NCPDP Version D.0 Payer Sheet

Transcription

1 NCPDP Version D.0 Payer heet Payer Name: EH Date: 9/15/2011 Plan Name/Group Name: ALL PLAN BIN: PCN: eho udl Plan Name/Group Name: ALL PLAN BIN: PCN: Plan Name/Group Name: ALL Walgreen s Non-Workers Comp Rxs BIN: PCN: Plan Name/Group Name: ALL TET CLAI BIN: PCN: Processor: EH Effective as of: 1/01/2012 NCPDP Telecommunication tandard Version/Release #: D.0 NCPDP Data Dictionary Version Date: Date of Publication NCPDP External Code List Version Date: Contact/Information ource: Trent Lanham. trent@ehorx.com - (254) Certification Testing Window: 9/15/ /31/2011 Certification Contact Information: Certification Not Required Provider Relations Help Desk Info: (800) ther versions supported: Version 5.1 will be supported through 6/30/2012 Transaction Header egment Payer ituation 1Ø1-A1 BIN NUBER (see above) 1Ø2-A2 VERIN/RELEAE NUBER DØ 1Ø3-A3 TRANACTIN CDE B1, B3 1Ø4-A4 PRCER CNTRL NUBER 1Ø9-A9 TRANACTIN CUNT 1 2Ø2-B2 ERVICE PRVIDER ID QUALIFIER 01 NPI NLY 2Ø1-B1 ERVICE PRVIDER ID 10 digit NPI number 4Ø1-D1 DATE F ERVICE 11Ø-AK FTWARE VENDR/CERTIFICATIN ID Insurance egment egment Identification (111-A) = Ø4 Payer ituation 3Ø2-C2 CARDHLDER ID 312-CC CARDHLDER FIRT NAE 313-CD CARDHLDER LAT NAE 314-CE HE PLAN 524-F PLAN ID 3Ø1-C1 GRUP ID Always required. Refer to ember ID Card. 3Ø3-C3 PERN CDE Varies by plan 3Ø6-C6 PATIENT RELATINHIP CDE Varies by plan 359-2A EDIGAP ID 36Ø-2B EDICAID INDICATR 361-2D PRVIDER ACCEPT AIGNENT INDICATR 997-G2 C PART D DEFINED QUALIFIED FACILITY 115-N5 EDICAID ID NUBER

2 Patient egment egment Identification (111-A) = Ø1 Field NCPDP Field Name Value Payer 331-CX PATIENT ID QUALIFIER R 332-CY PATIENT ID R 3Ø4-C4 DATE F BIRTH R 3Ø5-C5 PATIENT GENDER CDE R 31Ø-CA PATIENT FIRT NAE R 311-CB PATIENT LAT NAE R 322-C PATIENT TREET ADDRE 323-CN PATIENT CITY ADDRE 324-C PATIENT TATE / PRVINCE ADDRE 325-CP PATIENT ZIP/PTAL ZNE 326-CQ PATIENT PHNE NUBER 3Ø7-C7 PLACE F ERVICE 333-CZ EPLYER ID 384-4X PATIENT REIDENCE Payer ituation Claim egment egment Identification (111-A) = Ø7 455-E PRECRIPTIN/ERVICE REFERENCE Ø1 = Rx Billing NUBER QUALIFIER 4Ø2-D2 PRECRIPTIN/ERVICE REFERENCE NUBER 436-E1 PRDUCT/ERVICE ID QUALIFIER 4Ø7-D7 PRDUCT/ERVICE ID 442-E7 QUANTITY DIPENED R 4Ø3-D3 FILL NUBER R 4Ø5-D5 DAY UPPLY R 4Ø6-D6 CPUND CDE R 4Ø8-D8 DIPENE A WRITTEN (DAW)/PRDUCT R ELECTIN CDE 414-DE DATE PRECRIPTIN WRITTEN R 415-DF NUBER F REFILL AUTHRIZED Payer ituation 419-DJ PRECRIPTIN RIGIN CDE RW Varies by plan 354-NX UBIIN CLARIFICATIN CDE CUNT 42Ø-DK UBIIN CLARIFICATIN CDE 3Ø8-C8 THER CVERAGE CDE RW aximum count of 3. Required if ubmission Clarification Code (42Ø-DK) is used. Required for Coordination of Benefits. 453-EJ RIGINALLY PRECRIBED PRDUCT/ERVICE ID QUALIFIER Required if riginally Prescribed Product/ervice Code (455-EA) is used. 445-EA RIGINALLY PRECRIBED PRDUCT/ERVICE CDE 446-EB RIGINALLY PRECRIBED QUANTITY 418-DI LEVEL F ERVICE 461-EU PRIR AUTHRIZATIN TYPE CDE RW Varies by plan

3 Claim egment egment Identification (111-A) = Ø7 462-EV PRIR AUTHRIZATIN NUBER RW UBITTED 995-E2 RUTE F ADINITRATIN 996-G1 CPUND TYPE 147-U7 PHARACY ERVICE TYPE Payer ituation Varies by plan Prescriber egment egment Identification (111-A) = Ø3 466-EZ PRECRIBER ID QUALIFIER Payer ituation 411-DB PRECRIBER ID NPI should be submitted whenever possible 427-DR PRECRIBER LAT NAE 498-P PRECRIBER PHNE NUBER 468-2E PRIARY CARE PRVIDER ID QUALIFIER 421-DL PRIARY CARE PRVIDER ID 47Ø-4E PRIARY CARE PRVIDER LAT NAE 364-2J PRECRIBER FIRT NAE 365-2K PRECRIBER TREET ADDRE PRECRIBER CITY ADDRE 367-2N PRECRIBER TATE/PRVINCE ADDRE 368-2P PRECRIBER ZIP/PTAL ZNE Coordination of Benefits/ther Payments egment egment Identification (111-A) = Ø5 ituational 337-4C CRDINATIN F BENEFIT/THER aximum count of 9. R PAYENT CUNT 338-5C THER PAYER CVERAGE TYPE R 339-6C THER PAYER ID QUALIFIER R Required if ther Payer ID (34Ø-7C) is used. 34Ø-7C THER PAYER ID R Required if identification of the ther Payer is necessary for claim/encounter adjudication. 443-E8 THER PAYER DATE R Required if identification of the ther Payer Date is necessary for claim/encounter adjudication. 341-HB THER PAYER AUNT PAID CUNT aximum count of 9. RW Required if ther Payer Amount Paid Qualifier (342-HC) is used. 342-HC THER PAYER AUNT PAID QUALIFIER RW Required if ther Payer Amount Paid (431- DV) is used. 431-DV THER PAYER AUNT PAID Required if other payer has approved payment for some/all of the billing. Not used for patient financial responsibility only billing. Not used for non-governmental agency programs if ther Payer-Patient Responsibility Amount (352-NQ) is submitted E THER PAYER REJECT CUNT aximum count of 5. RW Required if ther Payer Reject Code (472-6E) is used.

4 Coordination of Benefits/ther Payments egment egment Identification (111-A) = Ø5 ituational 472-6E THER PAYER REJECT CDE RW Required when the other payer has denied the payment for the billing, designated with ther Coverage Code (3Ø8-C8) = 3 (ther Coverage Billed claim not covered). Coordination of Benefits/ther Payments egment egment Identification (111-A) = Ø5 cenario 2- ther Payer-Patient Responsibility Amount Repetitions Payer ituation 337-4C CRDINATIN F BENEFIT/THER aximum count of 9. PAYENT CUNT 338-5C THER PAYER CVERAGE TYPE 339-6C THER PAYER ID QUALIFIER Imp Guide: Required if ther Payer ID (34Ø- 7C) is used. 34Ø-7C THER PAYER ID 443-E8 THER PAYER DATE 353-NR THER PAYER-PATIENT REPNIBILITY AUNT CUNT aximum count of 25. Imp Guide: Required if ther Payer-Patient Responsibility Amount Qualifier (351-NP) is used. 351-NP THER PAYER-PATIENT REPNIBILITY AUNT QUALIFIER Imp Guide: Required if ther Payer-Patient Responsibility Amount (352-NQ) is used. 352-NQ THER PAYER-PATIENT REPNIBILITY AUNT Imp Guide: Required if necessary for patient financial responsibility only billing. Pricing egment egment Identification (111-A) = 11 4Ø9-D9 INGREDIENT CT UBITTED R 412-DC DIPENING FEE UBITTED R 433-DX PATIENT PAID AUNT UBITTED 438-E3 INCENTIVE AUNT UBITTED 478-H7 THER AUNT CLAIED UBITTED CUNT This segment is always sent aximum count of 3. Required if ther Amount Claimed ubmitted Qualifier (479-H8) is used. 479-H8 THER AUNT CLAIED UBITTED QUALIFIER Required if ther Amount Claimed ubmitted (48Ø-H9) is used. 48Ø-H9 THER AUNT CLAIED UBITTED 481-HA FLAT ALE TAX AUNT UBITTED 482-GE 483-HE PERCENTAGE ALE TAX AUNT UBITTED PERCENTAGE ALE TAX RATE UBITTED Imp Guide: Required if Percentage ales Tax Amount ubmitted (482-GE) and Percentage ales Tax Basis ubmitted (484-JE) are used. 484-JE PERCENTAGE ALE TAX BAI UBITTED Imp Guide: Required if Percentage ales Tax Amount ubmitted (482-GE) and Percentage ales Tax Rate ubmitted (483-HE) are used.

5 Pricing egment egment Identification (111-A) = 11 This segment is always sent 426-DQ UUAL AND CUTARY CHARGE R 43Ø-DU GR AUNT DUE R 423-DN BAI F CT DETERINATIN R Imp Guide: Required if needed for receiver claim/encounter adjudication. Compound egment ptional egment egment Identification (111-A) = 1Ø Required for Compounds Payer ituation 45Ø-EF CPUND DAGE FR DECRIPTIN CDE RW Required when compound is being submitted. 451-EG CPUND DIPENING UNIT FR RW INDICATR 447-EC CPUND INGREDIENT CPNENT aximum 25 ingredients RW CUNT 488-RE CPUND PRDUCT ID QUALIFIER RW 489-TE CPUND PRDUCT ID RW 448-ED CPUND INGREDIENT QUANTITY RW 449-EE CPUND INGREDIENT DRUG CT RW Required if needed for receiver claim determination when multiple products are billed. 49Ø-UE CPUND INGREDIENT BAI F CT DETERINATIN 362-2G CPUND INGREDIENT DIFIER CDE CUNT 363-2H CPUND INGREDIENT DIFIER CDE RW Imp Guide: Required if needed for receiver claim determination when multiple products are billed. aximum count of 1Ø. Imp Guide: Required when Compound Ingredient odifier Code (363-2H) is sent. Clinical egment egment Identification (111-A) = 13 Payer ituation 491-VE DIAGNI CDE CUNT aximum count of 5. Imp Guide: Required if Diagnosis Code Qualifier (492-WE) and Diagnosis Code (424-D) are used. 492-WE DIAGNI CDE QUALIFIER Imp Guide: Required if Diagnosis Code (424- D) is used. 424-D DIAGNI CDE Clinical egment egment Identification (111-A) = 13 Payer ituation 491-VE DIAGNI CDE CUNT aximum count of 5. Imp Guide: Required if Diagnosis Code Qualifier (492-WE) and Diagnosis Code (424-D) are used. 492-WE DIAGNI CDE QUALIFIER Imp Guide: Required if Diagnosis Code (424- D) is used. 424-D DIAGNI CDE

6 CLAI BILLING/CLAI REBILL PAID (R DUPLICATE F PAID) REPNE Response Transaction Header egment 1Ø2-A2 VERIN/RELEAE NUBER DØ 1Ø3-A3 TRANACTIN CDE B1, B3 1Ø9-A9 TRANACTIN CUNT ame value as in request 5Ø1-F1 HEADER REPNE TATU A = Accepted 2Ø2-B2 ERVICE PRVIDER ID QUALIFIER ame value as in request 2Ø1-B1 ERVICE PRVIDER ID ame value as in request 4Ø1-D1 DATE F ERVICE ame value as in request Accepted/Paid Payer ituation Response essage egment egment Identification (111-A) = 2Ø Accepted/Paid Payer ituation 5Ø4-F4 EAGE Imp Guide: Required if text is needed for clarification or detail. Response Insurance egment egment Identification (111-A) = 25 Payer ituation 3Ø1-C1 GRUP ID R 524-F PLAN ID Part-D Commercial 3Ø2-C2 CARDHLDER ID Imp Guide: Required if the identification to be used in future transactions is different than what was submitted on the request. Response Patient egment egment Identification (111-A) = 29 31Ø-CA PATIENT FIRT NAE 311-CB PATIENT LAT NAE 3Ø4-C4 DATE F BIRTH Payer ituation Response tatus egment egment Identification (111-A) = AN TRANACTIN REPNE TATU P=Paid D=Duplicate of Paid 5Ø3-F3 AUTHRIZATIN NUBER R 547-5F APPRVED EAGE CDE CUNT aximum count of F APPRVED EAGE CDE 13Ø-UF ADDITINAL EAGE INFRATIN aximum count of 25. CUNT 132-UH ADDITINAL EAGE INFRATIN QUALIFIER 526-FQ ADDITINAL EAGE INFRATIN 131-UG ADDITINAL EAGE INFRATIN CNTINUITY Payer ituation

7 Response Claim egment egment Identification (111-A) = E PRECRIPTIN/ERVICE REFERENCE NUBER QUALIFIER Payer ituation 1 = RxBilling Imp Guide: For Transaction Code of B1, in the Response Claim egment, the Prescription/ervice Reference Number Qualifier (455-E) is 1 (Rx Billing). 4Ø2-D2 PRECRIPTIN/ERVICE REFERENCE NUBER 551-9F PREFERRED PRDUCT CUNT aximum count of 6. Future capabilities 552-AP PREFERRED PRDUCT ID QUALIFIER Future capabilities 553-AR PREFERRED PRDUCT ID Future capabilities 554-A PREFERRED PRDUCT INCENTIVE Future capabilities 555-AT PREFERRED PRDUCT CT HARE Future capabilities INCENTIVE 556-AU PREFERRED PRDUCT DECRIPTIN Future capabilities Response Pricing egment egment Identification (111-A) = 23 Payer ituation 5Ø5-F5 PATIENT PAY AUNT R 5Ø6-F6 INGREDIENT CT PAID R 5Ø7-F7 DIPENING FEE PAID R 558-AW FLAT ALE TAX AUNT PAID 559-AX PERCENTAGE ALE TAX AUNT PAID 56Ø-AY PERCENTAGE ALE TAX RATE PAID Imp Guide: Required if Percentage ales Tax Amount Paid (559-AX) is greater than zero (Ø). 561-AZ PERCENTAGE ALE TAX BAI PAID Imp Guide: Required if Percentage ales Tax Amount Paid (559-AX) is greater than zero (Ø). 521-FL INCENTIVE AUNT PAID Required if Incentive Amount ubmitted (438-E3) is greater than zero (Ø). 563-J2 THER AUNT PAID CUNT aximum count of 3. Imp Guide: Required if ther Amount Paid (565-J4) is used. 564-J3 THER AUNT PAID QUALIFIER Imp Guide: Required if ther Amount Paid (565-J4) is used. 565-J4 THER AUNT PAID Required if ther Amount Claimed ubmitted (48Ø-H9) is greater than zero (Ø). 566-J5 THER PAYER AUNT RECGNIZED Required if ther Payer Amount Paid (431- DV) is greater than zero (Ø) and Coordination of Benefits/ther Payments egment is supported. 5Ø9-F9 TTAL AUNT PAID R 522-F BAI F REIBUREENT DETERINATIN Required if Basis of Cost Determination (432-DN) is submitted on billing. 523-FN AUNT ATTRIBUTED T ALE TAX Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes sales tax that is the financial responsibility of the member but is not also included in any of the other fields that add up to Patient Pay Amount. 512-FC ACCUULATED DEDUCTIBLE AUNT 513-FD REAINING DEDUCTIBLE AUNT 514-FE REAINING BENEFIT AUNT 517-FH AUNT APPLIED T PERIDIC DEDUCTIBLE 518-FI AUNT F CPAY 52Ø-FK AUNT EXCEEDING PERIDIC BENEFIT AXIU 572-4U AUNT F CINURANCE 392-U BENEFIT TAGE CUNT aximum count of 4. Imp Guide: Required if Benefit tage Amount (394-W) is used.

8 Response Pricing egment egment Identification (111-A) = 23 Payer ituation 393-V BENEFIT TAGE QUALIFIER Imp Guide: Required if Benefit tage Amount (394-W) is used. 394-W BENEFIT TAGE AUNT Imp Guide: Required when a edicare Part D payer applies financial amounts to edicare Part D beneficiary benefit stages. 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. 577-G3 ETIATED GENERIC AVING 128-UC PENDING ACCUNT AUNT REAINING 133-UJ AUNT ATTRIBUTED T PRVIDER NETWRK ELECTIN 134-UK AUNT ATTRIBUTED T PRDUCT ELECTIN/BRAND DRUG 135-U AUNT ATTRIBUTED T PRDUCT ELECTIN/NN-PREFERRED FRULARY ELECTIN 136-UN AUNT ATTRIBUTED T PRDUCT ELECTIN/BRAND NN-PREFERRED FRULARY ELECTIN 137-UP AUNT ATTRIBUTED T CVERAGE GAP Required if necessary for state/federal/regulatory agency programs. Response DUR/PP egment egment Identification (111-A) = 24 ituation egment 567-J6 DUR/PP REPNE CDE CUNTER aximum 9 occurrences supported. 439-E4 REAN FR ERVICE CDE 528-F CLINICAL IGNIFICANCE CDE 529-FT THER PHARACY INDICATR 53Ø-FU PREVIU DATE F FILL 531-FV QUANTITY F PREVIU FILL 532-FW DATABAE INDICATR 533-FX THER PRECRIBER INDICATR 544-FY DUR FREE TEXT EAGE 57Ø-N DUR ADDITINAL TEXT Accepted/Paid Payer ituation Response Coordination of Benefits/ther Payers egment egment Identification (111-A) = 28 ituation egment 355-NT THER PAYER ID CUNT aximum count of C THER PAYER CVERAGE TYPE 339-6C THER PAYER ID QUALIFIER 34Ø-7C THER PAYER ID 991-H THER PAYER PRCER CNTRL NUBER 356-NU THER PAYER CARDHLDER ID 992-J THER PAYER GRUP ID 142-UV THER PAYER PERN CDE Accepted/Paid Payer ituation

9 Response Coordination of Benefits/ther Payers egment egment Identification (111-A) = 28 ituation egment 127-UB THER PAYER HELP DEK PHNE NUBER 143-UW THER PAYER PATIENT RELATINHIP CDE 144-UX THER PAYER BENEFIT EFFECTIVE DATE 145-UY THER PAYER BENEFIT TERINATIN DATE Accepted/Paid Payer ituation Response Claim egment Claim Reversal Accepted/Rejected egment Identification (111-A) = 22 Payer ituation 455-E PRECRIPTIN/ERVICE REFERENCE NUBER QUALIFIER 1 = RxBilling Imp Guide: For Transaction Code of B2, in the Response Claim egment, the Prescription/ervice Reference Number Qualifier (455-E) is 1 (Rx Billing). 4Ø2-D2 PRECRIPTIN/ERVICE REFERENCE NUBER