BDG BDGP CNC1 CNCN CNC2 CNCP CPD CPDP DAW DAWP

Post Payment Pharmacy Audit Discrepancy Tool
Michigan Department of Community Health (MDCH)
Documentation: If a prescription is created, signed, transmitted, and received electronically, all records related to that prescription must be retained electronically. Photocopies or images of pharmacy records submitted for audit documentation must include all annotated notes required to satisfy State and Federal
requirements and MDCH policy. Photocopies or images of prescriber medical record documentation may also be provided to validate prescriptions, however, prescriber affidavits, attestations, and retroactively dated prescriptions will not be accepted as pharmacy documentation during post payment audits. Audit
concerns about the validity of prescriptions based on documentation originally submitted by the pharmacy can be resolved by providing photocopies or images of the prescriber medical record. All prescriber medical record documentation submitted to verify an original prescription order must identify the beneficiary,
date ordered, medication name, drug name and strength, quantity, number of refills and directions for use. Electronically documented refill information should be recorded in a static electronic field and must clearly indicate the date entered into the prescription record for purposes of preventing alteration at a later
date. Any patient statements submitted in lieu of signature logs must: (1) include their address and telephone number, (2) clearly reference the medication(s), date(s) of service, etc. and (3) include the signature of the patient or patient's representative.
Old Discrepancy Code
New Discrepancy Code
Code Description
Discrepancy Recovery Discription
Documentation
MI Admin Code, MCL or CFR
MDCH Medicaid Provider
Manual
Financial
Error
A claim is submitted for a brand medication and the
generic form of that medication is dispensed to the
patient.
Partial Recovery - Discrepancy that may be due to an
overpayment that does not require a full recovery.
Recovery is calculated difference brand vs generic
Patterns will be referred to MDCH as a Fraud, Waste
and Abuse referral.
MCL 333.17755(1)
Pharmacy Chapter Section 19
Inaccurate Billing
X
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
A controlled and a non-controlled substance are written
administrative errors. There is no monetary penalty. This
on the same prescription.
discrepancy does not apply to claims submitted after
12/12/2013.
Rx must be copied. The control stickers for the
control Rx are to be put on one copy and the noncontrol stickers put on the other copy.
These citations only apply to claims
submitted before 12/12/2013
-R 338.479b (5) &
R338.3161 (6)
R
338.3153(6)(a)(b)
X
Rx must be copied. The
control stickers for the control
Rx are to be put on one copy
and the non-control stickers
put on the other copy
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
A controlled and a non-controlled substance are written
dispensing fee will be recouped.)
on the same prescription.
Recovery will be equal to the dispensing fee. This
discrepancy does not apply to claims submitted after
12/12/2013.
Rx must be copied. The control stickers for the
control Rx are to be put on one copy and the noncontrol stickers put on the other copy.
These citations only apply to claims
submitted before 12/12/2013
-R 338.479b (5) &
-R338.3161 (6)
R
338.3153(6)(a)(b)
X
Rx must be copied. The
control stickers for the control
Rx are to be put on one copy
and the non-control stickers
put on the other copy.
BDG
BDGP
(Brand/Generic)
(Brand/Generic)
CNC1
CNCN
(Control/Non Control)
(Control/Non Control)
CNC2
CNCP
(Control/Non Control)
(Control/Non Control)
CPD
CPDP
(Compounding Error)
(Compounding Error)
DAW
DAWP
(Dispense as Written)
(Dispense as Written)
DEA1
DEAN
(No DEA)
(No DEA)
DEA2
DEAP
(No DEA)
(No DEA)
DEA3
DEAF
(No DEA)
(No DEA)
DID1
DIDN
(Wrong Prescriber
Identifier)
(Wrong Prescriber
Identifier)
DID2
DIDP
(Wrong Prescriber
Identifier)
(Wrong Prescriber
Identifier)
DID3
DIDF
(Wrong Prescriber
Identifier)
(Wrong Prescriber
Identifier)
DN
DNRF
(Did Not Respond)
(Did Not Respond)
Office of Health Services Inspector General
Admin
Error
Coverage
Error
Claim Rebill/Reverse
The billed quantity for covered NDC ingredients of the
compound do not match the quantity(s) dispensed in
the compound.
Partial Recovery - Discrepancy that may be due to an
overpayment that does not require a full recovery.
Recovery is calculated difference between amount paid and
amount allowed.
Request a compound Worksheet w/ NDC, Qty, &
Pharmacy usual and customary amount for all
ingredients.
A brand medication is billed, but the physician's
"brand-only" order is not properly documented.
Partial Recovery - Discrepancy that may be due to an
overpayment that does not require a full recovery.
Recovery is dollar amount difference between the allowed
payment for brand versus generic
Patterns will be referred to MDCH for as a FWA
referral. Brand payment will only occur in the POS
System if DAW override is granted when there are 2 or
more generic equivalents of the brand product resulting
in a MAC price for the brand.
MCL 333.17755 (3)
The DEA number is not included on the hard copy
and/or pharmacy label, front or back of prescription.
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Total Recovery if Prescriber DEA is not valid.
(Cll-CV only)
Patterns will be referred to MDCH as a FWA referral.
R338.3161 (1)(b)
Pharmacy Chapter Section 19
Prescription Documentation
X
Correct DEA number on
pharmacy label
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Patterns will be referred to MDCH as a FWA referral.
Recovery will be equal to the dispensing fee.
Total Recovery if Prescriber DEA is not valid.
(Cll-CV only)
R338.3161 (1)(b)
Pharmacy Chapter Section 19
Prescription Documentation
X
Correct DEA number on
pharmacy label
The DEA number is not included on the hard copy
and/or pharmacy label, front or back of prescription.
Pharmacy Chapter Section 19
Compounds
X
X
The DEA number is not included on the hard copy
and/or pharmacy label, front or back of prescription.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
Patterns will be referred to MDCH as a FWA referral.
R338.3161 (1)(b)
Pharmacy Chapter Section 19
Prescription Documentation
The claim for the prescription contains an incorrect
prescriber identifier.
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
NPI of individual prescriber is required. Noncompliance patterns will be referred to MDCH as a
FWA referral.
MCL 400.111b(21)
Pharmacy Chapter Section 2.2
Prescriber Identification
X
The claim for the prescription contains an incorrect
prescriber identifier.
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee.
NPI of individual prescriber is required. Noncompliance patterns will be referred to MDCH as a
FWA referral.
MCL 400.111b(21)
Pharmacy Chapter Section 2.2
Prescriber Identification
X
The claim for the prescription contains an incorrect
prescriber identifier.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
NPI of individual prescriber is required. Noncompliance patterns will be referred to MDCH as a
FWA referral.
MCL 400.111b(21)
Pharmacy Chapter Section 2.2
Prescriber Identification
X
The provider did not respond to the audit request. No
documentation was submitted.
Total Recovery -Discrepancy in which the prescription and
signature log was not validated by the pharmacy. Recovery
will be the entire claim amount.
Copy of the Rx in question or prescriber medical
records required to validate the medication. Original
signature log or a signed statement from the member
verifying receipt of medication. The signed statement
must contain the beneficiary's contact information.
21 CFR [§1304.04 (h)(2)(4)]
MCL 333.17752(1)
-General Information for
Providers Chapter Section 5
Signature Log, Data Collection
& Documentation
-General Information for
1 of 7
X
X
Last Modified: 08/05/2014
MDCH Post Payment Pharmacy Audit Discrepancy Tool (cont.)
Old Discrepancy Code
Admin
Error
Coverage
Error
Discrepancy Recovery Discription
The patient identified on a hard copy prescription is
not the patient identified on the paid claim.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
A prescribed drug is handwritten on a preprinted
prescription form
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Total recovery if prescription not validated. This
discrepancy does not apply to claims submitted after
12/12/2013.
Prescriber medical records required to validate the
medication
This citation only apply to claims
submitted before 12/12/2013
R 338.479b (4)
X
A prescribed drug is handwritten on a preprinted
prescription form
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee.
Total recovery if prescription not validated. This discrepancy
does not apply to claims submitted after 12/12/2013.
Prescriber medical records required to validate the
medication
This citation only apply to claims
submitted before 12/12/2013
R 338.479b (4)
X
A prescribed drug is handwritten on a preprinted
prescription form
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount. This discrepancy does not apply to claims
submitted after 12/12/2013.
This citation only apply to claims
submitted before 12/12/2013
R 338.479b (4)
X
Multiple claims for the same prescription fill are
submitted and paid.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
The number of drugs prescribed on the hard copy
exceed the number allowed on one prescription.
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Total recovery if prescription not validated.
This
discrepancy only apply to Non-Control Prescriptions
Prescriber medical records required to validate the
medication
Noncontrolled
R 338.479b (3)(a)-(b)
X
The number of drugs prescribed on the hard copy
exceed the number allowed on one prescription.
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee
Total recovery if prescription not validated.
This
discrepancy only apply to Non-Control Prescriptions
Prescriber medical records required to validate the
medication
Noncontrolled
R 338.479b (3)(a)-(b)
X
The number of drugs prescribed on the hard copy
exceed the number allowed on one prescription.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
Total recovery if prescription not validated.
This
discrepancy only apply to Non-Control Prescriptions
Noncontrolled
R 338.479b (3)(a)-(b)
X
The prescription is filled or refilled beyond the
documented prescriber, plan, or legal time limits.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
-CII MCL 333.7333 (3)
-CIII-CIV R338.3168 (2)
-CV R338.3168 (4)
-Noncontrolled R338.479b (6) This
citation only apply to claims
submitted before 12/12/2013
-Noncontrolled R338.479b (4) This
citation only apply to claims
submitted after 12/12/2013
X
Filled before authorized: Rx was filled before date
written on the prescription.
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Total recovery if prescription not validated.
DPN
DPNF
(Wrong Patient Billed)
DPP1
DPPN
(Drugs Prescribed on
Preprinted Form)
(Drugs Prescribed on
Preprinted Form)
DPP2
DPPP
(Drugs Prescribed on
Preprinted Form)
(Drugs Prescribed on
Preprinted Form)
DPP3
DPPF
(Drugs Prescribed on
Preprinted Form)
(Drugs Prescribed on
Preprinted Form)
DUP
DUPF
(Duplicate Claim)
(Duplicate Claim)
EDP1
EDPN
(Exceeds # of Drugs per
Prescription)
(Exceeds # of Drugs per
Prescription)
EDP2
EDPP
(Exceeds # of Drugs per
Prescription)
(Exceeds # of Drugs per
Prescription)
EDP3
EDPF
(Exceeds # of Drugs per
Prescription)
(Exceeds # of Drugs per
Prescription)
EXP
EXPF
(Exceeds Time Limit)
(Exceeds Time Limit)
FBA1
FBAN
(Filled Before
Authorized)
(Filled Before
Authorized)
Office of Health Services Inspector General
MI Admin Code, MCL or CFR
Financial
Error
Code Description
(Wrong Patient Billed)
Documentation
MDCH Medicaid Provider
Manual
New Discrepancy Code
Pharmacy Chapter Section 19
Prescription Documentation
X
Pharmacy Chapter Section 19
Changing Claim Information
Clerical date errors on the prescriber's end are not
subject to total recovery when medical record
documentation supports prescribed on/before the date
filled.
2 of 7
CII-CV MCL 333.7333(7)
Pharmacy Chapter Section 19
Changing Claim Information
Claim Rebill/Reverse
X
X
Last Modified: 08/05/2014
MDCH Post Payment Pharmacy Audit Discrepancy Tool (cont.)
Old Discrepancy Code
New Discrepancy Code
FBA2
FBAP
(Filled Before
Authorized)
(Filled Before
Authorized)
FBA3
FBAF
(Filled Before
Authorized)
(Filled Before
Authorized)
ICS
ICSP
(Wrong Strength/Pack
Size)
(Wrong Strength/Pack
Size)
IDS
IDSN
(Wrong Day Supply)
(Wrong Day Supply)
IDS
IDSP
(Wrong Day Supply)
(Wrong Day Supply)
INV1
IDWN
(No Prescription Date
Written)
(No Prescription Date
Written)
INV2
IDWP
(No Prescription Date
Written)
(No Prescription Date
Written)
INV3
IDWF
(No Prescription Date
Written)
(No Prescription Date
Written)
MIS
MISN
(Miscellaneous
Discrepancies)
(Miscellaneous
Discrepancies)
MIS
MISP
(Miscellaneous
Discrepancies)
(Miscellaneous
Discrepancies)
MIS
MISF
(Miscellaneous
Discrepancies)
(Miscellaneous
Discrepancies)
MP-1
MPXN
(Missing Hardcopy
Prescription)
(Missing Hardcopy
Prescription)
MP-2
MPXP
(Missing Hardcopy
Prescription)
(Missing Hardcopy
Prescription)
Office of Health Services Inspector General
Code Description
Filled before authorized: Rx was filled before date
written on the prescription.
Filled before authorized: Rx was filled before date
written on the prescription.
Discrepancy Recovery Discription
Documentation
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
Clerical date errors on the prescriber's end are not
repeat of the nonmonetary finding and the pharmacy
subject to total recovery when medical record
dispensing fee will be recouped.)
documentation supports prescribed on/before the date
Recovery will be equal to the dispensing fee.
filled.
Total recovery if prescription not validated.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
MI Admin Code, MCL or CFR
MDCH Medicaid Provider
Manual
CII-CV MCL 333.7333(7)
Pharmacy Chapter Section 19
Changing Claim Information
X
CII-CV MCL 333.7333(7)
Pharmacy Chapter Section 19
Changing Claim Information
X
Partial Recovery - Discrepancy that may be due to an
The Strength/package size identified on the claim
overpayment that does not require a full recovery.
differs from the Strength/package size dispensed to the
Recovery is the calculated difference in reimbursement based
patient
on cost for different Strength/package sizes.
The days supply value submitted by the pharmacy is
not consistent with the quantity and directions.
The days supply value submitted by the pharmacy is
not consistent with the quantity and directions.
Pharmacy Chapter Section 19
Changing Claim Information
Financial
Error
Admin
Error
-Pharmacy Chapter Sections
11.1
Pharmacy Chapter 19 Days
Supply
X
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
Correct day supply is required. Non-compliance
repeat of the nonmonetary finding and the pharmacy
patterns will be referred to MDCH as an FWA referral.
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee.
-Pharmacy Chapter Sections
11.1
Pharmacy Chapter 19 Days
Supply
X
The hard copy prescription contains no original
prescription date written
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Total recovery if prescription not validated.
Prescriber medical records required to validate the
medication
-CII-CV R338.3161 (1)
R338.479b (1)
-R338.480 (1)
-
The hard copy prescription contains no original
prescription date written
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee.
Total recovery if prescription not validated.
Prescriber medical records required to validate the
medication
-CII-CV R338.3161 (1)
R338.479b (1)
-R338.480 (1)
-
The hard copy prescription contains no original
prescription date written
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
-CII-CV R338.3161 (1)
R338.479b (1)
-R338.480 (1)
-
Assessed when an issue has been cited that is not
listed elsewhere on the Discrepancy Sheet Follow up
research may be required.
Nonmonetary-Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty if
Administrative Error
Dependent upon the Discrepancy
Assessed when an issue has been cited that is not
listed elsewhere on the Discrepancy Sheet Follow up
research may be required.
Partial recovery-Discrepancy that may be due to an
overpayment that does not require a full recovery if Financial
Error;
Dependent upon the Discrepancy
Assessed when an issue has been cited that is not
listed elsewhere on the Discrepancy Sheet Follow up
research may be required.
Total Recovery-Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount if Coverage Error;
Dependent upon the Discrepancy
Original hard-copy prescription cannot be found on file
during the audit.
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Total recovery if prescription not validated.
Copy of the Rx in question or prescriber medical
records required to validate the medication
-R 338.480a (3)(a)
-MCL 333.17752 (1)
-Pharmacy Chapter Section 19
Prescription Documentation
- General Information for
Providers Chapter Section 15
Record Keeping
X
Original hard-copy prescription cannot be found on file
during the audit.
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee.
Total recovery if prescription not validated.
Copy of the Rx in question or prescriber medical
records required to validate the medication
-R 338.480a (3)(a)
-MCL 333.17752 (1)
-Pharmacy Chapter Section 19
Prescription Documentation
- General Information for
Providers Chapter Section 15
Record Keeping
X
3 of 7
Claim Rebill/Reverse
X
Correct day supply is required. Non-compliance
patterns will be referred to MDCH as an FWA referral.
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Coverage
Error
X
X
X
Last Modified: 08/05/2014
MDCH Post Payment Pharmacy Audit Discrepancy Tool (cont.)
Old Discrepancy Code
New Discrepancy Code
MP-3
MPXF
(Missing Hardcopy
Prescription)
(Missing Hardcopy
Prescription)
MSF1
MSFN
(Missing Security Feature (Missing Security Feature
on Rx Blank)
on Rx Blank)
MSF2
MSFP
MSF3
MSFF
Code Description
Discrepancy Recovery Discription
Original hard-copy prescription cannot be found on file
during the audit.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
Prescription written on prescription blank that does not
have required security features.
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Total recovery if prescription not validated.
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee.
Total recovery if prescription not validated.
Prescription written on prescription blank that does not
(Missing Security Feature (Missing Security Feature
have required security features.
on Rx Blank)
on Rx Blank)
(Missing Security Feature (Missing Security Feature
on Rx Blank)
on Rx Blank)
MSL
MSLF
(Missing Signature Log)
(Missing Signature Log)
NCI
NCIF
(Drug Not Covered)
(Drug Not Covered)
NDA1
NDAN
(No Doctor Address)
(No Doctor Address)
NDA2
NDAP
(No Doctor Address)
(No Doctor Address)
NDA3
NDAF
(No Doctor Address)
(No Doctor Address)
NPA1
NPAN
(No Patient Address - CII- (No Patient Address - CIICV only)
CV only)
NPA2
NPAP
NPA3
NPAF
Office of Health Services Inspector General
MDCH Medicaid Provider
Manual
-R 338.480a (3)(a)
-MCL 333.17752 (1)
-Pharmacy Chapter Section 19
Prescription Documentation
- General Information for
Providers Chapter Section 15
Record Keeping
X
Prescriber medical records required to validate the
medication
42 U.S.C 1936 b (i) (23)
Pharmacy Chapter Section 11.5
Tamper Resistant Prescriptions
X
Prescriber medical records required to validate the
medication
42 U.S.C 1936 b (i) (23)
Pharmacy Chapter Section 11.5
Tamper Resistant Prescriptions
X
42 U.S.C 1936 b (i) (23)
Pharmacy Chapter Section 11.5
Tamper Resistant Prescriptions
X
-General Information for
Providers Chapter Section 5 Signature Log, Data Collection
& Documentation
-Pharmacy Chapter Section 19 Signature Requirement
-General Information for
X
Prescription written on prescription blank that does not
have required security features.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
No signature could be found documenting receipt of
new prescriptions or refills.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
Pharmacy was paid for an item considered "not
covered".
Referral to [email protected] for POS
coding/Corrective Action (if warranted)
The hardcopy prescription does not include the
prescribers' address.
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Total recovery if prescription not validated.
Prescriber medical records required to validate the
medication
The hardcopy prescription does not include the
prescribers' address.
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee.
Total recovery if prescription not validated.
Prescriber medical records required to validate the
medication
The hardcopy prescription does not include the
prescribers' address.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
The hardcopy or label on either the front or back of the
prescription contains no patient address. Applies to
controlled substances only.
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Total recovery if prescription not validated.
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee.
Total recovery if prescription not validated.
The hardcopy or label on either the front or back of the
(No Patient Address - CII- (No Patient Address - CII- prescription contains no patient address. Applies to
controlled substances only.
CV only)
CV only)
(No Patient Address - CII- (No Patient Address - CIICV only)
CV only)
MI Admin Code, MCL or CFR
Documentation
The hardcopy or label on either the front or back of the
prescription contains no patient address. Applies to
controlled substances only.
Original signature log or a signed statement from the
member verifying receipt of medication. The signed
statement must contain the beneficiary's contact
information
Financial
Error
Admin
Error
Pharmacy Chapter Section 6
General Noncovered Services
X
-CII-CV R338.3161 (1)(b)
-Noncontrolled R338.479b (1)(b)
Pharmacy Chapter Section 19
Prescription Documentation
X
-CII-CV R338.3161 (1)(b)
-Noncontrolled R338.479b (1)(b)
Pharmacy Chapter Section 19
Prescription Documentation
X
-CII-CV R338.3161 (1)(b)
-Noncontrolled R338.479b (1)(b)
Pharmacy Chapter Section 19
Prescription Documentation
X
Prescriber medical records required to validate the
medication
R 338.3161 (1)(a)
Pharmacy Chapter Section 19
Prescription Documentation
X
Prescriber medical records required to validate the
medication
R 338.3161 (1)(a)
Pharmacy Chapter Section 19
Prescription Documentation
X
R 338.3161 (1)(a)
Pharmacy Chapter Section 19
Prescription Documentation
X
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
4 of 7
Coverage
Error
Claim Rebill/Reverse
Last Modified: 08/05/2014
MDCH Post Payment Pharmacy Audit Discrepancy Tool (cont.)
New Discrepancy Code
Code Description
Discrepancy Recovery Discription
Documentation
MI Admin Code, MCL or CFR
MDCH Medicaid Provider
Manual
Financial
Error
NQY2
NQYP
(No Quantity)
The hardcopy prescription does not indicate the
quantity of the drug to be dispensed.
Partial Recovery - Discrepancy that may be due to an
overpayment that does not require a full recovery.
Recovery is dollar amount of drug in excess of amount
allowed by Plan or authorized by prescriber.
Prescriber medical records required to validate the
medication
-R 338.479b (1)(d)
-CII-CV MCL 333.7333(6)
Noncontrolled
Pharmacy Chapter Section 19
Prescription Documentation
X
(No Quantity)
The hardcopy prescription has no quantity of the drug
to be dispensed indicated.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
-R 338.479b (1)(d)
-CII-CV MCL 333.7333(6)
Noncontrolled
Pharmacy Chapter Section 19
Prescription Documentation
The hardcopy or label of the prescription contains no
unique prescription identifier number.
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Total recovery if prescription not validated.
Prescriber medical records required to validate the
medication
R 338.480 (1)
Pharmacy Chapter Section 19
Prescription Documentation
X
The hardcopy or label of the prescription contains no
unique prescription identifier number.
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee.
Total recovery if prescription not validated.
Prescriber medical records required to validate the
medication
R 338.480 (1)
Pharmacy Chapter Section 19
Prescription Documentation
X
The hardcopy or label of the prescription contains no
unique prescription identifier number.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
R 338.480 (1)
Pharmacy Chapter Section 19
Prescription Documentation
X
The hard copy prescription does not indicate directions
for use or medication dosing and therefore does not
document the prescriber's intended days supply.
Partial Recovery - Discrepancy that may be due to an
overpayment that does not require a full recovery.
Recovery is dollar amount of drug in excess of amount
allowed by Plan or authorized by prescriber.
-R 338.479b (1) (e)
-CII-CV R338.3161 (1) (e)
Noncontrolled
Pharmacy Chapter Section 19
Prescription Documentation
X
The hard copy prescription does not indicate directions
for use or medication dosing and therefore does not
document the prescriber's intended days supply.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
-R 338.479b (1) (e)
-CII-CV R338.3161 (1) (e)
Noncontrolled
Pharmacy Chapter Section 19
Prescription Documentation
X
The hard copy prescription does not contain the name
of the drug to be dispensed.
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Total recovery if prescription not validated.
Prescriber medical records required to validate the
medication
-CII-CV 338.3161 (1)(c)
-R338.479b (1)(c)
Pharmacy Chapter Section 19
Prescription Documentation
X
The hard copy prescription does not contain the name
of the drug to be dispensed.
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee.
Total recovery if prescription not validated.
Prescriber medical records required to validate the
medication
-CII-CV 338.3161 (1)(c)
-R338.479b (1)(c)
Pharmacy Chapter Section 19
Prescription Documentation
X
-CII-CV 338.3161 (1)(c)
-R338.479b (1)(c)
Pharmacy Chapter Section 19
Prescription Documentation
X
Old Discrepancy Code
NQY3
NQYF
(No Quantity)
(No Quantity)
NRX1
NRXN
(No Rx Number)
(No Rx Number)
NRX2
NRXP
(No Rx Number)
(No Rx Number)
NRX3
NRXF
(No Rx Number)
(No Rx Number)
NSI2
NSIP
(No Directions for Use)
(No Directions for Use)
NSI3
NSIF
(No Directions for Use)
(No Directions for Use)
NVD1
NVDN
(No Drug Name)
(No Drug Name)
NVD2
NVDP
(No Drug Name)
(No Drug Name)
Prescriber medical records required to validate the
medication
Admin
Error
Coverage
Error
X
NVD3
NVDF
(No Drug Name)
(No Drug Name)
The hard copy prescription does not contain the name
of the drug to be dispensed.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
NVN1
NVNN
The hard-copy prescription contains no patient name.
(No Patient Name)
Prescriber medical records required to validate the
medication
-CII-CV R338.3161 (1)(a)
-Noncontrolled R338.479b (1)(a)
Pharmacy Chapter Section 19
Prescription Documentation
X
(No Patient Name)
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Total recovery if prescription not validated.
The hard-copy prescription contains no patient name.
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee.
Total recovery if prescription not validated.
Prescriber medical records required to validate the
medication
-CII-CV R338.3161 (1)(a)
-Noncontrolled R338.479b (1)(a)
Pharmacy Chapter Section 19
Prescription Documentation
X
The hard-copy prescription contains no patient name.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
-CII-CV R338.3161 (1)(a)
-Noncontrolled R338.479b (1)(a)
Pharmacy Chapter Section 19
Prescription Documentation
X
NVN2
NVNP
(No Patient Name)
(No Patient Name)
NVN3
NVNF
(No Patient Name)
(No Patient Name)
Office of Health Services Inspector General
5 of 7
Claim Rebill/Reverse
Last Modified: 08/05/2014
MDCH Post Payment Pharmacy Audit Discrepancy Tool (cont.)
Old Discrepancy Code
New Discrepancy Code
NVP
INVF
(Invalid Prescriber)
(Invalid Prescriber)
NVS1
NVSN
(No Strength)
(No Strength)
NVS2
NVSP
(No Strength)
(No Strength)
NVS3
NVSF
(No Strength)
(No Strength)
OBQ
OBQP
(Exceeds Quantity Limits) (Exceeds Quantity Limits)
QND1
QNDN
(Quantity not Properly
Documented)
(Quantity not Properly
Documented)
QND2
QNDP
(Quantity not Properly
Documented)
(Quantity not Properly
Documented)
QND3
QNDF
(Quantity not Properly
Documented)
(Quantity not Properly
Documented)
RTS
RTSF
(Refill too Soon)
(Refill too Soon)
RXC
RXCF
(Altered Prescription
(Altered Prescription
Drug, Quantity, or Refills Drug, Quantity, or Refills
Altered)
Altered)
SNV1
SNVN
(Signature is not Valid)
(Signature is not Valid)
SNV2
SNVP
(Signature is not Valid)
(Signature is not Valid)
SNV3
SNVF
(Signature is not Valid)
(Signature is not Valid)
UAR
UARF
(Unauthorized Refills)
(Unauthorized Refills)
Office of Health Services Inspector General
Code Description
Discrepancy Recovery Discription
Documentation
MI Admin Code, MCL or CFR
MDCH Medicaid Provider
Manual
For dates of service 10/1/14 and after, the prescriber
on the claim is incorrect and the correct prescriber is
sanctioned by the federal or state government or is not
enrolled with Michigan Medicaid.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
Correct NPI of individual prescriber is required.
MCL 400.111b(21)
Pharmacy Chapter Section 2.2
Prescriber Identification
The hard-copy prescription, for a drug available in
more than one strength, fails to identify the strength to
be dispensed.
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Total recovery if dispensed strength is not prescriber's
intended strength
Prescriber medical records required to validate the
medication
-CII-CV R338.3161 (1)(c)
-Noncontrolled R338.479b (1)(c)
Pharmacy Chapter Section 19
Prescription Documentation
X
The hard-copy prescription, for a drug available in
more than one strength, fails to identify the strength to
be dispensed.
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee.
Total recovery if dispensed strength is not prescriber's
intended strength
Prescriber medical records required to validate the
medication
-CII-CV R338.3161 (1)(c)
-Noncontrolled R338.479b (1)(c)
Pharmacy Chapter Section 19
Prescription Documentation
X
The hard-copy prescription, for a drug available in
more than one strength, fails to identify the strength to
be dispensed.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
-CII-CV R338.3161 (1)(c)
-Noncontrolled R338.479b (1)(c)
Pharmacy Chapter Section 19
Prescription Documentation
Quantity billed exceeds the quantity authorized by the
prescriber/plan.
Partial Recovery - Discrepancy that may be due to an
overpayment that does not require a full recovery.
Recovery is dollar amount of drug in excess of amount
allowed by Plan or authorized by prescriber.
A prescription for a controlled substance does not
contain the quantity in BOTH written and numerical
terms.
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Prescriber medical records required to validate the
medication
-R 338.3161 (1)(d)
-MCL 333.7333 (6)
X
A prescription for a controlled substance does not
contain the quantity in BOTH written and numerical
terms.
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee.
Total recovery if prescription not validated.
Prescriber medical records required to validate the
medication
-R 338.3161 (1)(d)
-MCL 333.7333 (6)
X
A prescription for a controlled substance does not
contain the quantity in BOTH written and numerical
terms.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
Prescription is refilled sooner than appropriate with
respect to quantity and directions for use within plan
defined utilization limits.
Referral to [email protected] for
investigation to determine whether POS coding error, POS
override granted or if recovery is appropriate
Pharmacy Chapter Section 19
Changing Claim Information
Drug, Quantity or Refills altered with no
documentation on the prescription.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
Pharmacy Chapter Section 19
Changing Claim Information
The hardcopy prescription does not include a valid
prescriber signature.
Nonmonetary - Discrepancy that may require prescriber
records to mitigate the discrepancy. Usually are
administrative errors. There is no monetary penalty.
Total recovery if prescription not validated.
Prescriber medical records required to validate the
medication
-CII-CV R338.3161 (1)
-Noncontrolled R338.479b (1)
X
The hardcopy prescription does not include a valid
prescriber signature.
Partial Recovery - Discrepancy that had been previously
reported to the pharmacy as a nonmonetary discrepancy (i.e a
repeat of the nonmonetary finding and the pharmacy
dispensing fee will be recouped.)
Recovery will be equal to the dispensing fee.
Prescriber medical records required to validate the
medication
-CII-CV R338.3161 (1)
-Noncontrolled R338.479b (1)
X
The hardcopy prescription does not include a valid
prescriber signature.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
-CII-CV R338.3161 (1)
-Noncontrolled R338.479b (1)
X
The number of refills billed and paid to the provider
exceeds the limits set by the Plan/Prescriber.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
-CII R 338.3168 (1)
- CIII-CV 338.3168 (2) - (4)
Pharmacy Chapter Section 11
Dispensing Policy
Financial
Error
Admin
Error
Claim Rebill/Reverse
X
X
X
-R 338.3161 (1)(d)
-MCL 333.7333 (6)
6 of 7
Coverage
Error
X
Pharmacy Chapter Section 11
Dispensing Policy
X
X
X
Last Modified: 08/05/2014
MDCH Post Payment Pharmacy Audit Discrepancy Tool (cont.)
Old Discrepancy Code
New Discrepancy Code
VBL
VBLF
(Verbal Order Cannot be (Verbal Order Cannot be
Confirmed)
Confirmed)
WD
WDRF
(Wrong Drug)
(Wrong Drug)
Code Description
Discrepancy Recovery Discription
The auditor could not verify the verbal order with the
prescriber listed on the prescription.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
A pharmacy was paid for a medication that was not
ordered by the prescriber.
Total Recovery -Discrepancy in which the prescription was
not validated by the pharmacy. Recovery will be the entire
claim amount.
Documentation
MI Admin Code, MCL or CFR
R 338.490 Rule 20.(1)
MDCH Medicaid Provider
Manual
Financial
Error
Admin
Error
Coverage
Error
Pharmacy Chapter Section 19
Pharmacy Audit Documentation
X
Pharmacy Chapter Section 19
Inaccurate Billing
X
Claim Rebill/Reverse
*If supporting documentation submitted prior to the issuance of the audit's Final Notice of Recovery letter validates the prescription, the finding will be deemed nonmonetary. However, continued violations of administrative errors in subsequent audits may be subject to the recoupment of dispensing fees and if prescription is determined to not be valid,
the claims may be subject to total recovery.
The last letter of the discrepancy code indicates the type of recovery that will be pursued. The codes previously used to identify the type of recovery (1 = Nonmonetary, 2 = Partial Recovery & 3 = Full Recovery) will no longer be used. The following Recovery Codes will be used:
N = Nonmonetary Recovery
P = Partial Recovery
F = Full Recovery
Office of Health Services Inspector General
7 of 7
Last Modified: 08/05/2014

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