NCPDP VERSION D.Ø - Optum

[Pages:5]Hospice Pharmacy Services

OPTUM - NCPDP VERSION D.? REQUEST CLAIM BILLING PAYER SHEET

GENERAL INFORMATION

Payer Name: Catamaran / Optum Hospice Pharmacy 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: Optum Hospice Pharmacy Services Call Center: 1-800-427-4893

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

Other versions supported: None

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

Catamaran/Optum

1,2,3, 4

M

Accept 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

Claim Billing

Value

1 = Rx 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 4?3-D3

QUANTITY DISPENSED FILL NUMBER

? = If Compound, otherwise

M

11 digit NDC

M

? = 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

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.

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

Check

X

?1 ? NPI 12 ? DEA

Claim Billing If Situational, Payer Situation

Claim Billing/Claim Rebill

M

NPI should be used DEA allowed if NPI

not available

411-DB PRESCRIBER ID

427-DR PRESCRIBER LAST NAME

Pricing Segment Questions

Check

This Segment is always sent

X

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

M M Claim Billing

Claim Billing

Field # 4?9-D9

412-DC

NCPDP Field Name INGREDIENT COST SUBMITTED

DISPENSING FEE SUBMITTED

Value

438-E3 INCENTIVE AMOUNT SUBMITTED

481-HA FLAT SALES TAX AMOUNT SUBMITTED

482-GE

PERCENTAGE SALES TAX AMOUNT SUBMITTED

483-HE

PERCENTAGE SALES TAX RATE SUBMITTED

484-JE

PERCENTAGE SALES TAX BASIS SUBMITTED

426-DQ 43?-DU 423-DN

USUAL AND CUSTOMARY CHARGE GROSS AMOUNT DUE BASIS OF COST DETERMINATION

Payer Usage M

RW

Payer Situation

Imp Guide: Required if its value has an effect on the Gross Amount Due (43?-DU) calculation.

Payer Requirement Same as

Implementation Guide

RW

Imp Guide: Required if its value has an

effect on the Gross Amount Due (43?-DU)

calculation.

Payer Requirement: Same as

Implementation Guide

RW

Imp Guide: Required if its value has an

effect on the Gross Amount Due (43?-DU)

calculation.

Payer Requirement: Same as

Implementation Guide

RW

Imp Guide: Required if its value has an

effect on the Gross Amount Due (43?-DU)

calculation.

Payer Requirement: Same as

Implementation Guide

RW

Imp Guide: Required if Percentage Sales

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

Implementation Guide

RW

Imp Guide: Required if Percentage Sales

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 Implementation Guide R

R

R

Coordination of Benefits/Other Payments Segment Questions This Segment is situational

Scenario 1 ? Other Payer Amount Paid Repetitions Only

Check X X

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

Claim Billing If Situational, Payer Situation Required only for secondary, tertiary, etc claims.

Claim Billing Scenario 1 ? Other Payer Amount Paid Repetitions Only

Field # 337-4C

338-5C

NCPDP Field Name COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT

OTHER PAYER COVERAGE TYPE

Value Maximum count of 9.

Blank = Not Specified

01 = Primary ? First ?2 = Secondary ? Second ?3 = Tertiary ? Third ?4 = Quaternary ? Fourth ?5 = Quinary ? Fifth ?6 = Senary ? Sixth ?7 = Septenary ? Seventh ?8 = Octonary ? Eighth ?9 = Nonary ? Ninth

339-6C OTHER PAYER ID QUALIFIER

34?-7C 443-E8

341-HB 342-HC 431-DV

OTHER PAYER ID OTHER PAYER DATE

OTHER PAYER AMOUNT PAID COUNT Maximum count of 9. OTHER PAYER AMOUNT PAID QUALIFIER OTHER PAYER AMOUNT PAID

Payer Usage Payer Situation M

M

RW

RW

RW

Reporting other payer amount paid

RW

Reporting other payer amount paid

RW

Reporting other payer amount paid

RW Not used for patient financial responsibility only billing.

Not used for non-governmental agency programs if Other Payer-Patient Responsibility Amount (352-NQ) is submitted.

Compound Segment Questions This Segment is situational

Field #

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

NCPDP Field Name

Check X

Value

Claim Billing If Situational, Payer Situation

Required to be sent if prescription is a compound.

Claim Billing

Payer Usage Payer Situation

45?-EF COMPOUND DOSAGE FORM DESCRIPTION CODE

451-EG

447-EC

488-RE 489-TE 448-ED 49?-UE

COMPOUND DISPENSING UNIT FORM INDICATOR

COMPOUND INGREDIENT COMPONENT COUNT COMPOUND PRODUCT ID QUALIFIER COMPOUND PRODUCT ID COMPOUND INGREDIENT QUANTITY COMPOUND INGREDIENT BASIS OF COST DETERMINATION

.

Maximum 25 ingredients 03 = NDC -National Drug Code

M

M

All Values accepted

M

M

M

M

M

All values accepted

Required for Compound claim

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download