Michigan NCPDP D.0 Payer Specifications - Magellan Rx Management
Michigan Medicaid NCPDP D.0 Payer Specifications
October 10, 2022
Request Claim Billing/Claim Re-Bill Payer Sheet
**Start of Request Claim Billing/Claim Re-Bill (B1/B3) Payer Sheet**
General Information
Payer Name: Michigan Medicaid
Plan Name/Group Name: MI01/MIMEDICAID
BIN:009737
PCN: P008009737
Processor: Processor/Fiscal Intermediary
Effective as of: 01/01/2012
NCPDP Telecommunication Standard Version/Release #: D.0
NCPDP Data Dictionary Version Date: 10/2017 NCPDP External Code List Version Date: 10/2017
Contact/Information Source:
Certification Testing Window: TBD
Certification Contact Information: 804-217-7900
Provider Relations Help Desk Info: 866-254-1669
Other versions supported: VERSION 5.1 UNTIL 01/01/2012 ¡° SUBJECT TO CHANGE*
? 2016¨C2023 by Magellan Rx Management, LLC. All rights reserved.
Magellan Medicaid Administration is a division of Magellan Rx Management, LLC.
Other Transactions Supported
Payer: Please list each transaction supported with the segments, fields, and pertinent information
on each transaction.
Transaction Code
Transaction Name
B1
Claim Billing
B2
Claim Reversal
B3
Claim Re-bill
E1
Eligibility Verification
Field Legend for Columns
Payer Usage Column
Value
Explanation
Payer Situation
Column
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.
Page 2
|
Michigan Medicaid NCPDP D.0 Payer Specifications
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
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
009737
M
1?2-A2 VERSION/RELEASE
NUMBER
D?
M
1?3-A3 TRANSACTION CODE
? B1
M
Payer Situation
Michigan Department of
Community Health
? B1 Billing
? B2
? B2 Reversal
? B3
? B3 Re-bill
? E1
? E1 Eligibility Verification
1?4-A4 PROCESSOR CONTROL
NUMBER
P008009737
M
1?9-A9 Transaction Count
? 1 One Occurrence
M
? 2 Two Occurrences
? 3 Three Occurrences
Specify max number of
transactions supported for each
transaction code.
? 4 Four Occurrences
2?2-B2 SERVICE PROVIDER ID
QUALIFIER
?1 ¨C National Provider
Identifier (NPI)
M
2?1-B1 SERVICE PROVIDER ID
NPI
M
4?1-D1 DATE OF SERVICE
Format = CCYYMMDD
M
Michigan Medicaid NCPDP D.0 Payer Specifications
|
Page 3
Transaction Header Segment
Field #
NCPDP Field Name
Claim Billing/Claim Re-bill
Payer
Usage
Value
11?-AK SOFTWARE
VENDOR/CERTIFICATION
ID
Insurance Segment Questions
This Segment is always sent
M
NCPDP Field Name
X
Claim Billing/Claim Re-bill
Value
3?2-C2 CARDHOLDER ID
3?1-C1 GROUP ID
Assigned by Magellan Medicaid
Administration
Claim Billing/Claim Re-bill
If Situational, Payer Situation
Check
Insurance Segment
Segment Identification (111-AM) = ¡°?4¡±
Field #
Payer Situation
Payer
Usage
M
MIMEDICAID
Payer Situation
Medicaid ID Number 10-digit ID
R
Imp Guide: Required if needed to
3?3-C3 PERSON CODE
uniquely identify the family
members within the Cardholder
ID.
Payer Requirement: Same as
Imp Guide.
3?6-C6 PATIENT RELATIONSHIP
CODE
1 = Cardholder
36?-2B MEDICAID INDICATOR
Two-character State
Postal Code indicating
the state where
Medicaid coverage
exists.
RW
A unique member
identification number
assigned by the
Medicaid Agency
RW
115-N5 MEDICAID ID NUMBER
Patient Segment Questions
Check
R
Imp Guide: Required, if known,
when patient has Medicaid
coverage.
Ex: MI
Imp Guide: Required, if known,
when patient has Medicaid
coverage.
Claim Billing/Claim Re-bill
If Situational, Payer Situation
This Segment is always sent
This Segment is situational
Page 4
|
X
Michigan Medicaid NCPDP D.0 Payer Specifications
Required for B1 and B3 transactions
Patient Segment
Segment Identification (111-AM) = ¡°?1¡±
Field #
NCPDP Field Name
331-CX PATIENT ID QUALIFIER
Claim Billing/Claim Re-bill
Value
? ?1 = Social Security
Number
Payer
Usage
RW
Payer Situation
Imp Guide: Required if Patient
ID (332-CY) is used.
EA = Medical Record
Identification Number (EHR)
? 1J = Facility ID
Number
Payer Requirement: Same as
Imp Guide.
? ?2 = Driver's License
Number
? ?3 = US Military ID
? ?4 = Non-SSN-based
patient identifier
assigned by health
plan
? ?5 = SSN-based
patient identifier
assigned by health
plan
? ?6 = Medicaid ID
? ?7 = State Issued ID
? ?8 = Passport ID
? ?9 = Medicare HIC#
? 1? = Employer
Assigned ID
? 11 = Payer/PBM
Assigned ID
? 12 = Alien Number
? 13 = Government
Student VISA
Number
? 14 = Indian Tribal ID
? 99 = Other
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.
31?-CA PATIENT FIRST NAME
R
Imp Guide: Required when the
311-CB PATIENT LAST NAME
R
Imp Guide: Required when the
patient has a first name.
patient has a last name.
Michigan Medicaid NCPDP D.0 Payer Specifications
|
Page 5
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- dmas new pharmacy benefit administration frequently asked questions faqs
- magellan rx management provider manual
- dmba medical pharmacy program
- connecticut aids drug assistance program adap ncpdp d 0 payer
- member instructions for sending the member drug error report
- important notice qualchoice
- magellan rx commercial ncpdp d 0 payer specifications
- michigan ncpdp d 0 payer specifications magellan rx management
- mrx caterpillar ncpdp d 0 payer specifications magellan rx management
- pbm bins help desk pba health
Related searches
- d link 192 168 0 1 admin
- d link 192 168 0 1 setup configuration
- 192 168 0 1 admin wireless settings d link
- d link router setup 192 168 0 1
- 192 168 0 1 setup wizard d link
- square d nema 0 starter
- square d size 0 starter
- d link 192 168 0 1
- 192 168 0 1 d link setup
- 192 168 0 50 d link setup
- d d 5 0 monster manual pdf
- magellan rx medicare