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Spectrum Pharmacy SolutionsNCPDP vD.0 Payer SheetClaim Billing / Claim Re-billGENERAL INFORMATIONPayer Name: Spectrum Pharmacy SolutionsDate: 06/01/2019Plan Name/Group Name: Hospice Health PlanBIN: 021411PCN: SPSProcessor: Change HealthcareEffective as of: 06/01/2019NCPDP Telecommunication Standard Version/Release #: D.0NCPDP Data Dictionary Version Date: 9/2010NCPDP External Code List Version Date: 9/2010Contact/Information Source: General website 1-8SPECTRUM4 (877.328.7864)Pharmacy Help Desk Info: FORMTEXT 800-451-5059Field Legend for ColumnsPayer Usage ColumnValueExplanationPayer Situation ColumnMANDATORYMThe Field is mandatory for the Segment in the designated Transaction.NoRequiredRThe Field has been designated with the situation of "Required" for the Segment in the designated Transaction.NoQualified RequirementRW“Required when”. The situations designated have qualifications for usage ("Required if x", "Not required if y").YesFields 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 TRANSACTIONThe 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 QuestionsCheckClaim Billing/Claim Re-bill If Situational, Payer SituationThis Segment is always sentX Transaction Header SegmentClaim Billing/Claim Re-billField # NCPDP Field Name ValuePayer Usage Payer Situation1?1-A1BIN Number 021411M1?2-A2Version/Release NumberD?M1?3-A3Transaction CodeB1 or B3M1?4-A4Processor Control NumberM1?9-A9Transaction Count1 M2?2-B2Service Provider ID Qualifier01 – NPIM2?1-B1Service Provider ID NPIM4?1-D1Date of ServiceM11?-AKSoftware Vendor/Certification IDAll SpacesMInsurance Segment QuestionsCheckClaim Billing/Claim Re-bill If Situational, Payer SituationThis Segment is always sentX Insurance SegmentSegment Identification (111-AM) = “?4”Claim Billing/Claim Re-billField #NCPDP Field NameValuePayer UsagePayer Situation3?2-C2CARDHOLDER IDMBuilt at the time of adjudication3?1-C1GROUP IDSPSADVSPSRELSPSAPLRVaries by PlanPatient Segment QuestionsCheckClaim Billing/Claim Re-bill If Situational, Payer SituationThis Segment is always sentX This Segment is situationalPatient SegmentSegment Identification (111-AM) = “?1”Claim Billing/Claim Re-billField NCPDP Field NameValuePayer UsagePayer Situation3?4-C4DATE OF BIRTHR3?5-C5PATIENT GENDER CODEM, F, XR31?-CAPATIENT FIRST NAMERImp Guide: Required when the patient has a first name.311-CBPATIENT LAST NAMER322-CMPATIENT STREET ADDRESSRWImp Guide: Optional.Payer Requirement: Required when available.323-CNPATIENT CITY ADDRESSRWImp Guide: Optional.Payer Requirement : Required when available.324-COPATIENT STATE / PROVINCE ADDRESSRWImp Guide: Optional.Payer Requirement : Required when available.325-CPPATIENT ZIP / POSTAL ZONERWImp Guide: Optional.Payer Requirement: Required when available.326-CQPATIENT PHONE NUMBER RWImp Guide: Optional.Payer Requirement: Required when available.35?-HNPATIENT E-MAIL ADDRESSRWImp Guide: May be submitted for the receiver to relay patient health care communications via the Internet when provided by the patient.Payer Requirement: Required when available.Claim Segment QuestionsCheckClaim Billing/Claim Re-bill If Situational, Payer SituationThis Segment is always sentX This payer supports partial fillsThis payer does not support partial fillsXClaim SegmentSegment Identification (111-AM) = “?7”Claim Billing/Claim Re-billField #NCPDP Field NameValuePayer UsagePayer Situation455-EMPREscription/Service Reference Number Qualifier1 = Rx BillingMImp Guide: For Transaction Code of “B1”, in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is “1” (Rx Billing).4?2-D2Prescription/Service Reference Numberup to 12 positionsM436-E1Product/Service ID Qualifier?1 = Universal Product Code (UPC)?3 = National Drug Code (NDC)M00 if Compound Code (406-D6) = 24?7-D7Product/Service ID11 digit NDCM0 if Compound Code (406-D6) = 2442-E7QUANTITY DISPENSEDFormat 9(7)V999 R4?3-D3FILL NUMBERNew = 00 (zeros must be sent) R4?5-D5DAYS SUPPLYR4?6-D6COMPOUND CODE1 = Not a Compound2 = Compound RRefer to Compound Segment when Compound Code (406-D6) = 24?8-D8DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODER414-DEDATE PRESCRIPTION WRITTENR415-DFNUMBER OF REFILLS AUTHORIZEDRImp Guide: Required if necessary for plan benefit administration.419-DJPRESCRIPTION ORIGIN CODERImp Guide: Required if necessary for plan benefit administration.354-NXSUBMISSION CLARIFICATION CODE COUNTMaximum count of 3.RWImp Guide: Required if Submission Clarification Code (42?-DK) is used.Payer Requirement: Same as Imp Guide42?-DKSUBMISSION CLARIFICATION CODERWImp Guide: Required if clarification is needed and value submitted is greater than zero (?).If the Date of Service (4?1-D1) contains the subsequent payer coverage date, the Submission Clarification Code (42?-DK) is required with value of “19” (Split Billing – indicates the quantity dispensed is the remainder billed to a subsequent payer when Medicare Part A expires. Used only in long-term care settings) for individual unit of use medications.Payer Requirement: Same as Imp Guide46?-ETQUANTITY PRESCRIBEDRWImp Guide: Required for all drugs dispensed as Schedule II. Payer Requirement: Must submit quantity Prescribed and Quantity dispensed Number of Refills Authorized should be 03?8-C8OTHER COVERAGE CODE0 = Not specified by patient1 = No other coverage3 = Other coverage exist – claim not covered*8 = Claim is billing for patient financial responsibility only*RWImp Guide: Required if needed by receiver, to communicate a summation of other coverage information that has been collected from other payers.Required for Coordination of Benefits.Payer Requirement: Same as Imp Guide. *requires COB segment to be sent.461-EUPRIOR AUTHORIZATION TYPE CODE1 = Prior Authorization, if applicableRWImp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility.Payer Requirement: Same as Imp Guide462-EVPRIOR AUTHORIZATION NUMBER SUBMITTEDIf applicable to RxRWImp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility.Payer Requirement: Same As Imp Guide995-E2ROUTE OF ADMINISTRATIONRWImp Guide: Required if specified in trading partner agreement.Payer Requirement: When compound code (406-D6) = 2Pricing Segment QuestionsCheckClaim Billing/Claim Re-bill If Situational, Payer SituationThis Segment is always sentX Pricing SegmentSegment Identification (111-AM) = “11”Claim Billing/Claim Re-billField #NCPDP Field NameValuePayer UsagePayer Situation4?9-D9INGREDIENT COST SUBMITTEDR412-DCDISPENSING FEE SUBMITTEDR Imp Guide: Required if its value has an effect on the Gross Amount Due (43?-DU) calculation. 433-DXPATIENT PAID AMOUNT SUBMITTEDRImp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility.438-E3INCENTIVE AMOUNT SUBMITTEDRWImp Guide: Required if its value has an effect on the Gross Amount Due (43?-DU) calculation.Payer Requirement: Same as Imp Guide478-H7OTHER AMOUNT CLAIMED SUBMITTED COUNTMaximum count of 3. RWImp Guide: Required if Other Amount Claimed Submitted Qualifier (479-H8) is used.Payer Requirement: Same as Imp Guide479-H8 OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER RWImp Guide: Required if Other Amount Claimed Submitted (48?-H9) is used.Payer Requirement: Same as Imp Guide48?-H9OTHER AMOUNT CLAIMED SUBMITTED RWImp Guide: Required if its value has an effect on the Gross Amount Due (43?-DU) calculation. Payer Requirement: Same as Imp Guide481-HAFLAT SALES TAX AMOUNT SUBMITTEDRWImp Guide: Required if its value has an effect on the Gross Amount Due (43?-DU) calculation. Payer Requirement: Same as Imp Guide. If Sales Tax applies to State.482-GEPERCENTAGE SALES TAX AMOUNT SUBMITTEDRWImp Guide: Required if its value has an effect on the Gross Amount Due (43?-DU) calculation. Payer Requirement: Same as Imp Guide. If Sales Tax applies to State.483-HEPERCENTAGE SALES TAX RATE SUBMITTED RWImp Guide: Required if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Basis Submitted (484-JE) are used.Required if this field could result in different pricing.Required if needed to calculate Percentage Sales Tax Amount Paid (559-AX).Payer Requirement: Same as Imp Guide. If Sales Tax applies to State.484-JE PERCENTAGE SALES TAX BASIS SUBMITTEDRWImp Guide: Required if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Rate Submitted (483-HE) are used. Required if this field could result in different pricing.Required if needed to calculate Percentage Sales Tax Amount Paid (559-AX).Payer Requirement: Same as Imp Guide. If Sales Tax applies to State.426-DQUSUAL AND CUSTOMARY CHARGERImp Guide: Required if needed per trading partner agreement.43?-DUGROSS AMOUNT DUER423-DNBASIS OF COST DETERMINATIONRImp Guide: Required if needed for receiver claim/encounter adjudication.Prescriber Segment QuestionsCheckClaim Billing/Claim Re-bill If Situational, Payer SituationThis Segment is always sentX This Segment is situationalPrescriber SegmentSegment Identification (111-AM) = “?3”Claim Billing/Claim Re-billField #NCPDP Field NameValuePayer UsagePayer Situation466-EZ PRESCRIBER ID QUALIFIER 01 – NPI12 - DEARImp Guide: Required if Prescriber ID (411-DB) is used. 411-DBPRESCRIBER ID NPI or DEARImp Guide: Required if this field could result in different coverage or patient financial responsibility.Required if necessary for state/federal/regulatory agency programs.427-DRPRESCRIBER LAST NAMERWImp Guide: Required when the Prescriber ID (411-DB) is not known.Required if needed for Prescriber ID (411-DB) validation/clarification.Payer Requirement: Required when submitting DEA364-2JPRESCRIBER FIRST NAMERWImp Guide: Required if needed to assist in identifying the prescriber. Required if necessary for state/federal/regulatory agency programs.Payer Requirement: Required when submitting DEA365-2KPRESCRIBER STREET ADDRESSRWImp Guide: Required if needed to assist in identifying the prescriber. Required if necessary for state/federal/regulatory agency programs.Payer Requirement: Required when submitting DEA366-2MPRESCRIBER CITY ADDRESSRWImp Guide: Required if needed to assist in identifying the prescriber. Required if necessary for state/federal/regulatory agency programs.Payer Requirement: Required when submitting DEA367-2NPRESCRIBER STATE/PROVINCE ADDRESSRWImp Guide: Required if needed to assist in identifying the prescriber. Required if necessary for state/federal/regulatory agency programs.Payer Requirement: Required when submitting DEA368-2PPRESCRIBER ZIP/POSTAL ZONERWImp Guide: Required if needed to assist in identifying the prescriber. Required if necessary for state/federal/regulatory agency programs.Payer Requirement: Required when submitting DEADUR/PPS Segment QuestionsCheckClaim Billing/Claim Re-bill If Situational, Payer SituationThis Segment is always sent This Segment is situationalXfor use to define professional service or override clinical editsDUR/PPS SegmentSegment Identification (111-AM) = “?8”Claim Billing/Claim Re-billField #NCPDP Field NameValuePayer UsagePayer Situation473-7EDUR/PPS CODE COUNTERMaximum of 9 occurrences.RImp Guide: Required if DUR/PPS Segment is used.439-E4REASON FOR SERVICE CODERImp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.Required if this field affects payment for or documentation of professional pharmacy service.44?-E5PROFESSIONAL SERVICE CODERImp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.Required if this field affects payment for or documentation of professional pharmacy service.441-E6RESULT OF SERVICE CODERImp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.Required if this field affects payment for or documentation of professional pharmacy service.474-8EDUR/PPS LEVEL OF EFFORTRImp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.Required if this field affects payment for or documentation of professional pharmacy service.475-J9DUR CO-AGENT ID QUALIFIERRImp Guide: Required if DUR Co-Agent ID (476-H6) is used.476-H6DUR CO-AGENT ID RImp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.Required if this field affects payment for or documentation of professional pharmacy pound Segment QuestionsCheckClaim Billing/Claim Re-bill If Situational, Payer SituationThis Segment is always sent This Segment is situationalXrequired when Compound Code (406-D6) = 2Compound SegmentSegment Identification (111-AM) = “1?”Claim Billing/Claim Re-billField #NCPDP Field NameValuePayer UsagePayer Situation45?-EFCompound Dosage Form Description CodeM451-EGCompound Dispensing Unit Form IndicatorM447-ECCompound Ingredient Component CountMaximum 25 ingredientsM488-RECompound Product ID Qualifier03 - NDCM489-TECompound Product ID 11 digit NDCM448-EDCompound Ingredient QuantityM449-EECOMPOUND INGREDIENT DRUG COSTRImp Guide: Required if needed for receiver claim determination when multiple products are billed.49?-UECOMPOUND INGREDIENT BASIS OF COST DETERMINATIONRImp Guide: Required if needed for receiver claim determination when multiple products are billed.** End of Request Claim Billing/Claim Re-bill (B1/B3) Payer Sheet**Spectrum Pharmacy SolutionsNCPDP vD.0 Payer SheetClaim Billing / Claim Re-bill ResponseGENERAL INFORMATIONPayer Name: Spectrum Pharmacy SolutionsDate: 06/01/2019Plan Name/Group Name: Hospice Health PlanBIN: 021411PCN: SPSPlan Name/Group Name: BIN: PCN: Plan Name/Group Name: BIN: PCN: Claim Billing/Claim Re-bill PAID (or Duplicate of PAID) ResponseThe following lists the segments and fields in a Claim Billing or Claim Re-bill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.?. Response Transaction Header Segment QuestionsCheckClaim Billing/Claim Re-bill Accepted/Paid (or Duplicate of Paid)If Situational, Payer SituationThis Segment is always sentX Response Transaction Header SegmentClaim Billing/Claim Re-bill – Accepted/Paid (or Duplicate of Paid)Field #NCPDP Field NameValuePayer UsagePayer Situation1?2-A2Version/Release NumberD?M1?3-A3Transaction CodeB1, B3 M1?9-A9Transaction Count1 M5?1-F1Header Response StatusA = AcceptedM2?2-B2Service Provider ID QualifierSame value as in requestM2?1-B1Service Provider ID Same value as in requestM4?1-D1Date of ServiceSame value as in requestMResponse Message Segment QuestionsCheckClaim Billing/Claim Re-bill Accepted/Paid (or Duplicate of Paid)If Situational, Payer SituationThis Segment is always sent This Segment is situationalXProvide general information when used for transmission level messaging.Response Message SegmentSegment Identification (111-AM) = “2?”Claim Billing/Claim Re-bill – Accepted/Paid (or Duplicate of Paid)Field #NCPDP Field NameValuePayer UsagePayer Situation5?4-F4MessageRWImp Guide: Required if text is needed for clarification or detail.Payer Requirement: Same as Imp GuideResponse Insurance Segment QuestionsCheckClaim Billing/Claim Re-bill Accepted/Paid (or Duplicate of Paid)If Situational, Payer SituationThis Segment is always sent This Segment is situationalXResponse Insurance SegmentSegment Identification (111-AM) = “25”Claim Billing/Claim Re-bill – Accepted/Paid (or Duplicate of Paid)Field #NCPDP Field NameValuePayer UsagePayer Situation545-2FNETWORK REIMBURSEMENT IDRWImp Guide: Required if needed to identify the network for the covered member.Required if needed to identify the actual Network Reimbursement ID, when applicable and/or available.Required to identify the actual Network Reimbursement ID that was used when multiple Network Reimbursement IDs exist.Response Status Segment QuestionsCheckClaim Billing/Claim Re-bill Accepted/Paid (or Duplicate of Paid)If Situational, Payer SituationThis Segment is always sentX Response Status SegmentSegment Identification (111-AM) = “21”Claim Billing/Claim Re-bill – Accepted/Paid (or Duplicate of Paid)Field #NCPDP Field NameValuePayer UsagePayer Situation112-ANTransaction Response StatusP=PaidD=Duplicate of Paid M?3-F3AUTHORIZATION NUMBERRImp Guide: Required if needed to identify the transaction.13?-UFADDITIONAL MESSAGE INFORMATION COUNTMaximum count of 25.RWImp Guide: Required if Additional Message Information (526-FQ) is used.Payer Requirement: Same as Imp Guide132-UHADDITIONAL MESSAGE INFORMATION QUALIFIERRWImp Guide: Required if Additional Message Information (526-FQ) is used.Payer Requirement: Same as Imp Guide526-FQADDITIONAL MESSAGE INFORMATIONRWImp Guide: Required when additional text is needed for clarification or detail.Payer Requirement: Same as Imp Guide131-UGADDITIONAL MESSAGE INFORMATION CONTINUITYRWImp Guide: Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.Payer Requirement: Same as Imp Guide549-7FHELP DESK PHONE NUMBER QUALIFIERRWImp Guide: Required if Help Desk Phone Number (55?-8F) is used.Payer Requirement: Same as Imp Guide55?-8FHELP DESK PHONE NUMBERRWImp Guide: Required if needed to provide a support telephone number to the receiver.Payer Requirement: Same as Imp GuideResponse Claim Segment QuestionsCheckClaim Billing/Claim Re-bill Accepted/Paid (or Duplicate of Paid)If Situational, Payer SituationThis Segment is always sentX Response Claim SegmentSegment Identification (111-AM) = “22”Claim Billing/Claim Re-bill – Accepted/Paid (or Duplicate of Paid)Field #NCPDP Field NameValuePayer UsagePayer Situation455-EMPrescription/Service Reference Number Qualifier1 = Rx BillingMImp Guide: For Transaction Code of “B1”, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is “1” (Rx Billing).4?2-D2Prescription/Service Reference NumberMResponse Pricing Segment QuestionsCheckClaim Billing/Claim Re-bill Accepted/Paid (or Duplicate of Paid)If Situational, Payer SituationThis Segment is always sentX Response Pricing SegmentSegment Identification (111-AM) = “23”Claim Billing/Claim Re-bill – Accepted/Paid (or Duplicate of Paid)Field #NCPDP Field NameValuePayer UsagePayer Situation5?5-F5PATIENT PAY AMOUNT R5?6-F6INGREDIENT COST PAID R5?7-F7DISPENSING FEE PAID RImp Guide: Required if this value is used to arrive at the final reimbursement.557-AVTAX EXEMPT INDICATORRWImp Guide: Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing.Payer Requirement: Same as Imp Guide558-AWFLAT SALES TAX AMOUNT PAIDRWImp Guide: Required if Flat Sales Tax Amount Submitted (481-HA) is greater than zero (?) or if Flat Sales Tax Amount Paid (558-AW) is used to arrive at the final reimbursement.Payer Requirement: Same as Imp Guide559-AXPERCENTAGE SALES TAX AMOUNT PAIDRWImp Guide: Required if this value is used to arrive at the final reimbursement.Required if Percentage Sales Tax Amount Submitted (482-GE) is greater than zero (?). Required if Percentage Sales Tax Rate Paid (56?-AY) and Percentage Sales Tax Basis Paid (561-AZ) are used.Payer Requirement: Same as Imp Guide56?-AYPERCENTAGE SALES TAX RATE PAID RWImp Guide: Required if Percentage Sales Tax Amount Paid (559-AX) is greater than zero (?).Payer Requirement: Same as Imp. Guide561-AZPERCENTAGE SALES TAX BASIS PAIDRWImp Guide: Required if Percentage Sales Tax Amount Paid (559-AX) is greater than zero (?).Payer Requirement: Same as Imp Guide521-FLINCENTIVE AMOUNT PAIDRWImp Guide: Required if this value is used to arrive at the final reimbursement.Required if Incentive Amount Submitted (438-E3) is greater than zero (?). Payer Requirement: Same as Imp Guide563-J2OTHER AMOUNT PAID COUNT Maximum count of 3.RWImp Guide: Required if Other Amount Paid (565-J4) is used.Payer Requirement: Same as Imp Guide564-J3OTHER AMOUNT PAID QUALIFIERRWImp Guide: Required if Other Amount Paid (565-J4) is used.Payer Requirement: Same as Imp Guide565-J4OTHER AMOUNT PAIDRWImp Guide: Required if this value is used to arrive at the final reimbursement.Required if Other Amount Claimed Submitted (48?-H9) is greater than zero (?). Payer Requirement: Same as Imp Guide5?9-F9TOTAL AMOUNT PAIDR522-FMBASIS OF REIMBURSEMENT DETERMINATION RImp Guide: Required if Ingredient Cost Paid (5?6-F6) is greater than zero (?).Required if Basis of Cost Determination (432-DN) is submitted on billing.523-FNAMOUNT ATTRIBUTED TO SALES TAXRWImp Guide: Required if Patient Pay Amount (5?5-F5) includes sales tax that is the financial responsibility of the member but is not also included in any of the other fields that add up to Patient Pay Amount. Payer Requirement: Same as Imp Guide517-FHAMOUNT APPLIED TO PERIODIC DEDUCTIBLERWImp Guide: Required if Patient Pay Amount (5?5-F5) includes deductiblePayer Requirement: Same as Imp Guide518-FIAMOUNT OF COPAYRImp Guide: Required if Patient Pay Amount (5?5-F5) includes co-pay as patient financial responsibility.575-EQPatient sales tax amountRWImp Guide: Used when necessary to identify the Patient’s portion of the Sales Tax. Provided for informational purposes only.Payer Requirement: Same As Imp Guide574-2YPlan sales tax amountRWImp Guide: Used when necessary to identify the Plan’s portion of the Sales Tax. Provided for informational purposes only.Payer Requirement: Same As Imp Guide572-4UAmount of CoinsuranceRWImp Guide: Required if Patient Pay Amount (5?5-F5) includes coinsurance as patient financial responsibility.Payer Requirement: Same As Imp Guide133-UJAmount Attributed to provider Network selectionRWImp Guide: Required if Patient Pay Amount (5?5-F5) includes an amount that is attributable to a cost share differential due to the selection of one pharmacy over anotherPayer Requirement: Same As Imp Guide134-UKamount attributed to product selection/brand drugRWImp Guide: Required if Patient Pay Amount (5?5-F5) includes an amount that is attributable to a patient’s selection of a Brand drug.Payer Requirement: Same As Imp Guide135-UMamount attributed to product selection/non-preferred formulary selectionRWImp Guide: Required if Patient Pay Amount (5?5-F5) includes an amount that is attributable to a patient’s selection of a non-preferred formulary product.Payer Requirement: Same As Imp Guide136-UNamount attributed to product selection/Brand non-preferred formulary selectionRWImp Guide: Required if Patient Pay Amount (5?5-F5) includes an amount that is attributable to a patient’s selection of a Brand non-preferred formulary product.Payer Requirement: Same As Imp Guide148-U8INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNTRWImp Guide: Required when Basis of Reimbursement Determination (522-FM) is “14” (Patient Responsibility Amount) or “15” (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. Payer Requirement: Same As Imp Guide 149-U9DISPENSING FEE CONTRACTED/REIMBURSABLE AMOUNTRWImp Guide: Required when Basis of Reimbursement Determination (522-FM) is “14” (Patient Responsibility Amount) or “15” (Patient Pay Amount) unless prohibited by state/federal/regulatory agency.Payer Requirement: Same As Imp GuideResponse DUR/PPS Segment QuestionsCheckClaim Billing/Claim Re-bill Accepted/Paid (or Duplicate of Paid)If Situational, Payer SituationThis Segment is always sent This Segment is situationalXResponse DUR/PPS SegmentSegment Identification (111-AM) = “24”Claim Billing/Claim Re-bill – Accepted/Paid (or Duplicate of Paid)Field #NCPDP Field NameValuePayer UsagePayer Situation567-J6DUR/PPS RESPONSE CODE COUNTER Maximum 9 occurrences supported.RWImp Guide: Required if Reason For Service Code (439-E4) is used.Payer Requirement: Same As Imp Guide439-E4REASON FOR SERVICE CODERWImp Guide: Required if utilization conflict is detected.Payer Requirement: Same As Imp Guide528-FSCLINICAL SIGNIFICANCE CODERWImp Guide: Required if needed to supply additional information for the utilization conflict.Payer Requirement: Same As Imp Guide529-FTOTHER PHARMACY INDICATORRWImp Guide: Required if needed to supply additional information for the utilization conflict.Payer Requirement: Same As Imp Guide53?-FUPREVIOUS DATE OF FILLRWImp Guide: Required if needed to supply additional information for the utilization conflict.Required if Quantity of Previous Fill (531-FV) is used.Payer Requirement: Same As Imp Guide531-FVQUANTITY OF PREVIOUS FILLRWImp Guide: Required if needed to supply additional information for the utilization conflict.Required if Previous Date Of Fill (53?-FU) is used.Payer Requirement: Same As Imp Guide532-FWDATABASE INDICATORRWImp Guide: Required if needed to supply additional information for the utilization conflict.Payer Requirement : Same As Imp Guide533-FXOTHER PRESCRIBER INDICATORRWImp Guide: Required if needed to supply additional information for the utilization conflict.Payer Requirement: Same As Imp Guide544-FYDUR FREE TEXT MESSAGERWImp Guide: Required if needed to supply additional information for the utilization conflict.Payer Requirement: Same As Imp GuideClaim Billing/Claim Re-bill accepted/rejected ResponseResponse Transaction Header Segment QuestionsCheckClaim Billing/Claim Re-bill Accepted/Rejected If Situational, Payer SituationThis Segment is always sentX Response Transaction Header SegmentClaim Billing/Claim Re-bill Accepted/RejectedField #NCPDP Field NameValuePayer UsagePayer Situation1?2-A2Version/Release NumberD?M1?3-A3Transaction CodeB1, B3 M1?9-A9Transaction CountSame value as in requestM5?1-F1Header Response StatusA = AcceptedM2?2-B2Service Provider ID QualifierSame value as in requestM2?1-B1Service Provider ID Same value as in request M4?1-D1Date of ServiceSame value as in requestMResponse Message Segment QuestionsCheckClaim Billing/Claim Re-bill Accepted/Rejected If Situational, Payer SituationThis Segment is always sent This Segment is situationalXProvide general information when used for transmission level messaging.Response Message SegmentSegment Identification (111-AM) = “2?”Claim Billing/Claim Re-bill Accepted/RejectedField #NCPDP Field NameValuePayer UsagePayer Situation5?4-F4MESSAGERWImp Guide: Required if text is needed for clarification or detail. Payer Requirement: Same As Imp GuideResponse Insurance Segment QuestionsCheckClaim Billing/Claim Re-bill Accepted/Rejected If Situational, Payer SituationThis Segment is always sent This Segment is situationalX545-2FNETWORK REIMBURSEMENT IDRWImp Guide: Required if needed to identify the network for the covered member.Required if needed to identify the actual Network Reimbursement ID, when applicable and/or available.Required to identify the actual Network Reimbursement ID that was used when multiple Network Reimbursement IDs exist.Response Status Segment QuestionsCheckClaim Billing/Claim Re-bill Accepted/Rejected If Situational, Payer SituationThis Segment is always sentX Response Status SegmentSegment Identification (111-AM) = “21”Claim Billing/Claim Re-bill Accepted/RejectedField #NCPDP Field NameValuePayer UsagePayer Situation112-ANTRANSACTION RESPONSE STATUSR = RejectM5?3-F3AUTHORIZATION NUMBERRImp Guide: Required if needed to identify the transaction.51?-FAREJECT COUNTMaximum count of 5.R511-FBREJECT CODER546-4FREJECT FIELD OCCURRENCE INDICATORRWImp Guide: Required if a repeating field is in error, to identify repeating field occurrence.Payer Requirement: Same As Imp Guide13?-UFADDITIONAL MESSAGE INFORMATION COUNTMaximum count of 25.RWImp Guide: Required if Additional Message Information (526-FQ) is used.Payer Requirement: Same As Imp Guide132-UHADDITIONAL MESSAGE INFORMATION QUALIFIERRWImp Guide: Required if Additional Message Information (526-FQ) is used.Payer Requirement : Same As Imp Guide526-FQADDITIONAL MESSAGE INFORMATIONRWImp Guide: Required when additional text is needed for clarification or detail.Payer Requirement: Same As Imp Guide131-UGADDITIONAL MESSAGE INFORMATION CONTINUITYRWImp Guide: Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.Payer Requirement: Same As Imp Guide549-7FHELP DESK PHONE NUMBER QUALIFIERRWImp Guide: Required if Help Desk Phone Number (55?-8F) is used.Payer Requirement: Same As Imp Guide 55?-8FHELP DESK PHONE NUMBERRWImp Guide: Required if needed to provide a support telephone number to the receiver.Payer Requirement: Same As Imp Guide987-MAURLRWImp Guide: Provided for informational purposes only to relay health care communications via the Internet.Payer Requirement: Same As Imp GuideResponse Claim Segment QuestionsCheckClaim Billing/Claim Re-bill Accepted/Rejected If Situational, Payer SituationThis Segment is always sentX Response Claim SegmentSegment Identification (111-AM) = “22”Claim Billing/Claim Re-bill Accepted/RejectedField #NCPDP Field NameValuePayer UsagePayer Situation455-EMPRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER1 = Rx BillingMImp Guide: For Transaction Code of “B1”, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is “1” (Rx Billing).4?2-D2PRESCRIPTION/SERVICE REFERENCE NUMBERMResponse DUR/PPS Segment QuestionsCheckClaim Billing/Claim Re-bill Accepted/Rejected If Situational, Payer SituationThis Segment is always sent This Segment is situationalXResponse DUR/PPS SegmentSegment Identification (111-AM) = “24”Claim Billing/Claim Re-bill Accepted/RejectedField #NCPDP Field NameValuePayer UsagePayer Situation567-J6DUR/PPS RESPONSE CODE COUNTER Maximum 9 occurrences supported.RWImp Guide: Required if Reason For Service Code (439-E4) is used.Payer Requirement: Same As Imp Guide439-E4REASON FOR SERVICE CODERWImp Guide: Required if utilization conflict is detected.Payer Requirement: Same As Imp Guide528-FSCLINICAL SIGNIFICANCE CODERWImp Guide: Required if needed to supply additional information for the utilization conflict.Payer Requirement: Same As Imp Guide529-FTOTHER PHARMACY INDICATORRWImp Guide: Required if needed to supply additional information for the utilization conflict.Payer Requirement: Same As Imp Guide53?-FUPREVIOUS DATE OF FILLRWImp Guide: Required if needed to supply additional information for the utilization conflict.Required if Quantity of Previous Fill (531-FV) is used.Payer Requirement: Same As Imp Guide531-FVQUANTITY OF PREVIOUS FILLRWImp Guide: Required if needed to supply additional information for the utilization conflict.Required if Previous Date Of Fill (53?-FU) is used.Payer Requirement: Same As Imp Guide532-FWDATABASE INDICATORRWImp Guide: Required if needed to supply additional information for the utilization conflict.Payer Requirement: Same As Imp Guide533-FXOTHER PRESCRIBER INDICATORRWImp Guide: Required if needed to supply additional information for the utilization conflict.Payer Requirement: Same As Imp Guide544-FYDUR FREE TEXT MESSAGERWImp Guide: Required if needed to supply additional information for the utilization conflict.Payer Requirement: Same As Imp Guide57?-NSDUR ADDITIONAL TEXTRWImp Guide: Required if needed to supply additional information for the utilization conflict.Payer Requirement: Same As Imp GuideClaim Billing/Claim Re-bill Rejected/Rejected ResponseResponse Transaction Header Segment QuestionsCheckClaim Billing/Claim Re-bill Rejected/Rejected If Situational, Payer SituationThis Segment is always sentX Response Transaction Header SegmentClaim Billing/Claim Re-bill Rejected/RejectedField #NCPDP Field NameValuePayer UsagePayer Situation1?2-A2Version/Release NumberD?M1?3-A3Transaction CodeB1, B3M1?9-A9Transaction CountSame value as in requestM5?1-F1Header Response StatusR = RejectedM2?2-B2Service Provider ID QualifierSame value as in requestM2?1-B1Service Provider ID Same value as in request M4?1-D1Date of ServiceSame value as in requestMResponse Message Segment QuestionsCheckClaim Billing/Claim Re-bill Rejected/Rejected If Situational, Payer SituationThis Segment is always sent This Segment is situationalXProvide general information when used for transmission level messaging.Response Message SegmentSegment Identification (111-AM) = “2?”Claim Billing/Claim Re-bill Rejected/RejectedField #NCPDP Field NameValuePayer UsagePayer Situation5?4-F4MESSAGERWImp Guide: Required if text is needed for clarification or detail. Payer Requirement : Same As Imp GuideResponse Status Segment QuestionsCheckClaim Billing/Claim Re-bill Rejected/Rejected If Situational, Payer SituationThis Segment is always sentX Response Status SegmentSegment Identification (111-AM) = “21”Claim Billing/Claim Re-bill Rejected/RejectedField #NCPDP Field NameValuePayer UsagePayer Situation112-ANTRANSACTION RESPONSE STATUSR = RejectM5?3-F3AUTHORIZATION NUMBERRImp Guide: Required if needed to identify the transaction.51?-FAREJECT COUNTMaximum count of 5.R511-FBREJECT CODER546-4FREJECT FIELD OCCURRENCE INDICATORRWImp Guide: Required if a repeating field is in error, to identify repeating field occurrence.Payer Requirement : Same As Imp Guide13?-UFADDITIONAL MESSAGE INFORMATION COUNTMaximum count of 25.RWImp Guide: Required if Additional Message Information (526-FQ) is used.Payer Requirement: Same As Imp Guide132-UHADDITIONAL MESSAGE INFORMATION QUALIFIERRWImp Guide: Required if Additional Message Information (526-FQ) is used.Payer Requirement: Same As Imp Guide526-FQADDITIONAL MESSAGE INFORMATIONRWImp Guide: Required when additional text is needed for clarification or detail.Payer Requirement: Same As Imp Guide131-UGADDITIONAL MESSAGE INFORMATION CONTINUITYRWImp Guide: Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.Payer Requirement: Same As Imp Guide549-7FHELP DESK PHONE NUMBER QUALIFIERRWImp Guide: Required if Help Desk Phone Number (55?-8F) is used.Payer Requirement: Same As Imp Guide55?-8FHELP DESK PHONE NUMBERRWImp Guide: Required if needed to provide a support telephone number to the receiver.Payer Requirement: Same As Imp Guide** End of Response Claim Billing/Claim Re-bill (B1/B3) Payer Sheet ** ................
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