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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: Varies, refer to Patient ID Card	BIN: 016523	PCN: 622
Processor: Magellan Pharmacy Solutions
Effective as of: 06/01/2013	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 If Situational, Payer Situation
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 If Situational, Payer Situation
This Segment is always sent	X

Insurance Segment Segment Identification (111-AM) = “Ø4”		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 If Situational, Payer Situation
This Segment is always sent	X

Patient Segment Segment Identification (111-AM) = “Ø1”		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 If Situational, Payer Situation
This Segment is always sent	X
This payer supports partial fills	X

Claim Segment Segment Identification (111-AM) = “Ø7”		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 If Situational, Payer Situation
This Segment is always sent	X

Pricing Segment Segment Identification (111-AM) = “11”		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 If Situational, Payer Situation
This Segment is always sent	X

Prescriber Segment Segment Identification (111-AM) = “Ø3”		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 If Situational, Payer Situation
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 Segment Identification (111-AM) = “Ø5”		Claim Billing/Claim Re-bill Scenario 1 – Other Payer Amount Paid Repetitions Only
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 If Situational, Payer Situation
This Segment is situational	X

DUR/PPS Segment Segment Identification (111-AM) = “Ø8”		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 If Situational, Payer Situation
This Segment is situational	X

Compound Segment Segment Identification (111-AM) = “1Ø”		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 If Situational, Payer Situation
This Segment is situational	X

Clinical Segment Segment Identification (111-AM) = “13”		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 Accepted/Approved If Situational, Payer Situation
This Segment is always sent	X

Response Transaction Header Segment		Claim Reversal Accepted/Approved
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 Accepted/Approved If Situational, Payer Situation
This Segment is always sent
This Segment is situational	X	Provide general information when used for transmission-level messaging.

Response Transaction Header Segment Segment Identification (111-AM) = “2Ø”		Claim Reversal Accepted/Approved
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 Accepted/Approved If Situational, Payer Situation
This Segment is always sent	X

Response Status Segment Segment Identification (111-AM) = “21”		Claim Reversal Accepted/Approved
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 Accepted/Approved If Situational, Payer Situation
This Segment is always sent	X

Response Claim Segment Segment Identification (111-AM) = “22”		Claim Reversal Accepted/Approved
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 Accepted/Approved If Situational, Payer Situation
This Segment is always sent
This Segment is situational	X

Response Transaction Header Segment Segment Identification (111-AM) = “23”		Claim Reversal Accepted/Approved
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 Accepted/Rejected If Situational, Payer Situation
This Segment is always sent	X
This Segment is situational

Response Transaction Header Segment		Claim Reversal Accepted/Rejected
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 Accepted/Rejected If Situational, Payer Situation
This Segment is always sent
This Segment is situational	X

Response Message Segment
Segment Identification (111-AM) = “2Ø”

Claim Reversal
Accepted/Rejected

Field #

NCPDP Field Name

Value

Payer Usage

Payer Situation

5Ø4-F4

MESSAGE

Imp Guide: Required if text is needed for clarification or detail.

Payer Requirement: Same as Imp Guide.

Response Status Segment Questions	Check	Claim Reversal Accepted/Rejected If Situational, Payer Situation
This Segment is always sent	X

Response Status Segment Segment Identification (111-AM) = “21”		Claim Reversal Accepted/Rejected
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 Accepted/Rejected If Situational, Payer Situation
This Segment is always sent	X

Response Claim Segment Segment Identification (111-AM) = “22		Claim Reversal Accepted/Rejected
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 Rejected/Rejected If Situational, Payer Situation
This Segment is always sent	X

Response Transaction Header Segment		Claim Reversal Rejected/Rejected
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 Rejected/Rejected If Situational, Payer Situation
This Segment is always sent
This Segment is situational	X