Department of Health Care Services CA-MMIS. National Council for Prescription Drug Programs (NCPDP) D.0. Real-Time Tes ting V 2.0
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1 Department of Health Care Services CA-MMIS National Council for Prescription Drug Programs (NCPDP) D.0 Real-Time Tes ting V /15/2012
2 2012 Xerox Corporation and ACS, A Xerox Company. All rights reserved. ACS and the ACS design are trademarks of ACS Marketing LP in the United States and/or other countries. Xerox and Xerox and Design are trademarks of Xerox Corporation in the United States and/or other countries. June 2012 Page 2
3 Steps before submitting Point of Service (POS) Network test cases The National Council for Prescription Drug Programs (NCPDP) D.0 is the existing standard process used by providers and software vendors to submit real-time pharmacy claims. For a provider or vendor to be activated for testing a new version of NCPDP, the provider or vendor would need to have completed and been approved for two agreements: a Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153) and the Medi-Cal Point of Service (POS) Network/Internet Agreement (PROPubs 11/11). The provider or vendor can download these forms from the Forms page on the Medi-Cal website: If the provider or vendor has completed these applications, then the provider or vendor will have been assigned a Submitter ID of three characters (such as 1JV ), and the provider must have a National Provider Identifier (NPI) or Legacy Provider Number (if atypical provider). The provider or vendor can then submit the set of pre-defined test cases using software that has been validated and authorized by the POS/Internet Help Desk. Once testing has been successfully completed, the software will be approved for pharmacy transactions, including eligibility and prior authorization transactions. A test response will be returned for each test case transaction. For each pharmacy test case, use the table value in the service provider id field as the key for submitting this claim. If the specific key is not found on the test verification file, the error message ERROR UNABLE TO DETERMINE TEST CASE will be returned. Software Validation Process Software developers interested in validating their software must contact the POS/Internet Help Desk by calling the Telephone Service Center (TSC) at (border providers and out-of-state billers billing for in-state providers, call [916] ) and selecting the option for Technical Help Desk, then the option for POS/Internet Help Desk, and finally, the option for submitter. If claims are currently submitted through Computer Media Claims (CMC), developers will not be assigned another submitter ID. Developers will need to supply the POS/Internet Help Desk with the Vendor s three digit Submitter ID and a four-character version number, which will be the PC/POS version number used in all transactions submitted to the POS Network. The POS/Internet Help Desk will verify this number to ensure the software has been validated and is authorized to submit transactions. Prior to testing each new software release/upgrade, the POS/Internet Help Desk will need to be notified of the new four-character version number for that software. When the POS/Internet Help Desk determines that all tests have achieved successful results, then the test submitter will be approved for submitting NCPDP D.0. June 2012 Page 3
4 Pre-defined Test Cases for POS Transmission This section only reflects values for required fields. You must use the values given (such as shown in Test Case 1 below) for the Service Provider ID (not a valid NPI) for the test cases to work. The 110-AK field is comprised of 3 pieces: 3 digit Vendor ID, 4 digit software version and 3 digit Submitter ID. The example in the test cases below shows a version number of XXX0100AAA for illustration purposes only; it is broken down as follows: Your 3 digit Vendor ID 4 digit software version number for D.0 AAA for the 3 digit Submitter ID (you must use AAA and not a real submitter ID) In addition, all spaces in the examples are indicated by a period (.), as are non-displayable hexadecimal characters. Test cases begin on page 5 June 2012 Page 4
5 NCPDP D.0 Pharmacy Claim Test Case 1 Claim without DUR information filled in. The claim is paid. 103-A3 Transaction Code 'B1 201-B1 Service Provider ID ' ' 401-D1 Date of Service (CCYYMMDD) ' ' 110-AK Software Vendor/Certification ID XXX0100AAA 302-C2 Cardholder ID ' ' 304-C4 Date of Birth (CCYYMMDD) ' ' 305-C5 Patient Gender Code '1' 307-C7 Place of Service '01' 455-EM Prescription/Service Reference 1 Qualifier 402-D2 Prescription Number Numeric value *** 436-E1 Product/Service Id Qualifier D7 Product/Service ID ' ' 442-E7 Quantity Dispensed [Qty. = 100] ' ' or ** 405-D5 Days Supply '030' or D6 Compound Code '1' 420-DK Submission Clarification Code '07' 308-C8 Other Coverage Code EU Prior Authorization Type Code EV Prior Authorization Number (TCN) DX Patient Paid Amount [$01.00] ' ' or 0100 * 430-DU Gross Amount Due [$22.00] or 2200 * 423-DN Basis of Cost Determination EZ Prescriber ID Qualifier DB Prescriber ID * Implied decimal, two places ** Implied decimal, three places *** Maximum of 12 June 2012 Page 5
6 Medi-Cal POS Third Party Vendors (Dial-Up / Leased D0B XXX0100AAA...AM04.C AM01.C C51.C701~..AM07.EM1.D E103.D E D5030.D61.DK07.C801.EU01.EV AM11.DX DU DN00..AM03.EZ01.DB OR D0B XXX0100AAA...AM04.C AM01.C C51.C701~..AM07.EM1.D E103.D E D530.D61.DK07.C801.EU01.EV AM11.DX0100.DU2200.DN00..AM03.EZ01. DB Response: 103-A3 Transaction Code 'B1 501-F1 Response Status (trailer) 'A' 201-B1 Service Provider ID ' ' 401-D1 Date of Service ' ' 112-AN Transaction Response Status P 310-CA Patient First Name FRANK 311-CB Patient Last Name JONES 455-EM Prescription/Service Ref. Num. Qualifier D2 Prescription/Service Ref Num Numeric Value 505-F5 Patient Pay Amount F6 Ingredient Cost Paid F9 Total Paid Amount [$12.00] * EDSH01IZ513U...D0B11A AM29.CAFRANK.CBJONES...AM21.ANP..AM22.EM1.D AM23.F {.F {.F { * Implied decimal, two places ** Implied decimal, three places June 2012 Page 6
7 Medi-Cal POS NCPDP D.0 Pharmacy Claim Test Case 2: Claim Reversal The claim is reversed 101-A1 BIN Number A3 Transaction Code 'B2 201-B1 Service Provider ID ' ' 401-D1 Date Filled (CCYYMMDD) ' ' 110-AK Software Vendor/Certification ID XXX0100AAA 302-C2 Cardholder ID ' ' 455-EM Prescription/Service Ref. Num. 1 Qualifier 402-D2 Prescription/Service Ref Num Numeric Value 436-E1 Product/Service ID Qualifier D7 Product/Service ID ' ' D0B XXX0100AAA~..AM04.C AM07.EM1.D E103.D Response: 103-A3 Transaction Type 'B2 501-F1 Response Status (trailer) 'A' 201-B1 Service Provider ID ' ' 401-D1 Date Filled (CCYYMMDD) ' ' 112-AN Transaction Response Status A 455-EM Prescription/Service Ref. Num. 1 Qualifier 402-D2 Prescription Number Numeric Value EDSH01IZ513U...D0B21A AM21.ANA..AM22.EM1.D June 2012 Page 7
8 Medi-Cal POS NCPDP D.0 Pharmacy Claim Test Case 3: Claim without DUR information filled in. Claim is rejected 103-A3 Transaction Code 'B1' 201-B1 Service Provider ID ' ' 401-D1 Date of Service (CCYYMMDD) ' ' 110-AK Software Vendor/Certification ID XXX0100AAA 302-C2 Cardholder ID ' ' 304-C4 Date of Birth (CCYYMMDD) ' ' 305-C5 Patient Gender Code '1' 307-C7 Place of service '01' 455-EM Prescription/Service Ref. Num. Qualifier D2 Prescription/Service Ref. Num. Numeric Value 436-E1 Product Service ID Qualifier D7 Product/Service ID ' ' 442-E7 Quantity Dispensed [Qty = 250] ' ' or D5 Days Supply '030' or D6 Compound Code '1' 420-DK Submission Clarification Code '07' 308-C8 Other Coverage Code EU Prior Authorization Type Code EV Prior Authorization Number (TCN) DU Gross Amount Due [$14.50] or 1450 * 423-DN Basis of Cost Determination EZ Prescriber ID Qualifier DB Prescriber ID or D0B XXX0100AAA...AM04.C AM01.C C51.C701~..AM07.EM1.D E103.D E D5030.D61.DK07.C801.EU01.EV AM11.DU DN00..AM03.EZ01.DB OR D0B XXX0100AAA...AM04.C AM01.C C51.C701~..AM07.EM1.D E103.D E D530.D61.DK07.C801.EU01.EV AM11.DU1450.DN00..AM03.EZ01.DB June 2012 Page 8
9 Medi-Cal POS Response: Field Number Field Name Field 103-A3 Transaction Code 'B1' 501-F1 Response Status (trailer) 'R' 201-B1 Service Provider ID ' ' 401-D1 Date of Service (CCYYMMDD) ' ' 112-AN Transaction response Status R 510-FA Reject Count FB Reject Code FB Reject Code UF Additional Message Information Count UH Additional Message Information Qualifier FQ Additional Message Information 131-UG Additional Message Information Continuity UH Additional Message Information Qualifier FQ Additional Message Information F Help Desk Phone Number Qualifier 01 55Ø-8F Help Desk Phone Number ' EDSH01IZ513U...D0B11R AM21.ANR.FA02. FB65. FB21.UF02.UH01.FQ...UG+.UH02.FQ F01.8F * Implied decimal, two places ** Implied decimal, three places June 2012 Page 9
10 Medi-Cal POS NCPDP D.0 Pharmacy Claim Test Case 4: Claim without DUR information filled in. Claim is rejected for DUR Alert 103-A3 Transaction Code 'B1' 201-B1 Service Provider ID ' ' 401-D1 Date of Service (CCYYMMDD) ' ' was AK Software Vendor/Certification ID XXX0100AAA 302-C2 Cardholder ID ' ' 304-C4 Date of Birth (CCYYMMDD) ' ' 305-C5 Patient Gender Code '2' 307-C7 Place of service '01' 455-EM Prescription/Service Reference Qualifier D2 Prescription Number Numeric value 436-E1 Product/Service Id Qualifier D7 Product/Service ID ' ' 442-E7 Quantity Dispensed [Qty. = 100] ' ' or ** 405-D5 Days Supply '030' or D6 Compound Code '1' 420-DK Submission Clarification Code '07' 308-C8 Other Coverage Code EU Prior Auth Type Code EV Prior Auth Number (TCN) DU Gross Amount Due [$21.00] or 2100 * 423-DN Basis of Cost Determination EZ Prescriber ID Qualifier DB Prescriber ID ' ' D0B XXX0100AAA..AM04.C AM01.C C52.C701~..AM07.EM1.D E103.D E D5030.D61.DK07.C801.EU01.EV AM11.DU DN00..AM03.EZ01.DB OR D0B AAAPROV XXX0100AAA..AM04.C AM01.C C52.C701~..AM07.EM1.D E103.D E D530.D61.DK07.C801.EU01.EV AM11.DU2100.DN00..AM03.EZ01.DB June 2012 Page 10
11 Medi-Cal POS Response: 103-A3 Transaction Code 'B1' 501-F1 Response Status (Header) 'A' 201-B1 Service Provider ID ' ' 401-D1 Date of Service (CCYYMMDD) ' ' 112-AN Transaction Response Status 'R' 510-FA Reject Count '01' 511-FB Reject Code '88' 130-UF Additional Message Information Count UH Additional Message Information Qualifier FQ Additional Message Information ' 131-UG Additional Message Information Continuity UH Additional Message Information Qualifier FQ Additional Message Information ' 1030' 549-7F Help Desk Phone Number Qualifier F Help Desk Phone Number EM Prescription/Service Reference Qualifier D2 Prescription Number Numeric Value 567-J6 DUR/PPS Response Code Counter '1' 439-E4 Reason for Service Code PA 528-FS Clinical Significance Code FT Other Pharmacy Indicator FU Previous Date of Fill FV Quantity of Previous Fill [Qty = 0] FW Database Indicator FX Other Prescriber Indicator FY DUR Free Text Message AGE WARNING EDSH01IZ513U...D0B11A AM21.ANR.FA01. FB88. UF02.UH01.FQ...UG+.UH02.FQ F01.8F AM22.EM1.D AM24.J61. E4PA.FS1.FT0.FU FV FW1.FX0.FYAGE WARNING * Implied decimal, two places ** Implied decimal, three places Medi-Cal June 2012 Page 11
12 POS NCPDP D.0 Pharmacy Claim Test Case 5: Claim DUR Override. Claim is paid 103-A3 Transaction Code 'B1 201-B1 Service Provider ID ' ' 401-D1 Date of Service (CCYYMMDD) AK Software Vendor/Certification ID XXX0100AAA 302-C2 Cardholder ID Num ' ' 304-C4 Date of Birth (CCYYMMDD) ' ' 305-C5 Patient Gender Code '2' 307-C7 Place of service ' EM Prescription/Service Reference Qualifier D2 Prescription Number Numeric Value 436-E1 Product/Service Id Qualifier D7 Product/Service ID ' ' 442-E7 Quantity Dispensed [Qty = 100] ' ' or D5 Days Supply '030' or D6 Compound Code '1' 420-DK Submission Clarification Code '07' 308-C8 Other Coverage Code EU Prior Authorization Type Code EV Prior Authorization Number (TCN) DU Gross Amount Due [$14.50] or 2100 * 423-DN Basis of Cost Determination EZ Prescriber ID Qualifier DB Prescriber ID E DUR/PPS Code Counter E4 Reason of Service Code PA 440-E5 Professional Service Code M0 441-E6 Result of Service Code 1E D0B XXX0100AAA...AM04.C AM01.C C52.C701~..AM07.EM1.D E103.D E D5030.D61.DK07.C801.EU01.EV AM11.DU DN00..AM03.EZ01.DB AM08.7E1.E4PA.E5M0.E61E OR June 2012 Page 12
13 610442D0B XXX0100AAA...AM04.C AM01.C C52.C700~..AM07.EM1.D E103.D E D530.D61.DK07.C801.EU01.EV AM11.DU2100.DN00..AM03.EZ01.DB AM08.7E1.E4PA.E5M0.E61E Response: 103-A3 Transaction Type 'B1' 501-F1 Response Status (Header) 'A' 201-B1 Service Provider ID ' ' 401-D1 Date of Service (CCYYMMDD) F1 Response Status (Claim) 'P' 310-CA Patient First Name 'JENNIFER 311-CB Patient Last Name 'SMITH ' 455-EM Prescription/Service Ref. Num. Qualifier D2 Prescription/Service Ref. Num. Numeric Value 505-F5 Patient Pay Amount F6 Ingredient Cost Paid F9 Total Paid Amount [$21.00] ' ' EDSH01IZ513U...D0B11A AM29.CAJENNIFER....CBSMITH...AM21.ANP..AM22.EM1.D AM23.F {.F {.F { * Implied decimal, two places ** Implied decimal, three places June 2012 Page 13
14 Medi-Cal POS NCPDP D.0 Pharmacy Claim Test Case 6: Claim without DUR information filled in Claim is rejected for DUR Alert 103-A3 Transaction Code 'B1' 201-B1 Service Provider ID ' ' 401-D1 Date of Service (CCYYMMDD) AK Software Vendor/Certification ID XXX0100AAA 302-C2 Cardholder ID ' ' 304-C4 Date of Birth (CCYYMMDD) ' ' 305-C5 Patient Gender Code '2' 307-C7 Place of service '01' 455-EM Prescription/Service Reference Qualifier D2 Prescription Number Numeric Value 436-E1 Product Service ID Qualifier D7 Product/Service ID ' ' 442-E7 Quantity Dispensed [Qty = 100] ' ' or ** 405-D5 Days Supply '030' or D6 Compound Code '1' 420-DK Submission Clarification Code '07' 308-C8 Other Coverage Code EU Prior Authorization Type Code EV Prior Authorization Number (TCN) DU Gross Amount Due [$21.00] or 2100 * 423-DN Basis of Cost Determination EZ Prescriber ID Qualifier DB Prescriber ID ' ' D0B XXX0100AAA...AM04.C AM01.C C52.C701~..AM07.EM1.D E102.D E D5030.D61.DK07.C801.EU01.EV AM11.DU DN00..AM03.EZ01.DB OR D0B XXX0100AAA...AM04.C AM01.C C52.C701~..AM07.EM1.D E102.D E D530.D61.DK07.C801.EU01.EV AM11.DU2100.DN00..AM03.EZ01.DB June 2012 Page 14
15 Medi-Cal POS Response: 103-A3 Transaction Code 'B1' 501-F1 Response Status (Header) 'A' 201-B1 Service Provider ID ' ' 401-D1 Date of Service (CCYYMMDD) AN Transaction Response Status 'R' 510-FA Reject Count '01' 511-FB Reject Code '88' 130-UF Additional Message Information Count UH Additional Message Information Qualifier FQ Additional Message Information ' ' 131-UG Additional Message Information UH Additional Message Information Qualifier FQ Additional Message Information '1030' 549-7F Help Desk Phone Number Qualifier F Help Desk Phone Number EM Prescription/Service Ref. Num. Qualifier D2 Prescription/Service Ref. Num. Numeric Value 567-J6 DUR/PPS Response Code Counter '1' 439-E4 Reason for Service Code PA 528-FS Clinical Significance Code FT Other Pharmacy Indicator FU Previous Date of Fill FV Quantity of Previous Fill [Qty = 0] FW Database Indicator FX Other Prescriber Indicator FY DUR Free Text Message AGE WARNING EDSH01IZ513U...D0B11A AM21.ANR.FA01. FB88. UF02.UH01.FQ...UG+.UH02.FQ F01.8F AM22.EM1.D AM24.J61. E4PA.FS1.FT0.FU FV FW1.FX0.FYAGE WARNING * Implied decimal, two places June 2012 Page 15
16 ** Implied decimal, three places Medi-Cal POS NCPDP D.0 Pharmacy Claim Test Case 7: Claim Cancelled Claim is not paid 103-A3 Transaction Code 'B1' 201-B1 Service Provider ID D1 Date of Service (CCYYMMDD) ' ' 110-AK Software Vendor/Certification ID XXX0100AAA 302-C2 Cardholder ID ' ' 304-C4 Date of Birth (CCYYMMDD) ' ' 305-C5 Patient Gender Code '2' 307-C7 Place of service '01' 455-EM Prescription/Service Reference Qualifier D2 Prescription Number Numeric Value 436-E1 Product Service ID Qualifier D7 Product/Service ID ' ' 442-E7 Quantity Dispensed [Qty = 100] ' ' or D5 Days Supply '030' or D6 Compound Code '1' 420-DK Submission Clarification Code '07' 308-C8 Other Coverage Code EU Prior Auth Type Code EV Prior Auth Number (TCN) DU Gross Amount Due [$21.00] or 2100 * 423-DN Basis of Cost Determination EZ Prescriber ID Qualifier AM Prescriber ID ' E DUR/PPS Code Counter E4 Reason for Service Code PA 440-E5 Professional Service Code M0 441-E6 Result of Service Code 2A D0B XXX0100AAA...AM04.C AM01.C C52.C701~..AM07.EM1.D E103.D E D5030.D61.DK07.C801.EU01.EV AM11.DU DN00..AM03.EZ01.DB AM08.7E1.E4PA.E5M0.E62A June 2012 Page 16
17 Medi-Cal POS OR D0B XXX0100AAA...AM04.C AM01.C C52.C701~..AM07.EM1.D E103.D E D530.D61.DK07.C801.EU01.EV AM11.DU2100.DN00..AM03.EZ01.DB AM08.7E1.E4PA.E5M0.E62A Response: 103-A3 Transaction Type 'B1' 501-F1 Response Status (Header) 'A' 201-B1 Service Provider ID D1 Date of Service (CCYYMMDD) ' ' 112-AN Transaction Response Status 'C' 310-CA Patient First Name 'JENNIFER 311-CB Patient Last Name 'SMITH ' 455-EM Prescription/Service Ref. Num. Qualifier D2 Prescription/Service Ref. Num. Numeric Values EDSH01IZ513U...D0B11A AM29.CAJENNIFER...CB SMITH...AM21.ANC..AM22.EM1.D * Implied decimal, two places ** Implied decimal, three places June 2012 Page 17
18 Medi-Cal POS NCPDP D.0 Pharmacy Claim Test Case 8: Claim Reversal. The claim is not reversed. 103-A3 Transaction Type 'B2' 201-B1 Service Provider ID ' ' 401-D1 Date of Service (CCYYMMDD) ' ' 110-AK Software Vendor/Certification ID XXX0100AAA 302-C2 Cardholder ID ' ' 455-EM Prescription/Service Reference Qualifier D2 Prescription Number Numeric Value 436-E1 Product/Service ID Qualifier D7 Product/Service ID ' ' D0B XXX0100AAA..AM04.C AM07.EM1.D E103.D June 2012 Page 18
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20 Medi-Cal POS Response: 103-A3 Transaction Code 'B2' 501-F1 Response Status (Header) 'R' 201-B1 Service Provider ID ' ' 401-D1 Date of Service (CCYYMMDD) ' ' 112-AN Transaction response Status R 510-FA Reject Count '01' 511-FB Reject Code '16' 130-UF Additional Message Information Count UH Additional Message Information Qualifier FQ Additional Message Information ' 131-UG ' Additional Message Information Continuity UH Additional Message Information Qualifier FQ Additional Message Information ' 0867' 549-7F Help Desk Phone Number Qualifier 01 55Ø-8F Help Desk Phone Number EDSH01IZ513U...D0B21R AM21.ANR.FA01. FB16. UF02.UH01.FQ...UG+.UH02.FQ F01.8F Eligibility Verification There are no test cases for NCPDP Eligibility Verification transactions. Once testing for NCPDP Pharmacy Claims is successfully completed, a provider or vendor will also be approved to submit NCPDP Eligibility Verification requests. June 2012 Page 19
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