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Question	Answer
Form Name	Vyvanse Coupon
Form Length	23 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	5 min 45 sec
Other names	therapy first copay card, coupon for vyvanse, therapy first patient choice vyvanse, vyvanse coupon

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Emdeon

PATIENT CHOICE / THERAPY FIRST / THERAPY FIRST PLUS

NCPDP vD.0 Payer Sheet

Claim Billing / Claim Re-bill

GENERAL INFORMATION

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

Contact/Information Source: 800-422-5604

Pharmacy Help Desk Info: 800-422-5604

Other versions supported: 5.1 Telecommunication Standard Supported until 12/31/2011. Refer to the 5.1 payer sheet.

OTHER TRANSACTIONS SUPPORTED

Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

Transaction Code	Transaction Name
B1	Billing Transaction
B2	Reversal Transaction
B3	Re-Bill Transaction

FIELD LEGEND FOR COLUMNS

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").

Fields that are not used in the Claim Billing/Claim Re-bill transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template.

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

CLAIM BILLING/CLAIM RE-BILL TRANSACTION

The following lists the segments and fields in a Claim Billing or Claim Re-bill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø.

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.

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			Patient Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			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

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			Claim Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			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

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

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.

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			Pricing Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			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
					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) =
			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

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			Prescriber Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			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

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

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

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.

Imp Guide: Required if Other Payer Reject

Code (472-6E) is used.

Payer Requirement: Same as Imp Guide

472-6E

OTHER PAYER REJECT CODE

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.

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

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

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

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.

Imp Guide: Required if DUR/PPS

Segment is used.

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			DUR/PPS Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			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,
						patient financial responsibility, and/or drug
						utilization review outcome.
						Required if this field affects payment for or
						documentation of professional pharmacy
						service.
	475-J9	DUR CO-AGENT ID QUALIFIER			R	Imp Guide: Required if DUR Co-Agent ID
						(476-H6) is used.
	476-H6	DUR CO-AGENT ID			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.

Compound Segment Questions

Check

Claim Billing/Claim Re-bill

If Situational, Payer Situation

This Segment is always sent

This Segment is situational

required when Compound Code (406-D6) = 2

Compound Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“1Ø”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

45Ø-EF

COMPOUND DOSAGE FORM

DESCRIPTION CODE

451-EG

COMPOUND DISPENSING UNIT

FORM INDICATOR

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

447-EC	COMPOUND INGREDIENT	Maximum 25 ingredients	M
	COMPONENT COUNT
488-RE	COMPOUND PRODUCT ID	03 - NDC	M
	QUALIFIER
489-TE	COMPOUND PRODUCT ID	11 digit NDC	M
448-ED	COMPOUND INGREDIENT QUANTITY		M
449-EE	COMPOUND INGREDIENT DRUG		R	Imp Guide: Required if needed for
	COST			receiver claim determination when
				multiple products are billed.
49Ø-UE	COMPOUND INGREDIENT BASIS OF		R	Imp Guide: Required if needed for
	COST DETERMINATION			receiver claim determination when
				multiple products are billed.

	End of Request Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

Emdeon

PATIENT CHOICE / THERAPY FIRST / THERAPY FIRST PLUS

NCPDP vD.0 Payer Sheet

Claim Billing / Claim Re-bill Response

GENERAL INFORMATION

Payer Name: Patient Choice / Therapy First / Therapy First Plus

Plan Name/Group Name: Patient Choice

Plan Name/Group Name: Therapy First

Plan Name/Group Name: Therapy First Plus

Date: 10/17/2011

BIN: 004682

PCN: CN

CLAIM BILLING/CLAIM RE-BILL PAID (OR DUPLICATE OF PAID) RESPONSE

The following lists the segments and fields in a Claim Billing or Claim Re-bill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø.

Response Transaction Header Segment

Check

Claim Billing/Claim Re-bill

Questions

Accepted/Paid (or Duplicate of Paid)

If Situational, Payer Situation

This Segment is always sent

Response Transaction Header

Claim Billing/Claim Re-bill –

Segment

Accepted/Paid (or Duplicate of Paid)

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

1Ø2-A2

VERSION/RELEASE NUMBER

DØ

1Ø3-A3

TRANSACTION CODE

B1, B3

1Ø9-A9

TRANSACTION COUNT

5Ø1-F1

HEADER RESPONSE STATUS

A = Accepted

2Ø2-B2

SERVICE PROVIDER ID QUALIFIER

Same value as in request

2Ø1-B1

SERVICE PROVIDER ID

Same value as in request

4Ø1-D1

DATE OF SERVICE

Same value as in request

Response Message Segment Questions

Check

Claim Billing/Claim Re-bill

Accepted/Paid (or Duplicate of Paid)

If Situational, Payer Situation

This Segment is always sent

This Segment is situational

Provide general information when used for transmission level

messaging.

Response Message Segment

Claim Billing/Claim Re-bill –

Segment Identification (111-AM) = “2Ø”

Accepted/Paid (or Duplicate of Paid)

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

5Ø4-F4

MESSAGE

Imp Guide: Required if text is needed for

clarification or detail.

Payer Requirement: Same as Imp Guide

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

Response Insurance Segment Questions		Check		Claim Billing/Claim Re-bill

				Accepted/Paid (or Duplicate of Paid)
				If Situational, Payer Situation
This Segment is always sent
This Segment is situational			X

	Response Insurance Segment					Claim Billing/Claim Re-bill –
	Segment Identification (111-AM) = “25”					Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name		Value		Payer	Payer Situation
					Usage
545-2F	NETWORK REIMBURSEMENT ID				RW	Imp Guide: Required if needed to identify
						the network for the covered member.
						Required if needed to identify the actual
						Network Reimbursement ID, when
						applicable and/or available.
						Required to identify the actual Network
						Reimbursement ID that was used when
						multiple Network Reimbursement IDs
						exist.

Response Status Segment Questions		Check		Claim Billing/Claim Re-bill

				Accepted/Paid (or Duplicate of Paid)
				If Situational, Payer Situation
This Segment is always sent			X

	Response Status Segment					Claim Billing/Claim Re-bill –
	Segment Identification (111-AM) = “21”					Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name		Value		Payer	Payer Situation
					Usage
112-AN	TRANSACTION RESPONSE STATUS		P=Paid		M
			D=Duplicate of Paid
Ø3-F3	AUTHORIZATION NUMBER				R	Imp Guide: Required if needed to identify
						the transaction.
13Ø-UF	ADDITIONAL MESSAGE		Maximum count of 25.		RW	Imp Guide: Required if Additional
	INFORMATION COUNT					Message Information (526-FQ) is used.
						Payer Requirement: Same as Imp Guide
132-UH	ADDITIONAL MESSAGE				RW	Imp Guide: Required if Additional
	INFORMATION QUALIFIER					Message Information (526-FQ) is used.
						Payer Requirement: Same as Imp Guide
526-FQ	ADDITIONAL MESSAGE				RW	Imp Guide: Required when additional text
	INFORMATION					is needed for clarification or detail.
						Payer Requirement: Same as Imp Guide
131-UG	ADDITIONAL MESSAGE				RW	Imp Guide: Required if and only if current
	INFORMATION CONTINUITY					repetition of Additional Message
						Information (526-FQ) is used, another
						populated repetition of Additional Message
						Information (526-FQ) follows it, and the
						text of the following message is a
						continuation of the current.
						Payer Requirement: Same as Imp Guide
549-7F	HELP DESK PHONE NUMBER				RW	Imp Guide: Required if Help Desk Phone
	QUALIFIER					Number (55Ø-8F) is used.
						Payer Requirement: Same as Imp Guide

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

	Response Status Segment			Claim Billing/Claim Re-bill –
	Segment Identification (111-AM) = “21”			Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name	Value	Payer	Payer Situation
			Usage
55Ø-8F	HELP DESK PHONE NUMBER		RW	Imp Guide: Required if needed to provide
				a support telephone number to the
				receiver.
				Payer Requirement: Same as Imp Guide

Response Claim Segment Questions		Check		Claim Billing/Claim Re-bill

				Accepted/Paid (or Duplicate of Paid)
				If Situational, Payer Situation
This Segment is always sent			X

	Response Claim Segment					Claim Billing/Claim Re-bill –
	Segment Identification (111-AM) = “22”					Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name		Value		Payer	Payer Situation
					Usage
455-EM	PRESCRIPTION/SERVICE		1 = Rx Billing		M	Imp Guide: For Transaction Code of “B1”,
	REFERENCE NUMBER QUALIFIER					in the Response Claim Segment, the
						Prescription/Service Reference Number
						Qualifier (455-EM) is “1” (Rx Billing).
4Ø2-D2	PRESCRIPTION/SERVICE				M
	REFERENCE NUMBER

Response Pricing Segment Questions		Check		Claim Billing/Claim Re-bill
				Accepted/Paid (or Duplicate of Paid)
				If Situational, Payer Situation
This Segment is always sent			X

	Response Pricing Segment					Claim Billing/Claim Re-bill –
	Segment Identification (111-AM) = “23”					Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name		Value		Payer	Payer Situation
					Usage
5Ø5-F5	PATIENT PAY AMOUNT				R
5Ø6-F6	INGREDIENT COST PAID				R
5Ø7-F7	DISPENSING FEE PAID				R	Imp Guide: Required if this value is used
						to arrive at the final reimbursement.
557-AV	TAX EXEMPT INDICATOR				RW	Imp Guide: Required if the sender (health
						plan) and/or patient is tax exempt and
						exemption applies to this billing.
						Payer Requirement: Same as Imp Guide
558-AW	FLAT SALES TAX AMOUNT PAID				RW	Imp Guide: Required if Flat Sales Tax
						Amount Submitted (481-HA) is greater
						than zero (Ø) or if Flat Sales Tax Amount
						Paid (558-AW) is used to arrive at the final
						reimbursement.
						Payer Requirement: Same as Imp Guide

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

	Response Pricing Segment			Claim Billing/Claim Re-bill –
	Segment Identification (111-AM) = “23”			Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name	Value	Payer	Payer Situation
			Usage
559-AX	PERCENTAGE SALES TAX AMOUNT		RW	Imp Guide: Required if this value is used
	PAID			to arrive at the final reimbursement.
				Required if Percentage Sales Tax Amount
				Submitted (482-GE) is greater than zero
				(Ø).
				Required if Percentage Sales Tax Rate
				Paid (56Ø-AY) and Percentage Sales Tax
				Basis Paid (561-AZ) are used.
				Payer Requirement: Same as Imp Guide
56Ø-AY	PERCENTAGE SALES TAX RATE PAID		RW	Imp Guide: Required if Percentage Sales
				Tax Amount Paid (559-AX) is greater than
				zero (Ø).
				Payer Requirement: Same as Imp. Guide
561-AZ	PERCENTAGE SALES TAX BASIS		RW	Imp Guide: Required if Percentage Sales
	PAID			Tax Amount Paid (559-AX) is greater than
				zero (Ø).
				Payer Requirement: Same as Imp Guide
521-FL	INCENTIVE AMOUNT PAID		RW	Imp Guide: Required if this value is used
				to arrive at the final reimbursement.
				Required if Incentive Amount Submitted
				(438-E3) is greater than zero (Ø).
				Payer Requirement: Same as Imp Guide
563-J2	OTHER AMOUNT PAID COUNT	Maximum count of 3.	RW	Imp Guide: Required if Other Amount Paid
				(565-J4) is used.
				Payer Requirement: Same as Imp Guide
564-J3	OTHER AMOUNT PAID QUALIFIER		RW	Imp Guide: Required if Other Amount Paid
				(565-J4) is used.
				Payer Requirement: Same as Imp Guide
565-J4	OTHER AMOUNT PAID		RW	Imp Guide: Required if this value is used
				to arrive at the final reimbursement.
				Required if Other Amount Claimed
				Submitted (48Ø-H9) is greater than zero
				(Ø).
				Payer Requirement: Same as Imp Guide
5Ø9-F9	TOTAL AMOUNT PAID		R
522-FM	BASIS OF REIMBURSEMENT		R	Imp Guide: Required if Ingredient Cost
	DETERMINATION			Paid (5Ø6-F6) is greater than zero (Ø).
				Required if Basis of Cost Determination
				(432-DN) is submitted on billing.
523-FN	AMOUNT ATTRIBUTED TO SALES TAX		RW	Imp Guide: Required if Patient Pay
				Amount (5Ø5-F5) includes sales tax that is
				the financial responsibility of the member
				but is not also included in any of the other
				fields that add up to Patient Pay Amount.
				Payer Requirement: Same as Imp Guide

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

	Response Pricing Segment			Claim Billing/Claim Re-bill –
	Segment Identification (111-AM) = “23”			Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name	Value	Payer	Payer Situation
			Usage
517-FH	AMOUNT APPLIED TO PERIODIC		RW	Imp Guide: Required if Patient Pay
	DEDUCTIBLE			Amount (5Ø5-F5) includes deductible
				Payer Requirement: Same as Imp Guide
518-FI	AMOUNT OF COPAY		R	Imp Guide: Required if Patient Pay
				Amount (5Ø5-F5) includes co-pay as
				patient financial responsibility.
575-EQ	PATIENT SALES TAX AMOUNT		RW	Imp Guide: Used when necessary to
				identify the Patient’s portion of the Sales
				Tax. Provided for informational purposes
				only.
				Payer Requirement: Same As Imp Guide
574-2Y	PLAN SALES TAX AMOUNT		RW	Imp Guide: Used when necessary to
				identify the Plan’s portion of the Sales Tax.
				Provided for informational purposes only.
				Payer Requirement: Same As Imp Guide
572-4U	AMOUNT OF COINSURANCE		RW	Imp Guide: Required if Patient Pay
				Amount (5Ø5-F5) includes coinsurance as
				patient financial responsibility.
				Payer Requirement: Same As Imp Guide
133-UJ	AMOUNT ATTRIBUTED TO PROVIDER		RW	Imp Guide: Required if Patient Pay
	NETWORK SELECTION			Amount (5Ø5-F5) includes an amount that
				is attributable to a cost share differential
				due to the selection of one pharmacy over
				another
				Payer Requirement: Same As Imp Guide
134-UK	AMOUNT ATTRIBUTED TO PRODUCT		RW	Imp Guide: Required if Patient Pay
	SELECTION/BRAND DRUG			Amount (5Ø5-F5) includes an amount that
				is attributable to a patient’s selection of a
				Brand drug.
				Payer Requirement: Same As Imp Guide
135-UM	AMOUNT ATTRIBUTED TO PRODUCT		RW	Imp Guide: Required if Patient Pay
	SELECTION/NON-PREFERRED			Amount (5Ø5-F5) includes an amount that
	FORMULARY SELECTION			is attributable to a patient’s selection of a
				non-preferred formulary product.
				Payer Requirement: Same As Imp Guide
136-UN	AMOUNT ATTRIBUTED TO PRODUCT		RW	Imp Guide: Required if Patient Pay
	SELECTION/BRAND NON-			Amount (5Ø5-F5) includes an amount that
	PREFERRED FORMULARY			is attributable to a patient’s selection of a
	SELECTION			Brand non-preferred formulary product.
				Payer Requirement: Same As Imp Guide
148-U8	INGREDIENT COST		RW	Imp Guide: Required when Basis of
	CONTRACTED/REIMBURSABLE			Reimbursement Determination (522-FM) is
	AMOUNT			“14” (Patient Responsibility Amount) or
				“15” (Patient Pay Amount) unless
				prohibited by state/federal/regulatory
				agency.
				Payer Requirement: Same As Imp Guide

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

	Response Pricing Segment			Claim Billing/Claim Re-bill –
	Segment Identification (111-AM) = “23”			Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name	Value	Payer	Payer Situation
			Usage
149-U9	DISPENSING FEE		RW	Imp Guide: Required when Basis of
	CONTRACTED/REIMBURSABLE			Reimbursement Determination (522-FM) is
	AMOUNT			“14” (Patient Responsibility Amount) or
				“15” (Patient Pay Amount) unless
				prohibited by state/federal/regulatory
				agency.
				Payer Requirement: Same As Imp Guide

Response DUR/PPS Segment Questions		Check		Claim Billing/Claim Re-bill
				Accepted/Paid (or Duplicate of Paid)
				If Situational, Payer Situation
This Segment is always sent
This Segment is situational			X

	Response DUR/PPS Segment					Claim Billing/Claim Re-bill –
	Segment Identification (111-AM) = “24”					Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name		Value		Payer	Payer Situation
					Usage
567-J6	DUR/PPS RESPONSE CODE COUNTER		Maximum 9 occurrences		RW	Imp Guide: Required if Reason For
			supported.			Service Code (439-E4) is used.
						Payer Requirement: Same As Imp Guide
439-E4	REASON FOR SERVICE CODE				RW	Imp Guide: Required if utilization conflict is
						detected.
						Payer Requirement: Same As Imp Guide
528-FS	CLINICAL SIGNIFICANCE CODE				RW	Imp Guide: Required if needed to supply
						additional information for the utilization
						conflict.
						Payer Requirement: Same As Imp Guide
529-FT	OTHER PHARMACY INDICATOR				RW	Imp Guide: Required if needed to supply
						additional information for the utilization
						conflict.
						Payer Requirement: Same As Imp Guide
53Ø-FU	PREVIOUS DATE OF FILL				RW	Imp Guide: Required if needed to supply
						additional information for the utilization
						conflict.
						Required if Quantity of Previous Fill (531-
						FV) is used.
						Payer Requirement: Same As Imp Guide
531-FV	QUANTITY OF PREVIOUS FILL				RW	Imp Guide: Required if needed to supply
						additional information for the utilization
						conflict.
						Required if Previous Date Of Fill (53Ø-FU)
						is used.
						Payer Requirement: Same As Imp Guide

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

	Response DUR/PPS Segment			Claim Billing/Claim Re-bill –
	Segment Identification (111-AM) = “24”			Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name	Value	Payer	Payer Situation
			Usage
532-FW	DATABASE INDICATOR		RW	Imp Guide: Required if needed to supply
				additional information for the utilization
				conflict.
				Payer Requirement : Same As Imp Guide
533-FX	OTHER PRESCRIBER INDICATOR		RW	Imp Guide: Required if needed to supply
				additional information for the utilization
				conflict.
				Payer Requirement: Same As Imp Guide
544-FY	DUR FREE TEXT MESSAGE		RW	Imp Guide: Required if needed to supply
				additional information for the utilization
				conflict.
				Payer Requirement: Same As Imp Guide

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

CLAIM BILLING/CLAIM RE-BILL ACCEPTED/REJECTED RESPONSE

Response Transaction Header Segment		Check		Claim Billing/Claim Re-bill Accepted/Rejected
Questions				If Situational, Payer Situation
This Segment is always sent			X

	Response Transaction Header Segment					Claim Billing/Claim Re-bill
						Accepted/Rejected
Field #	NCPDP Field Name		Value		Payer	Payer Situation
					Usage
1Ø2-A2	VERSION/RELEASE NUMBER		DØ		M
1Ø3-A3	TRANSACTION CODE		B1, B3		M
1Ø9-A9	TRANSACTION COUNT		Same value as in request		M
5Ø1-F1	HEADER RESPONSE STATUS		A = Accepted		M
2Ø2-B2	SERVICE PROVIDER ID QUALIFIER		Same value as in request		M
2Ø1-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 Re-bill Accepted/Rejected
				If Situational, Payer Situation
This Segment is always sent
This Segment is situational			X	Provide general information when used for transmission level
				messaging.

	Response Message Segment					Claim Billing/Claim Re-bill
	Segment Identification (111-AM) = “2Ø”					Accepted/Rejected
Field #	NCPDP Field Name		Value		Payer	Payer Situation
					Usage
5Ø4-F4	MESSAGE				RW	Imp Guide: Required if text is needed for
						clarification or detail.
						Payer Requirement: Same As Imp Guide

Response Insurance Segment Questions		Check		Claim Billing/Claim Re-bill Accepted/Rejected
				If Situational, Payer Situation
This Segment is always sent
This Segment is situational			X

545-2F

NETWORK REIMBURSEMENT ID

Imp Guide: Required if needed to identify the network for the covered member.

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

Required to identify the actual Network Reimbursement ID that was used when multiple Network Reimbursement IDs exist.

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

Response Status Segment Questions		Check		Claim Billing/Claim Re-bill Accepted/Rejected
				If Situational, Payer Situation
This Segment is always sent			X

	Response Status Segment					Claim Billing/Claim Re-bill
	Segment Identification (111-AM) = “21”					Accepted/Rejected
Field #	NCPDP Field Name		Value		Payer	Payer Situation
					Usage
112-AN	TRANSACTION RESPONSE STATUS		R = Reject		M
5Ø3-F3	AUTHORIZATION NUMBER				R	Imp Guide: Required if needed to identify
						the transaction.
51Ø-FA	REJECT COUNT		Maximum count of 5.		R
511-FB	REJECT CODE				R
546-4F	REJECT FIELD OCCURRENCE				RW	Imp Guide: Required if a repeating field is
	INDICATOR					in error, to identify repeating field
						occurrence.
						Payer Requirement: Same As Imp Guide
13Ø-UF	ADDITIONAL MESSAGE INFORMATION		Maximum count of 25.		RW	Imp Guide: Required if Additional
	COUNT					Message Information (526-FQ) is used.
						Payer Requirement: Same As Imp Guide
132-UH	ADDITIONAL MESSAGE INFORMATION				RW	Imp Guide: Required if Additional
	QUALIFIER					Message Information (526-FQ) is used.
						Payer Requirement : Same As Imp Guide
526-FQ	ADDITIONAL MESSAGE INFORMATION				RW	Imp Guide: Required when additional text
						is needed for clarification or detail.
						Payer Requirement: Same As Imp Guide
131-UG	ADDITIONAL MESSAGE INFORMATION				RW	Imp Guide: Required if and only if current
	CONTINUITY					repetition of Additional Message
						Information (526-FQ) is used, another
						populated repetition of Additional Message
						Information (526-FQ) follows it, and the
						text of the following message is a
						continuation of the current.
						Payer Requirement: Same As Imp Guide
549-7F	HELP DESK PHONE NUMBER				RW	Imp Guide: Required if Help Desk Phone
	QUALIFIER					Number (55Ø-8F) is used.
						Payer Requirement: Same As Imp Guide
55Ø-8F	HELP DESK PHONE NUMBER				RW	Imp Guide: Required if needed to provide
						a support telephone number to the
						receiver.
						Payer Requirement: Same As Imp Guide
987-MA	URL				RW	Imp Guide: Provided for informational
						purposes only to relay health care
						communications via the Internet.
						Payer Requirement: Same As Imp Guide

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

Response Claim Segment Questions		Check		Claim Billing/Claim Re-bill Accepted/Rejected
				If Situational, Payer Situation
This Segment is always sent			X

	Response Claim Segment					Claim Billing/Claim Re-bill
	Segment Identification (111-AM) = “22”					Accepted/Rejected
Field #	NCPDP Field Name		Value		Payer	Payer Situation
					Usage
455-EM	PRESCRIPTION/SERVICE REFERENCE		1 = Rx Billing		M	Imp Guide: For Transaction Code of “B1”,
	NUMBER QUALIFIER					in the Response Claim Segment, the
						Prescription/Service Reference Number
						Qualifier (455-EM) is “1” (Rx Billing).
4Ø2-D2	PRESCRIPTION/SERVICE REFERENCE				M
	NUMBER

Response DUR/PPS Segment Questions		Check		Claim Billing/Claim Re-bill Accepted/Rejected
				If Situational, Payer Situation
This Segment is always sent
This Segment is situational			X

	Response DUR/PPS Segment					Claim Billing/Claim Re-bill
	Segment Identification (111-AM) = “24”					Accepted/Rejected
Field #	NCPDP Field Name		Value		Payer	Payer Situation
					Usage
567-J6	DUR/PPS RESPONSE CODE COUNTER		Maximum 9 occurrences		RW	Imp Guide: Required if Reason For
			supported.			Service Code (439-E4) is used.
						Payer Requirement: Same As Imp Guide
439-E4	REASON FOR SERVICE CODE				RW	Imp Guide: Required if utilization conflict is
						detected.
						Payer Requirement: Same As Imp Guide
528-FS	CLINICAL SIGNIFICANCE CODE				RW	Imp Guide: Required if needed to supply
						additional information for the utilization
						conflict.
						Payer Requirement: Same As Imp Guide
529-FT	OTHER PHARMACY INDICATOR				RW	Imp Guide: Required if needed to supply
						additional information for the utilization
						conflict.
						Payer Requirement: Same As Imp Guide
53Ø-FU	PREVIOUS DATE OF FILL				RW	Imp Guide: Required if needed to supply
						additional information for the utilization
						conflict.
						Required if Quantity of Previous Fill (531-
						FV) is used.
						Payer Requirement: Same As Imp Guide
531-FV	QUANTITY OF PREVIOUS FILL				RW	Imp Guide: Required if needed to supply
						additional information for the utilization
						conflict.
						Required if Previous Date Of Fill (53Ø-FU)
						is used.
						Payer Requirement: Same As Imp Guide

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

	Response DUR/PPS Segment		Claim Billing/Claim Re-bill
	Segment Identification (111-AM) = “24”		Accepted/Rejected
	Segment Identification (111-AM) = “24”		Accepted/Rejected
532-FW	DATABASE INDICATOR	RW	Imp Guide: Required if needed to supply
			additional information for the utilization
			conflict.
			Payer Requirement: Same As Imp Guide
533-FX	OTHER PRESCRIBER INDICATOR	RW	Imp Guide: Required if needed to supply
			additional information for the utilization
			conflict.
			Payer Requirement: Same As Imp Guide
544-FY	DUR FREE TEXT MESSAGE	RW	Imp Guide: Required if needed to supply
			additional information for the utilization
			conflict.
			Payer Requirement: Same As Imp Guide
57Ø-NS	DUR ADDITIONAL TEXT	RW	Imp Guide: Required if needed to supply
			additional information for the utilization
			conflict.
			Payer Requirement: Same As Imp Guide

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

CLAIM BILLING/CLAIM RE-BILL REJECTED/REJECTED RESPONSE

Response Transaction Header Segment					Check		Claim Billing/Claim Re-bill Rejected/Rejected
Questions							If Situational, Payer Situation
This Segment is always sent						X

		Response	Transaction	Header						Claim Billing/Claim Re-bill
		Segment								Rejected/Rejected
	Field #	NCPDP Field Name				Value		Payer		Payer Situation
								Usage
	1Ø2-A2	VERSION/RELEASE NUMBER				DØ			M
	1Ø3-A3	TRANSACTION CODE				B1, B3			M
	1Ø9-A9	TRANSACTION COUNT				Same value as in request			M
	5Ø1-F1	HEADER RESPONSE STATUS				R = Rejected			M
	2Ø2-B2	SERVICE PROVIDER ID QUALIFIER				Same value as in request			M
	2Ø1-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 Re-bill Rejected/Rejected
							If Situational, Payer Situation
This Segment is always sent
This Segment is situational						X	Provide general information when used for transmission level
							messaging.

		Response Message Segment								Claim Billing/Claim Re-bill
		Segment Identification (111-AM)			=					Rejected/Rejected
		“2Ø”
Field #		NCPDP Field Name				Value			Payer	Payer Situation
								Usage
	5Ø4-F4	MESSAGE							RW	Imp Guide: Required if text is needed for
										clarification or detail.
										Payer Requirement : Same As Imp
										Guide

Response Status Segment Questions					Check		Claim Billing/Claim Re-bill Rejected/Rejected
							If Situational, Payer Situation
This Segment is always sent						X

		Response Status Segment								Claim Billing/Claim Re-bill
		Segment Identification (111-AM)			=					Rejected/Rejected
		“21”
Field #		NCPDP Field Name				Value		Payer		Payer Situation
								Usage
	112-AN	TRANSACTION RESPONSE STATUS				R = Reject			M
	5Ø3-F3	AUTHORIZATION NUMBER							R	Imp Guide: Required if needed to identify
										the transaction.
	51Ø-FA	REJECT COUNT				Maximum count of 5.			R
	511-FB	REJECT CODE							R
	546-4F	REJECT FIELD OCCURRENCE							RW	Imp Guide: Required if a repeating field
		INDICATOR								is in error, to identify repeating field
										occurrence.
										Payer Requirement : Same As Imp
										Guide
	13Ø-UF	ADDITIONAL MESSAGE				Maximum count of 25.			RW	Imp Guide: Required if Additional
		INFORMATION COUNT								Message Information (526-FQ) is used.
										Payer Requirement: Same As Imp
										Guide

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

Response Status Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

Rejected/Rejected

“21”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

132-UH

ADDITIONAL MESSAGE

Imp Guide: Required if Additional

INFORMATION QUALIFIER

Message Information (526-FQ) is used.

Payer Requirement: Same As Imp

Guide

526-FQ

ADDITIONAL MESSAGE

Imp Guide: Required when additional

INFORMATION

text is needed for clarification or detail.

Payer Requirement: Same As Imp

Guide

131-UG

ADDITIONAL MESSAGE

Imp Guide: Required if and only if current

INFORMATION CONTINUITY

repetition of Additional Message

Information (526-FQ) is used, another

populated repetition of Additional

Message Information (526-FQ) follows it,

and the text of the following message is

a continuation of the current.

Payer Requirement: Same As Imp

Guide

549-7F

HELP DESK PHONE NUMBER

Imp Guide: Required if Help Desk Phone

QUALIFIER

Number (55Ø-8F) is used.

Payer Requirement: Same As Imp

Guide

55Ø-8F

HELP DESK PHONE NUMBER

Imp Guide: Required if needed to provide

a support telephone number to the

receiver.

Payer Requirement: Same As Imp

Guide

** End of Response Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template**

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

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