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Payer Name: Patient Choice / Therapy First / Therapy First

Date: 10/17/2011

Plus

Plan Name/Group Name: Patient Choice

BIN: 004682

PCN: CN

Plan Name/Group Name: Therapy First

BIN: 004682

PCN: CN

Plan Name/Group Name: Therapy First Plus

BIN: 004682

PCN: CN

Processor: Emdeon

Effective as of: 11/17/2011

NCPDP Telecommunication Standard Version/Release #: D.0

NCPDP Data Dictionary Version Date: 9/2010

NCPDP External Code List Version Date: 9/2010

Transaction Code

Transaction Name

B1

Billing Transaction

B2

Reversal Transaction

B3

Re-Bill Transaction

Payer Usage

Value

Explanation

Payer

Column

Situation

Column

MANDATORY

M

The Field is mandatory for the Segment in

No

the designated Transaction.

REQUIRED

R

The Field has been designated with the

No

situation of "Required" for the Segment in the

designated Transaction.

QUALIFIED

RW

“Required when”. The situations designated

Yes

REQUIREMENT

have qualifications for usage ("Required if x",

"Not required if y").

Transaction Header Segment Questions

Check

Claim Billing/Claim Re-bill

If Situational, Payer Situation

This Segment is always sent

X

Transaction Header Segment

Claim Billing/Claim Re-bill

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

1Ø1-A1

BIN NUMBER

004682

M

1Ø2-A2

VERSION/RELEASE NUMBER

DØ

M

1Ø3-A3

TRANSACTION CODE

B1 OR B3

M

1Ø4-A4

PROCESSOR CONTROL NUMBER

CN

M

1Ø9-A9

TRANSACTION COUNT

1

M

2Ø2-B2

SERVICE PROVIDER ID QUALIFIER

01 – NPI

M

2Ø1-B1

SERVICE PROVIDER ID

NPI

M

4Ø1-D1

DATE OF SERVICE

M

11Ø-AK

SOFTWARE

ALL SPACES

M

VENDOR/CERTIFICATION ID

Insurance Segment Questions

Check

Claim Billing/Claim Re-bill

If Situational, Payer Situation

This Segment is always sent

X

Insurance Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“Ø4”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

3Ø2-C2

CARDHOLDER ID

M

3Ø1-C1

GROUP ID

R

Imp Guide: Required if necessary for

state/federal/regulatory agency programs.

Required if needed for pharmacy claim

processing and payment.

Patient Segment Questions

Check

Claim Billing/Claim Re-bill

If Situational, Payer Situation

This Segment is always sent

X

This Segment is situational

Patient Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“Ø1”

Field

NCPDP Field Name

Value

Payer

Payer Situation

Usage

3Ø4-C4

DATE OF BIRTH

R

3Ø5-C5

PATIENT GENDER CODE

R

31Ø-CA

PATIENT FIRST NAME

R

Imp Guide: Required when the patient has

a first name.

311-CB

PATIENT LAST NAME

R

322-CM

PATIENT STREET ADDRESS

RW

Imp Guide: Optional.

Payer Requirement: Required when

available.

Patient Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“Ø1”

Field

NCPDP Field Name

Value

Payer

Payer Situation

Usage

323-CN

PATIENT CITY ADDRESS

RW

Imp Guide: Optional.

Payer Requirement : Required when

available.

324-CO

PATIENT STATE /

RW

Imp Guide: Optional.

PROVINCE ADDRESS

Payer Requirement : Required when

available.

325-CP

PATIENT ZIP / POSTAL ZONE

RW

Imp Guide: Optional.

Payer Requirement: Required when

available.

326-CQ

PATIENT PHONE NUMBER

RW

Imp Guide: Optional.

Payer Requirement: Required when

available.

35Ø-HN

PATIENT E-MAIL ADDRESS

RW

Imp Guide: May be submitted for the

receiver to relay patient health care

communications via the Internet when

provided by the patient.

Payer Requirement: Required when

available.

Claim Segment Questions

Check

Claim Billing/Claim Re-bill

If Situational, Payer Situation

This Segment is always sent

X

This payer supports partial fills

This payer does not support partial fills

X

Claim Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“Ø7”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

455-EM

PRESCRIPTION/SERVICE

1 = Rx Billing

M

Imp Guide: For Transaction Code of

REFERENCE NUMBER QUALIFIER

“B1”, in the Claim Segment, the

Prescription/Service Reference Number

Qualifier (455-EM) is “1” (Rx Billing).

4Ø2-D2

PRESCRIPTION/SERVICE

up to 12 positions

M

REFERENCE NUMBER

436-E1

PRODUCT/SERVICE ID QUALIFIER

03 - NDC

M

00 if Compound Code (406-D6) = 2

4Ø7-D7

PRODUCT/SERVICE ID

11 digit NDC

M

0 if Compound Code (406-D6) = 2

442-E7

QUANTITY DISPENSED

Format 9(7)V999

R

4Ø3-D3

FILL NUMBER

New = 00 (zeros must be

R

sent)

4Ø5-D5

DAYS SUPPLY

R

4Ø6-D6

COMPOUND CODE

1 = Not a Compound

R

Refer to Compound Segment when

2 = Compound

Compound Code (406-D6) = 2

4Ø8-D8

DISPENSE AS WRITTEN

R

(DAW)/PRODUCT SELECTION CODE

414-DE

DATE PRESCRIPTION WRITTEN

R

415-DF

NUMBER OF REFILLS AUTHORIZED

R

Imp Guide: Required if necessary for plan

benefit administration.

“Materials Reproduced With the Consent of

Claim Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“Ø7”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

419-DJ

PRESCRIPTION ORIGIN CODE

R

Imp Guide: Required if necessary for plan

benefit administration.

354-NX

SUBMISSION CLARIFICATION CODE

Maximum count of 3.

RW

Imp Guide: Required if Submission

COUNT

Clarification Code (42Ø-DK) is used.

Payer Requirement: Same as Imp Guide

42Ø-DK

SUBMISSION CLARIFICATION CODE

RW

Imp Guide: Required if clarification is

needed and value submitted is greater

than zero (Ø).

If the Date of Service (4Ø1-D1) contains

the subsequent payer coverage date, the

Submission Clarification Code (42Ø-DK)

is required with value of “19” (Split Billing

– indicates the quantity dispensed is the

remainder billed to a subsequent payer

when Medicare Part A expires. Used only

in long-term care settings) for individual

unit of use medications.

Payer Requirement: Same as Imp Guide

3Ø8-C8

OTHER COVERAGE CODE

0 = Not specified by patient

RW

Imp Guide: Required if needed by

1 = No other coverage

receiver, to communicate a summation of

3 = Other coverage exist –

other coverage information that has been

claim not covered*

collected from other payers.

8 = Claim is billing for patient

financial responsibility

Required for Coordination of Benefits.

only*

Payer Requirement: Same as Imp Guide.

*requires COB segment to be sent.

461-EU

PRIOR AUTHORIZATION TYPE CODE

1 = Prior Authorization, if

RW

Imp Guide: Required if this field could

applicable

result in different coverage, pricing, or

patient financial responsibility.

Payer Requirement: Same as Imp Guide

462-EV

PRIOR AUTHORIZATION NUMBER

If applicable to Rx

RW

Imp Guide: Required if this field could

SUBMITTED

result in different coverage, pricing, or

patient financial responsibility.

Payer Requirement: Same As Imp Guide

995-E2

ROUTE OF ADMINISTRATION

RW

Imp Guide: Required if specified in trading

partner agreement.

Payer Requirement: When compound

code (406-D6) = 2

Pricing Segment Questions

Check

Claim Billing/Claim Re-bill

If Situational, Payer Situation

This Segment is always sent

X

Pricing Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“11”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

4Ø9-D9

INGREDIENT COST SUBMITTED

R

412-DC

DISPENSING FEE SUBMITTED

R

Imp Guide: Required if its value has an

effect on the Gross Amount Due (43Ø-

DU) calculation.

433-DX

PATIENT PAID AMOUNT SUBMITTED

R

Imp Guide: Required if this field could

result in different coverage, pricing, or

patient financial responsibility.

438-E3

INCENTIVE AMOUNT SUBMITTED

RW

Imp Guide: Required if its value has an

effect on the Gross Amount Due (43Ø-

DU) calculation.

Payer Requirement: Same as Imp Guide

478-H7

OTHER AMOUNT CLAIMED

Maximum count of 3.

RW

Imp Guide: Required if Other Amount

SUBMITTED COUNT

Claimed Submitted Qualifier (479-H8) is

used.

Payer Requirement: Same as Imp Guide

479-H8

OTHER AMOUNT CLAIMED

RW

Imp Guide: Required if Other Amount

SUBMITTED QUALIFIER

Claimed Submitted (48Ø-H9) is used.

Payer Requirement: Same as Imp Guide

48Ø-H9

OTHER AMOUNT CLAIMED

RW

Imp Guide: Required if its value has an

SUBMITTED

effect on the Gross Amount Due (43Ø-

DU) calculation.

Payer Requirement: Same as Imp Guide

481-HA

FLAT SALES TAX AMOUNT

RW

Imp Guide: Required if its value has an

SUBMITTED

effect on the Gross Amount Due (43Ø-

DU) calculation.

Payer Requirement: Same as Imp Guide.

If Sales Tax applies to State.

482-GE

PERCENTAGE SALES TAX AMOUNT

RW

Imp Guide: Required if its value has an

SUBMITTED

effect on the Gross Amount Due (43Ø-

DU) calculation.

Payer Requirement: Same as Imp Guide.

If Sales Tax applies to State.

483-HE

PERCENTAGE SALES TAX RATE

RW

Imp Guide: Required if Percentage Sales

SUBMITTED

Tax Amount Submitted (482-GE) and

Percentage Sales Tax Basis Submitted

(484-JE) are used.

Required if this field could result in

different pricing.

Required if needed to calculate

Percentage Sales Tax Amount Paid (559-

AX).

Payer Requirement: Same as Imp Guide.

If Sales Tax applies to State.

Pricing Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“11”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

484-JE

PERCENTAGE SALES TAX BASIS

RW

Imp Guide: Required if Percentage Sales

SUBMITTED

Tax Amount Submitted (482-GE) and

Percentage Sales Tax Rate Submitted

(483-HE) are used.

Required if this field could result in

different pricing.

Required if needed to calculate

Percentage Sales Tax Amount Paid (559-

AX).

Payer Requirement: Same as Imp Guide.

If Sales Tax applies to State.

426-DQ

USUAL AND CUSTOMARY CHARGE

R

Imp Guide: Required if needed per trading

partner agreement.

43Ø-DU

GROSS AMOUNT DUE

R

423-DN

BASIS OF COST DETERMINATION

R

Imp Guide: Required if needed for

receiver claim/encounter adjudication.

Prescriber Segment Questions

Check

Claim Billing/Claim Re-bill

If Situational, Payer Situation

This Segment is always sent

X

This Segment is situational

Prescriber Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“Ø3”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

466-EZ

PRESCRIBER ID QUALIFIER

01 – NPI

R

Imp Guide: Required if Prescriber ID (411-

12 - DEA

DB) is used.

411-DB

PRESCRIBER ID

NPI or DEA

R

Imp Guide: Required if this field could

result in different coverage or patient

financial responsibility.

Required if necessary for

state/federal/regulatory agency programs.

427-DR

PRESCRIBER LAST NAME

RW

Imp Guide: Required when the Prescriber

ID (411-DB) is not known.

Required if needed for Prescriber ID (411-

DB) validation/clarification.

Payer Requirement: Required when

submitting DEA

364-2J

PRESCRIBER FIRST NAME

RW

Imp Guide: Required if needed to assist in

identifying the prescriber.

Required if necessary for

state/federal/regulatory agency programs.

Payer Requirement: Required when

submitting DEA

Prescriber Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“Ø3”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

365-2K

PRESCRIBER STREET ADDRESS

RW

Imp Guide: Required if needed to assist in

identifying the prescriber.

Required if necessary for

state/federal/regulatory agency programs.

Payer Requirement: Required when

submitting DEA

366-2M

PRESCRIBER CITY ADDRESS

RW

Imp Guide: Required if needed to assist in

identifying the prescriber.

Required if necessary for

state/federal/regulatory agency programs.

Payer Requirement: Required when

submitting DEA

367-2N

PRESCRIBER STATE/PROVINCE

RW

Imp Guide: Required if needed to assist in

ADDRESS

identifying the prescriber.

Required if necessary for

state/federal/regulatory agency programs.

Payer Requirement: Required when

submitting DEA

368-2P

PRESCRIBER ZIP/POSTAL ZONE

RW

Imp Guide: Required if needed to assist in

identifying the prescriber.

Required if necessary for

state/federal/regulatory agency programs.

Payer Requirement: Required when

submitting DEA

Coordination of Benefits/Other Payments

Check

Claim Billing/Claim Re-bill

Segment Questions

If Situational, Payer Situation

This Segment is always sent

This Segment is situational

X

Required

only for secondary, tertiary, etc claims.

Other

Coverage

Code (308-C8) = 3 or 8.

Scenario 2 - Other Payer-Patient Responsibility

X

Required

only for secondary, tertiary, etc claims.

Other

Coverage

Amount Repetitions and Benefit Stage Repetitions

Code (308-C8) = 3 or 8.

Only

Coordination of Benefits/Other

Claim Billing/Claim Re-bill

Payments Segment

Segment Identification (111-AM) =

Scenario 2- Other Payer-Patient

“Ø5”

Responsibility Amount Repetitions and

Benefit Stage Repetitions Only

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

337-4C

COORDINATION OF

Maximum count of 9.

M

BENEFITS/OTHER PAYMENTS

COUNT

338-5C

OTHER PAYER COVERAGE TYPE

M

339-6C

OTHER PAYER ID QUALIFIER

03 - BIN

R

Imp Guide: Required if Other Payer ID

(34Ø-7C) is used.

“Materials Reproduced With the Consent of

Coordination of Benefits/Other

Claim Billing/Claim Re-bill

Payments Segment

Segment Identification (111-AM) =

Scenario 2- Other Payer-Patient

“Ø5”

Responsibility Amount Repetitions and

Benefit Stage Repetitions Only

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

34Ø-7C

OTHER PAYER ID

BIN

R

Imp Guide: Required if identification of the

Other Payer is necessary for

claim/encounter adjudication.

471-5E

OTHER PAYER REJECT COUNT

Maximum count of 5.

RW

Imp Guide: Required if Other Payer Reject

Code (472-6E) is used.

Payer Requirement: Same as Imp Guide

472-6E

OTHER PAYER REJECT CODE

RW

Imp Guide: Required when the other

payer has denied the payment for the

billing, designated with Other Coverage

Code (3Ø8-C8) = 3 (Other Coverage

Billed – claim not covered).

Payer Requirement: Same as Imp Guide

353-NR

OTHER PAYER-PATIENT

Maximum count of 25.

RW

Imp Guide: Required if Other Payer-

RESPONSIBILITY AMOUNT COUNT

Patient Responsibility Amount Qualifier

(351-NP) is used.

Payer Requirement: Same as Imp Guide

351-NP

OTHER PAYER-PATIENT

RW

Imp Guide: Required if Other Payer-

RESPONSIBILITY AMOUNT

Patient Responsibility Amount (352-NQ) is

QUALIFIER

used.

Payer Requirement: Same as Imp Guide

352-NQ

OTHER PAYER-PATIENT

RW

Imp Guide: Required if necessary for

RESPONSIBILITY AMOUNT

patient financial responsibility only billing.

Required if necessary for

state/federal/regulatory agency programs.

Not used for non-governmental agency

programs if Other Payer Amount Paid

(431-DV) is submitted.

Payer Requirement: Same as Imp Guide

DUR/PPS Segment Questions

Check

Claim Billing/Claim Re-bill

If Situational, Payer Situation

This Segment is always sent

This Segment is situational

X

for use to define professional service or override clinical edits

DUR/PPS Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“Ø8”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

473-7E

DUR/PPS CODE COUNTER

Maximum of 9 occurrences.

R

Imp Guide: Required if DUR/PPS

Segment is used.

DUR/PPS Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“Ø8”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

439-E4

REASON FOR SERVICE CODE

R

Imp Guide: Required if this field could

result in different coverage, pricing,

patient financial responsibility, and/or drug

utilization review outcome.

Required if this field affects payment for or

documentation of professional pharmacy

service.

44Ø-E5

PROFESSIONAL SERVICE CODE

R

Imp Guide: Required if this field could

result in different coverage, pricing,

patient financial responsibility, and/or drug

utilization review outcome.

Required if this field affects payment for or

documentation of professional pharmacy

service.

441-E6

RESULT OF SERVICE CODE

R

Imp Guide: Required if this field could

result in different coverage, pricing,

patient financial responsibility, and/or drug

utilization review outcome.

Required if this field affects payment for or

documentation of professional pharmacy

service.

474-8E

DUR/PPS LEVEL OF EFFORT

R

Imp Guide: Required if this field could

result in different coverage, pricing,