falls outside configured floor or ceiling limits or does not align with allowed multiples. | NDC-11, Quantity Dispensed |
Claim Expired | Appears when a claim is submitted outside the manufacturer's allowed lookback window following the Date of Service. | Date Of Service, NDC-11 |
Entity Type Invalid | The covered entity type is not eligible under the applicable manufacturer policy. | 340B ID, NDC-11 |
Duplicate | A duplicate claim was submitted by a single or multiple covered entities based on key claim attributes; only the first conforming claim submission is considered eligible for rebate payment. | Date Of Service, Service Provider ID, NDC-11, Rx Number, 340B ID |
Ineligible Entity | The covered entity was not active in HRSA OPAIS on the Date Of Service. | 340B ID, Date Of Service
|
NDC Expired | The Date Of Service falls outside the NDC's effective period. | Date Of Service, NDC-11 |
Pre-Policy | The Date Of Service occurred before the manufacturer's policy effective date. | Date Of Service, NDC-11, Quantity Dispensed |
Pre-Policy Claims Limit Reached | The submission exceeds the allowable number of packages permitted as unreplenished accumulation. | Date Of Service, NDC-11 |
Inactive Prescriber | The prescriber NPI was not active in the NPI registry on the Date Of Service. | Date Of Service, Prescriber ID |
Not a Prescriber | The Prescriber ID does not correspond to a valid provider in the NPI registry. | Prescriber ID |
Not a Facility / Pharmacy | The Service Provider ID is not a valid organization or pharmacy NPI. | Service Provider ID |
Not a Contracted Facility / Pharmacy | The Service Provider ID is not an in-house pharmacy and does not have an active contract pharmacy relationship with the covered entity on the Date Of Service. | Service Provider ID, Date Of Service, 340B ID |
Ineligible Facility / Pharmacy | The contract pharmacy is not eligible under the applicable manufacturer policy. | Service Provider ID, NDC-11, 340B ID |
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