Handling your Claim Exceptions

Please note that you can only Check and send Claim Exceptions from the Claims Machine. You can 'FIX' Claim Exceptions on any pc from the claims module. You have the first 3 WORKING days of the month to send your claim to the PCRS. You then have the following 5 WORKING days to send your reclaims to the PCRS.

How to Check for Exceptions

Once your claim has been sent and processed by the PCRS you will then receive Claim Exception scripts back from them. These script will need to be 'fixed' and sent back in a certain timeframe in order to receive payment for them.

To check for Claim Exceptions from the PCRS:

Go to Modules and Claims

You will then be brought into the claims section. Select the Claim Exceptions tab. You can then select the claim period and the scheme from the dropdowns.

You will see the Claim Exceptions that have been rejected by the PCRS. These Claim Exceptions will generally have a message attached to them that will indicate why they have been rejected by the PCRS.

Claim Exception Reasons and what to do with them

How to Fix Claim Exceptions

N.B. once a customer had made a change to the system e.g. changed Rx Type against a doctor, changed a patient's Scheme Reference / Card No. etc... this information will then be sent when the customer reclaims for the items.

Exception Reason & What to Do?

• Incorrect Claim Version Number | When you send a Claim for an item to the PCRS you send a Version Number to them to track how many times this item in this script for this patient has been sent to the PCRS. If the item is rejected and is then reclaimed the Version Number will increase. Sometimes the PCRS do not send us back the correct Version Number. I.E. the item is on v1.3 as it has gone over and back 3 times but the PCRS send back v1.1. This means when you send it back to them you will send v1.2. Since they will be expecting v1.3 they will reject it again. Simply sending it again will normally resolve the issue, however, it may take a few transmissions for it to catch up with the correct Version Number. |

Reclaiming for fixed Exceptions

N.B. Claim Exceptions can only be RECLAIMED for during the RECLAIM PERIOD in the month they were rejected. e.g. it is April 2nd 2019, you have sent your MARCH 2019 claim and you are dealing with your claim exceptions. You have a Claim Exception for a script from DECEMBER 2018 and a Claim Exception for a script from MARCH 2019. You will be able to edit and fix any Claim Exceptions and you can push them into the Send Claim tab however ONLY the MARCH 2019 script will be reclaimed when you hit Send Reclaim in the Send Claim tab to reclaim your rejected items after fixing them. The DECEMBER 2018 script will stay in the Send Claim tab until it comes time to send your next FULL claim i.e. the APRIL 2019 claim and will be reclaimed then.

If you are in the Send Claim tab in the Claims module and there is no Send Claim button, please ensure you are on your Claiming PC. They will not be able to send their Claim on any other RX PC