medco version d.0 medicare part d payer sheet - … 100 parsons pond drive franklin lakes, nj 07417...

Medco100 Parsons Pond DriveFranklin Lakes, NJ 07417

“Materials Reproduced With the Consent of©National Council for Prescription Drug Programs, Inc.

2008 NCPDP”

12_v7

Medco Version D.0 Medicare Part D Payer Sheet

GENERAL INFORMATIONPayer Name: Medco Date: 10/11/2011Plan Name/Group Name: MEDICARE PART D AS PAYER orMEDICARE PART D AS SECONDARY PAYER

BIN: 610014 PCN: MEDDPRIME

Plan Name/Group Name BIN: PCN:Plan Name/Group Name: BIN: PCN:Plan Name/Group Name: BIN: PCN:Processor: TelePAID

®System

Effective as of: 12/08/2011 NCPDP Telecommunication Standard Version/Release #: D.0NCPDP Data Dictionary Version Date: 07/01/2007 NCPDP External Code List Version Date: 10/01/2009

NCPDP Emergency External Code List Version Date: 07/01/2011

Contact/Information Source: General Website: www.medcohealth.com/medco/corporate/home.jspPayer sheets available at: www.medco.com/rph

Certification Testing Window The TelePAID test system is available on Monday through Friday from 9:00 a.m. to 12:00 p.m.,eastern time, and 1:00 p.m. to 4:00 p.m., eastern time.Certification Contact Information: Pharmacy Certification Voice Mail Box 1 201 269-5168

Medco Version D.0 Questions team @ [email protected]

Provider Relations Help Desk Info: Pharmacy Services 1 800 922-1557

Other versions supported: Other versions 5.1 Telecommunication Standard Supported until 1/1/2012 Refer to the 5.1 payer sheet

OTHER TRANSACTIONS SUPPORTEDPayer: Please list each transaction supported with the segments, fields, and pertinent information on each

transaction.Transaction Code Transaction NameB1 Billing TransactionB2 Billing Reversal

FIELD LEGEND FOR COLUMNSPayer Usage

ColumnValue Explanation Payer

SituationColumn

MANDATORY M The Field is mandatory for the Segment inthe designated Transaction.

No

REQUIRED R The Field has been designated with thesituation of "Required" for the Segment in thedesignated Transaction.

No

QUALIFIEDREQUIREMENT

RW “Required when”. The situations designatedhave 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 qualifiedrequirements (i.e., not used) for this payer are excluded from the template.

CLAIM BILLING TRANSACTIONThe following lists the segments and fields in a Claim Billing for the NCPDP Telecommunication StandardImplementation Guide Version D.Ø. Please note the payer requirement is considered to be the same as statedin the Imp Guide statement of the Payer Situation unless otherwise noted.

http://www.medcohealth.com/medco/corporate/home.jsp

http://www.medco.com/rph

mailto:[email protected]



2008 NCPDP”

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Transaction Header Segment Questions Check Claim BillingIf Situational, Payer Situation

This Segment is always sent XSource of certification IDs required in SoftwareVendor/Certification ID (11Ø-AK) is Payer Issued

X

Source of certification IDs required in SoftwareVendor/Certification ID (11Ø-AK) is Switch/VAN issuedSource of certification IDs required in SoftwareVendor/Certification ID (11Ø-AK) is Not used

Transaction Header Segment Claim Billing

Field # NCPDP Field Name Value PayerUsage

Payer Situation

1Ø1-A1 BIN NUMBER 610014 M

1Ø2-A2 VERSION/RELEASE NUMBER DØ M1Ø3-A3 TRANSACTION CODE B1 M1Ø4-A4 PROCESSOR CONTROL NUMBER MEDDPRIME M

1Ø9-A9 TRANSACTION COUNT 1 M2Ø2-B2 SERVICE PROVIDER ID QUALIFIER 01 M2Ø1-B1 SERVICE PROVIDER ID NPI M4Ø1-D1 DATE OF SERVICE M

11Ø-AK SOFTWAREVENDOR/CERTIFICATION ID

Assigned when certifiedby TelePAID®

M

Insurance Segment Questions Check Claim BillingIf Situational, Payer Situation

This Segment is always sent X

Insurance SegmentSegment Identification (111-AM) =“Ø4”

Claim Billing


Payer Situation

3Ø2-C2 CARDHOLDER ID M3Ø1-C1 GROUP ID M Imp Guide: Required if necessary for

state/federal/regulatory agencyprograms.Required if needed for pharmacy claimprocessing and payment.

3Ø3-C3 PERSON CODE RW Imp Guide: Required if needed touniquely identify the family memberswithin the Cardholder ID.

Payer Requirement: Required WhenPerson Number is provided on the IDcard.

3Ø6-C6 PATIENT RELATIONSHIP CODE R Imp Guide: Required if needed touniquely identify the relationship of thePatient to the Cardholder.

997-G2 CMS PART D DEFINED QUALIFIEDFACILITY

RW Imp Guide: Required if specified intrading partner agreement.

Payer Requirement: May be submittedby Long Term Care Pharmacies.



2008 NCPDP”

32_v7

Patient Segment Questions Check Claim BillingIf Situational, Payer Situation

This Segment is always sent XThis Segment is situational

Patient SegmentSegment Identification (111-AM) =“Ø1”

Claim Billing


Payer Situation

3Ø4-C4 DATE OF BIRTH R

3Ø5-C5 PATIENT GENDER CODE R

31Ø-CA PATIENT FIRST NAME R Imp Guide: Required when the patienthas a first name.

311-CB PATIENT LAST NAME R

325-CP PATIENT ZIP/POSTAL ZONE RW Imp Guide: Optional.

Payer Requirement Emergency/DisasterSituations; Patient Zip Code of theemergency should be entered.

3Ø7-C7 PLACE OF SERVICE 01(Pharmacy) RW Imp Guide: Required if this field couldresult in different coverage, pricing, orpatient financial responsibility.

Payer Requirement: Required when thePatient Residence and PharmacyService Type submitted are for LongTerm Care, Asst Living or HomeInfusion processing. Values enteredshould be consistent with yourcontract.

Long Term Care Facility FieldCombinations:Place of Service 307-C7 = "1"Patient Residence 384-4X = “3”Pharmacy Service Type147-U7 =“5”or“3" or "1"

Assisted Living FacilityPlace of Service 307-C7 = "1"Patient Residence 384-4X = "4"Pharmacy Service Type 147-U7 = “5" or"1"

Home Infusion TherapyPlace of Service 307-C7 = "1"Patient Residence 384-4X = "1" or "4"Pharmacy Service Type 147-U7 = “3”



2008 NCPDP”

42_v7

Patient SegmentSegment Identification (111-AM) =“Ø1”

Claim Billing


Payer Situation

384-4X PATIENT RESIDENCE 1(Home)3(Nursing Facility)4(Assisted Living Facility)

RW Imp Guide: Required if this field couldresult in different coverage, pricing, orpatient financial responsibility.

Payer Requirement: Required when thePatient Residence and Pharmacy ServiceType submitted are for Long Term Care,Asst Living or Home Infusion processing.Values entered should be consistent withyour contract.

Long Term Care Facility FieldCombinations:Place of Service 307-C7 = "1"Patient Residence 384-4X = “3”Pharmacy Service Type 147-U7 = “5” or“3” or "1"

Assisted Living FacilityPlace of Service 307-C7 = "1"Patient Residence 384-4X = "4"Pharmacy Service Type 147-U7 = “5" or"1"

Home Infusion TherapyPlace of Service 307-C7 = "1"Patient Residence384-4X = "1"or “4”Pharmacy Service Type 147-U7 = “3”



2008 NCPDP”

52_v7

Claim Segment Questions Check Claim BillingIf Situational, Payer Situation

This Segment is always sent XThis payer does support partial fills

This payer does not support partial fills X

Claim SegmentSegment Identification (111-AM) =“Ø7”

Claim Billing


Payer Situation

455-EM PRESCRIPTION/SERVICEREFERENCE NUMBER QUALIFIER

1(Rx Billing) M Imp Guide: For Transaction Code of“B1”, in the Claim Segment, thePrescription/Service ReferenceNumber Qualifier (455-EM) is “1”(Rx Billing).

4Ø2-D2 PRESCRIPTION/SERVICEREFERENCE NUMBER

M

436-E1 PRODUCT/SERVICE ID QUALIFIER 00 (Not Specified)03(NDC)

M Use 00 for Multi- ingredientcompound claim.

4Ø7-D7 PRODUCT/SERVICE ID M Use 0 for Multi- ingredientcompound claim.

442-E7 QUANTITY DISPENSED R

4Ø3-D3 FILL NUMBER R

4Ø5-D5 DAYS SUPPLY R

4Ø6-D6 COMPOUND CODE 1(Not a Compound)2 (Compound)

R See Compound Segment forsupport of multi-ingredientcompounds when compound = 2.

4Ø8-D8 DISPENSE AS WRITTEN(DAW)/PRODUCT SELECTIONCODE

R

414-DE DATE PRESCRIPTION WRITTEN R

419-DJ PRESCRIPTION ORIGIN CODE R Imp Guide: Required if necessary forplan benefit administration.

354-NX SUBMISSION CLARIFICATIONCODE COUNT

Maximum count of 3. RW Imp Guide: Required if SubmissionClarification Code (42Ø-DK) is used.

42Ø-DK SUBMISSION CLARIFICATIONCODE

RW Imp Guide: Required if clarification isneeded and value submitted is greaterthan zero (Ø).

If the Date of Service (4Ø1-D1) containsthe subsequent payer coverage date, theSubmission Clarification Code (42Ø-DK) isrequired with value of “19” (Split Billing –indicates the quantity dispensed is theremainder billed to a subsequent payerwhen Medicare Part A expires. Used onlyin long-term care settings) for individualunit of use medications.

Payer Requirement: The value of 2 isused to respond to a Max DailyDose/High Dose Reject.



2008 NCPDP”

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Claim Billing


Payer Situation

3Ø8-C8 OTHER COVERAGE CODE 2(Other coverage exists-payment collected )

3(Other Coverage Billed –claim not covered)

4(Other coverage exists-payment not collected)

RW Imp Guide: Required if needed byreceiver, to communicate asummation of other coverageinformation that has been collectedfrom other payers.

Required for Coordination of Benefits.

418-DI LEVEL OF SERVICE RW Imp Guide: Required if this field couldresult in different coverage, pricing, orpatient financial responsibility.

461-EU PRIOR AUTHORIZATION TYPECODE

1(Prior Authorization)8(Payer Defined Exemption)9(Emergency Preparedness)


Payer Requirement:This field is used in conjunction withthe Prior Authorization NumberSubmitted field. Based on benefit setup, a client may allow for TCO(temporary Coverage Overrides,Transaction Supplies or EmergencyFills).

Value 9 effective 1/1/2012.

462-EV PRIOR AUTHORIZATION NUMBERSUBMITTED


Payer Requirement:When 1 in field 461-EU, then 1111populated.When 8 in field 461-EU, then 9999populated.

Value 9 effective 1/1/2012.When 9 in field 461-EU, then one ofthe 911-0 thru 5 populatedor when applicable from theappropriate reject claim response usethe value returned from field 498-PYPRIOR AUTHORIZATION NUMBER–ASSIGNED.

357-NV DELAY REASON CODE 1(Proof of eligibility unknownor unavailable)

2(Litigation)

7(Third party processingdelay)

8(Delay in eligibility

RW Imp Guide: Required when needed tospecify the reason that submission ofthe transaction has been delayed.

Payer Requirement: MED D Only -processor accepts following values tooverride a claim reject '81'.



2008 NCPDP”

72_v7


Claim Billing


Payer Situation

determination)

9(Original claims rejected ordenied…)

10(Administration delay in theprior approval process)

995-E2 ROUTE OF ADMINISTRATION RW Imp Guide: Required if specified intrading partner agreement.

Payer Requirement: Required whenCompound Code (4Ø6-D6) = 2(compound).

147-U7 PHARMACY SERVICE TYPE 1 (Community/RetailPharmacy Services)

3( Home Infusion TherapyServices)

5( Long Term Care PharmacyServices)

RW Imp Guide: Required when thesubmitter must clarify the type ofservices being performed as acondition for proper reimbursement bythe payer.

Payer Requirement:Values 1, 3, or 5 required when thePatient Residence and PharmacyService Type submitted are for LongTerm Care, Asst Living or HomeInfusion processing. Values enteredshould be consistent with yourcontract.

Long Term Care Facility FieldCombinations:Place of Service 307-C7 = "1"Patient Residence 384-4X = “3”Pharmacy Service Type 147-U7 = “5”or “3" or "1"

Assisted Living FacilityPlace of Service 307-C7 = "1"Patient Residence 384-4X = "4"Pharmacy Service Type 147-U7 = “5"or "1"

Home Infusion TherapyPlace of Service 307-C7 = "1"Patient Residence 384-4X = "1" or “4”Pharmacy Service Type 147-U7 = “3”



2008 NCPDP”

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Pricing Segment Questions Check Claim BillingIf Situational, Payer Situation


Pricing SegmentSegment Identification (111-AM) =“11”

Claim Billing


Payer Situation

4Ø9-D9 INGREDIENT COST SUBMITTED R412-DC DISPENSING FEE SUBMITTED RW Imp Guide: Required if its value has

an effect on the Gross Amount Due(43Ø-DU) calculation.

Payer Requirement: Effective01/01/2012 Dispensing FeeSubmitted is required whenSubmission Clarification Code=19(Split Billing).Pharmacy shouldprovide appropriate dispensing fee forthe transaction.

438-E3 INCENTIVE AMOUNT SUBMITTED RW Imp Guide: Required if its value hasan effect on the Gross Amount Due(43Ø-DU) calculation.

Payer Requirement: Required whensubmitting a claim for a vaccine drugand administrative fee together.

481-HA FLAT SALES TAX AMOUNTSUBMITTED

RW Imp Guide: Required if its value hasan effect on the Gross Amount Due(43Ø-DU) calculation.

482-GE PERCENTAGE SALES TAX AMOUNTSUBMITTED

RW Imp Guide: Required if its value hasan effect on the Gross Amount Due(43Ø-DU) calculation.

483-HE PERCENTAGE SALES TAX RATESUBMITTED

RW Imp Guide: Required if PercentageSales Tax Amount Submitted (482-GE) and Percentage Sales Tax BasisSubmitted (484-JE) are used.

Required if this field could result indifferent pricing.

Required if needed to calculatePercentage Sales Tax Amount Paid(559-AX).

484-JE PERCENTAGE SALES TAX BASISSUBMITTED

RW Imp Guide: Required if PercentageSales Tax Amount Submitted (482-GE) and Percentage Sales Tax RateSubmitted (483-HE) are used.

Required if this field could result indifferent pricing.



2008 NCPDP”

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Pricing SegmentSegment Identification (111-AM) =“11”

Claim Billing


Payer Situation

Required if needed to calculatePercentage Sales Tax Amount Paid(559-AX).

426-DQ USUAL AND CUSTOMARY CHARGE R Imp Guide: Required if needed pertrading partner agreement.

43Ø-DU GROSS AMOUNT DUE R423-DN BASIS OF COST DETERMINATION R Imp Guide: Required if needed for

receiver claim/encounter adjudication.

Payer Requirement: Basis of CostDetermination not required for MultiIngredient Compound claims.

Prescriber Segment Questions Check Claim BillingIf Situational, Payer Situation

This Segment is always sent XThis Segment is situational

Prescriber SegmentSegment Identification (111-AM) =“Ø3”

Claim Billing


Payer Situation

466-EZ PRESCRIBER ID QUALIFIER 01(NPI)08(State License)12(DEA)

R Imp Guide: Required if Prescriber ID(411-DB) is used.

411-DB PRESCRIBER ID NPI #, DEA# or StateLicense #

R Imp Guide: Required if this field couldresult in different coverage or patientfinancial responsibility.

Required if necessary forstate/federal/regulatory agencyprograms.

Payer Requirement: NPI, DEA orState License Number

427-DR PRESCRIBER LAST NAME RW Imp Guide: Required when thePrescriber ID (411-DB) is not known.

Required if needed for Prescriber ID(411-DB) validation/clarification.

Payer Requirement: Required whenPrescriber Id Qualifier =08 (StateLicense) is submitted.



2008 NCPDP”

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Prescriber SegmentSegment Identification (111-AM) =“Ø3”

Claim Billing


Payer Situation

367-2N PRESCRIBER STATE/PROVINCEADDRESS

RW Imp Guide: Required if needed toassist in identifying the prescriber.


Payer Requirement: Required whensubmitting Prescriber Id Qualifier = 8(State License) or Prescriber IdQualifier = 12 (DEA) is submitted.

Coordination of Benefits/Other Payments SegmentQuestions

Check Claim BillingIf Situational, Payer Situation

This Segment is situational X Required only for secondary, tertiary, etc claims.

Scenario 1 - Other Payer Amount Paid Repetitions Only X

Scenario 2 - Other Payer-Patient Responsibility AmountRepetitions and Benefit Stage Repetitions Only

Scenario 3 - Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit StageRepetitions Present (Government Programs)

Coordination of Benefits/OtherPayments SegmentSegment Identification (111-AM) =“Ø5”

Claim BillingScenario 1- Other Payer AmountPaid Repetitions Only


Payer Situation

337-4C COORDINATION OFBENEFITS/OTHER PAYMENTSCOUNT

Maximum count of 9. M

338-5C OTHER PAYER COVERAGE TYPE M339-6C OTHER PAYER ID QUALIFIER 03(BIN) M Imp Guide: Required if Other Payer ID

(34Ø-7C) is used.34Ø-7C OTHER PAYER ID M Imp Guide: Required if identification of

the Other Payer is necessary forclaim/encounter adjudication.

443-E8 OTHER PAYER DATE RW Imp Guide: Required if identification ofthe Other Payer Date is necessary forclaim/encounter adjudication.

341-HB OTHER PAYER AMOUNT PAIDCOUNT

Maximum count of 9. RW Imp Guide: Required if Other PayerAmount Paid Qualifier (342-HC) isused.

342-HC OTHER PAYER AMOUNT PAID RW Imp Guide: Required if Other Payer



2008 NCPDP”

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Coordination of Benefits/OtherPayments SegmentSegment Identification (111-AM) =“Ø5”

Claim BillingScenario 1- Other Payer AmountPaid Repetitions Only


Payer Situation

QUALIFIER Amount Paid (431-DV) is used.

431-DV OTHER PAYER AMOUNT PAID RW Imp Guide: Required if Other Payerhas approved payment for some/all ofthe billing.

471-5E OTHER PAYER REJECT COUNT Maximum count of 5. RW Imp Guide: Required if Other PayerReject Code (472-6E) is used.

472-6E OTHER PAYER REJECT CODE RW Imp Guide: Required when the otherpayer has denied the payment for thebilling.

DUR/PPS Segment Questions Check Claim BillingIf Situational, Payer Situation

This Segment is always sentThis Segment is situational X Based on pharmacy determination for clinical or vaccine

processing. When submitting a claim for a vaccine andadministration fee, only the 440-E5 (Professional ServiceCode) field is required in this segment.

DUR/PPS SegmentSegment Identification (111-AM) =“Ø8”

Claim Billing


Payer Situation

473-7E DUR/PPS CODE COUNTER Maximum of 9 occurrences. R Imp Guide: Required if DUR/PPSSegment is used.

439-E4 REASON FOR SERVICE CODE Values as defined by theExternal Code List

RW Imp Guide: Required if this field couldresult in different coverage, pricing,patient financial responsibility, and/ordrug utilization review outcome.

Required if this field affects payment foror documentation of professionalpharmacy service.

44Ø-E5 PROFESSIONAL SERVICE CODE Values as defined by theExternal Code List



Payer Requirement: Value = MA(Medication Administered), is requiredwhen submitting a claim for vaccine



2008 NCPDP”

122_v7

DUR/PPS SegmentSegment Identification (111-AM) =“Ø8”

Claim Billing


Payer Situation

drug and the administrative fee.

441-E6 RESULT OF SERVICE CODE Values as defined by theExternal Code List



Compound Segment Questions Check Claim BillingIf Situational, Payer Situation

This Segment is always sentThis Segment is situational X This segment is required when submitting a claim for Multi

Ingredient Claim Transaction (Compound Code =2).

Compound SegmentSegment Identification (111-AM) =“1Ø”

Claim Billing


Payer Situation

45Ø-EF COMPOUND DOSAGE FORMDESCRIPTION CODE

M

451-EG COMPOUND DISPENSING UNITFORM INDICATOR

M

447-EC COMPOUND INGREDIENTCOMPONENT COUNT

Maximum 25 ingredients M

488-RE COMPOUND PRODUCT IDQUALIFIER

M

489-TE COMPOUND PRODUCT ID M448-ED COMPOUND INGREDIENT

QUANTITYM

449-EE COMPOUND INGREDIENT DRUGCOST

R Imp Guide: Required if needed forreceiver claim determination whenmultiple products are billed.

49Ø-UE COMPOUND INGREDIENT BASISOF COST DETERMINATION

R Imp Guide: Required if needed forreceiver claim determination whenmultiple products are billed.

Clinical Segment Questions Check Claim BillingIf Situational, Payer Situation

This Segment is always sentThis Segment is situational X This segment may be required as determined by benefit

design. When the segment is submitted then the fieldsdefined below are mandatory.



2008 NCPDP”

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Clinical SegmentSegment Identification (111-AM) =“13”

Claim Billing


Payer Situation

491-VE DIAGNOSIS CODE COUNT Maximum count of 5. M Imp Guide: Required if DiagnosisCode Qualifier (492-WE) andDiagnosis Code (424-DO) areused.

492-WE DIAGNOSIS CODE QUALIFIER 01 M Imp Guide: Required if DiagnosisCode (424-DO) is used.

424-DO DIAGNOSIS CODE M Imp Guide: Required if this fieldcould result in different coverage,pricing, patient financialresponsibility, and/or drugutilization review outcome.

Required if this field affectspayment for professional pharmacyservice.

Required if this information can beused in place of prior authorization.




2008 NCPDP”

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CLAIM BILLING RESPONSE

GENERAL INFORMATIONPayer Name: Medco Date: 12/08/2011

Plan Name/Group Name: MEDICARE PART D AS PAYER orMEDICARE PART D AS A SECONDARY PAYER

BIN: 610014 PCN:MEDDPRIME

Plan Name/Group Name: Plan Name/Group Name: BIN: PCN:

Plan Name/Group Name: Plan Name/Group Name BIN: PCN:

CLAIM BILLING PAID (OR DUPLICATE OF PAID) RESPONSEThe following lists the segments and fields in a Claim Billing response (Paid or Duplicate of Paid) Transaction for theNCPDP Telecommunication Standard Implementation Guide Version D.Ø. Please note the payer requirement isconsidered to be the same as stated in the Imp Guide statement of the Payer Situation unless otherwisenoted.

Response Transaction Header Segment Questions Check Claim BillingAccepted/Paid (or Duplicate of Paid)If Situational, Payer Situation


Response Transaction HeaderSegment

Claim BillingAccepted/Paid (or Duplicate ofPaid)


Payer Situation

1Ø2-A2 VERSION/RELEASE NUMBER DØ M

1Ø3-A3 TRANSACTION CODE B1 M1Ø9-A9 TRANSACTION COUNT Same value as in request M5Ø1-F1 HEADER RESPONSE STATUS A M

2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Same value as in request M

2Ø1-B1 SERVICE PROVIDER ID Same value as in request M4Ø1-D1 DATE OF SERVICE Same value as in request M

Response Message Header Segment Questions Check Claim BillingAccepted/Paid (or Duplicate of Paid)If Situational, Payer Situation

This Segment is always sentThis Segment is situational X Provided when additional message text is necessary

Response Message SegmentSegment Identification (111-AM) =“2Ø”



Payer Situation

5Ø4-F4 MESSAGE RW Imp Guide: Required if text is neededfor clarification or detail.

Response Insurance Header Segment Questions Check Claim BillingAccepted/Paid (or Duplicate of Paid)If Situational, Payer Situation




2008 NCPDP”

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Response Insurance SegmentSegment Identification (111-AM) =“25”

Claim BillingAccepted/Paid (or Duplicate of

Paid)


Payer Situation

3Ø1-C1 GROUP ID R Imp Guide: Required if needed toidentify the actual cardholder oremployer group, to identifyappropriate group number, whenavailable.

Required to identify the actual groupthat was used when multiple groupcoverages exist.

545-2F NETWORK REIMBURSEMENT ID R Imp Guide: Required if needed toidentify the network for the coveredmember.

Required if needed to identify theactual Network Reimbursement ID,when applicable and/or available.

Required to identify the actualNetwork Reimbursement ID that wasused when multiple NetworkReimbursement IDs exist.

3Ø2-C2 CARDHOLDER ID RW Imp Guide: Required if theidentification to be used in futuretransactions is different than whatwas submitted on the request.

Response Status Segment Questions Check Claim BillingAccepted/Paid (or Duplicate of Paid)If Situational, Payer Situation


Response Status SegmentSegment Identification (111-AM) =“21”



Payer Situation

112-AN TRANSACTION RESPONSESTATUS

P, D M



2008 NCPDP”

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Payer Situation

5Ø3-F3 AUTHORIZATION NUMBER R Imp Guide: Required if needed toidentify the transaction.

547-5F APPROVED MESSAGE CODECOUNT

Maximum count of 5. RW Imp Guide: Required if ApprovedMessage Code (548-6F) is used.

548-6F APPROVED MESSAGE CODE RW Imp Guide: Required if ApprovedMessage Code Count (547-5F) isused and the sender needs tocommunicate additional follow up fora potential opportunity.

13Ø-UF ADDITIONAL MESSAGEINFORMATION COUNT

Maximum count of 9. RW Imp Guide: Required if AdditionalMessage Information (526-FQ) isused.

132-UH ADDITIONAL MESSAGEINFORMATION QUALIFIER

RW Imp Guide: Required if AdditionalMessage Information (526-FQ) isused.

526-FQ ADDITIONAL MESSAGEINFORMATION

RW Imp Guide: Required when additionaltext is needed for clarification ordetail.

131-UG ADDITIONAL MESSAGEINFORMATION CONTINUITY

RW Imp Guide: Required if and only ifcurrent repetition of AdditionalMessage Information (526-FQ) isused, another populated repetition ofAdditional Message Information (526-FQ) follows it, and the text of thefollowing message is a continuation ofthe current.

549-7F HELP DESK PHONE NUMBERQUALIFIER

RW Imp Guide: Required if Help DeskPhone Number (55Ø-8F) is used.

55Ø-8F HELP DESK PHONE NUMBER RW Imp Guide: Required if needed toprovide a support telephone numberto the receiver.



2008 NCPDP”

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Response Claim Segment Questions Check Claim BillingAccepted/Paid (or Duplicate of Paid)If Situational, Payer Situation


Response Claim SegmentSegment Identification (111-AM) =“22”



Payer Situation


M Imp Guide: For Transaction Code of“B1”, in the Response ClaimSegment, the Prescription/ServiceReference Number Qualifier (455-EM)is “1” (Rx Billing).


M

551-9F PREFERRED PRODUCT COUNT Maximum count of 6. RW Imp Guide: Required if PreferredProduct ID (553-AR) is used.

Payer Requirement: Based on benefitand when preferred alternative areavailable for the submitted productservice ID.

552-AP PREFERRED PRODUCT IDQUALIFIER

RW Imp Guide: Required if PreferredProduct ID (553-AR) is used.

553-AR PREFERRED PRODUCT ID RW Imp Guide: Required if a productpreference exists that needs to becommunicated to the receiver via anID.

556-AU PREFERRED PRODUCTDESCRIPTION

RW Imp Guide: Required if a productpreference exists that either cannotbe communicated by the PreferredProduct ID (553-AR) or to clarify thePreferred Product ID (553-AR).

Response Pricing Segment Questions Check Claim BillingAccepted/Paid (or Duplicate of Paid)If Situational, Payer Situation


Response Pricing SegmentSegment Identification (111-AM) =“23”



Payer Situation

5Ø5-F5 PATIENT PAY AMOUNT R5Ø6-F6 INGREDIENT COST PAID R5Ø7-F7 DISPENSING FEE PAID R Imp Guide: Required if this value is

used to arrive at the finalreimbursement.



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Payer Situation

557-AV TAX EXEMPT INDICATOR R Imp Guide: Required if the sender(health plan) and/or patient is taxexempt and exemption applies tothis billing.

558-AW FLAT SALES TAX AMOUNT PAID RW Imp Guide: Required if Flat SalesTax Amount Submitted (481-HA) isgreater than zero (Ø) or if Flat SalesTax Amount Paid (558-AW) is usedto arrive at the final reimbursement.

559-AX PERCENTAGE SALES TAXAMOUNT PAID

RW Imp Guide: Required if this value isused to arrive at the finalreimbursement.

Required if Percentage Sales TaxAmount Submitted (482-GE) isgreater than zero (Ø).

Required if Percentage Sales TaxRate Paid (56Ø-AY) and PercentageSales Tax Basis Paid (561-AZ) areused.

56Ø-AY PERCENTAGE SALES TAX RATEPAID

RW Imp Guide: Required if PercentageSales Tax Amount Paid (559-AX) isgreater than zero (Ø).

561-AZ PERCENTAGE SALES TAX BASISPAID

RW Imp Guide: Required if PercentageSales Tax Amount Paid (559-AX) isgreater than zero (Ø).

521-FL INCENTIVE AMOUNT PAID RW Imp Guide: Required if this value isused to arrive at the finalreimbursement.

Required if Incentive AmountSubmitted (438-E3) is greater thanzero (Ø).

5Ø9-F9 TOTAL AMOUNT PAID R522-FM BASIS OF REIMBURSEMENT

DETERMINATIONR Imp Guide: Required if Ingredient

Cost Paid (5Ø6-F6) is greater thanzero (Ø).

Required if Basis of CostDetermination (432-DN) is submittedon billing.



2008 NCPDP”

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Payer Situation

523-FN AMOUNT ATTRIBUTED TO SALESTAX

RW Imp Guide: Required if Patient PayAmount (5Ø5-F5) includes sales taxthat is the financial responsibility ofthe member but is not also includedin any of the other fields that add upto Patient Pay Amount.

512-FC ACCUMULATED DEDUCTIBLEAMOUNT

RW Imp Guide: Provided forinformational purposes only.

513-FD REMAINING DEDUCTIBLEAMOUNT

RW Imp Guide: Provided forinformational purposes only.

514-FE REMAINING BENEFIT AMOUNT RW Imp Guide: Provided forinformational purposes only.

517-FH AMOUNT APPLIED TO PERIODICDEDUCTIBLE

RW Imp Guide: Required if Patient PayAmount (5Ø5-F5) includesdeductible

518-FI AMOUNT OF COPAY RW Imp Guide: Required if Patient PayAmount (5Ø5-F5) includes copay aspatient financial responsibility.

52Ø-FK AMOUNT EXCEEDING PERIODICBENEFIT MAXIMUM

RW Imp Guide: Required if Patient PayAmount (5Ø5-F5) includes amountexceeding periodic benefitmaximum.

571-NZ AMOUNT ATTRIBUTED TOPROCESSOR FEE

RW Imp Guide: Required if the customeris responsible for 1ØØ% of theprescription payment and when theprovider net sale is less than theamount the customer is expected topay.

575-EQ PATIENT SALES TAX AMOUNT RW Imp Guide: Used when necessary toidentify the Patient’s portion of theSales Tax.

574-2Y PLAN SALES TAX AMOUNT RW Imp Guide: Used when necessary toidentify the Plan’s portion of theSales Tax.



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Payer Situation

572-4U AMOUNT OF COINSURANCE RW Imp Guide: Required if Patient PayAmount (5Ø5-F5) includescoinsurance as patient financialresponsibility.

392-MU BENEFIT STAGE COUNT Maximum count of 4. R Imp Guide: Required if BenefitStage Amount (394-MW) is used.

393-MV BENEFIT STAGE QUALIFIER R Imp Guide: Required if BenefitStage Amount (394-MW) is used.

Payer Requirement: Effective1/1/2012, Benefit Stage Qualifiers50,60,70 or 80 will be returned toidentify situations required for aMedicare Part D payer to identify aclaim which was not paid under thePart D benefit.

394-MW BENEFIT STAGE AMOUNT R Imp Guide: Required when aMedicare Part D payer appliesfinancial amounts to Medicare PartD beneficiary benefit stages. Thisfield is required when the plan is aparticipant in a Medicare Part Dprogram that requires reporting ofbenefit stage specific financialamounts.


Payer Requirement: Effective1/1/2012,amount will be returned asappropriate for the correspondingBenefit Stage Qualifiers (393-MV).

577-G3 ESTIMATED GENERIC SAVINGS RW Imp Guide: This information shouldbe provided when a patient selectedthe brand drug and a generic form ofthe drug was available. It will containan estimate of the differencebetween the cost of the brand drugand the generic drug, when thebrand drug is more expensive thanthe generic.



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Payer Situation

128-UC SPENDING ACCOUNT AMOUNTREMAINING

RW Imp Guide: This dollar amount willbe provided, if known, to thereceiver when the transaction hadspending account dollars reportedas part of the patient pay amount.

129-UD HEALTH PLAN-FUNDEDASSISTANCE AMOUNT

RW Imp Guide: Required when thepatient meets the plan-fundedassistance criteria, to reduce PatientPay Amount (5Ø5-F5). The resultingPatient Pay Amount (5Ø5-F5) mustbe greater than or equal to zero.

133-UJ AMOUNT ATTRIBUTED TOPROVIDER NETWORK SELECTION

RW Imp Guide: Required if Patient PayAmount (5Ø5-F5) includes anamount that is attributable to a costshare differential due to theselection of one pharmacy overanother.

134-UK AMOUNT ATTRIBUTED TOPRODUCT SELECTION/BRANDDRUG

RW Imp Guide: Required if Patient PayAmount (5Ø5-F5) includes anamount that is attributable to apatient’s selection of a Brand drug.

135-UM AMOUNT ATTRIBUTED TOPRODUCT SELECTION/NON-PREFERRED FORMULARYSELECTION

RW Imp Guide: Required if Patient PayAmount (5Ø5-F5) includes anamount that is attributable to apatient’s selection of a non-preferredformulary product.

136-UN AMOUNT ATTRIBUTED TOPRODUCT SELECTION/BRANDNON-PREFERRED FORMULARYSELECTION

RW Imp Guide: Required if Patient PayAmount (5Ø5-F5) includes anamount that is attributable to apatient’s selection of a Brand non-preferred formulary product.

137-UP AMOUNT ATTRIBUTED TOCOVERAGE GAP

RW Imp Guide: Required when thepatient’s financial responsibility isdue to the coverage gap.

566-J5 OTHER PAYER AMOUNTRECOGNIZED

Imp Guide: Required if this value isused to arrive at the finalreimbursement.

Required if Other Payer AmountPaid (431-DV) is greater than zero(Ø) and Coordination ofBenefits/Other Payments Segmentis supported.



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Response DUR/PPS Segment QuestionsCheck Claim Billing

Accepted/Paid (or Duplicate of Paid)If Situational, Payer Situation

This Segment is always sentThis Segment is situational X When DUR Information to be provided

Response DUR/PPS SegmentSegment Identification (111-AM) =“24”



Payer Situation

567-J6 DUR/PPS RESPONSE CODECOUNTER

Maximum 9 occurrencessupported.

RW Imp Guide: Required if ReasonFor Service Code (439-E4) isused.

439-E4 REASON FOR SERVICE CODE RW Imp Guide: Required if utilizationconflict is detected.

528-FS CLINICAL SIGNIFICANCE CODE RW Imp Guide: Required if needed tosupply additional information forthe utilization conflict.

529-FT OTHER PHARMACY INDICATOR RW Imp Guide: Required if needed tosupply additional information forthe utilization conflict.

53Ø-FU PREVIOUS DATE OF FILL RW Imp Guide: Required if needed tosupply additional information forthe utilization conflict.

Required if Quantity of PreviousFill (531-FV) is used.

531-FV QUANTITY OF PREVIOUS FILL RW Imp Guide: Required if needed tosupply additional information forthe utilization conflict.

Required if Previous Date Of Fill(53Ø-FU) is used.

532-FW DATABASE INDICATOR RW Imp Guide: Required if needed tosupply additional information forthe utilization conflict.

533-FX OTHER PRESCRIBER INDICATOR RW Imp Guide: Required if needed tosupply additional information forthe utilization conflict.

544-FY DUR FREE TEXT MESSAGE RW Imp Guide: Required if needed tosupply additional information forthe utilization conflict.



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Payer Situation

57Ø-NS DUR ADDITIONAL TEXT RW Imp Guide: Required if needed tosupply additional information forthe utilization conflict.

Response Coordination of Benefits/Other PayersSegment Questions

Check Claim BillingAccepted/Paid (or Duplicate of Paid)If Situational, Payer Situation

This Segment is situational X When available 4Rx or Medicare D OHI DATA to be returned.

Response Coordination ofBenefits/Other Payers SegmentSegment Identification (111-AM) =“28”

Claim BillingAccepted/Paid (or Duplicate of Paid)


Payer Situation

355-NT OTHER PAYER ID COUNT Maximum count of 3. M338-5C OTHER PAYER COVERAGE TYPE M339-6C OTHER PAYER ID QUALIFIER RW Imp Guide: Required if Other Payer ID

(34Ø-7C) is used.

Payer Requirement: When availableand required, 4Rx (Primary) orMedicare D OHI Data may be returnedon a claim response.

34Ø-7C OTHER PAYER ID RW Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.


991-MH OTHER PAYER PROCESSORCONTROL NUMBER

RW Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.


356-NU OTHER PAYER CARDHOLDER ID RW Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.




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Claim BillingAccepted/Paid (or Duplicate of Paid)


Payer Situation

992-MJ OTHER PAYER GROUP ID RW Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.


142-UV OTHER PAYER PERSON CODE RW Imp Guide: Required if needed touniquely identify the family memberswithin the Cardholder ID, as assignedby the other payer.


127-UB OTHER PAYER HELP DESKPHONE NUMBER

RW Imp Guide: Required if needed toprovide a support telephone number ofthe other payer to the receiver.


CLAIM BILLING/ACCEPTED/REJECTED RESPONSEResponse Transaction Header Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected

If Situational, Payer SituationThis Segment is always sent X


Claim BillingAccepted/Rejected


Payer Situation

1Ø2-A2 VERSION/RELEASE NUMBER DØ M1Ø3-A3 TRANSACTION CODE B1 M1Ø9-A9 TRANSACTION COUNT Same value as in request M

5Ø1-F1 HEADER RESPONSE STATUS A M2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Same value as in request M2Ø1-B1 SERVICE PROVIDER ID Same value as in request M

4Ø1-D1 DATE OF SERVICE Same value as in request M

Response Message Segment Questions Check Claim Billing/Claim Rebill Accepted/RejectedIf Situational, Payer Situation

This Segment is always sentThis Segment is situational X Provided when additional message text



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Payer Situation

5Ø4-F4 MESSAGE Imp Guide: Required if text isneeded for clarification or detail.

Response Insurance Segment Questions Check Claim Billing Accepted/RejectedIf Situational, Payer Situation


This Segment is situational

Response Insurance SegmentSegment Identification (111-AM) =“25”



Payer Situation

3Ø1-C1 GROUP ID RW Imp Guide: Required if needed toidentify the actual cardholder oremployer group, to identifyappropriate group number, whenavailable.

Required to identify the actual groupthat was used when multiple groupcoverages exist.

545-2F NETWORK REIMBURSEMENT ID RW Imp Guide: Required if needed toidentify the network for the coveredmember.

Required if needed to identify theactual Network Reimbursement ID,when applicable and/or available.

Required to identify the actualNetwork Reimbursement ID thatwas used when multiple NetworkReimbursement IDs exist.

3Ø2-C2 CARDHOLDER ID RW Imp Guide: Required if theidentification to be used in futuretransactions is different than whatwas submitted on the request.



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Response Status Segment Questions Check Claim BillingAccepted/RejectedIf Situational, Payer Situation



Claim Billing Accepted/Rejected


Payer Situation


R = Reject M

51Ø-FA REJECT COUNT Maximum count of 5. R511-FB REJECT CODE R546-4F REJECT FIELD OCCURRENCE

INDICATORRW Imp Guide: Required if a repeating

field is in error, to identify repeatingfield occurrence






RW Imp Guide: Required whenadditional text is needed forclarification or detail.


RW Imp Guide: Required if and only ifcurrent repetition of AdditionalMessage Information (526-FQ) isused, another populated repetitionof Additional Message Information(526-FQ) follows it, and the text ofthe following message is acontinuation of the current.



55Ø-8F HELP DESK PHONE NUMBER RW Imp Guide: Required if needed toprovide a support telephonenumber.

987-MA URL RW Imp Guide: Provided forinformational purposes only to relayhealthcare communications via theInternet.

Payer Requirement: Will returnWWW. MEDCO.COM/RPH



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Response Claim Segment Questions Check Claim Billing Accepted/RejectedIf Situational, Payer Situation


Response Claim SegmentSegment Identification (111-AM) =“22”



Payer Situation


1 M Imp Guide: For Transaction Codeof “B1”, in the Response ClaimSegment, the Prescription/ServiceReference Number Qualifier (455-EM) is “1” (Rx Billing).


M

551-9F PREFERRED PRODUCT COUNT Maximum count of 6. RW Imp Guide: Required if PreferredProduct ID (553-AR) is used.

552-AP PREFERRED PRODUCT IDQUALIFIER

RW Imp Guide: Required if PreferredProduct ID (553-AR) is used.

553-AR PREFERRED PRODUCT ID RW Imp Guide: Required if a productpreference exists that needs to becommunicated to the receiver viaan ID.

556-AU PREFERRED PRODUCTDESCRIPTION

RW Imp Guide: Required if a productpreference exists that either cannotbe communicated by the PreferredProduct ID (553-AR) or to clarifythe Preferred Product ID (553-AR).

Response DUR/PPS Segment Questions Check Claim Billing Accepted/RejectedIf Situational, Payer Situation

This Segment is always sentThis Segment is situational X When DUR has additional information to be returned


Claim Billing/Accepted/Rejected


Payer Situation



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567-J6 DUR/PPS RESPONSE CODECOUNTER

Maximum 9 occurrencessupported.

RW Imp Guide: Required if and only ifcurrent repetition of AdditionalMessage Information (526-FQ) isused, another populated repetitionof Additional Message Information(526-FQ) follows it, and the text ofthe following message is acontinuation of the current.

439-E4 REASON FOR SERVICE CODE RW Imp Guide: Required if utilizationconflict is detected.

528-FS CLINICAL SIGNIFICANCE CODE RW Imp Guide: Required if needed tosupply additional information for theutilization conflict.

529-FT OTHER PHARMACY INDICATOR RW Imp Guide: Required if needed tosupply additional information for theutilization conflict.

53Ø-FU PREVIOUS DATE OF FILL RW Imp Guide: Required if needed tosupply additional information for theutilization conflict.

Required if Quantity of Previous Fill(531-FV) is used.

531-FV QUANTITY OF PREVIOUS FILL RW Imp Guide: Required if needed tosupply additional information for theutilization conflict.

Required if Previous Date Of Fill(53Ø-FU) is used.

532-FW DATABASE INDICATOR RW Imp Guide: Required if needed tosupply additional information for theutilization conflict.

533-FX OTHER PRESCRIBER INDICATOR RW Imp Guide: Required if needed tosupply additional information for theutilization conflict.

544-FY DUR FREE TEXT MESSAGE RW Imp Guide: Required if needed tosupply additional information for theutilization conflict.

57Ø-NS DUR ADDITIONAL TEXT RW Imp Guide: Required if needed tosupply additional information for theutilization conflict.



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Response Prior Authorization Segment Questions Check Claim Billing Accepted/RejectedIf Situational, Payer Situation

This Segment is always sentThis Segment is situational X Provided when the receiver has the opportunity to reprocess

the claim with using a Prior Authorization Number.

Response Prior AuthorizationSegmentSegment Identification (111-AM) =“26”



Payer Situation

498-PY PRIOR AUTHORIZATIONNUMBER–ASSIGNED

RW Imp Guide: Required whenthe receiver must submit this PriorAuthorization Number in order toreceive payment for the claim.

Payer Requirement: The valuereturned in this field will provide thevalue that may be submitted in PriorAuthorization Number Submitted,field 462-EV. This value must besubmitted with appropriatecorresponding Prior AuthorizationType Code, field 461-EU.

Response Coordination of Benefits/Other PayersSegment Questions

Check Claim Billing Accepted/RejectedIf Situational, Payer Situation

This Segment is situational X When 4Rx or Medicare OHI data available




Payer Situation

355-NT OTHER PAYER ID COUNT Maximum count of 3. M338-5C OTHER PAYER COVERAGE TYPE M339-6C OTHER PAYER ID QUALIFIER 03 RW Imp Guide: Required if Other Payer ID

(34Ø-7C) is used.

Payer Requirement: The 4Rx datasubmitted on the claim must beupdated this field maybe returned orwhen available Medicare D OHI Datamay be returned.



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Payer Situation

34Ø-7C OTHER PAYER ID RW Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.


991-MH OTHER PAYER PROCESSORCONTROL NUMBER

RW Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.


356-NU OTHER PAYER CARDHOLDER ID RW Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.


992-MJ OTHER PAYER GROUP ID RW Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.


142-UV OTHER PAYER PERSON CODE RW Imp Guide: Required if needed touniquely identify the family memberswithin the Cardholder ID, as assignedby the other payer.




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Payer Situation

127-UB OTHER PAYER HELP DESKPHONE NUMBER

RW Imp Guide: Required if needed toprovide a support telephone number ofthe other payer to the receiver.


CLAIM BILLING REJECTED/REJECTED RESPONSEResponse Transaction Header Segment Questions Check Claim Billing

Rejected/RejectedIf Situational, Payer Situation



Claim BillingRejected/Rejected


Payer Situation

1Ø2-A2 VERSION/RELEASE NUMBER DØ M1Ø3-A3 TRANSACTION CODE B1 M

1Ø9-A9 TRANSACTION COUNT Same value as in request M5Ø1-F1 HEADER RESPONSE STATUS R M2Ø2-B2 SERVICE PROVIDER ID

QUALIFIERSame value as in request M

2Ø1-B1 SERVICE PROVIDER ID Same value as in request M4Ø1-D1 DATE OF SERVICE Same value as in request M

Response Message Segment Questions Check Claim BillingRejected/RejectedIf Situational, Payer Situation

This Segment is always sentThis Segment is situational X




Payer Situation

5Ø4-F4 MESSAGE Imp Guide: Required if text is neededfor clarification or detail.



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Response Status Segment Questions Check Claim Billing/Rejected/RejectedIf Situational, Payer Situation





Payer Situation


R M

5Ø3-F3 AUTHORIZATION NUMBER RW Imp Guide: Required if needed toidentify the transaction.

51Ø-FA REJECT COUNT Maximum count of 5. R511-FB REJECT CODE R546-4F REJECT FIELD OCCURRENCE

INDICATORRW Imp Guide: Required if a repeating

field is in error, to identify repeatingfield occurrence.






RW Imp Guide: Required when additionaltext is needed for clarification ordetail.


RW Imp Guide: Required if and only ifcurrent repetition of AdditionalMessage Information (526-FQ) isused, another populated repetition ofAdditional Message Information (526-FQ) follows it, and the text of thefollowing message is a continuation ofthe current.



55Ø-8F HELP DESK PHONE NUMBER RW Imp Guide: Required if needed toprovide a support telephone numberto the receiver.



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medco version d.0 medicare part d payer sheet - … 100 parsons pond drive franklin lakes, nj 07417...

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