emedny New York State Department Of Companion Guide Version Number: 1.2 May 22, 2014 Health Insurance Programs (OHIP)

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1 New York State Department of Health (NYS DOH) Office of Health Insurance Programs (OHIP) New York State Department New of Health York (NYS State DOH) Office of Health Insurance Department Programs (OHIP) of Health (NYS DOH) New York State Office of Health Insurance Programs (OHIP) Department of Health (NYS DOH) Office of Standard Companion Guide Transaction Information Health Insurance Programs (OHIP) emedny Instructions related to Transactions based on NCPDP Telecommunications Implementation Guide, version D.0 and related documents New York State Department Of Companion Guide Version Number: 1.2 Health Office May 22, 2014 of Health Insurance Programs National Council for Prescription Drug Programs (NCPDP) Version 5.1 (EQUEST) NYSDOH 1 emedny

2 Table of Contents NCPDP National Council for Prescription Drug Programs... 5 INTODUCTION... 5 COMPANION GUIDE DISCLAIME:... 6 CG MODIFICATION TACKING:... 6 NYS MEDICAID NOTE:... 6 PUPOSE... 7 SYSTEM AVAILABILITY... 7 NCPDP D.0 TANSACTIONS SUPPOTED by NYSDOH... 7 ELIGIBILITY VEIFICATION EQUEST... 8 ELIGIBILITY VEIFICATION EQUEST ( Payer Sheet )... 8 ELIGIBILITY VEIFICATION ESPONSE Eligibility VEIFICATION ESPONSE (Transmission Accepted / Transaction Approved) 11 ELIGIBILITY VEIFICATION ESPONSE (Transmission Accepted / Transaction ejected) ELIGIBILITY VEIFICATION ESPONSE (Transmission ejected / Transaction ejected) CLAIM BILLING / CLAIM EBILL CLAIM BILLING / CLAIM EBILL EQUEST ( Payer Sheet ) CLAIM BILLING / CLAIM EBILL ESPONSE CLAIM BILLING / CLAIM EBILL ESPONSE (Accepted/Captured (or Duplicate of Captured)) CLAIM BILLING / CLAIM EBILL ESPONSE (Transmission Accepted / Transaction ejected) CLAIM BILLING / CLAIM EBILLESPONSE (Transmission ejected / Transaction ejected) CLAIM EVESAL CLAIM EVESAL EQUEST ( Payer Sheet ) CLAIM EVESAL ESPONSE CLAIM EVESAL ESPONSE (Accepted/Captured (or Duplicate of Captured)) CLAIM EVESAL ESPONSE (Transmission Accepted / Transaction ejected) CLAIM EVESAL ESPONSE (Transmission ejected / Transaction ejected) INFOMATION EPOTING / INFOMATION EBILL INFOMATION EPOTING / INFOMATION EBILL EQUEST (Payer Sheet) INFOMATION EPOTING / INFOMATION EBILL ESPONSE INFOMATION EPOTING / INFOMATION EBILL ESPONSE (Accepted/Captured (or Duplicate of Captured)) INFOMATION EPOTING / INFOMATION EBILL (Transmission Accepted / Transaction ejected) INFOMATION EPOTING / INFOMATION EBILL (Transmission ejected / Transaction ejected) INFOMATION EPOTING EVESAL INFOMATION EPOTING EVESAL EQUEST ( Payer Sheet ) INFOMATION EPOTING EVESAL ESPONSE INFOMATION EPOTING EVESAL ESPONSE (Accepted/Captured (or Duplicate of Captured)) NYSDOH 2 emedny

3 INFOMATION EPOTING EVESAL ESPONSE (Transmission Accepted / Transaction ejected) INFOMATION EPOTING EVESAL ESPONSE (Transmission ejected / Transaction ejected) SEVICE BILLING / SEVICE EBILL SEVICE BILLING / SEVICE EBILL EQUEST ( Payer Sheet ) SEVICE BILLING / SEVICE EBILL ESPONSE SEVICE BILLING / SEVICE EBILL ESPONSE (Accepted/Captured (or Duplicate of Captured)) SEVICE BILLING / SEVICE EBILL ESPONSE (Transmission Accepted / Transaction ejected) SEVICE BILLING / SEVICE EBILL ESPONSE (Transmission ejected / Transaction ejected) SEVICE EVESAL SEVICE EVESAL EQUEST ( Payer Sheet ) SEVICE EVESAL ESPONSE SEVICE EVESAL ESPONSE (Accepted/Captured (or Duplicate of Captured)) SEVICE EVESAL ESPONSE (Transmission Accepted / Transaction ejected) SEVICE EVESAL ESPONSE (Transmission ejected / Transaction ejected) PIO AUTHOIZATION EQUEST / BILLING EQUEST PIO AUTHOIZATION EQUEST / BILLING EQUEST ( Payer Sheet ) PIO AUTHOIZATION EQUEST / BILLING EQUEST ESPONSE PIO AUTHOIZATION EQUEST / BILLING EQUEST ESPONSE (Accepted/Captured (or Duplicate of Captured)) PIO AUTHOIZATION EQUEST / BILLING EQUEST ESPONSE (Transmission Accepted / Transaction ejected) PIO AUTHOIZATION EQUEST / BILLING EQUEST ESPONSE (Transmission ejected / Transaction ejected) PIO AUTHOIZATION EVESAL PIO AUTHOIZATION EVESAL ( Payer Sheet ) PIO AUTHOIZATION EVESAL ESPONSE PIO AUTHOIZATION EVESAL ESPONSE (Accepted/Captured (or Duplicate of Captured)) PIO AUTHOIZATION EVESAL ESPONSE (Transmission Accepted / Transaction ejected) PIO AUTHOIZATION EVESAL ESPONSE (Transmission ejected / Transaction ejected) PIO AUTHOIZATION EQUEST ONLY PIO AUTHOIZATION EQUEST ONLY EQUEST ( Payer Sheet ) PIO AUTHOIZATION EQUEST ONLY ESPONSE PIO AUTHOIZATION EQUEST ONLY ESPONSE (Captured (or Duplicate of Captured) PIO AUTHOIZATION EQUEST ONLY ESPONSE (Transmission Accepted / Transaction ejected) PIO AUTHOIZATION EQUEST ONLY ESPONSE (Transmission ejected / Transaction ejected) NYSDOH 3 emedny

4 NCPDP 1.2 Batch Transactions NCPDP 1.2 Batch Transaction ecord Structure TANSMISSION / SENDE TO ECEIVE / ECOD STUCTUE NYSDOH 4 emedny

5 NCPDP NATIONAL COUNCIL FO PESCIPTION DUG POGAMS INTODUCTION The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carry provisions for administrative simplification. This requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard. The National Council for Prescription Drug Programs (NCPDP) is a non-profit organization formed in It is dedicated to the development and dissemination of voluntary consensus standards that are necessary to transfer information that is used to administer the prescription drug benefit program. efer to the NCPDP Telecommunication Version D documents Telecommunication Standard Implementation Guide Version D.Ø, Data Dictionary, External Code List, and Telecommunication Version D Questions, Answers and Editorial Updates for more detailed information on field values and segments. The following information is intended to serve only as a Companion Guide to the aforementioned NCPDP Telecommunications Standard Version D.0 Documents. The use of this Companion Guide is solely for the purpose of clarification. The information describes specific requirements to be used for processing data. This Companion Guide supplements, but does not contradict any requirements in the NCPDP Telecommunications Standard Version D.0 Implementation Guide and related documents. To request a copy of the NCPDP Standard Formats or for more information contact the National Council for Prescription Drug Programs, Inc. at The contact information is as follows: National Council for Prescription Drug Programs 924Ø East aintree Drive Scottsdale, AZ 8526Ø Phone: (48Ø) 477-1ØØØ Fax (48Ø) 767-1Ø42 Materials eproduced With the Consent of National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP NYSDOH 5 emedny

6 COMPANION GUIDE DISCLAIME: The New York State Department of Health (NYSDOH) has provided this Payer Sheet Companion Guide for the NCPDP transactions to assist Providers, Clearinghouses and all Covered Entities in preparing HIPAA compliant transactions. This document was prepared using the Telecommunication Standard Implementation Guide Version D.Ø, Data Dictionary, External Code List, and Telecommunication Version D Questions, Answers and Editorial Updates. NYSDOH does not offer individual training to assist Providers in the use of the NCPDP transactions. The information provided herein is believed to be true and correct based on the aforementioned NCPDP Telecommunication Standard Version D.0 Implementation Guide and the related documents. The HIPAA regulations are continuing to evolve. Therefore, NYS Medicaid makes no guarantee, expressed or implied, as to the accuracy of the information provided herein. Furthermore, this is a living document and the information provided herein is subject to change as NYSDOH policy changes or as HIPAA legislation is updated or revised. CG MODIFICATION TACKING: >V1.2 - emedny Standard Companion Guide publication updates Publication Date: 05/22/2014 Add additional accepted code set values to 351-NP Specify accepted values in 3Ø8-C8 >V1.1 - emedny Standard Companion Guide publication corrections Publication Date: 01/20/2012 Add COB/Other Payments Segment to Claim eversal (B2) & Service eversal (S2) equest Add ICD code reporting format comment to 424-DO transmit ICD with decimal point implied. Chg. reporting note on 419-DJ Codes 0 thru 4 are accepted. >V1.0 - emedny Standard Companion Guide initial publication Publication Date: 04/22/2011 NYS MEDICAID NOTE: Under HIPAA the National Council for Prescription Drug Programs (NCPDP) Telecommunication Standard Implementation Guide Version D.Ø, Data Dictionary, and External Code List, has been adopted by Health and Human Services as standard transactions for etail Pharmacy. This Companion Guide, which is provided by the New York State Department of Health (NYSDOH), outlines the required format for the New York State Medicaid etail Pharmacy transactions. It is important that Providers study the Companion Guide and become familiar with the data that will be expected by NYS Medicaid in transmission of a Pharmacy Transaction. This Companion Guide does not modify the standards; rather, it puts forth the subset of information from the NCPDP Telecommunications Standard Version D.0 Implementation Guide, Data Dictionary, External Code List, and Version D.0 Editorial Updates that will be required for processing transactions. It is important that providers use this Companion Guide as a supplement to the NCPDP Standard D.0 documents. Within the IG, there are data elements, which have many different qualifiers available for use. Each qualifier identifies a different piece of information. This document omits code qualifiers that are not necessary for NYS Medicaid processing. Although not all available codes are listed in this document, NYSDOH will accept any codes named or listed in the NCPDP Data Dictionary and External Code List. When necessary, NYS Medicaid notes are included under to describe the NYSDOH specific requirements. NYSDOH 6 emedny

7 Although not all IG items are listed in the Companion Guide, NYS Medicaid will accept and capture the data from all transactions that comply with the HIPAA IG. Providers are required to use the NCPDP Telecommunication Standard Implementation Guide Version D.Ø, the Data Dictionary, and the External Code List, (ECL) to understand the positioning, format and usage of the transaction and data elements. Please refer to the Technical Supplementary Companion Guide for Information about transaction header structures, transaction size limits, electronic communications methods, and enrollment. This document is available for download at Providers with questions regarding HIPAA compliance billing please call CSC s support unit at Pharmacy Providers can acquire the aforementioned NCPDP documents from PUPOSE This guide is intended to provide guidelines to software vendors, switching companies and pharmacy providers as they implement the NCPDP D.0 Standard. The information included in this companion guide is separated into two sections; the D.0 transactions supported by NYSDOH and the 1.2 Batch transaction record structure. The 1.2 section of this document is only pertinent to those entities that will be sending batch transactions to NYSDOH. SYSTEM AVAILABILITY The New York State Medicaid NCPDP transaction submission system is available to providers 24 hours a day, seven days a week. NCPDP D.0 TANSACTIONS SUPPOTED BY NYSDOH Transaction Name E1 B1 B2 B3 N1 N2 N3 P1 P2 P4 S1 S2 S3 Eligibility Claim Billing Claim eversal Claim ebill Information eporting Information eporting eversal Information eporting ebill Prior Authorization equest & Billing Prior Authorization eversal Prior Authorization equest Only Service Billing Service eversal Service ebill NYSDOH does not support the following transactions: C1, C2, C3, D1, and P3. NYSDOH does not support/require the following segments: Coupon and Workers Comp. Transaction Format Information New York State Medicaid will only accept NCPDP Telecommunication Standard Version D.0 with the implementation of the New York State Medicaid system on Jan. 1 st Please refer to the NCPDP D.0 Implementation Guide, Data Dictionary and External Code List to understand the positioning, format and use of the data elements. NYSDOH 7 emedny

8 ELIGIBILITY VEIFICATION EQUEST ELIGIBILITY VEIFICATION EQUEST ( Payer Sheet ) ** Start of equest Eligibility Verification Segments (E1) Payer Sheet ** GENEAL INFOMATION Payer Name: New York State Department of Health (NYSDOH) Date: 04/22/2011 Plan Name/Group Name: NYS Medicaid BIN: PCN: NYS Medicaid ID Processor: Computer Science Corporation (CSC) Effective as of: 07/21/2011 NCPDP Telecommunication Standard Version/elease #: D.0 NCPDP Data Dictionary Version Date: 07/2007 NCPDP External Code List Version Date: 09/2010 Contact/Information Source: Provider Manuals available at General Website Provider elations Help Desk Info: Other versions supported: NCPDP Telecommunication version 5.1 until: 01/01/2012 OTHE TANSACTIONS SUPPOTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Transaction Name B1 Claim Billing B2 Claim eversal B3 Claim ebill N1 Information eporting N2 Information eporting eversal N3 Information eporting ebill P1 Prior Authorization equest & Billing P2 Prior Authorization eversal P4 Prior Authorization equest Only S1 Service Billing S2 Service eversal S3 Service ebill FIELD LEGEND FO COLUMNS Payer Column Value Explanation Column MANDATOY M The Field is mandatory for the Segment in the designated Transaction. No EQUIED The Field has been designated with the situation of "equired" for the Segment in the designated Transaction. QUALIFIED EQUIEMENT W equired when. The situations designated have qualifications for usage ("equired if x", "Not required if y"). Fields that are not used in the Eligibility Verification equest transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template. ELIGIBILITY VEIFICATION EQUEST TANSACTION The following lists the segments and fields in an Eligibility Verification equest Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. No Yes NYSDOH 8 emedny

9 Transaction Header Segment Questions Check Eligibility Verification equest Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Payer Issued Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Switch/VAN issued Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Not used Transaction Header Segment Eligibility Verification equest 1Ø1-A1 BIN NUMBE M BIN for NYS Medicaid 1Ø2-A2 VESION/ELEASE NUMBE DØ M 1Ø3-A3 TANSACTION CODE E1 M 1Ø4-A4 POCESSO CONTOL NUMBE The PCN 10 Character formats: M 3 Character ETIN: (PIC (1), PIC (2), PIC (4), PIC (3)) 4 Character ETIN: (PIC (2), PIC (4), PIC (4)) 1Ø9-A9 TANSACTION COUNT Ø1 = One occurrence M 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Ø1 = National Provider ID M 2Ø1-B1 SEVICE POVIDE ID M 4Ø1-D1 DATE OF SEVICE M 11Ø-AK SOFTWAE VENDO/CETIFICATION ID Blank fill M Blank fill The Processor Control Number field has two formats. Providers with a 3 character or a 4 character Electronic Transmitter Identification Number (ETIN). 3 Character ETIN: The ead Certification Indicator (PIC (01)), the Pharmacist's Initials (PIC (02)), Provider Personal Identification Number (PIN) (PIC (04)) and the Provider ETIN (PIC (03)). 4 Character ETIN: The Pharmacist's Initials (PIC (02)), Provider Personal Identification Number (PIN) (PIC (04)) and the ETIN (PIC (04)). Insurance Segment Questions Check Eligibility Verification equest Insurance Segment Segment Identification (111-AM) = Ø4 Eligibility Verification equest 3Ø2-C2 CADHOLDE ID M The 8 character alpha numeric Member Number. Patient Segment Questions Check Eligibility Verification equest This Segment is situational Patient Segment Segment Identification (111-AM) = Ø1 Field NCPDP Field Name Value Payer 3Ø4-C4 DATE OF BITH Eligibility Verification equest 3Ø5-C5 PATIENT GENDE CODE 1 = Male 2 = Female 31Ø-CA PATIENT FIST NAME Imp Guide: equired when the patient has a first name. NYSDOH 9 emedny

10 Patient Segment Segment Identification (111-AM) = Ø1 Field NCPDP Field Name Value Payer 311-CB PATIENT LAST NAME Eligibility Verification equest Payer equirement: ** End of equest Eligibility Verification equest (E1) Payer Sheet ** NYSDOH 10 emedny

11 ELIGIBILITY VEIFICATION ESPONSE ** Start of Eligibility Verification esponse (E1) Payer Sheet ** GENEAL INFOMATION Payer Name: New York State Department of Health (NYSDOH) Date: 04/22/2011 Plan Name/Group Name: NYS Medicaid BIN: PCN: NYS Medicaid ID Eligibility VEIFICATION ESPONSE (Transmission Accepted / Transaction Approved) ELIGIBILITY VEIFICATION ESPONSE (TANSMISSION ACCEPTED/TANSACTION APPOVED) esponse Transaction Header Segment Questions Check Eligibility Verification esponse (Transmission Accepted/Transaction Approved) esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUMBE DØ M 1Ø3-A3 TANSACTION CODE E1 M 1Ø9-A9 TANSACTION COUNT Same value as in request M 5Ø1-F1 HEADE ESPONSE STATUS A = Accepted M 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request M 2Ø1-B1 SEVICE POVIDE ID Same value as in request M 4Ø1-D1 DATE OF SEVICE Same value as in request M Eligibility Verification esponse (Transmission Accepted/Transaction Approved) esponse Message Header Segment Questions Check Eligibility Verification esponse (Transmission Accepted/Transaction Approved) This Segment is situational Provide general information when used for transmission-level messaging. esponse Message Segment Segment Identification (111-AM) = 2Ø Eligibility Verification esponse (Transmission Accepted/Transaction Approved) NYSDOH 11 emedny

12 esponse Message Segment Segment Identification (111-AM) = 2Ø 5Ø4-F4 MESSAGE Medicaid Number (8) Filler Value = Space (1) County Code = (2) Field Separator Value = * (1) Anniversary Mo. = (2) (values: 01 12) Filler Value = Space (1) Patient Gender code = (1) (values: M or F) Year of Birth = (3) (Format = CYY) Filler Value = Space (1) Category of Assistance = (1) Filler Value = Space (1) e-certification Month = (2) (values: 01 12) Filler Value = Space (1) Office Number (3) Field Separator Value = & (1) Service Date = (8) (Format = CCYYMMDD) Total bytes = 37 Eligibility Verification esponse (Transmission Accepted/Transaction Approved) Imp Guide: equired if text is needed for clarification or detail. Payer equirement: esponse Status Segment Questions Check Eligibility Verification esponse (Transmission Accepted/Transaction Approved) esponse Status Segment Segment Identification (111-AM) = AN TANSACTION ESPONSE STATUS A=Approved M 13Ø-UF ADDITIONAL MESSAGE INFOMATION Maximum count of 25. COUNT Value = 3 Eligibility Verification esponse (Transmission Accepted/Transaction Approved) Imp Guide: equired if Additional Message Information (526-FQ) is used. 132-UH ADDITIONAL MESSAGE INFOMATION QUALIFIE Payer equirement: NYSDOH will return a count of 3. Value = 01 Imp Guide: equired if Additional Message Information (526-FQ) is used. 526-FQ ADDITIONAL MESSAGE INFOMATION MEVS esponse Code (3) Space field separator (1) Utilization Threshold Code (2) Separator Value = $ (1) Maximum Per Unit Price (9) " Separator Value = % (1) Co-Payment Code (3) Space field separator (1) Co-Payment Met Date (8) Separator Value of (=) (1) Medicare Coverage Code (2) Space field separator (1) HIC Number 1 st 7 bytes (7) Payer equirement: NYSDOH will return a qualifier of 01 Imp Guide: equired when additional text is needed for clarification or detail. Payer equirement: ADDITIONAL MESSAGE 01 = (40 bytes) NYSDOH 12 emedny

13 esponse Status Segment Segment Identification (111-AM) = UG ADDITIONAL MESSAGE INFOMATION CONTINUITY Eligibility Verification esponse (Transmission Accepted/Transaction Approved) + Imp Guide: equired 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. 132-UH ADDITIONAL MESSAGE INFOMATION QUALIFIE Payer equirement: NYSDOH will return a + Value = 02 Imp Guide: equired if Additional Message Information (526-FQ) is used. 526-FQ ADDITIONAL MESSAGE INFOMATION HIC Number last 5 bytes (5) Separator Value = # (1) 1 st Insurance Carrier Code (6) Separator Value = / (1) 1 st Insurance Coverage Codes (14) Separator Value (1) 2 nd Insurance Carrier Code (6) Separator Value = / (1) 2 nd Insur.Coverage Codes (5) 131-UG ADDITIONAL MESSAGE INFOMATION CONTINUITY Payer equirement: NYSDOH will return a qualifier of 02 Imp Guide: equired when additional text is needed for clarification or detail. Payer equirement: ADDITIONAL MESSAGE 02 = (40 bytes) + Imp Guide: equired 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. 132-UH ADDITIONAL MESSAGE INFOMATION QUALIFIE Payer equirement: NYSDOH will return a + Value = 03 Imp Guide: equired if Additional Message Information (526-FQ) is used. 526-FQ ADDITIONAL MESSAGE INFOMATION 2 nd Insur.Coverage Codes (9) Separator Value = + (1) Indication of Additional Coverage (2) Separator Value = * (1) Exception Codes: "xx xx xx xx" (11) Total (24) Payer equirement: NYSDOH will return a qualifier of 03 Imp Guide: equired when additional text is needed for clarification or detail. Payer equirement: ADDITIONAL MESSAGE 03 = (24 bytes) ELIGIBILITY VEIFICATION ESPONSE (Transmission Accepted / Transaction ejected) ELIGIBILITY VEIFICATION ESPONSE (TANSMISSION ACCEPTED/TANSACTION EJECTED) esponse Transaction Header Segment Questions Check Eligibility Verification esponse (Transmission Accepted/Transaction ejected) esponse Transaction Header Segment Eligibility Verification esponse (Transmission Accepted/Transaction ejected) NYSDOH 13 emedny

14 1Ø2-A2 VESION/ELEASE NUMBE DØ M 1Ø3-A3 TANSACTION CODE E1 M 1Ø9-A9 TANSACTION COUNT Same value as in request M 5Ø1-F1 HEADE ESPONSE STATUS A = Accepted M 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request M 2Ø1-B1 SEVICE POVIDE ID Same value as in request M 4Ø1-D1 DATE OF SEVICE Same value as in request M esponse Status Segment Questions Check Eligibility Verification esponse (Transmission Accepted/Transaction ejected) esponse Status Segment Segment Identification (111-AM) = AN TANSACTION ESPONSE STATUS = eject M 51Ø-FA EJECT COUNT Maximum count of FB EJECT CODE 13Ø-UF ADDITIONAL MESSAGE INFOMATION Maximum count of 25. COUNT Value = 1 Eligibility Verification esponse (Transmission Accepted/Transaction ejected) Imp Guide: equired if Additional Message Information (526-FQ) is used. 132-UH ADDITIONAL MESSAGE INFOMATION QUALIFIE Payer equirement: NYSDOH will return a count of 1. Value = 01 Imp Guide: equired if Additional Message Information (526-FQ) is used. Payer equirement: NYSDOH will return a message code FQ ADDITIONAL MESSAGE INFOMATION MEVS Denial Code = (3) Imp Guide: equired when additional text is needed for clarification or detail. Payer equirement: NYSDOH will return a MEVS Denial Code. NYSDOH 14 emedny

15 ELIGIBILITY VEIFICATION ESPONSE (Transmission ejected / Transaction ejected) ELIGIBILITY VEIFICATION ESPONSE (TANSMISSION EJECTED/ TANSACTION EJECTED) esponse Transaction Header Segment Questions Check Eligibility Verification esponse ejected/ejected esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUMBE DØ M 1Ø3-A3 TANSACTION CODE E1 M 1Ø9-A9 TANSACTION COUNT Same value as in request M 5Ø1-F1 HEADE ESPONSE STATUS = ejected M 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request M 2Ø1-B1 SEVICE POVIDE ID Same value as in request M 4Ø1-D1 DATE OF SEVICE Same value as in request M Eligibility Verification esponse ejected/ejected esponse Status Segment Questions Check Eligibility Verification esponse ejected/ejected esponse Status Segment Segment Identification (111-AM) = 21 Eligibility Verification esponse ejected/ejected 112-AN TANSACTION ESPONSE STATUS = eject M 51Ø-FA EJECT COUNT Maximum count of FB EJECT CODE NYSDOH will return 1 to 5 eject codes. ** End of esponse Eligibility Verification esponse (E1) Payer Sheet ** NYSDOH 15 emedny

16 CLAIM BILLING / CLAIM EBILL CLAIM BILLING / CLAIM EBILL EQUEST ( Payer Sheet ) ** Start of equest Claim Billing/Claim ebill (B1/B3) Payer Sheet ** GENEAL INFOMATION Payer Name: New York State Department of Health (NYSDOH) Date: 04/22/2011 Plan Name/Group Name: NYS Medicaid BIN: PCN: NYS Medicaid ID Processor: Computer Science Corporation (CSC) Effective as of: 07/21/2011 NCPDP Telecommunication Standard Version/elease #: D.0 NCPDP Data Dictionary Version Date: 07/2007 NCPDP External Code List Version Date: 09/2010 Contact/Information Source: Provider Manuals available at General Website Provider elations Help Desk Info: MEVS Unit Other versions supported: NCPDP Telecommunication version 5.1 until: 01/01/2012 OTHE TANSACTIONS SUPPOTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Transaction Name B2 Claim eversal E1 Eligibility Verification N1 Information eporting N2 Information eporting eversal N3 Information eporting ebill P1 Prior Authorization equest & Billing P2 Prior Authorization eversal P4 Prior Authorization equest Only S1 Service Billing S2 Service eversal S3 Service ebill FIELD LEGEND FO COLUMNS Payer Column Value Explanation Column MANDATOY M The Field is mandatory for the Segment in the designated Transaction. No EQUIED The Field has been designated with the situation of "equired" for the Segment in the designated Transaction. QUALIFIED EQUIEMENT W equired when. The situations designated have qualifications for usage ("equired if x", "Not required if y"). Fields that are not used in the Claim Billing/Claim ebill transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template. CLAIM BILLING/CLAIM EBILL TANSACTION The following lists the segments and fields in a Claim Billing or Claim ebill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Transaction Header Segment Questions Check Claim Billing/Claim ebill Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Payer Issued Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Switch/VAN issued Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Not used No Yes NYSDOH 16 emedny

17 Transaction Header Segment Claim Billing/Claim ebill 1Ø1-A1 BIN NUMBE M BIN for NYS Medicaid 1Ø2-A2 VESION/ELEASE NUMBE DØ M 1Ø3-A3 TANSACTION CODE B1, B3 M 1Ø4-A4 POCESSO CONTOL NUMBE The PCN 10 Character formats: M 3 Character ETIN: (PIC (1), PIC (2), PIC (4), PIC (3)) 4 Character ETIN: (PIC (2), PIC (4), PIC (4)) 1Ø9-A9 TANSACTION COUNT Ø1 = One occurrence M Ø2 = Two occurrences Ø3 = Three occurrences Ø4 = Four occurrences 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Ø1 = National Provider ID M 2Ø1-B1 SEVICE POVIDE ID M 4Ø1-D1 DATE OF SEVICE M 11Ø-AK SOFTWAE VENDO/CETIFICATION ID Blank fill M Blank fill The Processor Control Number field has two formats. Providers with a 3 character or a 4 character Electronic Transmitter Identification Number (ETIN). 3 Character ETIN: The ead Certification Indicator (PIC (01)), the Pharmacist's Initials (PIC (02)), Provider Personal Identification Number (PIN) (PIC (04)) and the Provider ETIN (PIC (03)). 4 Character ETIN: The Pharmacist's Initials (PIC (02)), Provider Personal Identification Number (PIN) (PIC (04)) and the ETIN (PIC (04)). Insurance Segment Questions Check Claim Billing/Claim ebill Insurance Segment Claim Billing/Claim ebill Segment Identification (111-AM) = Ø4 3Ø2-C2 CADHOLDE ID M The 8 character alpha numeric Member Number. 3Ø9-C9 ELIGIBILITY CLAIFICATION CODE 2 = Override W Imp Guide: equired if needed for receiver inquiry validation and/or determination, when eligibility is not maintained at the dependent level. equired in special situations as defined by the code to clarify the eligibility of an individual, which may extend coverage. Payer equirement: equired when indicating an eligibility override as follows: Code '2' indicates: an eligibility override for spend down/ excess income when the member's liability has been met, but there is a time lag in updating the eligibility system. a nursing home override Patient Segment Questions Check Claim Billing/Claim ebill This Segment is situational NYSDOH 17 emedny

18 Patient Segment Segment Identification (111-AM) = Ø1 Field NCPDP Field Name Value Payer 3Ø4-C4 DATE OF BITH Claim Billing/Claim ebill 3Ø5-C5 PATIENT GENDE CODE 1 = Male 2 = Female 31Ø-CA PATIENT FIST NAME W Imp Guide: equired when the patient has a first name. 311-CB PATIENT LAST NAME 3Ø7-C7 PLACE OF SEVICE All code set values supported CMS Maintained code set. Payer equirement: Imp Guide: equired if this field could result in different coverage, pricing, or patient financial responsibility C PEGNANCY INDICATO Blank=Not Specified, 1=Not pregnant, 2=Pregnant W Payer equirement: Imp Guide: equired if pregnancy could result in different coverage, pricing, or patient financial responsibility. equired if required by law as defined in the HIPAA final Privacy regulations section 164.5Ø1 definitions (45 CF Parts 16Ø and 164 Standards for Privacy of Individually Identifiable Health Information; Final ule- Thursday, December 28, 2ØØØ, page 828Ø3 and following, and Wednesday, August 14, 2ØØ2, page and following.) Payer equirement: equired when the member is known to be pregnant. Claim Segment Questions Check Claim Billing/Claim ebill This payer supports partial fills This payer does not support partial fills Claim Segment Claim Billing/Claim ebill Segment Identification (111-AM) = Ø7 455-EM PESCIPTION/SEVICE EFEENCE NUMBE QUALIFIE 1 = x Billing M Imp Guide: For Transaction Code of B1, in the Claim Segment, the Prescription/Service eference Number Qualifier (455-EM) is 1 (x Billing). 4Ø2-D2 PESCIPTION/SEVICE EFEENCE NUMBE The prescription number assigned by the pharmacy. M 436-E1 PODUCT/SEVICE ID QUALIFIE ØØ = Not Specified Ø3 = NDC Ø9 = HCPCS M If billing for a multi-ingredient prescription, Product/Service ID Qualifier (436-E1) is zero ( ØØ ). NYSDOH requires one of these codes. 4Ø7-D7 PODUCT/SEVICE ID M If billing for a multi-ingredient prescription, Product/Service ID (4Ø7-D7) is zero. (Zero means Ø.) NYSDOH requires an NDC code, a HCPCS Code, or 0 (zero). 458-SE POCEDUE MODIFIE CODE COUNT Maximum count of 1Ø. W Imp Guide: equired if Procedure Modifier Code (459-E) is used. Payer equirement: NYSDOH will map up to 4 modifiers. NYSDOH 18 emedny

19 Claim Segment Claim Billing/Claim ebill Segment Identification (111-AM) = Ø7 459-E POCEDUE MODIFIE CODE W Imp Guide: equired to define a further level of specificity if the Product/Service ID (4Ø7-D7) indicated a Procedure Code was submitted. equired if this field could result in different coverage, pricing, or patient financial responsibility. 442-E7 QUANTITY DISPENSED 4Ø3-D3 FILL NUMBE ØØ = New Prescription Ø1 = First efill Ø2 = Second efill Ø3 = Third efill Ø4 = Fourth efill Ø5 = Fifth efill 4Ø5-D5 DAYS SUPPLY 4Ø6-D6 COMPOUND CODE 1 = Not Compound 2 = Compound 4Ø8-D8 DISPENSE AS WITTEN (DAW)/PODUCT Ø = No Product Selection SELECTION CODE Indicated 1= Substitute Not Allowed by Prescriber 4 = Sub Allowed-Generic Drug Not in Stock 5 = Sub Allowed-Brand Drug Dispensed as Generic 7 = Sub Not Allowed-Brand Drug Mandated by Law 8 = Sub Allowed-Generic Drug Not Avail. in Market 9 = Sub Allowed By Prescriber- Plan equests Brand 414-DE DATE PESCIPTION WITTEN 415-DF NUMBE OF EFILLS AUTHOIZED ØØ = No efill Authorized Ø1 = 1 efill Ø2 = 2 efills Ø3 = 3 efills Ø4 = 4 efills Ø5 = 5 efills 419-DJ PESCIPTION OIGIN CODE Code values 0, 1, 2, 3, and 4 are accepted. Payer equirement: NYSDOH will map up to 4 modifiers. NYSDOH allows a maximum of 5 refills. NYSDOH requires one of the listed codes to process a claim. Imp Guide: equired if necessary for plan benefit administration. Payer equirement: NYSDOH allows a maximum of 5 refills. Imp Guide: equired if necessary for plan benefit administration. 354-N SUBMISSION CLAIFICATION CODE COUNT Payer equirement: NYS DOH will use code 3 for administration of the e-prescribing incentive. Maximum count of 3. W Imp Guide: equired if Submission Clarification Code (42Ø-DK) is used. Payer equirement: NYSDOH 19 emedny

20 Claim Segment Segment Identification (111-AM) = Ø7 42Ø-DK SUBMISSION CLAIFICATION CODE Ø1 = No Override W Ø2 = Other Override Ø5 = Therapy Change Ø6 = Starter Dose Ø7 = Medically Necessary Ø8 = Process Compound for Approved Ingredients Ø9 = Encounters 99 = Other Claim Billing/Claim ebill Imp Guide: equired if clarification is needed and value submitted is greater than zero (Ø). If the Date of Service (4Ø1-D1) contains the subsequent payer coverage date, the Submission Clarification Code (42Ø-DK) is required with value of 19 (Split Billing indicates the quantity dispensed is the remainder billed to a subsequent payer when Medicare Part A expires. Used only in longterm care settings) for individual unit of use medications. 3Ø8-C8 OTHE COVEAGE CODE Accepted Values: 1 = Not Specified 2= Other Coverage Exists- Payment Collected 3= Other Coverage Exists- This Claim Not Covered 4=Other Coverage Exists- Payment Not Collected W Payer equirement: equired if clarification is needed when value submitted is greater than zero (Ø). NYSDOH will process up to three occurrences of the codes listed. Imp Guide: equired if needed by receiver, to communicate a summation of other coverage information that has been collected from other payers. equired for Coordination of Benefits. Payer equirement: equired when other insurance coverage exists. 454-EK SCHEDULED PESCIPTION ID NUMBE Imp Guide: equired if necessary for state/federal/regulatory agency programs. Payer equirement: NYSDOH requires the Prescription Pad Serial Number from the Official NYS Prescription blank. When the following scenarios exist, use the following values in lieu of reporting the Official Prescription Form Serial Number: 461-EU PIO AUTHOIZATION TYPE CODE ØØ = Not Specified Ø1 = Prior Authorization Ø4 = Exempt Copay a/o Coinsur. W Prescriptions received via Fax or electronically, use EEEEEEEE. Prescriptions on carve-out drugs for Nursing Home patients, use NNNNNNNN. Prescriptions written by Out of State Prescribers, use ZZZZZZZZ. Oral Prescriptions, use Imp Guide: equired if this field could result in different coverage, pricing, or patient financial responsibility. 462-EV PIO AUTHOIZATION NUMBE SUBMITTED W Payer equirement: equired when the claim requires Prior Authorization/Approval, or is copay exempt. Imp Guide: equired if this field could result in different coverage, pricing, or patient financial responsibility. Payer equirement: equired when a Prior Authorization/Approval number has been assigned for this claim. 357-NV DELAY EASON CODE All code set values W Imp Guide: equired when needed to specify the reason that submission of the transaction has been delayed. Payer equirement: NYSDOH 20 emedny

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