DC Medicaid Medical Assistance Programs Request Claim Billing/Claim Rebill (B1/B3) Payer Sheet

Transcription

1 DC edicaid edical Assistance Programs Request (B1/B3) Payer Sheet GENERAL INFORATION Payer Name: DC edical Assistance Administration Date: Date of Publication of this Template Plan Name/Group Name: DC edicaid edical Assistance Programs BIN: 61ØØ84 PCN: DRDCPROD = Production Plan Name/Group Name: DC edicaid edical Assistance Programs (test) Processor: ACS, A erox Company Effective as of: January 1, 2012 NCPDP Data Dictionary Version Date: July, 2007 Contact/Information Source: Other references such as Provider anuals, Payer phone number, web site, etc. Certification Testing Window: Certification Testing Dates Certification Contact Information: Certification phone number and information Pharmacy Help Desk Info: 8ØØ Other versions supported: 5.1 supported through 12/31/2011 BIN: 61ØØ84 PCN: DRDCACCP = Test (after 1/1/2012) PCN: DRDCDV5S (thru 12/31/2011 for D.Ø testing) NCPDP Telecommunication Standard Version/Release #: D.Ø NCPDP External Code List Version Date: Date of Publication OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Transaction Code Transaction Name B1 Billing B3 Rebilling FIELD LEGEND FOR COLUNS Payer Column Value Explanation Column ANDATORY 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. QUALIFIED REQUIREENT Required when. The situations designated have qualifications for usage ("Required if x", "Not required if y"). Fields that are not used in the transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template. CLAI BILLING/CLAI REBILL TRANSACTION The following lists the segments and fields in a Claim Billing or Claim Rebill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Transaction Header Segment Questions Check Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Not used No Yes Transaction Header Segment 1Ø1-A1 BIN NUBER 61ØØ84 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B1 = Billing B3 = Rebill 1Ø4-A4 PROCESSOR CONTROL NUBER DRDCPROD = Production DRDCDV5S = D.Ø Test DRDCACCP = Test 1Ø9-A9 TRANSACTION COUNT 1 = One Occurrence 2 = Two Occurrences 3 = Three Occurrences 4 = Four Occurrences 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1 = National Provider Identifier (NPI) 2Ø1-B1 SERVICE PROVIDER ID NPI Number Claim Billing, Claim Rebill Use PCN DRDCDV5S for D.Ø Testing through 12/31/2011

2 Transaction Header Segment 4Ø1-D1 DATE OF SERVICE CCYYDD 11Ø-AK SOFTWARE VENDOR/CERTIFICATION ID This will be provided by the provider's software vender If no number is supplied, populate with zeros Insurance Segment Questions Check Insurance Segment Segment Identification (111-A) = Ø4 3Ø2-C2 CARDHOLDER ID Recipient s edicaid ID Number 8 digit number 3Ø1-C1 GROUP ID DCEDICAID R 3Ø6-C6 Patient Relationship Code 1 = Cardholder R Patient Segment Questions Check Patient Segment Segment Identification (111-A) = Ø1 Field NCPDP Field Name Value Payer 3Ø4-C4 DATE OF BIRTH CCYYDD R 3Ø5-C5 PATIENT GENDER CODE Ø = Not Specified R 1 = ale 2 = Female 31Ø-CA PATIENT FIRST NAE R 311-CB PATIENT LAST NAE R 335-2C PREGNANCY INDICATOR Blank = Not Specified 1 = Not pregnant 2 = Pregnant PATIENT RESIDENCE 2 = Skilled Nursing 3 = Nursing Facility Required when submitting a claim for a pregnant member Required when the claim is for LTC status Claim Segment Questions Check This payer does not support partial fills Claim Segment Segment Identification (111-A) = Ø7 455-E PRESCRIPTION/SERVICE REFERENCE 1 = Rx Billing NUBER QUALIFIER 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE Rx Number assigned by the NUBER pharmacy 436-E1 PRODUCT/SERVICE ID QUALIFIER Ø3 = National Drug Code 4Ø7-D7 PRODUCT/SERVICE ID National Drug Code (NDC) 442-E7 QUANTITY DISPENSED etric Decimal Quantity R 4Ø3-D3 FILL NUBER Ø = Original Dispensing 1-3 = Refill number 4Ø5-D5 DAYS SUPPLY ax = 31 Retail ax = 34 LTC 4Ø6-D6 COPOUND CODE 1 = Not a compound 2 = Compound 4Ø8-D8 DISPENSE AS WRITTEN (DAW)/PRODUCT Ø = No Product Selection SELECTION CODE Indicated 1 = Substitution Not Allowed by R R R R District policy allows the original fill plus 3 refills. There are exceptions for birth control pills, please see the provider manual for details. Claims submitted with DAW = 1 will deny for PA Required

3 Claim Segment Segment Identification (111-A) = Ø7 Prescriber 5 = Substitution Allowed-Generic Drug Not in Stock 8 = Substitution allowed Generic drug not available in marketplace 414-DE DATE PRESCRIPTION WRITTEN CCYYDD R 415-DF NUBER OF REFILLS AUTHORIZED Ø = Not Specified R 1-99 = number of refill 419-DJ PRESCRIPTION ORIGIN CODE Ø = Not Known 1 = Written R Required for the Tamper Proof Resistant Pad Legislation 2 = Telephone 3 = Electronic 4 = Facsimile 5 = Pharmacy 354-N SUBISSION CLARIFICATION CODE COUNT aximum count of 3. Required if Submission Clarification Code (42Ø- DK) is used. 42Ø-DK SUBISSION CLARIFICATION CODE 8 = Process compound for Approved ingredients 8 Required to allow payment for covered ingredients and ignore and not pay for noncovered ingredients in a compound 3Ø8-C8 OTHER COVERAGE CODE Ø = Not Specified 1 = No other Coverage Identified 2 = Other coverage existspayment collected 3 = Other coverage exists-this claim not covered 4 = Other coverage existspayment not collected 429-DT SPECIAL PACKAGING INDICATOR Ø = Not specified 1 = Not Unit Dose 2 = anufacturer Unit Dose 3 = Pharmacy Unit Dose Required when submitting a claim for a recipient who has other coverage. Required when a pharmacy has repackaged a non-unit dose product. 418-DI LEVEL OF SERVICE 3 = Emergency Use for emergency 3 day fill 461-EU PRIOR AUTHORIZATION TYPE CODE 4 = Exemption from Copay and/or Coinsurance 462-EV PRIOR AUTHORIZATION NUBER SUBITTED 995-E2 ROUTE OF ADINISTRATION SNOED CT Values required for D.0 Required when the Rx is a compound Pricing Segment Questions Check Pricing Segment Segment Identification (111-A) = 11 4Ø9-D9 INGREDIENT COST SUBITTED R 412-DC DISPENSING FEE SUBITTED Required if needed to balance claim 426-DQ USUAL AND CUSTOARY CHARGE R 43Ø-DU GROSS AOUNT DUE R Prescriber Segment Questions Check Prescriber Segment Segment Identification (111-A) = Ø3

4 Prescriber Segment Segment Identification (111-A) = Ø3 466-EZ PRESCRIBER ID QUALIFIER Ø1=National Provider Identifier R (NPI) 411-DB PRESCRIBER ID NPI Number R Coordination of Benefits/Other Payments Segment Questions Check This Segment is situational Required only for secondary, tertiary, etc claims. Scenario 3 - Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) If the Payer supports the Coordination of Benefits/Other Payments Segment, only one scenario method shown above may be supported per template. The template shows the Coordination of Benefits/Other Payments Segment that must be used for each scenario method. The Payer must choose the appropriate scenario method with the segment chart, and delete the other scenario methods with their segment charts. See section Coordination of Benefits (COB) Processing for more information. Coordination of Benefits/Other Payments Segment Segment Identification (111-A) = Ø C COORDINATION OF BENEFITS/OTHER aximum count of 3 PAYENTS COUNT 338-5C OTHER PAYER COVERAGE TYPE Blank=Not Specified Ø1=Primary Ø2=Secondary Ø3=Tertiary 339-6C OTHER PAYER ID QUALIFIER Ø3=Bank Information Number R (BIN) Scenario 3 - Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) Required if Other Payer ID (34Ø-7C) is used. 34Ø-7C OTHER PAYER ID Use proprietary program codes for the Other Payer ID. 443-E8 OTHER PAYER DATE CCYYDD Required when there is payment or denial from another source. 341-HB OTHER PAYER AOUNT PAID COUNT aximum count of 9. Required when billing for COB Required if Other Payer Amount Paid Qualifier (342-HC) is used. 342-HC OTHER PAYER AOUNT PAID QUALIFIER Ø1=Delivery Ø2=Shipping Ø3=Postage Ø4=Administrative Ø5=Incentive Ø6=Cognitive Service Ø7=Drug Benefit Ø9=Compound Preparation Cost 1Ø=Sales Tax Required when there is payment from another source 431-DV OTHER PAYER AOUNT PAID Required if other payer has approved payment for some/all of the billing E OTHER PAYER REJECT COUNT aximum count of 5. R Required if Other Payer Reject Code (472-6E) is used E OTHER PAYER REJECT CODE R Required when the other payer has denied the payment for the billing, designated with Other Coverage Code (3Ø8-C8) = 3 (Other Coverage Billed claim not covered). 353-NR OTHER PAYER-PATIENT RESPONSIBILITY 1 R Required if Other Payer-Patient Responsibility

5 Coordination of Benefits/Other Payments Segment Segment Identification (111-A) = Ø5 AOUNT COUNT Scenario 3 - Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) Amount Qualifier (351-NP) is used. 351-NP OTHER PAYER-PATIENT RESPONSIBILITY AOUNT QUALIFIER Ø6=Patient Pay Amount (5Ø5-F5) R Required if Other Payer-Patient Responsibility Amount (352-NQ) is used. 352-NQ OTHER PAYER-PATIENT RESPONSIBILITY R AOUNT 392-U BENEFIT STAGE COUNT aximum count of 4. Required if Benefit Stage Amount (394-W) is used. 393-V BENEFIT STAGE QUALIFIER Required if Benefit Stage Amount (394-W) is used. 394-W BENEFIT STAGE AOUNT This field is required when the plan is a participant in a edicare Part D program that requires reporting of benefit stage specific financial amounts. DUR/PPS Segment Questions Check This Segment is situational DUR/PPS Segment Segment Identification (111-A) = Ø E DUR/PPS CODE COUNTER aximum of 9 occurrences. Required if DUR/PPS Segment is used. 439-E4 REASON FOR SERVICE CODE See Attached list of valid Values Required when there is a conflict to resolve or reason for service to be explained (ax 9) Code identifying the type of utilization conflict detected or the reason for the pharmacist s professional service. 44Ø-E5 PROFESSIONAL SERVICE CODE See Attached list of valid Values 441-E6 RESULT OF SERVICE CODE See Attached list of valid Values Required when there is a professional service to be identified (ax 9) Code identifying pharmacist intervention when a conflict code has been identified or service has been rendered. Required when There is a result of service to be Submitted (ax = 9). Action taken by a pharmacist in response to a conflict or the result of a pharmacist s professional service. Compound Segment Questions Check This Segment is situational Required when billing for a compound Compound Segment Segment Identification (111-A) = 1Ø

6 Compound Segment Segment Identification (111-A) = 1Ø 45Ø-EF COPOUND DOSAGE FOR DESCRIPTION Ø1=Capsule CODE Ø2=Ointment Ø3=Cream Ø4=Suppository Ø5=Powder Ø6=Emulsion Ø7=Liquid 1Ø=Tablet 11=Solution 12=Suspension 13=Lotion 14=Shampoo 15=Elixir 16=Syrup 17=Lozenge 18=Enema 451-EG COPOUND DISPENSING UNIT FOR INDICATOR 1=Each 2=Grams 3=illiliters aximum 25 ingredients 447-EC COPOUND INGREDIENT COPONENT COUNT 488-RE COPOUND PRODUCT ID QUALIFIER Ø3= National Drug Code (NDC) 489-TE COPOUND PRODUCT ID 448-ED COPOUND INGREDIENT QUANTITY ** End of Request (B1/B3) Payer Sheet Template**

7 RESPONSE CLAI BILLING/CLAI REBILL PAYER SHEET CLAI BILLING/CLAI REBILL ACCEPTED/PAID (OR DUPLICATE OF PAID) RESPONSE ** Start of Response (B1/B3) Payer Sheet Template** GENERAL INFORATION Payer Name: DC edical Assistance Administration Date: January 1, 2Ø12 Plan Name/Group Name: DC edicaid edical Assistance Programs BIN: 61ØØ84 PCN: DRDCPROD = Production Plan Name/Group Name: DC edicaid edical Assistance Programs (test) BIN: 61ØØ84 PCN: DRDCACCP = Test (after 1/1/2012) PCN: DRDCDV5S (thru 12/31/2011 for D.Ø testing) CLAI BILLING/CLAI REBILL PAID (OR DUPLICATE OF PAID) RESPONSE The following lists the segments and fields in a Claim Billing or Claim Rebill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Response Transaction Header Segment Questions Check Accepted/Paid (or Duplicate of Paid) Response Transaction Header Segment 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B1, B3 1Ø9-A9 TRANSACTION COUNT Same value as in request 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Same value as in request 2Ø1-B1 SERVICE PROVIDER ID Same value as in request 4Ø1-D1 DATE OF SERVICE Same value as in request Accepted/Paid (or Duplicate of Paid) Response essage Segment Questions Check Accepted/Paid (or Duplicate of Paid) This Segment is situational Segment sent if required for clarification Response essage Segment Segment Identification (111-A) = 2Ø Accepted/Paid (or Duplicate of Paid) 5Ø4-F4 ESSAGE Text essage Required if text is needed for clarification or detail. Response Insurance Segment Questions Check Accepted/Paid (or Duplicate of Paid) Response Insurance Segment Segment Identification (111-A) = 25 Accepted/Paid (or Duplicate of Paid) 3Ø1-C1 GROUP ID R Used to identify the group number used in claim adjudication. 524-FO PLAN ID R Used to identify the actual plan ID that was used in claim adjudication. Response Status Segment Questions Check Accepted/Paid (or Duplicate of Paid) Response Status Segment Segment Identification (111-A) = 21 Accepted/Paid (or Duplicate of Paid)

8 112-AN TRANSACTION RESPONSE STATUS P=Paid D=Duplicate of Paid 5Ø3-F3 AUTHORIZATION NUBER 17-digit TCN R 13Ø-UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. Required if Additional essage Information (526-FQ) is used. 132-UH ADDITIONAL ESSAGE INFORATION QUALIFIER Required if Additional essage Information (526-FQ) is used. 526-FQ ADDITIONAL ESSAGE INFORATION Required when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFORATION CONTINUITY Required if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526-FQ) follows it, and the text of the following message is a continuation of the current. Response Claim Segment Questions Check Accepted/Paid (or Duplicate of Paid) Response Claim Segment Segment Identification (111-A) = E PRESCRIPTION/SERVICE REFERENCE 1 = Rx Billing NUBER QUALIFIER 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUBER Accepted/Paid (or Duplicate of Paid) Response Pricing Segment Questions Check Accepted/Paid (or Duplicate of Paid) Response Pricing Segment Segment Identification (111-A) = 23 Accepted/Paid (or Duplicate of Paid) 5Ø5-F5 PATIENT PAY AOUNT R 5Ø6-F6 INGREDIENT COST PAID R 5Ø7-F7 DISPENSING FEE PAID R 559-A PERCENTAGE SALES TA AOUNT R Populated with zeros PAID 566-J5 OTHER PAYER AOUNT RECOGNIZED Required if Other Payer Amount Paid (431- DV) is greater than zero (Ø) and Coordination of Benefits/Other Payments Segment is supported. 5Ø9-F9 TOTAL AOUNT PAID R 522-F BASIS OF REIBURSEENT DETERINATION Required if Ingredient Cost Paid (5Ø6-F6) is greater than zero (Ø). 514-FE REAINING BENEFIT AOUNT R Populated with zeros. 517-FH AOUNT APPLIED TO PERIODIC R Populated with zeros. DEDUCTIBLE 518-FI AOUNT OF COPAY R Patient Copay 52Ø-FK AOUNT ECEEDING PERIODIC BENEFIT AIU R Populated with zeros.

9 Response DUR/PPS Segment Questions Check Accepted/Paid (or Duplicate of Paid) This Segment is situational Sent to provide information about DUR conflicts Response DUR/PPS Segment Segment Identification (111-A) = 24 Accepted/Paid (or Duplicate of Paid) 567-J6 DUR/PPS RESPONSE CODE COUNTER aximum 9 occurrences supported. Required if Reason For Service Code (439- E4) is used. 439-E4 REASON FOR SERVICE CODE Required if utilization conflict is detected. 528-FS CLINICAL SIGNIFICANCE CODE Required if needed to supply additional 529-FT OTHER PHARACY INDICATOR Required if needed to supply additional 53Ø-FU PREVIOUS DATE OF FILL CCYYDD Required if needed to supply additional 531-FV QUANTITY OF PREVIOUS FILL Required if needed to supply additional 532-FW DATABASE INDICATOR 1 = First DataBank a drug database company Required if needed to supply additional 533-F OTHER PRESCRIBER INDICATOR Required if needed to supply additional 544-FY DUR FREE TET ESSAGE Required if needed to supply additional CLAI BILLING/CLAI REBILL ACCEPTED/REJECTED RESPONSE CLAI BILLING/CLAI REBILL ACCEPTED/REJECTED RESPONSE Response Transaction Header Segment Questions Check Accepted/Rejected Response Transaction Header Segment 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B1, B3 1Ø9-A9 TRANSACTION COUNT Same value as in request 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Same value as in request 2Ø1-B1 SERVICE PROVIDER ID Same value as in request 4Ø1-D1 DATE OF SERVICE Same value as in request Accepted/Rejected Response essage Segment Questions Check Accepted/Rejected This Segment is situational Segment sent if required for reject clarification Response essage Segment Segment Identification (111-A) = 2Ø Accepted/Rejected 5Ø4-F4 ESSAGE Text essage Required if text is needed for clarification or detail. Response Insurance Segment Questions Check Accepted/Rejected This Segment is situational

10 Response Insurance Segment Segment Identification (111-A) = 25 Accepted/Rejected 3Ø1-C1 GROUP ID R Used to identify the actual group ID used during adjudication. 524-FO PLAN ID R Used to identify the actual plan ID used during adjudication. Response Status Segment Questions Check Accepted/Rejected Response Status Segment Segment Identification (111-A) = AN TRANSACTION RESPONSE STATUS R = Reject 5Ø3-F3 AUTHORIZATION NUBER 17-digit TCN R 546-4F REJECT FIELD OCCURRENCE INDICATOR 13Ø-UF ADDITIONAL ESSAGE INFORATION COUNT Accepted/Rejected Required if a repeating field is in error, to identify repeating field occurrence. aximum count of 25. Required if Additional essage Information (526-FQ) is used. 132-UH ADDITIONAL ESSAGE INFORATION QUALIFIER Required if Additional essage Information (526-FQ) is used. 526-FQ ADDITIONAL ESSAGE INFORATION Required when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFORATION CONTINUITY Required if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526-FQ) follows it, and the text of the following message is a continuation of the current. Response Claim Segment Questions Check Accepted/Rejected Response Claim Segment Segment Identification (111-A) = E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUBER Accepted/Rejected 1 = RxBilling For Transaction Code of B1, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 1 (Rx Billing). Response DUR/PPS Segment Questions Check Accepted/Rejected This Segment is situational Response DUR/PPS Segment Segment Identification (111-A) = 24 Accepted/Rejected 567-J6 DUR/PPS RESPONSE CODE COUNTER aximum 9 occurrences supported. Required if Reason For Service Code (439- E4) is used. 439-E4 REASON FOR SERVICE CODE Required if utilization conflict is detected. 528-FS CLINICAL SIGNIFICANCE CODE Required if needed to supply additional 529-FT OTHER PHARACY INDICATOR Required if needed to supply additional

11 Response DUR/PPS Segment Segment Identification (111-A) = 24 Accepted/Rejected 53Ø-FU PREVIOUS DATE OF FILL CCYYDD Required if needed to supply additional 531-FV QUANTITY OF PREVIOUS FILL Required if needed to supply additional 532-FW DATABASE INDICATOR 1 = First DataBank a drug database company Required if needed to supply additional 533-F OTHER PRESCRIBER INDICATOR Required if needed to supply additional 544-FY DUR FREE TET ESSAGE Required if needed to supply additional CLAI BILLING/CLAI REBILL REJECTED/REJECTED RESPONSE CLAI BILLING/CLAI REBILL REJECTED/REJECTED RESPONSE Response Transaction Header Segment Questions Check Rejected/Rejected Response Transaction Header Segment 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B1, B3 1Ø9-A9 TRANSACTION COUNT Same value as in request 5Ø1-F1 HEADER RESPONSE STATUS R = Rejected 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Same value as in request 2Ø1-B1 SERVICE PROVIDER ID Same value as in request 4Ø1-D1 DATE OF SERVICE Same value as in request Rejected/Rejected Response essage Segment Questions Check Rejected/Rejected This Segment is situational Segment sent if required for reject clarification Response essage Segment Segment Identification (111-A) = 2Ø Rejected/Rejected 5Ø4-F4 ESSAGE Text essage Required if text is needed for clarification or detail. Response Status Segment Questions Check Rejected/Rejected Response Status Segment Segment Identification (111-A) = 21 Rejected/Rejected 112-AN TRANSACTION RESPONSE STATUS R = Reject 5Ø3-F3 AUTHORIZATION NUBER 17-digit TCN Required if needed to identify the transaction. 51Ø-FA REJECT COUNT aximum count of 5. R 511-FB REJECT CODE R 546-4F REJECT FIELD OCCURRENCE INDICATOR Required if a repeating field is in error, to identify repeating field occurrence. 13Ø-UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. Required if Additional essage Information (526-FQ) is used.

12 Response Status Segment Segment Identification (111-A) = UH ADDITIONAL ESSAGE INFORATION QUALIFIER Rejected/Rejected Required if Additional essage Information (526-FQ) is used. 526-FQ ADDITIONAL ESSAGE INFORATION Required when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFORATION CONTINUITY Required if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526-FQ) follows it, and the text of the following message is a continuation of the current. ** End of Response (B1/B3) Payer Sheet Template**

13 Additional Claim Information DUR Codes Reason for Service Codes (439-E4): DUR Conflict Codes Code eaning Code eaning AT Additive Toxicity LD Low Dose Alert CH Call Help Desk LR Under Use Precaution DA Drug Allergy Alert C Drug Disease Precaution DC Inferred Drug Disease Precaution N Insufficient Duration Alert DD Drug-Drug Interaction Excessive Duration Alert DF Drug Food Interaction OH Alcohol Precaution DI Drug Incombatability PA Drug Age Precaution DL Drug Lab Conflict PG Drug Pregnancy Alert DS Tobacco Use Precaution PR Prior Adverse Drug Reaction ER Over Use Conflict SE Side Effect Alert HD High Dose Alert S Drug Gender Alert IC Iatrogenic Condition Alert TD Therapeutic Duplication ID Ingredient Duplication Professional Service Codes (44Ø-E5): Intervention Codes Code eaning Code eaning Ø Prescriber Consulted - D Interface RØ Pharmacist Consulted Other Source - Pharmacist reviewed PØ Patient Consulted - patient interaction Result of Service Codes (441-E6): Intervention Codes Code eaning Code eaning 1A Filled As Is False Positive 1F Filled Different Quantity 1B Filled Prescription As Is 1G Filled after prescriber approval 1C Filled With Different Dose 2A Not Filled 1D Filled With Different Directions 2B Not Filled Directions Clarified Route of Administration Codes (995-E2): SNOED CT Values Required Old NCPDP Value Description High Level SNOED CT SNOED CT Description 1 Buccal Buccal route (qualifier value) 2 Dental Dental route (qualifier value) 3 Inhalation By inhalation (route) (qualifier value) 4 Injection By injection (route) qualifier value) 5 Intraperitoneal Intraperitoneal route (qualifier value) 6 Irrigation By irrigation (route) (qualifier value) 7 outh/throat Oral route (qualifier value) 8 ucous embrane Submucosal route (qualifier value) 9 Nasal Nasal route (qualifier value) 10 Opthalmic Ophthalmic route (qualifier value) 11 Oral Oral route (qualifier value)

14 12 Other/iscellaneous N/A 13 Otic Otic route (qualifier value) 14 Perfusion C By infusion (route) qualifier value) 15 Rectal Per rectum (route) (qualifier value) 16 Sublingual Sublingual route (qualifier value) 17 Topical Iontophoresis route (qualifier value) 18 Transdermal Intradermal route (qualifier value) 19 Translingual Sublingual route (qualifier value) 20 Urethral Urethral route (qualifier value) 21 Vaginal Per vagina (route) (qualifier value) 22 Enteral Enteral route (qualifier value)