Therapy First Copay Card Details

If you are prescribed Vyvanse for ADHD, there is a coupon form that can help you save on your prescription. This helpful form provides discounts on the medication so that it is more affordable. By taking advantage of this coupon, you could potentially save hundreds of dollars on your prescription each year. Be sure to check with your insurance company to see if they will cover the cost of the medication before using the coupon. If you have any questions about how to use the Vyvanse Coupon Form, be sure to speak with your doctor or pharmacist. They can help guide you through the process and answer any questions you may have.

Below is the data regarding the file you were seeking to fill in. It will show you the time it should take to complete vyvanse coupon, what parts you will have to fill in and a few other specific facts.

QuestionAnswer
Form NameVyvanse Coupon
Form Length23 pages
Fillable?No
Fillable fields0
Avg. time to fill out5 min 45 sec
Other namestherapy first copay card, coupon for vyvanse, therapy first patient choice vyvanse, vyvanse coupon

Form Preview Example

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

1

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

 

 

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

2

 

 

 

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

 

 

©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

3

 

 

 

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

“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

4

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

5

 

 

 

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

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

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6

 

 

 

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

 

 

 

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7

 

 

 

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.

“Materials Reproduced With the Consent of

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8

 

 

 

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,

 

 

 

 

 

 

 

 

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

 

 

 

 

X

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

 

 

 

 

 

M

 

 

 

 

DESCRIPTION CODE

 

 

 

 

 

 

 

 

 

451-EG

 

COMPOUND DISPENSING UNIT

 

 

 

 

 

M

 

 

 

 

FORM INDICATOR

 

 

 

 

 

 

 

 

“Materials Reproduced With the Consent of

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9

 

 

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.

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

10

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

BIN: 004682

BIN: 004682

PCN: CN

PCN: CN

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

 

 

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

M

 

 

 

 

1Ø3-A3

TRANSACTION CODE

 

 

 

B1, B3

 

 

M

 

 

 

 

1Ø9-A9

TRANSACTION COUNT

 

1

 

 

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/Paid (or Duplicate of Paid)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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/Paid (or Duplicate of Paid)

 

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

 

“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

11

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

12

 

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

13

 

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

©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

14

 

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

©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

15

 

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

©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

16

 

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

©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

17

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

 

 

 

 

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

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.

“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

18

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

©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

19

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

©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

20

 

Response DUR/PPS Segment

 

 

Claim Billing/Claim Re-bill

 

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

©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

21

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

 

 

 

 

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

©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

22

 

 

 

 

 

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

 

 

 

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

 

 

 

 

INFORMATION

 

 

 

 

 

text 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

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

** End of Response 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

23