SPAK-ITS New exico edicaid D.0 CO Payer Sheet B1-B3 Expert ode (E) Project anagement ethodology October 1, 2014 Version 1.0
2011-2012 Xerox Corporation, Xerox and Xerox and Design are trademarks of Xerox Corporation in the United States and/or other countries. This document is produced for N edicaid Project and cannot be reproduced or distributed to any third party without prior written consent. No part of this document may be modified, deleted, or expanded by any process or means without prior written permission from Xerox.
evision History Version Number Date Description Author 1.0 10/01/14 Initial document with the incentive amount included for Naloxone (Added DU/PPS Segment & 438- E3 and 440-E5 also updated) Christine arshall Configuration of This Document This document is under full configuration management. See Configuration Items List. CO Encounter Claim Submission Guide iii
Table of Contents evision History... iii Configuration of This Document... iii 1.0 Purpose... 1 2.0 General Information... 3 3.0 Instructions for Batch Submissions... 3 4.0 Batch Detail ecord Formats for B1/B3 & B2 Transactions 4 4.1 B1/B3 Transactions... 1 4.2 B2 Transactions... 7 CO Encounter Claim Submission Guide iv
1.0 Purpose This guide was developed to facilitate the submission of pharmacy claim transaction data by New exico anaged Care Organizations (COs) to the State of New exico. This guid is based upon the Batch Transaction Standard Version 1.2 and the Telecommunication Standard Version D.0 but may contain some non-standard use of fields as necessary to gather complete information. Field formats and values are compliant with the NCPDP Data Dictionary and External Code List (ECL) dated arch, 2010. The CO will create batches of claims for submission to Xerox, the pharmacy claim processor for New exico edicaid. Each batch must contain one transaction header, one transaction trailer, and detail records in the specified format. Xerox will verify the integrity of the batch file prior to processing any of the claim data submitted. If the integrity of the file is found to be flawed, Xerox will notify the CO that an error exists and no claims will be processed. The CO may include transactions for multiple pharmacies within the batch. The header, detail and trailer records all include a text indicator to designate where one record stops and the next record starts consistent with the Batch Transaction Standard Version 1.2. The message field on the trailer record is used to explain reasons why an entire batch is in error, or any other information that may need to be sent regarding the batch. FIELD LEGEND FO COLUNS Payer Column Value Explanation Payer Situation Column ANDATOY The Field is mandatory for the Segment in the designated Transaction. EQUIED The Field has been designated with the situation of "equired" for the Segment in the designated Transaction. QUALIFIED EQUIEENT BATCH TANSACTION HEADE ECOD equired when. The situations designated have qualifications for usage ("equired if x", "Not required if y"). FIELD FIELD NAE TYPE LENGTH STAT END VALUE 88Ø-K4 Text Indicator A/N 1 1 1 Start of Text (STX ) = X Ø2 7Ø1 Segment A/N 2 2 3 ØØ = File Control (header) Identifier 88Ø-K6 Transmission A/N 1 4 4 T = Transaction Type 88Ø-K1 Sender ID A/N 24 5 28 Populate as the CO edicaid Network Number preceded by 1. The edicaid Network number for the COs for Dates of No No Yes CO Encounter Claim Submission Guide 1
Service < 1/1/2014 is as follows: 796 Lovelace 808 olina 814 Presbyterian 850 University of New exico 855 Value Options 869 AmeriGroup 871 Evercare 873 BCBS New exico 879 Optum Health (BHO) The CO edicaid Network number for Dates of Service >= 1/1/2014 is as follows: 820 BCBS New exico 822 - olina 824 Presbyterian 826 United Healthcare 8Ø6-5C Batch Number N 7 29 35 atches Trailer 88Ø-K2 Creation Date N 8 36 43 Format = CCYYDD 88Ø-K3 Creation Time N 4 44 47 Format = HH 7Ø2 File Type A/N 1 48 48 P = production T = test 1Ø2-A2 Version A/N 2 49 5Ø 12 /elease Number 88Ø-K7 eceiver ID A/N 24 51 74 NAD 88Ø-K4 Text Indicator A/N 1 75 75 End of Text (ETX) = X Ø3 BATCH DETAIL ECOD FIELD FIELD NAE TYPE LENGTH STAT END VALUE 88Ø-K4 Text Indicator A/N 1 1 1 Start of Text (STX) = X Ø2 7Ø1 Segment A/N 2 2 3 G1 = Detail Data ecord Identifier 88Ø-K5 Transaction A/N 1Ø 4 13 To be determined by provider eference Number Claim Detail Varies 14 varies Data ecord 88Ø-K4 Text Indicator A/N 1 varies varies End of Text (ETX) = X Ø3 BATCH TAILE ECOD FIELD FIELD NAE TYPE LENGTH STAT END VALUE 88Ø-K4 Text Indicator A/N 1 1 1 Start of Text (STX) = X Ø2 7Ø1 Segment A/N 2 2 3 99 = File Trailer Identifier 8Ø6-5C Batch Number N 7 4 1Ø atches header 751 ecord Count N 1Ø 11 2Ø 5Ø4-F4 essage A/N 35 21 55 88Ø-K4 Text Indicator A/N 1 56 56 End of Text (ETX) = X Ø3 CO Encounter Claim Submission Guide 2
2.0 General Information GENEAL INFOATION Payer Name: New exico edicaid Plan Name/Group Name: N BIN: 610084 edicaid anaged Care Plan Name/Group Name: N edicaid anaged Care (test) PCN: DNPOD BIN: 610084 PCN: DNACCP (after 1/1/2012) PCN: DNDV5S (thru 12/31/2011 for D.Ø testing) Processor: Xerox Effective as of: 12/11/2011 NCPDP Telecommunication Standard Version/elease #: D.0 NCPDP Data Dictionary Version Date: October, NCPDP External Code List Version Date: arch, 2010 2007 Contact/Information Source: Other references such as Provider anuals, Payer phone number, web site, etc. Certification Testing Window: Certification is not required Certification Contact Information: Certification phone number and information Provider elations Help Desk Info: 8ØØ-365-4944 Other versions supported: 5.1 supported through 12/31/2011 3.0 Instructions for Batch Submissions NCPDP batches are submitted to the New exico DZ secure web site. For instructions and zip file naming procedures please refer to the N DZ Naming Document located at: It is on the DZ in the / Distribution/ N Operations/ Provider, ate & Formulary Files/. Xerox prefers to receive separate batches for B3 (rebilling) transactions. B2 (reversal) transactions can be submitted intermixed with B1 (billing). It is assumed that the CO will not submit a transaction when both the B1 & B2 occur within the same file submission. CO Encounter Claim Submission Guide 3
4.0 Batch Detail ecord Formats for B1/B3 & B2 Transactions Use B1 Transaction Code for billing requests. Use B2 for eversals and use B3 Transaction Code for rebilling/adjustment requests. CO must use the original B1 transaction and only change the transaction code from B1 to B3 and any of the fields being adjusted when submitting a rebill (adjustment) request (B3). A rebill request cannot be approved if all the mandatory segments are not received and the Servicing Pharmacy, Date of Service, Cardholder ID, Prescription Number, and NDC code do not match a previously paid encounter claim in the New exico IS system. Use B2 Transaction Code for reversal/void requests. An CO may use the abbreviated reversal format or the original B1 transaction and only change the transaction code from B1 to B2 to submit a reversal request. A reversal request cannot be denied if more than the mandatory segments are received. CO Encounter Claim Submission Guide 4
4.1 B1/B3 Transactions TANSACTION HEADE: ANDATOY Usag e 1Ø1-A1 BIN NUBE 61ØØ84 1Ø2-A2 VESION/ELEASE DØ NUBE 1Ø3-A3 TANSACTION CODE B1, B3 Claim Billing, Claim ebill 1Ø4-A4 POCESSO CONTOL DNPOD = NUBE Production DNACCP = Test 1Ø9-A9 TANSACTION COUNT 1 = One Occurrence Only 1 claim occurrence per detail record in a batch allowed 2Ø2-B2 SEVICE POVIDE ID Ø1 National NPI mandated Ø2/Ø1/2ØØ8 QUALIFIE Provider Identifier 2Ø1-B1 SEVICE POVIDE ID National Provider NPI mandated Ø2/Ø1/2ØØ8 Identifier (NPI) 4Ø1-D1 DATE OF SEVICE CCYYDD 11Ø-AK SOFTWAE VENDO/CETIFICATIO N ID ØØØØØØØØØØ Populate with zeros PATIENT SEGENT: EQUIED 111-A SEGENT Ø1 Patient Segment 3Ø4-C4 DATE OF BITH CCYYDD 31Ø-CA PATIENT FIST NAE 12 Characters 311-CB PATIENT LAST NAE 15 Characters 335-2C PEGNANCY INDICATO Blank=Not Specified 1=Not pregnant 2=Pregnant equired if pregnant INSUANCE SEGENT: ANDATOY 111-A SEGENT Ø4 Insurance Segment 3Ø2-C2 CADHOLDE ID 3Ø1-C1 GOUP ID NEWENCOED 3Ø6-C6 PATIENT ELATIONSHIP CODE 1 = Cardholder CLAI SEGENT: ANDATOY 111-A SEGENT Ø7 Claim Segment CO Encounter Claim Submission Guide 1
Field # NCPDP Field Name Value Payer 455-E PESCIPTION/SEVIC 1 = x Billing E EFEENCE NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVIC E EFEENCE NUBE 436-E1 PODUCT/SEVICE ID Ø3 = National Drug QUALIFIE Code 4Ø7-D7 PODUCT/SEVICE ID National Drug Code (NDC) 456-EN ASSOCIATED x number of the PESCIPTION/SEVIC associated partial fill E EFEENCE NUBE claim 457-EP ASSOCIATED PESCIPTION/SEVIC E DATE Used when submitting a claim for 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 Ø = Not specified 1= Not a compound 2 = Compound 4Ø8-D8 419-DJ 354-NX 42Ø-DK 3Ø8-C8 DISPENSE AS WITTEN (DAW)/PODUCT SELECTION CODE PESCIPTION OIGIN CODE SUBISSION CLAIFICATION CODE COUNT SUBISSION CLAIFICATION CODE OTHE COVEAGE CODE 1=Written 2=Telephone 3=Electronic 4=Facsimile 5=Transfer Payer Situation equired for the completion transaction in a partial fill (Dispensing Status (343-HD) = C ). Date of the Associated Prescription/Service eference Number. Pass through value as submitted by pharmacy Value Ø (Not known) will not be accepted by N. aximum count of 3. equired if Submission Clarification Code (42Ø-DK) is used. 8=Process compound for Approved Ingredients Ø = Not specified by Patient 1 = No Other Coverage Identified 2 = Other Coverage Exists Payment Collected 3 = Other Coverage Billed claim not covered 4 = Other Coverage Exists Payment Not Collected 8 = Claim is Billing for Patient Financial esponsibility only equired when submitting a claim for a multi line compound that includes non-approved ingredients or ingredients without an NDC number. Value indicates POVIDE approval to accept reimbursement for covered items only. Pass through value as submitted by pharmacy 453-EJ OIGINALLY Complete when product prescribed is CO Encounter Claim Submission Guide 2
Field # NCPDP Field Name Value Payer PESCIBED PODUCT/SEVICE ID QUALIFIE 445-EA OIGINALLY PESCIBED PODUCT/SEVICE CODE 446-EB OIGINALLY PESCIBED QUANTITY 33Ø-CW ALTENATE ID CO TCN is entered here 461-EU PIO AUTHOIZATION TYPE CODE 462-EV PIO AUTHOIZATION NUBE SUBITTED 343-HD DISPENSING STATUS P = Initial Fill C = Completion Fill 344-HF QUANTITY INTENDED TO BE DISPENSED 345-HG DAYS SUPPLY INTENDED TO BE DISPENSED 995-E2 OUTE OF ADINISTATION Payer Situation different than the product supplied. equired when field 445-EA is submitted and a pharmacist dispenses a medication other than the originally prescribed. Code of the initially prescribed product or service. This is TCN and not patient ID Pass through value if submitted by pharmacy Pass through value if submitted by pharmacy equired for the partial fill or the completion fill of a prescription. equired when submitting a claim for a partial fill equired when submitting a claim for a partial fill equired when submitting compounds. Code for the route of administration of the complete compound mixture. SNOED Values required for D.0 PESCIBE SEGENT: EQUIED 111-A SEGENT Ø3 Prescriber Segment 466-EZ PESCIBE ID QUALIFIE Ø1=National Provider Identifier (NPI) 411-DB PESCIBE ID National Provider Identifier (NPI) COB/OTHE PAYENTS SEGENT: EQUIED FO COB CLAIS 111-A SEGENT Ø5 COB Segment 337-4C COODINATION OF BENEFITS/OTHE PAYENTS COUNT aximum count of 9. 338-5C OTHE PAYE COVEAGE TYPE Blank=Not Specified Ø1=Primary Ø2=Secondary - Second Ø3=Tertiary - Third Ø4=Quaternary - Fourth Ø5=Quinary - Fifth Note: Values 98 Coupon and 99 Composite which are listed on 5.1 Payer Sheet are no longer valid. CO Encounter Claim Submission Guide 3
339-6C OTHE PAYE ID QUALIFIE Pass through whatever was submitted by the pharmacy 34Ø-7C OTHE PAYE ID Pass through of whatever was submitted 443-E8 OTHE PAYE DATE CCYYDD equired when there is payment or denial from another source 341-HB OTHE PAYE AOUNT PAID COUNT aximum count of 9. Imp Guide: equired if Other Payer Amount Paid Qualifier (342-HC) is used. 342-HC OTHE PAYE AOUNT PAID QUALIFIE 431-DV OTHE PAYE AOUNT PAID 471-5E OTHE PAYE EJECT COUNT 472-6E OTHE PAYE EJECT CODE 353-N OTHE PAYE-PATIENT ESPONSIBILITY AOUNT COUNT Ø1=Delivery Ø2=Shipping Ø3=Postage Ø4=Administrative Ø5=Incentive Ø6=Cognitive Service Ø7=Drug Benefit Ø9=Compound Preparation Cost 1Ø=Sales Tax equired when there is payment from another source Payer equirement: equired when 308-C8 = 2 S$$$$$$cc equired if OCC = 2 aximum count of 5. Imp Guide: equired if Other Payer eject Code (472-6E) is used. Payer equirement: equired if OCC = 3 Imp Guide: equired when the other payer has denied the payment for the billing, designated with Other Coverage Code (3Ø8-C8) = 3 (Other aximum count of 25. Coverage Billed claim not covered). Imp Guide: equired if Other Payer- Patient esponsibility Amount Qualifier (351-NP) is used. 351-NP OTHE PAYE-PATIENT ESPONSIBILITY AOUNT QUALIFIE Ø1=Amt Applied to Periodic Deductible Ø2=Amt Attributed to Product Selection/Brand Drug Ø3=Amt Attributed to Sales Tax Ø4=Amt Exceeding Periodic Benefit aximum Ø5=Amount of Copay Ø6=Patient Pay Amount Ø7=Amount of Coinsurance Ø8=Amt Attributed to Product Selection/Non-Pref Formulary Ø9=Amt Attributed to Health Plan Funded Assistance Amount equired if Other Payer-Patient esponsibility Amount (352-NQ) is used. Use to indicate patient responsibility amount when 308-C8 = 2 or 4 CO Encounter Claim Submission Guide 4
Field # NCPDP Field Name Value Payer 1Ø= Amt Attributed to Provider Network Selection 11=Amt Attributed to Product Selection/Brand Non-Preferred Formulary Selection 12=Amt Attributed to Coverage Gap 13=Amt Attributed to Processor Fee 352-NQ OTHE PAYE-PATIENT ESPONSIBILITY AOUNT Payer Situation equired when Other Coverage Code 308-C8 = 2 or 4 DU/PPS Segment Questions Check Claim Billing/Claim ebill If Situational, Payer Situation This Segment is always sent This Segment is situational X DU/PPS Segment Segment Identification (111-A) = Ø8 Field # NCPDP Field Name Value Payer 473-7E DU/PPS CODE COUNTE aximum of 9 occurrences. Claim Billing/Claim ebill Payer Situation equired if DU/PPS Segment is used. 44Ø-E5 POFESSIONAL SEVICE CODE A = edication administration Use A for vaccine administration and naloxone rescue kit incentive amount. ust equal a value of A (edication Administered) when Incentive Amount Submitted (438-E3) is greater than zero (Ø). Payer equirement: Enter one professional service code only, indicating the type of service. N edicaid Valid Values: A = edication Administration PICING SEGENT: ANDATOY 111-A SEGENT 11 Pricing Segment 4Ø9-D9 INGEDIENT COST Pass through of This field is required to be submitted 412-DC 433-DX SUBITTED DISPENSING FEE SUBITTED PATIENT PAID AOUNT SUBITTED 438-E3 INCENTIVE AOUNT SUBITTED 478-H7 OTHE AOUNT CLAIED SUBITTED COUNT submitted Pass through of submitted aximum count of 3. in D.0 which is a change from 5.1 equired if necessary as component part of Gross Amount Due Amount the pharmacy received from the patient for the prescription dispensed. equired when submitting for Naloxone escue Kit. Imp Guide: equired if Other Amount Claimed Submitted Qualifier (479-H8) is used. 479-H8 OTHE AOUNT Ø9=Compound If a compounding fee is being CO Encounter Claim Submission Guide 5
Field # NCPDP Field Name Value Payer CLAIED SUBITTED Preparation Cost QUALIFIE Submitted 48Ø-H9 426-DQ OTHE AOUNT CLAIED SUBITTED USUAL AND CUSTOAY CHAGE Payer Situation requested in addition to the dispensing fee enter Ø9. New qualifier value added in D.0 Pass through if populated by pharmacy Amount charged cash customers for the prescription exclusive of sales tax or other amounts claimed. 43Ø-DU GOSS AOUNT DUE CO total amount paid 423-DN BASIS OF COST DETEINATION Ø8=340B/Disproport ionate Share Pricing/Public Health Service equired to identify 340b acquisition cost. COPOUND SEGENT: EQUIED FO COPOUND CLAIS 111-A SEGENT 1Ø Compound Segment 45Ø-EF COPOUND DOSAGE Ø1=Capsule Dosage form of the complete FO DESCIPTION 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 compound mixtur 451-EG 447-EC 488-E 489-TE 448-ED 449-EE 49Ø-UE COPOUND DISPENSING UNIT FO INDICATO COPOUND INGEDIENT COPONENT COUNT COPOUND PODUCT ID QUALIFIE COPOUND PODUCT ID COPOUND INGEDIENT QUANTITY COPOUND INGEDIENT DUG COST COPOUND INGEDIENT BASIS OF COST DETEINATION 18=Enema 1=Each 2=Grams 3=illiliters aximum 25 ingredients Ø3=NDC NDC 9(7)v999 Ø8=340B / Disproportionate Share Pricing/Public Health Count of compound product IDs (both active and inactive) in the compound mixture submitted. Use to submit compound ingredient cost paid. Populate as $0.00 if nothing was paid for the particular ingredient. Submit Ø8 to identify 340b acquisition cost CO Encounter Claim Submission Guide 6
4.2 B2 Transactions TANSACTION HEADE: ANDATOY 1Ø1-A1 BIN NUBE 61ØØ84 1Ø2-A2 VESION/ELEASE DØ NUBE 1Ø3-A3 TANSACTION CODE B2 eversal 1Ø4-A4 POCESSO CONTOL NUBE DNPOD = Production DNACCP = Test 1Ø9-A9 TANSACTION COUNT 1 = One Occurrence Only 1 claim occurrence per detail record in a batch allowed 2Ø2-B2 SEVICE POVIDE ID Ø1 National NPI mandated Ø2/Ø1/2ØØ8 QUALIFIE Provider Identifier 2Ø1-B1 SEVICE POVIDE ID National Provider NPI mandated Ø2/Ø1/2ØØ8 Identifier (NPI) 4Ø1-D1 DATE OF SEVICE CCYYDD 11Ø-AK SOFTWAE VENDO/CETIFICATIO N ID ØØØØØØØØØØ Populate with zeros INSUANCE SEGENT: ANDATOY 111-A SEGENT Ø4 Insurance Segment 3Ø2-C2 CADHOLDE ID 3Ø1-C1 GOUP ID NEWENCOED CLAI SEGENT: ANDATOY 111-A SEGENT Ø7 Claim Segment 455-E PESCIPTION/SEVIC 1 = x Billing E EFEENCE NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVIC E EFEENCE NUBE 436-E1 PODUCT/SEVICE ID Ø3 = National Drug QUALIFIE Code 4Ø7-D7 PODUCT/SEVICE ID National Drug Code (NDC) 343-HD DISPENSING STATUS P = Initial Fill equired for the partial fill or the 33Ø-CW ALTENATE ID C = Completion Fill CO TCN is entered here completion fill of a prescription. If submitted will be returned on IS 070/071 report. CO Encounter Claim Submission Guide 7
ADDITIONAL INFOATION Code Definition andatory - These fields must be populated in the order for the claim to be processed. equired - These data fields must also be populated in order to have the claim processed. equired When (Conditional) - These fields depend on other claim information or eligibility information to determine if they are required. CO Encounter Claim Submission Guide 8