HOSPISCRIPT SERVICES - NCPDP VERSION D.Ø

HOSPISCRIPT SERVICES - NCPDP VERSION D.? REQUEST CLAIM BILLING PAYER SHEET

GENERAL INFORMATION

Payer Name: Catamaran / Hospiscript Services

Date: Date of Publication of this Template?1/?1/2011

Plan Name/Group Name:

BIN: 011891

PCN:

Processor: Catamaran

Effective as of: Date that the Plan will begin accepting transactions

NCPDP Telecommunication Standard

using this payer sheet 06/01/2011

Version/Release #: D.?

NCPDP Data Dictionary Version Date: July, 2007

NCPDP External Code List Version Date:

October 2009

Contact/Information Source: Hospiscript Services Call Center: 1-800-427-4893

Certification Testing Window: Testing optional beginning 10/25/2011 Certification Contact Information: hdpr@

Other versions supported: Other versions 5.1 Telecommunication Standard Supported until 1/1/2012. Refer to the v5.1 payer sheet.

Transaction Code B2

OTHER TRANSACTIONS SUPPORTED

Transaction Name Reversal

Payer Usage Column

MANDATORY

REQUIRED

QUALIFIED REQUIREMENT

FIELD LEGEND FOR COLUMNS

Value

Explanation

M

The Field is mandatory for the Segment in the

designated Transaction.

Payer Situation Column No

R

The Field has been designated with the situation of

No

"Required" for the Segment in the designated

Transaction.

RW

"Required when". The situations designated have

Yes

qualifications for usage ("Required if x", "Not

required if y").

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

CLAIM BILLING TRANSACTION The following lists the segments and fields in a Claim Billing Transaction for the NCPDP Telecommunication Standard Implementation Guide vD.?.

Transaction Header Segment Questions

This Segment is always sent

Transaction Header Segment

Field #

NCPDP Field Name

1?1-A1 BIN NUMBER

1?2-A2 VERSION/RELEASE NUMBER

1?3-A3 TRANSACTION CODE

1?4-A4 PROCESSOR CONTROL NUMBER

1?9-A9 TRANSACTION COUNT

2?2-B2 2?1-B1 4?1-D1 11?-AK

SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE SOFTWARE VENDOR/CERTIFICATION ID

Check

Claim Billing

If Situational, Payer Situation

X

Claim Billing

Value

Payer Usage Payer Situation

011891

M

D?

M

B1- Claim

M

System Vendor ID

M

Processor Control Number for

CatalystRxCatamaran/Hospiscript Services

1,2,3, 4

M

TAecsctept up to 1 to 4 transactions per

transmission except for Multi-Ingredient

Compound claims which should be only

1 transaction.

?1- NPI - National Provider ID

M

Only value ?1 (NPI) accepted.

M

NPI OF PHARMACY

M

M

Use spaces

Patient Segment Questions

This Segment is always sent

Field

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

3?4-C4 DATE OF BIRTH 3?5-C5 PATIENT GENDER CODE

31?-CA PATIENT FIRST NAME 311-CB PATIENT LAST NAME 3?7-C7 PLACE OF SERVICE 384-4X PATIENT RESIDENCE

Insurance Segment Questions This Segment is always sent

Field #

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

NCPDP Field Name

3?2-C2 3?1-C1 3?3-C3 3?6-C6

CARDHOLDER ID GROUP ID PERSON CODE PATIENT RELATIONSHIP CODE

Check X

Claim Billing If Situational, Payer Situation

Claim Billing

Value

? - Not Specified 1 - Male 2 - Female

Payer Usage

M M

Payer Situation

?1=Pharmacy ?3=Nursing home

M

M

S

Required for Long Term Care Claims

S

Required for Long Term Care Claims

Check X

Value

Claim Billing If Situational, Payer Situation

Claim Billing

Payer Usage Payer Situation

M

RW

S

Use if available on card

M

Claim Segment Questions

This Segment is always sent This payer does not support partial fills

Field # 455-EM

Claim Segment Segment Identification (111-AM) = "?7" NCPDP Field Name PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER

4?2-D2 436-E1

PRESCRIPTION/SERVICE REFERENCE NUMBER

PRODUCT/SERVICE ID QUALIFIER

Check

X X

Claim Billing If Situational, Payer Situation

Value 1 = Rx Billing

Claim Billing

Payer Usage M

Payer Situation

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

M

M ?? ? If Compound ?3 = National Drug Code

4?7-D7 PRODUCT/SERVICE ID 442-E7 QUANTITY DISPENSED

? = If Compound, otherwise

M

11 digit NDC

M

4?3-D3 FILL NUMBER

? = New - Original

M

1-99 =Refill number

Field # 4?5-D5

Claim Segment Segment Identification (111-AM) = "?7" NCPDP Field Name DAYS SUPPLY

Value

Claim Billing

Payer Usage Payer Situation M

4?6-D6 COMPOUND CODE

1 = NOT A COMPOUND 2 = COMPOUND

M

Compound Code = 2 required

when submitting multi-ingredient

compound prescription

4?8-D8 DISPENSE AS WRITTEN (DAW)/PRODUCT

M

SELECTION CODE

414-DE DATE PRESCRIPTION WRITTEN

M

419-DJ PRESCRIPTION ORIGIN CODE

1 = Written ? Prescription obtained

M

Payer Requirement:

via paper.

Required value of 1,2,3,or 4

2 = Telephone ? Prescription

If claim denies,

obtained via oral instructions or

will return NCPDP Reject

interactive voice response using a

Code ,,33 (M/I Prescription

phone.

Origin Code).

3 = Electronic ? Prescription

obtained via SCRIPT or HL7

Standard transactions

4 = Facsimile ? Prescription

obtained via transmission using a

fax machine.

354-NX 42?-DK

SUBMISSION CLARIFICATION CODE COUNT

SUBMISSION CLARIFICATION CODE

8 = Process Compound For Approved Ingredients

RW

Imp Guide: Required if clarification is

needed and value submitted is greater than

zero (?).

Payer Requirement:. Initial compound claim may be submitted without 8 to determine which drugs will be covered, but claims must then be resubmitted with SCC8 to accept payment of covered drugs.

3?8-C8 OTHER COVERAGE CODE

418-DI LEVEL OF SERVICE 996-G1 COMPOUND TYPE Prescriber Segment Questions This Segment is always sent

Prescriber segment (111-AM)= "?3" 466-EZ PRESCRIBER ID QUALIFIER

411-DB PRESCRIBER ID 427-DR PRESCRIBER LAST NAME Pricing Segment Questions This Segment is always sent

2 = Other coverage existspayment collected ? Code used in coordination of benefits transactions to convey that other coverage is available, the payer has been billed and payment received.

RW Required for Coordination of Benefits.

Check X ?1 ? NPI 12 ? DEA

Check X

Claim Billing If Situational, Payer Situation

Claim Billing/Claim Rebill

M

NPI should be used DEA allowed if NPI

not available

M M Claim Billing

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

Claim Billing

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