845 PRICE AUTHORIZATION ACKNOWLEDGEMENT/STATUS - VERSION 5010

Transcription

1 845 PRICE AUTHORIZATION ACKNOWLEDGEMENT/STATUS - VERSION 5010 This example represents a contract notification being sent by a Manufacturer to a Distributor eligible to service a contract to an end user or GPO. 845 Price Authorization Acknowledgement/Status Example 1 This is example is for a new contract containing both membership and products. TRANSACTION SET HEADER ST*845* Transaction Set Identifier Code ST X12 Price Authorization Acknowledgement/Status Transaction Set Control Number ST BEGINNING SEGMENT FOR PRICE AUTHORIZATION ACKNOWLEDGEMENT/STATUS BPA*00* Transaction Set Purpose Code BPA01 00 Original Qualifier BPA of Transaction CONTRACT NUMBER DETAIL CON*CT* *OC Reference Identification Qualifier CON01 CT Contract Number Qualifier Reference Identifiction CON Contract Number Contract Status Code CON03 OC Original Contract REFERENCE IDENTIFICATION REF*CT*GPO Name* Reference Identification Qualifier REF01 CT Contract Number Qualifier Reference Identification REF02 GPO Name Name of Contract DTM*091* /Time Qualifier DTM Contract Effective Qualifier DTM Contract Effective

2 DTM*092* /Time Qualifier DTM Contract Expiration Qualifier DTM Contract Expiration NAME N1*MF*MANUFACTURER NAME*21*75KGDC100 Entity Identifier Code N101 MF Manufacturer of Goods Qualifier Name N102 MANUFACTURER NAME Identification Code Qualifier N HIN Number Qualifier Identification Code N104 75KGDC100 HIN for Manufacturer ADDRESS INFORMATION N3*1234 Main Street Address Information N Main Street GEOGRAPHIC LOCATION N4*FRANKLIN LAKES*NJ*07417 City Name N401 FRANKLIN LAKES City of Manufacturer State or Provice Code N402 NJ State of Manufacturer Postal Code N Zip Code of Manufacturer. NAME N1*DB*M & D OF SHREVEPORT*21*BZ0521P00 Entity Identifier Code N101 DB Distributor Branch Qualifier Name N102 M & D OF SHREVEPORT Identification Code Qualifier N HIN Number Qualifier Identification Code N104 BZ0521P00 HIN Number ADDRESS INFORMATION N3*One First Street*Storage Location 1 Address Information

3 N301 One First Street Address 1 N302 Storage Location 1 Address 2 GEOGRAPHIC LOCATION N4*Shreveport*LA*60054 City N401 Shreveport City State N402 LA State Postal Code N Postal Code NAME N1*EB*VALLEY HOSPITAL*21*221070C00 Entity Identifier Code N101 EB Eligible Party to the Contract Qualifier Name N102 VALLEY HOSPITAL Qualifier N HIN Number Qualifier DEA Number N C00 HIN Number ADDRESS INFORMATION N3*507 Maple Avenue Address Information N Maple Avenue Address 1 GEOGRAPHIC LOCATION N4*Ridgewood*NJ*07450 City N401 Ridgewood City State N402 NJ State Postal Code N Postal Code REFERENCE IDENTIFICATION REF*TD*A Reference Identification Qualifier REF01 TD Reason for Change Qualifier Reference Identification REF02 A Customer Add DTM*129*

4 /Time Qualifier DTM Customer Contract Effective Qualifier DTM Customer Contract Effective DTM*130* /Time Qualifier DTM Customer Contract Expiration Qualifier DTM Customer Contract Expiration PRODUCT ADJUSTMENT DETAIL PAD*0001**AI Assigned Identification PAD Line Item Number Change or Response Type Code PAD03 AI Add Item(s) PRODUCT/ITEM DESCRIPTION PID*F****Surgical Blade - Size 11 Item Description Type PID01 F Free-form Description PID05 Surgical Blade - Size 11 ITEM IDENTIFICATION LIN*0001*MG* Assigned Identification LIN Line Number Product/Service ID Qualifier LIN02 MG Manufacturer's Part Number Qualifier Product/Service ID LIN Manufacturer's Part Number PRICING INFORMATION CTP**CON*65.00*1*CA Price Identifier Code CTP02 CON Contract Price Qualifier Unit Price CTP Contract Unit Price Quantity CTP04 1 Quantity Composite Unit of Measure CTP05 CA Case

5 DTM*131* /Time Qualifier DTM Item Contract Effective Qualifier DTM Item Contract Effective DTM*132* /Time Qualifier DTM Item Contract Expiration Qualifier DTM Item Contract Expiration TRANSACTION TOTALS CTT*1 Number of Line Items CTT01 1 TRANSATION SET TRAILER SE*16* Number of Included Segments SE01 16 Transaction Set Control Number SE Transmission File: ST*845* BPA*00* CON*CT* *OC REF*CT*GPO Name DTM*091* DTM*092* N1*MF*MANUFACTURER NAME*21*75KGDC100 N3*123 MAIN STREET N4*FRANKLIN LAKES*NJ*07417 N1*DB*M&D OF SHREVEPORT*21*BZ0521P00 N3*One First Street*Storage Location 1 N4*Shreveport*LA*60054 N1*EB*VALLEY HOSPITAL*21*221070C00 N3*507 MAPLE AVENUE N4*RIDGEWOOD*NJ*07450 REF*TD*A DTM*129* DTM*130* PAD*0001*AI PID*F****Surgical Blade- Size 11 LIN*0001*MG* CPT**CON*65.00*1*CA

6 DTM*131* DTM*132* CTT*1