After a Medical 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 administering location 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 |
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 | The same claim was submitted by one or multiple covered entities; 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 Claims Limit Reached | The submission exceeds the allowable number of packages permitted as unreplenished accumulation. | 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 |
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 does not have the required relationship with the covered entity on the Date of Service. | Service Provider ID, Date of Service, 340B ID |
Ineligible Facility / Pharmacy | The Service Provider is not eligible under the applicable manufacturer policy. | Service Provider ID, NDC-11, 340B ID |
Invalid Unit of Measure | The Unit of Measure provided does not match the expected unit of measure for the submitted product. | Unit of Measure, NDC-11 |
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