Denials, Rejections, Appeals, and Compliance
Codes, appeal paths, and the audit trail
Read rejection codes literally. Codes a candidate should recognize: 41, submit bill to another payer; 70, NDC not covered; 75, prior authorization required; 76, plan limitations exceeded such as quantity or age limits; 79, refill too soon; 88, DUR conflict. Each demands a different action: 79 needs a wait or an override, 75 needs a PA, and 41 needs a different payer order.
Prior authorization, step therapy, quantity limits, and formulary exclusions are utilization management tools. Appeal paths usually begin with the plan's internal redetermination, then independent external review; for Medicare Part D there is a coverage determination with exceptions for formulary, tiering, and prior authorization rules.
Compliance is the other half of the domain. Never change a date of service to make a claim pay, never reverse and rebill to evade refill-too-soon edits, and never bill for a prescription that was not dispensed. Documentation supports everything: signature logs, hard copies, prescriber verification, and PA records must be retrievable for the audit lookback period, commonly 10 years for Medicare Part D. Desk and on-site audits by PBMs and Medicare administrative contractors recoup funds when records are missing, so a technically clean claim with thin documentation can still become a recoupment.
Rule of thumb: when a rejection appears, ask whether it is a data problem, an order-of-payer problem, or a coverage problem. The answer tells you whether to fix a field, bill another payer, or start a prior authorization.