NCPDP REFERENCE MANUAL - CMS

[Pages:132]NCPDP REFERENCE MANUAL

Chapter 3: NCPDP Flat File Format

About the Flat File Format (FFF) File Layout

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires that a single standard be used for the electronic submission of retail pharmacy claims--NCPDP format. These incoming claims are first passed through an NCPDP translator and stored in a Flat-File-Format (FFF). ViPS programs pass the FFF data through a series of editing programs and produce reports that list the claims included in the transmission and identify any errors in the submitted data. The process then formats the FFF file into the Claims-In-Process (CIP) format used by the VMS subsystems and the Certificate of Medical Necessity (CMN) format used for DME.

There are three transmission record types that the ViPS NCPDP recognizes, as described below.

Batch Header Record

The batch header record is the first record on the NCPDP file. It occurs only once. Field definitions begin on page 3-3.

For additional information about the batch header record, refer to the NCPDP Batch Standard Implementation Guide, Version 1.1.

Detail Data Records

Record Name ViPS Segment Record

Transmission Header Record

Transmission Patient Record Transmission Pharmacy Record Transmission Prescriber Record Transmission Insurance Record

Level

Required? Max Records

Comments

Transmission

Yes

1 per transmission Generated by ViPS for

internal processing; occurs

once before each Transaction

Header Record.

Transmission

Yes

1 per transmission Occurs once per set of

records that constitute a

single claim. It must be the

first record in the set.

Transmission

Yes

1 per transmission

Transaction

No

1 per transaction

Transaction

Yes

1 per transaction

Transmission

Yes

1 per transmission

Rev. 2005-4/October

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? 2002 VIPS, Inc. All Rights Reserved.

Use or disclosure of the information contained on this page is subject to the restrictions on the title page of this material.

Chapter 3: NCPDP Flat File Format

NCPDP Reference Manual

Record Name

Transmission Other COB Record Transmission Work Comp Record Transmission Claim Record Transmission DUR-PPS Record Transmission Coupon Record Transmission Compound Record

Transmission Pricing Record Transmission Prior Auth Record

Transmission Clinical Record

Level Transaction Transaction Transaction Transaction Transaction Transaction

Transaction Transaction

Transaction

Required? No No Yes No No No

Yes Yes, depending on procedure

Yes

Max Records 1 per transaction 1 per transaction 1 per transaction 1 per transaction 1 per transaction 1 per transaction

1 per transaction 1 per transaction

1 per transaction

Comments

May have 1?4 occurrences per transmission.

If this segment is present, there should be only one transaction in the transmission. May have 1?4 occurrences per transmission. Required for procedure codes requiring CMN form 08.02, 10.02A, or 10.02B to store CMN information; not used otherwise.

Field definitions begin on page 3-5. For additional information about the detail data records, refer to the NCPDP Telecommunications Standard Implementation Guide, Version 5.1.

Batch Trailer Record

The batch trailer record is the last record on the NCPDP file. It occurs only once. Field definitions begin on page 3-953-93.

For additional information about the batch trailer record, refer to the NCPDP Batch Standard Implementation Guide, Version 1.1.

3-2

Rev. 2005-4/October

? 2002 VIPS, Inc. All Rights Reserved.

Use or disclosure of the information contained on this page is subject to the restrictions on the title page of this material.

NCPDP Reference Manual

Chapter 3: NCPDP Flat File Format

Batch Header Record

Batch Header Record

NCPDP Data

Field

Dictionary Name Number

Definition of Field

Format Valid Values Copybook

Sender ID* Segment Identifier* Segment Identification* Version *1 Batch Number* Transaction Reference Number*

Group Indicator *1

880-K1 701

111-AM N/A

806-5C 880-K5

N/A

Identification number assigned to the sender of the data by the processor of the data.

Unique record type required on Batch Transaction Standard.

Identifies the segment in the request record. This field is only populated on records with Segment Identifier G1.

Represents the current version of VIPs NCPDP software that is being used.

Number assigned by processor. Matches trailer record.

Number assigned by provider to each transaction record. This number is unique to each set of flat file records that represent a single claim. This field is only populated on records with Segment Identifier G1.

This field is used to indicate a group of related segments. These segments together represent the equivalent of 1 claim line. This field is only populated on records with Segment Identification '07' (claim segment).

X(24) X(02) X(02) X(01) 9(07) X(10)

X(01)

NCPKFLAT

00 =File Header NCPKFLAT

Spaces

NCPKFLAT

A Spaces

NCPKFLAT NCPKFLAT NCPKFLAT

N

NCPKFLAT

* Part of the key portion of the portion of the flat file record format; present on every flat file record. 1 ViPS generated; does not correspond to any NCPDP field name. 2 Contains a value that is not on the list in the Data Dictionary (ViPS Segment Record and Transmission Prior Auth Record only).

Starting Position

1 25 27 29 30 37

47

Ending Position

24 26 28 29 36 46

47

Rev. 2005-4/October

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Use or disclosure of the information contained on this page is subject to the restrictions on the title page of this material.

NCPDP Reference Manual

Chapter 3: NCPDP Flat File Format

Batch Header Record

NCPDP Data Dictionary Name

Filler*1 Segment Identification

Transmission Type

Field Number

N/A 111-AM

880-K6

Definition of Field

Reserved for future use. Identifies the segment in the request record. Defines the Type of transmission being sent.

Format

X(13) X(02) X(01)

Sender ID Batch Number Creation Date

880-K1 806-5C 880-K2

Identification number assigned to the sender of the data by the processor of the data.

Number assigned by processor. Matches trailer record.

Date the file was created.

X(24) 9(07) 9(08)

Creation Time

880-K3 Time the file was created.

9(04)

File Type

702

Test or Production.

X(01)

Version/Release Number

Receiver ID1

102-A2 880-K7

Code identifying the release syntax and corresponding Data Dictionary.

Determined by VIPs.

X(02) X(24)

Valid Values

Spaces 00

T = Transaction R = Response E = Error

Format = CCYYMMDD Format = HHMM T = Test P = Production 51

Copybook

Starting Position

NCPKFLAT

48

NCPSB00A

61

NCPSB00A

63

NCPSB00A

64

NCPSB00A

88

NCPSB00A

95

NCPSB00A

103

NCPSB00A

107

NCPSB00A

108

NCPSB00A

110

Ending Position

60 62 63

87

94 102 106 107 109 133

* Part of the key portion of the portion of the flat file record format; present on every flat file record. 1 ViPS generated; does not correspond to any NCPDP field name. 2 Contains a value that is not on the list in the Data Dictionary (ViPS Segment Record and Transmission Prior Auth Record only).

Rev. 2005-4/October

3-4

? 2002 VIPS, Inc. All Rights Reserved.

Use or disclosure of the information contained on this page is subject to the restrictions on the title page of this material.

NCPDP Reference Manual

Chapter 3: NCPDP Flat File Format

Detail Data Records

ViPS Segment Record

NCPDP Data Dictionary Name

Sender ID*

Segment Identifier*2 Segment Identification* Version *1 Batch Number* Transaction Reference Number*

ViPS Segment Record

Field Number

Definition of Field

Format

880-K1

701 111-AM

N/A 806-5C 880-K5

Identification number assigned to the sender of the data by the processor of the data.

Unique record type required on Batch Transaction Standard.

Identifies the segment in the request record. This field is only populated on records with Segment Identifier G1.

Represents the current version of VIPs NCPDP software that is being used.

Number assigned by processor. Matches trailer record.

Number assigned by provider to each transaction record. This number is unique to each set of flat file records that represent a single claim. This field is only populated on records with Segment Identifier G1.

X(24)

X(02) X(02)

X(01) 9(07) X(10)

Valid Values

Copybook

NCPKFLAT

Starting Position

1

Ending Position

24

01 = ViPS

NCPKFLAT

25

26

Segment

Spaces

NCPKFLAT

27

28

A

NCPKFLAT

29

29

NCPKFLAT

30

36

NCPKFLAT

37

46

* Part of the key portion of the portion of the flat file record format; present on every flat file record. 1 ViPS generated; does not correspond to any NCPDP field name. 2 Contains a value that is not on the list in the Data Dictionary (ViPS Segment Record and Transmission Prior Auth Record only).

Rev. 2005-4/October

3-5

? 2002 VIPS, Inc. All Rights Reserved.

Use or disclosure of the information contained on this page is subject to the restrictions on the title page of this material.

NCPDP Reference Manual

Chapter 3: NCPDP Flat File Format

NCPDP Data Dictionary Name

Group Indicator *1

Filler*1

ViPS Segment Record

Field Number

Definition of Field

Format

N/A

This field is used to indicate a group of

related segments. These segments

together represent the equivalent of 1

claim line. This field is only populated on

records with Segment Identification '07'

(claim segment).

N/A

Reserved for future use.

X(01) X(13)

Valid Values

N

Copybook

NCPKFLAT

Starting Position

47

Ending Position

47

Spaces

NCPKFLAT

48

60

* Part of the key portion of the portion of the flat file record format; present on every flat file record. 1 ViPS generated; does not correspond to any NCPDP field name. 2 Contains a value that is not on the list in the Data Dictionary (ViPS Segment Record and Transmission Prior Auth Record only).

Rev. 2005-4/October

3-6

? 2002 VIPS, Inc. All Rights Reserved.

Use or disclosure of the information contained on this page is subject to the restrictions on the title page of this material.

NCPDP Reference Manual

Chapter 3: NCPDP Flat File Format

Transmission Header Record

Transmission Header Record

NCPDP Data Dictionary Name

Sender ID*

Segment Identifier* Segment Identification* Version *1 Batch Number* Transaction Reference Number*

Group Indicator *1

Field Number

Definition of Field

880-K1 701

111-AM N/A

806-5C 880-K5

N/A

Identification number assigned to the sender of the data by the processor of the data.

Unique record type required on Batch Transaction Standard.

Identifies the segment in the request record. This field is only populated on records with Segment Identifier G1.

Represents the current version of VIPs NCPDP software that is being used.

Number assigned by processor.

Number assigned by provider to each transaction record. This number is unique to each set of flat file records that represent a single claim. This field is only populated on records with Segment Identifier G1.

This field is used to indicate a group of related segments. These segments together represent the equivalent of 1 claim line. This field is only populated on records with Segment Identification '07' (claim segment).

Format

X(24)

Valid Values

Copybook

NCPKFLAT

Starting Position

1

Ending Position

24

X(02)

G1 =Data Detail NCPKFLAT

25

26

Record

X(02)

00

NCPKFLAT

27

28

X(01)

A

9(07) X(10)

NCPKFLAT

29

29

NCPKFLAT

30

36

NCPKFLAT

37

46

X(01)

N

NCPKFLAT

47

47

* Part of the key portion of the portion of the flat file record format; present on every flat file record. 1 ViPS generated; does not correspond to any NCPDP field name. 2 Contains a value that is not on the list in the Data Dictionary (ViPS Segment Record and Transmission Prior Auth Record only).

Rev. 2005-4/October

3-7

? 2002 VIPS, Inc. All Rights Reserved.

Use or disclosure of the information contained on this page is subject to the restrictions on the title page of this material.

NCPDP Reference Manual

Chapter 3: NCPDP Flat File Format

Transmission Header Record

NCPDP Data Dictionary Name

Filler*1 BIN Number

Version/Release Number Transaction Code

Field Number

Definition of Field

N/A 101-A1 102-A2 103-A3

Reserved for future use.

Card Issuer or Bank ID used for network routing.

Code identifying the release syntax and corresponding Data Dictionary.

Identifies type of transaction

Processor Control Number Transaction Count

Service Provider ID Qualifier Service Provider ID

104-A4 Number assigned by processor.

109-A9 202-B2

Number of transactions in the transmission.

Code qualifying the Service Provider ID

201-B1 ID assigned to pharmacy or provider.

Date of Service

Software Vendor/ Certification ID Claim Control Number1

401-D1 110-AK

N/A

Identifies the date the prescription was filled.

ID assigned by the switch or processor to identify the software source.

Claim number assigned by VIPs for internal processing.

Format

X(13) 9(06) X(02) X(02) X(10) 9(01) X(02) X(15) 9(08) X(10) 9(14)

Valid Values

Copybook

Starting Position

Ending Position

Spaces

NCPKFLAT

48

60

NCPST00BN

61

66

CPST00A

51

NCPST00BN

67

68

CPST00A

B1

NCPST00BN

69

70

CPST00A

NCPST00BN

71

80

CPST00A

1, 2, 3, 4

NCPST00BN

81

81

CPST00A

04

NCPST00BN

82

83

CPST00A

NCPST00BN

84

98

CPST00A

Format =

NCPST00BN

99

106

CCYYMMDD

CPST00A

NCPST00BN

107

116

CPST00A

NCPST00BN

117

130

CPST00A

* Part of the key portion of the portion of the flat file record format; present on every flat file record. 1 ViPS generated; does not correspond to any NCPDP field name. 2 Contains a value that is not on the list in the Data Dictionary (ViPS Segment Record and Transmission Prior Auth Record only).

Rev. 2005-4/October

3-8

? 2002 VIPS, Inc. All Rights Reserved.

Use or disclosure of the information contained on this page is subject to the restrictions on the title page of this material.

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