Breast and Cervical Cancer Diagnosis and Treatment (BCCDT)
Breast and Cervical Cancer Diagnosis and Treatment (BCCDT)
I. Contact Number: 410-767-6787
II. Drug Coverage:
BCCDT-2 – Covered Drugs for All Groups
|Drug Code |Drug Name |Comments |
|H3A |Analgesics, Narcotics | |
|H3D |Analgesics, Salicylates |Oral forms only covered |
|H3E |Analgesics/Antipyretics, Non-Salicylates |Oral forms only covered |
|H6J |Anti-emetics |Exclude HSN 002005 – Scopoloamine |
|S2B |Anti-Inflammatory Agents |Oral forms only covered |
|W1W |Cephalosporins – 1st gen |Oral forms only covered |
|W1X |Cephalosporins – 2nd gen |Oral forms only covered |
|W1Y |Cephalosporins – 3rd gen |Oral forms only covered |
|W1Z |Cephalosporins – 4th gen |Oral forms only covered |
|W1K |Lincosamides |Oral forms only covered |
|W1D |Macrolides |Oral forms only covered |
|W2F |Nitrofuran Derivatives |Oral forms only covered |
|H2E |Non-Barbiturates, Sedative-Hypnotic |Oral forms only covered |
|W1A |Penicillins |Oral forms only covered |
|W1Q |Quinolones |Oral forms only covered |
|H7E |Serot-2 Amtag/Reuptake Inhib (SARIS) |Oral forms only covered |
|H7C |Serot-Norepineph Reup-Inhib (SNRIS) |Oral forms only covered |
|H2S |Serotonin Spec Reuptake Inhib (SSRI) |Oral forms only covered |
|W1C |Tetracyclines |Oral forms only covered |
|W4E |Trichomonacides |Oral forms only covered |
|H2U |Tricy Antidepr & Rel NSRUI |Oral forms only covered |
|HSN 010249 |Anastrozole | |
|HSN 001653 |Bupropion HCL |Exclude GSN 031439 |
|HSN 018385 |Capecitabine | |
|HSN 002860 |Cortisone Acetate | |
|HSN 003893 |Cyclophosphamide | |
|HSN 002889 |Dexamethasone | |
|HSN 001847 |Deflunisal | |
|HSN 020803 |Exemestane | |
|GSN 011832, 001645, 001646, 017378 |Ferrous Sulfate |OTC TO COVER |
|HSN 002867 |Hydrocortisone | |
|HSN 012351 |Letrozole | |
|HSN 001975 |Meclizine HCL | |
|HSN 002877 |Methylprednisolone | |
|HSN 002148 |Metoclopramide HCL | |
|HSN 004129 |Nystatin | |
|HSN 002874 |Prednisolone | |
|HSN 002879 |Prednisone | |
|HSN 012014 |Promethazine HCL |Rectal forms only covered |
|HSN 011632 |Toremifene Citrate | |
|HSN 018801 |Trastuzumab | |
|F1A |Androgenic Agents | |
|TC 48 |Anticonvulsants | |
|D6D |Anti-diarrheal Agents | |
|Z2A |Antihistamines | |
|TC 30 |Antineoplastic Agents | |
|TC 16 |Antitussives – Expectorants | |
|TC 15 |Bronchodilators | |
|TC 76 |Cardiovascular Preparations, Other | |
|P5A |Corticosteroids, Inhaled | |
|TC 58 |Diabetic Therapy | |
|TC 74 |Digitalis Preparations | |
|TC 79 |Diuretics | |
|Q6I |Eye Antibiotic – Coticoid Combination | |
|Q6W |Eye Antibiotics | |
|Q6P |Eye Antiinflammatory Agent | |
|Q6V |Eye Antiviral | |
|Q6S |Eye Sulfonamide | |
|TC 71 |Hypotensive, Others | |
|D6S |Laxatives & Cathartics | |
|H7J |MAOIS – Non-Selective & Irreversible | |
|M9P |Platelet Aggregation Inhibitors | |
|C1D |Potassium Replacement | |
|H6H |Skeletal Muscle Relaxants | |
|TC 55 |Thyroid Preparations | |
|Q5P |Topical Antiinflammatory (corticosteroids) | |
|Q4F |Vaginal Antifungals | |
|TC 72 |Vasodilators, Coronary | |
|TC 73 |Vasodilators, Peripheral | |
|HSN 004047 |Bacitracin | |
|HSN 007708 |Cadexomer Iodine | |
|HSN 009005 |Fosfomycin Tromethamine | |
|HSN 022142 |HC Acetate/Lidocaine HCL | |
|GSN 007062 |HC Acetate/Pramoxine HCL | |
|HSN 015176 |Hydrocortisone/Pramoxine HCL | |
|GSN 040262 |Lidocaine | |
|GSN 043256 |Lidocaine | |
|GSN 003407 |Lidocaine HCL | |
|GSN 003411 |Lidocaine HCL | |
|GSN 003412 |Lidocaine HCL | |
|GSN 007407 |Lidocaine HCL | |
|GSN 007409 |Lidocaine HCL | |
|HSN 016196 |Lidocaine/Prilocaine | |
|HSN 003385 |Mupirocin | |
|HSN 007527 |Mupirocin Calcium | |
|HSN 003363 |Neomy Sulf/Bacitra/Polymyxin B | |
|HSN 004107 |Phenazopy HCL/Hyoscy/Butabarb | |
|GSN 009477 |Phenazopyridine HCL | |
|GSN 009478 |Phenazopyridine HCL | |
|HSN 004284 |Sodium CL 0.45PC Irrig. Soln | |
|HSN 004285 |Sodium CL Irrig Soln | |
|HSN 004270 |Sodium Hypochlorite | |
|HSN 020355 |Temozolomide | |
|HSN 004283 |Water for Irrigation, Sterile | |
|W3B |Antifungal Agents | |
|P4B |Bone Form, Stim Agents Parathy | |
|P4L |Bone Ossification Suppression Agent | |
|D4K |Gastric Acid Secretion Reducers | |
|N1B |Hemantinics, Other | |
|M9K |Heparin Preparations | |
|N1C |Leukocyte (Wbc) Stimulants | |
|M9L |Oral Anticoagulants, Coumarin Type | |
|Q5F |Topical Antifungals | |
|Q4W |Vaginal Antibiotics | |
|Q4S |Vaginal Sulfonamides | |
|HSN 003904 |Carboplatin | |
|HSN 010798 |Gemcitabine HCL | |
|HSN 004570 |Ifosfamide | |
|HSN 010778 |Irinotecan HCL | |
|HSN 007845 |Melphalan | |
|HSN 010166 |Paclitaxel, Semi-Synthetic | |
|HSN 025963 |Bevacizumab | |
|HSN 002285 |Biafine Cream | |
|HSN 010280 |Docetaxel | |
|HSN 003916 |Doxorubicin HCL | |
|HSN 006578 |Epirubicin | |
|HSN 023523 |Fulvestrant | |
|HSN 021114 |Goserelin Acetate | |
|HSN 021102 |Leuprolide Acetate | |
|HSN 003923 |Megestrol Acetate | |
|HSN 003905 |Methotrexate Sodium | |
|HSN 003926 |Tamoxifen Citrate | |
|HSN 003912 |Vinblastine | |
|HSN 003913 |Vincristine Sulfate | |
|HSN 009614 |Vinorelbine Tartrate | |
|Q4K |Vaginal Estrogen Preparations | |
|HSN 003902 |Cisplatin | |
|HSN 003907 |Fluorouracil | |
|HSN 004101 |Methanamine Hippurate | |
|HSN 004102 |Methenamine Mandelate | |
|HSN 004094 |MTH/ME BLUE/BA/SALICY/ATP/HYOS | |
|G1A |Estrogenic Agents |Oral forms only |
|HIC3 = C5U |Nutritional Therapy, Med Cond Special Electrolytes & |Includes products for disease-specific |
| |Misc. Nutrients |nutritional therapy |
|HIC3 = C5F |Dietary Supplements |Includes Ensure-type products |
|HIC3 = C1W |Electrolyte Maintenance |Includes electrolyte solutions |
|HIC3 = C5G |Food Oils |Includes corn, safflower oils |
|HIC3 = M4B |IV Fat Emulsions | |
|TC = 68 |Protein Lysates |Includes amino acid products |
|HSN 004182, 004183 |Acyclovir, Zovirax | |
|HSN 009007 |famcyclovir | |
|HSN 010117 |valacyclovir | |
|HSN 013221 |foscarnet | |
BCCDT-3 – OTC exception list
|OTC Exception List – All OTCs to deny w/ NCPDP 70 – Drug Not Covered w/the exception of the products listed below |
|Drug Code |Drug Name |Comments |
|HIC3 = C5U |Nutritional Therapy, Med Cond Special Electrolytes & |Includes products for disease-specific |
| |Misc. Nutrients |nutritional therapy |
|HIC3 = C5F |Dietary Supplements |Includes Ensure-type products |
|HIC3 = C1W |Electrolyte Maintenance |Includes electrolyte solutions |
|HIC3 = C5G |Food Oils |Includes corn, safflower oils |
|HIC3 = M4B |IV Fat Emulsions | |
|GSN 011832, 001645, 001646, 017378 |Ferrous Sulfate |OTC TO COVER |
BCCDT-4 - Medicare Covered Drugs
|Medicare Covered Drugs - NCPDP 70- NDC Not Covered, Bill Medicare. |
|Providers will contact vendor Call center for PA if not covered by Medicare. |
|Drug Code |Oral Chemotherapy | |
|GSN = 008838 |VePesid( (Etoposide) | |
|GSN = 008770, 008771 |Cytoxan( (Cyclophosphamide) | |
|GSN = 008773 |Alkeran( (Melphalan) | |
|GSN = 036872, 045266, 035928, 036874, 047823, |Methotrexate | |
|047824 | | |
|HSN = 018385 |Xeloda( (Capecitabine) | |
BCCDT-5 - Drugs Requiring PA – All Groups
|These drugs will deny with NCPDP 75 – Prior Authorization Required: MD Call 410-767-6787 for PA |
|Drug Code |Drug Name |Comments |
|F1A |Androgenic Agents | |
|TC 48 |Anticonvulsants | |
|D6D |Anti-diarrheal Agents | |
|Z2A |Antihistamines | |
|TC 30 |Antineoplastic Agents |EXCLUDE HSN – 025963, 003904, 003902, |
| | |010280, 003916, 006578, 003907, 023523, |
| | |010798, 021114, 004570, 010778, 021102, |
| | |003923, 007845, 003905, 010166, 003926, |
| | |003912, 003913, 009614, 010249, 018385, |
| | |020803, 012351, 011632, 011801 |
|TC 16 |Antitussives – Expectorants | |
|TC 15 |Bronchodilators | |
|TC 76 |Cardiovascular Preparations, Other | |
|P5A |Corticosteroids, Inhaled | |
|TC 58 |Diabetic Therapy | |
|TC 74 |Digitalis Preparations | |
|TC 79 |Diuretics | |
|Q6I |Eye Antibiotic – Coticoid Combination | |
|Q6W |Eye Antibiotics | |
|Q6P |Eye Antiinflammatory Agent | |
|Q6V |Eye Antiviral | |
|Q6S |Eye Sulfonamide | |
|TC 71 |Hypotensive, Others | |
|D6S |Laxatives & Cathartics | |
|H7J |MAOIS – Non-Selective & Irreversible | |
|M9P |Platelet Aggregation Inhibitors | |
|C1D |Potassium Replacement | |
|H6H |Skeletal Muscle Relaxants | |
|TC 55 |Thyroid Preparations | |
|Q5P |Topical Antiinflammatory (corticosteroids) | |
|Q4F |Vaginal Antifungals | |
|TC 72 |Vasodilators, Coronary | |
|TC 73 |Vasodilators, Peripheral | |
|HSN 004047 |Bacitracin | |
|HSN 007708 |Cadexomer Iodine | |
|HSN 009005 |Fosfomycin Tromethamine | |
|HSN 022142 |HC Acetate/Lidocaine HCL | |
|GSN 007062 |HC Acetate/Pramoxine HCL | |
|HSN 015176 |Hydrocortisone/Pramoxine HCL | |
|GSN 040262 |Lidocaine | |
|GSN 043256 |Lidocaine | |
|GSN 003407 |Lidocaine HCL | |
|GSN 003411 |Lidocaine HCL | |
|GSN 003412 |Lidocaine HCL | |
|GSN 007407 |Lidocaine HCL | |
|GSN 007409 |Lidocaine HCL | |
|HSN 016196 |Lidocaine/Prilocaine | |
|HSN 003385 |Mupirocin | |
|HSN 007527 |Mupirocin Calcium | |
|HSN 003363 |Neomy Sulf/Bacitra/Polymyxin B | |
|HSN 004107 |Phenazopy HCL/Hyoscy/Butabarb | |
|GSN 009477 |Phenazopyridine HCL | |
|GSN 009478 |Phenazopyridine HCL | |
|HSN 004284 |Sodium CL 0.45PC Irrig. Soln | |
|HSN 004285 |Sodium CL Irrig Soln | |
|HSN 004270 |Sodium Hypochlorite | |
|HSN 020355 |Temozolomide | |
|HSN 004283 |Water for Irrigation, Sterile | |
|HIC3 = C5U |Nutritional Therapy, Med Cond Special Electrolytes & |Includes products for disease-specific |
| |Misc. Nutrients |nutritional therapy |
|HIC3 = C5F |Dietary Supplements |Includes Ensure-type products |
|HIC3 = C1W |Electrolyte Maintenance |Includes electrolyte solutions |
|HIC3 = C5G |Food Oils |Includes corn, safflower oils |
|HIC3 = M4B |IV Fat Emulsions | |
|TC = 68 |Protein Lysates |Includes amino acid products |
|D4K |Gastric Acid secretion Reducers |Prerequisite rules still apply |
|HSN 004182, 004183 |Acyclovir, Zovirax | |
|HSN 009007 |Famcyclovir | |
|HSN 010117 |Valacyclovir | |
|HSN 013221 |Foscarnet | |
BCCDT-6 - Drugs Requiring PA for BCCDT1
|Drugs Requiring Prior Authorization for recipients with diagnosis of Breast Cancer – Group ID = BCCDT1. |
|These drugs will deny with NCPDP 75 – Prior Authorization Required: MD Call 410-767-6787 FOR PA |
|Drug Code |Drug Name |Comments |
|Q4K |Vaginal Estrogen Preparations | |
|HSN 003902 |Cisplatin | |
|HSN 003907 |Fluorouracil | |
|HSN 004101 |Methanamine Hippurate | |
|HSN 004102 |Methenamine Mandelate | |
|G1A |Estrogenic Agents |Oral forms only |
|HSN 004094 |MTH/ME BLUE/BA/SALICY/ATP/HYOS | |
BCCDT-7 - Drugs Requiring PA for BCCDT2
|Drugs Requiring Prior Authorization for recipients with diagnosis of Cervical Cancer – Group ID = BCCDT2. |
|These drugs will deny with NCPDP 75 – Prior Authorization Required: MD Call 410-767-6787 FOR PA |
|Drug Code |Drug Name |Comments |
|HSN 025963 |Bevacizumab | |
|HSN 002285 |Biafine Cream | |
|HSN 010280 |Docetaxel | |
|HSN 003916 |Dosorubicin HCL | |
|HSN 006578 |Epirubicin | |
|HSN 023523 |Fulvestrant | |
|HSN 021114 |Goserelin Acetate | |
|HSN 021102 |Leuprolide Acetate | |
|HSN 003905 |Methotrexate Sodium | |
|HSN 003926 |Tamoxifen Citrate | |
|HSN 003912 |Vinblastine | |
|HSN 003913 |Vincristine Sulfate | |
|HSN 009614 |Vinorelbine Tartrate | |
|HSN 003893 |Cyclophosphamide | |
BCCDT-8 - Drugs Requiring PA for BCCDT3
|These drugs will deny with NCPDP 75 – Prior Authorization Required: MD Call 410-767-4787 FOR PA |
|Drug Code |Drug Name |Comments |
|W3B |Antifungal Agents | |
|P4B |Bone Form, Stim Agents Parathy | |
|P4L |Bone Ossification Suppression Agent | |
|D4K |Gastric Acid Secretion Reducers | |
|N1B |Hemantinics, Other | |
|M9K |Heparin Preparations | |
|N1C |Leukocyte (Wbc) Stimulants | |
|M9L |Oral Anticoagulants, Coumarin Type | |
|Q5F |Topical Antifungals | |
|Q4W |Vaginal Antibiotics | |
|Q4S |Vaginal Sulfonamides | |
|HSN 003904 |Carboplatin | |
|HSN 010798 |Gemcitabine HCL | |
|HSN 004570 |Ifosfamide | |
|HSN 010778 |Irinotecan HCL | |
|HSN 007845 |Melphalan | |
|HSN 010166 |Paclitaxel, Semi-Synthetic | |
|HSN 025963 |Bevacizumab | |
|HSN 002285 |Biafine Cream | |
|HSN 010280 |Docetaxel | |
|HSN 003916 |Dosorubicin HCL | |
|HSN 006578 |Epirubicin | |
|HSN 023523 |Fulvestrant | |
|HSN 021114 |Goserelin Acetate | |
|HSN 021102 |Leuprolide Acetate | |
|HSN 003923 |Megestrol Acetate | |
|HSN 003905 |Methotrexate Sodium | |
|HSN 003926 |Tamoxifen Citrate | |
|HSN 003912 |Vinblastine | |
|HSN 003913 |Vincristine Sulfate | |
|HSN 009614 |Vinorelbine Tartrate | |
|Q4K |Vaginal Estrogen Preparations | |
|HSN 003902 |Cisplatin | |
|HSN 003907 |Fluorouracil | |
|HSN 004101 |Methanamine Hippurate | |
|HSN 004102 |Methenamine Mandelate | |
|HSN 004094 |MTH/ME BLUE/BA/SALICY/ATP/HYOS | |
|HSN 003893 |Cyclophosphamide | |
|HSN 003923 |Megestrol | |
|G1A |Estrogenic Agents |Oral forms only |
|All extended release narcotics (such as | | |
|Oxycontin, Duragesic, Kadian, Actiq, etc.) | | |
BCCDT-9 - Rebate Exclusion List
|Rebate Exclusion List – Rebate is not required for the following products: |
|HSN = 008966 |Pen Needles | |
|DCC = M |Needles & Syringes | |
|DCC = N |Needles & Syringes | |
|DCC = O |Needles & Syringes | |
|DCC = P |Needles & Syringes | |
|DCC = Q |Needles & Syringes | |
|DCC = R |Needles & Syringes | |
|HIC3 = C5U |Nutritional Therapy, Med Cond Special Electrolytes & |Includes products for disease-specific |
| |Misc. Nutrients |nutritional therapy |
|HIC3 = C5F |Dietary Supplements |Includes Ensure-type products |
|HIC3 = C1W |Electrolyte Maintenance |Includes electrolyte solutions |
|HIC3 = C5G |Food Oils |Includes corn, safflower oils |
|HIC3 = M4B |IV Fat Emulsions | |
|TC = 68 |Protein Lysates |Includes amino acid products |
BCCDT-10 - Inj Products /Needles and Syringes last 34 days.
|Injectable Products that will allow Needles and Syringes to pay as long as the RX has been filled within the last 34 days. |
|Drug Code |Drug Name |Comments |
|H3A |Analgesics, Narcotics | |
|F1A |Androgenic Agents | |
|W3B |Antifungal Agents | |
|H6J |Anti-emetics Agents | |
|TC 30 |Antineoplastic Agents | |
|P4B |Bone Formation Stimulants | |
|P4L |Bone Ossification Suppression Agents | |
|G1A |Estrogrenic Agents | |
|N1B |Hemantinics, Other | |
|M9K |Heparin Preparations | |
|C4G |Insulin | |
|N1C |Leukocyte Stimulants | |
BCCDT-11 - Brand Medically Necessary Exclusions
|Brand Medically Necessary Exclusions (all other brands deny with NCPDP 22) |
|GSN = 004558, 016773, 016774, 038014, 043880 |Carbamazepine 200mg tab |Except: Ciba Geigy may be substituted |
| | |w/Lemon Co. Epitol |
|GSN = 004521 |Phenytoin Sodium Extended 100mg cap | |
|GSN = 004543 |Primidone 250mg tab | |
|GSN = 004536 |Valproic Acid 250mg cap | |
|GSN = 000090, 000091, 000093, 036890, 039837, |Theophylline Extended Release 100mg, 200mg & 300mg tabs | |
|043541 | | |
|GSN = 006561, 006560, 006562 |Warfarin 2mg, 2 ½ mg & 5mg tabs | |
BCCDT-12 - Unit Dose Drugs Exceptions
|Unit Dose Drugs Exceptions for Retail Claims (all other U/D will deny with NCPDP 70 – NDC not covered)/ “Unit Dose Package Size” |
|HSN = 000739; and UD |Ferrous Sulfate (single ingredient products only) | |
|GSN = 040910, 040911, 047126; and UD |Micardis 20mg, 40mg & 80mg | |
|GSN = 047326 |Micardis HCT 40/12.5mg | |
|HSN = 001578; and UD |Chloral Hydrate | |
|GSN = 031055, 031056; and UD |Pepcid RPD | |
|GSN = 049296, 040887; and UD |Prevacid Liquid | |
|GSN = 001171; and UD |Water for Inhalation | |
|GSN = 000591, 000592; and UD |Mucomyst | |
|GSN = 000586; and UD |Sodium Chloride | |
|GSN = 045215, 045216; and UD |Androgel | |
|GSN = 009326, 009327; and UD |Vancocin HCL | |
|GSN = 048463; and UD |Zomig ZMT | |
|GSN = 045266; and UD |Methotrexate Dose Pak | |
|GSN = 041562, 041563; and UD |Zofran ODT | |
|GSN = 046565; and UD |Pulmicort | |
|HSN = 000057; and UD |Ipratropium Bromide | |
|Route = ophthalmic; and UD |Eye Drops | |
III. Payer Specific Information
Payer Sheet:
NCPDP VERSION 5.1 PAYER SHEET – B1/B3 Transactions
**GENERAL INFORMATION**
|Payer Name: Maryland Medical Assistance Program |Date: January 1, 2007 |
|Plan Name/Group Name: Breast and Cervical Cancer Diagnosis and Treatment |
|Processor: ACS |Help Desk: TBD |
|Effective as of: January 1, 2007 |Version/Release #: 5.1 |
|Contact/Information Source: Help Desk, Payer Sheet |
|Certification Testing Window: |
|Provider Relations Help Desk Info: |
|Other versions supported: None |
** OTHER TRANSACTIONS SUPPORTED **
|Transaction Code |Transaction Name |
|B1 |Billing |
|B3 |ReBill |
BILLING TRANSACTION:
Transaction Header Segment: Mandatory in all cases
|Field # |NCPDP Field Name/length |Value |M/R/RW |Comment |
|1Ø1-A1 |BIN Number |61ØØ84 |M | |
|1Ø2-A2 |Version/Release Number |51 |M | |
|1Ø3-A3 |Transaction Code |B1 = Billing |M | |
| | |B2 = Reversals | | |
| | |B3 = Rebill | | |
|1Ø4-A4 |Processor Control Number |DRBCPROD = Production |M | |
| | |DRBCACCP = Test | | |
|1Ø9-A9 |Transaction Count |1 = One Occurrence |M | |
| | |2 = Two Occurrences | | |
| | |3 = Three Occurrences | | |
| | |4 = Four Occurrences | | |
|2Ø2-B2 |Service Provider ID Qualifier |07 – NCPDP ID Number |M | |
|2Ø1-B1 |Service Provider ID |NABP / NCPDP Provider number |M | |
|4Ø1-D1 |Date of Service |CCYYMMDD |M | |
|11Ø-AK |Software Vendor/Certification ID |ØØØØØØØØØØ (zeros) |M |Zero fill or use current |
| | | | |Certification number |
Patient Segment: Required
|Field |NCPDP Field Name |Value |M/R/RW |Comment |
|111-AM |Segment Identification |Ø1 |M |Patient Segment |
|331-CX |Patient ID Qualifier |Blank = Not Specified |NA |Not used by MD BCCDT |
| | |Ø1=Social Security Number | | |
| | |Ø2=Driver’s License Number | | |
| | |Ø3=U.S. Military ID | | |
| | |99=Other | | |
|332-CY |Patient ID | |NA |Not used by MD BCCDT |
|304-C4 |Date of Birth |CCYYMMDD |R | |
|305-C5 |Patient Gender Code |Ø =Not specified |R | |
| | |1=Male | | |
| | |2=Female | | |
|310 –CA |Patient First Name | |R |First 5 characters |
|311 – CB |Patient Last Name | |R |First 5 characters |
|322-CM |Patient Street Address | |NA |Not used by MD BCCDT |
|323-CN |Patient City Address | |NA |Not used by MD BCCDT |
|324-CO |Patient State/Province Address | |NA |Not used by MD BCCDT |
|325-CP |Patient Zip/POSTAL Zone | |NA |Not used by MD BCCDT |
|326-CQ |Patient Phone Number | |NA |Not Used by MD BCCDT |
|307-C7 |Patient Location |0=Not specified |NA | |
| | |1=Home | | |
| | |2=Inter-Care | | |
| | |3=Nursing Home | | |
| | |4=Long Term/Extended Care | | |
| | |5=Rest Home | | |
| | |6=Boarding Home | | |
| | |7=Skilled Care Facility | | |
| | |8=Sub-Acute care Facility | | |
| | |9=Acute Care Facility | | |
| | |10=Outpatient | | |
| | |11=Hospice | | |
|333-CZ |Employer ID | |NS |Not Supported |
|334-1C |Smoker/Non-Smoker Code | |NS |Not Supported |
|335-2C |Pregnancy Indicator |Blank=Not Specified |NA |Not used by MD BCCDT |
| | |1=Not pregnant | | |
| | |2=Pregnant | | |
Insurance Segment: Mandatory
|Field # |NCPDP Field Name |Value |M/R/RW |Comment |
|111-AM |Segment Identification |Ø4 |M |Insurance Segment |
|3Ø2-C2 |Cardholder ID |Member’s MDBCCT ID Number |M |9 characters |
|312-CC |Cardholder First Name | |NA |Not used by MD BCCDT |
|313-CD |Cardholder Last Name | |NA |Not used by MD BCCDT |
|314-CE |Home Plan | |NS |Not Supported |
|524-FO |Plan ID | |NA |Not used by MD BCCDT |
|309-C9 |Eligibility Clarification Code |Ø =Not specified |NA |Not used by MD BCCDT |
| | |1=No Override | | |
| | |2=Override | | |
| | |3=Full Time Student | | |
| | |4=Disabled Dependent | | |
| | |5=Dependent Parent | | |
| | |6=Significant Other | | |
|336-8C |Facility ID | |NS |Not Supported |
|301-C1 |Group ID |MDBCCDT |R | |
|306-C6 |Patient Relationship Code |1 = Cardholder |R |1 = Cardholder |
| | |2 = Spouse | | |
| | |3=Child | | |
| | |4=Other | | |
Claim Segment: Mandatory
|Field # |NCPDP Field Name |Value |M/R/RW |Comment |
|111-AM |Segment Identification |Ø7 |M |Claim Segment |
|455-EM |Prescription/Service Reference Number Qualifier |1 = Rx Billing |M | |
|4Ø2-D2 |Prescription/Service Reference Number |Rx Number assigned by the pharmacy |M | |
|436-E1 |Product/Service ID Qualifier |Ø3 = National Drug Code |M | |
|4Ø7-D7 |Product/Service ID |NDC Number |M | |
|456-EN |Associated Prescription/Service Reference # |New to MDBCCT |RW |Required when submitting a |
| | | | |claim for a completion fill |
|457-EP |Associated Prescription/Service Date |New to MDBCCDT |RW |Required when submitting a |
| | | | |claim for a completion fill |
|458-SE |Procedure Modifier Count | |NA |Not Used by MD BCCDT |
|459-ER |Procedure Modifier Code Count | |NA |Not Used by MD BCCDT |
|442-E7 |Quantity Dispensed |Metric Decimal Quantity |R | |
|403-D3 |Fill Number |Ø = Original Dispensing |R |The system will edit on the |
| | |1-99 = Number of refills | |12th refill |
|405-D5 |Days Supply | |R | |
|406-D6 |Compound Code | Ø = Not specified |R | |
| | |1= Not a compound | | |
| | |2 = Compound | | |
|408-D8 |Dispense as Written (DAW) |Ø =Default, no product selection |RW |Allow 0,1 or 5 |
| | |indicated | | |
| | |1=Physician request | | |
| | |2=patient request | | |
| | |3=pharmacist request | | |
| | |4=generic out of stock (temp) | | |
| | |5=brand used as generic | | |
| | |6=override | | |
| | |7=brand mandated by law | | |
| | |8=generic not available in | | |
| | |marketplace | | |
| | |9=not used | | |
|414-DE |Date Prescription Written |CCYYMMDD |R | |
|415-DF |Number of Refills Authorized |Ø =Not Specified |R | |
| | |1-99=number of refill | | |
|419-DJ |Prescription Origin Code |0=Not specified |NA |Not used by MD BCCDT |
| | |1=Written | | |
| | |2=Telephone | | |
| | |3=Electronic | | |
| | |4=Facsimile | | |
|420-DK |Submission Clarification Code |Ø =Not specified, default |RW |Can be submitted when |
| | |1=No override | |submitting a multi-line |
| | |2=Other override | |compound claim. |
| | |3=Vacation Supply | | |
| | |4=Lost Prescription | | |
| | |5=Therapy Change | | |
| | |6=Starter Dose | | |
| | |7=Medically Necessary | | |
| | |8=Process compound for Approved | | |
| | |Ingredients | | |
| | |9=Encounters | | |
| | |99=Other | | |
|460-ET |Quantity Prescriber | |NS |Not Used, use 442-E7 |
|308-C8 |Other Coverage Code |Ø=Not Specified |R | |
| | |1=No other Coverage Identified | | |
| | |2=Other coverage exists-payment | | |
| | |collected | | |
| | |3=Other coverage exists-this claim | | |
| | |not covered | | |
| | |4=Other coverage exists-payment not| | |
| | |collected | | |
| | |5=Managed care plan denial | | |
| | |6=Other coverage exists, not a | | |
| | |participating provider | | |
| | |7=Other Coverage exists-not in | | |
| | |effect at time of service | | |
| | |8=Claim is a billing for a copay | | |
|429-DT |Unit Dose Indicator |Ø =Not specified | |3 = Pharmacy Unit Dose |
| | |1=Not Unit Dose | | |
| | |2=Manufacturer Unit Dose | | |
| | |3=Pharmacy Unit Dose | | |
|453-EJ |Orig Prescribed Product/Service ID Qual |Ø3=National Drug Code (NDC) |NA |Not used by MD BCCDT |
|445-EA |Originally Prescribed Product/Service Code | |NA |Not used by MD BCCDT |
|446-EB |Originally Prescribed Quantity | |NA |Not used by MD BCCDT |
|330-CW |Alternate ID | |NS |Not supported |
|454-EK |Scheduled prescription ID Number | |NS |Not Supported |
|418-DI |Level of Service |3 = Emergency |RW |Required when submitting a |
| | | | |claim for an emergency fill. |
|461-EU |Prior Authorization Type Code |Ø=Not Specified |RW | |
| | |1=Prior Authorization | | |
| | |2=Medical Certification | | |
| | |3=EPSDT (Early Periodic Screening | | |
| | |Diagnosis Treatment) | | |
| | |4=Exemption from Copay | | |
| | |5=Exemption from RX | | |
| | |6=Family Plan. Indic. | | |
| | |7=AFDC (Aid to Families with | | |
| | |Dependent Children) | | |
| | |8=Payer Defined Exemption | | |
|462-EV |Prior Authorization Number Submitted | |RW | |
|463-EW |Intermediary Authorization Type ID | |NA |Not used by MD BCCDT |
|464-EX |Intermediary Authorization ID | |NA |Not used by MD BCCDT |
|343-HD |Dispensing Status |P = initial Fill |RW |Required when submitting a |
| | |C=Completion Fill | |claim for a partial fill |
| | |New to MDBCCDT | | |
|344-HF |Quantity Intended to be Dispensed |New to MDBCCDT |RW |Required when submitting a |
| | | | |claim for a partial fill |
|345-HG |Days Supply Intended to be Dispensed |New to MDBCCDT |RW |Required when submitting a |
| | | | |claim for a partial fill |
|600-28 |Unit of Measure | |NS |Not Supported |
Pharmacy Provider Segment: Optional - Not used by MDBCCDT
|Field # |NCPDP Field Name |Value |M/R/RW |Comment |
|111-AM |Segment Identification |Ø2 |NA |Pharmacy Provider Segment |
|465-EY |Provider ID Qualifier |Blank=Not specified |NA |Not used by MD BCCDT |
| | |Ø1=Drug Enforcement Administration | | |
| | |(DEA) | | |
| | |Ø2=State License | | |
| | |Ø3=Social Security Number (SSN) | | |
| | |Ø4=Name | | |
| | |Ø5=National Provider Identifier | | |
| | |(NPI) | | |
| | |Ø6=Health Industry Number (HIN) | | |
| | |Ø7=State Issued | | |
| | |99=Other | | |
|444-E9 |Provider ID | |NA |Not used by MD BCCDT |
Prescriber Segment: Required
|Field # |NCPDP Field Name |Value |M/R/RW |Comment |
|111-AM |Segment Identification |Ø3 |M |Prescriber Segment |
|466-EZ |Prescriber ID Qualifier |12 = DEA |R | |
|411-DB |Prescriber ID |DEA Number |R |. |
|467-1E |Prescriber Location Code | |NS |Not Supported |
|427-DR |Prescriber Last Name | |NA |Not used by MD BCCDT |
|498-PM |Prescriber Phone Number | |NA |Not used by MD BCCDT |
|468-2E |Primary Care Provider ID Qualifier |Blank=Not Specified |NA | Not Used by MD BCCDT |
| | |Ø1=National Provider ID (NPI) | | |
| | |Ø2=Blue Cross | | |
| | |Ø3=Blue Shield | | |
| | |Ø4=Medicare | | |
| | |Ø5=Medicaid | | |
| | |Ø6=UPIN | | |
| | |Ø7=NCPDP Provider ID | | |
| | |Ø8=State License | | |
| | |Ø9=Champus | | |
| | |1Ø=Health Industry Number (HIN) | | |
| | |11=Federal Tax ID | | |
| | |12=Drug Enforcement Administration | | |
| | |(DEA) | | |
| | |13=State Issued | | |
| | |14=Plan Specific | | |
| | |99=Other | | |
|421-DL |Primary Care Provider ID | |NA |Not used by MD BCCDT |
|469-H5 |Primary care Provider Location Code | |NS |Not Supported |
|470-4E |Primary Care Provider Last Name | |NS |Not Supported |
COB/Other Payments Segment: Optional
|Field # |NCPDP Field Name |Value |M/R/RW |Comment |
|111-AM |Segment Identification |Ø5 |M |COB/Other Payments Segment |
|337-4C |Coordination of Benefits/Other Payments Count | |M | |
|338-5C |Other Payer Coverage Type | |M | |
| | | |(Repeating) | |
|339-6C |Other Payer Id Qualifier |Blank=Not Specified |R |Required when submitting a |
| | |Ø1=National Payer ID | |COB claim |
| | |Ø2=Health Industry Number | |Valid Value = 99 |
| | |Ø3=Bank Information Number (BIN) | | |
| | |Ø4=National Association of | | |
| | |Insurance Commissioners (NAIC) | | |
| | |Ø9=Coupon | | |
| | |99-Other | | |
|340-7C |Other Payer ID | |R |Valid Values = |
| | | | |88888. |
| | | | |77777 for Med D |
|443-E8 |Other Payer Date |CCYYMMDD |R |Required when there is |
| | | | |payment from another source|
|341-HB |Other Payer Amount Paid Count | |R |Required when submitting |
| | | | |this segment |
|342-HC |Other Payer Amount Paid Qualifier |Blank=Not specified |R |Required when the re is |
| | |Ø1=Delivery |(Repeating) |payment from another source|
| | |Ø2=Shipping | | |
| | |Ø3=Postage | | |
| | |Ø4=Administrative | | |
| | |Ø5=Incentive | | |
| | |Ø6=Cognitive Service | | |
| | |Ø7=Drug Benefit | | |
| | |Ø 8=Sum of all Reimbursement | | |
| | |98=Coupon | | |
| | |99=Other | | |
|431-DV |Other Payer Amount Paid | |R |Required when there is |
| | | | |payment from another source|
|471-5E |Other Payer Reject Count | |NA |Not used by MD BCCDT |
|472-6E |Other Payer Reject Code | |NA |Not used by MD BCCDT |
DUR/PPS Segment: Optional
|Field # |NCPDP Field Name |Value |M/R/RW |Comment |
|111-AM |Segment Identification |Ø8 |M |DUR/PPS Segment |
|473-7E |DUR/PPS Code counter | |M |Required when submitting this|
| | | | |segment |
|439-E4 |Reason For Service Code |See Attached list of valid values |R |Required when there is a |
| | | |(Repeating) |conflict to resolve or reason|
| | | | |for service to be explained |
|440-E5 |Professional Service Code |See Attached list of valid values |R |Required when there is a |
| | | | |professional service to be |
| | | | |identified |
|441-E6 |Result of Service Code |See attached list of valid values |R |Required when There is a |
| | | | |result of service to be |
| | | | |submitted |
|478-8E |DUR/PPS Level of Effort | |NA |Not used by MD BCCDT |
|475-J9 |DUR Co-Agent ID Qualifier | |NA |Not used by MD BCCDT |
|476-H6 |DUR Co-Agent ID | |NA |Not Used by MD BCCDT |
Pricing Segment: Mandatory
|Field # |NCPDP Field Name |Value |M/R/RW |Comment |
|111-AM |Segment Identification |11 |M |Pricing Segment |
|409-D9 |Ingredient Cost Submitted | |NA | |
|412-DC |Dispensing Fee Submitted | |NA |Not used by MD BCCDT |
|477-BE |Professional Service Fee Submitted | |NA |Not used by MD BCCDT |
|433-DX |Patient Paid Amount | |NA |Not used by MD BCCDT |
|478-H7 |Other Amount Claimed Submitted Count |Used with Other Coverage code 8 |RW |Required when submitting a |
| | | | |co-pay only claim |
|479-H8 |Other Amount Claimed Submitted Qualifier | |RW |Required when submitting a |
| | | | |claim for a co-pay only |
|480-H9 |Other Amount Claimed Submitted | |RW |Required when submitting a |
| | | | |claim for a copay only. This |
| | | | |amount must equal Field 430-DQ|
|481-HA |Flat Sales Tax Amount Submitted | |NA |Not used by MD BCCDT |
|482-GE |Percentage Sales Tax Amount Submitted | |NA |Not used by MD BCCDT |
|484-JE |Percentage Sales Tax Basis Submitted |Blank=Not specified |NA |Not used by MD BCCDT |
| | |01=Gross Amount Due | | |
| | |02=Ingredient Cost | | |
| | |03=Ingredient Cost + Dispensing Fee| | |
|426-DQ |Usual and Customary Charge | |R | |
|430–DU |Gross Amount Due | |R |For copay only claims – this |
| | | | |amount must equal the amount |
| | | | |in field 480-H9 |
|423-DN |Basis of Cost Determination |Blank=Not specified |NA |Not used by MD BCCDT |
| | |00=Not specified | | |
| | |Ø1=AWP (Average Wholesael Price) | | |
| | |Ø2=Local Wholesaler | | |
| | |Ø3=Direct | | |
| | |Ø4=EAC (Estimated Acquisition Cost)| | |
| | |Ø5=cquisition | | |
| | |Ø6=MAC (Maximum Allowable Cost) | | |
| | |Ø7=Usual & customary | | |
| | |Ø9=Other | | |
Coupon Segment: Segment is not supported
|Field # |NCPDP Field Name |Value |M/R/RW |Comment |
|111-AM |Segment Identification |Ø9 |NS |Coupon Segment |
|485-KE |Coupon Type | |NS | |
|486-ME |Coupon Number | |NS | |
|487-NE |Coupon Value Amount | |NS | |
Compound Segment: Required When Submitting a Multi-Line Compound Claim
|Field # |NCPDP Field Name |Value |M/R/RW |Comment |
|111-AM |Segment Identification |1Ø |M |Compound Segment |
|45Ø-EF |Compound Dosage Form Description Code | |M |Ø1=Capsule |
| | | | |Ø2=Ointment |
| | | | |Ø3=Cream |
| | | | |Ø4=Suppository |
| | | | |Ø5=Powder |
| | | | |Ø6=Emulsion |
| | | | |Ø7=Liquid |
| | | | |1Ø=Tablet |
| | | | |11=Solution |
| | | | |12=Suspension |
| | | | |13=Lotion |
| | | | |14=Shampoo |
| | | | |15=Elixir |
| | | | |16=Syrup |
| | | | |17=Lozenge |
| | | | |18=Enema |
|451-EG |Compound Dispensing Unit Form Indicator | |M |1=Each |
| | | | |2=Grams |
| | | | |3=Milliliters |
|452-EH |Compound Route of Administration | |M |1=Buccal |
| | | | |2=Dental |
| | | | |3=Inhalation |
| | | | |4=Injection |
| | | | |5=Intraperitoneal |
| | | | |6=Irrigation |
| | | | |7=Mouth/Throat |
| | | | |8=Mucous Membrane |
| | | | |9=Nasal |
| | | | |1Ø=Ophthalmic |
| | | | |11=Oral |
| | | | |12=Other/Miscellaneous |
| | | | |13=Otic |
| | | | |14=Perfusion |
| | | | |15=Rectal |
| | | | |16=Sublingual |
| | | | |17=Topical |
| | | | |18=Transdermal |
| | | | |19=Translingual |
| | | | |2Ø=Urethral |
| | | | |21=Vaginal |
| | | | |22=Enteral |
| | | | | |
| | | | | |
| | | | | |
|447-EC |Compound Ingredient Component (Count) | |M | |
| | | |(Repeating) | |
|488-RE |Compound Product ID Qualifier | |M |Ø3=National Drug Code (NDC) |
| | | |(Repeating) | |
|489-TE |Compound Product ID | |M | |
| | | |(Repeating) | |
|448-ED |Compound Ingredient Quantity | |M | |
| | | |(Repeating) | |
|449-EE |Compound Ingredient Drug Cost | |NA |Not used by MD BCCDT |
|490-UE |Compound ingredient basis of Cost Determination |Blank=Not specified |NA |Not used by MD BCCDT |
| | |Ø1=AWP | | |
| | |Ø2=Local Wholesaler | | |
| | |Ø3=Direct | | |
| | |Ø4=EAC | | |
| | |Ø5=Acquisition | | |
| | |Ø6=MAC | | |
| | |Ø7=Usual & customary | | |
| | |Ø9=Other | | |
Prior Authorization Segment: Not Used by MDBCCDT Medicaid
|Field # |NCPDP Field Name |Value |M/R/RW |Comment |
|111-AM |Segment Identification |12 |NA |Prior Authorization Segment |
|498-PA |Request Type | |NA | |
|498-PB |Request Period Date –Begin | |NA | |
|498-PC |Request Period Date- End | |NA | |
|498-PD |Basis of Request | |NA | |
|498-PE |Authorized Representative First Name | |NA | |
|498-PF |Authorized Representative Last Name | |NA | |
|498-PG |Authorized Representative Street Address | |NA | |
|498-PH |Authorized Representative City Address | |NA | |
|498-PJ |Authorized Representative State/Province Address | |NA | |
|498-PK |Authorized Representative Zip/Postal Code | |NA | |
|498-PY |Prior Authorization Number Assigned | |NA | |
|503-F3 |Authorization Number | |NA | |
|498-PP |Prior Authorization Supporting Documentation | |NA | |
Clinical Segment: Optional for MDBCCDT
|Field # |NCPDP Field Name |Value |M/R/RW |Comment |
|111-AM |Segment Identification |13 |NA |Clinical Segment |
|491-VE |Diagnosis Code Count | |RW |Required when a DX is used to |
| | | | |determine coverage |
|492-WE |Diagnosis Code | |RW |Required when a DX is used to |
| | | | |determine coverage |
|424-DO |Diagnosis Code | |RW |Required when a DX is used to |
| | | | |determine coverage |
|493-XE |Clinical Information Counter | |NA | |
|494-ZE |Measurement Date | |NA | |
|495-H1 |Measurement Time | |NA | |
|496-H2 |Measurement Dimension | |NA | |
|497-H3 |Measurement Unit | |NA | |
|499-H4 |Measurement Value | |NA | |
Additional Claim Information
DUR Codes
Reason for Service Codes (DUR Conflict Codes)
|Code |Meaning |Code |Meaning |
|AT |Additive Toxicity |LD |Low Dose alert |
|CH |Call Help Desk |LR |Under Use Precaution |
|DA |Drug Allergy Alert |MC |Drug Disease Precaution |
|DC |Inferred Drug Disease Precaution |MN |Insufficient Duration Alert |
|DD |Drug-Drug Interaction |MX |Excessive Duration Alert |
|DF |Drug Food Interactions |OH |Alcohol Precaution |
|DI |Drug Incompatibility |PA |Drug Age Precaution |
|DL |Drug Lab conflict |PG |Drug Pregnancy alert |
|DS |Tobacco use precaution |PR |Prior Adverse drug reaction |
|ER |Over Use precaution |SE |Side effect alert |
|HD |High Dose alert |SX |Drug gender alert |
|IC |Iatrogenic condition alert |TD |Therapeutic Duplication |
|ID |Ingredient Duplication | | |
Professional Service Codes (Intervention Codes)
|Code |Meaning |Code | Meaning |
|M0 |MD Interface |R0 |Pharmacist reviewed |
|P0 |Patient Interaction | | |
Result of Service Codes (DUR Outcome Codes)
|Code |Meaning |Code |Meaning |
|1A |Filled – False Positive |1F |Filled – Different quantity |
|1B |Filled as is |1G |Filled after prescriber approval |
|1C |Filled with different dose |2A |Not Filled |
|1D |Filled with different directions |2B |Not Filled – Directions Clarified |
IV. Provider Information :
Provider Manual
Provider Cheat Sheet
V. Emergency Procedures:
Not Applicable
................
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