Claims help resources - PAN Foundation

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

Myelodysplastic Syndromes, 99990454

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.