Maryland AIDS Drug Assistance Program (MADAP)

aryland AIDS Drug Assistance Program ADAP equest (B1/B3) Payer Sheet GENEAL INFOATION Payer Name: aryland edical Assistance Program Date: September 19, 2011 Plan Name/Group Name: aryland AIDS Drug Assistance Program BIN: 61ØØ84 PCN: DAPPOD = Production (ADAP) Plan Name/Group Name: aryland AIDS Drug Assistance Program (ADAP) (test) BIN: 61ØØ84 PCN: DAPACCP = Test (after 1/1/2012) PCN: DAPDV5S = Test (thru 12/31/2011 for D.Ø) Processor: ACS, A erox Company Effective as of: January 1, 2012 NCPDP Telecommunication Standard Version/elease #: D.Ø NCPDP Data Dictionary Version Date: Date of Publication NCPDP External Code List Version Date: Date of Publication 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 elations Help Desk Info: 8ØØ-932-3918 Other versions supported: 5.1 supported through 12/31/2011 OTHE TANSACTIONS SUPPOTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Transaction Code Transaction Name B1 Billing B3 ebilling FIELD LEGEND FO COLUNS Payer Column Value Explanation Column ANDATOY The Field is mandatory for the Segment in the designated Transaction. No EQUIED The Field has been designated with the situation of "equired" for the Segment in the designated Transaction. QUALIFIED EQUIEENT equired when. The situations designated have qualifications for usage ("equired if x", "Not required if y"). Fields that are not used in the transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template. CLAI BILLING/CLAI EBILL TANSACTION The following lists the segments and fields in a Claim Billing or Claim ebill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Transaction Header Segment Questions Check Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Not used No Yes Transaction Header Segment 1Ø1-A1 BIN NUBE 61ØØ84 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B1 = Billing B3 = ebill 1Ø4-A4 POCESSO CONTOL NUBE DAPPOD = Production DAPDV5S = D.0 Test DAPACCP = Test 1Ø9-A9 TANSACTION COUNT 1 = One Occurrence 2 = Two Occurrences 3 = Three Occurrences 4 = Four Occurrences Claim Billing, Claim ebill Use PCN DAPDV5S for D.Ø Testing through 12/31/2011

Transaction Header Segment 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Ø1 = National Provider Identifier (NPI) 2Ø1-B1 SEVICE POVIDE ID NPI Number 4Ø1-D1 DATE OF SEVICE CCYYDD 11Ø-AK SOFTWAE VENDO/CETIFICATION ID This will be provided by the provider's software vender If no number is supplied, populate with zeros Insurance Segment Questions Check Insurance Segment Segment Identification (111-A) = Ø4 3Ø2-C2 CADHOLDE ID ecipient s ADAP ID Number 11 character number 3Ø1-C1 GOUP ID ADAP 3Ø6-C6 Patient elationship Code 1 = Cardholder Patient Segment Questions Check Patient Segment Segment Identification (111-A) = Ø1 Field NCPDP Field Name Value Payer 3Ø4-C4 DATE OF BITH CCYYDD 3Ø5-C5 PATIENT GENDE CODE Ø = Not Specified 1 = ale 2 = Female 31Ø-CA PATIENT FIST NAE First 3 characters used for verification 311-CB PATIENT LAST NAE First 5 characters used for verification 384-4 PATIENT ESIDENCE Ø = Not specified 3 = Nursing Facility 11 = Hospice Claim Segment Questions Check This payer supports partial fills Enter value 3 or 11 to indicate the patient is in a LTC setting or hospice Claim Segment Segment Identification (111-A) = Ø7 455-E PESCIPTION/SEVICE EFEENCE 1 = x Billing NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE x Number assigned by the NUBE pharmacy 436-E1 PODUCT/SEVICE ID QUALIFIE Ø3 = National Drug Code 4Ø7-D7 PODUCT/SEVICE ID National Drug Code (NDC) 456-EN ASSOCIATED PESCIPTION/SEVICE x number of the associated EFEENCE NUBE partial fill claim 457-EP ASSOCIATED PESCIPTION/SEVICE Used when submitting a claim for DATE a partial fill 442-E7 QUANTITY DISPENSED etric Decimal Quantity 4Ø3-D3 FILL NUBE Ø = Original Dispensing 1-99 = efill number 4Ø5-D5 DAYS SUPPLY 4Ø6-D6 COPOUND CODE 1 = Not a compound 2 = Compound equired for the completion transaction in a partial fill (Dispensing Status (343-HD) = C ). Date of the Associated Prescription/Service eference Number. 2 must be entered for submission of a multi line compound.

Claim Segment Segment Identification (111-A) = Ø7 4Ø8-D8 DISPENSE AS WITTEN (DAW)/PODUCT Ø = No Product Selection SELECTION CODE Indicated 1 = Substitution Not Allowed by Prescriber 5 = Substitution Allowed-Brand Drug Dispense as Generic 6 = Override 414-DE DATE PESCIPTION WITTEN CCYYDD DAW 6 is used for brand name drugs that aryland ADAP has designated as preferred over the generic 354-N SUBISSION CLAIFICATION CODE COUNT aximum count of 3. equired if Submission Clarification Code (42Ø- DK) is used. 42Ø-DK SUBISSION CLAIFICATION CODE 8 = Process compound for Approved Ingredients 99 = Other 8 is used when provider is willing to accept payment only for covered items of a multi line compound. 99 is used for the submission of an IV claim. 3Ø8-C8 OTHE COVEAGE CODE Ø = Not Specified 1 = No other Coverage Identified 2 = Other coverage existspayment collected 3 = Other coverage exists-this claim not covered 4 = Other coverage existspayment not collected 429-DT SPECIAL PACKAGING INDICATO Ø = Not specified 1 = Not Unit Dose 2 = anufacturer Unit Dose 3 = Pharmacy Unit Dose equired when submitting a claim for a recipient who has other coverage. 3 = Pharmacy Unit Dose Denies as noncovered at etail. 418-DI LEVEL OF SEVICE 3 = Emergency equired when submitting a claim for an emergency fill. Logic: NH recipients can receive 1 per month and they receive a 30-day supply. This is per x. 461-EU PIO AUTHOIZATION TYPE CODE 2 = edical Certification 4 = Exemption from Copay and/or Coinsurance 5 = Exemption from x etail 2 per script per month. Only for PDL denials. D edicaid only accepts 2, 4 and 5 343-HD DISPENSING STATUS P = Initial Fill C = Completion Fill equired for the partial fill or the completion of a partial fill. 344-HF QUANTITY INTENDED TO BE DISPENSED equired when submitting a partial fill or the completion of a partial fill. 345-HG DAYS SUPPLY INTENDED TO BE DISPENSED equired when submitting a partial fill or the completion of a partial fill. 995-E2 OUTE OF ADINISTATION SNOED CT Value equired when the x is a compound Pricing Segment Questions Check Pricing Segment Segment Identification (111-A) = 11 4Ø9-D9 INGEDIENT COST SUBITTED equired field in D.Ø. 412-DC DISPENSING FEE SUBITTED equired if needed to balance claim 426-DQ USUAL AND CUSTOAY CHAGE 43Ø-DU GOSS AOUNT DUE

Prescriber Segment Questions Check Prescriber Segment Segment Identification (111-A) = Ø3 466-EZ PESCIBE ID QUALIFIE Ø1=National Provider Identifier (NPI) 411-DB PESCIBE ID NPI Number Coordination of Benefits/Other Payments Segment Check Questions This Segment is situational equired only for secondary, tertiary, etc claims. Scenario 3 - Other Payer Amount Paid, Other Payer-Patient esponsibility Amount, and Benefit Stage epetitions 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 Segment Identification (111-A) = Ø5 Scenario 3 - Other Payer Amount Paid, Other Payer-Patient esponsibility Amount, and Benefit Stage epetitions Present (Government Programs) 337-4C COODINATION OF BENEFITS/OTHE aximum count of 9. PAYENTS COUNT 338-5C OTHE PAYE COVEAGE TYPE Blank=Not Specified Ø1=Primary Ø2=Secondary Ø3=Tertiary 339-6C OTHE PAYE ID QUALIFIE 99=Other equired if Other Payer ID (34Ø-7C) is used. equired for this program 99=Other 34Ø-7C OTHE PAYE ID Third Party Payer ID 443-E8 OTHE PAYE DATE CCYYDD equired when there is payment or denial from another source. 341-HB OTHE PAYE AOUNT PAID COUNT equired if Other Payer Amount Paid Qualifier (342-HC) is used. 342-HC OTHE PAYE AOUNT PAID QUALIFIE Ø1=Delivery Ø2=Shipping equired when there is payment from another source Ø3=Postage Ø4=Administrative Ø5=Incentive Ø6=Cognitive Service Ø7=Drug Benefit Ø9=Compound Preparation Cost 1Ø=Sales Tax 431-DV OTHE PAYE AOUNT PAID S$$$$$$cc equired if other payer has approved payment for some/all of the billing. 471-5E OTHE PAYE EJECT COUNT aximum count of 5. equired if Other Payer eject Code (472-6E) is used. 472-6E OTHE PAYE EJECT CODE equired 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-N OTHE PAYE-PATIENT ESPONSIBILITY AOUNT COUNT aximum count of 25. equired if Other Payer-Patient esponsibility Amount Qualifier (351-NP) is used.

Coordination of Benefits/Other Payments Segment Segment Identification (111-A) = Ø5 Scenario 3 - Other Payer Amount Paid, Other Payer-Patient esponsibility Amount, and Benefit Stage epetitions Present (Government Programs) 351-NP OTHE PAYE-PATIENT ESPONSIBILITY AOUNT QUALIFIE Ø1=Amount Applied to Periodic Deductible (517-FH) Ø2=Amount Attributed to Product Selection/Brand Drug (134-UK) Ø3=Amount Attributed to Sales Tax (523-FN) Ø4=Amount Exceeding Periodic Benefit aximum (52Ø-FK) Ø5=Amount of Copay (518-FI) Ø6=Patient Pay Amount (5Ø5-F5) Ø7=Amount of Coinsurance (572-4U) Ø8=Amount Attributed to Product Selection/Non-Preferred Formulary Selection (135-U) Ø9=Amount Attributed to Health Plan Assistance Amount (129-UD) 1Ø=Amount Attributed to Provider Network Selection (133-UJ) 11=Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) 12=Amount Attributed to Coverage Gap (137-UP) 13=Amount Attributed to Processor Fee (571-NZ) equired if Other Payer-Patient esponsibility Amount (352-NQ) is used. 352-NQ OTHE PAYE-PATIENT ESPONSIBILITY AOUNT equired if OCC=2 or 4 DU/PPS Segment Questions Check This Segment is situational DU/PPS Segment Segment Identification (111-A) = Ø8 473-7E DU/PPS CODE COUNTE aximum of 9 occurrences. equired if DU/PPS Segment is used. 439-E4 EASON FO SEVICE CODE See Attached list of valid Values equired when there is a conflict to resolve or reason for service to be explained (ax 9) 44Ø-E5 POFESSIONAL SEVICE CODE See Attached list of valid Values 441-E6 ESULT OF SEVICE CODE See Attached list of valid Values equired when there is a professional service to be identified (ax 9) equired when There is a result of service to be Submitted (ax = 9). Compound Segment Questions Check This Segment is situational equired when billing for a compound Compound Segment Segment Identification (111-A) = 1Ø

Compound Segment Segment Identification (111-A) = 1Ø 45Ø-EF COPOUND DOSAGE FO DESCIPTION Ø1=Capsule CODE Ø2=Ointment Ø3=Cream Ø4=Suppository Ø5=Powder Ø6=Emulsion Ø7=Liquid 1Ø=Tablet 11=Solution 12=Suspension 13=Lotion 14=Shampoo 15=Elixir 16=Syrup 17=Lozenge 18=Enema 451-EG COPOUND DISPENSING UNIT FO INDICATO 1=Each 2=Grams 3=illiliters aximum 25 ingredients 447-EC COPOUND INGEDIENT COPONENT COUNT 488-E COPOUND PODUCT ID QUALIFIE Ø3= National Drug Code (NDC) 489-TE COPOUND PODUCT ID 448-ED COPOUND INGEDIENT QUANTITY Facility Segment Questions Check This Segment is situational Facility Segment Segment Identification (111-A) = 15 336-8C FACILITY ID aryland assigned 9-character Facility ID number equired when Patient is in a Hospice or NH/LTC setting for validation of Patient esidence. Patient esidence field must also be populated. ** End of equest (B1/B3) Payer Sheet Template**

Additional Claim Information DU Codes eason for Service Codes (439-E4): DU Conflict Codes Code eaning Code eaning AT Additive Toxicity LD Low Dose Alert CH Call Help Desk L Under Use Precaution DA Drug Allergy Alert C Drug Disease Precaution DC Inferred Drug Disease Precaution N Insufficient Duration Alert DD Drug-Drug Interaction Excessive Duration Alert DF Drug Food Interaction OH Alcohol Precaution DI Drug Incombatability PA Drug Age Precaution DL Drug Lab Conflict PG Drug Pregnancy Alert DS Tobacco Use Precaution P Prior Adverse Drug eaction E Over Use Conflict SE Side Effect Alert HD High Dose Alert S Drug Gender Alert IC Iatrogenic Condition Alert TD Therapeutic Duplication ID Ingredient Duplication Professional Service Codes (44Ø-E5): Intervention Codes Code eaning Code eaning Ø Prescriber Consulted - D Interface PE Patient Education/Instruction PØ Patient Consulted - patient interaction Ø Pharmacist Consulted Other Source - Pharmacist reviewed esult of Service Codes (441-E6): Intervention Codes Code eaning Code eaning 1A Filled As Is False Positive 1D Filled With Different Directions 1B Filled Prescription As Is 1F Filled Different Quantity 1C Filled With Different Dose 1G Filled after prescriber approval

ESPONSE CLAI BILLING/CLAI EBILL PAYE SHEET TEPLATE CLAI BILLING/CLAI EBILL ACCEPTED/PAID (O DUPLICATE OF PAID) ESPONSE ** Start of esponse (B1/B3) Payer Sheet Template** GENEAL INFOATION Payer Name: aryland edical Assistance Program Date: January 1, 2Ø12 Plan Name/Group Name: aryland AIDS Drug Assistance Program BIN: 61ØØ84 PCN: DAPPOD = Production (ADAP) Plan Name/Group Name: aryland AIDS Drug Assistance Program (ADAP) - test BIN: 61ØØ84 PCN: DAPACCP = Test (after 1/1/2012) PCN: DAPDV5S (thru 12/31/2011 for D.Ø testing) CLAI BILLING/CLAI EBILL PAID (O DUPLICATE OF PAID) ESPONSE The following lists the segments and fields in a Claim Billing or Claim ebill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. esponse Transaction Header Segment Questions Check esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B1, B3 1Ø9-A9 TANSACTION COUNT Same value as in request 5Ø1-F1 HEADE ESPONSE STATUS A = Accepted 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request 2Ø1-B1 SEVICE POVIDE ID Same value as in request 4Ø1-D1 DATE OF SEVICE Same value as in request Accepted/Paid esponse essage Segment Questions Check This Segment is situational Segment sent if required for clarification esponse essage Segment Segment Identification (111-A) = 2Ø Accepted/Paid 5Ø4-F4 ESSAGE Text essage equired if text is needed for clarification or detail. esponse Insurance Segment Questions Check esponse Insurance Segment Segment Identification (111-A) = 25 Accepted/Paid 3Ø1-C1 GOUP ID Used to identify the group number used in claim adjudication. 524-FO PLAN ID Used to identify the actual plan ID that was used in claim adjudication. esponse Status Segment Questions Check esponse Status Segment Segment Identification (111-A) = 21 Accepted/Paid

112-AN TANSACTION ESPONSE STATUS P=Paid D=Duplicate of Paid 5Ø3-F3 AUTHOIZATION NUBE 17-digit TCN 13Ø-UF ADDITIONAL ESSAGE INFOATION COUNT aximum count of 25. equired if Additional essage Information (526-FQ) is used. 132-UH ADDITIONAL ESSAGE INFOATION QUALIFIE equired if Additional essage Information (526-FQ) is used. 526-FQ ADDITIONAL ESSAGE INFOATION equired when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFOATION CONTINUITY equired if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526-FQ) follows it, and the text of the following message is a continuation of the current. esponse Claim Segment Questions Check esponse Claim Segment Segment Identification (111-A) = 22 455-E PESCIPTION/SEVICE EFEENCE 1 = x Billing NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE NUBE Accepted/Paid esponse Pricing Segment Questions Check esponse Pricing Segment Segment Identification (111-A) = 23 Accepted/Paid 5Ø5-F5 PATIENT PAY AOUNT 5Ø6-F6 INGEDIENT COST PAID 5Ø7-F7 DISPENSING FEE PAID 559-A PECENTAGE SALES TA AOUNT Populated with zeros PAID 566-J5 OTHE PAYE AOUNT ECOGNIZED equired if Other Payer Amount Paid (431- DV) is greater than zero (Ø) and Coordination of Benefits/Other Payments Segment is supported. 5Ø9-F9 TOTAL AOUNT PAID 522-F BASIS OF EIBUSEENT DETEINATION equired if Ingredient Cost Paid (5Ø6-F6) is greater than zero (Ø). 514-FE EAINING BENEFIT AOUNT Populated with zeros. 517-FH AOUNT APPLIED TO PEIODIC Populated with zeros. DEDUCTIBLE 518-FI AOUNT OF COPAY Patient Copay 52Ø-FK AOUNT ECEEDING PEIODIC BENEFIT AIU Populated with zeros.

esponse DU/PPS Segment Questions Check This Segment is situational Sent to provide information about DU conflicts esponse DU/PPS Segment Segment Identification (111-A) = 24 Accepted/Paid 567-J6 DU/PPS ESPONSE CODE COUNTE aximum 9 occurrences supported. equired if eason For Service Code (439- E4) is used. 439-E4 EASON FO SEVICE CODE equired if utilization conflict is detected. 528-FS CLINICAL SIGNIFICANCE CODE equired if needed to supply additional 529-FT OTHE PHAACY INDICATO equired if needed to supply additional 53Ø-FU PEVIOUS DATE OF FILL CCYYDD equired if needed to supply additional 531-FV QUANTITY OF PEVIOUS FILL equired if needed to supply additional 532-FW DATABASE INDICATO 1 = First DataBank a drug database company equired if needed to supply additional 533-F OTHE PESCIBE INDICATO equired if needed to supply additional 544-FY DU FEE TET ESSAGE equired if needed to supply additional CLAI BILLING/CLAI EBILL ACCEPTED/EJECTED ESPONSE CLAI BILLING/CLAI EBILL ACCEPTED/EJECTED ESPONSE esponse Transaction Header Segment Questions Check Accepted/ejected esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B1, B3 1Ø9-A9 TANSACTION COUNT Same value as in request 5Ø1-F1 HEADE ESPONSE STATUS A = Accepted 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request 2Ø1-B1 SEVICE POVIDE ID Same value as in request 4Ø1-D1 DATE OF SEVICE Same value as in request Accepted/ejected esponse essage Segment Questions Check Accepted/ejected This Segment is situational Segment sent if required for reject clarification esponse essage Segment Segment Identification (111-A) = 2Ø Accepted/ejected 5Ø4-F4 ESSAGE Text essage equired if text is needed for clarification or detail. esponse Insurance Segment Questions Check Accepted/ejected This Segment is situational

esponse Insurance Segment Segment Identification (111-A) = 25 Accepted/ejected 3Ø1-C1 GOUP ID Used to identify the actual group ID used during adjudication. 524-FO PLAN ID Used to identify the actual plan ID used during adjudication. esponse Status Segment Questions Check Accepted/ejected esponse Status Segment Segment Identification (111-A) = 21 112-AN TANSACTION ESPONSE STATUS = eject 5Ø3-F3 AUTHOIZATION NUBE 17-digit TCN 546-4F EJECT FIELD OCCUENCE INDICATO 13Ø-UF ADDITIONAL ESSAGE INFOATION COUNT Accepted/ejected equired if a repeating field is in error, to identify repeating field occurrence. aximum count of 25. equired if Additional essage Information (526-FQ) is used. 132-UH ADDITIONAL ESSAGE INFOATION QUALIFIE equired if Additional essage Information (526-FQ) is used. 526-FQ ADDITIONAL ESSAGE INFOATION equired when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFOATION CONTINUITY equired if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526-FQ) follows it, and the text of the following message is a continuation of the current. esponse Claim Segment Questions Check Accepted/ejected esponse Claim Segment Segment Identification (111-A) = 22 455-E PESCIPTION/SEVICE EFEENCE NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE NUBE Accepted/ejected 1 = xbilling For Transaction Code of B1, in the esponse Claim Segment, the Prescription/Service eference Number Qualifier (455-E) is 1 (x Billing). esponse DU/PPS Segment Questions Check Accepted/ejected This Segment is situational esponse DU/PPS Segment Segment Identification (111-A) = 24 Accepted/ejected 567-J6 DU/PPS ESPONSE CODE COUNTE aximum 9 occurrences supported. equired if eason For Service Code (439- E4) is used. 439-E4 EASON FO SEVICE CODE equired if utilization conflict is detected. 528-FS CLINICAL SIGNIFICANCE CODE equired if needed to supply additional 529-FT OTHE PHAACY INDICATO equired if needed to supply additional

esponse DU/PPS Segment Segment Identification (111-A) = 24 Accepted/ejected 53Ø-FU PEVIOUS DATE OF FILL CCYYDD equired if needed to supply additional 531-FV QUANTITY OF PEVIOUS FILL equired if needed to supply additional 532-FW DATABASE INDICATO 1 = First DataBank a drug database company equired if needed to supply additional 533-F OTHE PESCIBE INDICATO equired if needed to supply additional 544-FY DU FEE TET ESSAGE equired if needed to supply additional 1.1.1 CLAI BILLING/CLAI EBILL EJECTED/EJECTED ESPONSE CLAI BILLING/CLAI EBILL EJECTED/EJECTED ESPONSE esponse Transaction Header Segment Questions Check ejected/ejected esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B1, B3 1Ø9-A9 TANSACTION COUNT Same value as in request 5Ø1-F1 HEADE ESPONSE STATUS = ejected 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request 2Ø1-B1 SEVICE POVIDE ID Same value as in request 4Ø1-D1 DATE OF SEVICE Same value as in request ejected/ejected esponse essage Segment Questions Check ejected/ejected This Segment is situational Segment sent if required for reject clarification esponse essage Segment Segment Identification (111-A) = 2Ø ejected/ejected 5Ø4-F4 ESSAGE Text essage equired if text is needed for clarification or detail. esponse Status Segment Questions Check ejected/ejected esponse Status Segment Segment Identification (111-A) = 21 ejected/ejected 112-AN TANSACTION ESPONSE STATUS = eject 5Ø3-F3 AUTHOIZATION NUBE 17-digit TCN equired if needed to identify the transaction. 51Ø-FA EJECT COUNT aximum count of 5. 511-FB EJECT CODE 546-4F EJECT FIELD OCCUENCE INDICATO equired if a repeating field is in error, to identify repeating field occurrence. 13Ø-UF ADDITIONAL ESSAGE INFOATION COUNT aximum count of 25. equired if Additional essage Information (526-FQ) is used.

esponse Status Segment Segment Identification (111-A) = 21 132-UH ADDITIONAL ESSAGE INFOATION QUALIFIE ejected/ejected equired if Additional essage Information (526-FQ) is used. 526-FQ ADDITIONAL ESSAGE INFOATION equired when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFOATION CONTINUITY equired if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526-FQ) follows it, and the text of the following message is a continuation of the current. ** End of esponse (B1/B3) Payer Sheet Template**