aryland edical Assistance Program edicaid Request Payer Sheet ** Start of Request (B2) Payer Sheet Template** GENERAL INFORATION Payer Name: aryland edical Assistance Program Date: January 1, 2Ø12 Plan Name/Group Name: aryland Department of Health and ental BIN: 61ØØ84 Hygiene Plan Name/Group Name: aryland Department of Health and ental BIN: 61ØØ84 Hygiene (test) PCN: DRDPROD = Production PCN: DRDACCP = Test FIELD LEGEND FOR COLUNS Payer Column Value Explanation Column ANDATORY The Field is mandatory for the Segment in the designated Transaction. No REQUIRED R The Field has been designated with the situation of Required for the Segment in the designated Transaction. QUALIFIED REQUIREENT RW Required when. The situations designated have qualifications for usage ( Required if x, Not required if y ). No Yes Question What is your reversal window? (If transaction is billed today what is the timeframe for reversal to be submitted?) Answer 365 days CLAI REVERSAL TRANSACTION The following lists the segments and fields in a Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Transaction Header Segment Questions Check Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Not used Transaction Header Segment 1Ø1-A1 BIN NUBER 610084 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B2 1Ø4-A4 PROCESSOR CONTROL NUBER DRDPROD = Production DRDACCP = Test. 1Ø9-A9 TRANSACTION 1 = One Occurrence 2Ø2-B2 SERVICE PROVIDER ID Ø1 = National Provider Identifier 2Ø1-B1 SERVICE PROVIDER ID NPI Number 4Ø1-D1 DATE OF SERVICE CCYYDD 11Ø-AK SOFTWAREVENDOR/CERTIFICATION 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 CARDHOLDER ID Recipient s 11digits edicaid ID 3Ø1-C1 GROUP ID DEDICAID R Claim Segment Questions Check Claim Segment Segment Identification (111-A) = Ø7 455-E PRESCRIPTION/SERVICE REFERENCE NUBER 1 = R Billing 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 Number assigned by pharmacy NUBER 436-E1 PRODUCT/SERVICE ID Ø3 = NDC 4Ø7-D7 PRODUCT/SERVICE ID NDC Number 4Ø3-D3 FILL NUBER Ø = Original Dispensing 1-99 = Number of refills 3Ø8-C8 OTHER COVERAGE CODE Ø=Not Specified 1=No other Coverage Identified 2=Other coverage exists-payment collected 3=Other coverage exists-this claim not covered 4=Other coverage exists-payment not collected R RW ** End of Request (B2) Payer Sheet Template** Imp Guide: Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (4Ø2- D2) occur on the same day. Imp Guide: Required if needed by receiver to match the claim that is being reversed. RESPONSE CLAI REVERSAL PAYER SHEET TEPLATE CLAI REVERSAL ACCEPTED/APPROVED RESPONSE ** Start of Response (B2) Payer Sheet Template** GENERAL INFORATION Payer Name: aryland edical Assistance Program Date: January 1, 2Ø12 Plan Name/Group Name: aryland Department of Health and ental BIN: 61ØØ84 Hygiene Plan Name/Group Name: aryland Department of Health and ental BIN: 61ØØ84 Hygiene (test) PCN: DRDPROD = Production PCN: DRDACCP = Test CLAI REVERSAL ACCEPTED/APPROVED RESPONSE The following lists the segments and fields in a response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Questions Check 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B2 1Ø9-A9 TRANSACTION 1 = One Occurrence 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 2Ø2-B2 SERVICE PROVIDER ID Ø1 = National Provider Identifier 2Ø1-B1 SERVICE PROVIDER ID NPI Number
4Ø1-D1 DATE OF SERVICE CCYYDD Questions Check Segment Identification (111-A) = 21 112-AN TRANSACTION RESPONSE STATUS A = Approved 5Ø3-F3 AUTHORIZATION NUBER 17-digit D TCN R 13Ø-UF ADDITIONAL ESSAGE INFORATION aximum count of 25. RW Required if Additional essage Information 132-UH ADDITIONAL ESSAGE INFORATION RW Required if Additional essage Information 526-FQ ADDITIONAL ESSAGE INFORATION RW Required when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFORATION RW 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. Response Claim Segment Questions Check Response Claim Segment Segment Identification (111-A) = 22 455-E PRESCRIPTION/SERVICE REFERENCE NUBER 1 = RxBilling For Transaction Code of B2, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 1 (Rx Billing). 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUBER Number assigned by the pharmacy CLAI REVERSAL ACCEPTED/REJECTED RESPONSE Questions Check - Accepted/Rejected 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B2 1Ø9-A9 TRANSACTION 1 = One Occurrence 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 2Ø2-B2 SERVICE PROVIDER ID Ø1 = National Provider Identifier 2Ø1-B1 SERVICE PROVIDER ID NPI Number 4Ø1-D1 DATE OF SERVICE CCYYDD Accepted/Rejected Response essage Segment Questions Check - Accepted/Rejected This Segment is situational Segment sent if required for reject clarification
Response essage Segment Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE RW Required if text is needed for clarification or detail. Questions Check - Accepted/Rejected Accepted/Rejected Segment Identification (111-A) = 21 112-AN TRANSACTION RESPONSE STATUS R = Reject 5Ø3-F3 AUTHORIZATION NUBER R 51Ø-FA REJECT aximum count of 5. R 511-FB REJECT CODE R 546-4F REJECT FIELD OCCURRENCE INDICATOR RW Required if a repeating field is in error, to identify repeating field occurrence. 13Ø-UF ADDITIONAL ESSAGE INFORATION aximum count of 25. RW Imp Guide: Required if Additional essage Information 132-UH ADDITIONAL ESSAGE INFORATION RW Required if Additional essage Information 526-FQ ADDITIONAL ESSAGE INFORATION RW Required when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFORATION Response Claim Segment Questions Check - Accepted/Rejected 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. Response Claim Segment Accepted/Rejected Segment Identification (111-A) = 22 455-E PRESCRIPTION/SERVICE REFERENCE NUBER 1 = Rx Billing For Transaction Code of B2, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 1 (Rx Billing). 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUBER Number assigned by the pharmacy
CLAI REVERSAL REJECTED/REJECTED RESPONSE Questions Check - Rejected/Rejected 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B2 1Ø9-A9 TRANSACTION 1 = One Occurrence 5Ø1-F1 HEADER RESPONSE STATUS R = Rejected 2Ø2-B2 SERVICE PROVIDER ID Ø1 = National Provider Identifier 2Ø1-B1 SERVICE PROVIDER ID NPI Number 4Ø1-D1 DATE OF SERVICE CCYYDD Rejected/Rejected Response essage Segment Questions Check Rejected/Rejected This Segment is situational Used if necessary to elaborate on Header level rejects. Response essage Segment Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE RW Required if text is needed for clarification or detail. Questions Check - Rejected/Rejected Rejected/Rejected Segment Identification (111-A) = 21 112-AN TRANSACTION RESPONSE STATUS R = Reject 5Ø3-F3 AUTHORIZATION NUBER R 51Ø-FA REJECT aximum count of 5. R 511-FB REJECT CODE R 546-4F REJECT FIELD OCCURRENCE INDICATOR RW Required if a repeating field is in error, to identify repeating field occurrence. 13Ø-UF ADDITIONAL ESSAGE INFORATION aximum count of 25. RW Required if Additional essage Information 132-UH ADDITIONAL ESSAGE INFORATION RW Required if Additional essage Information 526-FQ ADDITIONAL ESSAGE INFORATION RW Imp Guide: Required when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFORATION 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. ** End of (B2) Response Payer Sheet Template**