Magellan Rx Commercial NCPDP D.0 Payer Specifications

Magellan Rx Management NCPDP D.0 Payer Specification

October 10, 2022

**Start of Request Claim Billing/Claim Re-bill (B1/B3) Payer Sheet**

General Information

Payer Name: Magellan Rx Management

Date: May 1, 2016

Plan Name/Group Name: Magellan Rx Management Employees

BIN: 017035

PCN: 605

Plan Name/Group Name: MRx Commercial ¨C CBA Blue

BIN: 017449

PCN: CBG

Plan Name/Group Name: MRx Commercial ¨C Legacy Partners Rx

Clients

BIN: 015243

PCN: PRX1000

Plan Name/Group Name: MRx Commercial ¨C Lucent Technologies BIN: 017465

PCN: LUCENT

Plan Name/Group Name: MRx Commercial ¨C Standard

BIN: 017449

PCN: 6792000

Plan Name/Group Name: MRx Commercial ¨C Employee Benefit

Management Services

BIN: 017431

PCN: EBMS

Plan Name/Group Name: FlexScripts

BIN: 017472

PCN: FLEXRX

Plan Name/Group Name: MRx Commercial ¨C Union

BIN: 017449

PCN: UNION

Payer Name: Magellan Rx Management

Date: July 1, 2017

Plan Name/Group Name: MRx Commercial ¨C Cash Card

BIN: 018679

PCN: 6775000 GRP: 040116

Plan Name/Group Name: Yale University

BIN: 017449

PCN: YALE

GRP: PRXYAL

Processor: Magellan Rx Management

Effective as of: 08/01/2014

NCPDP Telecommunication Standard Version/Release #: D.0

NCPDP Data Dictionary Version Date: In accordance

with NCPDP Version Standards

NCPDP External Code List Version Date: In accordance with

NCPDP Version Standards

Contact/Information Source:

Certification Testing Window: TBD

Certification Contact Information: 804-548-0130

Provider Relations Help Desk Info: 800-424-3312

Other versions supported: No other versions supported

? 2014¨C2023 by Magellan Rx Management, LLC. All rights reserved.

Other Transactions Supported

Payer: Please list each transaction supported with the segments, fields, and pertinent information

on each transaction.

Transaction Code

E1

Transaction Name

Eligibility Transaction

Field Legend for Columns

Payer Usage Column

Value

Payer Situation

Column

Explanation

MANDATORY

M

The Field is mandatory for the Segment in the designated

Transaction.

No

REQUIRED

R

The Field has been designated with the situation of

¡°Required¡± for the Segment in the designated Transaction.

No

¡°Required when¡±. The situations designated have

qualifications for usage (¡°Required if x,¡± ¡°Not required if y¡±).

Yes

QUALIFIED REQUIREMENT

RW

Fields that are not used in the Claim Billing/Claim Re-bill transactions and those that do not have

qualified requirements (i.e., not used) for this payer are excluded from the template.

Claim Billing/Claim Re-bill Transaction

The following lists the segments and fields in a Claim Billing or Claim Re-bill Transaction for the

NCPDP Telecommunication Standard Implementation Guide Version D.?.

Transaction Header Segment Questions

Claim Billing/Claim Re-bill

If Situational, Payer Situation

Check

This Segment is always sent

X

Source of certification IDs required in

Software Vendor/Certification ID (11?-AK) is

Payer Issued

X

Required when vendor certification is

required by Magellan Rx Management ¨C

otherwise submit all zeroes

Source of certification IDs required in

Software Vendor/Certification ID (11?-AK) is

Switch/VAN issued

Source of certification IDs required in

Software Vendor/Certification ID (11?-AK) is

Not used

Transaction Header Segment

Field #

Claim Billing/Claim Re-bill

NCPDP Field Name

Value

Payer

Usage

1?1-A1

BIN NUMBER

See above

M

1?2-A2

VERSION/RELEASE NUMBER

D?

M

1?3-A3

TRANSACTION CODE

B1, B3

M

Page 2

|

MRx Payer NCPDP D.0 Payer Specifications

Payer Situation

Transaction Header Segment

Field #

Claim Billing/Claim Re-bill

NCPDP Field Name

Value

Payer

Usage

1?4-A4

PROCESSOR CONTROL

NUMBER

See above

M

1?9-A9

TRANSACTION COUNT

Up to 4

M

2?2-B2

SERVICE PROVIDER ID

QUALIFIER

01

M

2?1-B1

SERVICE PROVIDER ID

M

4?1-D1

DATE OF SERVICE

M

11?-AK

SOFTWARE

VENDOR/CERTIFICATION ID

M

Insurance Segment Questions

This Segment is always sent

NCPDP Field Name

Required for all claims

NPI of submitting pharmacy

provider

Required when vendor certification

is required by Magellan Rx

Management ¨C otherwise submit all

zeroes

Claim Billing/Claim Re-bill

If Situational, Payer Situation

Check

X

Insurance Segment

Segment Identification (111-AM) = ¡°?4¡±

Field #

Payer Situation

Claim Billing/Claim Re-bill

Value

Payer

Usage

3?2-C2

CARDHOLDER ID

M

312-CC

CARDHOLDER FIRST NAME

R

313-CD

CARDHOLDER LAST NAME

R

3?9-C9

ELIGIBILITY CLARIFICATION

CODE

RW

Payer Situation

Imp Guide: Required if needed for

receiver inquiry validation and/or

determination, when eligibility is

not maintained at the dependent

level. Required in special situations

as defined by the code to clarify the

eligibility of an individual, which

may extend coverage.

Payer Requirement: Same as Imp

Guide

3?1-C1

GROUP ID

3?3-C3

PERSON CODE

R

RW

See ID card.

Imp Guide: Required if needed to

uniquely identify the family

members within the Cardholder ID.

Payer Requirement: Same as Imp

Guide

MRx Payer NCPDP D.0 Payer Specifications

|

Page 3

Insurance Segment

Segment Identification (111-AM) = ¡°?4¡±

Field #

3?6-C6

NCPDP Field Name

Claim Billing/Claim Re-bill

Value

PATIENT RELATIONSHIP

CODE

Payer

Usage

RW

Payer Situation

Imp Guide: Required if needed to

uniquely identify the relationship of

the Patient to the Cardholder.

Payer Requirement: Same as Imp

Guide

Patient Segment Questions

This Segment is always sent

Claim Billing/Claim Re-bill

If Situational, Payer Situation

Check

X

This Segment is situational

Patient Segment

Segment Identification (111-AM) = ¡°?1¡±

Field

331-CX

NCPDP Field Name

Claim Billing/Claim Re-bill

Value

PATIENT ID QUALIFIER

Payer

Usage

RW

Payer Situation

Imp Guide: Required if Patient ID

(332-CY) is used.

Payer Requirement: Same as Imp

Guide

332-CY

PATIENT ID

RW

Imp Guide: Required if necessary for

state/federal/regulatory agency

programs to validate dual eligibility.

Payer Requirement: Same as Imp

Guide

3?4-C4

DATE OF BIRTH

R

3?5-C5

PATIENT GENDER CODE

R

31?-CA

PATIENT FIRST NAME

R

311-CB

PATIENT LAST NAME

R

3?7-C7

PLACE OF SERVICE

RW

Imp Guide: Required if this field

could result in different coverage,

pricing, or patient financial

responsibility.

Payer Requirement: Same as Imp

Guide

333-CZ

Page 4

EMPLOYER ID

|

MRx Payer NCPDP D.0 Payer Specifications

RW

Imp Guide: Required if ¡°required by

law¡± as defined in the HIPAA final

Privacy regulations section 164.5?1

definitions (45 CFR Parts 16? and

164 Standards for Privacy of

Individually Identifiable Health

Information; Final Rule -

Patient Segment

Segment Identification (111-AM) = ¡°?1¡±

Field

NCPDP Field Name

Claim Billing/Claim Re-bill

Value

Payer

Usage

Payer Situation

Thursday, December 28, 2000, page

82803 and following, and

Wednesday, August 14, 2002, page

53267 and following.)

Required if needed for Workers¡¯

Compensation billing.

Payer Requirement: Same as Imp

Guide

335-2C

PREGNANCY INDICATOR

RW

Imp Guide: Required if pregnancy

could result in different coverage,

pricing, or patient financial

responsibility.

Required if ¡°required by law¡± as

defined in the HIPAA final Privacy

regulations section 164.5?1

definitions (45 CFR Parts 16? and

164 Standards for Privacy of

Individually

Identifiable Health Information;

Final RuleThursday, December 28, 2000, page

82803 and following, and

Wednesday, August 14, 2002, page

53267 and following.)

Payer Requirement: Same as Imp

Guide

384-4X

PATIENT RESIDENCE

RW

Imp Guide: Required if this field

could result in different coverage,

pricing, or patient financial

responsibility.

Payer Requirement: Same as Imp

Guide

Claim Segment Questions

Check

This Segment is always sent

X

This payer supports partial fills

X

Claim Billing/Claim Re-bill

If Situational, Payer Situation

This payer does not support partial fills

MRx Payer NCPDP D.0 Payer Specifications

|

Page 5

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

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

Google Online Preview   Download