This guide provides a quick reference for pharmacy program messages, codes, and responses. The information below reflects vendor-provided content.
If you have any questions regarding pharmacy benefits processing for North Dakota Workforce Safety & Insurance members, contact the LucyRx Pharmacy Help Desk at 877-846-3397.
These codes are utilized to properly identify an Injured Worker and his/her injury.
302-C2 – Patient ID
304-C4 – Date of Birth
435-DZ – WSI Claim Number
434-DY – Date of Injury
315-CF – Employer Name
These related error codes and messages indicate one or more of the required fields is missing or does not match patient eligibility records.
52, 07 – Non-matched or M/I Cardholder ID
09 – M/I Date of Birth
DZ – M/I Claim Reference ID
DY – M/I Date of Injury Patient/Injury Mismatch
Product Selection Co-Pay
Patients electing branded products when generic equivalents are available are responsible for product selection co-pay.
Coverage Outside Submitted Date of Service; Date of Service Outside of WC Claim Effective Dates
Dates of service after the termination date will be denied. The submitted claim has been assigned a medical cutoff date.
Payment not guaranteed. Once determined, IPM will notify via remittance advice.
Claim Captured; Inactive Claim: Compensability to be determined - No recent billing activity on the submitted injury. WSI to determine compensability.
Claim Captured; Pending Status Claim - Compensability of submitted injury has not been determined.
The First Fill Program covers pharmacy bills submitted for injuries not yet reported to WSI.
First Fill; exceeds 7-day limit
First Fill Program allows up to 7-day supply of a drug product.
First Fill benefit must be received within 30 days
First Fill Program allows processing within 30 days of date of injury.
78 – Cost Exceeds Maximum; Dollars exceed plan limitations. Max 100.
First Fill Program allows up to $100 benefit.
25 – M/I Prescriber ID
Plan requires a valid NPI number.
71 – Prescriber Not Covered : Prescriber Excluded For Patient
Physician may need to be added to WSI’s approved list of physicians for this injury.
76 – Plan Limitations Exceeded
Specific limit exceeded will be specified in the message returned
75 – Prior Authorization Required Contact Workforce Safety Customer Service
Specific drug products require prior authorization; WSI will determine approvals.
70 – NDC Not Covered Non Formulary – Not Allowed
Specific drug products are excluded from coverage. Some products are further restricted for “First Fill” bill.
9G – Quantity dispensed exceeds maximum allowed
Quantity limit exceeded
7X – Claim days supply exceeds dispensing limit
Days’ supply exceeded
Aggravation of existing condition: partial coverage
WSI has determined patient is responsible for percentage of the cost
Allowed Claim; benefit suspended; 100% patient pay
Patient responsible for payment until amount of 3 rd party settlement is met.