Pharmacy
Rx payer specifications
NCDP Version D Claim Billing/Claim Re-bill D.0 Payer Specifications
Request Claim Billing/Claim Re-bill Payer
General Information
Payer Name: Magellan Complete Care |
Date: April 10, 2014 |
|
Plan Name/Group Name: |
BIN: |
PCN: |
Processor: Magellan Pharmacy Solutions |
||
Effective as of: |
NCPDP Telecommunication Standard Version/Release #:D.0 |
|
Pharmacy Support: 800-327-8613 |
||
NCPDP Data Dictionary Version Date: October 2011 |
NCPDP External Code List Version Date: October 2011 |
|
Other versions supported: No lower versions supported. |
Other Transactions Supported
Transaction Code |
Transaction Name |
B2 |
Reversal |
B3 |
Re-bill |
E1 |
Eligibility Verification |
First Legent for Columns
Payer Usage Column |
Value |
Explanation |
Payer Situation Column |
MANDATORY |
M |
The Field is mandatory for the Segment in the designated Transaction. |
No |
Required |
R |
The Field has been designated with the situation of “Required” for the Segment in the designated Transaction. |
No |
Qualified Requirement |
RW |
“Required when.” The situations designated have qualifications for usage (“Required if x,” “Not required if y"). |
Yes |
Fields that are not used in the Claim Billing/Claim Re-bill transactions and those that do not have qualified requirements (i.e., not used) for this payer are excluded from the template.
Claim Billing/Claim Re-bill Transaction
The following lists the segments and fields in a Claim Billing or Claim Re-bill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø.
Transaction Header Segment Questions |
Check |
Claim Billing/Claim Re-bill |
This Segment is always sent |
X |
|
Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is not used |
X |
|
Transaction Header Segment |
Claim Billing/Claim Re-bill |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
1Ø1-A1 |
BIN Number |
016523 |
M |
|
1Ø2-A2 |
VERSION/RELEASE NUMBER |
DØ |
M |
|
1Ø3-A3 |
TRANSACTION CODE |
B1, B3 |
M |
|
1Ø4-A4 |
PROCESSOR CONTROL NUMBER |
622 |
M |
|
1Ø9-A9 |
Transaction Count |
1–4 Max of ‘1’ allowed for compound transactions. |
M |
|
2Ø2-B2 |
Service Provider ID Qualifier |
‘01’ = National Provider ID |
M |
|
2Ø1-B1 |
Service Provider ID |
NPI |
M |
|
4Ø1-D1 |
Date of Service |
|
M |
|
11Ø-AK |
SOFTWARE VENDOR/CERTIFICATION ID |
|
M |
Assigned when vendor is certified with Magellan Pharmacy Solutions |
Insurance Segment Questions |
Check |
Claim Billing/Claim Re-bill |
This Segment is always sent |
X |
|
Insurance Segment |
Claim Billing/Claim Re-bill |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
3Ø2-C2 |
CARDHOLDER ID |
|
M |
|
312-CC |
CARDHOLDER FIRST NAME |
|
R |
|
313-CD |
CARDHOLDER LAST NAME |
|
R |
|
3Ø1-C1 |
GROUP ID |
Varies |
R |
Varies, refer to Patient ID Card |
3Ø3-C3 |
PERSON CODE |
|
R |
|
3Ø6-C6 |
PATIENT RELATIONSHIP CODE |
|
R |
|
Patient Segment Questions |
Check |
Claim Billing/Claim Re-bill |
This Segment is always sent |
X |
|
Patient Segment |
Claim Billing/Claim Re-bill |
|||
Field |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
331-CX |
PATIENT ID QUALIFIER |
|
RW |
Required if Patient ID (332-CY) is used. |
332-CY |
PATIENT ID |
|
RW |
Required if necessary for state/federal/regulatory agency programs to validate dual eligibility. |
3Ø4-C4 |
DATE OF BIRTH |
Patient’s Date of Birth |
R |
|
3Ø5-C5 |
PATIENT GENDER CODE |
|
R |
|
31Ø-CA |
PATIENT FIRST NAME |
|
R |
|
311-CB |
PATIENT LAST NAME |
|
R |
|
3Ø7-C7 |
PLACE OF SERVICE |
|
RW |
Required if this field could result in different coverage, pricing, or patient financial responsibility. |
335-2C |
PREGNANCY INDICATOR |
|
RW |
Required if pregnancy could result in different coverage, pricing, or patient financial responsibility. |
384-4X |
PATIENT RESIDENCE |
|
RW |
Required if this field could result in different coverage, pricing, or patient financial responsibility. Required when known. |
Claim Segment Questions |
Check |
Claim Billing/Claim Re-bill |
This Segment is always sent |
X |
|
This payer supports partial fills |
X |
|
Claim Segment |
Claim Billing/Claim Re-bill |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
455-EM |
PREscription/Service Reference Number Qualifier |
1 = Rx Billing |
M |
For Transaction Code of “B1”, in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is “1” (Rx Billing). |
4Ø2-D2 |
Prescription/Service Reference Number |
|
M |
|
436-E1 |
Product/Service ID Qualifier |
‘03’ = National Drug Code (NDC) ‘00’ = Not Specified (Use for Compounds) |
M |
|
4Ø7-D7 |
Product/Service ID |
National Drug Code (NDC) ‘Ø’ for Compound |
M |
|
456-EN |
ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER |
|
RW |
Required if the “completion” transaction in a partial fill (Dispensing Status (343-HD) = “C” (Completed)). Required if the Dispensing Status (343-HD) = “P” (Partial Fill) and there are multiple occurrences of partial fills for this prescription. |
457-EP |
ASSOCIATED PRESCRIPTION/SERVICE DATE |
|
RW |
Required if the “completion” transaction in a partial fill (Dispensing Status (343-HD) = “C” (Completed)). Required if Associated Prescription/Service Reference Number (456-EN) is used. Required if the Dispensing Status (343-HD) = “P” (Partial Fill) and there are multiple occurrences of partial fills for this prescription. |
442-E7 |
QUANTITY DISPENSED |
|
R |
|
4Ø3-D3 |
FILL NUMBER |
|
R |
|
4Ø5-D5 |
DAYS SUPPLY |
|
R |
|
4Ø6-D6 |
COMPOUND CODE |
|
R |
|
4Ø8-D8 |
DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE |
|
R |
|
414-DE |
DATE PRESCRIPTION WRITTEN |
|
R |
|
415-DF |
NUMBER OF REFILLS AUTHORIZED |
|
R |
|
419-DJ |
PRESCRIPTION ORIGIN CODE |
1 = Written 2 = Telephone 3 = Electronic 4 = Facsimile 5 = Pharmacy |
R |
|
354-NX |
SUBMISSION CLARIFICATION CODE COUNT |
Maximum count of 3 |
RW |
Required if Submission Clarification Code (42Ø-DK) is used. |
42Ø-DK |
SUBMISSION CLARIFICATION CODE |
|
RW |
Required if clarification is needed and value submitted is greater than zero (Ø). |
3Ø8-C8 |
OTHER COVERAGE CODE |
‘00’ = Not specified ‘01’ = No other coverage ‘02’ = Other coverage exists – payment collected ‘03’ = Other coverage exists – claim not covered ‘04’ = Other coverage exists – payment not collected |
RW |
Imp Guide: Required if needed by receiver, to communicate a summation of other coverage information that has been collected from other payers. Required for Coordination of Benefits. |
6ØØ-28 |
UNIT OF MEASURE |
EA = Each GM = Grams ML = Milliliters |
R |
|
418-DI |
LEVEL OF SERVICE |
|
RW |
Required if this field could result in different coverage, pricing, or patient financial responsibility. |
461-EU |
PRIOR AUTHORIZATION TYPE CODE |
|
RW |
Required if this field could result in different coverage, pricing, or patient financial responsibility. |
462-EV |
PRIOR AUTHORIZATION NUMBER SUBMITTED |
|
RW |
Required if this field could result in different coverage, pricing, or patient financial responsibility. |
343-HD |
DISPENSING STATUS |
|
RW |
Required for the partial fill or the completion fill of a prescription. |
344-HF |
QUANTITY INTENDED TO BE DISPENSED |
|
RW |
Required for the partial fill or the completion fill of a prescription. |
345-HG |
DAYS SUPPLY INTENDED TO BE DISPENSED |
|
RW |
Required for the partial fill or the completion fill of a prescription. |
995-E2 |
ROUTE OF ADMINISTRATION |
SNOMED |
RW |
Required if specified in trading partner agreement. Payer Requirement: Required when submitting Compounds |
996-G1 |
COMPOUND TYPE |
|
RW |
Required if specified in trading partner agreement. Payer Requirement: Required when known. |
147-U7 |
PHARMACY SERVICE TYPE |
|
RW |
Required when the submitter must clarify the type of services being performed as a condition for proper reimbursement by the payer. Payer Requirement: Required when known. |
Pricing Segment Questions |
Check |
Claim Billing/Claim Re-bill |
This Segment is always sent |
X |
|
Pricing Segment |
Claim Billing/Claim Re-bill |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
4Ø9-D9 |
INGREDIENT COST SUBMITTED |
|
R |
|
412-DC |
DISPENSING FEE SUBMITTED |
|
RW |
Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. |
433-DX |
PATIENT PAID AMOUNT SUBMITTED |
|
RW |
Required if this field could result in different coverage, pricing, or patient financial responsibility. |
438-E3 |
INCENTIVE AMOUNT SUBMITTED |
|
RW |
Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. |
478-H7 |
OTHER AMOUNT CLAIMED SUBMITTED COUNT |
Maximum count of 3 |
RW |
Required if Other Amount Claimed Submitted Qualifier (479-H8) is used. |
479-H8 |
OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER |
|
RW |
Required if Other Amount Claimed Submitted (48Ø-H9) is used. |
48Ø-H9 |
OTHER AMOUNT CLAIMED SUBMITTED |
|
RW |
Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. |
481-HA |
FLAT SALES TAX AMOUNT SUBMITTED |
|
RW |
Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. |
482-GE |
PERCENTAGE SALES TAX AMOUNT SUBMITTED |
|
RW |
Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. |
483-HE |
PERCENTAGE SALES TAX RATE SUBMITTED |
|
RW |
Required if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Basis Submitted (484-JE) are used. Required if this field could result in different pricing. Required if needed to calculate Percentage Sales Tax Amount Paid (559-AX). |
484-JE |
PERCENTAGE SALES TAX BASIS SUBMITTED |
|
RW |
Required if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Rate Submitted (483-HE) are used. Required if this field could result in different pricing. Required if needed to calculate Percentage Sales Tax Amount Paid (559-AX). |
426-DQ |
USUAL AND CUSTOMARY CHARGE |
|
R |
Required if needed per trading partner agreement. |
43Ø-DU |
GROSS AMOUNT DUE |
|
R |
|
423-DN |
BASIS OF COST DETERMINATION |
|
RW |
Required if needed for receiver claim/encounter adjudication. |
Prescriber Segment Questions |
Check |
Claim Billing/Claim Re-bill |
This Segment is always sent |
X |
|
Prescriber Segment |
Claim Billing/Claim Re-bill |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
466-EZ |
PRESCRIBER ID QUALIFIER |
Ø1 = NPI |
R |
|
411-DB |
PRESCRIBER ID |
NPI |
R |
|
427-DR |
PRESCRIBER LAST NAME |
|
RW |
Required when the Prescriber ID (411-DB) is not known. |
Coordination of Benefits/Other Payments Segment Questions |
Check |
Claim Billing/Claim Re-bill |
||
This Segment is situational |
X |
Required only for secondary, tertiary, etc., claims |
||
|
|
|
||
Scenario 1 – Other Payer Amount Paid Repetitions Only |
|
|
Coordination of Benefits/Other Payments Segment |
Claim Billing/Claim Re-bill |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
337-4C |
Coordination of Benefits/Other Payments Count |
Maximum count of 9 |
M |
|
338-5C |
Other Payer Coverage Type |
Blank = Not Specified Ø1 = Primary – First Ø2 = Secondary – Second Ø3 = Tertiary – Third Ø4 = Quaternary – Fourth Ø5 = Quinary – Fifth Ø6 = Senary – Sixth Ø7 = Septenary – Seventh Ø8 = Octonary – Eighth Ø9 = Nonary – Ninth |
M |
|
339-6C |
OTHER PAYER ID QUALIFIER |
Ø1 = National Payer ID Ø2 = Health Industry Number (HIN) Ø3 = Bank Information Number (BIN) Card Issuer ID Ø4 = National Association of Insurance Commissioners (NAIC) Ø5 = Medicare Carrier Number 99 = Other |
RW |
Required if Other Payer ID (34Ø-7C) is used. |
34Ø-7C |
OTHER PAYER ID |
|
RW |
Required if identification of the Other Payer is necessary for claim/encounter adjudication. |
443-E8 |
OTHER PAYER DATE |
|
RW |
Required if identification of the Other Payer Date is necessary for claim/encounter adjudication. |
341-HB |
OTHER PAYER AMOUNT PAID COUNT |
Maximum count of 9 |
R |
Required if Other Payer Amount Paid Qualifier (342-HC) is used. |
342-HC |
OTHER PAYER AMOUNT PAID QUALIFIER |
Ø1 = Delivery Ø2 = Shipping Ø3 = Postage Ø4 = Administrative Ø5 = Incentive Ø6 = Cognitive Service Ø7 = Drug Benefit Ø9 = Compound Preparation Cost Submitted 1Ø = Sales Tax |
R |
Required if Other Payer Amount Paid (431-DV) is used. |
431-DV |
OTHER PAYER AMOUNT PAID |
|
R |
Required if other payer has approved payment for some/all of the billing. |
471-5E |
OTHER PAYER REJECT COUNT |
Maximum count of 5 |
RW |
Required if Other Payer Reject Code (472-6E) is used. |
472-6E |
OTHER PAYER REJECT CODE |
|
RW |
Required when the other payer has denied the payment for the billing. |
353-NR |
OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT |
Maximum count of 25. |
RW |
Required if Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. |
351-NP |
OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER |
Blank = Not Specified Ø1 = Amount Applied to Periodic Deductible (517-FH) as reported by previous payer Ø2 = Amount Attributed to Product Selection/Brand Drug (134-UK) as reported by previous payer Ø3 = Amount Attributed to Sales Tax (523-FN) as reported by previous payer Ø4 = Amount Exceeding Periodic Benefit Maximum (52Ø-FK) as reported by previous payer Ø5 = Amount of Copay (518-FI) as reported by previous payer Ø6 = Patient Pay Amount (5Ø5-F5) as reported by previous payer Ø7 = Amount of Coinsurance (572-4U) as reported by previous payer Ø8 = Amount Attributed to Product Selection/Non-Preferred Formulary Selection (135-UM) as reported by previous payer Ø9 = Amount Attributed to Health Plan Assistance Amount (129-UD) as reported by previous payer (If Other Payer-Patient Responsibility Amount Qualifier is 09, then the Other Payer-Patient Responsibility Amount (Field # 352-NQ) MUST be = $0 or the claim will reject for NCPDP “NP M/I Other Payer Patient Responsibility Amount Qlfr.”) 1Ø = Amount Attributed to Provider Network Selection (133-UJ) as reported by previous payer 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) as reported by previous payer 12 = Amount Attributed to Coverage Gap (137-UP) that was collected from the patient due to a coverage gap 13 = Amount Attributed to Processor Fee (571-NZ) as reported by previous payer |
RW |
Required if Other Payer-Patient Responsibility Amount (352-NQ) is used. |
352-NQ |
OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT |
|
RW |
Required if Other Payer Amount Paid (431-DV) is submitted or the claim will reject for NCPDP “NP M/I Other Payer Patient Responsibility Amount Qlfr.” |
DUR/PPS Segment Questions |
Check |
Claim Billing/Claim Re-bill |
This Segment is situational |
X |
|
DUR/PPS Segment |
Claim Billing/Claim Re-bill |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
473-7E |
DUR/PPS CODE COUNTER |
Maximum of 9 occurrences. (‘1’ – Maximum of one allowed) |
R*** |
Required if DUR/PPS Segment is used. |
439-E4 |
REASON FOR SERVICE CODE |
|
RW*** |
Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required if this field affects payment for or documentation of professional pharmacy service. |
44Ø-E5 |
PROFESSIONAL SERVICE CODE |
|
RW*** |
Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required if this field affects payment for or documentation of professional pharmacy service. |
441-E6 |
RESULT OF SERVICE CODE |
|
RW*** |
Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required if this field affects payment for or documentation of professional pharmacy service. |
474-8E |
DUR/PPS LEVEL OF EFFORT |
|
RW |
Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required if this field affects payment for or documentation of professional pharmacy service. Payer Requirement: Required for Compounds |
Compound Segment Questions |
Check |
Claim Billing/Claim Re-bill |
This Segment is situational |
X |
|
Compound Segment |
Claim Billing/Claim Re-bill |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
45Ø-EF |
Compound Dosage Form Description Code |
|
M |
|
451-EG |
Compound Dispensing Unit Form Indicator |
|
M |
|
447-EC |
Compound Ingredient Component Count |
|
M |
Maximum 25 ingredients |
488-RE |
Compound Product ID Qualifier |
|
M*** |
|
489-TE |
Compound Product ID |
|
M*** |
|
448-ED |
Compound Ingredient Quantity |
|
M*** |
|
449-EE |
COMPOUND INGREDIENT DRUG COST |
|
M*** |
|
49Ø-UE |
COMPOUND INGREDIENT BASIS OF COST DETERMINATION |
|
R*** |
|
Clinical Segment Questions |
Check |
Claim Billing/Claim Re-bill |
This Segment is situational |
X |
|
Clinical Segment |
Claim Billing/Claim Re-bill |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
491-VE |
DIAGNOSIS CODE COUNT |
Maximum count of 5. (‘1’ – Maximum of one allowed) |
RW |
Required if Diagnosis Code Qualifier (492-WE) and Diagnosis Code (424-DO) are used. |
492-WE |
DIAGNOSIS CODE QUALIFIER |
|
RW*** |
Required if Diagnosis Code (424-DO) is used. |
424-DO |
DIAGNOSIS CODE |
|
RW*** |
Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required if this field affects payment for professional pharmacy service. Required if this information can be used in place of prior authorization. Required if necessary for state/federal/regulatory agency programs. |
493-XE |
CLINICAL INFORMATION COUNTER |
|
RW*** |
Grouped with Measurement fields (Measurement Date (494-ZE), Measurement Time (495-H1), Measurement Dimension (496-H2), Measurement Unit (497-H3), Measurement Value (499-H4). |
494-ZE |
MEASUREMENT DATE |
|
RW*** |
Required if necessary when this field could result in different coverage and/or drug utilization review outcome. |
495-H1 |
MEASUREMENT TIME |
|
RW*** |
Required if Time is known or has impact on measurement. Required if necessary when this field could result in different coverage and/or drug utilization review outcome. |
496-H2 |
MEASUREMENT DIMENSION |
|
RW*** |
Required if Measurement Unit (497-H3) and Measurement Value (499-H4) are used. Required if necessary when this field could result in different coverage and/or drug utilization review outcome. Required if necessary for patient’s weight and height when billing Medicare for a claim that includes a Certificate of Medical Necessity (CMN). |
497-H3 |
MEASUREMENT UNIT |
|
RW*** |
Required if Measurement Dimension (496-H2) and Measurement Value (499-H4) are used. Required if necessary for patient’s weight and height when billing Medicare for a claim that includes a Certificate of Medical Necessity (CMN). Required if necessary when this field could result in different coverage and/or drug utilization review outcome. |
499-H4 |
MEASUREMENT VALUE |
|
RW*** |
Required if Measurement Dimension (496-H2) and Measurement Unit (497-H3) are used. Required if necessary for patient’s weight and height when billing Medicare for a claim that includes a Certificate of Medical Necessity (CMN). Required if necessary when this field could result in different coverage and/or drug utilization review outcome. |
Claim Reversal Accepted/Approved Response
General Information
Payer Name: Magellan Complete Care |
Date: June 1, 2013 |
|
Plan Name/Group Name: Varies, refer to Patient ID Card |
BIN:016523 |
PCN:622 |
Claim Reversal Accepted/Approved Response
The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP
Telecommunication Standard Implementation Guide Version D.Ø.
Response Transaction Header Segment Questions |
Check |
Claim Reversal |
This Segment is always sent |
X |
|
Response Transaction Header Segment |
Claim Reversal |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
1Ø2-A2 |
VERSION/RELEASE NUMBER |
DØ |
M |
|
1Ø3-A3 |
TRANSACTION CODE |
B2 |
M |
|
1Ø9-A9 |
TRANSACTION COUNT |
1–4 Max of ‘1’ allowed for compound transactions. |
M |
|
5Ø1-F1 |
HEADER RESPONSE STATUS |
A = Accepted |
M |
|
2Ø2-B2 |
SERVICE PROVIDER ID QUALIFIER |
01 |
M |
01 – National Provider Identifier (NPI) |
2Ø1-B1 |
SERVICE PROVIDER ID |
National Provider Identifier (NPI) |
M |
|
4Ø1-D1 |
DATE OF SERVICE |
Same value as in request |
M |
|
Response Transaction Header Segment Questions |
Check |
Claim Reversal |
This Segment is always sent |
|
|
This Segment is situational |
X |
Provide general information when used for transmission-level messaging. |
Response Transaction Header Segment |
Claim Reversal |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
5Ø4-F4 |
MESSAGE |
|
RW |
Imp Guide: Required if text is needed for clarification or detail. Payer Requirement: Same as Imp Guide. |
Response Status Segment Questions |
Check |
Claim Reversal |
This Segment is always sent |
X |
|
Response Status Segment |
Claim Reversal |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
112-AN |
TRANSACTION RESPONSE STATUS |
A = Approved |
M |
|
5Ø3-F3 |
AUTHORIZATION NUMBER |
|
RW |
Imp Guide: Required if needed to identify the transaction. Payer Requirement: Same as Imp Guide. |
547-5F |
APPROVED MESSAGE CODE COUNT |
Maximum count of 5. |
RW*** |
Imp Guide: Required if Approved Message Code (548-6F) is used. Payer Requirement: Same as Imp Guide. |
548-6F |
APPROVED MESSAGE CODE |
|
RW*** |
Imp Guide: Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. Payer Requirement: Same as Imp Guide. |
13Ø-UF |
ADDITIONAL MESSAGE INFORMATION COUNT |
Maximum count of 25. |
RW*** |
Imp Guide: Required if Additional Message Information (526-FQ) is used. Payer Requirement: Same as Imp Guide. |
132-UH |
ADDITIONAL MESSAGE INFORMATION QUALIFIER |
|
RW*** |
Imp Guide: Required if Additional Message Information (526-FQ) is used. Payer Requirement: Same as Imp Guide. |
526-FQ |
ADDITIONAL MESSAGE INFORMATION |
|
RW*** |
Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Same as Imp Guide. |
131-UG |
ADDITIONAL MESSAGE INFORMATION CONTINUITY |
|
RW*** |
Imp Guide: Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current. Payer Requirement: Same as Imp Guide. |
549-7F |
HELP DESK PHONE NUMBER QUALIFIER |
|
RW |
Imp Guide: Required if Help Desk Phone Number (55Ø-8F) is used. Payer Requirement: Same as Imp Guide. |
55Ø-8F |
HELP DESK PHONE NUMBER |
|
RW |
Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Same as Imp Guide. |
Response Claim Segment Questions |
Check |
Claim Reversal |
This Segment is always sent |
X |
|
Response Claim Segment |
Claim Reversal |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
455-EM |
PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER |
1 |
M |
Imp Guide: For Transaction Code of “B2,” in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is “1” (Rx Billing). |
4Ø2-D2 |
PRESCRIPTION/SERVICE REFERENCE NUMBER |
|
M |
|
Response Pricing Segment Questions |
Check |
Claim Reversal |
This Segment is always sent |
|
|
This Segment is situational |
X |
|
Response Transaction Header Segment |
Claim Reversal |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
521-FL |
INCENTIVE AMOUNT PAID |
|
RW |
Imp Guide: Required if this field is reporting a contractually agreed upon payment. Payer Requirement: Same as Imp Guide. |
5Ø9-F9 |
TOTAL AMOUNT PAID |
|
RW |
Imp Guide: Required if any other payment fields sent by the sender. Payer Requirement: Same as Imp Guide. |
Claim Reversal Accepted/Rejected Response
Response Transaction Header Questions |
Check |
Claim Reversal |
This Segment is always sent |
X |
|
This Segment is situational |
|
|
Response Transaction Header Segment |
Claim Reversal |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
1Ø2-A2 |
VERSION/RELEASE NUMBER |
DØ |
M |
|
1Ø3-A3 |
TRANSACTION CODE |
B2 |
M |
|
1Ø9-A9 |
TRANSACTION COUNT |
Same value as in request |
M |
|
5Ø1-F1 |
HEADER RESPONSE STATUS |
A = Accepted |
M |
|
2Ø2-B2 |
SERVICE PROVIDER ID QUALIFIER |
01 |
M |
01 – National Provider Identifier (NPI) |
2Ø1-B1 |
SERVICE PROVIDER ID |
National Provider Identifier (NPI) |
M |
|
4Ø1-D1 |
DATE OF SERVICE |
Same value as in request |
M |
|
Response Message Segment Questions |
Check |
Claim Reversal |
This Segment is always sent |
|
|
This Segment is situational |
X |
|
Response Message Segment |
Claim Reversal |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
5Ø4-F4 |
MESSAGE |
|
RW |
Imp Guide: Required if text is needed for clarification or detail. Payer Requirement: Same as Imp Guide. |
Response Status Segment Questions |
Check |
Claim Reversal |
This Segment is always sent |
X |
|
Response Status Segment |
Claim Reversal |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
112-AN |
TRANSACTION RESPONSE STATUS |
R = Reject |
M |
|
5Ø3-F3 |
AUTHORIZATION NUMBER |
|
R |
|
51Ø-FA |
REJECT COUNT |
Maximum count of 5. |
R |
|
511-FB |
REJECT CODE |
|
R |
|
546-4F |
REJECT FIELD OCCURRENCE INDICATOR |
|
RW*** |
Imp Guide: Required if a repeating field is in error, to identify repeating field occurrence. Payer Requirement: Same as Imp Guide. |
13Ø-UF |
ADDITIONAL MESSAGE INFORMATION COUNT |
Maximum count of 25. |
RW*** |
Imp Guide: Required if Additional Message Information (526-FQ) is used. Payer Requirement: Same as Imp Guide. |
132-UH |
ADDITIONAL MESSAGE INFORMATION QUALIFIER |
|
RW*** |
Imp Guide: Required if Additional Message Information (526-FQ) is used. Payer Requirement: Same as Imp Guide. |
526-FQ |
ADDITIONAL MESSAGE INFORMATION |
|
RW*** |
Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Same as Imp Guide. |
131-UG |
ADDITIONAL MESSAGE INFORMATION CONTINUITY |
|
RW*** |
Imp Guide: Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current. Payer Requirement: Same as Imp Guide. |
549-7F |
HELP DESK PHONE NUMBER QUALIFIER |
|
RW |
Imp Guide: Required if Help Desk Phone Number (55Ø-8F) is used.Payer Requirement: Same as Imp Guide. |
55Ø-8F |
HELP DESK PHONE NUMBER |
|
RW |
Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Same as Imp Guide. |
Response Claim Segment Questions |
Check |
Claim Reversal |
This Segment is always sent |
X |
|
Response Claim Segment |
Claim Reversal |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
455-EM |
PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER |
1 |
M |
Imp Guide: For Transaction Code of “B2,” in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455–EM) is “1” (Rx Billing). |
4Ø2-D2 |
PRESCRIPTION/SERVICE REFERENCE NUMBER |
|
M |
|
Claim Reversal Rejected/Rejected Response
Response Transaction Header Segment Questions |
Check |
Claim Reversal |
This Segment is always sent |
X |
|
Response Transaction Header Segment |
Claim Reversal |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
1Ø2-A2 |
VERSION/RELEASE NUMBER |
DØ |
M |
|
1Ø3-A3 |
TRANSACTION CODE |
B2 |
M |
|
1Ø9-A9 |
TRANSACTION COUNT |
Same value as in request |
M |
|
5Ø1-F1 |
HEADER RESPONSE STATUS |
A = Accepted |
M |
|
2Ø2-B2 |
SERVICE PROVIDER ID QUALIFIER |
01 |
M |
01 – National Provider Identifier (NPI) |
2Ø1-B1 |
SERVICE PROVIDER ID |
National Provider Identifier (NPI) |
M |
|
4Ø1-D1 |
DATE OF SERVICE |
Same value as in request |
M |
|
Response Segment Questions |
Check |
Claim Reversal |
This Segment is always sent |
|
|
This Segment is situational |
X |
|
Response Message Segment |
Claim Reversal |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
5Ø4-F4 |
MESSAGE |
|
RW |
Imp Guide: Required if text is needed for clarification or detail. Payer Requirement: Same as Imp Guide. |
Response Segment Questions |
Check |
Claim Reversal |
This Segment is always sent |
X |
|
Response Message Segment |
Claim Reversal |
|||
Field # |
NCPDP Field Name |
Value |
Payer Usage |
Payer Situation |
112-AN |
TRANSACTION RESPONSE STATUS |
R = Reject |
M |
|
5Ø3-F3 |
AUTHORIZATION NUMBER |
|
R |
|
51Ø-FA |
REJECT COUNT |
Maximum count of 5. |
R |
|
511-FB |
REJECT CODE |
|
R |
|
546-4F |
REJECT FIELD OCCURRENCE INDICATOR |
|
RW*** |
Imp Guide: Required if a repeating field is in error, to identify repeating field occurrence. Payer Requirement: Same as Imp Guide. |
13Ø-UF |
ADDITIONAL MESSAGE INFORMATION COUNT |
Maximum count of 25. |
RW*** |
Imp Guide: Required if Additional Message Information (526-FQ) is used. Payer Requirement: Same as Imp Guide. |
132-UH |
ADDITIONAL MESSAGE INFORMATION QUALIFIER |
|
RW*** |
Imp Guide: Required if Additional Message Information (526-FQ) is used. Payer Requirement: Same as Imp Guide. |
526-FQ |
ADDITIONAL MESSAGE INFORMATION |
|
RW*** |
Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Same as Imp Guide. |
131-UG |
ADDITIONAL MESSAGE INFORMATION CONTINUITY |
|
RW*** |
Imp Guide: Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current. Payer Requirement: Same as Imp Guide. |
549-7F |
HELP DESK PHONE NUMBER QUALIFIER |
|
RW |
Imp Guide: Required if Help Desk Phone Number (55Ø-8F) is used. Payer Requirement: Same as Imp Guide. |
55Ø-8F |
HELP DESK PHONE NUMBER |
|
RW |
Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Same as Imp Guide. |
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