Example 2: Claim Level Status Request and Response using NCPDP Reject Code

Business Scenario Explanation:
ABC RX Insurance has a payer identification of 12345 (Loop 2100A NM109). XYZ Service, a Clearinghouse, has an Electronic Transmitter Identification Number of X67E (Loop 2100B NM109) that it uses to conduct electronic business transactions with ABC RX Insurance.

Home Hospital Pharmacy uses XYZ Service to submit electronic claims and claim status requests to ABC RX Insurance. Home Hospital Pharmacy’s National Provider Identifier (NPI) is 1666666662 (Loop 2100C NM109).

Fred Smith has a Subscriber Identifier of 123456789012 (Loop 2100D NM109) and his birth date is 12/10/1980 (Loop 2000D DMG02). Home Hospital Pharmacy requested the status of a claim for a pharmacy service rendered to Mr. Smith on February 27, 2026 in the amount of $85 (Loop 2200D AMT02) and assigned a Claim Status Trace Number of ABCXYZ1 (Loop 2200D TRN02). Home Hospital Pharmacy also provided a Pharmacy Prescription Number of 7654321 (Loop 2200D REF01=XZ).

A finalized claim was located by ABC RX Insurance. It had been received on February 28, 2026 (Loop 2200D DTP01=050) assigned a Payer Claim Control Number of 05347006051 (Loop 2200D REF01=1K). ABC RX Insurance returned a Health Care Claim Status Response which reported Claim Status Category F2 - Finalized/Denied (Loop 2200D STC01-01), a National Council for Prescription Drug Programs Reject Code of 80 - Drug- diagnosis mismatch (Loop 2200D STC01-02) along with the Code List Qualifer Code of RX (Loop 2200D STC01-04) as required. The Heath Care Claim Status Response also reported the Adjudication Finalized Date as March 4, 2026 (Loop 2200D STC06), the Remittance Date as March 6, 2026 (Loop 2200D STC08) and the Check Number/Remittance Trace Number of 77772389230014 (Loop 2200D STC09).