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

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

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

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

 

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/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

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

 

 

 

 

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

Claim Reversal
Rejected/Rejected

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
Rejected/Rejected
If Situational, Payer Situation

This Segment is always sent

X

 

 

 

 

Response Message Segment
Segment Identification (111-AM) = “21”

Claim Reversal
Rejected/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.

 

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