This page provides additional resources for pharmacies and healthcare providers, including claims denial reasons and remediation, and prescription group numbers for pharmacies.
Learn more about claims and billing
- Pharmacy claims and billing – complete information for pharmacies about submitting claims, claims adjustments, getting payments, and services covered.
- Provider claims and billing – complete information for healthcare providers about submitting claims, getting payments, and services covered.
- PAN grant use policy – policy of grant use within eligibility periods, requesting an extension, and grant reinstatement
- PAN portal information and guides – guide to what you can find in your PAN portal, how to check your balance, creating a new account, and more. Includes detailed PAN guides to enrolling a new patient, applying for additional funding, renewal grants, wait lists, and more.
Denied pharmacy claims
The following are the most common claim denial messages and reasons. If you do not see your claim denial message here, please contact us.
| Denial message | Reason for denial | Steps to take |
| Product/service not covered plan/benefit exclusion Non-matched product/service ID number | Drug or NDC excluded from plan formulary or disease fund. | 1. Verify if medication(s) are covered under the disease fund. 2. Contact PAN if the rejection is an error. |
| Non-matched cardholder ID | Member ID is not on file. | 1. Verify member ID and resubmit. 2. Contact PAN if it is an initial enrollment. |
| M/I group ID | Incorrect RxGroup number. | Verify RxGroup number |
| M/I date of birth | Date of birth (DOB) does not match member’s information. | 1. Verify correct DOB and resubmit. 2. Contact PAN if the listed DOB is incorrect. |
| M/I other coverage code COB/other payments segment incorrectly formatted | PAN only covers OCC8. Cannot use any other coverage code. Other Payer Amount Paid (OPAP) field must be blank. | Resubmit with OCC8, other payer patient responsibility amount (OPPRA). |
| M/I ingredient cost submitted | This is a required field to process the claim | Resubmit with ingredient cost (wholesale price). |
| Claim submitted does not match prior authorization | Authorization number must match for the claim to process. | Contact PAN. |
| Patient is not covered | Date of service (DOS) is outside of the eligibility period. Member not eligible on date filled. | 1. If DOS falls after the eligibility period, check the disease fund status to renew grant. 2. Contact PAN for possible coverage. |
| Fill too soon | Refill is too soon. | Contact PAN if there is an extenuating circumstance. |
| Claim too old | This claim was submitted after the timely filing period of 60 days. | Refer to our pharmacy claims page to learn more. |
| Duplicate paid/captured claim | Same claim was submitted previously. | Verify if this claim was previously submitted and paid. |
| Claim has not been paid/captured | Fund limit exhausted. | If the balance is exhausted and the eligibility period has not ended, refer to our guides on applying for additional funding. |
| M/I gross amount due | This field cannot be blank. | Enter the total cost of the drug. |
Denied provider claims
| Denial message | Reason for denial | Steps to take |
| Non-covered service or diagnosis (or similar denials) The patient is responsible for the billed charges. | The diagnosis code and/or service code submitted on the claim form for the date(s) of service is not covered under the patient’s disease fund. | 1. Review services that PAN does not cover. 2. Verify if the diagnosis code and/or medication are covered by the disease fund. 3. If the diagnosis code and/or medication are covered under the disease fund, update the claim form and resubmit with EOB. Write “Corrected Claim” on the claim form. 4. If a denial was issued for a medication that is listed as covered by the disease fund, contact PAN to request a review. |
| Secondary payment cannot be issued. A copy of the primary plan’s EOB must be submitted to consider these charges. | The insurance plan’s EOB was not submitted with the claim form. The EOB must be submitted to be considered for reprocessing. | Resubmit the claim form with a copy of the EOB from the insurance plan. |
| An itemized primary EOB must be submitted to consider these charges. | The EOB from the insurance plan is not itemized; an itemized EOB must be submitted to determine payment for the covered charges. | 1. Contact patient’s insurance plan to obtain an itemized EOB. Write “Corrected Claim” on the claim form when resubmitting. 2. If an itemized EOB is not available, contact PAN to advise. |
| Please resubmit the claim with a copy of the primary and secondary plan’s EOB. | Patient has primary and secondary plan coverage; both the primary and secondary plans EOBs must be submitted for claim reimbursement to be considered for processing. | 1. Submit the claim form with the EOBs for both the primary and secondary insurances. Write “Corrected Claim” on the claim form when resubmitting. 2. If there is no longer a secondary plan or the secondary plan does not cover the medication, contact PAN. |
| Duplicate charge previously processed | The services submitted were previously processed and paid. | 1. If resubmitting a claim with updated information, please write “Corrected Claim” on top of the second claim submission. 2. If the claim was denied in error, contact PAN and request a review. |
| Ineligible patient. Patient responsible for billed charges. | The grant was not effective on the date of service billed. | 1. If DOS falls after the eligibility period, check the disease fund status to renew the grant. 2. Contact PAN for possible coverage. |
| Fund limit exhausted. No payment issued. Partial reimbursement issued. Fund limit exhausted. | The claim was denied or partially paid because the grant does not have any more funds available to process the claim. | If the balance is exhausted and the eligibility period has not ended, learn how to apply for additional funding. |
| Timely filing period exceeded. | Claim submitted outside the timely filing period of 60 days after the end of the grant eligibility period. | Refer to our provider claims page to learn more. |
Pharmacy Rx Group Numbers
Acromegaly, 99990616
Acute Myeloid Leukemia, 99992776
Amyloidosis, 99994000
Ankylosing Spondylitis, 99991108
Asthma, 99990668
Atopic Dermatitis, 99993729
Basal Cell Carcinoma, 99991104
Biliary Tract Cancer, 99994090
Bipolar Disorder, 99994065
Bladder Cancer, 99993890
Breast Cancer, 99990647
Chronic Lymphocytic Leukemia, 99991004
Colorectal Cancer, 99990438
Cushing’s Disease or Syndrome, 99991289
Diabetic Foot Ulcers, 99990617
Duchenne Muscular Dystrophy, 99993825
Fabry Disease, 99993910
Follicular Lymphoma, 99993740
Gastrointestinal Stromal Tumors, 99991197
Gaucher Disease, 99990456
Glioblastoma Multiforme, 99993800
Graft Vs Host Disease, 99993815
Heart Failure, 99992637
Hemolytic Uremic Syndrome, 99993865
Hemophilia, 99993830
Hepatitis C, 99990613
HIV Treatment and Prevention, 99991280
Hypercholesterolemia, 99991258
Hyperkalemia, 99991257
Immune Thrombocytopenic Purpura, 99990657
Inflammatory Bowel Disease, 99990512
Inherited Retinal Disease, 99993810
Liver Cancer, 99994045
Long-Chain Fatty Acid Oxidation Disorders, 99993770
Lysosomal Acid Lipase Deficiency, 99993790
Macular Diseases, 99990418
Mantle Cell Lymphoma, 99991223
Melanoma, 99991237
Multiple Myeloma, 99993757
Multiple Sclerosis, 99990457
Myasthenia Gravis, 99994015
Neurofibromatosis, 99993760
Neuromyelitis Optica Spectrum Disorder, 99994110
Neurotrophic Keratitis, 99994010
Neutropenia, 99990658
Non-Hodgkin’s Lymphoma, 99990463
Non-Small Cell Lung Cancer, 99990459
Ovarian Cancer, 99991497
Pancreatic Cancer, 99990460
Parkinson’s Disease, 99991255
Paroxysmal Nocturnal Hemoglobinuria, 99993805
Pemphigus Vulgaris, 99993895
Philadelphia Chromosome Negative Myeloproliferative Neoplasms, 99990651
Plaque Psoriasis, 99991109
Pompe Disease 99994075
Postmenopausal Osteoporosis, 99991105
Prostate Cancer, 99991142
Psoriatic Arthritis, 99991107
Pulmonary Hypertension 99993820
Renal Cell Carcinoma, 99990594
Retinal Vein Occlusion, 99991026
Rett Syndrome, 99993795
Rheumatoid Arthritis, 99990664
Schizophrenia, 99994080
Short Bowel Syndrome, 99992330
Sickle Cell Disease, 99993940
Small Cell Lung Cancer, 99994055
Spinal Muscular Atrophy, 99994030
Systemic Lupus Erythematosus, 99993840
Type 2 Diabetes, 99993885
Uveitis, 99991039
Venous Leg Ulcers, 99991256
Von Willebrand Disease, 99993960
Waldenstrom Macroglobulinemia, 99993950
Claims and billing help
For claims and billing help, message PAN through your PAN portal account, or call us at 1-866-316-7263, Monday through Friday, 9:00 a.m. to 5:30 p.m. ET. You can also submit an inquiry via our website.