Magellan Rx Commercial NCPDP D.0 Payer Specifications
嚜燐agellan 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 每 CBA Blue
BIN: 017449
PCN: CBG
Plan Name/Group Name: MRx Commercial 每 Legacy Partners Rx
Clients
BIN: 015243
PCN: PRX1000
Plan Name/Group Name: MRx Commercial 每 Lucent Technologies BIN: 017465
PCN: LUCENT
Plan Name/Group Name: MRx Commercial 每 Standard
BIN: 017449
PCN: 6792000
Plan Name/Group Name: MRx Commercial 每 Employee Benefit
Management Services
BIN: 017431
PCN: EBMS
Plan Name/Group Name: FlexScripts
BIN: 017472
PCN: FLEXRX
Plan Name/Group Name: MRx Commercial 每 Union
BIN: 017449
PCN: UNION
Payer Name: Magellan Rx Management
Date: July 1, 2017
Plan Name/Group Name: MRx Commercial 每 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每2023 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 每
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
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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 每 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
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