Prescription Claims Processing and Submission
Building the claim
A pharmacy claim is submitted in real time under the NCPDP Telecommunication Standard. The pharmacy management system assembles the required fields: BIN, PCN, group, cardholder ID and person code, date of service, the 11-digit NDC in 5-4-2 format (pad with leading zeros, never truncate), metric quantity, days supply, DAW code, prescriber NPI, submission clarification code, other coverage code, and patient pay amount.
Adjudication returns one of three outcomes: paid; rejected, meaning the claim never processed because of bad data, wrong BIN, or refill-too-soon; or captured/denied, meaning it processed but is not payable. The distinction matters. A rejection asks you to correct a field and resubmit; a denial asks you to justify, document, or appeal.
Field traps cost the most points. Quantity is the metric units dispensed; days supply is how long those units should last at the prescribed directions. They are related but not interchangeable: 90 tablets at one tablet twice daily is a 45-day supply. DAW 0 means no product selection indicated, so generic substitution is allowed; DAW 1 means the prescriber insisted on the brand, which can change the pricing basis and shift cost to the patient.
Use transaction codes correctly: B1 for the original billing, B2 for a full reversal of a paid claim, B3 to rebill. Reversals must be complete and inside the plan's reversal window, and a rebill keeps the same prescription number.
Rule of thumb: before resubmitting, verify quantity, days supply, and DAW. Most repeat rejections trace to one of those three fields.