Over the following pages, the IPU Contract Unit provides a comprehensive overview of the reasons why pharmacy claims may be rejected, and how you can ensure your rejects are minimised.

Claims processing  

After pharmacies submit their claims, the PCRS processes the claims and may reject some items if there is an issue with eligibility or if a claim fails to meet the criteria for payment.

Exception file 

The exception file becomes available shortly after electronic claims are submitted and it identifies claims which have an issue that may lead to a rejected claim. This gives pharmacies an opportunity to correct the issue to prevent it rejecting. Therefore, exceptions should be downloaded and resubmitted by the eighth working day of the month before they become final rejects. There are no restrictions on the number of times you can resubmit the early exception file. If items are not dealt with at this stage, then they will move to being rejected in your claim payment. Therefore, dealing with issues in the exception file can save time in the reclaiming process and ensure that your claim is fully reimbursed.

Rejects: Common reasons and solutions 

The main reasons for rejects have been identified through PCRS analysis of claims submitted via the monthly electronic claim file.

Top five reject reasons

The top five reject reasons account for 30 per cent of all rejects so it is important to pay particular attention to these:

1. E1010 — Withdrawn drug code: Certain GMS codes may be withdrawn due to product discontinuation or the removal of a GMS code. This can lead to a high number of claim rejects if these codes continue to be used after the code has been withdrawn. The most commonly claimed withdrawn drug codes giving rise to rejects are stated in Table 1. To prevent this type of reject, particular care should be taken when dispensing ‘repeat’ prescriptions to ensure that the drug code remains valid.

Table 1: The most claimed withdrawn codes

2. E2026 — There is an undischarged owing against this item for this patient. Please submit a dispensed owing: Each owing raised and submitted to the PCRS will need to have a dispensed owing submitted before the same product can be claimed for the patient again. If this does not happen then this reject type will occur. To prevent this type of reject, ensure that a dispensed owing is submitted for any open owings before submitting another claim for the same product.
3. E0961 — Patient specific approval not in place on date of claim: Table 3 reports the top 10 products which are most often rejected for payment due to the lack of patient approval for an item. To prevent this type of reject, ensure that patient specific approval is in place for your patients by checking the ‘PCRS Secure Scheme Checker’ before supplying these items.

Table 2: Most common patient approval rejects 

4. E1115 – LTI patient exceeded quota for non-approved drugs: Only items listed on the published LTI Core List for the patient’s LTI illness are reimbursable under the LTI Scheme. Pharmacies can seek approval for items which are not on the LTI Core List through the PCRS LTI Drug Request screen. To prevent this type of error pharmacies should check if the product to be dispensed under the LTI Scheme is on the LTI Core List for the patient’s illness type. If it is not, then pharmacies should check on the PCRS Secure Scheme Checker to see if the patient has approval for the item.
5. E1117 — High Tech drugs must have been dispensed in previous three months: Claims for the High-Tech non-dispensing fee will be reimbursed for up to three consecutive months after the last High-Tech dispensing. To prevent this type of error, check if the patient has been dispensed a High-Tech medication in the previous three months before claiming the non-dispensing fee.

Additional reasons for rejected claims 

Patient errors 

To eliminate errors related to patient eligibility and scheme inclusion, please check the patient’s eligibility in the ‘PCRS Secure Scheme Checker’, which provides the most accurate, real-time data.

Some examples of this type of reject include:

• E0522 — Patient number is invalid or blank;
• E0311 — Eligibility expired;
• E0312 — Card number not known;
• E0046 — Incomplete claim, eligibility of patient cannot be verified; or
• E2243 — Doctor Visit Card number not applicable on GMS Pharmacy claims

Product errors 

Product-related issues represent the most complex category of errors, including factors such as the reimbursement list, scheme coverage, reimbursement restrictions, and supportive documentation. Certain items like compression hosiery, GLP-1 agonists for Diabetes Mellitus, and Nicotine Replacement Therapy (NRT) are not reimbursable under the DPS.

Some examples of this type of reject include:

• E1122 — Drug not active on date of claim;
• E1180 — Quantity exceeds diabetic strips allowance;
• E0961 — Patient specific approval not in place;
• E7014 — Duplicate item-not payable;
• E1104 — Maximum quantity exceeded; or
• E1115 — LTI Pat exceeded quota for non-approved drugs.

44 per cent of all errors are product related.

Doctor errors 

Referring to the list of GPs with GMS Contracts published on the PCRS online services will help resolve most doctor-related issues. Additionally, to claim for mental health service prescriptions under the GMS scheme, the prescriber number 55555 has been assigned. It is also important to only apply the 61559 under the Hospital Emergency Scheme as if it is used under the GMS Scheme it will generate a reject with the reason ‘Doctor Number is not valid’. Some examples of this type of reject include:

• E1003 — Invalid doctor number;
• E1089 — Doctor number is not valid; and
• E0002 —Error: Doctor number does not exist.

Miscellaneous reject reasons

• High-Tech Patient Care Fee: A monthly fee is only payable to one contractor for each registered patient;
• Express LTI / Emergency DPS: The claim date be on or after the application date. Claims placed before registration will be rejected;
• EHC Professional Service Fee Service Code: The EHC Consultation Professional Service Fee Code is required alongside the EHC medication code;
• Drug code not allowed: This could arise because 777xx coded items are not allowed on GMS prescriptions and only certain items are reimbursable on dental prescriptions; or
• Detailed breakdown of items: Extemporaneous preparations must contain the relevant code with a description of the preparation, formula used, the quantity dispensed and the ingredient cost.

“Pharmacies should have a procedure in place to deal with any outstanding rejected claims in a timely manner. This will prevent future rejects and mitigate against potential losses.”  

Pharmacy Claim Enquiry Tool 

Further information about a rejected claim can be found on the Pharmacy Claim Enquiry Tool on the PCRS Pharmacy Application Suite. This screen shows claim status details for any claims submitted, including the reason for rejected claims.

Step-by-step 

1. Choose the claim type you would like to query from the dropdown menu;
2. Enter a claim number, form number, patient number, or the month/year for which you would like to retrieve data and click on retrieve claims; and
3. The claim(s) will display in tabular format and provide details such as whether the claim was paid or rejected.

Resubmission of rejected claims 

Pharmacies should have a procedure in place to deal with any outstanding rejected claims in a timely manner. This will prevent future rejects and mitigate against potential losses.

If pharmacies have a query about a reject, then they can be submitted using the Pharmacy Query Form which is available for download on the Pharmacy Application Suite and also at pcrs.ie > Online Services > Services for Pharmacists Only > Query Form for Pharmacists.

When the rejects have been fixed, the rejected claims can be resubmitted for payment. Some PMR vendors support electronic reclaims after the final exception file has been downloaded. Electronic resubmission is quicker if it is available, but reclaims which must be submitted manually or where additional information is required to generate reimbursement, should be submitted to the Pharmacy Processing Unit, P.O Box 7062, Finglas, Dublin 11 D11 PXT0.

After 18 months, reclaim submission can only be submitted manually.

Figure 1: Pharmacy Claim Enquiry Tool

HSE Claim Reimbursement Quality Report  

The HSE Claim Reimbursement Quality Report is displayed at the back of the PCRS Claim Listings. This report records reject rates as a key quality metric and can be used as a benchmarking tool. Figure 1 demonstrates the level of fully paid claims. In 2024, early reject rates showed minimal variations, peaking in July after adjustments to the reimbursement application system for CGM sensors. However, most of the initially rejected claims are correctly reviewed and resolved.

The total number of claims submitted keeps increasing, driven by the growing number of eligible patients under community drug schemes, as well as the launching of new programmes like the Free Contraception Scheme. Importantly, despite this increase, the final claim reject rate has not risen.

Conclusion

By understanding the common reasons for claim rejects and implementing the proposed solutions, pharmacies can achieve full reimbursement and eliminate the time taken to deal with rejects and reclaims.

Pharmacy success rate

• 98 per cent of pharmacies had greater than 98 per cent of items paid initially in 2024;
• 99.98 per cent of items are fully paid within six months of the initial claim; and
• 6.9 per cent of pharmacies are fully paid (100 per cent) on initial claim submission.

Top tips 

Prior approval required:

• Non-first line standard oral nutritional supplements (ONS);

• Medical Cannabis Access Programme (MCAP);
• Phased dispensing;
• Fampyra;
• Versatis;
• Nadolol EMP;
• Pre-exposure Prophylaxis (PrEP);
• Entresto;
• Saxenda;
• Xarelto 2.5mg; and
• Continuous Blood Glucose Monitoring Sensors.

Scheme controlled items:

• Fampyra (GMS & LTI);
• Victoza (GMS & LTI);
• Ozempic (GMS & LTI);
• Trulicity (GMS & LTI);
• Cariban (GMS & DPS);
• Saxenda (GMS and DPS);
• Phased Dispensing (GMS);
• Some dressings (DPS only);
• NRT (GMS); and
• Compression hosiery (GMS).

Contract team would like to include the following previously used:

December 2024 and October 2024