NCPDP PAYER SHEET TEMPLATE



Maryland Medicaid – COVID – 19 Specimen CollectionRequest Claim Billing/Claim Rebill (B1/B3) Payer Sheet GENERAL INFORMATIONPayer Name: Maryland Department of HealthDate: August 10th 2020Plan Name/Group Name: Maryland Department of HealthBIN: 61??84PCN: DRMDPROD = Production Processor: CONDUENTEffective as of: 08/14/2020NCPDP Telecommunication Standard Version/Release #: D.?NCPDP Data Dictionary Version Date: July, 2007NCPDP External Code List Version Date: March, 2010Contact/Information Source: Other references such as Provider Manuals, Payer phone number, web site, etc.Certification Testing Window: Certification Testing DatesCertification Contact Information: Certification phone number and informationProvider Relations Help Desk Info: 8??-932-3918OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.Transaction CodeTransaction NameB1BillingB3RebillingField Legend for ColumnsPayer Usage ColumnValueExplanationPayer Situation ColumnMANDATORYMThe Field is mandatory for the Segment in the designated Transaction.NoRequiredRThe Field has been designated with the situation of "Required" for the Segment in the designated Transaction.NoQualified RequirementRW“Required when”. The situations designated have qualifications for usage ("Required if x", "Not required if y").YesFields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template. CLAIM BILLING/CLAIM REBILL TRANSACTIONThe following lists the segments and fields in a Claim Billing or Claim Rebill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.?. Transaction Header Segment QuestionsCheckClaim Billing/Claim Rebill If Situational, Payer SituationThis Segment is always sentX Source of certification IDs required in Software Vendor/Certification ID (11?-AK) is Not usedXTransaction Header SegmentClaim Billing/Claim RebillField #NCPDP Field NameValuePayer UsagePayer Situation1?1-A1BIN Number61??84M1?2-A2Version/Release NumberD?M1?3-A3Transaction CodeB1 = BillingB3 = RebillMClaim Billing, Claim Rebill1?4-A4Processor Control NumberDRMDPROD = ProductionM1?9-A9Transaction Count1 = One OccurrenceM2?2-B2Service Provider ID Qualifier?1 = National Provider Identifier (NPI)M2?1-B1Service Provider ID NPI NumberM4?1-D1Date of ServiceCCYYMMDDM11?-AKSoftware Vendor/Certification IDThis will be provided by the provider's software venderMIf no number is supplied, populate with zerosInsurance Segment QuestionsCheckClaim Billing/Claim Rebill If Situational, Payer SituationThis Segment is always sentX Insurance SegmentSegment Identification (111-AM) = “?4”Claim Billing/Claim RebillField #NCPDP Field NameValuePayer UsagePayer Situation3?2-C2CARDHOLDER IDRecipient’s Medicaid ID NumberM11 character number3?1-C1GROUP IDMDMEDICAIDR3?6-C6 Patient Relationship Code 1 = Cardholder R Patient Segment QuestionsCheckClaim Billing/Claim Rebill If Situational, Payer SituationThis Segment is always sentX Patient SegmentSegment Identification (111-AM) = “?1”Claim Billing/Claim RebillField NCPDP Field NameValuePayer UsagePayer Situation3?4-C4DATE OF BIRTHCCYYMMDDR3?5-C5PATIENT GENDER CODE? = Not Specified1 = Male2 = FemaleR31?-CAPATIENT FIRST NAMERFirst 3 characters used for verification311-CBPATIENT LAST NAMERFirst 5 characters used for verification384-4XPATIENT RESIDENCE? = Not specified3 = Nursing Facility11 = HospiceRWEnter value ‘3’ or ‘11’ to indicate the patient is in a LTC setting or hospice.Claim Segment QuestionsCheckClaim Billing/Claim Rebill If Situational, Payer SituationThis Segment is always sentX This payer supports partial fillsXClaim SegmentSegment Identification (111-AM) = “?7”Claim Billing/Claim RebillField #NCPDP Field NameValuePayer UsagePayer Situation455-EMPREscription/Service Reference Number Qualifier1 = Rx BillingM4?2-D2Prescription/Service Reference NumberRx Number assigned by the pharmacyM436-E1Product/Service ID Qualifier?3 = National Drug CodeM4?7-D7Product/Service IDNational Drug Code (NDC)MNDCs:11877001126220660005116000404178099999099211442-E7QUANTITY DISPENSED 1ROne Kit4?3-D3FILL NUMBER? = Original DispensingROriginal dispensing4?5-D5DAYS SUPPLY 1ROne Day’s supply4?6-D6COMPOUND CODE 1 = Not a compoundRCompund code 2 is not allowed4?8-D8DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE? = No Product Selection IndicatedRDAW 6 is used for brand name drugs that Maryland Medicaid has designated as preferred over the generic414-DEDATE PRESCRIPTION WRITTENCCYYMMDDRPricing Segment QuestionsCheckClaim Billing/Claim Rebill If Situational, Payer SituationThis Segment is always sentX Pricing SegmentSegment Identification (111-AM) = “11”Claim Billing/Claim RebillField #NCPDP Field NameValuePayer UsagePayer Situation4?9-D9INGREDIENT COST SUBMITTEDR$0.01 will be paid412-DCDISPENSING FEE SUBMITTEDRWRequired if its value has an effect on the Gross Amount Due (43?-DU) calculation. 438-E3INCENTIVE AMOUNT SUBMITTEDR$23.12 will be paid426-DQUSUAL AND CUSTOMARY CHARGER43?-DUGROSS AMOUNT DUER 423-DNBASIS OF COST DETERMINATION?5 – Nominal Price claim?8 – 340B claim?9 – Federal Supply Schedule (FSS)RWRequired when submitting a 340B claim or FSS claim at Nominal Price claim.Prescriber Segment QuestionsCheckClaim Billing/Claim Rebill If Situational, Payer SituationThis Segment is always sentX Prescriber SegmentSegment Identification (111-AM) = “?3”Claim Billing/Claim RebillField #NCPDP Field NameValuePayer UsagePayer Situation466-EZ PRESCRIBER ID QUALIFIER ?1=National Provider Identifier (NPI) R411-DBPRESCRIBER IDPRESCRIBER NPI numberRSubmit prescriber or pharmacy NPIPharmacy must maintain record of NPI of pharmacy or pharmacist responsible for ordering the test.Pharmacy Provider Segment QuestionsCheckClaim Billing/Claim Rebill If Situational, Payer SituationThis Segment is always sentX Prescriber SegmentSegment Identification (111-AM) = “?2”Claim Billing/Claim RebillField #NCPDP Field NameValuePayer UsagePayer Situation465-EY PROVIDER ID QUALIFIER ?1=National Provider Identifier (NPI) R444-E9PROVIDER IDPHARMACY PROVIDER NPI numberRSubmit pharmacy provider NPIPharmacy must maintain record of NPI of pharmacist responsible for administration of the specimen collection.DUR/PPS Segment QuestionsCheckClaim Billing/Claim Rebill If Situational, Payer SituationThis Segment is situationalXDUR/PPS SegmentSegment Identification (111-AM) = “?8”Claim Billing/Claim RebillField #NCPDP Field NameValuePayer UsagePayer Situation473-7EDUR/PPS CODE COUNTER1RRequired – 1st DUR activity44?-E5PROFESSIONAL SERVICE CODEMARMedication Administered (test sent to outside lab)Special Insturctions:** End of Request Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template** ................
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