AETNA NCPDP D.Ø CLAIM BILLING (B1) MEDICARE PAYER SHEET IMPLEMENTATION GUIDE FOR VERSION D.Ø VERSION 5.Ø

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1 AETNA NCPDP D.Ø CLAI BILLING (B1) EDICAE PAYE SHEET IPLEENTATION GUIDE FO VESION D.Ø VESION 5.Ø April 2013

2 TABLE OF CONTENTS 1. NCPDP VESION D CLAI BILLING EDICAE EQUEST CLAI BILLING EDICAE PAYE SHEET ESPONSE CLAI BILLING EDICAE PAYE SHEET edicare Accepted/Paid (or Duplicate of Paid) esponse edicare Accepted/ejected esponse edicare ejected/ejected esponse FEQUENTLY ASKED QUESTIONS APPENDI A. HISTOY OF IPLEENTATION GUIDE CHANGES VESION 1.Ø VESION 2.Ø VESION 3.Ø VESION 4.Ø VESION 5.Ø

3 1. NCPDP VESION D CLAI BILLING EDICAE 1.1 EQUEST CLAI BILLING EDICAE PAYE SHEET ** Start of equest (B1) Payer Sheet ** GENEAL INFOATION Payer Name: Aetna Date: October 2012 Plan Name/Group Name: edicare Part D BIN: 61Ø5Ø2 PCN: EDDAET Plan Name/Group Name: edicare Advantage Part D BIN: 61Ø5Ø2 PCN: EDDAET Plan Name/Group Name: edicare Advantage Only (Part B Only) BIN: 61Ø5Ø2 PCN: PATBAET Processor: Aetna Pharmacy anagement Effective as of: 1/1/2013 NCPDP Telecommunication Standard Version/elease #: D.Ø NCPDP Data Dictionary Version Date: October 2011 NCPDP External Code List Version Date: October 2011 Contact/Information Source: [email protected] Provider elations Help Desk Info: 8ØØ OTHE TANSACTIONS SUPPOTED Transaction Code B2 Transaction Name Billing eversal FIELD LEGEND FO COLUNS Payer Column Value Explanation Column ANDATOY The Field is mandatory for the Segment in the designated Transaction. No EQUIED The Field has been designated with the situation No of "equired" for the Segment in the designated Transaction. QUALIFIED EQUIEENT equired when. The situations designated have Yes qualifications for usage ("equired if x", "Not required if y"). NOT USED NA The field is not used. Do not submit. No OPTIONAL O The field is optional. Yes Fields that are defined as NOT USED in the D.Ø implementation guide should not be submitted. If a field that is defined as NOT USED is submitted, the transaction will be rejected. Fields that are defined as Optional in the D.Ø Implementation guide are not required for Aetna Processing however if they are submitted they must conform to NCPDP format. All Character fields will be checked for length limitations and the exceeding characters will be truncated. Example: A field can hold 2 Chars. If the value received for the field is ABC, the value will be truncated to 2 Chars and send AB. NOTE: Aetna only supports B1 and B2 Transactions

4 CLAI BILLING TANSACTION 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 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 1Ø1-A1 BIN NUBE 61Ø5Ø2 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B1 1Ø4-A4 POCESSO CONTOL NUBE EDDAET PATBAET 1Ø9-A9 TANSACTION COUNT 1 PDP/APD = EDDAET A Only = PATBAET 1=One Occurrence 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Ø1 Ø1 = NPI 2Ø1-B1 SEVICE POVIDE ID NPI 4Ø1-D1 DATE OF SEVICE 11Ø-AK SOFTWAE VENDO/CETIFICATION ID Insurance Segment Questions Check Insurance Segment Segment Identification (111-A) = Ø4 3Ø2-C2 CADHOLDE ID 336-8C FACILITY ID NA 3Ø1-C1 GOUP ID The Group number from the member's ID card must be entered exactly as written on the card, excluding dashes and spaces. 3Ø3-C3 PESON CODE 3Ø6-C6 PATIENT ELATIONSHIP CODE Patient Segment Questions Check This Segment is situational Patient Segment Segment Identification (111-A) = Ø1 Field NCPDP Field Name Value Payer 3Ø4-C4 DATE OF BITH 3Ø5-C5 PATIENT GENDE CODE 31Ø-CA PATIENT FIST NAE 311-CB PATIENT LAST NAE 334-1C SOKE/NON-SOKE CODE NA - 4 -

5 Patient Segment Segment Identification (111-A) = Ø1 Field NCPDP Field Name Value Payer PATIENT ESIDENCE 0, 1, 3, 4, 6, 9, 11, 15 0=Not Specified 1=Home 3=Nursing Facility 4=Assisted Living Facility 6= Group Home 9= Intermediate care facilities for the mentally retarded (ICF/) and Institutes for mental disease (ID) 11=Hospice 15=Correctional Institution Claim Segment Questions Check This payer supports partial fills This payer does not support partial fills Claim Segment Segment Identification (111-A) = Ø7 455-E PESCIPTION/SEVICE EFEENCE 1 = x Billing NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE NUBE 436-E1 PODUCT/SEVICE ID QUALIFIE ØØ, Ø3 ØØ-Not Specified Ø3-National Drug Code (NDC) Use ØØ when Compound Code (4Ø6-D6) = 2 Use Ø3 when Compound Code (4Ø6-D6) = 1 4Ø7-D7 PODUCT/SEVICE ID Use Ø when Compound Code (4Ø6-D6) = E7 QUANTITY DISPENSED ust be greater than zero 4Ø3-D3 FILL NUBE Ø - Original dispensing efill number 4Ø5-D5 DAYS SUPPLY 4Ø6-D6 COPOUND CODE 1, 2 1 = Not a Compound 2 = Compound 4Ø8-D8 DISPENSE AS WITTEN Ø - No Product Selection (DAW)/PODUCT SELECTION CODE Indicated 1 - Substitution Not Allowed by Prescriber 2 - Substitution Allowed-Patient equested Product Dispensed 3 - Substitution Allowed- Pharmacist Selected Product Dispensed 4 - Substitution Allowed-Generic Drug Not in Stock 5 - Substitution Allowed-Brand Drug Dispensed as a Generic 6 - Override 7 - Substitution Not Allowed-Brand Drug andated by Law 8 - Substitution Allowed-Generic Drug Not Available in arketplace 9 - Substitution Allowed By Prescriber but Plan equests Brand 414-DE DATE PESCIPTION WITTEN When claim is for a ulti-source Brand the Dispense As Written cannot be Ø. If the DAW submitted is Ø the claim will reject

6 Claim Segment Segment Identification (111-A) = Ø7 419-DJ PESCIPTION OIGIN CODE Ø N SUBISSION CLAIFICATION CODE COUNT Ø - Not Known 1 - Written 2 - Telephone 3 - Electronic 4 - Facsimile 1, 2 or 3 equired if Submission Clarification Code (42Ø-DK) is used. 42Ø-DK SUBISSION CLAIFICATION CODE 3, 4, 5, 7, 8, 13, 19, 21 36, Vacation Supply 4 - Lost Prescription 5 - Therapy Change 7 - edically Necessary 8 - Process Compound For Approved Ingredients 13 - Payer-ecognized Emergency/Disaster Assistance equest 19-Split Billing 21- LTC Dispensing: 14 days or less not applicable 22- LTC Dispensing: 7 days 23- LTC Dispensing: 4 days 24- LTC Dispensing: 3 days 25- LTC Dispensing : 2 days 26- LTC Dispensing: 1 day 27- LTC Dispensing: 4-3 days 28- LTC Dispensing: days 29- LTC Dispensing: daily and 3- day weekend 30- LTC Dispensing: Per shift dispensing 31-LTC Dispensing: Per med pass dispensing 32- LTC Dispensing: PN on demand 33- LTC Dispensing: 7 day or less dispensing method not listed above 34- LTC Dispensing: 14 day or less 35- LTC Dispensing: 8-14 day dispensing method not listed above 36- LTC Dispensing: dispensed outside short cycle 42 - Prescriber ID Submitted has been validated, is active 46Ø-ET QUANTITY PESCIBED NA 3Ø8-C8 OTHE COVEAGE CODE Ø - Not Specified by patient 1 - No other coverage equired when pharmacist approves to process Compound for approved ingredients only or when submitting for LTC Short Cycle Dispening or when submitting a split billing claim from a LTC or to override rejected claims due to a DU threshold being met. See COB Payer Sheet for COB values. 418-DI LEVEL OF SEVICE 3 - Emergency equired when filling an emergency prescription. 88Ø-K5 TANSACTION EFEENCE NUBE NA 995-E2 OUTE OF ADINISTATION O 996-G1 COPOUND TYPE equired when Compound Code (4Ø6-D6) = U7 PHAACY SEVICE TYPE 1 8, 99 1=Community//etail Pharmacy Services - 6 -

7 Claim Segment Segment Identification (111-A) = Ø7 2=Compounding Pharmacy Services 3=Home Infusion Therapy Provider Services 4=Institutional Pharmacy Services 5=Long Term Care Pharmacy Services 6=ail Order Pharmacy Services 7=anaged Care Organization Pharmacy Services 8=Specialty Care Pharmacy Services 99=Other 429-DT SPECIAL PACKAGING INDICATO 0-8 equired for LTC Short Cycle Dispensing 0- Not Specified 1- Not Unit Dose 2- anufacturer Unit Does 3- Pharmacy Unit Does 4- Pharmacy Unit Does Patient Compliance Packaging 5- Pharmacy ulti-drug Patient Compliance Packaging 6- emote device unit does 7- emote device ulti-drug compliance 8- anufacturer unit of use packaging Pricing Segment Questions Check Pricing Segment Segment Identification (111-A) = 11 4Ø9-D9 INGEDIENT COST SUBITTED 412-DC DISPENSING FEE SUBITTED 477-BE POFESSIONAL SEVICE FEE NA SUBITTED 438-E3 INCENTIVE AOUNT SUBITTED equired if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. 478-H7 OTHE AOUNT CLAIED SUBITTED COUNT equired when for edicare Part D Vaccine Administration Fee. Valid values - Ø, 1, 2, 3 equired if Other Amount Claimed Submitted Qualifier (479-H8) is used. 479-H8 OTHE AOUNT CLAIED SUBITTED QUALIFIE Valid values - Ø1 to Ø4, 99 equired when Other Amount Claimed Submitted Qualifier and Other Amount Claimed Submitted Amount are used. equired if Other Amount Claimed Submitted (48Ø-H9) is used. (Blank is not allowed) Ø1 - Delivery Cost Ø2 - Shipping Cost Ø3 - Postage Cost Ø4 - Administrative Cost 99 - Other equired when Other Amount Claimed Submitted Count and Other Amount Claimed Submitted Amount are used. 48Ø-H9 OTHE AOUNT CLAIED SUBITTED equired if its value has an effect on the Gross

8 Pricing Segment Segment Identification (111-A) = 11 Amount Due (43Ø-DU) calculation. equired when Other Amount Claimed Submitted Count and Other Amount Claimed Submitted Qualifier are used. 481-HA FLAT SALES TA AOUNT SUBITTED equired if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. 482-GE PECENTAGE SALES TA AOUNT SUBITTED equired if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. equired when Percentage Sales Tax ate Submitted and Percentage Sales Tax Basis Submitted are used. equired when percentage sales tax applies to the claim for states with sales tax. 483-HE PECENTAGE SALES TA ATE SUBITTED Note: This currently applies to the following states: IL, and LA (for non-part D drugs) equired when Percentage Sales Tax ate Submitted and Percentage Sales Tax Basis Submitted are used. 484-JE PECENTAGE SALES TA BASIS SUBITTED Ø2, Ø3 Ø2 - Ingredient Cost Ø3 - Ingredient Cost + Dispensing Fee equired if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax ate Submitted (483-HE) are used. 426-DQ USUAL AND CUSTOAY CHAGE 43Ø-DU GOSS AOUNT DUE Value in this field must balance with all submitted amount fields. 423-DN BASIS OF COST DETEINATION Ø1-13 Ø1 - AWP (Average Wholesale Price) Ø2 - Local Wholesaler Ø3 - Direct Ø4 - EAC (Estimated Acquisition Cost) Ø5 - Acquisition Ø6 - AC (aximum Allowable Cost) Ø7 - Usual & Customary Ø8-34ØB / Disproportionate Share Pricing/Public Health Service Ø9 - Other 1Ø - ASP (Average Sales Price) 11 - AP (Average anufacturer Price) 12 - WAC (Wholesale Acquisition Cost) 13 - Special Patient Pricing The cost calculated by the pharmacy for the drug for this special patient

9 Prescriber Segment Questions Check This Segment is situational Prescriber Segment Segment Identification (111-A) = Ø3 466-EZ PESCIBE ID QUALIFIE Ø1 Ø1=National Provider Identifier (NPI) 411-DB PESCIBE ID Effective 5/6/13 CS has indicated that only Type 1 Prescribe IDs are acceptable E PESCIBE LOCATION CODE NA DU/PPS Segment Questions Check This Segment is situational DU/PPS Segment Segment Identification (111-A) = Ø E DU/PPS CODE COUNTE aximum of 9 occurrences. equired if DU/PPS Segment is used. 439-E4 EASON FO SEVICE CODE equired when used for DU conflict resolution (drug/drug interactions or therapeutic duplication) 44Ø-E5 POFESSIONAL SEVICE CODE equired when used for DU conflict resolution Use value A when billing for edicare Part D Vaccine Administration Fee. 441-E6 ESULT OF SEVICE CODE equired when used for DU conflict resolution 474-8E DU/PPS LEVEL OF EFFOT Ø, equired when Compound Code (4Ø6-D6) = 2 Ø - Not Specified 11 - Level 1 (Lowest) 12 - Level Level Level Level 5 (Highest) Coupon Segment Questions Check This Segment is situational Coupon Segment Segment Identification (111-A) = Ø9 485-KE COUPON TYPE 486-E COUPON NUBE Compound Segment Questions Check This Segment is situational Compound Segment Segment Identification (111-A) = 1Ø - 9 -

10 45Ø-EF COPOUND DOSAGE FO DESCIPTION CODE 451-EG COPOUND DISPENSING UNIT FO INDICATO 447-EC COPOUND INGEDIENT COPONENT aximum 25 ingredients COUNT 488-E COPOUND PODUCT ID QUALIFIE Ø3-National Drug Code (NDC) 489-TE COPOUND PODUCT ID 448-ED COPOUND INGEDIENT QUANTITY ust be greater than zero. 449-EE COPOUND INGEDIENT DUG COST ust be greater than zero. 49Ø-UE COPOUND INGEDIENT BASIS OF COST DETEINATION Ø1 - AWP (Average Wholesale Price) Ø2 - Local Wholesaler Ø3 - Direct Ø4 - EAC (Estimated Acquisition Cost) Ø5 - Acquisition Ø6 - AC (aximum Allowable Cost) Ø7 - Usual & Customary Ø8-34ØB /Disproportionate Share Pricing/Public Health Service Ø9 - Other 1Ø - ASP (Average Sales Price) 11 - AP (Average anufacturer Price) 12 - WAC (Wholesale Acquisition Cost) 13 - Special Patient Pricing The cost calculated by the pharmacy for the drug for this special patient. Clinical Segment Questions Check This Segment is situational Clinical Segment Segment Identification (111-A) = VE DIAGNOSIS CODE COUNT 492-WE DIAGNOSIS CODE QUALIFIE 424-DO DIAGNOSIS CODE O 493-E CLINICAL INFOATION COUNTE O 494-ZE EASUEENT DATE O 495-H1 EASUEENT TIE O 496-H2 EASUEENT DIENSION O 497-H3 EASUEENT UNIT O 499-H4 EASUEENT VALUE O ** End of equest (B1) Payer Sheet **

11 1.2 ESPONSE CLAI BILLING EDICAE PAYE SHEET CLAI BILLING EDICAE ACCEPTED/PAID (O DUPLICATE OF PAID) ESPONSE ** Start of esponse (B1) Payer Sheet ** GENEAL INFOATION Payer Name: Aetna Date: July 2Ø12 Plan Name/Group Name: edicare Part D BIN: 61Ø5Ø2 PCN: EDDAET Plan Name/Group Name: edicare Advantage Part D BIN: 61Ø5Ø2 PCN: EDDAET Plan Name/Group Name: edicare Advantage Only (Part B Only) BIN: 61Ø5Ø2 PCN: PATBAET CLAI BILLING PAID (O DUPLICATE OF PAID) ESPONSE The following lists the segments and fields in a response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. esponse Transaction Header Segment Questions Check Accepted/Paid (or Duplicate of Paid) esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B1 1Ø9-A9 TANSACTION COUNT Same value as in request 5Ø1-F1 HEADE ESPONSE STATUS A = Accepted 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request 2Ø1-B1 SEVICE POVIDE ID Same value as in request 4Ø1-D1 DATE OF SEVICE Same value as in request Accepted/Paid (or Duplicate of Paid) esponse essage Segment Questions Check Accepted/Paid (or Duplicate of Paid) This Segment is situational If transmission level messaging applies. esponse essage Segment Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE O Accepted/Paid (or Duplicate of Paid) esponse Insurance Segment Questions Check Accepted/Paid (or Duplicate of Paid) This Segment is situational esponse Insurance Segment Segment Identification (111-A) = 25 Accepted/Paid (or Duplicate of Paid) 3Ø1-C1 GOUP ID 524-FO PLAN ID O Will send back if available

12 esponse Insurance Segment Segment Identification (111-A) = J7 PAYE ID QUALIFIE Ø3 Accepted/Paid (or Duplicate of Paid) Ø3 = Bank Identification Number (BIN) 569-J8 PAYE ID 61Ø5Ø2 3Ø2-C2 CADHOLDE ID O Will Send back the ID that is used in Adjudication, only if different than what was submitted on request. esponse Patient Segment Questions Check Accepted/Paid (or Duplicate of Paid) This Segment is situational When the submitted Patient First Name and/or Last Name are different than what is on the member record. esponse Patient Segment Segment Identification (111-A) = 29 31Ø-CA PATIENT FIST NAE 311-CB PATIENT LAST NAE 3Ø4-C4 DATE OF BITH Accepted/Paid (or Duplicate of Paid) esponse Status Segment Questions Check Accepted/Paid (or Duplicate of Paid) esponse Status Segment Segment Identification (111-A) = AN TANSACTION ESPONSE STATUS P=Paid D=Duplicate of Paid 5Ø3-F3 AUTHOIZATION NUBE Accepted/Paid (or Duplicate of Paid) 13Ø-UF ADDITIONAL ESSAGE INFOATION COUNT aximum count of 9. equired if Additional essage Information (526-FQ) is used. 132-UH ADDITIONAL ESSAGE INFOATION QUALIFIE equired if Additional essage Information (526-FQ) is used. 526-FQ ADDITIONAL ESSAGE INFOATION equired when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFOATION CONTINUITY equired if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526-FQ) follows it, and the text of the following message is a continuation of the current F HELP DESK PHONE NUBE Ø3 QUALIFIE 55Ø-8F HELP DESK PHONE NUBE 8ØØ

13 esponse Claim Segment Questions Check Accepted/Paid (or Duplicate of Paid) esponse Claim Segment Segment Identification (111-A) = E PESCIPTION/SEVICE EFEENCE NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE NUBE Accepted/Paid (or Duplicate of Paid) 1 = xbilling Imp Guide: For Transaction Code of B1, in the esponse Claim Segment, the Prescription/Service eference Number Qualifier (455-E) is 1 (x Billing). esponse Pricing Segment Questions Check Accepted/Paid (or Duplicate of Paid) esponse Pricing Segment Segment Identification (111-A) = 23 Accepted/Paid (or Duplicate of Paid) 5Ø5-F5 PATIENT PAY AOUNT 5Ø6-F6 INGEDIENT COST PAID 5Ø7-F7 DISPENSING FEE PAID 558-AW FLAT SALES TA AOUNT PAID equired if Flat Sales Tax Amount Submitted (481-HA) is greater than zero (Ø) or if Flat Sales Tax Amount Paid (558-AW) is used to arrive at the final reimbursement. 559-A PECENTAGE SALES TA AOUNT PAID equired if Percentage Sales Tax Amount Submitted (482-GE) is greater than zero (Ø). equired if Percentage Sales Tax ate Paid (56Ø-AY) and Percentage Sales Tax Basis Paid (561-AZ) are used. 56Ø-AY PECENTAGE SALES TA ATE PAID equired if Percentage Sales Tax Amount Paid (559-A) is greater than zero (Ø). 561-AZ PECENTAGE SALES TA BASIS PAID equired if Percentage Sales Tax Amount Paid (559-A) is greater than zero (Ø). 521-FL INCENTIVE AOUNT PAID equired if Incentive Amount Submitted (438-E3) is greater than zero (Ø). 563-J2 OTHE AOUNT PAID COUNT aximum count of 3. equired if Other Amount Paid (565-J4) is used. 564-J3 OTHE AOUNT PAID QUALIFIE equired if Other Amount Paid (565-J4) is used. 565-J4 OTHE AOUNT PAID equired if Other Amount Claimed Submitted (48Ø-H9) is greater than zero (Ø). 5Ø9-F9 TOTAL AOUNT PAID 522-F BASIS OF EIBUSEENT DETEINATION 512-FC ACCUULATED DEDUCTIBLE AOUNT eturned if known or if applicable. 513-FD EAINING DEDUCTIBLE AOUNT eturned if known or if applicable. 514-FE EAINING BENEFIT AOUNT eturned if known or if applicable. 517-FH AOUNT APPLIED TO PEIODIC eturned if known and impacts Patient Pay DEDUCTIBLE 518-FI AOUNT OF COPAY eturned if known and impacts Patient Pay

14 esponse Pricing Segment Segment Identification (111-A) = 23 Accepted/Paid (or Duplicate of Paid) 52Ø-FK AOUNT ECEEDING PEIODIC eturned if known and impacts Patient Pay. BENEFIT AIU 572-4U AOUNT OF COINSUANCE eturned if known and impacts Patient Pay. 392-U BENEFIT STAGE COUNT equired if Benefit Stage Amount (394-W) is used. 393-V BENEFIT STAGE QUALIFIE equired if Benefit Stage Amount (394-W) is used. 394-W BENEFIT STAGE AOUNT equired when financial amounts are applied to edicare Part D beneficiary benefit stages. 129-UD HEALTH PLAN-FUNDED ASSISTANCE AOUNT eturned if known and impacts Patient Pay. 134-UK 137-UP AOUNT ATTIBUTED TO PODUCT SELECTION/BAND DUG AOUNT ATTIBUTED TO COVEAGE GAP eturned if known and impacts Patient Pay. eturned if known and impacts Patient Pay. esponse DU/PPS Segment Questions Check Accepted/Paid (or Duplicate of Paid) This Segment is situational If DU information applies. esponse DU/PPS Segment Segment Identification (111-A) = J6 DU/PPS ESPONSE CODE COUNTE aximum 9 occurrences supported. Accepted/Paid (or Duplicate of Paid) equired if eason For Service Code (439-E4) is used. 439-E4 EASON FO SEVICE CODE equired if utilization conflict is detected. 528-FS CLINICAL SIGNIFICANCE CODE equired if needed to supply additional information for the utilization conflict. 529-FT OTHE PHAACY INDICATO equired if needed to supply additional information for the utilization conflict. 53Ø-FU PEVIOUS DATE OF FILL equired if needed to supply additional information for the utilization conflict. 531-FV QUANTITY OF PEVIOUS FILL equired if needed to supply additional information for the utilization conflict. 532-FW DATABASE INDICATO equired if needed to supply additional information for the utilization conflict. 533-F OTHE PESCIBE INDICATO equired if needed to supply additional information for the utilization conflict. 544-FY DU FEE TET ESSAGE equired if needed to supply additional information for the utilization conflict. 57Ø-NS DU ADDITIONAL TET equired if needed to supply additional information for the utilization conflict

15 1.2.2 CLAI BILLING EDICAE ACCEPTED/EJECTED ESPONSE CLAI BILLING EDICAE ACCEPTED/EJECTED ESPONSE esponse Transaction Header Segment Questions Check Accepted/ejected esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B1 1Ø9-A9 TANSACTION COUNT Same value as in request 5Ø1-F1 HEADE ESPONSE STATUS A = Accepted 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request 2Ø1-B1 SEVICE POVIDE ID Same value as in request 4Ø1-D1 DATE OF SEVICE Same value as in request Accepted/ejected esponse essage Segment Questions Check Accepted/ejected This Segment is situational If transmission level messaging applies. esponse essage Segment Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE O Accepted/ejected esponse Insurance Segment Questions Check Accepted/ejected This Segment is situational esponse Insurance Segment Accepted/ejected Segment Identification (111-A) = 25 3Ø1-C1 GOUP ID 524-FO PLAN ID O Will send back if available 568-J7 PAYE ID QUALIFIE Ø3 Ø3 = Bank Identification Number (BIN) 569-J8 PAYE ID 61Ø5Ø2 3Ø2-C2 CADHOLDE ID O Will Send back the ID that is used in Adjudication, only if different than what was submitted on request. esponse Patient Segment Questions Check Accepted/ejected This Segment is situational When the submitted Patient First Name and/or Last Name are different than is on the member record. esponse Patient Segment Segment Identification (111-A) = 29 31Ø-CA PATIENT FIST NAE Accepted/ejected 311-CB PATIENT LAST NAE 3Ø4-C4 DATE OF BITH

16 esponse Status Segment Questions Check Accepted/ejected esponse Status Segment Segment Identification (111-A) = AN TANSACTION ESPONSE STATUS = eject 5Ø3-F3 AUTHOIZATION NUBE 51Ø-FA EJECT COUNT aximum count of FB EJECT CODE 546-4F EJECT FIELD OCCUENCE INDICATO Accepted/ejected equired if a repeating field is in error, to identify repeating field occurrence. 13Ø-UF ADDITIONAL ESSAGE INFOATION COUNT aximum count of 9. equired if Additional essage Information (526-FQ) is used. 132-UH ADDITIONAL ESSAGE INFOATION QUALIFIE equired if Additional essage Information (526-FQ) is used. 526-FQ ADDITIONAL ESSAGE INFOATION equired when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFOATION CONTINUITY equired if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526-FQ) follows it, and the text of the following message is a continuation of the current F HELP DESK PHONE NUBE Ø3 QUALIFIE 55Ø-8F HELP DESK PHONE NUBE 8ØØ esponse Claim Segment Questions Check Accepted/ejected esponse Claim Segment Segment Identification (111-A) = E PESCIPTION/SEVICE EFEENCE 1 = xbilling NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE NUBE Accepted/ejected esponse DU/PPS Segment Questions Check Accepted/ejected This Segment is situational If DU information applies. esponse DU/PPS Segment Accepted/ejected Segment Identification (111-A) = J6 DU/PPS ESPONSE CODE COUNTE aximum 9 occurrences. Imp Guide: equired if eason For Service Code (439-E4) is used. 439-E4 EASON FO SEVICE CODE Imp Guide: equired if utilization conflict is detected

17 esponse DU/PPS Segment Accepted/ejected Segment Identification (111-A) = FS CLINICAL SIGNIFICANCE CODE equired if needed to supply additional information for the utilization conflict 529-FT OTHE PHAACY INDICATO equired if needed to supply additional information for the utilization conflict 53Ø-FU PEVIOUS DATE OF FILL equired if needed to supply additional information for the utilization conflict 531-FV QUANTITY OF PEVIOUS FILL equired if needed to supply additional information for the utilization conflict 532-FW DATABASE INDICATO equired if needed to supply additional information for the utilization conflict 533-F OTHE PESCIBE INDICATO equired if needed to supply additional information for the utilization conflict 544-FY DU FEE TET ESSAGE equired if needed to supply additional information for the utilization conflict 57Ø-NS DU ADDITIONAL TET equired if needed to supply additional information for the utilization conflict CLAI BILLING EDICAE EJECTED/EJECTED ESPONSE CLAI BILLING EDICAE EJECTED/EJECTED ESPONSE esponse Transaction Header Segment Questions Check ejected/ejected esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B1 1Ø9-A9 TANSACTION COUNT Same value as in request 5Ø1-F1 HEADE ESPONSE STATUS = ejected 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request 2Ø1-B1 SEVICE POVIDE ID Same value as in request 4Ø1-D1 DATE OF SEVICE Same value as in request ejected/ejected esponse essage Segment Questions Check ejected/ejected This Segment is situational If transmission level messaging applies. esponse essage Segment Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE O ejected/ejected esponse Status Segment Questions Check ejected/ejected esponse Status Segment Segment Identification (111-A) = AN TANSACTION ESPONSE STATUS = eject 5Ø3-F3 AUTHOIZATION NUBE 51Ø-FA EJECT COUNT aximum count of FB EJECT CODE 546-4F EJECT FIELD OCCUENCE INDICATO ejected/ejected Imp Guide: equired if a repeating field is in error, to identify repeating field occurrence

18 esponse Status Segment ejected/ejected Segment Identification (111-A) = 21 13Ø-UF ADDITIONAL ESSAGE INFOATION COUNT aximum count of 9. equired if Additional essage Information (526-FQ) is used 132-UH ADDITIONAL ESSAGE INFOATION QUALIFIE Imp Guide: equired if Additional essage Information (526-FQ) is used. 526-FQ ADDITIONAL ESSAGE INFOATION equired when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFOATION CONTINUITY equired if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526-FQ) follows it, and the text of the following message is a continuation of the current F HELP DESK PHONE NUBE Ø3 QUALIFIE 55Ø-8F HELP DESK PHONE NUBE 8ØØ ** End of esponse (B1) Payer Sheet **

19 2. FEQUENTLY ASKED QUESTIONS

20 3. APPENDI A. HISTOY OF IPLEENTATION GUIDE CHANGES 3.1 VESION 1.Ø July Initial Creation of Aetna NCPDP D.Ø (B1) edicare Payer Sheet. 3.2 VESION 2.Ø June odified ECL version to October 2011 from arch odified NCPDP Data Dictionary Version Date to October 2011 from arch VESION 3.Ø September odified 466-EZ PESCIBE ID QUALIFIE valid values to remove values: DEA (12), and State License (08). Note: Prescriber ID Qualifer field change is effective 1/1/2013. Added new value of 9 - Intermediate care facilities for the mentally retarded (ICF/) and Institutes for mental disease (ID) to PATIENT ESIDENCE. Updated 354-N SUBISSION CLAIFICATION CODE COUNT and 42Ø-DK SUBISSION CLAIFICATION CODE to be required when submitting for LTC Short Cycle Dispening or to override rejected claims due to a DU threshold being met. Added 429-DT SPECIAL PACKAGING INDICATO in the Claim Segment to be required when submitting for LTC Short Cycle Dispening. Added valid values to 42Ø-DK SUBISSION CLAIFICATION CODE and 429-DT SPECIAL PACKAGING INDICATO. Updated PATIENT ESIDENCE to be a required field and added valid values. Updated 147- U7 PHAACY SEVICE TYPE to be a required field. 3.4 VESION 4.Ø October Updated Patient esidence description of value 9 to state Intermediate care facilities for the mentally retarded (ICF/) and Institutes for mental disease (ID). Updated 42Ø-DK SUBISSION CLAIFICATION CODE to add "or when submitting a split billing claim from a LTC" Added value 19 Split Billing to 42Ø-DK SUBISSION CLAIFICATION CODE. 3.5 VESION 5.Ø April 2013 Updated 411-DB Prescriber ID to note Effective 5/6/13 CS has indicated that only Type 1 Prescribe IDs are acceptable