OptumRx NCPDP Version D.0 Payer Sheet COMMERCIAL AND MEDICAID

[Pages:13]OptumRx NCPDP Version D.0 Payer Sheet

COMMERCIAL AND MEDICAID

Payer Name: OptumRx

Date: 05/01/2021

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 Indiana

BIN: 610494

PCN: 4841

United Healthcare Community Plan of Texas

BIN: 610494

PCN: 4400

United Healthcare Community Plan of Arizona

BIN: 610494

PCN: 4100

United Healthcare Community Plan of Virginia

BIN: 610494

PCN 4900

UnitedHealthcare Community and State of MN BIN: 610494

PCN: 4846

MedalistRx

BIN: 016580

PCN:

Former Catalyst, informedRx and HealthTrans

BIN:

BIN:

BIN:

BIN:

PCN:

004428

012163

610182

610548

Varies by plan ? refer to ID card.

005947

012882

610593

610621

009992

005757

610679

610704

011297

007887

014681

015814

011867

009299

015839

017267

012353

011198

018643

060646

004469

011792

600471

601683

006524

012295

603286

610011

008985

012924

610140

610173

010553

012957

610527

610560

011321

013907

610619

610652

012155

014186

610604

020149

012502

014189

014872

024045

004919

015558

015756

007110

015921

020768

009117

017933

003650

010876

600428

009951

011677

603017

018704

001553

021049

601577

021684

021916

606464

003452

021825

610171

AARP

BIN: 610652

PCN: Varies ? refer to ID card

OptumRx

BIN: 610127

PCN:

PCN:

02330000

NCCSI

01960000

NCSF

01990000

NWSF

02330088

SCCSI

COSF

SCSF

GASF

OHSF

MASF

LDI / CastiaRx

BIN: 020321

PCN: COM

BIN: 800010

PCN: LDI

SavaScript Value Services

BIN: 023153

PCN: HT

Arizona Medicaid Fee For Service

BIN: 001553

PCN:

AZM

AIRAZM

SPCAZM

AZMCMDP

AZMDDD

AZMREF

TennCare

BIN: 001553

PCN:

TNM

CKDS

Processor: OptumRx

Effective as of: 06/01/2015

NCPDP Telecommunication Standard Version/Release #: D.0

NCPDP Data Dictionary Version Date: October 2017

NCPDP External Code List Version Date: October 2017

Website:

Contract Information:

Independent Contracting Contact: independent.contracting@

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

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

Value

Payer Usage

O O O O O O O O O

Claim Billing/Claim Rebill Payer Situation

Field

325-CP 326-CQ 3?7-C7 333-CZ

384-4X

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

NCPDP Field Name

PATIENT ZIP/POSTAL ZONE PATIENT PHONE NUMBER PLACE OF SERVICE EMPLOYER ID

PATIENT RESIDENCE

Value 84 Administration Only

Payer Usage

O O O O

RW

Claim Billing/Claim Rebill Payer Situation

Varies by Plan. Required when billing for additional administration services

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

?1 = Rx Billing

QUANTITY DISPENSED

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

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

Field #

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

367-2N

368-2P

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 PRESCRIBER ZIP/POSTAL ZONE

Payer Usage

M M O O O O O O O O

O

O

Claim Billing/Claim Rebill Payer Situation

NPI should be submitted whenever possible

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

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

Payer Usage

M M RW

RW

R

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.

Field # 353-NR 351-NP

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

NCPDP Field Name

Value

OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT

OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER

Maximum count of 25.

352-NQ

OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT

Payer Usage

RW RW

RW

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

Payer Situation

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

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

Optional Segment 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?.

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.

Field # 363-2H

Field #

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

NCPDP Field Name

COMPOUND INGREDIENT MODIFIER CODE

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

NCPDP Field Name

Optional Segment Required for Compounds Value

Value

491-VE DIAGNOSIS CODE COUNT

Maximum count of 5.

492-WE 424-DO

DIAGNOSIS CODE QUALIFIER DIAGNOSIS CODE

Payer Usage

O

Claim Billing/Claim Rebill Payer Situation

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.

Field # 1?2-A2 1?3-A3 1?9-A9 5?1-F1 2?2-B2 2?1-B1 4?1-D1

Field # 5?4-F4

Field # 3?1-C1 524-FO

3?2-C2

Field # 31?-CA 311-CB 3?4-C4

Field # 112-AN 5?3-F3 547-5F 548-6F 13?-UF 132-UH 526-FQ 131-UG

CLAIM BILLING/CLAIM REBILL PAID (OR DUPLICATE OF PAID) RESPONSE

Response Transaction Header Segment

NCPDP Field Name

VERSION/RELEASE NUMBER TRANSACTION CODE TRANSACTION COUNT HEADER RESPONSE STATUS SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE

Value

D? B1, B3 Same value as in request A = Accepted Same value as in request Same value as in request Same value as in request

Payer Usage

M M M M M M M

Claim Billing/Claim Rebill ? Accepted/Paid (or Duplicate of Paid)

Payer Situation

Response Message Segment Segment Identification (111-AM) = "2?" NCPDP Field Name

MESSAGE

Value

Payer Usage

S

Claim Billing/Claim Rebill ? Accepted/Paid (or Duplicate of Paid)

Payer Situation

Imp Guide: Required if text is needed for clarification or detail.

Response Insurance Segment Segment Identification (111-AM) = "25" NCPDP Field Name GROUP ID PLAN ID

Value

CARDHOLDER ID

Payer Usage

R S

S

Claim Billing/Claim Rebill ? Accepted/Paid (or Duplicate of Paid)

Payer Situation

Part-D Commercial Imp Guide: Required if the identification to be used in future transactions is different than what was submitted on the request.

Response Patient Segment Segment Identification (111-AM) = "29"

NCPDP Field Name

PATIENT FIRST NAME PATIENT LAST NAME DATE OF BIRTH

Value

Payer Usage

Claim Billing/Claim Rebill ? Accepted/Paid (or Duplicate of Paid)

Payer Situation

Response Status Segment Segment Identification (111-AM) = "21"

NCPDP Field Name

TRANSACTION RESPONSE STATUS

AUTHORIZATION NUMBER APPROVED MESSAGE CODE COUNT APPROVED MESSAGE CODE ADDITIONAL MESSAGE INFORMATION COUNT ADDITIONAL MESSAGE INFORMATION QUALIFIER ADDITIONAL MESSAGE INFORMATION ADDITIONAL MESSAGE INFORMATION CONTINUITY

Value P=Paid D=Duplicate of Paid

Maximum count of 5.

Maximum count of 25.

Payer Usage

M

R S S

Claim Billing/Claim Rebill ? Accepted/Paid (or Duplicate of Paid)

Payer Situation

Field #

Response Claim Segment Segment Identification (111-AM) = "22"

NCPDP Field Name

Value

455-EM

4?2-D2 551-9F 552-AP 553-AR 554-AS 555-AT 556-AU

Field # 5?5-F5 5?6-F6 5?7-F7 558-AW 559-AX

56?-AY

PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER

PRESCRIPTION/SERVICE REFERENCE NUMBER PREFERRED PRODUCT COUNT PREFERRED PRODUCT ID QUALIFIER PREFERRED PRODUCT ID PREFERRED PRODUCT INCENTIVE PREFERRED PRODUCT COST SHARE INCENTIVE PREFERRED PRODUCT DESCRIPTION

Response Pricing Segment Segment Identification (111-AM) = "23"

NCPDP Field Name

PATIENT PAY AMOUNT INGREDIENT COST PAID DISPENSING FEE PAID FLAT SALES TAX AMOUNT PAID PERCENTAGE SALES TAX AMOUNT PAID

PERCENTAGE SALES TAX RATE PAID

1 = RxBilling Maximum count of 6.

Value

561-AZ

521-FL 563-J2 564-J3 565-J4

PERCENTAGE SALES TAX BASIS PAID

INCENTIVE AMOUNT PAID OTHER AMOUNT PAID COUNT OTHER AMOUNT PAID QUALIFIER OTHER AMOUNT PAID

Maximum count of 3.

566-J5 OTHER PAYER AMOUNT RECOGNIZED

5?9-F9 522-FM

TOTAL AMOUNT PAID BASIS OF REIMBURSEMENT DETERMINATION

523-FN AMOUNT ATTRIBUTED TO SALES TAX

512-FC 513-FD 514-FE 517-FH 518-FI 52?-FK 572-4U 577-G3 128-UC

133-UJ

ACCUMULATED DEDUCTIBLE AMOUNT REMAINING DEDUCTIBLE AMOUNT REMAINING BENEFIT AMOUNT AMOUNT APPLIED TO PERIODIC DEDUCTIBLE AMOUNT OF COPAY AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM AMOUNT OF COINSURANCE ESTIMATED GENERIC SAVINGS SPENDING ACCOUNT AMOUNT REMAINING AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION

Payer Usage

M

M S S S S S S

Payer Usage

R R R S S

S

S S S S

S

R S

S

S S S S S S S S S S

Claim Billing/Claim Rebill ? Accepted/Paid (or Duplicate of Paid)

Payer Situation

Imp Guide: For Transaction Code of "B1", in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing).

Future capabilities Future capabilities Future capabilities Future capabilities

Future capabilities

Future capabilities

Claim Billing/Claim Rebill ? Accepted/Paid (or Duplicate of Paid)

Payer Situation

Imp Guide: Required if Percentage Sales Tax Amount Paid (559-AX) is greater than zero (?). Imp Guide: Required if Percentage Sales Tax Amount Paid (559-AX) is greater than zero (?). Required if Incentive Amount Submitted (438E3) is greater than zero (?). Imp Guide: Required if Other Amount Paid (565-J4) is used. Imp Guide: Required if Other Amount Paid (565-J4) is used. Required if Other Amount Claimed Submitted (48?-H9) is greater than zero (?). Required if Other Payer Amount Paid (431DV) is greater than zero (?) and Coordination of Benefits/Other Payments Segment is supported.

Required if Basis of Cost Determination (432DN) is submitted on billing. Imp Guide: Required if Patient Pay Amount (5?5-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.

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