OptumRx NCPDP Version D.0 Payer Sheet COMMERCIAL AND MEDICAID

OptumRx NCPDP Version D.0 Payer Sheet

COMMERCIAL AND MEDICAID

Payer Name: OptumRx

Date: 11/1/2020

Commercial and Medicaid

BIN: 610494

PCN: 9999

Community Health

BIN: 610613

PCN: 2417

ProAct

BIN: 017366

PCN: 9999

FlexScripts/ProAct

BIN: 018141

PCN: 9999

United Healthcare Community Plan of Texas

BIN: 610494

PCN: 4400

United Healthcare Community Plan of Arizona

BIN: 610494

PCN: 4100

MedalistRx

BIN: 016580

PCN:

Former Catalyst, informedRx and HealthTrans BIN:

BIN:

BIN:

BIN:

PCN:

004428 005947

012163 012882

610118 610182

018704 601577

Varies by plan ? refer to ID card.

008878 009992

005757 007887

610593 610679

606464 610171

011297 011867

009299 011198

014681 015566

610548 610621

012353 004469

011792 012295

015839 018643

610704 015383

006524 008985

012924 012957

600471 603286

015814 017267

010553 011321

013907 014186

610140 610527

060646 601683

012155 012502

014189 014582

610619 610604

610011 610173

004919 007110

015558 015921

014872 015756

610560 610652

009117 010876

017933 600428

020586 020768

610709 020149

011677 001553

603017 021049

003650 009951

015962

021684 003452

021916 021825

AARP

BIN: 610652

PCN: Varies ? refer to ID card

OptumRx

BIN: 610127

PCN:

PCN:

02330000 01960000

NCCSI NCSF

01990000 02330088

NWSF SCCSI

COSF GASF

SCSF OHSF

MASF

SavaScript Value Services

BIN: 023153

PCN: HT

Processor: OptumRx

Effective as of: 06/01/2015

NCPDP Telecommunication Standard Version/Release #: D.0

NCPDP Data Dictionary Version Date: October 201 7

NCPDP External Code List Version Date: October 201 7

Website:

Contract Information:

Provider Relations: Provider Relations Email:

1-877-633-4701 Provider.relations@

Website:



Certification Testing Window: Certification not required

Pharmacy Help Desk Information: Medicaid: 888-306-3243

OptumRx: 800-788-7871 FlexScripts: 800-603-7796

ProAct: 877-635-9545 MedalistRx: 855-633-2579

Other versions supported: ONLY D.0

CLAIM BILLING/CLAIM REBILL TRANSACTION

Field #

1?1-A1 1?2-A2 1?3-A3 1?4-A4 1?9-A9 2?2-B2 2?1-B1 4?1-D1 11?-AK

Transaction Header Segment

NCPDP Field Name

BIN NUMBER VERSION/RELEASE NUMBER TRANSACTION CODE PROCESSOR CONTROL NUMBER TRANSACTION COUNT SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE SOFTWARE VENDOR/CERTIFICATION ID

Value

(see above) D? B1, B3 See above Up to 4 01 10 digit NPI number

Payer Usage

M M M M M M M M O

Claim Billing/Claim Rebill Payer Situation

Required for all claims NPI ONLY

Field #

3?2-C2 312-CC 313-CD 314-CE 524-FO 3?1-C1 3?3-C3 3?6-C6 359-2A 36?-2B

361-2D

997-G2

115-N5

Insurance Segment Segment Identification (111-AM) = "?4"

NCPDP Field Name

CARDHOLDER ID CARDHOLDER FIRST NAME CARDHOLDER LAST NAME HOME PLAN PLAN ID GROUP ID PERSON CODE PATIENT RELATIONSHIP CODE

MEDIGAP ID

MEDICAID INDICATOR PROVIDER ACCEPT ASSIGNMENT INDICATOR CMS PART D DEFINED QUALIFIED FACILITY MEDICAID ID NUMBER

Value

Payer Usage

M M M O O M S S O O

O

Claim Billing/Claim Rebill Payer Situation

Always required. Refer to Member ID Card. Varies by plan Varies by plan

O O

Field

331-CX 332-CY 3?4-C4 3?5-C5 31?-CA 311-CB 322-CM 323-CN 324-CO 325-CP 326-CQ 3?7-C7 333-CZ 384-4X

Patient Segment Segment Identification (111-AM) = "?1"

NCPDP Field Name

PATIENT ID QUALIFIER PATIENT ID DATE OF BIRTH PATIENT GENDER CODE PATIENT FIRST NAME PATIENT LAST NAME PATIENT STREET ADDRESS PATIENT CITY ADDRESS PATIENT STATE / PROVINCE ADDRESS PATIENT ZIP/POSTAL ZONE PATIENT PHONE NUMBER PLACE OF SERVICE EMPLOYER ID PATIENT RESIDENCE

Value

Payer Usage

O O O O O O O O O O O O O O

Claim Billing/Claim Rebill Payer Situation

Field #

455-EM

4?2-D2 436-E1 4?7-D7 442-E7 4?3-D3 4?5-D5 4?6-D6 4?8-D8 414-DE 415-DF 419-DJ 354-NX 42?-DK

46?-ET

3?8-C8

429-DT 453-EJ

445-EA 446-EB 454-EK 6??-28 418-DI 461-EU 462-EV 995-E2 996-G1 147-U7

Claim Segment Segment Identification (111-AM) = "?7"

NCPDP Field Name

Value

PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUMBER PRODUCT/SERVICE ID QUALIFIER

PRODUCT/SERVICE ID

QUANTITY DISPENSED

?1 = Rx Billing

FILL NUMBER

DAYS SUPPLY

COMPOUND CODE DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE DATE PRESCRIPTION WRITTEN

NUMBER OF REFILLS AUTHORIZED

PRESCRIPTION ORIGIN CODE SUBMISSION CLARIFICATION CODE COUNT

Maximum count of 3.

SUBMISSION CLARIFICATION CODE

QUANTITY PRESCRIBED

00 02

OTHER COVERAGE CODE

03

04

08

SPECIAL PACKAGING INDICATOR

ORIGINALLY PRESCRIBED PRODUCT/SERVICE ID QUALIFIER

ORIGINALLY PRESCRIBED PRODUCT/SERVICE CODE

ORIGINALLY PRESCRIBED QUANTITY

SCHEDULED PRESCRIPTION ID NUMBER

UNIT OF MEASURE LEVEL OF SERVICE PRIOR AUTHORIZATION TYPE CODE PRIOR AUTHORIZATION NUMBER SUBMITTED ROUTE OF ADMINISTRATION

COMPOUND TYPE PHARMACY SERVICE TYPE

Field #

466-EZ 411-DB 427-DR 498-PM 468-2E 421-DL 47?-4E 364-2J 365-2K 366-2M

367-2N

Prescriber Segment Segment Identification (111-AM) = "?3"

NCPDP Field Name

Value

PRESCRIBER ID QUALIFIER PRESCRIBER ID PRESCRIBER LAST NAME PRESCRIBER PHONE NUMBER PRIMARY CARE PROVIDER ID QUALIFIER PRIMARY CARE PROVIDER ID PRIMARY CARE PROVIDER LAST NAME PRESCRIBER FIRST NAME

PRESCRIBER STREET ADDRESS

PRESCRIBER CITY ADDRESS PRESCRIBER STATE/PROVINCE ADDRESS

Payer Usage

M

Claim Billing/Claim Rebill Payer Situation

M

M M R R R R

R

R

R

RW Varies by plan

O

Required if Submission Clarification Code (42?DK) is used.

O

Effective 09/21/2020 RW Required when claim is for Schedule II drugs or

when a compound contains a Schedule II drug.

Required for Coordination of Benefits. RW

Varies by plan

O

O

Required if Originally Prescribed Product/Service Code (455-EA) is used.

O

O

RW

Required when required by state or local law/regulations

O

O

RW Varies by plan

RW Varies by plan

O O O

Payer Usage

M M O O O O O O O O

O

Claim Billing/Claim Rebill Payer Situation

NPI should be submitted whenever possible

Field # 368-2P

Prescriber Segment Segment Identification (111-AM) = "?3" NCPDP Field Name

PRESCRIBER ZIP/POSTAL ZONE

Value

Payer Usage

O

Claim Billing/Claim Rebill Payer Situation

Field # 337-4C 338-5C 339-6C 34?-7C 443-E8 341-HB 342-HC 431-DV 471-5E

472-6E

Field # 337-4C 338-5C 339-6C 34?-7C

443-E8

353-NR 351-NP

352-NQ

COB Scenario 1 and 2 are accepted based on plan design: Scenario 1 - Other Payer Amount Paid Repetitions Only.

Scenario 2 ? Other Payer -Patient Responsibility Amount Repetitions

Coordination of Benefits/Other Payments Segment Segment Identification (111-AM) = "?5"

NCPDP Field Name

Value

COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT OTHER PAYER COVERAGE TYPE OTHER PAYER ID QUALIFIER

OTHER PAYER ID

OTHER PAYER DATE

Maximum count of 9.

OTHER PAYER AMOUNT PAID COUNT Maximum count of 9.

OTHER PAYER AMOUNT PAID QUALIFIER

OTHER PAYER AMOUNT PAID

OTHER PAYER REJECT COUNT

Maximum count of 5.

OTHER PAYER REJECT CODE

Payer Usage

RM RM R R R RW

RW

M

RW

RW

Claim Billing/Claim Rebill Scenario 1 - Other Payer Amount Paid Repetitions Only

Situational

Required if Other Payer ID (34?-7C) is used. Other payer BIN

Required if Other Payer Amount Paid Qualifier (342-HC) is used. Required if Other Payer Amount Paid (431 -DV) is used. Required if other payer has approved payment for some/all of the billing. Required if Other Payer Reject Code (472-6E) is used. Required when the other payer has denied the payment for the billing, designated with Other Coverage Code (3?8-C8) = 3 (Other Coverage Billed ? claim not covered).

Coordination of Benefits/Other Payments Segment Segment Identification (111-AM) = "?5"

NCPDP Field Name

COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT OTHER PAYER COVERAGE TYPE

OTHER PAYER ID QUALIFIER

Value Maximum count of 9.

OTHER PAYER ID

OTHER PAYER DATE

OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT

OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER

Maximum count of 25.

OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT

Payer Usage

M M RW RW

R

RW RW

RW

Claim Billing/Claim Rebill Scenario 2 - Other Payer - Patient Responsibility Amount Repetitions

Payer Situation

Imp Guide: Required if Other Payer ID (34?-7C) is used. Imp Guide: Required if identification of the Other Payer is necessary for claim/encounter adjudication. Imp Guide: Required if identification of the Other Payer Date is necessary for claim/encounter adjudication. Imp Guide: Required if Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. Imp Guide: Required if Other Payer-Patient Responsibility Amount (352-NQ) is used. Imp Guide: Required if necessary for patient financial responsibility only billing.

Not used if Other Payer Amount Paid (431-DV) is submitted along with other coverage code 02 or 03.

Field # 4?9-D9 412-DC 438-E3 481-HA 482-GE

483-HE

484-JE 426-DQ 43?-DU 423-DN

Pricing Segment Segment Identification (111-AM) = "11"

NCPDP Field Name

INGREDIENT COST SUBMITTED DISPENSING FEE SUBMITTED INCENTIVE AMOUNT SUBMITTED FLAT SALES TAX AMOUNT SUBMITTED PERCENTAGE SALES TAX AMOUNT SUBMITTED PERCENTAGE SALES TAX RATE SUBMITTED PERCENTAGE SALES TAX BASIS SUBMITTED USUAL AND CUSTOMARY CHARGE GROSS AMOUNT DUE BASIS OF COST DETERMINATION

Value

Field #

473-7E 439-E4 44?-E5 441-E6

DUR/PPS Segment Segment Identification (111-AM) = "?8"

NCPDP Field Name

DUR/PPS CODE COUNTER REASON FOR SERVICE CODE PROFESSIONAL SERVICE CODE RESULT OF SERVICE CODE

Value Maximum of 9 occurrences.

Field #

45?-EF

451-EG

447-EC 488-RE 489-TE 448-ED 449-EE 49?-UE

362-2G

363-2H

Compound Segment

Optional Segment

Segment Identification (111-AM) = "1?" Required for Compounds

NCPDP Field Name

Value

COMPOUND DOSAGE FORM DESCRIPTION CODE

COMPOUND DISPENSING UNIT FORM INDICATOR

COMPOUND INGREDIENT COMPONENT COUNT COMPOUND PRODUCT ID QUALIFIER

COMPOUND PRODUCT ID COMPOUND INGREDIENT QUANTITY

Maximum 25 ingredients

COMPOUND INGREDIENT DRUG COST

COMPOUND INGREDIENT BASIS OF COST DETERMINATION

COMPOUND INGREDIENT MODIFIER CODE COUNT

Maximum count of 1?.

COMPOUND INGREDIENT MODIFIER CODE

Field #

Clinical Segment Segment Identification (111-AM) = "13"

NCPDP Field Name

Value

491-VE DIAGNOSIS CODE COUNT

Maximum count of 5.

492-WE 424-DO

DIAGNOSIS CODE QUALIFIER DIAGNOSIS CODE

Payer Usage

R R O O

O

S

S

M M R

Claim Billing/Claim Rebill This segment is always sent

Payer Usage

RW RW RW

RW

Claim Billing/Claim Rebill Payer Situation

Payer Usage

RW

Claim Billing/Claim Rebill Payer Situation Required when compound is being submitted.

RW

RW

RW

RW

RW

RW

Required if needed for receiver claim determination when multiple products are billed.

RW

Imp Guide: Required if needed for receiver claim determination when multiple products are billed.

O

Imp Guide: Required when Compound Ingredient Modifier Code (363-2H) is sent.

O

Payer Usage

O

O O

Claim Billing/Claim Rebill

Payer Situation

Imp Guide: Required if Diagnosis Code Qualifier (492-WE) and Diagnosis Code (424-DO) are used. Imp Guide: Required if Diagnosis Code (424DO) is used.

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