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	vyvanse coupon 2020, emdeon therapy first plus, therapy first coupon, vyvanse coupon

Payer Name: Patient Choice / Therapy First / Therapy First	Date: 10/17/2011
Plus
Plan Name/Group Name: Patient Choice	BIN: 004682	PCN: CN
Plan Name/Group Name: Therapy First	BIN: 004682	PCN: CN
Plan Name/Group Name: Therapy First Plus	BIN: 004682	PCN: CN
Processor: Emdeon
Effective as of: 11/17/2011	NCPDP Telecommunication Standard Version/Release #: D.0

NCPDP Data Dictionary Version Date: 9/2010	NCPDP External Code List Version Date: 9/2010

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

Payer Usage	Value	Explanation	Payer
Column			Situation
			Column
MANDATORY	M	The Field is mandatory for the Segment in	No
		the designated Transaction.

REQUIRED	R	The Field has been designated with the	No
		situation of "Required" for the Segment in the
		designated Transaction.
QUALIFIED	RW	“Required when”. The situations designated	Yes
REQUIREMENT		have qualifications for usage ("Required if x",
		"Not required if y").

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

		Transaction Header Segment				Claim Billing/Claim Re-bill
Field #		NCPDP Field Name	Value		Payer	Payer Situation
					Usage
	1Ø1-A1	BIN NUMBER	004682		M
	1Ø2-A2	VERSION/RELEASE NUMBER	DØ		M
	1Ø3-A3	TRANSACTION CODE	B1 OR B3		M
	1Ø4-A4	PROCESSOR CONTROL NUMBER	CN		M
	1Ø9-A9	TRANSACTION COUNT	1		M
	2Ø2-B2	SERVICE PROVIDER ID QUALIFIER	01 – NPI		M
	2Ø1-B1	SERVICE PROVIDER ID	NPI		M
	4Ø1-D1	DATE OF SERVICE			M
	11Ø-AK	SOFTWARE	ALL SPACES		M
		VENDOR/CERTIFICATION ID

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

		Insurance Segment					Claim Billing/Claim Re-bill
		Segment Identification (111-AM) =
		“Ø4”
Field #		NCPDP Field Name	Value		Payer		Payer Situation
					Usage
	3Ø2-C2	CARDHOLDER ID			M
	3Ø1-C1	GROUP ID			R	Imp Guide: Required if necessary for
						state/federal/regulatory agency programs.
						Required if needed for pharmacy claim
						processing and payment.

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

		Patient Segment					Claim Billing/Claim Re-bill
		Segment Identification (111-AM) =
		“Ø1”
Field		NCPDP Field Name	Value		Payer		Payer Situation
					Usage
	3Ø4-C4	DATE OF BIRTH			R
	3Ø5-C5	PATIENT GENDER CODE			R
	31Ø-CA	PATIENT FIRST NAME			R	Imp Guide: Required when the patient has
						a first name.
	311-CB	PATIENT LAST NAME			R
	322-CM	PATIENT STREET ADDRESS			RW	Imp Guide: Optional.
						Payer Requirement: Required when
						available.

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

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.

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

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

			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.

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

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