Version 1.Ø for 2Ø15

Transcription

1 2Ø15 Payer Sheet NCPDP Version D.Ø Version 1.Ø for 2Ø15 Release Date: December 1, 2Ø14 Effective Date: January 1, 2Ø15

2 Contents GENERAL INFORATION... 3 BIN INFORATION... 3 PCN LIST FOR BIN Ø PHARACY HELP DESK INFORATION:... 3 VERSION INFORATION... 3 NCPDP VERSION D.Ø CLAI BILLING TEPLATE... 5 REQUEST CLAI BILLING PAYER SHEET TEPLATE... 5 General Information... 5 Transactions Supported... 5 Field Legend for Columns... 5 Transaction... 6 RESPONSE CLAI BILLING PAYER SHEET TEPLATE General Information Accepted/Paid (or Duplicate of Paid) Response /Rejected Response NCPDP VERSION D.Ø CLAI REVERSAL TEPLATE REQUEST CLAI REVERSAL PAYER SHEET TEPLATE General Information Field Legend for Columns Request Claim Reversal Transaction RESPONSE CLAI REVERSAL PAYER SHEET TEPLATE General Information Claim Reversal Accepted/Rejected Response... 24

3 General Information BIN Information PCN List for BIN Ø17639 Pharmacy Help Desk Information: Inquiries to National Script pharmacy help desk may be directed to our 24 Hour Pharmacy Assistance Center**. All calls are toll free. Help Desk: Payer/Processor Name: BIN Number: Effective as of: NCPDP Version: National Script Ø17639 December 1, 2Ø14 D.Ø National Scripts All Groups PCN Plan/Group Line of Business Description NSCRIPT All Groups Commercial Commercial National Script Phone Fax E-ail All Groups Ø Ø5 Version Information VER. DATE PAGE FIELD NOTES 1.Ø 12/1/2Ø14 Payer Sheet Release for 2Ø15.

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5 NCPDP VERSION D.Ø Template Request Payer Sheet Template ** Start of Request (B1) Payer Sheet Template** General Information Payer Name: National Script BIN: Ø17639 Date: December 1, 2014 Plan Name/Group Name ALL GROUPS PCN NSCRIPT Effective as of: January 1, 2Ø14 NCPDP Data Dictionary Version Date: arch 2Ø1Ø NCPDP Telecommunication Standard Version/Release #: D.Ø NCPDP External Code List Version Date: arch 2Ø1Ø Contact/Information Source: National Script, 5ØØ Discovery Pkwy, Suite 375, Superior, CO 8ØØ127 Provider Relations Help Desk Info: Ø1 Other versions supported: None Transactions Supported Transaction Code B1 B2 Transaction Name Claim Reversal Field Legend for Columns Payer Column Value Explanation Column ANDATORY The Field is mandatory for the Segment in the designated Transaction 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") No No Yes

6 Transaction The following lists the segments and fields in a Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Transaction Header Segment Questions Check If Situational, Transaction Header Segment 1Ø1-A1 BIN NUBER Ø Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B1 Note: Rebill (B3) not supported 1Ø4-A4 PROCESSOR CONTROL NUBER Refer to PCN table on page 3. Use correct PCN for BIN/Group/Line of Business. 1Ø9-A9 TRANSACTION COUNT 1 Only one Transaction allowed in a single transmission 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1, Ø7 Ø1 = NPI Ø7 = NCPDP Provider ID 2Ø1-B1 SERVICE PROVIDER ID 4Ø1-D1 DATE OF SERVICE 11Ø-AK SOFTWARE VENDOR/ CERTIFICATION ID BLANKS Insurance Segment Questions Check If Situational, Insurance Segment Ø4 3Ø2-C2 CARDHOLDER ID 312-CC CARDHOLDER FIRST NAE 313-CD CARDHOLDER LAST NAE 3Ø6-C6 PATIENT RELATIONSHIP CODE Patient Segment Questions Check If Situational,

7 Patient Segment Ø1 Field NCPDP Field Name Value Payer 3Ø4-C4 DATE OF BIRTH R 3Ø5-C5 PATIENT GENDER CODE 1, 2 R 31Ø-CA PATIENT FIRST NAE R 311-CB PATIENT LAST NAE R 322-C PATIENT STREET ADDRESS R 323-CN PATIENT CITY ADDRESS R 324-CO PATIENT STATE / PROVINCE ADDRESS R 325-CP PATIENT ZIP/POSTAL ZONE R 3Ø7-C7 PLACE OF SERVICE Required for Home Infusion and LTC patients 35Ø-HN PATIENT E-AIL ADDRESS For informational purposes only PATIENT RESIDENCE Required when necessary to clarify coverage.

8 Claim Segment Questions Check If Situational, Claim Segment Ø7 455-E 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUBER Ø1 = Rx Billing Imp Guide: For Transaction Code of B1, in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 1 (Rx Billing). 436-E1 PRODUCT/SERVICE ID QUALIFIER Ø3 NDC Number 4Ø7-D7 PRODUCT/SERVICE ID = anufacturer assigned number DDDD = Drug ID PP = Package size Zero filled if product is a Compound. 442-E7 QUANTITY DISPENSED R 4Ø3-D3 FILL NUBER R 4Ø5-D5 DAYS SUPPLY R 4Ø6-D6 COPOUND CODE Ø, 1, 2 R Ø = Not specified 1 = Not a Compound 2 = Compound 4Ø8-D8 DISPENSE AS WRITTEN (DAW)/ PRODUCT SELECTION CODE Ø thru 9 R Ø = No Product Selection Indicated 1 = Prescriber DAW 2 = Patient Selection 3 = Pharmacist Selection 4 = No Generic Available at Pharmacy 5 = Brand Dispensed as Generic 6 = Override 7 = Brand andated by Law 8 = No Generic in arketplace 9 = Plan Requested Brand 414-DE DATE PRESCRIPTION WRITTEN R 415-DF NUBER OF REFILLS AUTHORIZED R 419-DJ PRESCRIPTION ORIGIN CODE 1,2,3,4 R 1 = Written 2 = Telephone 3 = Electronic 4 = Facsimile

9 Claim Segment Ø7 3Ø8-C8 OTHER COVERAGE CODE Ø, 1, 2, 3, 4, 8 R Ø = Not Specified 1 = No other coverage identified 2 = Other coverage exists payment collected. 3 = Other coverage exists this claim not covered. 4 = Other coverage exists payment not collected 8 = Claim is billing for copay only For Copay Only Billing: Use value 4 when payment was not collected due to previous payers deductible Use value 3 when payment was not collected from previous payer Use value 8 when payment was collected from previous payer and the claim is billing for copay only 147-U7 PHARACY SERVICE TYPE R 354-N SUBISSION CLARIFICATION CODE COUNT Up to 3 Field is Required when Patient Residence (384-4) = 3 Field is Required for 34ØB Claim Submissions 42Ø-DK SUBISSION CLARIFICATION CODE Field is Required when Patient Residence (384-4) = 3 Value 2Ø Required for 34ØB Claim Submissions

10 Pricing Segment Questions Check If Situational, Pricing Segment 11 4Ø9-D9 INGREDIENT COST SUBITTED R 412-DC DISPENSING FEE SUBITTED R 438-E3 INCENTIVE AOUNT SUBITTED Required when applicable 426-DQ USUAL AND CUSTOARY CHARGE R 43Ø-DU GROSS AOUNT DUE R Prescriber Segment Questions Check If Situational, Prescriber Segment Ø3 466-EZ PRESCRIBER ID QUALIFIER Ø1, 12 R Ø1 = NPI 12 = DEA 411-DB PRESCRIBER ID R Coordination of Benefits/Other Payments Segment Questions Check If Situational, This Segment is situational Required only for secondary, tertiary, claims. Coordination of Benefits/Other Payments Segment Ø5 Scenario 2- Other Payer-Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only 337-4C COORDIATION OF BENEFITS/ OTHER PAYENTS COUNT aximum count of C OTHER PAYER COVERAGE TYPE Ø1 thru Ø C OTHER PAYER ID QUALIFIER Ø3 R Ø3 = BIN 34Ø-7C OTHER PAYER ID R 443-E8 OTHER PAYER DATE R 341-HB OTHER PAYER AOUNT PAID COUNT aximum of 9 Required when 431-DV is used

11 Coordination of Benefits/Other Payments Segment Ø5 Scenario 2- Other Payer-Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only 342-HC OTHER PAYER AOUNT PAID QUALIFIER Ø1, Ø2, Ø3, Ø4, Ø5, Ø6, Ø7, Ø9 Required when 431-DV is used Ø1 Delivery Ø2 Shipping Ø3 Postage Ø4 Admin Ø5 Incentive Ø6 Cognitive Ø7 Drug Benefit Ø9 Compound Prep 431-DV OTHER PAYER AOUNT PAID Required when other payer payment is made 471-5E OTHER PAYER REJECT COUNT aximum count of 5. Required when Other Coverage Code (3Ø8-C8) = E OTHER PAYER REJECT CODE 6Ø, 61, 65, 66, 67, 68, 69, 7Ø, 76, AA, 1, RN Required when Other Coverage Code (3Ø8-C8) = NR OTHER PAYER-PATIENT RESPONSIBILITY AOUNT COUNT aximum count of 25. Required when Other Coverage Code (3Ø8-C8) = NP OTHER PAYER-PATIENT RESPONSIBILITY AOUNT QUALIFIER Ø1, Ø2, Ø4, Ø5, Ø6, Ø7, Ø8, Ø9, 11 Required when Other Coverage Code (3Ø8-C8) = NQ OTHER PAYER-PATIENT RESPONSIBILITY AOUNT Required when Other Coverage Code (3Ø8-C8) = 8 DUR/PPS Segment Questions Check If Situational, This Segment is situational When necessary to provide information on potential drug interactions DUR/PPS Segment Ø E DUR/PPS CODE COUNTER aximum of 9 occurrences 439-E4 REASON FOR SERVICE CODE DD, TD, S DD = Drug Drug TD = Duplicate Therapy S = Drug - Gender 44Ø-E5 PROFESSIONAL SERVICE CODE 441-E6 RESULT OF SERVICE CODE Compound Segment Questions Check If Situational, This Segment is situational For billing of compound medications.

12 Compound Segment 1Ø 45Ø-EF COPOUND DOSAGE FOR DESCRIPTION CODE Ø1 - Ø7, 1Ø - 17 Blank = Not Specified Ø1 = Capsule 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 451-EG COPOUND DISPENSING UNIT FOR INDICATOR 1, 2, 3 1 = Each 2 = Grams 3 = illiliters 447-EC COPOUND INGREDIENT COPONENT COUNT aximum 25 ingredients 488-RE COPOUND PRODUCT ID QUALIFIER 489-TE COPOUND PRODUCT ID 448-ED COPOUND INGREDIENT QUANTITY 449-EE COPOUND INGREDIENT DRUG COST R Enter ingredient cost for each product in the compound 49Ø-UE COPOUND INGREDIENT BASIS OF COST DETERINATION ** End of Request (B1) Payer Sheet Template** R

13 Response Payer Sheet Template ** Start of Response (B1) Payer Sheet Template** General Information Payer Name: National Script BIN: Ø17639 Date: Dec 1, 2Ø14 Plan Name/Group Name ALL GROUPS PCN NSCRIPT Effective as of: January 1, 2Ø14 NCPDP Data Dictionary Version Date: arch 2Ø1Ø NCPDP Telecommunication Standard Version/Release #: D.Ø NCPDP External Code List Version Date: arch 2Ø1Ø Contact/Information Source: National Script, 5ØØ Discovery Pkwy, Suite 375, Superior, CO 8ØØ127 Provider Relations Help Desk Info: Ø1 Other versions supported: None Accepted/Paid (or Duplicate of Paid) Response The following lists the segments and fields in a Accepted/Paid (or Duplicate of Paid) Response Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Response Transaction Header Segment Questions Response Transaction Header Segment Check Accepted/Paid (or Duplicate of Paid) If Situational, - Accepted/Paid (or Duplicate of Paid) 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B1 Note: Rebill (B3) not supported 1Ø9-A9 TRANSACTION COUNT 1 Only one transaction per transmission 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1, Ø7 Ø1 = NPI Ø7 = NCPDP 2Ø1-B1 SERVICE PROVIDER ID 4Ø1-D1 DATE OF SERVICE Response essage Header Segment Questions Check Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is situational When additional text is required for clarification or detail

14 Response essage Segment 2Ø - Accepted/Paid (or Duplicate of Paid) 5Ø4-F4 ESSAGE R

15 Response Insurance Header Segment Questions Check Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is situational Returned when Cardholder ID differs from Cardholder ID Submitted. Response Insurance Segment 25 3Ø2-C2 CARDHOLDER ID R Accepted/Paid (or Duplicate of Paid) Response Status Segment Questions Check Accepted/Paid (or Duplicate of Paid) If Situational, Response Status Segment 21 Accepted/Paid (or Duplicate of Paid) 112-AN TRANSACTION RESPONSE STATUS P=Paid D=Duplicate of Paid 5Ø3-F3 AUTHORIZATION NUBER R Response Claim Segment Questions Check Accepted/Paid (or Duplicate of Paid) If Situational, Response Claim Segment 22 Accepted/Paid (or Duplicate of Paid) 455-E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 1 = RxBilling 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUBER Response Pricing Segment Questions Check Accepted/Paid (or Duplicate of Paid) If Situational,

16 Response Pricing Segment 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 557-AV TA EEPT INDICATOR Ø4 R Ø4 = Neither Payer/Plan nor Patient are liable for tax 521-FL INCENTIVE AOUNT PAID Required when Professional Service Code = A 566-J5 OTHER PAYER AOUNT RECOGNIZED Required when Other Coverage Code = 2, 3, 4 5Ø9-F9 TOTAL AOUNT PAID R 522-F BASIS OF REIBURSEENT DETERINATION Required when Ingredient Cost Paid (5Ø6-F6) is greater than zero 517-FH AOUNT APPLIED TO PERIODIC DEDUCTIBLE Returned when applicable 518-FI AOUNT OF COPAY Returned when applicable 572-4U AOUNT OF COINSURANCE Returned when applicable 392-U BENEFIT STAGE COUNT aximum count of 4 Returned when applicable 393-V BENEFIT STAGE QUALIFIER Returned when applicable 394-W BENEFIT STAGE AOUNT Returned when applicable 133-UJ AOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION Returned when applicable 134-UK AOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG Returned when applicable 135-U AOUNT ATTRIBUTED TO PRODUCT SELECTION/NON- PREFERRED FORULARY SELECTION Returned when applicable 136-UN AOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NON-PREFERRED FORULARY SELECTION Returned when applicable 137-UP AOUNT ATTRIBUTED TO COVERAGE GAP Returned when applicable 148-U8 INGREDIENT COST CONTRACTED/ REIBURSABLE AOUNT Required when Other Coverage Code (3Ø8-C8) = 2 or U9 DISPENSING FEE CONTRACTED/ REIBURSABLE AOUNT Response DUR/PPS Segment Questions Check Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is situational Required when DUR warning is indicated. Required when Other Coverage Code (3Ø8-C8) = 2 or 8

17 Response DUR/PPS Segment 24 Accepted/Paid (or Duplicate of Paid) 567-J6 DUR/PPS RESPONSE CODE COUNTER aximum 9 occurrences supported Required when Reason For Service Code (439-E4) is used. 439-E4 REASON FOR SERVICE CODE Required when utilization conflict is detected 528-FS CLINICAL SIGNIFICANCE CODE Blank, 1,2,3 9 Required when necessary to provide conflict. 529-FT OTHER PHARACY INDICATOR Required when necessary to provide conflict. 53Ø-FU PREVIOUS DATE OF FILL Required when necessary to provide conflict. 531-FV QUANTITY OF PREVIOUS FILL Required when necessary to provide conflict. 532-FW DATABASE INDICATOR Required when necessary to provide conflict. 533-F OTHER PRESCRIBER INDICATOR Required when necessary to provide conflict. 544-FY DUR FREE TET ESSAGE Required when necessary to provide conflict. 57Ø-NS DUR ADDITIONAL TET Required when necessary to provide conflict.

18 Response Coordination of Benefits/Other Payers Segment Questions Check Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is situational For claims where other payer information is indicated Response Coordination of Benefits/ Accepted/Paid (or Other Payers Segment Duplicate of Paid) NT OTHER PAYER ID COUNT aximum count of C OTHER PAYER COVERAGE TYPE 339-6C OTHER PAYER ID QUALIFIER Required when secondary coverage is indicated for the member. 34Ø-7C OTHER PAYER ID Required when secondary coverage is indicated for the member. 991-H OTHER PAYER PROCESSOR CONTROL NUBER Required when secondary coverage is indicated for the member. 356-NU OTHER PAYER CARDHOLDER ID Required when secondary coverage is indicated for the member. 992-J OTHER PAYER GROUP ID Required when secondary coverage is indicated for the member. 142-UV OTHER PAYER PERSON CODE Required when secondary coverage is indicated for the member. 127-UB OTHER PAYER HELP DESK PHONE NUBER For informational purposes 143-UW OTHER PAYER PATIENT RELATIONSHIP CODE For informational purposes 144-U OTHER PAYER BENEFIT EFFECTIVE DATE For informational purposes 145-UY OTHER PAYER BENEFIT TERINATION DATE For informational purposes

19 /Rejected Response The following lists the segments and fields in a /Rejected Response Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Response Transaction Header Segment Questions Response Transaction Header Segment Check - Accepted/Rejected If Situational, - Accepted/Rejected 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B1 Note: Rebill (B3) not supported 1Ø9-A9 TRANSACTION COUNT 1 Only one transaction per transmission. 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 Response essage Segment Questions Check - Accepted/Rejected If Situational, This Segment is situational When required to clarify response Response essage Segment 2Ø - Accepted/Rejected 5Ø4-F4 ESSAGE R Response Claim Segment Questions Check - Accepted/Rejected If Situational, Response Claim Segment 22 - Accepted/Rejected 455-E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 1 = RxBilling Imp Guide: For Transaction Code of B1, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 1 (Rx Billing) 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUBER

20 Response DUR/PPS Segment Questions Check - Accepted/Rejected If Situational, This Segment is situational When DUR warning is indicated Response DUR/PPS Segment 24 - Accepted/Rejected 567-J6 DUR/PPS RESPONSE CODE COUNTER aximum 9 occurrences supported Required when Reason For Service Code (439-E4) is used 439-E4 REASON FOR SERVICE CODE Required when utilization conflict is detected 528-FS CLINICAL SIGNIFICANCE CODE Blank, 1,2,3,9 Required when necessary to provide conflict 529-FT OTHER PHARACY INDICATOR Required when necessary to provide conflict 53Ø-FU PREVIOUS DATE OF FILL Required when necessary to provide conflict 531-FV QUANTITY OF PREVIOUS FILL Required when necessary to provide conflict 532-FW DATABASE INDICATOR 1= First Databank 2=edispan Required when necessary to provide conflict 533-F OTHER PRESCRIBER INDICATOR Required when necessary to provide conflict 544-FY DUR FREE TET ESSAGE Required when necessary to provide conflict 57Ø-NS DUR ADDITIONAL TET Required when necessary to provide conflict ** End of Response (B1) Payer Sheet Template**

21 NCPDP Version D.Ø Claim Reversal Template Request Claim Reversal Payer Sheet Template ** Start of Request Claim Reversal (B2) Payer Sheet Template** General Information Payer Name: National Script BIN: Ø17639 Date: December 1, 2Ø14 Plan Name/Group Name All GROUPS PCN NSCRIPT Date: December 1, 2Ø14 Effective as of: January 1, 2Ø14 NCPDP Data Dictionary Version Date: arch 2Ø1Ø NCPDP Telecommunication Standard Version/Release #: D.Ø NCPDP External Code List Version Date: arch 2Ø1Ø Contact/Information Source: National Script, 5ØØ Discovery Pkwy, Suite 375, Superior, CO 8ØØ127 Provider Relations Help Desk Info: Ø1 Other versions supported: None Field Legend for Columns Payer Column Value Explanation ANDATORY The Field is mandatory for the Segment in the designated Transaction REQUIRED R The Field has been designated with the situation of Required for the Segment in the designated Transaction QUALIFIED REQUIREENT Question Required when the situations designated have qualifications for usage Answer What is your reversal window? (If transaction is billed today what is the timeframe for reversal to be submitted?) Request Claim Reversal Transaction The following lists the segments and fields in a Request Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. 6Ø Days from Date of Service Transaction Header Segment Questions Check Claim Reversal If Situational,

22 Transaction Header Segment Claim Reversal 1Ø1-A1 BIN NUBER Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B2 1Ø4-A4 PROCESSOR CONTROL NUBER Refer to PCN table on page 3. Use correct PCN for BIN/Group/Line of Business 1Ø9-A9 TRANSACTION COUNT 1 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1, Ø7 Ø1 = NPI Ø7 = NCPDP 2Ø1-B1 SERVICE PROVIDER ID 4Ø1-D1 DATE OF SERVICE 11Ø-AK SOFTWARE VENDOR/ CERTIFICATION ID Blanks Insurance Segment Questions Check Claim Reversal If Situational, Insurance Segment Ø4 Claim Reversal 3Ø2-C2 CARDHOLDER ID Claim Segment Questions Check Claim Reversal If Situational, Claim Segment Ø7 Claim Reversal 455-E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER Ø1=RxBilling 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUBER 436-E1 PRODUCT/SERVICE ID QUALIFIER Ø3 National Drug Code ØØ ulti-ingredient Compound 4Ø7-D7 PRODUCT/SERVICE ID Valid NDC or Ø if original claim was for a multi-ingredient compound ust contain product/service ID from original prescription billing

23 ** End of Request Claim Reversal (B2) Payer Sheet Template**

24 Response Claim Reversal Payer Sheet Template **Start of Claim Reversal Response (B2) Payer Sheet Template** General Information Payer Name: National Script BIN: Ø17639 Date: December 1, 2Ø14 Plan Name/Group Name ALL GROUPS PCN NSCRIPT Effective as of: January 1, 2Ø14 NCPDP Data Dictionary Version Date: arch 2Ø1Ø NCPDP Telecommunication Standard Version/Release #: D.Ø NCPDP External Code List Version Date: arch 2Ø1Ø Contact/Information Source: National Script, 5ØØ Discovery Pkwy, Suite 375, Superior, CO 8ØØ127 Provider Relations Help Desk Info: Other versions supported: None Claim Reversal Accepted/Rejected Response The following lists the segments and fields in a Claim Reversal (Accepted/Rejected) Response Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Response Transaction Header Segment Questions Response Transaction Header Segment Check Claim Reversal Accepted/Approved If Situational, Claim Reversal Accepted/Approved 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B2 1Ø9-A9 TRANSACTION COUNT 1 5Ø1-F1 HEADER RESPONSE STATUS A, R A = Accepted R = Rejected 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1, Ø7 Ø1 = NPI Ø7 = NCPDP 2Ø1-B1 SERVICE PROVIDER ID 4Ø1-D1 DATE OF SERVICE Response essage Header Segment Questions Check Claim Reversal Accepted/Approved If Situational, This Segment is situational x Required when necessary to clarify reversal.

25 Response essage Segment 2Ø Claim Reversal Accepted/Approved 5Ø4-F4 ESSAGE

26 Response Status Segment Questions Check Claim Reversal Accepted/Approved If Situational, Response Status Segment 21 Claim Reversal Accepted/Approved 112-AN TRANSACTION RESPONSE STATUS A, R A = Accepted R = Rejected Response Claim Segment Questions Check Claim Reversal Accepted/Approved If Situational, Response Claim Segment 22 Claim Reversal Accepted/Approved 455-E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 1 = RxBilling 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUBER **End of Claim Reversal Response (B2) Payer Sheet Template**