2013 Pharmacy Manual

Transcription

1 2013 Pharmacy anual Office: Plaza Drive, Rocklin, CA Fax: Office Fax [email protected]

2 Table of Contents Section 1 Section 2 Section 3 Section 4 Section 5 Section 6 Claim Submission Audit Product Selection Dispensing Limitations iscellaneous D.0 Implementation

3 Pharmacy anual This American Health Care Provider anual is designed to answer your questions regarding online claim submission for American Health Care. The Provider anual is an extension of the Participating Provider Agreement and is incorporated into the Participating Provider Agreement with American Health Care. The provider must adhere to the provisions and terms set forth in the Participating Provider Agreement. If you need additional information, please contact the applicable Provider Help Desk. American Health Care (Catamaran) PROVIDER HELP DESK For claims and online transaction response please call our Help Desk, representatives are available to assist onday through Friday from 5:00 A to 9:00 P PST and Saturday 8:30 A to 5:00 P PST: American Health Care ember Services It is important to always refer to the Provider Web Portal at Health Care.com/providers for the most up to date documents, manuals payer sheet and other important communications. General Questions can be referred to American Health Care, 3850 Atherton Road, Rocklin Ca, American Health Care (Catamaran) IDENTIFICATION CARDS/BANK IDENTIFICATION NUBERS (RxBINs):

4 Section 1 Claim Submission Provider Obligations All claims must be submitted online within 30 days of the date the prescription was filled. The following elements from the member identification card must be submitted for successful claims adjudication. ember identification number Person code (when printed on card) RxGRP (when printed on card) BIN/Processor Control Number Software All claims must be submitted using NCPDP Telecommunication Standard Version D.0, later version, or other standard as dictated by applicable governing or industry setting organizations as designated by American Health Care. Reversals Claims can be reversed up to 30 days after the submission date (or as specified by plan), but should be reversed within 14 days or as soon as reasonably practical or as specified by certain governing requirement to assure prescriptions with inaccurate information or those not dispensed to members are credited in a timely fashion. Compounds All American Health plans require multiple-ingredient compound claims submission. Please use the following guidelines when submitting compounds: One of the ingredients must be a legend drug product. Compound indicator field must indicate that the claim is for a compounded prescription.

5 Appropriate fields in the compound segment (see payer sheet for additional information) must be completed. In the event that a single product id is submitted please use the following guidelines when submitting compounds: One of the ingredients must be a legend drug product. Compound indicator field must indicate that the claim is for a compounded prescription. Product ID and total metric quantity of the most expensive legend prescription drug, and the total ingredient cost of all ingredients combined must be entered in the claim segment. Reimbursement is the lower of submitted cost, usual and customary price, or AWP. Other reimbursement pricing methods may be used. Submission of compounds with this method are subject to increased audit and may incur additional costs Note: Reconstituted preparations, such as powdered antibiotics that are mixed with water prior to dispensing are not considered compounded prescriptions. Tax Tax is calculated based on the applicable state or local law governing tax on prescription drugs. In order to be reimbursed for payment of tax, the Provider must enter the tax amount in the appropriate tax field. Claim System The electronic claim processing system is generally available 24 hours per day, 7 days per week, with the exception of regularly scheduled downtime, which generally occurs at non-peak hours in order to minimize the impact to our network providers. The transaction fee incurred by the Provider is up to twenty-five cents per on-line transaction. The transaction fee is assessed to support network Provider payment and reconciliation, help desk support, as well as but not limited to Provider network compliance, transactional, and billing education. However, excessive or disruptive process inquiries, including but not limited to non- contracted provider status, duplicate payment and

6 remittance requests, excessive member/provider grievances, third party biller intervention, incomplete or inaccurate credentialing submissions, contract compliance and/or failure of the Provider to submit claims through the American Health Care designated adjudication on-line adjudication process are subject to higher transaction fees, up to five dollars per transaction. Should a claim be submitted by a third party or other means separate from the provider itself, the claim may be subject to non-payment. American Health Care American reserves the right to make payment directly to Provider at its sole discretion.

7 Section 2 Audit I. Provider Audit American Health Care or its authorized agent or representatives reserves the right to audit a Provider s compliance with the agreements in effect. American Health Care has the right to inspect all records of the Provider relating to this agreement. The Provider shall maintain, adequate prescription records, and financial records relating to the provision of pharmaceutical services to our customers, including but not limited to: Provider books/databases, daily prescription logs, patient profiles, prescription hardcopy s, prescriber information, signature/delivery logs, refill information, wholesalermanufacturer- distributor and all other purchase invoices and documentation for all pharmaceutical services provided. This includes all policies and procedures related to maintenance of such records. Provider shall maintain and retain such records for a minimum of (10) ten years or as required by law. American Health Care Auditors shall have the right to audit any Provider submitting claims for payment during normal business hours and upon reasonable notice (usually 14 days) for any aspect of performance under their agreement by reviewing records and documents relating to such performance. Documents must be readily accessible. The Provider shall cooperate with American Health Care Auditors, and promptly provide access to all information or documents deemed necessary by the American Health Care Auditors. American Health Care at its sole expense may reproduce any record; however, no original copy may be removed from the Provider. A failure to cooperate with the aforementioned shall constitute a material breach of your American Health Care Agreement. In the event of a conflict between the Provider anual and the Agreement, the Provider anual prevails. American Health Care may report audit findings to its Clients, appropriate governmental entities, regulatory agencies, and professional review and audit organizations.

8 American Health Care does provide the opportunity to appeal the results of an audit based on state audit guidelines or mandates. However, be aware that the appeal process is not a vehicle for submission of new materials for inclusion in the audit review but is designed to provide a re-determination of previously submitted post audit documentation. II. Types of Audits American Health Care routinely monitors online claims data and conducts audits on a continuous basis. American Health Care Auditors conduct industry standard desktop audits and on-site audits, scheduled during normal business hours with prior written notice, and audits of an investigational nature. In order to conduct these audits, providers may be contacted by telephone, mail, fax, and or and are required to provide such records by the due date in a manner mutually agreeable by the parties, while at all times ensuring safe transmission of sensitive documentation. Onsite Auditors require a clutter free work area which is located away from the busiest area of the Pharmacy department with easy access to the required documents outlined in the audit notice; we attempt to minimize any disruption of the business processes while on-site. Please note; it is also helpful to have an assistant present to answer general questions, retrieve information required and facilitate an effective on-site audit. The Provider shall receive a post audit report, which allows for a 30 calendar day period to contest any findings identified. At the completion of the audit the Provider shall also receive a final audit report with the claims identified as discrepant and due for recovery. All documentation must be received no later than 30 calendar days from the date of the discrepancy report. Beyond that date, the audit shall be considered final. If an American Health Care Auditor is denied access to the Provider or is not provided access to the required requested audit documents, 100% of the amount paid for that claim(s) become due immediately.american Health Care may offset this said amount against any future payments due to the Provider and impose certain fines or penalties. III. Document Requirements All prescription documentation, regardless of the way it has been created, generated or transmitted shall contain the following:

9 Full name of the member for whom the prescription was written, and the address of the member along with a date of birth. Full name and address, telephone number and any other required identifiers of the prescriber. Name, strength and quantity of the medication prescribed. Specific dosing directions, if a prescription contains ambiguous directions the Provider must clarify these directions and notate the conversation to clarify. Substitution instructions where applicable, or substitution requested by member clearly notated. Refill instructions. iscellaneous or other informational notations as required by applicable laws or regulations. Compounded medications require a detailed compound worksheet; a valid prescription which also details the specific ingredients to be included in the compounded product. It is important to document the products, NDC s, quantity used, costs associated and procedures. Provider must utilize a signature/delivery log that contains all the information required by American Health Care. This should include; date of pick up, the prescription number, third party name, and the authorization to release information to a third party program. Provider must obtain a legible written signature that corresponds to a matched printed name or another authorized person to confirm receipt of the prescription product. If any state or federal laws require additional verification of the person picking up the medication, please include this notation on the signature log documents. Proper verification of the person picking up the prescription is essential to ensure the deterrence of potential fraud, waste and abuse. These prescription signature logs must be in date order and readily accessible for a minimum of three years or longer as required by law. Wholesaler, manufacturer and distributor invoices and other purchase invoices and documents must also be maintained for a minimum of three years or as required by law or regulation to substantiate that the drugs dispensed were purchased from an authorized source. The Provider must promptly comply with any requests to produce such documentation. If the Provider fails to promptly provide such requested documents,

10 American Health Care may offset 100% of the amount for any of the paid claims in question and impose additional fines or penalties. IV. Audit Processes In order to facilitate appropriate claim submission and to protect against fraud, waste, and abuse, American Health Care conducts Provider audits on a routine basis according to CS and American Health Care guidelines. American Health Care s Provider audit team works with our designated audit vendor to conduct desktop and on-site audits. Providers are identified for the desktop and on-site audit process based upon internal analysis. Please use the following information to help avoid problems and prepare for an audit. Day Supply Pharmacists are responsible for entering the correct day s supply of medication for all submissions. The results of an audit can include chargeable discrepancies for days supply error submission: The days supply for 25 doses of a medication, taken 25 per month, is 30 days. The days supply for 4 patches, 1 patch applied once weekly, is 28 days. If the prescribing provider indicates, "As directed," the Provider determines the dosing schedule in order to submit the correct days supply on the claim. Talk with the member/customer or call the prescriber to determine the appropriate amount to dispense. Claim reimbursement is based on quantity dispensed. It is important to remember that in order to provide appropriate pharmaceutical consultation, the Provider must be sure the member understands how much and how often the medication is to be taken. Insulin and Diabetic Supplies Use only the actual Product IDs (i.e. NDC numbers) of insulin and the supplies dispensed. Some patients require two types of insulin (i.e., long or short-acting). Often both medications appear on the same prescription. Since each drug has a unique NDC number, separate the prescription into two claims, submit the two products properly and

11 collect the appropriate copays. Diabetic supplies should be calculated properly and submitted according to the prescribers request and validated with the patient. Directions notated as needed or as directed require a documented interaction with the prescriber or patient on the prescription. Inhalers and Inhalation Products When submitting a claim, enter the quantity to be dispensed exactly as written by the prescriber on the prescription form. Dispensing limitations vary widely among plans. Depending on the patient s medical condition, it may be necessary to dispense more than one inhaler. If plan design allows and the prescriber writes accordingly, the patient may obtain more than one inhaler per prescription (Example: Proventil Inh -17g contains 200 puffs per canister; when used two puffs Q4H, one canister should last 17 days).

12 Section 3 Product Selection (aka Dispense as Written) American Health Care supports the NCPDP standard Product Selection Codes (PSC s). Accurate reimbursement is tied to proper PSC submission; the Provider must always specify the correct PSC when submitting a claim. American Health Care supports the NCPDP standard Product Selection Codes (PSC s). Accurate reimbursement is tied to proper PSC submission; the Provider must always specify the correct PSC when submitting a claim. Product Selection Codes (PSC): PSC 0 - NO DISPENSE AS WRITTEN (Substitution Allowed) (or no product selection indicated) Use the PSC 0 code when dispensing a generic drug; that is, when no party (i.e., neither prescriber, nor pharmacist, nor member) requests the branded version of a multi-source product. Use the PSC 0 code when dispensing a multi-source generic, even if the prescriber indicates the PSC code for the generic product and does not specify a manufacturer. PSC 1 PRESCRIBER writes DISPENSE AS WRITTEN Use when the Prescriber specifies the branded version of a drug on the hard copy prescription or in the orally communicated instructions. PSC 2 - EBER REQUESTED Valid Person Codes 001= Cardholder 002= Spouse 003, 004, etc. = Child (according to birth code)

13 PSC 3 - PHARACIST SELECTED BRAND PSC 4 - GENERIC NOT IN STOCK PSC 5 - BRAND DISPENSED, PRICED AS GENERIC Use when dispensing a brand as a generic. Claims submitted with PSC 5 are reimbursed at the generic price. PSC 6 OVERRIDE PSC 7 - SUBSTITUTION NOT ALLOWED; BRAND ANDATED BY LAW Do not use for NTI drugs, please use the correct codes 0, 1, or 2 and communicate with the prescriber. PSC 8 - GENERIC NOT AVAILABLE PSC 9 OTHER Some members have a choice between brand and generic drugs. However, in some programs, the member pays the difference between the cost of the brand and the available generic drug. Prescription Hard Copies A hard copy of each prescription must be readily retrievable upon request. Prescriptions for insulin and/or syringes must contain complete documentation of items and quantities dispensed along with directions for use. Prescription hard copies must be updated yearly unless state pharmacy law in which Provider is located specifically allows a prescription to be refilled after more than one year has passed. A prescription hard copy must be maintained for every prescription for ten years or longer as required by law. The hard copy (original and any updates) of the prescription, including telephone prescriptions, must contain data elements required by state pharmacy laws in which Provider is located and all of the prescriber instructions including Product Selection Code instructions that support the Provider s claim transmission.

14 Prescriptions in which the dosage/quantity is changed require either written documentation on the prescription or a new hard copy prescription to be issued. In cases of the prescriber writing As Directed, documentation as to the exact directions or, at a minimum, the maximum ( up to ) dose of medication taken per day must be documented on the hard copy or electronically and be viewable upon request. If undocumented at the time of the audit, the entire claim is marked as discrepant until proper documentation is provided. Only prescriptions generated by the prescriber are accepted as post audit documentation for as directed prescriptions. If less or more medication (if permitted) is given than ordered by the prescriber, the reason for this must be documented. Any increase in the amount of medication over the original prescribing order must be documented for prescriber authorization. Signature Log Provider shall require the signature of the member or the member s representative on a permanent record before dispensing any prescription. At each Provider location, Provider shall maintain a hard copy or (pre-approved by American Health Care) electronic signature log which contains the following: the prescription number; the date the medication is received by the member; and the signature of each member who receives a medication or the signature of his/her designee. A log in date order must be maintained for all claims submitted on-line to American Health Care. Signature logs must be maintained for ten years or longer corresponding to the state. Pharmacy laws in which Provider is located for retaining prescription hard copies. The logs must be available for inspection and audit by a representative of American Health Care and/or its designated agent.

15 Section 4 Dispensing Limitations Enter the quantity to be dispensed exactly as written on the prescription form. A 30-day supply is no longer standard; some programs permit extended days supplies. Always transmit the accurate days supply and allow the on-line system to communicate the allowable days supply. Note subsequent changes or refill authorizations approved by the prescriber on the hard copy, or in a readily retrievable electronic format, acceptable by the State Board of Pharmacy in which Provider is located. U&C Usual and Customary Charge means the usual and customary price charged by the Provider to the general public at the time of dispensing, including any advertised or sale prices, discounts, coupons or other deductions. PSC Submissions Incorrect PSC codes are the most common cause of Provider charge backs and may lead to removal from the network. When an auditor cites a prescription for a missing or incorrect PSC code, follow-up documentation is not permitted. A transmitted PSC 1 code must be supported on the prescription hard copy (original and update). No PSC 1 code defaults should be set; this leads to removal from the network. A PSC 2 code should be transmitted when the member requests that the prescriber be contacted to obtain approval for a brand drug when the prescriber did not initially mandate dispense as written. Avoid use of PSC 7 for NTI drugs, please use the correct codes 0, 1, or 2 and communicate with the prescriber.

16 iscellaneous Claims are adjudicated based on data provided to American Health Care. If a claim is adjudicated based on incorrectly submitted data, an adjustment may be necessary. To prevent audit charge backs on compounded or other prescriptions, the Provider must ensure its systems are not programmed to place an amount in the ingredient cost field that is equal to the AWP of the most expensive NDC multiplied by the final product quantity. Transmit the data as listed on the prescription and as ordered by the prescriber. Proper submission of days supply, quantity (obtain and document "as directed" instructions), NDC number, eligibility information, etc. Transmit PSC 1 code only when initially authorized by the prescriber; the prescription hard copy (including hard copies documenting phoned-in prescriptions) must support a PSC 1 code. Obtain a signature on the signature log. Pharmacists should monitor the will-call bin and process unclaimed prescriptions on a timely basis but no less than twice monthly. Reversals of prescriptions affect the member s deductible and copayment. Transmit proper member information, including relationship code, sex and proper prescriber identification number. Provider must charge the member the patient pay amount indicated in the on-line response. Remember to change the compound indicator if the Provider is filling a compounded drug product. Provider should follow all audit guidelines as notated on the communications to the Provider via telephone, letter or electronic requests. American Health Care may deny payment for unsupported claims or missing signatures. American Health Care may satisfy an unpaid audit liability by any of the following methods which may include but are not limited to: request for a check, offset against future claims payment and use of a collection agency. American Health Care has the right to assess reasonable fines, penalties and fees to cover unexpected costs. These actions may include the imposition of fines or penalties due to repeated audits, termination from the network, corrective action plans.

17 Summary of Audit Discrepancies Discrepancy Type Recovery Amount Documentation Allowed Y/N) issing Prescription Full Recovery Yes Unauthorized Refill Full Recovery No Quantity/Day Supply Discrepancy Partial Recovery No issing Signature from Signature Log Full Recovery Yes iss Fill Discrepancy Up to Full Recovery No Invalid Prescription Full Recovery No PSC Discrepancy Partial Recovery No Other/iscellaneous Up to Full Recovery Situational Fraud, Waste and Abuse American Health Care does not knowingly allow fraudulent activity of any kind by any of its contracted providers, associates, members, vendors, contractors and/or other business entities, and investigates and reports any such known activity to the appropriate regulatory, federal and state agencies for further action and investigation. The Provider can always report any suspected fraud, waste or abuse by calling the American Health Care Ethics and Compliance Hotline, toll-free number at available any time, 24 hours a day 7 days a week. Filling less than the prescribed quantity of a drug Billing for brand-name drugs when generic drugs are dispensed Billing multiple payers for the same prescriptions Dispensing expired or adulterated prescription drugs

18 Forging or altering prescriptions Refilling prescriptions erroneously Compliance/Fraud, Waste and Abuse (FWA) training is an important component of Provider operations and is required to be completed annually and upon intimal hire for all local, state and federally funded pharmacy benefit programs. To assist Providers with this training American Health Care has posted various materials on our website or Health Care.com Preferred Drug List AHC has established a list of pharmaceutical products which may be dispensed by the precipitating pharmacies to enrollees in accordance with the instructions found in this manual. This list is subject to periodic review and modification by AHC. Change Notification ember Pharmacy must immediately notify AHC in writing of any change in the information provided in the provider agreement, the pharmacy network participation acceptance form, or any information or documentation provided to AHC in connection with any credentialing or quality assurance initiatives. Any Changes in such documentation must be reported to: American Health Care 3850 Atherton Road Rocklin, CA 95675

19 aterials Reproduced With the Consent of National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP IPLEENTATION GUIDE FOR VERSION D.Ø 1. GENERAL INFORATION FOR A PAYER ABOUT THE TEPLATES COPYRIGHT INFORATION EXTERNAL CODE LIST GENERAL INSTRUCTIONS TO PAYERS HOW TO USE THIS DOCUENT TRANSISSIONS PLAN DIFFERENTIATION SEGENTS andatory Segments Situational Segments Optional Segments FIELDS OR VALUES Situations on Fields Counts and Counters Zero (0) and an O SPECIFIC TOPIC DISCUSSION Partial Fill Transaction Processing Coordination of benefits (COB) Processing Compounds Vaccine Administration 32

20 2.7 FIELD LEGEND ANDATORY FILED SITUATIONAL FIELDS - REQUIRED SITUATIONAL FEILEDS QUALIFIED REQUIREENT INFORATIONAL ONLY FIELDS OPTIONAL FIELDS NOT USED FIELDS NCPDP VERSION D CLAI BILLING/CLAI REBILL INSTRUCTIONS GENERAL INFORATION REQUEST TEPLATE INFORATION RESPONSE TEPLATE INFORATION CERTIFICATION AND/OR TEST DATA NCPDP VERSION D CLAI BILLING/CLAI REBILL TEPLATE REQUEST CLAI BILLING/CLAI REBILL PAYER SHEET TEPLATE RESPONSE CLAI BILLING/CLAI REBILL PAYER SHEET TEPLATE Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response Claim Billing/Claim Rebill Accepted/Rejected Response Claim Billing/Claim Rebill Rejected /Rejected Response NCPDP VERSION D CLAI REVERSAL INSTRUCTIONS GENERAL INFORATION REQUEST TEPLATE INFORATION RESPONSE TEPLATE INFORATION NCPDP VERSION D CLAI REVERSAL TEPLATE REQUEST CLAI REVERSAL PAYER SHEET TEPLATE 184

21 6.2 RESPONSE CLAI REVERSAL PAYER SHEET TEPLATE Claim Reversal Accepted/Approved Response Claim Reversal Accepted/Rejected Response Claim Reversal Rejected/Rejected Response EXAPLES OF PAYER TEPLATES EXAPLE 1 HEALTH PLAN OF AERICA PAYER SHEET Claim Billing/Claim Rebill CLAI BILLING/CLAI REBILL REQUEST CLAI BILLING/CLAI REBILL ACCEPTED/PAID (OR DUPLICATE OF PAID) RESPONSE CLAI BILLING/CLAI REBILL ACCEPTED/REJECTED RESPONSE CLAI BILLING/CLAI REBILL REJECTED/REJECTED RESPONSE Claim Reversal CLAI REVERSAL REQUESTED CLAI REVERSAL ACCEPTED/APPROVED RESPONSE CLAI REVERSAL ACCEPTED/REJECTED RESPONSE CLAI REVERSAL REJECTED/REJECTED RESPONSE EXAPLE 2 HEALTH SERVICE OF AERICA PAYER SHEET - SERVICE Service Billing/Service Rebill SERVICE BILLING/SERVICE REBILL REQUEST SERVICE BILLING/SERVICE REBILL ACCEPTED/PAID (OR DUPLICATE OF PAID) RESPONSE SERVICE BILLING/SERVICE REBILL ACCEPTED/REJECTED RESPONSE SERVICE BILLING/SERVICE REBILL REJECTED/REJECTED RESPONSE EXAPLE 3 ABC, INC. PAYER SHEET TWO PLANS 215

22 Workers Compensation Claim Billing WORKERS COPENSATION CLAI BILLING ACCEPTED/PAID (OR DUPLICATE OF PAID) RESPONSE 215 WORKERS COPENSATION CLAI BILLING ACCEPTED/REJECTED RESPONSE 215 WORKERS COPENSATION CALI BILLING REJECTED/REJECTED RESPONSE Workers Compensation Claim Reversal WORKERS COPENSATION CLAI REVERSAL REQUEST WORKERS COPENSATION CLAI REVERSAL ACCEPTED/APPROVED RESPONSE 216 WORKERS COPENSATION CLAI REVERSAL ACCEPTED/REJECTED RESPONSE 216 WORKERS COPENSATION CLAI REVERSAL REJECTED/REJECTED RESPONSE Non-Workers Compensation Claim NON-WORKERS COPENSATION CLAI REQUEST NON-WORKERS COPENSATION CLAI BILLING ACCEPTED/PAID (OR DUPLICATE OF PAID) RESPONSE 234 NON-WORKERS COPENSATION CLAI BILLING ACCEPTED/REJECTED RESPONSE 254 NON-WORKERS COPENSATION CLAI BILLING REJECTED/REJECTED RESPONSE Non-Workers Compensation Claim Reversal NON-WORKERS COPENSATION CLAI REVERSAL REQUEST NON-WORKERS COPENSATION CLAI REVERSAL ACCEPTED/APPROVED RESPONSE 280 NON-WORKERS COPENSATION CLAI REVERSAL ACCEPTED/REJECTED RESPONSE 286

23 NON-WORKERS COPENSATION CLAI REVERSAL REJECTED/REJECTED RESPONSE 291 EXAPLE 4 AERICAN PROCESSOR INC PAYER SHEET ULTIPLE PLANS Claim Billing/Claim Rebill CLAI BILLING/CLAI REBILL REQUEST FREQUENTLY ASKED QUESTIONS USE OF RED FONT FONT SIZE APPENDIX A. HISTORY OF IPLETENTATION GUIDE CHANGES EDITORIAL CORRECTIONS VERSION 1.1 CORRECTIONS VERSION VERSION

24 GENERAL INFORATION FOR A PAYER ABOUT THE TEPLATES This document is to be used as a reference in filling out and creating a Payer Sheet based on NCPDP Telecommunication Standard Implementation Guide Version D.Ø and above. The Payer Sheet must contain request and response information. Payers must read the instructional sections before filling out the templates. Payers may take the request template section and response template section, fill out the template per their usage, and send to their trading partners. Payer Sheets may be used in addition to provider manuals, or included in provider manuals. Payers must indicate any fields (if applicable) to be used in transaction processing, in accordance with the rules established in the NCPDP documents. Refer 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. For initial development considerations, refer also to the NCPDP SNIP Liaison Special Committee recommendations regarding suggestions for initial implementation and testing ( In this document, the following templates have been created: Claim Billing/Claim Rebill o Request o Responses (Paid and Rejected) Claim Reversal o Request o Responses (Approved and Rejected) Payers should fill out a template for each request and response transaction supported. If other transactions are supported (Service Billing request, responses, Service Reversal request, responses, Prior Authorization Inquiry request, responses, etc) payer templates should be created following the guidelines in this document. Payers are reminded to fill out template for each response type supported, including the Rejected transmission, Rejected transaction response.

25 If the payer does not support the Claim Rebill (B3) transaction, the Claim Rebill verbiage should be removed from the payer s template. The Examples sections show how segments and fields on payer sheets might be filled out. Transmissions Refer to the NCPDP Telecommunication Standard Implementation Guide Version D.Ø for the structure and syntax of the transaction(s) within the transmission. In the template, the (112-A) fields are not shown. Segment, Group, and Field Separators are not shown as they are part of the syntax. These fields are not shown because they are part of the underlying structure of the transaction and are covered in the guide. This template is to show the business and plan requirements. Plan Differentiation If the payer does not have different plans, this section can be skipped. If the payer supports multiple plans or has different BINs and/or PCNs that cause different segments to be used multiple payer templates must be created for each unique combination. For example ixing plans that are Primary only (i.e., Coordination Of Benefits/Other Payments Segment not used) with plans that are supplemental (i.e., COB Segment used) ixing plans where one or more use the Workers Compensation Segment while others do not ixing plans where one or more use the Coupon Segment while others do not Because a payer sheet may be created that represents the superset of requirements for multiple plans, the pharmacy will submit based on this superset. An individual plan(s) benefit under this superset may not require all of the fields in the superset In this

26 instance the plan will ignore the fields that do not apply to the particular transaction being submitted. For example One plan or more uses Patient Gender Code while others covered in the same template do not Scenario Examples BIN PCN Different Payer Templates Required? Comment The payer supports one BIN with multiple PCNs where some plans are Primary only and others are supplemental PCN = XYZ (Primary only) PCN = BBC (Supplemental) PCN = GAR (Supplemental) Yes Since one of the plans is Primary only, it needs a separate payer sheet. The payer supports one BIN with multiple PCNs. Each PCN supports the same method of coordination of benefit processing PCN = XYZ PCN = BBC PCN = GAR No Since all plans under this BIN have the same segments the same Payer Template can be used. (See section Specific Topic Discussion) The payer supports Workers Compensation claims and non- Workers Compensation claims under the same BIN. 61ØØ41 PCN = WRK for Workers Compensation claims PCN = ABC for non-workers Compensation claims. Yes Two Payer Templates must be used because different segments are used (Workers Compensation claims will use the Workers Compensation Segment; non-workers Compensation claims do not use the Workers Compensation Segment)

27 Scenario Examples BIN PCN Different Payer Templates Required? Comment The payer supports coupons claims and non-coupon claims under the same BIN. The payer supports claim and service billings under the same BIN. The payer supports a plan that may be primary or supplemental Has no impact Yes Two Payer Templates must be used because different segments are used (Coupon transactions will use the Coupon Segment non-coupon transactions do not use the Coupon Segment) Has no impact Yes Two Payer Templates must be used to avoid confusion in segments used for claim billing versus service billing Has no impact No One Payer Template should be used since all segments usage are the same, with the exception of the Coordination of Benefits/Other Payments Segment which will designate the usage of the supplemental rules. The processor supports plans that require their own BINs Has no impact No Since all plans for this processor have the same segments the same Payer Template can be used. (See section Specific Topic Discussion) Segments Each segment is listed as mandatory, situational, or optional for a given transaction in the NCPDP Telecommunication Standard Implementation Guide. If the segment is mandatory for a given transaction, that segment must be sent. If the segment is situational, the situations outlined

28 in the guide must be followed for use. If the segment is optional, please refer to the NCPDP Telecommunication Standard Implementation Guide Version D.Ø for more information on optional usage andatory Segments Segments which are designed mandatory in the NCPDP Telecommunication Standard Implementation Guide must be included on the Payer Sheet. In the mandatory segments, the Payer must fill in the values to be used in the mandatory or situational fields as defined in the NCPDP Telecommunication Standard Implementation Guide. On the template, each mandatory segment contains an initial question about the use of the segment (This Segment is always sent), with an X in the Check column. The Check X is in black and must not be modified by the Payer. An example: Situational Segments On the template, each situational segment contains two initial questions about the use of the segment (This Segment is always sent) and (This Segment is situational). The Payer must answer either of the initial questions with a check. If the Segment is situational, a situation for when the Segment is used must be described. An example The payer must: 1. If this situational segment is Not Used by the Payer, the segment and charts must not be shown (the initial question chart and the segment with fields chart should be deleted). 2. If this situational segment is used by the Payer, a. Either the question This Segment is always sent or This Segment is situation must contain a Check X on the template for each situational segment. This tells the reader how the segment is supported in this transaction. i. If This Segment is always sent is checked 1. The segment is used in every transaction associated with this template. 2. In the field charts, the Payer must list the fields supported and all situations applicable. 3. In the field charts, the Payer must exclude Not Used fields. ii. If This Segment is always situational is checked 1. The segment is used in some of the business cases of this transaction. 2. The Payer should provide guidance when this segment is used in the If Situational, column.

29 3. In the field charts, the Payer must list the fields supported and all situations applicable. If column is not applicable, it will be shaded (for example, If Situational, cell above for the question This Segment is always sent ). Optional Segments The NCPDP Telecommunication Standard Implementation Guide Version D.Ø allows segments defined as optional in the Controlled Substance Reporting transactions only. Use the methodology shown below for optional segments. On the template, the optional segment contains two initial questions about the use of the segment (This Segment is always sent) and (This Segment is optional). The Payer must answer either of the initial questions with a check. If the Segment is optional, a situation for when the Segment is used must be described. An example: Situations on Fields The Payer template has been pre-filled in the column with the field-level situations from the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. These pre-filled situations begin with the tag Imp Guide: If the payer wishes to further define the situation and explain their usage, situations can be added to the tag Payer Requirement: If the NCPDP Telecommunication Standard Implementation Guide Version D.Ø situation satisfies the payer s instructions, the statement can be entered Payer Requirement. Field # NCPDP Field Name Value Payer 414- DE DATE PRESCRIPTION TTEN R 354- NX SUBISSION CLARIFICATION CODE COUNT aximum count of 3. RW Imp Guide: Required if Submission Clarification Code (42Ø-DK) is used. Payer Requirement: Same as Imp Guide.

30 It is very important that the NCPDP Telecommunication Standard Implementation Guide Version D.Ø and above be consulted for full information on field usage. The following is an example of a pre-filled situation for a field. The tag Imp Guide: contains the field-level situation from the Imp Guide (Imp Guide: Required when the patient has a first name.). The tag Payer Requirement: contains further guidance of the situation(s) from the payer (Payer Requirement: Required as all patients are enrolled with a first name. If newborn, use BABY BOY or BABY GIRL. If person has only one name, put one name in this field.). Field # NCPDP Field Name Value Payer 31Ø- PATIEN RST E RW Imp Guide: Required when the patient has a first name. Payer Requirement: Required as all patients are enrolled with a first name. If newborn, use BABY BOY or BABY GIRL. If person has only one name, put one name in this field. Counts and Counters Each count and counter field has a maximum number of occurrences allowed in the NCPDP Telecommunication Standard Implementation Guide. If the payer supports less than the maximum number of occurrences, this must be explained for the appropriate field in the Payer Situation column of the template. 458-SE PROCEDURE ODIFIER CODE COUNT aximum count of 1Ø. Imp Guide: Required if Procedure odifier Code (459-ER) is used.

31 Payer Requirement: Zero (Ø) and an O When denoting a field or a value, the slashed zero (Ø) should be used to clearly differentiate between a zero (Ø) and an O. This is not a requirement, but is highly recommended for clarity. Specific Topic Discussion Partial Fill Transaction Processing If Partial Fill logic is supported electronically, Payer supports partial fills should be checked. If not supported, Payer does not support partial fills should be checked. (See Claim Segment in section Request Claim Billing/Claim Rebill Payer Sheet Template) If Partial Fill logic is not supported electronically, please explain the providers procedure for handling partial fill claims. Refer to section Specific Segment Discussion, Request Segments, Claim Segment, Partial Fill of the NCPDP Telecommunication Implementation Guide Version D.Ø. Coordination of Benefits (COB) Processing If the Coordination of Benefits Segment is used, indicate if you will be requiring providers to report: 1. Scenario 1 - Other Payer Amount Paid Repetitions Only or 2. Scenario 2 - Other Payer-Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only or 3. Scenario 3 - Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs). (Note: For additional information on the scenarios, see Coordination Of Benefits/Other Payments Segment, in section Request Claim Billing/Claim Rebill Payer Sheet Template) Only one scenario method may be supported per template. The template shows the Coordination of Benefits/Other Payments Segment that must be used for each scenario method. The Payer must choose the appropriate scenario method with the segment chart, and delete the other scenario methods with their segment charts.

32 For Coordination of Benefits (COB) the following considerations and information should be provided in the payer sheets: 1. This Segment is always sent must be checked if the payer is always a secondary or supplemental plan. This Segment is situational must be checked if the payer is sometimes a secondary or supplemental plan. 2. The Billing/Reversal windows should be stated since COB billing occurs among different payers. 3. If there is a different Help Desk phone number related to COB inquiries, it should be given. If additional information is needed, see section Specific Segment Discussion, Request Segments, Coordination of Benefits/Other Payments Segment and section Standard Conventions, Repetition and ultiple Occurrences, Repeating Data Elements, Request Segments, Coordination of Benefits/Other Payments Segment of the NCPDP Telecommunication Standard Implementation Guide Version D.Ø for information important to processing coordination of benefits. Compounds In the NCPDP Telecommunication Standard Implementation Guide Version D.Ø there is only one way for the pharmacy to submit and the processor to adjudicate compound claims. Use the Compound Segment for multi-ingredient prescriptions The other options allowed in previous implementation guides which are no longer supported by the Standard Determine and submit the most expensive legend drug s NDC with the quantity of the dispensed product The use of billing codes or dummy NDC values Vaccine Administration For vaccine administration, edicare Part D should be handled the same way in version 5.1 and D.0. For all other payers - If the vaccine administration fee is part of the drug benefit cost, the edicare Part D-based Claim Billing method can be used. Information is found in the

33 Telecommunication Version 5 Questions, Answers and Editorial Updates document ( If the vaccine administration fee is not part of the drug benefit cost, the Claim Billing is used for the drug benefit cost, and the Service Billing is to be used to bill the administration fee. The payer sheet should designate which way supported if the vaccine administration is part of the drug benefit cost, the appropriate fields should be designated on the Claim Billing. If vaccine administration is not part of the drug benefit cost, the Service Billing payer sheet is to be provided. Field Legend This legend is used by the Payer to determine how to complete the Payer Template for the field designations. Telecommunication Implementation Guide Designation Implementation Guide Value Explanation Payer Sheet Value Payer Situation Defined ANDATORY The Field is mandatory for the Segment in the Transaction. andatory elements have structural requirements. SITUATIONAL The Field has been further designated as R or Q, as shown below. Required R The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. R Qualified Requirement Q The situations designated have qualifications for usage ("Required if x", "Not RW (Required When). Yes for RW

34 Telecommunication Implementation Guide Designation Implementation Guide Value required if y"). Explanation Payer Sheet Value Payer Situation Defined If NA (Not Applicable by the Payer), do not list field. INFORATIONAL ONLY I The Field is for informational purposes only in the designated Transaction. RW (Required When). Yes for RW For response fields, if the payer supports the business usage, the informational field should be returned. If NA (Not Applicable by the Payer), do not list field. OPTIONAL O The Field has been designated as optional usage (situations were intentionally not defined). Limited usage. See requirements in NCPDP Telecommunication Standard Implementation Guide. RW (Required When). If NA (Not Applicable by the Payer), do not list field. Yes for RW NOT USED N The Field is not used for the Segment in the designated Transaction. If NA (Not Applicable by the Payer), do not list field. Not used are shaded for clarity.

35 Further explanation of this legend follows. andatory Fields Field Legend above: If a field is designated as (andatory) in the NCPDP Telecommunication Implementation Guide Version D.Ø, the only Payer Sheet Value is (andatory). The payer may not define a situation (column Defined = No). On the Payer Template: The Payer column is and the column is not filled out. The Value column of the template may contain instructional material. The template indicates the mandatory fields for each segment, as defined by the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. These are the only fields that have the andatory designation on the template. Situational Fields - Required Field Legend above: If a field is designated as R (Required) in the NCPDP Telecommunication Implementation Guide Version D.Ø for this transaction, the only Payer Sheet Value is R (Required). The payer may not define a situation (column Defined = No), as the situation is Required. On the Payer Template: The Payer column is R and the column is not filled out. The Value column of the template may contain instructional material. Situational Fields Qualified Requirement Field Legend above: If a field is designated as Q (Qualified Requirement) in the NCPDP Telecommunication Implementation Guide Version D.Ø for this transaction, the field may be used according to the situations defined in the implementation guide, or not used. On the Payer Template: The only Payer Sheet Values is RW (Required When). If RW, then Defined = Yes and the column must contain guidance for the implementer based on the situation(s) allowed by the NCPDP Telecommunication Implementation Guide Version D.Ø for this transaction. The Value column of the template will contain instructional material.

36 If the field is not used, Payers must not include the field in the segment (the row in the table should be deleted). Payers are not allowed to list the field with an NA (Not Applicable by the Payer) designation. Informational Only Fields Field Legend above: Fields that are defined with situations of I (Informational Only) for this transaction in the NCPDP Telecommunication Standard Implementation Guide Version D.Ø, provide additional data related to the transaction. If the field is designated as I (Informational Only) for this transaction, the field may be used according to the situations defined in the implementation guide, or not used. On the Payer Template: The only Payer Sheet Values is RW (Required When). If RW, then Defined = Yes and the column must contain guidance for the implementer based on the situation(s) allowed by the NCPDP Telecommunication Implementation Guide Version D.Ø for this transaction. If the field is not used, Payers must not include the field in the segment (the row in the table should be deleted). Payers are not allowed to list the field with an NA (Not Applicable by the Payer) designation. For response fields, if the payer supports the business usage, the informational field should be returned. Optional Fields Field Legend above: Fields that are defined with situations of O (Optional) for this transaction in the NCPDP Telecommunication Standard Implementation Guide Version D.Ø are fields in limited environments. Please refer to the guide for more information on optional field usage. The field may be not used. On the Payer Template: The only Payer Sheet Values is RW (Required When). When the Payer column is RW (Required When), the column must contain guidance for the implementer. Optional fields are limited and usage between trading partners must be well defined. See the requirements in the NCPDP Telecommunication Standard Implementation Guide.

37 If the field is not used, Payers must not include the field in the segment (the row in the table should be deleted). Payers are not allowed to list the field with an NA (Not Applicable by the Payer) designation. Not Used Fields Field Legend above: Fields that are defined with situations of Not Used in the NCPDP Telecommunication Standard Implementation Guide Version D.Ø for this transaction are not allowed to be used in the transaction. On the Payer Template: There is no Payer Sheet Value designated as the field must not be included in the chart. If the field is not used, Payers must not include the field in the segment (the row in the table should be deleted). Payers are not allowed to list the field with an NA (Not Applicable by the Payer) designation.

38 NCPDP VERSION D CLAI BILLING/CLAI REBILL INSTRUCTIONS General Information Areas of red text on the template are to be replaced by payer-designated information where applicable. Areas of black text on the template are not to be modified by the Payer, unless it is to remove a row for a field that is not applicable. Examples of payer sheet templates filled out can be found in section Examples of Payer Templates. If the payer does not support the Claim Rebill (B3) transaction, the Claim Rebill verbiage should be removed from the payer s template. Request Template Information Sections Instructions to Payers and Field Legend must be followed. The template information includes General Information Other Transactions Supported Field Legend for Columns Claim Billing/Claim Rebill Transaction (segments and fields) Response Template Information The Claim Billing/Claim Rebill response template defines the Claim Billing response transaction for a Paid or Rejected response. Payers should fill out a separate template for each transaction supported, with each response supported, as appropriate (for example, for Claim Billing Paid, Reject, Captured, etc response; for Service Billing Paid, Rejected, etc response; for Reversal Approved, Rejected, etc response) as appropriate for their business. Sections Instructions to Payers and Field Legend must be followed.

39 The template information includes General Information Field Legend for Columns Claim Billing Transaction Response (segments and fields) Certification and/or Test Data If a payer wishes to include certification requirements and/or test data for claims processing, these sections can be included after the templates. Some payers provide certification requirements in a separate certification package which is separate from the templates. Request Claim Billing/Claim Rebill Payer Sheet Template ** Start of Request Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template** GENERAL INFORATION Payer Name: Name Date: Date of Publication of this Template Plan Name/Group Name: Plan Name/Group Name Plan Name/Group Name: Plan Name/Group Name Plan Name/Group Name: Plan Name/Group Name Plan Name/Group Name: Plan Name/Group Name Processor: Processor/Fiscal Intermediary BIN: BIN: BIN: BIN: PCN: PCN: PCN: PCN: Effective as of: Date that the Plan will begin accepting transactions using this payer sheet NCPDP Data Dictionary Version Date: Date of Publication NCPDP Telecommunication Standard Version/Release #: x.x NCPDP External Code List Version Date: Date of Publication

40 Contact/Information Source: Other references such as Provider anuals, Payer phone number, web site, etc. Certification Testing Window: Certification Testing Dates Certification Contact Information: Certification phone number and information Provider Relations Help Desk Info: Phone number and information Other versions supported: Other versions of Telecommunication Standard Supported (if applicable) and information FIELD LEGEND FOR COLUNS Payer Column Value Explanation Payer Situation 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. No No QUALIFIED REQUIREENT RW Required when. The situations designated have qualifications for usage ("Required if x", "Not required if y"). Yes Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template.

41 CLAI BILLING/CLAI REBILL TRANSACTION Transaction Header Segment Questions This Segment is always sent 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 Check X Claim Billing/Claim Rebill If Situational, Transaction Header Segment Claim Billing/Claim Rebill 1Ø1- A1 BIN NUBER If more than one BIN/PCN but all plans use the same segments and fields and situations, enter multiple BIN/PCNs under General Information above. 1Ø2- A2 VERSION/RELEASE NUBER DØ 1Ø3- A3 TRANSACTION CODE B1, B3

42 Transaction Header Segment Claim Billing/Claim Rebill 1Ø4- A4 PROCESSOR CONTROL NUBER Specify how this field is used, if not blanks. 1Ø9- A9 TRANSACTION COUNT Specify max # of transactions supported for each transaction code. 2Ø2- B2 SERVICE PROVIDER ID QUALIFIER Specify value supported for this plan. 2Ø1- B1 SERVICE PROVIDER ID 4Ø1- D1 DATE OF SERVICE 11Ø- AK SOFTWARE VENDOR/CERTIFICATION ID Specify how this field is used, if not blanks. Insurance Segment Questions Check Claim Billing/Claim Rebill If Situational, This Segment is always sent X

43 Insurance Segment Claim Billing/Claim Rebill (111-A) = Ø4 3Ø2-C2 CARDHOLDER ID 312-CC CARDHOLDER FIRST NAE Imp Guide: Required if necessary for state/federal/regulatory agency programs when the cardholder has a first name. unique payer requirement(s)) 313-CD CARDHOLDER LAST NAE Imp Guide: Required if necessary for state/federal/regulatory agency programs. unique payer requirement(s)) 314-CE HOE PLAN Imp Guide: Required if needed for receiver billing/encounter validation and/or determination for Blue Cross or Blue Shield, if a Patient has coverage under more than one plan, to distinguish each plan. unique payer requirement(s))

44 Insurance Segment Claim Billing/Claim Rebill (111-A) = Ø4 524-FO PLAN ID Imp Guide: Optional. unique payer requirement(s)) 3Ø9-C9 ELIGIBILITY CLARIFICATION CODE Imp Guide: Required if needed for receiver inquiry validation and/or determination, when eligibility is not maintained at the dependent level. Required in special situations as defined by the code to clarify the eligibility of an individual, which may extend coverage. unique payer requirement(s)) 3Ø1-C1 GROUP ID Imp Guide: Required if necessary for state/federal/regulatory agency programs. Required if needed for pharmacy claim processing and payment. unique

45 Insurance Segment Claim Billing/Claim Rebill (111-A) = Ø4 payer requirement(s)) 3Ø3-C3 PERSON CODE Imp Guide: Required if needed to uniquely identify the family members within the Cardholder ID. unique payer requirement(s)) 3Ø6-C6 PATIENT RELATIONSHIP CODE Imp Guide: Required if needed to uniquely identify the relationship of the Patient to the Cardholder. unique payer requirement(s)) 359-2A EDIGAP ID Imp Guide: Required, if known, when patient has edigap coverage. unique payer requirement(s)) 36Ø-2B EDICAID INDICATOR Imp Guide: Required, if known, when patient has edicaid coverage.

46 Insurance Segment Claim Billing/Claim Rebill (111-A) = Ø4 unique payer requirement(s)) 361-2D PROVIDER ACCEPT ASSIGNENT INDICATOR Imp Guide: Required if necessary for state/federal/regulatory agency programs. unique payer requirement(s)) 997-G2 CS PART D DEFINED QUALIFIED FACILITY Imp Guide: Required if specified in trading partner agreement. unique payer requirement(s)) 115-N5 EDICAID ID NUBER Imp Guide: Required, if known, when patient has edicaid coverage. unique payer requirement(s))

47 Patient Segment Questions Check Claim Billing/Claim Rebill If Situational, This Segment is always sent This Segment is situational Patient Segment Claim Billing/Claim Rebill (111-A) = Ø1 Field NCPDP Field Name Value Payer 331-CX PATIENT ID QUALIFIER Imp Guide: Required if Patient ID (332-CY) is used. unique payer requirement(s)) 332-CY PATIENT ID Imp Guide: Required if necessary for state/federal/regulatory agency programs to validate dual eligibility. 3Ø4-C4 DATE OF BIRTH R unique payer requirement(s)) 3Ø5-C5 PATIENT GENDER CODE R 31Ø-CA PATIENT FIRST NAE Imp Guide: Required when the patient has a first name.

48 Patient Segment Claim Billing/Claim Rebill (111-A) = Ø1 Field NCPDP Field Name Value Payer unique payer requirement(s)) 311-CB PATIENT LAST NAE R 322-C PATIENT STREET ADDRESS Imp Guide: Optional. 323-CN PATIENT CITY ADDRESS unique payer requirement(s)) Imp Guide: Optional. unique payer requirement(s)) 324-CO PATIENT STATE / PROVINCE ADDRESS Imp Guide: Optional. 325-CP PATIENT ZIP/POSTAL ZONE unique payer requirement(s)) Imp Guide: Optional. 326-CQ PATIENT PHONE NUBER unique payer requirement(s)) Imp Guide: Optional. unique

49 Patient Segment Claim Billing/Claim Rebill (111-A) = Ø1 Field NCPDP Field Name Value Payer payer requirement(s)) 3Ø7-C7 PLACE OF SERVICE Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility. unique payer requirement(s)) 333-CZ EPLOYER ID Imp Guide: Required if required by law as defined in the HIPAA final Privacy regulations section 164.5Ø1 definitions (45 CFR Parts 16Ø and 164 Standards for Privacy of Individually Identifiable Health Information; Final Rule - Thursday, December 28, 2ØØØ, page 828Ø3 and following, and Wednesday, August 14, 2ØØ2, page and following.) Required if needed for Workers Compensation billing. unique payer requirement(s))

50 Patient Segment Claim Billing/Claim Rebill (111-A) = Ø1 Field NCPDP Field Name Value Payer 335-2C PREGNANCY INDICATOR Imp Guide: Required if pregnancy could result in different coverage, pricing, or patient financial responsibility C PREGNANCY INDICATOR Imp Guide: Required if pregnancy could result in different coverage, pricing, or patient financial responsibility. Required if required by law as defined in the HIPAA final Privacy regulations section 164.5Ø1 definitions (45 CFR Parts 16Ø and 164 Standards for Privacy of Individually Identifiable Health Information; Final Rule- Thursday, December 28, 2ØØØ, page 828Ø3 and following, and Wednesday, August 14, 2ØØ2, page and following.) unique

51 Patient Segment Claim Billing/Claim Rebill (111-A) = Ø1 Field NCPDP Field Name Value Payer 35Ø-HN PATIENT E-AIL ADDRESS payer requirement(s)) Imp Guide: ay be submitted for the receiver to relay patient health care communications via the Internet when provided by the patient. unique payer requirement(s)) 384-4X PATIENT RESIDENCE Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility. unique payer requirement(s)) Claim Segment Questions Check Claim Billing/Claim Rebill If Situational, This Segment is always sent X This payer supports partial fills This payer does not support partial fills

52 Claim Segment Claim Billing/Claim Rebill (111-A) = Ø E 4Ø2- D2 PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUBER 1 = 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 4Ø7- D7 PRODUCT/SERVICE ID 456-EN ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUBER Imp Guide: Required if the completion transaction in a partial fill (Dispensing Status (343-HD) = C (Completed)). Required if the Dispensing Status (343-HD) = P (Partial Fill) and there are multiple occurrences of partial fills for this prescription. 457-EP ASSOCIATED PRESCRIPTION/SERVICE Imp Guide: Required if the completion transaction in a

53 Claim Segment Claim Billing/Claim Rebill (111-A) = Ø7 DATE partial fill (Dispensing Status (343-HD) = C (Completed)). Required if Associated Prescription/Service Reference Number (456-EN) is used. Required if the Dispensing Status (343-HD) = P (Partial Fill) and there are multiple occurrences of partial fills for this prescription. 458-SE PROCEDURE ODIFIER CODE COUNT aximum count of 1Ø. Imp Guide: Required if Procedure odifier Code (459- ER) is used. 459-ER PROCEDURE ODIFIER CODE Imp Guide: Required to define a further level of specificity if the Product/Service ID (4Ø7- D7) indicated a Procedure Code

54 Claim Segment Claim Billing/Claim Rebill (111-A) = Ø7 was submitted. Required if this field could result in different coverage, pricing, or patient financial responsibility. 442-E7 QUANTITY DISPENSED R 4Ø3-D3 FILL NUBER 4Ø5-D5 DAYS SUPPLY 4Ø6-D6 COPOUND CODE 4Ø8-D8 DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE 414-DE DATE PRESCRIPTION WRITTEN R R R R R 415-DF NUBER OF REFILLS AUTHORIZED Imp Guide: Required if necessary for plan benefit administration.

55 Claim Segment Claim Billing/Claim Rebill (111-A) = Ø7 419-DJ PRESCRIPTION ORIGIN CODE Imp Guide: Required if necessary for plan benefit administration. 354-NX SUBISSION CLARIFICATION CODE COUNT aximum count of 3. Imp Guide: Required if Submission Clarification Code (42Ø-DK) is used. 42Ø-DK SUBISSION CLARIFICATION CODE Imp Guide: Required 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

56 Claim Segment Claim Billing/Claim Rebill (111-A) = Ø7 edicare Part A expires. Used only in long-term care settings) for individual unit of use medications. 3Ø8-C8 OTHER COVERAGE CODE Imp Guide: Required if needed by receiver, to communicate a summation of other coverage information that has been collected from other payers. Required for Coordination of Benefits. 429-DT SPECIAL PACKAGING INDICATOR Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility.

57 Claim Segment Claim Billing/Claim Rebill (111-A) = Ø7 453-EJ ORIGINALLY PRESCRIBED PRODUCT/SERVICE ID QUALIFIER Imp Guide: Required if Originally Prescribed Product/Service Code (455-EA) is used. 445-EA ORIGINALLY PRESCRIBED PRODUCT/SERVICE CODE Imp Guide: Required if the receiver requests association to a therapeutic, or a preferred product substitution, or when a DUR alert has been resolved by changing medications, or an alternative service than what was originally prescribed. 446-EB ORIGINALLY PRESCRIBED QUANTITY Imp Guide: Required if the receiver requests reporting for quantity changes due to a therapeutic substitution that has occurred or a preferred product/service substitution that has occurred, or when a DUR alert has been resolved by changing quantities.

58 Claim Segment Claim Billing/Claim Rebill (111-A) = Ø7 454-EK SCHEDULED PRESCRIPTION ID NUBER Imp Guide: Required if necessary for state/federal/regulatory agency programs. Payer Requirement: 6ØØ-28 UNIT OF EASURE Imp Guide: Required if necessary for state/federal/regulatory agency programs. Required if this field could result in different coverage, pricing, or patient financial responsibility. Payer Requirement: 418-DI LEVEL OF SERVICE Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility.

59 Claim Segment Claim Billing/Claim Rebill (111-A) = Ø7 Payer Requirement: 461-EU PRIOR AUTHORIZATION TYPE CODE Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility. Payer Requirement: 462-EV PRIOR AUTHORIZATION NUBER SUBITTED Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility. Payer Requirement: 463-EW INTEREDIARY AUTHORIZATION TYPE ID Imp Guide: Required for overriding an authorized intermediary system edit when the pharmacy participates with an intermediary. Required if Intermediary Authorization ID (464-EX) is used.

60 Claim Segment Claim Billing/Claim Rebill (111-A) = Ø7 464-EX INTEREDIARY AUTHORIZATION ID Imp Guide: Required for overriding an authorized intermediary system edit when the pharmacy participates with an intermediary. 343-HD DISPENSING STATUS Imp Guide: Required for the partial fill or the completion fill of a prescription. 344-HF QUANTITY INTENDED TO BE DISPENSED Imp Guide: Required for the partial fill or the completion fill of a prescription. 345-HG DAYS SUPPLY INTENDED TO BE DISPENSED Imp Guide: Required for the partial fill or the completion fill of a prescription.

61 Claim Segment Claim Billing/Claim Rebill (111-A) = Ø7 357-NV DELAY REASON CODE Imp Guide: Required when needed to specify the reason that submission of the transaction has been delayed. 391-T PATIENT ASSIGNENT INDICATOR (DIRECT EBER REIBURSEENT INDICATOR) Imp Guide: Required when the claims adjudicator does not assume the patient assigned his/her benefits to the provider or when the claims adjudicator supports a patient determination of whether he/she wants to assign or retain his/her benefits. 995-E2 ROUTE OF ADINISTRATION Imp Guide: Required if specified in trading partner agreement.

62 Claim Segment Claim Billing/Claim Rebill (111-A) = Ø7 996-G1 COPOUND TYPE Imp Guide: Required if specified in trading partner agreement. 147-U7 PHARACY SERVICE TYPE Imp Guide: Required when the submitter must clarify the type of services being performed as a condition for proper reimbursement by the payer. Pricing Segment Questions Check Claim Billing/Claim Rebill If Situational, This Segment is always sent X Pricing Segment Claim Billing/Claim Rebill (111-A) = 11

63 4Ø9-D9 INGREDIENT COST SUBITTED R 412-DC DISPENSING FEE SUBITTED Imp Guide: Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. 433-DX PATIENT PAID AOUNT SUBITTED Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility. 438-E3 INCENTIVE AOUNT SUBITTED Imp Guide: Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. 478-H7 OTHER AOUNT CLAIED SUBITTED COUNT aximum count of 3. Imp Guide: Required if Other Amount Claimed Submitted Qualifier (479-H8) is used.

64 Pricing Segment Claim Billing/Claim Rebill (111-A) = H8 OTHER AOUNT CLAIED SUBITTED QUALIFIER Imp Guide: Required if Other Amount Claimed Submitted (48Ø-H9) is used. 48Ø-H9 OTHER AOUNT CLAIED SUBITTED Imp Guide: Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. 481-HA FLAT SALES TAX AOUNT SUBITTED Imp Guide: Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. 482-GE PERCENTAGE SALES TAX AOUNT SUBITTED Imp Guide: Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation.

65 Pricing Segment Claim Billing/Claim Rebill (111-A) = HE PERCENTAGE SALES TAX RATE SUBITTED Imp Guide: Required if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Basis Submitted (484-JE) are used. Required if this field could result in different pricing. Required if needed to calculate Percentage Sales Tax Amount Paid (559-AX). 484-JE PERCENTAGE SALES TAX BASIS SUBITTED Imp Guide: Required if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Rate Submitted (483-HE) are used. Required if this field could

66 Pricing Segment Claim Billing/Claim Rebill (111-A) = 11 result in different pricing. Required if needed to calculate Percentage Sales Tax Amount Paid (559-AX). 426-DQ USUAL AND CUSTOARY CHARGE Imp Guide: Required if needed per trading partner agreement. 43Ø-DU GROSS AOUNT DUE R 423-DN BASIS OF COST DETERINATION Imp Guide: Required if needed for receiver claim/encounter adjudication.

67 Pharmacy Provider Segment Questions This Segment is always sent This Segment is situational Check Claim Billing/Claim Rebill If Situational, Pharmacy Provider Segment (111-A) = Ø2 Claim Billing/Claim Rebill 465-EY PROVIDER ID QUALIFIER Imp Guide: Required if Provider ID (444-E9) is used.

68 Pharmacy Provider Segment Claim Billing/Claim Rebill (111-A) = Ø2 444-E9 PROVIDER ID Imp Guide: Required if necessary for state/federal/regulatory agency programs. Required if necessary to identify the individual responsible for dispensing of the prescription. Required if needed for reconciliation of encounterreported data or encounter reporting. Prescriber Segment Questions Check Claim Billing/Claim Rebill If Situational, This Segment is always sent This Segment is situational

69 Prescriber Segment Claim Billing/Claim Rebill (111-A) = Ø3 466-EZ PRESCRIBER ID QUALIFIER Imp Guide: Required if Prescriber ID (411-DB) is used. 411-DB PRESCRIBER ID Imp Guide: Required if this field could result in different coverage or patient financial responsibility. Required if necessary for state/federal/regulatory agency programs. 427-DR PRESCRIBER LAST NAE Imp Guide: Required when the Prescriber ID (411-DB) is not known. Required if needed for Prescriber ID (411-DB) validation/clarification.

70 Prescriber Segment Claim Billing/Claim Rebill (111-A) = Ø3 498-P PRESCRIBER PHONE NUBER Imp Guide: Required if needed for Workers Compensation. Required if needed to assist in identifying the prescriber. Required if needed for Prior Authorization process E PRIARY CARE PROVIDER ID QUALIFIER Imp Guide: Required if Primary Care Provider ID (421-DL) is used. 421-DL PRIARY CARE PROVIDER ID Imp Guide: Required if needed for receiver claim/encounter determination, if known and available. Required if this field could

71 Prescriber Segment Claim Billing/Claim Rebill (111-A) = Ø3 result in different coverage or patient financial responsibility. Required if necessary for state/federal/regulatory agency programs. 47Ø-4E PRIARY CARE PROVIDER LAST NAE Imp Guide: Required if this field is used as an alternative for Primary Care Provider ID (421-DL) when ID is not known. Required if needed for Primary Care Provider ID (421-DL) validation/clarification J PRESCRIBER FIRST NAE Imp Guide: Required if needed to assist in identifying the prescriber.

72 Prescriber Segment Claim Billing/Claim Rebill (111-A) = Ø3 Required if necessary for state/federal/regulatory agency programs K PRESCRIBER STREET ADDRESS Imp Guide: Required if needed to assist in identifying the prescriber. Required if necessary for state/federal/regulatory agency programs PRESCRIBER CITY ADDRESS Imp Guide: Required if needed to assist in identifying the prescriber. Required if necessary for state/federal/regulatory agency programs.

73 Prescriber Segment Claim Billing/Claim Rebill (111-A) = Ø N PRESCRIBER STATE/PROVINCE ADDRESS Imp Guide: Required if needed to assist in identifying the prescriber. Required if necessary for state/federal/regulatory agency programs P PRESCRIBER ZIP/POSTAL ZONE Imp Guide: Required if needed to assist in identifying the prescriber. Required if necessary for state/federal/regulatory agency programs.

74 Coordination of Benefits/Other Payments Segment Questions This Segment is always sent This Segment is situational Check Claim Billing/Claim Rebill If Situational, Required only for secondary, tertiary, etc claims. Scenario 1 - Other Payer Amount Paid Repetitions Only Scenario 2 - Other Payer-Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only Scenario 3 - Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) If the Payer supports the Coordination of Benefits/Other Payments Segment, only one scenario method shown above may be supported per template. The template shows the Coordination of Benefits/Other Payments Segment that must be used for each scenario method. The Payer must choose the appropriate scenario method with the segment chart, and delete the other scenario methods with their segment charts. See section Coordination of Benefits (COB) Processing for more information Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 1 - Other Payer Amount Paid Repetitions Only 337-4C COORDINATION OF BENEFITS/OTHER PAYENTS COUNT aximum count of 9.

75 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 1 - Other Payer Amount Paid Repetitions Only 338-5C OTHER PAYER COVERAGE TYPE 339-6C OTHER PAYER ID QUALIFIER Imp Guide: Required if Other Payer ID (34Ø-7C) is used. 34Ø-7C OTHER PAYER ID Imp Guide: Required if identification of the Other Payer is necessary for claim/encounter adjudication. 443-E8 OTHER PAYER DATE Imp Guide: Required if identification of the Other Payer Date is necessary for claim/encounter adjudication. 341-HB OTHER PAYER AOUNT PAID COUNT aximum count of 9. Imp Guide: Required if Other Payer Amount Paid Qualifier

76 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 1 - Other Payer Amount Paid Repetitions Only (342-HC) is used. 342-HC OTHER PAYER AOUNT PAID QUALIFIER Imp Guide: Required if Other Payer Amount Paid (431-DV) is used. 431-DV OTHER PAYER AOUNT PAID Imp Guide: Required if other payer has approved payment for some/all of the billing. Not used for patient financial responsibility only billing. Not used for non-governmental agency programs if Other Payer-Patient Responsibility Amount (352-NQ) is submitted.

77 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 1 - Other Payer Amount Paid Repetitions Only 471-5E OTHER PAYER REJECT COUNT aximum count of 5. Imp Guide: Required if Other Payer Reject Code (472-6E) is used E OTHER PAYER REJECT CODE Imp Guide: Required when the other payer has denied the payment for the billing, designated with Other Coverage Code (3Ø8-C8) = 3 (Other Coverage Billed claim not covered).

78 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 2- Other Payer- Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only 337-4C COORDINATION OF BENEFITS/OTHER PAYENTS COUNT 338-5C OTHER PAYER COVERAGE TYPE aximum count of C OTHER PAYER ID QUALIFIER Imp Guide: Required if Other Payer ID (34Ø-7C) is used. 34Ø-7C OTHER PAYER ID Imp Guide: Required if identification of the Other Payer is necessary for claim/encounter adjudication. 443-E8 OTHER PAYER DATE Imp Guide: Required if identification of the Other Payer Date is necessary for claim/encounter adjudication.

79 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 2- Other Payer- Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only 471-5E OTHER PAYER REJECT COUNT aximum count of 5. Imp Guide: Required if Other Payer Reject Code (472-6E) is used E OTHER PAYER REJECT CODE Imp Guide: Required when the other payer has denied the payment for the billing, designated with Other Coverage Code (3Ø8-C8) = 3 (Other Coverage Billed claim not covered). 353-NR OTHER PAYER-PATIENT RESPONSIBILITY AOUNT COUNT aximum count of 25. Imp Guide: Required if Other Payer-Patient Responsibility Amount Qualifier (351-NP) is

80 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 2- Other Payer- Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only used. 351-NP OTHER PAYER-PATIENT RESPONSIBILITY AOUNT QUALIFIER Imp Guide: Required if Other Payer-Patient Responsibility Amount (352-NQ) is used. 352-NQ OTHER PAYER-PATIENT RESPONSIBILITY AOUNT Imp Guide: Required if necessary for patient financial responsibility only billing. Required if necessary for state/federal/regulatory agency programs. Not used for non-governmental agency programs if Other Payer Amount Paid (431-DV) is

81 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 2- Other Payer- Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only submitted. 392-U BENEFIT STAGE COUNT aximum count of 4. Imp Guide: Required if Benefit Stage Amount (394-W) is used. 393-V BENEFIT STAGE QUALIFIER Imp Guide: Required if Benefit Stage Amount (394-W) is used. 394-W BENEFIT STAGE AOUNT Imp Guide: Required if the previous payer has financial amounts that apply to edicare Part D beneficiary benefit stages. This field is required when the plan is a participant in

82 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 2- Other Payer- Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only a edicare Part D program that requires reporting of benefit stage specific financial amounts. Required if necessary for state/federal/regulatory agency programs. Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 3 - Other Payer Amount Paid, Other Payer- Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs)

83 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 3 - Other Payer Amount Paid, Other Payer- Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) 337-4C COORDINATION OF BENEFITS/OTHER PAYENTS COUNT 338-5C OTHER PAYER COVERAGE TYPE aximum count of C OTHER PAYER ID QUALIFIER Imp Guide: Required if Other Payer ID (34Ø-7C) is used. 34Ø-7C OTHER PAYER ID Imp Guide: Required if identification of the Other Payer is necessary for claim/encounter adjudication. 443-E8 OTHER PAYER DATE Imp Guide: Required if identification of the Other Payer Date is necessary for claim/encounter adjudication.

84 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 3 - Other Payer Amount Paid, Other Payer- Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) 341-HB OTHER PAYER AOUNT PAID COUNT aximum count of 9. Imp Guide: Required if Other Payer Amount Paid Qualifier (342-HC) is used. 342-HC OTHER PAYER AOUNT PAID QUALIFIER Imp Guide: Required if Other Payer Amount Paid (431-DV) is used. 431-DV OTHER PAYER AOUNT PAID Imp Guide: Required if other payer has approved payment for some/all of the billing. Not used for patient financial

85 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 3 - Other Payer Amount Paid, Other Payer- Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) responsibility only billing. Not used for non-governmental agency programs if Other Payer-Patient Responsibility Amount (352-NQ) is submitted E OTHER PAYER REJECT COUNT aximum count of 5. Imp Guide: Required if Other Payer Reject Code (472-6E) is used E OTHER PAYER REJECT CODE Imp Guide: Required when the other payer has denied the payment for the billing, designated with Other Coverage Code (3Ø8-C8) = 3 (Other Coverage Billed claim not

86 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 3 - Other Payer Amount Paid, Other Payer- Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) covered). 353-NR OTHER PAYER-PATIENT RESPONSIBILITY AOUNT COUNT aximum count of 25. Imp Guide: Required if Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. 351-NP OTHER PAYER-PATIENT RESPONSIBILITY AOUNT QUALIFIER Imp Guide: Required if Other Payer-Patient Responsibility Amount (352-NQ) is used. 352-NQ OTHER PAYER-PATIENT RESPONSIBILITY AOUNT Imp Guide: Required if necessary for patient financial responsibility only billing.

87 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 3 - Other Payer Amount Paid, Other Payer- Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) Required if necessary for state/federal/regulatory agency programs. Not used for non-governmental agency programs if Other Payer Amount Paid (431-DV) is submitted. 392-U BENEFIT STAGE COUNT aximum count of 4. Imp Guide: Required if Benefit Stage Amount (394-W) is used. 393-V BENEFIT STAGE QUALIFIER Imp Guide: Required if Benefit Stage Amount (394-W) is

88 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing/Claim Rebill Scenario 3 - Other Payer Amount Paid, Other Payer- Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) used. 394-W BENEFIT STAGE AOUNT Imp Guide: Required if the previous payer has financial amounts that apply to edicare Part D beneficiary benefit stages. This field is required when the plan is a participant in a edicare Part D program that requires reporting of benefit stage specific financial amounts. Required if necessary for state/federal/regulatory agency programs.

89 Workers Compensation Segment Questions This Segment is always sent This Segment is situational Check Claim Billing/Claim Rebill If Situational, Workers Compensation Segment (111-A) = Ø6 Claim Billing/Claim Rebill 434- DY DATE OF INJURY 315-CF EPLOYER NAE Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition. 316-CG EPLOYER STREET ADDRESS Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition. 317-CH EPLOYER CITY ADDRESS Imp Guide: Required if needed to process a claim/encounter for a work related injury or

90 Workers Compensation Segment Claim Billing/Claim Rebill (111-A) = Ø6 condition. 318-CI EPLOYER STATE/PROVINCE ADDRESS Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition. 319-CJ EPLOYER ZIP/POSTAL ZONE Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition. 32Ø-CK EPLOYER PHONE NUBER Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition.

91 Workers Compensation Segment Claim Billing/Claim Rebill (111-A) = Ø6 321-CL EPLOYER CONTACT NAE Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition. 327-CR CARRIER ID Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition. 435-DZ CLAI/REFERENCE ID Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition. 117-TR BILLING ENTITY TYPE INDICATOR R

92 Workers Compensation Segment Claim Billing/Claim Rebill (111-A) = Ø6 118-TS PAY TO QUALIFIER Imp Guide: Required if Pay To ID (119-TT) is used. 119-TT PAY TO ID Imp Guide: Required if transaction is submitted by a provider or agent, but paid to another party. 12Ø-TU PAY TO NAE Imp Guide: Required if transaction is submitted by a provider or agent, but paid to another party. 121-TV PAY TO STREET ADDRESS Imp Guide: Required if transaction is submitted by a provider or agent, but paid to another party.

93 Workers Compensation Segment Claim Billing/Claim Rebill (111-A) = Ø6 122-TW PAY TO CITY ADDRESS Imp Guide: Required if transaction is submitted by a provider or agent, but paid to another party. 123-TX PAY TO STATE/PROVINCE ADDRESS Imp Guide: Required if transaction is submitted by a provider or agent, but paid to another party. 124-TY PAY TO ZIP/POSTAL ZONE Imp Guide: Required if transaction is submitted by a provider or agent, but paid to another party. 125-TZ GENERIC EQUIVALENT Imp Guide: Required if Generic Equivalent Product ID (126-

94 Workers Compensation Segment Claim Billing/Claim Rebill (111-A) = Ø6 PRODUCT ID QUALIFIER UA) is used. 126-UA GENERIC EQUIVALENT PRODUCT ID Imp Guide: Required if necessary for state/federal/regulatory agency programs. DUR/PPS Segment Questions Check Claim Billing/Claim Rebill If Situational, This Segment is always sent This Segment is situational DUR/PPS Segment Claim Billing/Claim Rebill (111-A) = Ø8

95 DUR/PPS Segment Claim Billing/Claim Rebill (111-A) = Ø E DUR/PPS CODE COUNTER aximum of 9 occurrences. Imp Guide: Required if DUR/PPS Segment is used. 439-E4 REASON FOR SERVICE CODE Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required if this field affects payment for or documentation of professional pharmacy service. 44Ø-E5 PROFESSIONAL SERVICE CODE Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.

96 DUR/PPS Segment Claim Billing/Claim Rebill (111-A) = Ø8 Required if this field affects payment for or documentation of professional pharmacy service. 441-E6 RESULT OF SERVICE CODE Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required if this field affects payment for or documentation of professional pharmacy service E DUR/PPS LEVEL OF EFFORT Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.

97 DUR/PPS Segment Claim Billing/Claim Rebill (111-A) = Ø8 Required if this field affects payment for or documentation of professional pharmacy service. 475-J9 DUR CO-AGENT ID QUALIFIER Imp Guide: Required if DUR Co-Agent ID (476-H6) is used. 476-H6 DUR CO-AGENT ID Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required if this field affects payment for or documentation of professional pharmacy service.

98 DUR/PPS Segment Claim Billing/Claim Rebill (111-A) = Ø8 Coupon Segment Questions Check Claim Billing/Claim Rebill If Situational, This Segment is always sent This Segment is situational Coupon Segment Claim Billing/Claim Rebill (111-A) = Ø9

99 Coupon Segment Claim Billing/Claim Rebill (111-A) = Ø9 485-KE COUPON TYPE 486- E COUPON NUBER 487-NE COUPON VALUE AOUNT Imp Guide: Required if needed for receiver claim/encounter determination when a coupon value is known. Required if this field could result in different pricing and/or patient financial responsibility. Compound Segment Questions Check Claim Billing/Claim Rebill If Situational, This Segment is always sent This Segment is situational

100 Compound Segment Claim Billing/Claim Rebill (111-A) = 1Ø 45Ø- EF COPOUND DOSAGE FOR DESCRIPTION CODE 451-EG COPOUND DISPENSING UNIT FOR INDICATOR 447-EC COPOUND INGREDIENT COPONENT COUNT 488-RE COPOUND PRODUCT ID QUALIFIER 489-TE COPOUND PRODUCT ID 448-ED COPOUND INGREDIENT QUANTITY aximum 25 dients 449-EE COPOUND INGREDIENT DRUG COST Imp Guide: Required if needed for receiver claim determination when multiple products are billed. 49Ø-UE COPOUND INGREDIENT BASIS OF COST DETERINATION Imp Guide: Required if needed for receiver claim determination when multiple products are billed.

101 Compound Segment Claim Billing/Claim Rebill (111-A) = 1Ø 362-2G COPOUND INGREDIENT ODIFIER CODE COUNT aximum count of 1Ø. Imp Guide: Required when Compound Ingredient odifier Code (363-2H) is sent H COPOUND INGREDIENT ODIFIER CODE Imp Guide: Required if necessary for state/federal/regulatory agency programs. Clinical Segment Questions Check Claim Billing/Claim Rebill If Situational, This Segment is always sent This Segment is situational Clinical Segment Claim Billing/Claim Rebill (111-A) = 13

102 491-VE DIAGNOSIS CODE COUNT aximum count of 5. Imp Guide: Required if Diagnosis Code Qualifier (492- WE) and Diagnosis Code (424- DO) are used. unique payer requirement(s)) 492-WE DIAGNOSIS CODE QUALIFIER Imp Guide: Required if Diagnosis Code (424-DO) is used. unique payer requirement(s)) 424-DO DIAGNOSIS CODE Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required if this field affects payment for professional pharmacy service. Required if this information can be used in place of prior authorization. Required if necessary for state/federal/regulatory agency

103 Clinical Segment Claim Billing/Claim Rebill (111-A) = 13 programs. 493-XE CLINICAL INFORATION COUNTER aximum 5 occurrences supported. unique payer requirement(s)) Imp Guide: Grouped with easurement fields (easurement Date (494-ZE), easurement Time (495-H1), easurement Dimension (496- H2), easurement Unit (497- H3), easurement Value (499- H4). 494-ZE EASUREENT DATE unique payer requirement(s)) Imp Guide: Required if necessary when this field could result in different coverage and/or drug utilization review outcome. unique payer requirement(s)) 495-H1 EASUREENT TIE Imp Guide: Required if Time is known or has impact on measurement.

104 Clinical Segment Claim Billing/Claim Rebill (111-A) = 13 Required if necessary when this field could result in different coverage and/or drug utilization review outcome. unique payer requirement(s)) 496-H2 EASUREENT DIENSION Imp Guide: Required if easurement Unit (497-H3) and easurement Value (499-H4) are used. Required if necessary when this field could result in different coverage and/or drug utilization review outcome. Required if necessary for patient s weight and height when billing edicare for a claim that includes a Certificate of edical Necessity (CN). unique

105 Clinical Segment Claim Billing/Claim Rebill (111-A) = 13 payer requirement(s)) 497-H3 EASUREENT UNIT Imp Guide: Required if easurement Dimension (496- H2) and easurement Value (499-H4) are used. Required if necessary for patient s weight and height when billing edicare for a claim that includes a Certificate of edical Necessity (CN). Required if necessary when this field could result in different coverage and/or drug utilization review outcome. unique payer requirement(s)) 499-H4 EASUREENT VALUE Imp Guide: Required if easurement Dimension (496- H2) and easurement Unit (497-H3) are used. Required if necessary for patient s weight and height

106 Clinical Segment Claim Billing/Claim Rebill (111-A) = 13 when billing edicare for a claim that includes a Certificate of edical Necessity (CN). Required if necessary when this field could result in different coverage and/or drug utilization review outcome. unique payer requirement(s)) Additional Documentation Segment Questions This Segment is always sent This Segment is situational Check Claim Billing/Claim Rebill If Situational, Additional Documentation Segment (111-A) = 14 Claim Billing/Claim Rebill

107 Additional Documentation Segment Claim Billing/Claim Rebill (111-A) = Q ADDITIONAL DOCUENTATION TYPE ID 374-2V REQUEST PERIOD BEGIN DATE Imp Guide: Required if necessary for state/federal/regulatory agency programs W REQUEST PERIOD RECERT/REVISED DATE Imp Guide: Required if necessary for state/federal/regulatory agency programs. Required if the Request Status (373-2U) = 2 (Revision) or 3 (Recertification) U REQUEST STATUS Imp Guide: Required if necessary for state/federal/regulatory agency programs.

108 Additional Documentation Segment Claim Billing/Claim Rebill (111-A) = S LENGTH OF NEED QUALIFIER Imp Guide: Required if Length of Need (37Ø-2R) is used. 37Ø-2R LENGTH OF NEED Imp Guide: Required if necessary for state/federal/regulatory agency programs T PRESCRIBER/SUPPLIER DATE SIGNED Imp Guide: Required if necessary for state/federal/regulatory agency programs X SUPPORTING DOCUENTATION Imp Guide: Required if necessary for

109 Additional Documentation Segment Claim Billing/Claim Rebill (111-A) = 14 state/federal/regulatory agency programs (using Section C of edicare s CN forms) Z QUESTION NUBER/LETTER COUNT aximum count of 5Ø. Imp Guide: Required if needed to provide response to narratives B QUESTION NUBER/LETTER Imp Guide: Required if necessary for state/federal/regulatory agency programs to respond to questions included on a edicare form. Required if Question Number/Letter Count (377-2Z) is greater than Ø.

110 Additional Documentation Segment Claim Billing/Claim Rebill (111-A) = D QUESTION PERCENT RESPONSE Imp Guide: Required if necessary for state/federal/regulatory agency programs to respond to questions included on a edicare form that requires a percent as the response. 38Ø-4G QUESTION DATE RESPONSE Imp Guide: Required if necessary for state/federal/regulatory agency programs to respond to questions included on a edicare form that requires a date as the response H QUESTION DOLLAR AOUNT RESPONSE Imp Guide: Required if necessary for state/federal/regulatory agency programs to respond to questions included on a edicare form that requires a

111 Additional Documentation Segment Claim Billing/Claim Rebill (111-A) = 14 dollar amount as the response J QUESTION NUERIC RESPONSE Imp Guide: Required if necessary for State/federal/regulatory agency programs to respond to questions included on a edicare form that requires a numeric as the response K QUESTION ALPHANUERIC RESPONSE Imp Guide: Required if necessary for state/federal/regulatory agency programs to respond to questions included on a edicare form that requires an alphanumeric as the response.

112 Facility Segment Questions Check Claim Billing/Claim Rebill If Situational, This Segment is always sent This Segment is situational Facility Segment Claim Billing/Claim Rebill (111-A) = C FACILITY ID Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome Q FACILITY NAE Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome U FACILITY STREET ADDRESS Imp Guide: Required if this field could result in different coverage, pricing, patient

113 Facility Segment Claim Billing/Claim Rebill (111-A) = 15 financial responsibility, and/or drug utilization review outcome J FACILITY CITY ADDRESS Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome V FACILITY STATE/PROVINCE ADDRESS Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome D FACILITY ZIP/POSTAL ZONE Imp Guide: Required if this field could result in different coverage, pricing, patient

114 Facility Segment Claim Billing/Claim Rebill (111-A) = 15 financial responsibility, and/or drug utilization review outcome. Narrative Segment Questions Check Claim Billing/Claim Rebill If Situational, This Segment is always sent This Segment is situational Narrative Segment Claim Billing/Claim Rebill (111-A) = 16

115 Narrative Segment Claim Billing/Claim Rebill (111-A) = 16 39Ø- B NARRATIVE ESSAGE Imp Guide: Required if necessary only to support exception handling of pharmacy claims for edicare Part B claim billing. ** End of Request Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template** Response Claim Billing/Claim Rebill Payer Sheet Template Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response ** Start of Response Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template** GENERAL INFORATION Payer Name: Name Plan Name/Group Name: Plan Name/Group Name Plan Name/Group Name: Plan Name/Group Name Plan Name/Group Name: Plan Name/Group Name Date: Date BIN: BIN: BIN: PCN: PCN: PCN:

116 CLAI BILLING/CLAI REBILL PAID (OR DUPLICATE OF PAID) RESPONSE The following lists the segments and fields in a Claim Billing or Claim Rebill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Response Transaction Header Segment Questions This Segment is always sent Check X Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Response Transaction Header Segment Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 1Ø2- A2 VERSION/RELEASE NUBER DØ 1Ø3- A3 TRANSACTION CODE B1, B3 1Ø9- A9 TRANSACTION COUNT Same value as in request 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 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

117 Response essage Segment Questions This Segment is always sent This Segment is situational Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Provide general information when used for transmission-level messaging. Response essage Segment (111-A) = 2Ø Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 5Ø4-F4 ESSAGE Imp Guide: Required if text is needed for clarification or detail. Response Insurance Segment Questions This Segment is always sent This Segment is situational Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational,

118 Response Insurance Segment (111-A) = 25 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 3Ø1-C1 GROUP ID Imp Guide: Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. Required to identify the actual group that was used when multiple group coverage s exist.

119 Response Insurance Segment (111-A) = 25 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 524-FO PLAN ID Imp Guide: Required if needed to identify the actual plan parameters, benefit, or coverage criteria, when available. Required to identify the actual plan ID that was used when multiple group coverage s exist. Required if needed to contain the actual plan ID if unknown to the receiver.

120 Response Insurance Segment (111-A) = F NETWORK REIBURSEENT ID Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required if needed to identify the network for the covered member. Required if needed to identify the actual Network Reimbursement ID, when applicable and/or available. Required to identify the actual Network Reimbursement ID that was used when multiple Network Reimbursement IDs exist. 568-J7 PAYER ID QUALIFIER Imp Guide: Required if Payer ID (569-J8) is used.

121 Response Insurance Segment (111-A) = 25 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 569-J8 PAYER ID Imp Guide: Required to identify the ID of the payer responding. 3Ø2-C2 CARDHOLDER ID Imp Guide: Required if the identification to be used in future transactions is different than what was submitted on the request. Response Patient Segment Questions Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is always sent This Segment is situational

122 Response Patient Segment (111-A) = 29 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 31Ø- CA PATIENT FIRST NAE Imp Guide: Required if known. 311-CB PATIENT LAST NAE Imp Guide: Required if known. 3Ø4-C4 DATE OF BIRTH Imp Guide: Required if known. Response Status Segment Questions Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is always sent X

123 Response Status Segment (111-A) = 21 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 112-AN TRANSACTION RESPONSE STATUS P=Paid D=Duplicate of Paid 5Ø3-F3 AUTHORIZATION NUBER Imp Guide: Required if needed to identify the transaction F APPROVED ESSAGE CODE COUNT aximum count of 5. Imp Guide: Required if Approved essage Code (548-6F) is used F APPROVED ESSAGE CODE Imp Guide: Required if Approved essage Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity.

124 Response Status Segment (111-A) = 21 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 13Ø- UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. Imp Guide: Required if Additional essage Information (526-FQ) is used. 132-UH ADDITIONAL ESSAGE INFORATION QUALIFIER Imp Guide: Required if Additional essage Information (526-FQ) is used. 526-FQ ADDITIONAL ESSAGE INFORATION Imp Guide: Required when additional text is needed for clarification or detail.

125 Response Status Segment (111-A) = UG ADDITIONAL ESSAGE INFORATION CONTINUITY Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required 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 NUBER QUALIFIER Imp Guide: Required if Help Desk Phone Number (55Ø- 8F) is used. 55Ø-8F HELP DESK PHONE NUBER Imp Guide: Required if needed to provide a support telephone number to the receiver.

126 Response Claim Segment Questions Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is always sent X Response Claim Segment (111-A) = 22 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 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 551-9F PREFERRED PRODUCT COUNT aximum count of 6. Imp Guide: Required if Preferred Product ID (553- AR) is used.

127 Response Claim Segment (111-A) = 22 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 552-AP PREFERRED PRODUCT ID QUALIFIER Imp Guide: Required if Preferred Product ID (553- AR) is used. 553-AR PREFERRED PRODUCT ID Imp Guide: Required if a product preference exists that needs to be communicated to the receiver via an ID. 554-AS PREFERRED PRODUCT INCENTIVE Imp Guide: Required if there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU).

128 Response Claim Segment (111-A) = 22 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 555-AT PREFERRED PRODUCT COST SHARE INCENTIVE Imp Guide: Required if there is a known patient financial responsibility incentive amount associated with the Preferred Product ID (553- AR) and/or Preferred Product Description (556-AU). 556-AU PREFERRED PRODUCT DESCRIPTION Imp Guide: Required if a product preference exists that either cannot be communicated by the Preferred Product ID (553- AR) or to clarify the Preferred Product ID (553-AR). Response Pricing Segment Questions Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is always sent X

129 Field # Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 5Ø5- F5 5Ø6- F6 PATIENT PAY AOUNT INGREDIENT COST PAID R R 5Ø7- F7 DISPENSING FEE PAID Imp Guide: Required if this value is used to arrive at the final reimbursement AV TAX EXEPT INDICATOR unique payer requirement(s)) Imp Guide: Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. unique payer requirement(s))

130 Field # 558- AW Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer FLAT SALES TAX AOUNT PAID Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required 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. unique payer requirement(s))

131 Field # 559- AX Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer PERCENTAGE SALES TAX AOUNT PAID Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required if this value is used to arrive at the final reimbursement. Required if Percentage Sales Tax Amount Submitted (482-GE) is greater than zero (Ø). Required if Percentage Sales Tax Rate Paid (56Ø- AY) and Percentage Sales Tax Basis Paid (561-AZ) are used. 56Ø- AY PERCENTAGE SALES TAX RATE PAID unique payer requirement(s)) Imp Guide: Required if Percentage Sales Tax Amount Paid (559-AX) is greater than zero (Ø). unique payer requirement(s))

132 Field # 561- AZ Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer PERCENTAGE SALES TAX BASIS PAID Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required if Percentage Sales Tax Amount Paid (559-AX) is greater than zero (Ø) FL INCENTIVE AOUNT PAID unique payer requirement(s)) Imp Guide: Required if this value is used to arrive at the final reimbursement. Required if Incentive Amount Submitted (438- E3) is greater than zero (Ø). unique payer requirement(s))

133 Field # Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 563- J2 OTHER AOUNT PAID COUNT aximum count of 3. Imp Guide: Required if Other Amount Paid (565- J4) is used. unique payer requirement(s)) 564- J3 OTHER AOUNT PAID QUALIFIER Imp Guide: Required if Other Amount Paid (565- J4) is used. unique payer requirement(s))

134 Field # 565- J4 Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer OTHER AOUNT PAID Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required if this value is used to arrive at the final reimbursement. Required if Other Amount Claimed Submitted (48Ø- H9) is greater than zero (Ø) J5 OTHER PAYER AOUNT RECOGNIZED unique payer requirement(s)) Imp Guide: Required if this value is used to arrive at the final reimbursement. Required if Other Payer Amount Paid (431-DV) is greater than zero (Ø) and Coordination of Benefits/Other Payments Segment is supported. unique payer requirement(s))

135 Field # Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 5Ø9- F9 TOTAL AOUNT PAID R 522- F BASIS OF REIBURSEENT DETERINATION Imp Guide: Required if Ingredient Cost Paid (5Ø6- F6) is greater than zero (Ø). Required if Basis of Cost Determination (432-DN) is submitted on billing FN AOUNT ATTRIBUTED TO SALES TAX unique payer requirement(s)) Imp Guide: Required if Patient Pay Amount (5Ø5- F5) includes sales tax that is the financial responsibility of the member but is not also included in any of the other fields that add up to Patient Pay Amount. unique payer requirement(s))

136 Field # 512- FC Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer ACCUULATED DEDUCTIBLE AOUNT Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Provided for informational purposes only FD REAINING DEDUCTIBLE AOUNT unique payer requirement(s)) Imp Guide: Provided for informational purposes only. unique payer requirement(s)) 514- FE REAINING BENEFIT AOUNT Imp Guide: Provided for informational purposes only. unique payer requirement(s))

137 Field # 517- FH Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer AOUNT APPLIED TO PERIODIC DEDUCTIBLE Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required if Patient Pay Amount (5Ø5- F5) includes deductible 518- FI AOUNT OF COPAY unique payer requirement(s)) Imp Guide: Required if Patient Pay Amount (5Ø5- F5) includes copay as patient financial responsibility. 52Ø- FK AOUNT EXCEEDING PERIODIC BENEFIT AXIU unique payer requirement(s)) Imp Guide: Required if Patient Pay Amount (5Ø5- F5) includes amount exceeding periodic benefit maximum. unique payer requirement(s))

138 Field # 346- HH Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer BASIS OF CALCULATION DISPENSING FEE Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required if Dispensing Status (343- HD) on submission is P (Partial Fill) or C (Completion of Partial Fill) HJ BASIS OF CALCULATION COPAY unique payer requirement(s)) Imp Guide: Required if Dispensing Status (343- HD) on submission is P (Partial Fill) or C (Completion of Partial Fill). unique payer requirement(s))

139 Field # 348- HK Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer BASIS OF CALCULATION FLAT SALES TAX Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required if Dispensing Status (343- HD) on submission is P (Partial Fill) or C (Completion of Partial Fill) and Flat Sales Tax Amount Paid (558-AW) is greater than zero (Ø) H BASIS OF CALCULATION PERCENTAGE SALES TAX unique payer requirement(s)) Imp Guide: Required if Dispensing Status (343- HD) on submission is P (Partial Fill) or C (Completion of Partial Fill) and Percentage Sales Tax Amount Paid (559-AX) is greater than zero (Ø). unique payer requirement(s))

140 Field # 571- NZ Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer AOUNT ATTRIBUTED TO PROCESSOR FEE Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required if the customer is responsible for 1ØØ% of the prescription payment and when the provider net sale is less than the amount the customer is expected to pay EQ PATIENT SALES TAX AOUNT unique payer requirement(s)) Imp Guide: Used when necessary to identify the Patient s portion of the Sales Tax. Provided for informational purposes only. unique payer requirement(s))

141 Field # 574-2Y Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer PLAN SALES TAX AOUNT Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Used when necessary to identify the Plan s portion of the Sales Tax. Provided for informational purposes only U AOUNT OF COINSURANCE unique payer requirement(s)) Imp Guide: Required if Patient Pay Amount (5Ø5- F5) includes coinsurance as patient financial responsibility. unique payer requirement(s))

142 Field # 573-4V Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer BASIS OF CALCULATION- COINSURANCE Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required if Dispensing Status (343- HD) on submission is P (Partial Fill) or C (Completion of Partial Fill). unique payer requirement(s)) 392- U BENEFIT STAGE COUNT aximum count of 4. Imp Guide: Required if Benefit Stage Amount (394-W) is used. unique payer requirement(s)) 393- V BENEFIT STAGE QUALIFIER Imp Guide: Required if Benefit Stage Amount (394-W) is used. unique payer requirement(s))

143 Field # 394- W Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer BENEFIT STAGE AOUNT Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required when a edicare Part D payer applies financial amounts to edicare Part D beneficiary benefit stages. This field is required when the plan is a participant in a edicare Part D program that requires reporting of benefit stage specific financial amounts. Required if necessary for state/federal/regulatory agency programs. unique payer requirement(s))

144 Field # 577- G3 Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer ESTIATED GENERIC SAVINGS Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: This information should be provided when a patient selected the brand drug and a generic form of the drug was available. It will contain an estimate of the difference between the cost of the brand drug and the generic drug, when the brand drug is more expensive than the generic UC SPENDING ACCOUNT AOUNT REAINING unique payer requirement(s)) Imp Guide: This dollar amount will be provided, if known, to the receiver when the transaction had spending account dollars reported as part of the patient pay amount. unique payer requirement(s))

145 Field # 129- UD Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer HEALTH PLAN-FUNDED ASSISTANCE AOUNT Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required when the patient meets the planfunded assistance criteria, to reduce Patient Pay Amount (5Ø5-F5). The resulting Patient Pay Amount (5Ø5-F5) must be greater than or equal to zero UJ AOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION unique payer requirement(s)) Imp Guide: Required if Patient Pay Amount (5Ø5- F5) includes an amount that is attributable to a cost share differential due to the selection of one pharmacy over another unique payer requirement(s))

146 Field # 134- UK Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer AOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required if Patient Pay Amount (5Ø5- F5) includes an amount that is attributable to a patient s selection of a Brand drug U AOUNT ATTRIBUTED TO PRODUCT SELECTION/NON- PREFERRED FORULARY SELECTION unique payer requirement(s)) Imp Guide: Required if Patient Pay Amount (5Ø5- F5) includes an amount that is attributable to a patient s selection of a non-preferred formulary product. unique payer requirement(s))

147 Field # 136- UN Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer AOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NON-PREFERRED FORULARY SELECTION Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Imp Guide: Required if Patient Pay Amount (5Ø5- F5) includes an amount that is attributable to a patient s selection of a Brand nonpreferred formulary product UP AOUNT ATTRIBUTED TO COVERAGE GAP unique payer requirement(s)) Imp Guide: Required when the patient s financial responsibility is due to the coverage gap. unique payer requirement(s))

148 Field # Response Pricing Segment (111-A) = 23 NCPDP Field Name Value Payer Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 148-U8 INGREDIENT COST CONTRACTED/REIBURSABLE AOUNT Imp Guide: Required when Basis of Reimbursement Determination (522-F) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. unique payer requirement(s)) 149-U9 DISPENSING FEE CONTRACTED/REIBURSABLE AOUNT Imp Guide: Required when Basis of Reimbursement Determination (522-F) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. unique payer requirement(s))

149 Response DUR/PPS Segment Questions This Segment is always sent This Segment is situational Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Response DUR/PPS Segment (111-A) = 24 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 567-J6 DUR/PPS RESPONSE CODE COUNTER aximum 9 occurrences supported. Imp Guide: Required if Reason For Service Code (439-E4) is used. 439-E4 REASON FOR SERVICE CODE Imp Guide: Required if utilization conflict is detected.

150 Response DUR/PPS Segment (111-A) = 24 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 528-FS CLINICAL SIGNIFICANCE CODE Imp Guide: Required if needed to supply additional information for the utilization conflict. 529-FT OTHER PHARACY INDICATOR Imp Guide: Required if needed to supply additional information for the utilization conflict. 53Ø- FU PREVIOUS DATE OF FILL Imp Guide: Required if needed to supply additional information for the utilization conflict. Required if Quantity of Previous Fill (531-FV) is used.

151 Response DUR/PPS Segment (111-A) = 24 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 531-FV QUANTITY OF PREVIOUS FILL Imp Guide: Required if needed to supply additional information for the utilization conflict. Required if Previous Date Of Fill (53Ø-FU) is used FW DATABASE INDICATOR Imp Guide: Required if needed to supply additional information for the utilization conflict. 533-FX OTHER PRESCRIBER INDICATOR Imp Guide: Required if needed to supply additional information for the utilization conflict.

152 Response DUR/PPS Segment (111-A) = 24 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) 544-FY DUR FREE TEXT ESSAGE Imp Guide: Required if needed to supply additional information for the utilization conflict. 57Ø- NS DUR ADDITIONAL TEXT Imp Guide: Required if needed to supply additional information for the utilization conflict. Response Coordination of Benefits/Other Payers Segment Questions This Segment is always sent This Segment is situational Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational,

153 Response Coordination of Benefits/Other Payers Segment Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) (111-A) = NT OTHER PAYER ID COUNT 338-5C OTHER PAYER COVERAGE TYPE aximum count of C OTHER PAYER ID QUALIFIER Imp Guide: Required if Other Payer ID (34Ø-7C) is used. 34Ø- 7C OTHER PAYER ID Imp Guide: Required if other insurance information is available for coordination of benefits H OTHER PAYER PROCESSOR CONTROL NUBER Imp Guide: Required if other insurance information is available for coordination of benefits.

154 Response Coordination of Benefits/Other Payers Segment Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) (111-A) = NU OTHER PAYER CARDHOLDER ID Imp Guide: Required if other insurance information is available for coordination of benefits. 992-J OTHER PAYER GROUP ID Imp Guide: Required if other insurance information is available for coordination of benefits UV OTHER PAYER PERSON CODE Imp Guide: Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer.

155 Response Coordination of Benefits/Other Payers Segment Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) (111-A) = UB OTHER PAYER HELP DESK PHONE NUBER Imp Guide: Required if needed to provide a support telephone number of the other payer to the receiver UW OTHER PAYER PATIENT RELATIONSHIP CODE Imp Guide: Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer UX OTHER PAYER BENEFIT EFFECTIVE DATE Imp Guide: Required when other coverage is known which is after the Date of Service submitted.

156 Response Coordination of Benefits/Other Payers Segment Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) (111-A) = UY OTHER PAYER BENEFIT TERINATION DATE Imp Guide: Required when other coverage is known which is after the Date of Service submitted. Claim Billing/Claim Rebill Accepted/Rejected Response Response Transaction Header Segment Questions CLAI BILLING/CLAI REBILL ACCEPTED/REJECTED RESPONSE Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, This Segment is always sent X Response Transaction Header Segment Claim Billing/Claim Rebill Accepted/Rejected 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B1, B3 1Ø9-A9 TRANSACTION COUNT Same value as in request

157 Response Transaction Header Segment Claim Billing/Claim Rebill Accepted/Rejected 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 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 This Segment is always sent This Segment is situational Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, Response essage Segment (111-A) = 2Ø Claim Billing/Claim Rebill Accepted/Rejected

158 Response essage Segment (111-A) = 2Ø Claim Billing/Claim Rebill Accepted/Rejected 5Ø4-F4 ESSAGE Imp Guide: Required if text is needed for clarification or detail. Response Insurance Segment Questions This Segment is always sent This Segment is situational Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, Response Insurance Segment (111-A) = 25 Claim Billing/Claim Rebill Accepted/Rejected

159 Response Insurance Segment Claim Billing/Claim Rebill Accepted/Rejected (111-A) = 25 3Ø1-C1 GROUP ID Imp Guide: Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. Required to identify the actual group that was used when multiple group coverage s exist.

160 Response Insurance Segment Claim Billing/Claim Rebill Accepted/Rejected (111-A) = FO PLAN ID Imp Guide: Required if needed to identify the actual plan parameters, benefit, or coverage criteria, when available. Required to identify the actual plan ID that was used when multiple group coverage s exist. Required if needed to contain the actual plan ID if unknown to the receiver.

161 Response Insurance Segment Claim Billing/Claim Rebill Accepted/Rejected (111-A) = F NETWORK REIBURSEENT ID Imp Guide: Required if needed to identify the network for the covered member. Required if needed to identify the actual Network Reimbursement ID, when applicable and/or available. Required to identify the actual Network Reimbursement ID that was used when multiple Network Reimbursement IDs exist. 568-J7 PAYER ID QUALIFIER Imp Guide: Required if Payer ID (569-J8) is used.

162 Response Insurance Segment Claim Billing/Claim Rebill Accepted/Rejected (111-A) = J8 PAYER ID Imp Guide: Required to identify the ID of the payer responding. 3Ø2-C2 CARDHOLDER ID Imp Guide: Required if the identification to be used in future transactions is different than what was submitted on the request. Response Patient Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, This Segment is always sent This Segment is situational Response Patient Segment (111-A) = 29 Claim Billing/Claim Rebill Accepted/Rejected

163 31Ø- CA PATIENT FIRST NAE Imp Guide: Required if known. 311-CB PATIENT LAST NAE Imp Guide: Required if known. 3Ø4-C4 DATE OF BIRTH Imp Guide: Required if known. Response Status Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, This Segment is always sent X Response Status Segment (111-A) = 21 Claim Billing/Claim Rebill Accepted/Rejected

164 Response Status Segment (111-A) = 21 Claim Billing/Claim Rebill Accepted/Rejected 112-AN TRANSACTION RESPONSE STATUS R = Reject 5Ø3-F3 AUTHORIZATION NUBER Imp Guide: Required if needed to identify the transaction. 51Ø- FA REJECT COUNT aximum count of 5. R 511-FB REJECT CODE R 546-4F REJECT FIELD OCCURRENCE INDICATOR Imp Guide: Required if a repeating field is in error, to identify repeating field occurrence. 13Ø- UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. Imp Guide: Required if Additional essage Information (526-FQ) is used.

165 Response Status Segment (111-A) = UH ADDITIONAL ESSAGE INFORATION QUALIFIER Claim Billing/Claim Rebill Accepted/Rejected Imp Guide: Required if Additional essage Information (526-FQ) is used. 526-FQ ADDITIONAL ESSAGE INFORATION Imp Guide: Required when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFORATION CONTINUITY Imp Guide: Required 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.

166 Response Status Segment (111-A) = F HELP DESK PHONE NUBER QUALIFIER Claim Billing/Claim Rebill Accepted/Rejected Imp Guide: Required if Help Desk Phone Number (55Ø- 8F) is used. 55Ø-8F HELP DESK PHONE NUBER Imp Guide: Required if needed to provide a support telephone number to the receiver A URL Imp Guide: Provided for informational purposes only to relay health care communications via the Internet.

167 Response Claim Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, This Segment is always sent X Response Claim Segment (111-A) = 22 Claim Billing/Claim Rebill 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 551-9F PREFERRED PRODUCT COUNT aximum count of 6. Imp Guide: Required if Preferred Product ID (553- AR) is used. 552-AP PREFERRED PRODUCT ID QUALIFIER Imp Guide: Required if Preferred Product ID (553- AR) is used.

168 Response Claim Segment (111-A) = 22 Claim Billing/Claim Rebill Accepted/Rejected 553-AR PREFERRED PRODUCT ID Imp Guide: Required if a product preference exists that needs to be communicated to the receiver via an ID. 554-AS PREFERRED PRODUCT INCENTIVE Imp Guide: Required if there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). 555-AT PREFERRED PRODUCT COST SHARE INCENTIVE Imp Guide: Required if there is a known patient financial responsibility incentive amount associated with the Preferred Product ID (553- AR) and/or Preferred Product Description (556-AU).

169 Response Claim Segment (111-A) = AU PREFERRED PRODUCT DESCRIPTION Claim Billing/Claim Rebill Accepted/Rejected Imp Guide: Required if a product preference exists that either cannot be communicated by the Preferred Product ID (553- AR) or to clarify the Preferred Product ID (553-AR). Response DUR/PPS Segment Questions This Segment is always sent This Segment is situational Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, Response DUR/PPS Segment (111-A) = 24 Claim Billing/Claim Rebill Accepted/Rejected

170 Response DUR/PPS Segment Claim Billing/Claim Rebill Accepted/Rejected (111-A) = J6 DUR/PPS RESPONSE CODE COUNTER aximum 9 occurrences supported. Imp Guide: Required if Reason For Service Code (439-E4) is used. 439-E4 REASON FOR SERVICE CODE Imp Guide: Required if utilization conflict is detected. 528-FS CLINICAL SIGNIFICANCE CODE Imp Guide: Required if needed to supply additional information for the utilization conflict. 529-FT OTHER PHARACY INDICATOR Imp Guide: Required if needed to supply additional information for the utilization conflict.

171 Response DUR/PPS Segment Claim Billing/Claim Rebill Accepted/Rejected 53Ø- FU (111-A) = 24 PREVIOUS DATE OF FILL Imp Guide: Required if needed to supply additional information for the utilization conflict. Required if Quantity of Previous Fill (531-FV) is used. 531-FV QUANTITY OF PREVIOUS FILL Imp Guide: Required if needed to supply additional information for the utilization conflict. Required if Previous Date Of Fill (53Ø-FU) is used.

172 Response DUR/PPS Segment Claim Billing/Claim Rebill Accepted/Rejected 532- FW (111-A) = 24 DATABASE INDICATOR Imp Guide: Required if needed to supply additional information for the utilization conflict. 533-FX OTHER PRESCRIBER INDICATOR Imp Guide: Required if needed to supply additional information for the utilization conflict. 544-FY DUR FREE TEXT ESSAGE Imp Guide: Required if needed to supply additional information for the utilization conflict.

173 Response DUR/PPS Segment Claim Billing/Claim Rebill Accepted/Rejected 57Ø- NS (111-A) = 24 DUR ADDITIONAL TEXT Imp Guide: Required if needed to supply additional information for the utilization conflict. Response Prior Authorization Segment Questions This Segment is always sent This Segment is situational Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, Response Prior Authorization Segment (111-A) = 26 Claim Billing/Claim Rebill Accepted/Rejected

174 Response Prior Authorization Segment Claim Billing/Claim Rebill Accepted/Rejected (111-A) = PY PRIOR AUTHORIZATION NUBER ASSIGNED Imp Guide: Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. Response Coordination of Benefits/Other Payers Segment Questions This Segment is always sent This Segment is situational Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, Response Coordination of Benefits/Other Payers Segment (111-A) = 28 Claim Billing/Claim Rebill Accepted/Rejected 355-NT OTHER PAYER ID COUNT aximum count of 3.

175 Response Coordination of Benefits/Other Payers Segment Claim Billing/Claim Rebill Accepted/Rejected (111-A) = C OTHER PAYER COVERAGE TYPE 339-6C OTHER PAYER ID QUALIFIER Imp Guide: Required if Other Payer ID (34Ø-7C) is used. 34Ø- 7C OTHER PAYER ID Imp Guide: Required if other insurance information is available for coordination of benefits H OTHER PAYER PROCESSOR CONTROL NUBER Imp Guide: Required if other insurance information is available for coordination of benefits.

176 Response Coordination of Benefits/Other Payers Segment Claim Billing/Claim Rebill Accepted/Rejected (111-A) = NU OTHER PAYER CARDHOLDER ID Imp Guide: Required if other insurance information is available for coordination of benefits. 992-J OTHER PAYER GROUP ID Imp Guide: Required if other insurance information is available for coordination of benefits UV OTHER PAYER PERSON CODE Imp Guide: Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer.

177 Response Coordination of Benefits/Other Payers Segment Claim Billing/Claim Rebill Accepted/Rejected (111-A) = UB OTHER PAYER HELP DESK PHONE NUBER Imp Guide: Required if needed to provide a support telephone number of the other payer to the receiver UW OTHER PAYER PATIENT RELATIONSHIP CODE Imp Guide: Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer UX OTHER PAYER BENEFIT EFFECTIVE DATE Imp Guide: Required when other coverage is known which is after the Date of Service submitted.

178 Response Coordination of Benefits/Other Payers Segment Claim Billing/Claim Rebill Accepted/Rejected (111-A) = UY OTHER PAYER BENEFIT TERINATION DATE Imp Guide: Required when other coverage is known which is after the Date of Service submitted. Claim Billing/Claim Rebill Rejected/Rejected Response Response Transaction Header Segment Questions CLAI BILLING/CLAI REBILL REJECTED/REJECTED RESPONSE Check Claim Billing/Claim Rebill Rejected/Rejected If Situational, This Segment is always sent X Response Transaction Header Segment Claim Billing/Claim Rebill Rejected/Rejected 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B1, B3 1Ø9-A9 TRANSACTION COUNT Same value as in request

179 Response Transaction Header Segment Claim Billing/Claim Rebill Rejected/Rejected 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 This Segment is always sent This Segment is situational Check Claim Billing/Claim Rebill Rejected/Rejected If Situational, Response essage Segment (111-A) = 2Ø Claim Billing/Claim Rebill Rejected/Rejected

180 Response essage Segment (111-A) = 2Ø Claim Billing/Claim Rebill Rejected/Rejected 5Ø4-F4 ESSAGE Imp Guide: Required if text is needed for clarification or detail. Response Status Segment Questions Check Claim Billing/Claim Rebill Rejected/Rejected If Situational, This Segment is always sent X Response Status Segment (111-A) = 21 Claim Billing/Claim Rebill Rejected/Rejected 112- AN TRANSACTION RESPONSE STATUS R = Reject

181 Response Status Segment (111-A) = 21 Claim Billing/Claim Rebill Rejected/Rejected 5Ø3-F3 AUTHORIZATION NUBER Imp Guide: Required if needed to identify the transaction. 51Ø- FA REJECT COUNT aximum count of 5. R 511-FB REJECT CODE R 546-4F REJECT FIELD OCCURRENCE INDICATOR Imp Guide: Required if a repeating field is in error, to identify repeating field occurrence. 13Ø- UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. Imp Guide: Required if Additional essage Information (526-FQ) is used.

182 Response Status Segment (111-A) = 21 Claim Billing/Claim Rebill Rejected/Rejected 132- UH ADDITIONAL ESSAGE INFORATION QUALIFIER Imp Guide: Required if Additional essage Information (526-FQ) is used. 526-FQ ADDITIONAL ESSAGE INFORATION Imp Guide: Required when additional text is needed for clarification or detail UG ADDITIONAL ESSAGE INFORATION CONTINUITY Imp Guide: Required 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.

183 Response Status Segment (111-A) = F HELP DESK PHONE NUBER QUALIFIER Claim Billing/Claim Rebill Rejected/Rejected Imp Guide: Required if Help Desk Phone Number (55Ø- 8F) is used. 55Ø-8F HELP DESK PHONE NUBER Imp Guide: Required if needed to provide a support telephone number to the receiver. ** End of Response Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template**

184 NCPDP VERSION D CLAI REVERSAL INSTRUCTIONS General Information Fields shown in red text are to be filled out by the Payer. Fields shown in black text are not to be modified by the Payer. Examples of payer sheet templates filled out can be found in section Examples of Payer Templates. Request Template Information Sections Instructions to Payers and Field Legend must be followed. The template information includes General Information Field Legends for Columns Claim Reversal Transaction (segments and fields) Response Template Information The Claim Reversal response template defines the Claim Reversal response transaction for an Approved or Rejected response. Payers should fill out a separate template for each transaction supported, with each response supported, as appropriate (for example, for Claim Billing Paid, Reject, Captured, etc response; for Service Billing Paid, Rejected, etc response; for Reversal Approved, Rejected, etc response) as appropriate for their business. Sections Instructions to Payers and Field Legend must be followed. The template information includes General Information Field Legend for Columns Claim Reversal Transaction Response (segments and fields)

185 NCPDP VERSION D CLAI REVERSAL TEPLATE Request Claim Reversal Payer Sheet Template ** Start of Request Claim Reversal (B2) Payer Sheet Template** GENERAL INFORATION Payer Name: Name Plan Name/Group Name: Plan Name/Group Name Plan Name/Group Name: Plan Name/Group Name Plan Name/Group Name: Plan Name/Group Name Date: Date BIN: BIN: BIN: PCN: PCN: PCN: FIELD LEGEND FOR COLUNS 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. No No QUALIFIED REQUIREENT RW Required when. The situations designated have qualifications for usage ( Required if x, Not required if y ). Yes

186 Payer Column Value Explanation Column NOT USED NA The Field is not used for the Segment in the designated Transaction. No Not used are shaded for clarity for the Payer when creating the Template. For the actual Payer Template, not used fields must be deleted from the transaction (the row in the table removed). Question Answer What is your reversal window? (If transaction is billed today what is the timeframe for reversal to be submitted?) Specify timeframe

187 CLAI REVERSAL TRANSACTION The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Transaction Header Segment Questions This Segment is always sent 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 Check X Claim Reversal If Situational, Transaction Header Segment Claim Reversal 1Ø1- A1 BIN NUBER If more than one BIN/PCN but all plans use the same segments and fields and situations, enter multiple BIN/PCNs under General Information above.

188 Transaction Header Segment Claim Reversal 1Ø2- A2 VERSION/RELEASE NUBER DØ 1Ø3- A3 TRANSACTION CODE B2 1Ø4- A4 PROCESSOR CONTROL NUBER Specify how this field is used, if not blanks. 1Ø9- A9 TRANSACTION COUNT Specify max # of transactions supported for each transaction code. 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER 2Ø1-B1 SERVICE PROVIDER ID Specify value supported for this plan. 4Ø1- D1 DATE OF SERVICE 11Ø- AK SOFTWARE VENDOR/CERTIFICATION ID Specify how this field is used, if not blanks. Insurance Segment Questions Check Claim Reversal If Situational, This Segment is always sent This Segment is situational

189 Insurance Segment Claim Reversal (111-A) = Ø4 3Ø2-C2 CARDHOLDER ID 3Ø1-C1 GROUP ID Imp Guide: Required if needed to match the reversal to the original billing transaction A EDIGAP ID Imp Guide: Required, if known, when patient has edigap coverage. Claim Segment Questions Check Claim Reversal If Situational, This Segment is always sent X Claim Segment Claim Reversal (111-A) = Ø7

190 Claim Segment Claim Reversal (111-A) = Ø E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER Imp Guide: For Transaction Code of B2, in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 1 (Rx Billing). 4Ø2- D2 PRESCRIPTION/SERVICE REFERENCE NUBER 436-E1 PRODUCT/SERVICE ID QUALIFIER 4Ø7- D7 PRODUCT/SERVICE ID 4Ø3-D3 FILL NUBER Imp Guide: Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (4Ø2-D2) occur on the same day. 3Ø8-C8 OTHER COVERAGE CODE Imp Guide: Required if needed by receiver to match the claim that is being reversed.

191 Claim Segment Claim Reversal (111-A) = Ø7 147-U7 PHARACY SERVICE TYPE Imp Guide: Required when the submitter must clarify the type of services being performed as a condition for proper reimbursement by the payer. Service Billing/Service Rebill Accepted/Paid (Duplicate of Paid) N 112- TRANSACTION RESPONSE STATUS P=Paid D=Duplicate of Paid 5Ø3- F3 AUTHORIZATION NUBER RW Imp Guide: Required if needed to identify the transaction. Payer Requirement: Will contain the traceback number of the claim.

192 Claim Segment Claim Reversal (111-A) = Ø7 13Ø- UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Payer Requirement: aximum count of 2 will be returned UH ADDITIONAL ESSAGE INFORATION QUALIFIER Ø1 = Used for first line of free form text with no pre-defined structure. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Ø2 = Used for second line of free form text with no pre-defined structure. Payer Requirement: Only qualifier values cited will be returned FQ ADDITIONAL ESSAGE INFORATION RW Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Will be returned.

193 Claim Segment Claim Reversal (111-A) = Ø F HELP DESK PHONE NUBER QUALIFIER Ø3 = Processor/PB RW Imp Guide: Required if Help Desk Phone Number (55Ø- 8F) is used. Payer Requirement: Will be returned. 55Ø- 8F HELP DESK PHONE NUBER RW Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Will be returned. Response Claim Segment Questions Check Service Billing/Service Rebill Accepted/Paid (Duplicate of Paid) If Situational, This Segment is always sent X Response Claim Segment (111-A) = 22 Service Billing/Service Rebill Accepted/Paid (Duplicate of Paid)

194 455- E 4Ø2- D2 PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUBER 2 = Service Billing Imp Guide: For Transaction Code of S1 or S3, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 2 (Service Billing). Response Pricing Segment Questions Check Service Billing/Service Rebill Accepted/Paid (Duplicate of Paid) If Situational, This Segment is always sent X Response Pricing Segment (111-A) = 23 Service Billing/Service Rebill Accepted/Paid (Duplicate of Paid) 5Ø5-F5 PATIENT PAY AOUNT R

195 Response Pricing Segment (111-A) = 23 Service Billing/Service Rebill Accepted/Paid (Duplicate of Paid) 557-AV TAX EXEPT INDICATOR RW Imp Guide: Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. Payer Requirement: Same as Imp Guide AW FLAT SALES TAX AOUNT PAID RW Imp Guide: Required 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. Payer Requirement: Same as Imp Guide.

196 Response Pricing Segment (111-A) = 23 Service Billing/Service Rebill Accepted/Paid (Duplicate of Paid) 559-AX PERCENTAGE SALES TAX AOUNT PAID RW Imp Guide: Required if this value is used to arrive at the final reimbursement. Required if Percentage Sales Tax Amount Submitted (482- GE) is greater than zero (Ø). Required if Percentage Sales Tax Rate Paid (56Ø-AY) and Percentage Sales Tax Basis Paid (561-AZ) are used. Payer Requirement: Same as Imp Guide. 56Ø- AY PERCENTAGE SALES TAX RATE PAID RW Imp Guide: Required if Percentage Sales Tax Amount Paid (559-AX) is greater than zero (Ø). Payer Requirement: Same as Imp Guide. 562-J1 PROFESSIONAL SERVICE FEE PAID R 5Ø9-F9 TOTAL AOUNT PAID R

197 Response Pricing Segment (111-A) = 23 Service Billing/Service Rebill Accepted/Paid (Duplicate of Paid) 517-FH AOUNT APPLIED TO PERIODIC DEDUCTIBLE RW Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes deductible Payer Requirement: Same as Imp Guide. 518-FI AOUNT OF COPAY RW Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes copay as patient financial responsibility. Payer Requirement: Same as Imp Guide. 52Ø- FK AOUNT EXCEEDING PERIODIC BENEFIT AXIU RW Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes amount exceeding periodic benefit maximum. Payer Requirement: Same as Imp Guide.

198 Response Pricing Segment (111-A) = 23 Service Billing/Service Rebill Accepted/Paid (Duplicate of Paid) 572-4U AOUNT OF COINSURANCE RW Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes coinsurance as patient financial responsibility. Payer Requirement: Same as Imp Guide. 575-EQ PATIENT SALES TAX AOUNT RW Imp Guide: Used when necessary to identify the Patient s portion of the Sales Tax. Payer Requirement: Same as Imp Guide Y PLAN SALES TAX AOUNT RW Imp Guide: Used when necessary to identify the Plan s portion of the Sales Tax. Provided for informational purposes only. Payer Requirement: Same as Imp Guide.

199 Service Billing/Service Rebill Accepted/Rejected Response Response Transaction Header Segment Questions SERVICE BILLING/SERVICE REBILL ACCEPTED/REJECTED RESPONSE Check Service Billing/Service Rebill Accepted/Rejected If Situational, This Segment is always sent X Response Transaction Header Segment Service Billing/Service Rebill Accepted/Rejected 1Ø2- A2 VERSION/RELEASE NUBER DØ 1Ø3- A3 TRANSACTION CODE S1, S3 Service Billing, Service Rebill 1Ø9- A9 TRANSACTION COUNT Same value as in st 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 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

200 Response essage Segment Questions Check Service Billing/Service Rebill Accepted/Rejected If Situational, This Segment is always sent This Segment is situational X Will be returned on rejected claims when the error ransmission-level. Response essage Segment Service Billing/Service Rebill Accepted/Rejected (111-A) = 2Ø 5Ø4-F4 ESSAGE Imp Guide: Required if text is needed for clarification or detail. Payer Requirement: Will be returned when text information needs to be sent. Response Patient Segment Questions Check Service Billing/Service Rebill Accepted/Rejected This Segment is always sent If Situational, This Segment is situational X Will be returned if patient can be found.

201 Response Patient Segment (111-A) = 29 Service Billing/Service Rebill Accepted/Rejected 31Ø- CA PATIENT FIRST NAE RW Imp Guide: Required if known. Payer Requirement: Will be returned if patient can be found. 311-CB PATIENT LAST NAE RW Imp Guide: Required if known. Payer Requirement: Will be returned if patient can be found. 3Ø4- C4 DATE OF BIRTH RW Imp Guide: Required if known. Payer Requirement: Will be returned if patient can be found. Response Status Segment Questions Check Service Billing/Service Rebill Accepted/Rejected If Situational, This Segment is always sent X

202 Response Status Segment (111-A) = 21 Service Billing/Service Rebill Accepted/Rejected 112- AN TRANSACTION RESPONSE STATUS R = Reject 51Ø- FA REJECT COUNT aximum count of 5. R 511-FB REJECT CODE NCPDP Reject Codes 546-4F REJECT FIELD OCCURRENCE INDICATOR R RW Imp Guide: Required if a repeating field is in error, to identify repeating field occurrence. Payer Requirement: Same as Imp Guide. 13Ø- UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Payer Requirement: aximum count of 2 will be returned.

203 Response Status Segment (111-A) = 21 Service Billing/Service Rebill Accepted/Rejected 132- UH ADDITIONAL ESSAGE INFORATION QUALIFIER Ø1 = Used for first line of free form text with no pre-defined structure. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Ø2 = Used for second line of free form text with no pre-defined structure. Payer Requirement: Only qualifier values cited will be returned. 526-FQ ADDITIONAL ESSAGE INFORATION RW Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Will be returned F HELP DESK PHONE NUBER QUALIFIER Ø3 = Processor/PB RW Imp Guide: Required if Help Desk Phone Number (55Ø-8F) is used. Payer Requirement: Will be returned.

204 Response Status Segment (111-A) = 21 Service Billing/Service Rebill Accepted/Rejected 55Ø-8F HELP DESK PHONE NUBER RW Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Will be returned. Response Claim Segment Questions Check Service Billing/Service Rebill Accepted/Rejected If Situational, This Segment is always sent X Response Claim Segment (111-A) = 22 Service Billing/Service Rebill Accepted/Rejected 455- E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 2 = Service Billing Imp Guide: For Transaction Code of S1 or S3, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 2 (Service Billing).

205 Response Claim Segment (111-A) = 22 Service Billing/Service Rebill Accepted/Rejected 4Ø2- D2 PRESCRIPTION/SERVICE REFERENCE NUBER Response DUR/PPS Segment Questions Check Service Billing/Service Rebill Accepted/Rejected If Situational, This Segment is always sent This Segment is situational X This segment will be transmitted on a reject when a possible conflict is detected. Response DUR/PPS Segment Service Billing/Service Rebill Accepted/Rejected (111-A) = 24

206 Response DUR/PPS Segment Service Billing/Service Rebill Accepted/Rejected (111-A) = J6 DUR/PPS RESPONSE CODE COUNTER aximum 9 occurrences supported. RW Imp Guide: Required if Reason For Service Code (439-E4) is used. Payer Requirement: Same as Imp Guide. 439-E4 REASON FOR SERVICE CODE All values supported RW Imp Guide: Required if professional service opportunity reason is detected by the receiver that is different from the professional service submitted. 533-FX OTHER PRESCRIBER INDICATOR Payer Requirement: Same as Imp Guide. All values supported RW Imp Guide: Required if needed to supply additional information for the service. Payer Requirement: Same as Imp Guide.

207 Response DUR/PPS Segment Service Billing/Service Rebill Accepted/Rejected (111-A) = FY DUR FREE TEXT ESSAGE RW Imp Guide: Required if needed to supply additional information for the service. Payer Requirement: Same as Imp Guide. 57Ø- NS DUR ADDITIONAL TEXT RW Imp Guide: Required if needed to supply additional information for the service. Payer Requirement: Same as Imp Guide.

208 Service Billing/Service Rebill Rejected/Rejected Response Response Transaction Header Segment Questions SERVICE BILLING/SERVICE REBILL REJECTED/REJECTED RESPONSE Check Service Billing/Service Rebill Rejected/Rejected If Situational, This Segment is always sent X Response Transaction Header Segment Service Billing/Service Rebill Rejected/Rejected 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE S1, S3 Service Billing, Service Rebill 1Ø9-A9 TRANSACTION COUNT Same value as in request 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

209 Response essage Segment Questions This Segment is always sent Check Service Billing/Service Rebill Rejected/Rejected If Situational, This Segment is situational X Will be returned on rejected claims when the error ransmission-level. Response essage Segment Service Billing/Service Rebill Rejected/Rejected (111-A) = 2Ø 5Ø4-F4 ESSAGE RW Imp Guide: Required if text is needed for clarification or detail. Payer Requirement: Will be returned on rejected claims when the error is in Transaction Header fields. This Segment is always sent X Response Status Segment (111-A) = 21 Service Billing/Service Rebill Rejected/Rejected

210 112- AN TRANSACTION RESPONSE STATUS R = Reject 5Ø3-F3 AUTHORIZATION NUBER R 51Ø- FA REJECT COUNT aximum count of 5. R 511-FB REJECT CODE NCPDP Reject Codes 546-4F REJECT FIELD OCCURRENCE INDICATOR R RW Imp Guide: Required if a repeating field is in error, to identify repeating field occurrence. Payer Requirement: Same as Imp Guide. 13Ø- UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Payer Requirement: aximum count of 2 will be returned.

211 Response Status Segment (111-A) = 21 Service Billing/Service Rebill Rejected/Rejected 132- UH ADDITIONAL ESSAGE INFORATION QUALIFIER Ø1 = Used for first line of free form text with no pre-defined structure. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Ø2 = Used for second line of free form text with no pre-defined structure. Payer Requirement: Only qualifier values cited will be returned. 526-FQ ADDITIONAL ESSAGE INFORATION RW Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Will be returned UG ADDITIONAL ESSAGE INFORATION CONTINUITY RW Imp Guide: Required 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. Payer Requirement: Same as Imp Guide.

212 Response Status Segment (111-A) = 21 Service Billing/Service Rebill Rejected/Rejected 549-7F HELP DESK PHONE NUBER QUALIFIER Ø3 = Processor/PB RW Imp Guide: Required if Help Desk Phone Number (55Ø-8F) is used. Payer Requirement: Will be returned. 55Ø-8F HELP DESK PHONE NUBER RW Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Will be returned. ** End of Response Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template** Contact/Information Source: General website Provider anuals available at Certification Testing Window: onday Wednesday, 7 am PT 7 pm PT test against automated system Certification Contact Information: x 12Ø Certification Help Desk Provider Relations Help Desk Info:

213 Other versions supported: NCPDP Telecommunication version 5.1 until further notice 11Ø- AK SOFTWARE DOR/CERTIFICATION ID Blank fill Blank fill 337-4C COORDINATION OF BENEFITS/OTHER PAYENTS COUNT 338-5C OTHER PAYER COVERAGE TYPE aximum count of All values rted C OTHER PAYER ID QUALIFIER Ø3 = BIN RW Imp Guide: Required if Other Payer ID (34Ø-7C) is used. Payer Requirement: Required when claim has been paid or rejected by previous payer(s). 34Ø-7C OTHER PAYER ID RW Imp Guide: Required if identification of the Other Payer is necessary for claim/encounter adjudication. Payer Requirement: Required when claim has been paid or rejected by previous payer(s). 443-E8 OTHER PAYER DATE RW Imp Guide: Required if identification of the Other Payer Date is necessary for claim/encounter adjudication.

214 Payer Requirement: Required when claim has been paid or rejected by previous payer(s) E OTHER PAYER REJECT COUNT aximum count of 5. RW Imp Guide: Required if Other Payer Reject Code (472-6E) is used. Payer Requirement: Required when claim has been rejected by previous payer(s) E OTHER PAYER REJECT CODE RW Imp Guide: Required when the other payer has denied the payment for the billing, designated with Other Coverage Code (3Ø8-C8) = 3 (Other Coverage Billed claim not covered). Payer Requirement: Required when claim has been rejected by previous payer(s). 353-NR OTHER PAYER-PATIENT RESPONSIBILITY AOUNT COUNT aximum count of 25. RW Imp Guide: Required if Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. Payer Requirement: Same as Imp Guide. 351-NP OTHER PAYER-PATIENT RESPONSIBILITY AOUNT QUALIFIER All values supported. RW Imp Guide: Required if Other Payer-Patient Responsibility Amount (352-NQ) is used.

215 352-NQ OTHER PAYER-PATIENT RESPONSIBILITY AOUNT RW Payer Requirement: Same as Imp Guide. Imp Guide: Required if necessary for patient financial responsibility only billing. Required if necessary for state/federal/regulatory agency programs. Not used for non-governmental agency programs if Other Payer Amount Paid (431-DV) is submitted. Payer Requirement: Required. 451-EG COPOUND DISPENSING UNIT FOR INDICATOR All values rted. 447-EC COPOUND INGREDIENT COPONENT COUNT aximum of 25 ingredients. Payer Requirement: aximum of 1Ø ingredients. ** End of Request Claim Billing (B1) Payer Sheet Template** 4Ø1- D1 DATE OF SERVICE Same value as in request

216 This Segment is always sent This Segment is situational X XXX This Segment is always sent X 526-FQ ADDITIONAL ESSAGE INFORATION RW Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Will be returned. 131-UG ADDITIONAL ESSAGE INFORATION CONTINUITY RW Imp Guide: Required 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. Payer Requirement: Same as Imp Guide F HELP DESK PHONE NUBER QUALIFIER Ø3 = Processor/PB RW Imp Guide: Required if Help Desk Phone Number (55Ø-8F) is used. Payer Requirement: Will be returned.

217 55Ø-8F HELP DESK PHONE NUBER RW Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Will be returned E 4Ø2- D2 PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUBER 1 = RxBilling Imp Guide: For Transaction Code of B2, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 1 (Rx Billing). 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

218 5Ø4-F4 ESSAGE Imp Guide: Required if text is needed for clarification or detail. Payer Requirement: Will be returned when text information needs to be sent. Non-Workers Compensation Claim General Health Plan information from the same payer as above, ABC, Inc. Non-Workers Compensation Claim Request ** Start of Request Claim Billing Payer Sheet Template** GENERAL INFORATION Payer Name: ABC, Inc. Date: Ø1/Ø1/2Ø1Ø Plan Name/Group Name: General Health Plan BIN: PCN: Blank fill Processor: Effective as of: Ø7/Ø1/2Ø1Ø NCPDP Data Dictionary Version Date: Ø7/2ØØ7 NCPDP Telecommunication Standard Version/Release #: D.Ø NCPDP External Code List Version Date: Ø1/2ØØ8

219 Contact/Information Source: General website Provider anuals available at Certification Testing Window: onday Wednesday, 7 am PT 7 pm PT test against automated system Certification Contact Information: x 12Ø Certification Help Desk Provider Relations Help Desk Info: Other versions supported: NCPDP Telecommunication version 5.1 until further notice OTHER TRANSACTIONS SUPPORTED Transaction Code B2 Transaction Name Claim Reversal FIELD LEGEND FOR COLUNS Payer Column Value Explanation Payer Situation 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. No No QUALIFIED REQUIREENT RW Required when. The situations designated have qualifications for usage ("Required if x", "Not required if y"). Yes Fields that are not used in the Claim Billing transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template.

220 CLAI BILLING TRANSACTION Transaction Header Segment Questions This Segment is always sent 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 Check X X Claim Billing If Situational, Transaction Header Segment Claim Billing 1Ø1- A1 BIN NUBER BIN for General Health Plan 1Ø2- A2 VERSION/RELEASE BER DØ 1Ø3- A3 TRANSACTION CODE B1 Claim Billing 1Ø4- A4 PROCESSOR CONTROL BER Blank fill Blank fill 1Ø9- A9 TRANSACTION COUNT Ø1 = One occurrence

221 Transaction Header Segment Claim Billing 2Ø2- B2 SERVICE PROVIDER ID LIFIER Ø1 = National der ID 2Ø1- B1 SERVICE PROVIDER ID 4Ø1- D1 DATE OF SERVICE 11Ø- AK SOFTWARE DOR/CERTIFICATION ID Blank fill Blank fill Insurance Segment Questions Check Claim Billing If Situational, This Segment is always sent X Insurance Segment Claim Billing (111-A) = Ø4 3Ø2- C2 CARDHOLDER ID ember s ID as shown on card.

222 Insurance Segment Claim Billing (111-A) = Ø4 3Ø3- C3 PERSON CODE RW Imp Guide: Required if needed to uniquely identify the family members within the Cardholder ID. Payer Requirement: This information is located at the end of the Cardholder ID on the Benefit Card. 3Ø6- C8 PATIENT RELATIONSHIP E RW Imp Guide: Required if needed to uniquely identify the relationship of the Patient to the Cardholder. Payer Requirement: Required. Patient Segment Questions Check Claim Billing If Situational, This Segment is always sent X This Segment is situational Patient Segment Claim Billing (111-A) = Ø1

223 Field NCPDP Field Name Value Payer 3Ø4- DATE OF BIRTH R 3Ø5- PATIENT GENDER CODE R 31Ø- PATIENT FIRST NAE RW Imp Guide: Required when the patient has a first name. Payer Requirement: Required as all patients are enrolled with a first name. If newborn, use BABY BOY or BABY GIRL. If person has only one name, put one name in this field. 311-CB PATIENT LAST NAE R Claim Segment Questions Check Claim Billing If Situational, This Segment is always sent X This payer supports partial fills This payer does not support partial fills X Claim Segment Claim Billing (111-A) = Ø7

224 Claim Segment Claim Billing (111-A) = Ø E 4Ø2- D2 PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUBER 1 = 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 Ø1 = Universal Product Code (UPC) Ø3 = National Drug Code (NDC) 4Ø7- D7 PRODUCT/SERVICE ID 442-E7 QUANTITY DISPENSED R 4Ø3- D3 4Ø5- D5 FILL NUBER DAYS SUPPLY R R

225 Claim Segment Claim Billing (111-A) = Ø7 4Ø6- D6 COPOUND CODE Ø1 = Not a Compound R Ø2 = Compound See Compound Segment for support of multi-ingredient compounds 4Ø8- D8 DISPENSE AS WRITTEN (DAW/PRODUCT SELECTION CODE) All values rted. R 414-DE DATE PRESCRIPTION TTEN R 354- NX SUBISSION CLARIFICATION CODE COUNT aximum count of 3. RW Imp Guide: Required if Submission Clarification Code (42Ø-DK) is used. Payer Requirement: Same as Imp Guide.

226 Claim Segment Claim Billing (111-A) = Ø7 42Ø- DK SUBISSION CLARIFICATION CODE All values supported. RW Imp Guide: Required 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 edicare Part A expires. Used only in long-term care settings) for individual unit of use medications. Payer Requirement: Required when claim explanation is needed for overrides.

227 Claim Segment Claim Billing (111-A) = Ø7 3Ø8- C8 OTHER COVERAGE CODE All values supported. RW Imp Guide: Required if needed by receiver, to communicate a summation of other coverage information that has been collected from other payers. Required for Coordination of Benefits. Payer Requirement: Only used in COB claims. 995-E2 ROUTE OF ADINISTRATION RW Imp Guide: Required if specified in trading partner agreement. Payer Requirement: Required when Compound Code (4Ø6- D6) = 2 (compound). Pricing Segment Questions Check Claim Billing If Situational, This Segment is always sent X Pricing Segment Claim Billing (111-A) = 11

228 4Ø9- D9 INGREDIENT COST ITTED R 43Ø- DU GROSS AOUNT DUE R 412- DC DISPENSING FEE SUBITTED RW Imp Guide: Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. Payer Requirement: Same as Guide DQ USUAL AND TOARY CHARGE RW Imp Guide: Required if needed per trading partner agreement. Payer Requirement: Required. 478-H7 OTHER AOUNT CLAIED SUBITTED COUNT aximum count of 3. RW Imp Guide: Required if Other Amount Claimed Submitted Qualifier (479-H8) is used. Payer Requirement: Same as Imp Guide. 479-H8 OTHER AOUNT CLAIED SUBITTED QUALIFIER Ø1 = Delivery cost Ø4 = Administrative cost RW Imp Guide: Required if Other Amount Claimed Submitted (48Ø-H9) is used. Payer Requirement: Same as Imp Guide.

229 Pricing Segment Claim Billing (111-A) = 11 48Ø- H9 OTHER AOUNT CLAIED SUBITTED RW Imp Guide: Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. Payer Requirement: Required for values listed. 423-DN BASIS OF COST DETERINATION RW Imp Guide: Required if needed for receiver claim/encounter adjudication. Payer Requirement: Required. Prescriber Segment Questions Check Claim Billing If Situational, This Segment is always sent X This Segment is situational Prescriber Segment Claim Billing (111-A) = Ø3

230 Prescriber Segment Claim Billing (111-A) = Ø3 466-EZ PRESCRIBER ID LIFIER Ø1 = National Provider ID Ø8 = State License (if prescriber does not have an NPI or NPI is not known) RW Imp Guide: Required if Prescriber ID (411-DB) is used. Payer Requirement: Required to be either value on all claims PRESCRIBER ID RW Imp Guide: Required if this field could result in different coverage or patient financial responsibility. Required if necessary for state/federal/regulatory agency programs. Payer Requirement: Required when the Prescriber ID Qualifier is sent.

231 Coordination of Benefits/Other Payments Segment Questions This Segment is always sent Check Claim Billing If Situational, This Segment is situational X Required only for secondary, tertiary, etc claims. Scenario 1 - Other Payer Amount Paid Repetitions Only Scenario 2 - Other Payer-Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only Scenario 3 - Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) X Required when Other Coverage Code = 8 (Claim is billing for patient financial responsibility) Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing Scenario 2- Other Payer- Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only 337-4C COORDINATION OF BENEFITS/OTHER PAYENTS COUNT 338-5C OTHER PAYER COVERAGE TYPE aximum count of All values rted C OTHER PAYER ID Ø3 = BIN RW Imp Guide: Required if Other

232 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 QUALIFIER Claim Billing Scenario 2- Other Payer- Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only Payer ID (34Ø-7C) is used. Payer Requirement: Required when claim has been paid or rejected by previous payer(s). 34Ø-7C OTHER PAYER ID RW Imp Guide: Required if identification of the Other Payer is necessary for claim/encounter adjudication. Payer Requirement: Required when claim has been paid or rejected by previous payer(s). 443-E8 OTHER PAYER DATE RW Imp Guide: Required if identification of the Other Payer Date is necessary for claim/encounter adjudication. Payer Requirement: Required when claim has been paid or rejected by previous payer(s) E OTHER PAYER REJECT aximum count of 5. RW Imp Guide: Required if Other Payer Reject Code (472-6E) is

233 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 COUNT Claim Billing Scenario 2- Other Payer- Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only used. Payer Requirement: Required when claim has been rejected by previous payer(s) E OTHER PAYER REJECT CODE RW Imp Guide: Required when the other payer has denied the payment for the billing, designated with Other Coverage Code (3Ø8-C8) = 3 (Other Coverage Billed claim not covered). Payer Requirement: Required when claim has been rejected by previous payer(s). 353-NR OTHER PAYER-PATIENT RESPONSIBILITY AOUNT COUNT aximum count of 25. RW Imp Guide: Required if Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. Payer Requirement: Same as Imp Guide.

234 Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Claim Billing Scenario 2- Other Payer- Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only 351-NP OTHER PAYER-PATIENT RESPONSIBILITY AOUNT QUALIFIER RW Imp Guide: Required if Other Payer-Patient Responsibility Amount (352-NQ) is used. 352-NQ OTHER PAYER-PATIENT RESPONSIBILITY AOUNT RW Payer Requirement: Same as Imp Guide. Imp Guide: Required if necessary for patient financial responsibility only billing. Required if necessary for state/federal/regulatory agency programs. Not used for non-governmental agency programs if Other Payer Amount Paid (431-DV) is submitted. Payer Requirement: Required.

235 Compound Segment Questions Check Claim Billing This Segment is always sent If Situational, This Segment is situational X Required when Compound Code (4Ø6-D6) = 2 (compound). Compound Segment Claim Billing (111-A) = 1Ø 45Ø- EF COPOUND DOSAGE FOR DESCRIPTION CODE All values supported EG COPOUND DISPENSING UNIT FOR INDICATOR All values supported EC COPOUND INGREDIENT COPONENT COUNT aximum of 25 ingredients RE COPOUND PRODUCT ID QUALIFIER Ø1 = Universal Product Code (UPC) Payer Requirement: aximum of 1Ø ingredients. Ø3 = National Drug DC) 489-TE COPOUND PRODUCT ID 448- ED COPOUND INGREDIENT QUANTITY

236 Compound Segment Claim Billing (111-A) = 1Ø 449-EE COPOUND INGREDIENT DRUG COST RW Imp Guide: Required if needed for receiver claim determination when multiple products are billed. Payer Requirement: Required for each ingredient. ** End of Request Claim Billing (B1) Payer Sheet Template** Non-Workers Compensation Claim Billing Accepted/Paid (Or Duplicate of Paid) Response ** Start of Response Claim Billing (B1) Payer Sheet Template** Response Transaction Header Segment Questions CLAI BILLING ACCEPTED/PAID (OR DUPLICATE OF PAID) RESPONSE Check Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is always sent X Response Transaction Header Segment Claim Billing Paid (Duplicate of Paid)

237 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B1 Claim Billing 1Ø9-A9 TRANSACTION COUNT Same value as in st 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 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 This Segment is always sent Check Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is situational X Provide general information when used for transmission-level messaging. Response essage Segment Claim Billing Paid (Duplicate of aid) (111-A) = 2Ø

238 Response essage Segment Claim Billing Paid (Duplicate of aid) (111-A) = 2Ø 5Ø4- F4 ESSAGE RW Imp Guide: Required if text is needed for clarification or detail. Payer Requirement: Will be returned when text information needs to be sent. Response Patient Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is always sent This Segment is situational X Will be returned as verification Response Patient Segment (111-A) = 29 Claim Billing Paid (Duplicate of Paid)

239 Response Patient Segment (111-A) = 29 Claim Billing Paid (Duplicate of Paid) 31Ø- CA PATIENT FIRST NAE RW Imp Guide: 311-CB PATIENT LAST NAE RW Imp Guide: Payer Requirement: Will be sent every time. Payer Requirement: Will be sent every time. 3Ø4- C4 DATE OF BIRTH RW Imp Guide: Payer Requirement: Will be sent every time. Response Status Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is always sent X Response Status Segment (111-A) = 21 Claim Billing Paid (Duplicate of Paid)

240 112-AN TRANSACTION RESPONSE STATUS P=Paid D=Duplicate of Paid 5Ø3-F3 AUTHORIZATION NUBER RW Imp Guide: Required if needed to identify the transaction. Payer Requirement: Will contain the trace back number of the claim F APPROVED ESSAGE CODE COUNT aximum count of 5. RW Imp Guide: Required if Approved essage Code (548-6F) is used F APPROVED ESSAGE CODE RW Payer Requirement: Same as Imp Guide. Imp Guide: Required if Approved essage Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. Payer Requirement: Same as Imp Guide.

241 Response Status Segment (111-A) = 21 Claim Billing Paid (Duplicate of Paid) 13Ø- UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Payer Requirement: aximum count of 2 will be returned. 132-UH ADDITIONAL ESSAGE INFORATION QUALIFIER Ø1 = Used for first line of free form text with no pre-defined structure. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Ø2 = Used for second line of free form text with no pre-defined structure. Payer Requirement: Only qualifier values cited will be returned. 526-FQ ADDITIONAL ESSAGE INFORATION RW Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Will be returned.

242 Response Status Segment (111-A) = 21 Claim Billing Paid (Duplicate of Paid) 549-7F HELP DESK PHONE NUBER QUALIFIER Ø3 = Processor/PB RW Imp Guide: Required if Help Desk Phone Number (55Ø- 8F) is used. Payer Requirement: Will be returned. 55Ø-8F HELP DESK PHONE NUBER RW Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Will be returned. Response Claim Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is always sent X Response Claim Segment (111-A) = 22 Claim Billing Paid (Duplicate of Paid)

243 455- E 4Ø2- D2 PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUBER 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). Response Pricing Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is always sent X Response Pricing Segment (111-A) = 23 Claim Billing Paid (Duplicate of Paid) 5Ø5-F5 PATIENT PAY AOUNT R 5Ø6-F6 INGREDIENT COST PAID R

244 Response Pricing Segment (111-A) = 23 Claim Billing Paid (Duplicate of Paid) 5Ø7-F7 DISPENSING FEE PAID RW Imp Guide: Required if this value is used to arrive at the final reimbursement. Payer Requirement: Same as Imp Guide. And, if submitted, will be returned AV TAX EXEPT INDICATOR RW Imp Guide: Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. Payer Requirement: Same as Imp Guide AW FLAT SALES TAX AOUNT PAID RW Imp Guide: Required 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. Payer Requirement: Same as Imp Guide.

245 Response Pricing Segment (111-A) = 23 Claim Billing Paid (Duplicate of Paid) 559- AX PERCENTAGE SALES TAX AOUNT PAID RW Imp Guide: Required if this value is used to arrive at the final reimbursement. Required if Percentage Sales Tax Amount Submitted (482- GE) is greater than zero (Ø). Required if Percentage Sales Tax Rate Paid (56Ø-AY) and Percentage Sales Tax Basis Paid (561-AZ) are used. Payer Requirement: Same as Imp Guide. 56Ø- AY PERCENTAGE SALES TAX RATE PAID RW Imp Guide: Required if Percentage Sales Tax Amount Paid (559-AX) is greater than zero (Ø). Payer Requirement: Same as Imp Guide.

246 Response Pricing Segment (111-A) = 23 Claim Billing Paid (Duplicate of Paid) 561-AZ PERCENTAGE SALES TAX BASIS PAID RW Imp Guide: Required if Percentage Sales Tax Amount Paid (559-AX) is greater than zero (Ø). Payer Requirement: Same as Imp Guide. 521-FL INCENTIVE AOUNT PAID RW Imp Guide: Required if this value is used to arrive at the final reimbursement. Required if Incentive Amount Submitted (438-E3) is greater than zero (Ø). Payer Requirement: Same as Imp Guide. 563-J2 OTHER AOUNT PAID COUNT aximum count of 3. RW Imp Guide: Required if Other Amount Paid (565-J4) is used. Payer Requirement: Will be returned when submission includes Other Amount Claimed Submitted.

247 Response Pricing Segment (111-A) = 23 Claim Billing Paid (Duplicate of Paid) 564-J3 OTHER AOUNT PAID QUALIFIER Ø1 = Delivery cost Ø4 = Administrative cost RW Imp Guide: Required if Other Amount Paid (565-J4) is used. Payer Requirement: Will be returned when submission includes Other Amount Claimed Submitted. 565-J4 OTHER AOUNT PAID RW Imp Guide: Required if this value is used to arrive at the final reimbursement. Required if Other Amount Claimed Submitted (48Ø-H9) is greater than zero (Ø). 5Ø9-F9 TOTAL AOUNT PAID R Payer Requirement: Will be returned when submission includes Other Amount Claimed Submitted.

248 Response Pricing Segment (111-A) = 23 Claim Billing Paid (Duplicate of Paid) 522- F BASIS OF REIBURSEENT DETERINATION RW Imp Guide: Required if Ingredient Cost Paid (5Ø6-F6) is greater than zero (Ø). Required if Basis of Cost Determination (432-DN) is submitted on billing. Payer Requirement: Same as Imp Guide. 517-FH AOUNT APPLIED TO PERIODIC DEDUCTIBLE RW Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes deductible Payer Requirement: Same as Imp Guide. 575-EQ PATIENT SALES TAX AOUNT RW Imp Guide: Used when necessary to identify the Patient s portion of the Sales Tax. Payer Requirement: Same as Imp Guide.

249 Response Pricing Segment (111-A) = 23 Claim Billing Paid (Duplicate of Paid) 574-2Y PLAN SALES TAX AOUNT RW Imp Guide: Used when necessary to identify the Plan s portion of the Sales Tax. Provided for informational purposes only U AOUNT OF COINSURANCE RW Payer Requirement: Same as Imp Guide. Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes coinsurance as patient financial responsibility. Payer Requirement: Same as Imp Guide UK AOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG RW Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes an amount that is attributable to a patient s selection of a Brand drug. Payer Requirement: Same as Imp Guide.

250 Response Pricing Segment (111-A) = 23 Claim Billing Paid (Duplicate of Paid) 135- U AOUNT ATTRIBUTED TO PRODUCT SELECTION/NON- PREFERRED FORULARY SELECTION RW Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes an amount that is attributable to a patient s selection of a non-preferred formulary product. Payer Requirement: Same as Imp Guide UN AOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NON-PREFERRED FORULARY SELECTION RW Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes an amount that is attributable to a patient s selection of a Brand nonpreferred formulary product. Payer Requirement: Same as Imp Guide.

251 Response DUR/PPS Segment Questions This Segment is always sent Check Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is situational X This segment will be transmitted when a possible conflict is detected. Response DUR/PPS Segment Claim Billing Paid (Duplicate of Paid) (111-A) = J6 DUR/PPS RESPONSE CODE COUNTER aximum 9 occurrences supported. RW Imp Guide: Required if Reason For Service Code (439-E4) is used. Payer Requirement: Same as Imp Guide. 439-E4 REASON FOR SERVICE CODE All values supported. RW Imp Guide: Required if utilization conflict is detected. Payer Requirement: Same as Imp Guide.

252 Response DUR/PPS Segment Claim Billing Paid (Duplicate of Paid) (111-A) = FS CLINICAL SIGNIFICANCE CODE All values supported. RW Imp Guide: Required if needed to supply additional information for the utilization conflict. 529-FT OTHER PHARACY INDICATOR Payer Requirement: Same as Imp Guide. All values supported. RW Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same as Imp Guide. 53Ø- FU PREVIOUS DATE OF FILL RW Imp Guide: Required if needed to supply additional information for the utilization conflict. Required if Quantity of Previous Fill (531-FV) is used. Payer Requirement: Same as Imp Guide.

253 Response DUR/PPS Segment Claim Billing Paid (Duplicate of Paid) (111-A) = FV QUANTITY OF PREVIOUS FILL RW Imp Guide: Required if needed to supply additional information for the utilization conflict. Required if Previous Date Of Fill (53Ø-FU) is used. Payer Requirement: Same as Imp Guide FW DATABASE INDICATOR All values supported. RW Imp Guide: Required if needed to supply additional information for the utilization conflict. 533-FX OTHER PRESCRIBER INDICATOR Payer Requirement: Same as Imp Guide. All values supported. RW Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same as Imp Guide.

254 Response DUR/PPS Segment Claim Billing Paid (Duplicate of Paid) (111-A) = FY DUR FREE TEXT ESSAGE RW Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same as Imp Guide. 57Ø- NS DUR ADDITIONAL TEXT RW Imp Guide: Required if Reason For Service Code (439-E4) is used. Payer Requirement: Same as Imp Guide. Response Coordination of Benefits/Other Payers Segment Questions This Segment is always sent Check Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, This Segment is situational X Will be returned when other payers involved.

255 Response Coordination of Benefits/Other Payers Segment Claim Billing Paid (Duplicate of Paid) (111-A) = NT OTHER PAYER ID COUNT 338-5C OTHER PAYER COVERAGE TYPE aximum count of 3. All values supported C OTHER PAYER ID QUALIFIER Ø3 = BIN RW Imp Guide: Required if Other Payer ID (34Ø-7C) is used. Payer Requirement: Same as Imp Guide. 34Ø- 7C OTHER PAYER ID RW Imp Guide: Required if other insurance information is available for coordination of benefits. Payer Requirement: Same as Imp Guide NU OTHER PAYER CARDHOLDER ID RW Imp Guide: Required if other insurance information is available for coordination of benefits. Payer Requirement: Same as Imp Guide.

256 Response Coordination of Benefits/Other Payers Segment Claim Billing Paid (Duplicate of Paid) (111-A) = UB OTHER PAYER HELP DESK PHONE NUBER RW Imp Guide: Required if needed to provide a support telephone number of the other payer to the receiver. Payer Requirement: Same as Imp Guide. Non-Workers Compensation Claim Billing Accepted/Rejected Response CLAI BILLING ACCEPTED/REJECTED RESPONSE Response Transaction Header Segment Questions Check Claim Billing Accepted/Rejected If Situational, This Segment is always sent X Response Transaction Header Segment Claim Billing Accepted/Rejected 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B1 Claim Billing

257 Response Transaction Header Segment Claim Billing Accepted/Rejected 1Ø9-A9 TRANSACTION COUNT Same value as in st 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 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 This Segment is always sent Check Claim Billing Accepted/Rejected If Situational, This Segment is situational X Will be returned on rejected claims when the error ransmission-level. Response essage Segment Claim Billing Accepted/Rejected (111-A) = 2Ø

258 Response essage Segment Claim Billing Accepted/Rejected (111-A) = 2Ø 5Ø4-F4 ESSAGE RW Imp Guide: Required if text is needed for clarification or detail. Payer Requirement: Will be returned when text information needs to be sent. Response Patient Segment Questions Check Claim Billing Accepted/Rejected If Situational, This Segment is always sent This Segment is situational X Will be returned if patient can be found. Response Patient Segment (111-A) = 29 Claim Billing Accepted/Rejected

259 Response Patient Segment (111-A) = 29 Claim Billing Accepted/Rejected 31Ø- CA PATIENT FIRST NAE RW Imp Guide: 311-CB PATIENT LAST NAE RW Imp Guide: Payer Requirement: Will be sent if patient can be found. Payer Requirement: Will be sent if patient can be found. 3Ø4- C4 DATE OF BIRTH RW Imp Guide: Payer Requirement: Will be sent if patient can be found. Response Status Segment Questions Check Claim Billing Accepted/Rejected If Situational, This Segment is always sent X Response Status Segment (111-A) = 21 Claim Billing Accepted/Rejected

260 112- AN TRANSACTION RESPONSE STATUS R = Reject 51Ø- FA REJECT COUNT aximum count of 5. R 511-FB REJECT CODE R 546-4F REJECT FIELD OCCURRENCE INDICATOR RW Imp Guide: Required if a repeating field is in error, to identify repeating field occurrence. Payer Requirement: Only sent if reject is on a field that has multiple occurrences. 13Ø- UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Payer Requirement: aximum count of 2 will be returned UH ADDITIONAL ESSAGE INFORATION QUALIFIER Ø1 = Used for first line of free form text with no pre-defined structure. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Ø2 = Used for second line of free form text with no pre-defined structure. Payer Requirement: Only qualifier values cited will be returned.

261 Response Status Segment (111-A) = 21 Claim Billing Accepted/Rejected 526-FQ ADDITIONAL ESSAGE INFORATION RW Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Will be returned F HELP DESK PHONE NUBER QUALIFIER Ø3 = Processor/PB RW Imp Guide: Required if Help Desk Phone Number (55Ø-8F) is used. Payer Requirement: Will be returned. 55Ø-8F HELP DESK PHONE NUBER RW Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Will be returned.

262 Response Status Segment (111-A) = 21 Claim Billing Accepted/Rejected 987- A URL RW Imp Guide: Provided for informational purposes only to relay health care communications via the Internet. Payer Requirement: Will be returned. Response Claim Segment Questions Check Claim Billing Accepted/Rejected If Situational, This Segment is always sent X Response Claim Segment (111-A) = 22 Claim Billing 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).

263 Response Claim Segment (111-A) = 22 Claim Billing Accepted/Rejected 4Ø2- D2 PRESCRIPTION/SERVICE REFERENCE NUBER 551-9F PREFERRED PRODUCT COUNT aximum count of 6. RW Imp Guide: Required if Preferred Product ID (553- AR) is used. Payer Requirement: Preferred fields will be sent on a reject when there is a preferred product per the health plan s formulary. 552-AP PREFERRED PRODUCT ID QUALIFIER Ø3 = National Drug Code (NDC) RW Imp Guide: Required if Preferred Product ID (553- AR) is used. Payer Requirement: Same as Imp Guide AR PREFERRED PRODUCT ID RW Imp Guide: Required if a product preference exists that needs to be communicated to the receiver via an ID. Payer Requirement:

264 Response Claim Segment (111-A) = 22 Claim Billing Accepted/Rejected 554-AS PREFERRED PRODUCT INCENTIVE RW Imp Guide: Required if there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). Payer Requirement: Same as Imp Guide. 555-AT PREFERRED PRODUCT COST SHARE INCENTIVE RW Imp Guide: Required if there is a known patient financial responsibility incentive amount associated with the Preferred Product ID (553- AR) and/or Preferred Product Description (556-AU). Payer Requirement: Same as Imp Guide.

265 Response Claim Segment (111-A) = 22 Claim Billing Accepted/Rejected 556- AU PREFERRED PRODUCT DESCRIPTION RW Imp Guide: Required if a product preference exists that either cannot be communicated by the Preferred Product ID (553- AR) or to clarify the Preferred Product ID (553-AR). Payer Requirement: Same as Imp Guide. Response DUR/PPS Segment Questions This Segment is always sent Check Claim Billing Accepted/Rejected If Situational, This Segment is situational X This segment will be transmitted on a reject when a possible conflict is detected. Response DUR/PPS Segment Claim Billing Accepted/Rejected (111-A) = 24

266 Response DUR/PPS Segment Claim Billing Accepted/Rejected (111-A) = J6 DUR/PPS RESPONSE CODE COUNTER aximum 9 occurrences supported. RW Imp Guide: Required if Reason For Service Code (439-E4) is used. Payer Requirement: Same as Imp Guide. 439-E4 REASON FOR SERVICE CODE All values supported. RW Imp Guide: Required if utilization conflict is detected. 528-FS CLINICAL SIGNIFICANCE CODE Payer Requirement: Same as Imp Guide. All values supported. RW Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same as Imp Guide.

267 Response DUR/PPS Segment Claim Billing Accepted/Rejected (111-A) = FT OTHER PHARACY INDICATOR All values supported. RW Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same as Imp Guide. 53Ø- FU PREVIOUS DATE OF FILL RW Imp Guide: Required if needed to supply additional information for the utilization conflict. Required if Quantity of Previous Fill (531-FV) is used. Payer Requirement: Same as Imp Guide.

268 Response DUR/PPS Segment Claim Billing Accepted/Rejected (111-A) = FV QUANTITY OF PREVIOUS FILL RW Imp Guide: Required if needed to supply additional information for the utilization conflict. Required if Previous Date Of Fill (53Ø-FU) is used. Payer Requirement: Same as Imp Guide FW DATABASE INDICATOR All values supported. RW Imp Guide: Required if needed to supply additional information for the utilization conflict. 533-FX OTHER PRESCRIBER INDICATOR Payer Requirement: Same as Imp Guide. All values supported. RW Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same as Imp Guide.

269 Response DUR/PPS Segment Claim Billing Accepted/Rejected (111-A) = FY DUR FREE TEXT ESSAGE RW Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same as Imp Guide. 57Ø- NS DUR ADDITIONAL TEXT RW Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same as Imp Guide. Response Coordination of Benefits/Other Payers Segment Questions This Segment is always sent Check Claim Billing Accepted/Rejected If Situational, This Segment is situational X Will be sent if other payers known.

270 Response Coordination of Benefits/Other Payers Segment Claim Billing Accepted/Rejected (111-A) = NT OTHER PAYER ID COUNT 338-5C OTHER PAYER COVERAGE TYPE aximum count of 3. All values supported C OTHER PAYER ID QUALIFIER Ø3 = BIN RW Imp Guide: Required if Other Payer ID (34Ø-7C) is used. Payer Requirement: Same as Imp Guide. 34Ø- 7C OTHER PAYER ID RW Imp Guide: Required if other insurance information is available for coordination of benefits. Payer Requirement: Same as Imp Guide NU OTHER PAYER CARDHOLDER ID RW Imp Guide: Required if other insurance information is available for coordination of benefits. Payer Requirement: Same as Imp Guide.

271 Response Coordination of Benefits/Other Payers Segment Claim Billing Accepted/Rejected (111-A) = UB OTHER PAYER HELP DESK PHONE NUBER RW Imp Guide: Required if needed to provide a support telephone number of the other payer to the receiver. Payer Requirement: Same as Imp Guide. Non-Workers Compensation Claim Billing Rejected/Rejected Response CLAI BILLING REJECTED/REJECTED RESPONSE Response Transaction Header Segment Questions Check Claim Billing Rejected/Rejected If Situational, This Segment is always sent X Response Transaction Header Segment Claim Billing Rejected/Rejected 1Ø2- A2 VERSION/RELEASE NUBER DØ

272 Response Transaction Header Segment Claim Billing Rejected/Rejected 1Ø3- A3 TRANSACTION CODE B1 Claim Billing 1Ø9- A9 TRANSACTION COUNT Same value as in st 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 This Segment is always sent Check Claim Billing Rejected/Rejected If Situational, This Segment is situational X Will be returned on rejected claims when the error ransmission-level. Response essage Segment Claim Billing Rejected/Rejected (111-A) = 2Ø

273 5Ø4-F4 ESSAGE RW Imp Guide: Required if text is needed for clarification or detail. Payer Requirement: Will be returned when text information needs to be sent. Response Status Segment Questions Check Claim Billing Rejected/Rejected If Situational, This Segment is always sent X Response Status Segment (111-A) = 21 Claim Billing Rejected/Rejected 112- AN TRANSACTION RESPONSE STATUS R = Reject 51Ø- FA REJECT COUNT aximum count of 5. R 511-FB REJECT CODE NCPDP Reject Codes R

274 Response Status Segment (111-A) = 21 Claim Billing Rejected/Rejected 546-4F REJECT FIELD OCCURRENCE INDICATOR RW Imp Guide: Required if a repeating field is in error, to identify repeating field occurrence. Payer Requirement: Same as Imp Guide. 13Ø- UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Payer Requirement: aximum count of 2 will be returned UH ADDITIONAL ESSAGE INFORATION QUALIFIER Ø1 = Used for first line of free form text with no pre-defined structure. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Ø2 = Used for second line of free form text with no pre-defined structure. Payer Requirement: Only qualifier values cited will be returned.

275 Response Status Segment (111-A) = 21 Claim Billing Rejected/Rejected 526-FQ ADDITIONAL ESSAGE INFORATION RW Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Will be returned F HELP DESK PHONE NUBER QUALIFIER Ø3 = Processor/PB RW Imp Guide: Required if Help Desk Phone Number (55Ø-8F) is used. Payer Requirement: Will be returned. 55Ø-8F HELP DESK PHONE NUBER RW Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Will be returned. ** End of Response Claim Billing (B1) Payer Sheet Template**

276 Non-Workers Compensation Claim Reversal This is a continuation of the example of a payer sheet for a plan, with information about claims reversals for the non-workers compensation plan. The payer sheet shows an approved and a rejected response. Non-Workers Compensation Claim Reversal Request ** Start of Request Claim Reversal (B2) Payer Sheet Template** GENERAL INFORATION Payer Name: ABC, Inc. Date: Ø1/Ø1/2Ø1Ø Plan Name/Group Name: General Health Plan BIN: PCN: Blank fill FIELD LEGEND FOR COLUNS Payer Column Value Explanation Payer Situation 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. No No QUALIFIED REQUIREENT RW Required when. The situations designated have qualifications for usage ("Required if x", "Not required if y"). Yes Question Answer What is your reversal window? (If transaction is billed today what is the timeframe for reversal to be submitted?) 9Ø days

277 CLAI REVERSAL TRANSACTION Transaction Header Segment Questions This Segment is always sent 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 Check X X Claim Reversal If Situational, Transaction Header Segment Claim Reversal 1Ø1- A1 BIN NUBER BIN for General Health Plan 1Ø2- A2 VERSION/RELEASE NUBER DØ 1Ø3- A3 TRANSACTION CODE B2 Claim Reversal 1Ø4- A4 PROCESSOR CONTROL NUBER Blank fill Blank fill

278 Transaction Header Segment Claim Reversal 1Ø9- A9 TRANSACTION COUNT Ø1 = One rence Ø2 = Two rences Ø3 = Three rences Ø4 = Four rences 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER 2Ø1-B1 SERVICE PROVIDER ID Ø1 = National der ID 4Ø1- D1 11Ø- AK DATE OF SERVICE SOFTWARE VENDOR/CERTIFICATION ID Blank fill Blank fill Insurance Segment Questions Check Claim Reversal If Situational, This Segment is always sent X This Segment is situational

279 Insurance Segment Claim Reversal (111-A) = Ø4 3Ø2-C2 CARDHOLDER ID ember s ID as shown on card. Claim Segment Questions Check Claim Reversal If Situational, This Segment is always sent X Claim Segment Claim Reversal (111-A) = Ø7

280 Claim Segment Claim Reversal (111-A) = Ø E 4Ø2- D2 PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUBER 1 = Rx Billing Imp Guide: For Transaction Code of B2, in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 1 (Rx Billing). 436-E1 PRODUCT/SERVICE ID QUALIFIER Ø1 = Universal Product Code (UPC) Ø3 = National Drug Code (NDC) 4Ø7- D7 PRODUCT/SERVICE ID 4Ø3-D3 FILL NUBER RW Imp Guide: Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (4Ø2-D2) occur on the same day. 3Ø8-C8 OTHER COVERAGE CODE 1 = No other coverage 2 = Other coverage exists payment collected RW Payer Requirement: Same as Imp Guide. Imp Guide: Required if needed by receiver to match the claim that is being reversed.

281 Claim Segment Claim Reversal (111-A) = Ø7 8 = Claim is billing for patient financial responsibility only Payer Requirement: Only used in COB claims. Pricing Segment Questions Check Claim Reversal This Segment is always sent If Situational, This Segment is situational X Segment is sent if contract to provider allows for tive. Pricing Segment Claim Reversal (111-A) = E3 INCENTIVE AOUNT SUBITTED RW Imp Guide: Required if this field could result in contractually agreed upon payment. Payer Requirement: Submit based on contracted agreement. 43Ø-DU GROSS AOUNT DUE RW Imp Guide: Required if this field could result in

282 Pricing Segment Claim Reversal (111-A) = 11 contractually agreed upon payment. Payer Requirement: If Incentive is sent, this field must be sent. ** End of Request Claim Reversal (B2) Payer Sheet Template** Non-Workers Compensation Claim Reversal Accepted/Approved Response ** Start of Claim Reversal Response (B2) Payer Sheet Template** GENERAL INFORATION Payer Name: ABC, Inc. Date: Ø1/Ø1/2Ø1Ø Plan Name/Group Name: General Health Plan BIN: PCN: Blank fill Response Transaction Header Segment Questions CLAI REVERSAL ACCEPTED/APPROVED RESPONSE Check Claim Reversal Accepted/Approved If Situational, This Segment is always sent X Response Transaction Header Segment Claim Reversal Accepted/Approved

283 1Ø2- A2 VERSION/RELEASE NUBER DØ 1Ø3- A3 TRANSACTION CODE B2 Claim Reversal 1Ø9- A9 TRANSACTION COUNT Same value as in st 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 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 Status Segment Questions Check Claim Reversal Accepted/Approved If Situational, This Segment is always sent X Response Status Segment (111-A) = 21 Claim Reversal Accepted/Approved N 112- TRANSACTION RESPONSE STATUS A = Approved

284 Response Status Segment (111-A) = 21 Claim Reversal Accepted/Approved 5Ø3-F3 AUTHORIZATION NUBER RW Imp Guide: Required if needed to identify the transaction. Payer Requirement: Will contain the trace back number of the reversal. 13Ø- UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Payer Requirement: aximum count of 2 will be returned UH ADDITIONAL ESSAGE INFORATION QUALIFIER Ø1 = Used for first line of free form text with no pre-defined structure. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Ø2 = Used for second line of free form text with no pre-defined structure. Payer Requirement: Only qualifier values cited will be returned.

285 Response Status Segment (111-A) = 21 Claim Reversal Accepted/Approved 526-FQ ADDITIONAL ESSAGE INFORATION RW Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Will be returned F HELP DESK PHONE NUBER QUALIFIER Ø3 = Processor/PB RW Imp Guide: Required if Help Desk Phone Number (55Ø-8F) is used. Payer Requirement: Will be returned. 55Ø-8F HELP DESK PHONE NUBER RW Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Will be returned. Response Claim Segment Questions Check Claim Reversal Accepted/Approved If Situational, This Segment is always sent X

286 Response Claim Segment (111-A) = 22 Claim Reversal Accepted/Approved 455- E 4Ø2- D2 PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUBER 1 = RxBilling Imp Guide: For Transaction Code of B2, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 1 (Rx Billing). Response Pricing Segment Questions Check Claim Reversal Accepted/Approved This Segment is always sent If Situational, This Segment is situational X Will be returned when submission includes tive. Response Pricing Segment (111-A) = 23 Claim Reversal Accepted/Approved

287 Response Pricing Segment (111-A) = 23 Claim Reversal Accepted/Approved 521-FL INCENTIVE AOUNT PAID RW Imp Guide: Required if this field is reporting a contractually agreed upon payment. Payer Requirement: Submit based on contracted agreement. 5Ø9-F9 TOTAL AOUNT PAID RW Imp Guide: Required if any other payment fields sent by the sender. Payer Requirement: If Incentive is sent, this field must be sent. Non-Workers Compensation Claim Reversal Accepted/Rejected Response CLAI REVERSAL ACCEPTED/REJECTED RESPONSE Transaction Header Segment Questions Check Claim Reversal - Accepted/Rejected If Situational, This Segment is always sent X

288 Transaction Header Segment Claim Reversal Accepted/Rejected 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B2 Claim Reversal 1Ø9-A9 TRANSACTION COUNT Same value as in st 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 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 This Segment is always sent Check Claim Reversal - Accepted/Rejected If Situational, This Segment is situational X Will be returned on rejected claims when the error ransmission-level. Response essage Segment (111-A) = 2Ø Claim Reversal Accepted/Rejected

289 5Ø4-F4 ESSAGE RW Imp Guide: Required if text is needed for clarification or detail. Payer Requirement: Will be returned when text information needs to be sent. Response Status Segment Questions Check Claim Reversal - Accepted/Rejected If Situational, This Segment is always sent X Response Status Segment (111-A) = 21 Claim Reversal Accepted/Rejected 112-AN TRANSACTION RESPONSE STATUS R = Reject 51Ø- FA REJECT COUNT aximum count of 5. R 511-FB REJECT CODE NCPDP Reject Codes R

290 Response Status Segment (111-A) = 21 Claim Reversal Accepted/Rejected 546-4F REJECT FIELD OCCURRENCE INDICATOR RW Imp Guide: Required if a repeating field is in error, to identify repeating field occurrence. Payer Requirement: Only sent if reject is on a field that has multiple occurrences. 13Ø- UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Payer Requirement: aximum count of 2 will be returned. 132-UH ADDITIONAL ESSAGE INFORATION QUALIFIER Ø1 = Used for first line of free form text with no pre-defined structure RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Ø2 = Used for second line of free form text with no pre-defined structure. Payer Requirement: Only qualifier values cited will be returned.

291 Response Status Segment (111-A) = 21 Claim Reversal Accepted/Rejected 526-FQ ADDITIONAL ESSAGE INFORATION RW Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Will be returned F HELP DESK PHONE NUBER QUALIFIER Ø3 = Processor/PB RW Imp Guide: Required if Help Desk Phone Number (55Ø- 8F) is used. Payer Requirement: Will be returned. 55Ø-8F HELP DESK PHONE NUBER RW Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Will be returned. Response Claim Segment Questions Check Claim Reversal - Accepted/Rejected If Situational, This Segment is always sent X

292 Response Claim Segment (111-A) = 22 Claim Reversal Accepted/Rejected 455- E 4Ø2- D2 PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUBER 1 = RxBilling Imp Guide: For Transaction Code of B2, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 1 (Rx Billing). Non-Workers Compensation Claim Reversal Rejected/Rejected Response CLAI REVERSAL REJECTED/REJECTED RESPONSE Response Transaction Header Segment Questions Check Claim Reversal - Rejected/Rejected If Situational, This Segment is always sent X Response Transaction Header Segment Claim Reversal Rejected/Rejected 1Ø2- A2 VERSION/RELEASE NUBER DØ 1Ø3- A3 TRANSACTION CODE B2 Claim Reversal

293 Response Transaction Header Segment Claim Reversal Rejected/Rejected 1Ø9- A9 TRANSACTION COUNT Same value as in st 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 This Segment is always sent Check Claim Reversal Rejected/Rejected If Situational, This Segment is situational X Will be returned on rejected claims when the error is at transmission-level. Response essage Segment Claim Reversal Rejected/Rejected (111-A) = 2Ø

294 Response essage Segment Claim Reversal Rejected/Rejected (111-A) = 2Ø 5Ø4-F4 ESSAGE RW Imp Guide: Required if text is needed for clarification or detail. Payer Requirement: Will be returned when text information needs to be sent. Response Status Segment Questions Check Claim Reversal - Rejected/Rejected If Situational, This Segment is always sent X Response Status Segment (111-A) = 21 Claim Reversal Rejected/Rejected 112-AN TRANSACTION RESPONSE STATUS R = Reject 51Ø- FA REJECT COUNT aximum count of 5. R

295 Response Status Segment (111-A) = 21 Claim Reversal Rejected/Rejected 511-FB REJECT CODE NCPDP Reject Codes 546-4F REJECT FIELD OCCURRENCE INDICATOR R RW Imp Guide: Required if a repeating field is in error, to identify repeating field occurrence. Payer Requirement: Only sent if reject is on a field that has multiple occurrences. 13Ø- UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Payer Requirement: aximum count of 2 will be returned. 132-UH ADDITIONAL ESSAGE INFORATION QUALIFIER Ø1 = Used for first line of free form text with no pre-defined structure RW Imp Guide: Required if Additional essage Information (526-FQ) is used. Ø2 = Used for second line of free form text with no pre-defined structure. Payer Requirement: Only qualifier values cited will be returned.

296 Response Status Segment (111-A) = 21 Claim Reversal Rejected/Rejected 526-FQ ADDITIONAL ESSAGE INFORATION RW Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Will be returned F HELP DESK PHONE NUBER QUALIFIER Ø3 = Processor/PB RW Imp Guide: Required if Help Desk Phone Number (55Ø- 8F) is used. Payer Requirement: Will be returned. 55Ø-8F HELP DESK PHONE NUBER RW Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Will be returned. ** End of Claim Reversal (B2) Response Payer Sheet Template**

297 EXAPLE 4 AERICAN PROCESSOR INC PAYER SHEET - ULTIPLE PLANS One Payer (American Processor Inc) with multiple plans (General Plan A, B, C, and D) that all have the same requirements may use the same payer template. (If this processor supports multiple plans (different BINs and/or PCNs) that cause different segments to be used, multiple payer templates must be created for each unique combination (see section Plan Differentiation). Claim Billing/Claim Rebill Request This is an excerpt showing just the General Information section of the payer sheet. The payer sheet shows how this payer would expect to receive a standard request and how the payer would respond. ** Start of Request Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template** GENERAL INFORATION Payer Name: American Processor Inc Date: Ø1/Ø1/2Ø1Ø Plan Name/Group Name: General Plan A BIN: 5511ØØ PCN: Blank fill Plan Name/Group Name: General Plan B BIN: PCN: Blank fill Plan Name/Group Name: General Plan C BIN: PCN: Blank fill Plan Name/Group Name: General Plan D BIN: PCN: Blank fill Processor: American Processor Inc. Effective as of: Ø7/Ø1/2Ø1Ø NCPDP Data Dictionary Version Date: Ø7/2ØØ7 NCPDP Telecommunication Standard Version/Release #: D.Ø NCPDP External Code List Version Date: Ø1/2ØØ8

298 Contact/Information Source: Provider anuals available at General website Certification Testing Window: onday-friday 8 am ET 5 pm ET Certification Contact Information: Certification packet available Provider Relations Help Desk Info: Pharmacy Help Desk: Physician Help Desk: Other versions supported: NCPDP Telecommunication version 5.1 until Ø7/Ø1/2Ø11 The payer sheet information would follow. All the plans for this processor use the same requirements (such as Example 1 above). ** End of Request Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template**

299 FREQUENTLY ASKED QUESTIONS Use of Red Font Question: Does the red font shown in the payer templates need to be used by the industry? Response: No. The red font is shown in this guide as a tool for understanding how to prepare the payer template correctly. Font Size Question: Do the payer templates need to be use the small font shown? Response: No. The small font shown in this guide is only to minimize the size of this document. Actual payer templates should use larger font sizes for readability.

300 APPENDIX A. HISTORY OF IPLEENTATION GUIDE CHANGES Editorial Corrections Field DUR Additional Text (57Ø-NS) was inadvertently left off the Response DUR/PPS Segment in section Non-Workers Compensation Claim Billing Accepted/Paid (Or Duplicate of Paid) Response. The Prescription/Service Reference Number Qualifier (455-E) values were used inconsistently throughout the documents and were modified to reflect 1 for Rx Billing and 2 for Service Billing. The word Header was removed from the Response Insurance Segment and the Response essage Segment references to correctly reflect the name of the segment. Version 1.1 Corrections The field Scheduled Prescription ID Number (454-EK) was changed from Not Used to Situational and added to the Claim Segment. Version 1.2 Response Insurance Segment in section Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response inadvertently included an X in the Response Insurance Segment Questions. It has been removed. Section Vaccine Administration was added to Specific Topic Discussion. Version 1.3 The Response Pricing Segment on the paid responses in examples now includes the two tax amount paid fields. Since the requirement in the Implementation Guide is that the field must be

301 returned if the pharmacy submitted anything greater than zero in the corresponding fields of the Request Pricing Segment, it is necessary to include these fields in every payer sheet since it isn't possible to know when the pharmacy will submit tax amounts, even if the plan will not determine any payment is due. Per the Implementation Guide, the plan is to reference that the fields will always be returned with a zero amount if the corresponding request was submitted, but they cannot ignore it and remove it from the payer sheet. The informational plan and payer sales tax fields have been added also. In sections Claim Billing/Claim Rebill Accepted/Rejected Response and Claim Billing/Claim Rebill Rejected/Rejected Response Authorization Number (5Ø3-F3) was inadvertently marked RW in Payer. The column has removed this designation as it would be used in examples, not the template.

302 Quick Reference List American Health care (AHC) Contact Information: Corporate Headquarters 3850 Atherton Road Rocklin, California T: (800) T: (916) F: (916) ember Services T: (800) F: (916) Pharmacy Support Center Compliance Hotline: (866) TDD/TTY: (866) or (916)