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Neighborhood Health Plan (NHP) Standard Consolidated Payer Updated – 2/22/12 Bin #: Destination: Accepting: Format: Effective: ECL:
610593 SXC Health Solutions / RxClaim Claim Adjudication, Reversals NCPDP Version D.0 1/1/2012 NCPDP External Code List Version Date: October 2009
BILLING (B1), REVERSAL (B2), and REBILLING (B3) TRANSACTION DATA ELEMENTS FIELD LEGEND FOR COLUMNS Value Explanation
Payer Usage Column MANDATORY
M
The Field is mandatory for the Segment in the designated Transaction.
REQUIRED
R
QUALIFIED REQUIREMENT
RW
The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. “Required when”. The situations designated have qualifications for usage ("Required if x", "Not required if y").
Payer Situation Column No No
Yes
Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. not used) are excluded from the template. PRIMARY CLAIM SUBMISSIONS.
Other Coverage Codes (OCC) 00 and 01 are accepted for Primary Claims Submissions COORDINATION OF BENEFIT CLAIM SUBMISSIONS.
OCC 02 and 04 are accepted with primary claim response and proper COB field information. OCC 03 is accepted when appropriate Other Payer Reject Codes are submitted. OCC 05, 06, 07 and 08 are not accepted and will reject. ELIGIBILITY VERIFICATION (E1) TRANSACTION DATA ELEMENTS
This client does NOT SUPPORT eligibility verification transactions. PRIOR AUTHORIZATION (P1, P2, P3) TRANSACTION DATA ELEMENTS
This client does NOT SUPPORT prior authorization transactions. The use of the Prior Authorization Segment is NOT SUPPORTED. INFORMATION (N1, N2, N3) TRANSACTION DATA ELEMENTS
This client does NOT SUPPORT informational transactions. CONTROLLED SUBSTANCE REPORTING (C1, C2, C3) TRANSACTION DATA ELEMENTS
-
This client does NOT SUPPORT controlled substance reporting transactions
PARTIAL FILL TRANSACTION REPORTING USE OF PARTIAL FILE DATA ELEMENTS is NOT SUPPORTED Reverse original partial claim and resubmit with final dispensed quantity. COUPON REPORTING USE OF THE COUPON SEGMENT DATA ELEMENTS is NOT FULLY SUPPORTED MULTIPLE-INGREDIENT COMPOUND CLAIMS SUBMISSION The COMPOUND SEGMENT for multi-ingredient compound claims is supported Single-ingredient compound claims are no longer accepted by this client. Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP”
CLAIM BILLING/CLAIM REBILL TRANSACTION Transaction Header Segment
Check
This Segment is always sent
Field #
X
Transaction Header Segment NCPDP Field Name
Claim Billing/Claim Rebill Required for B1, B2 & B3 Transactions.
Value
1Ø1-A1 1Ø2-A2 1Ø3-A3 1Ø4-A4
BIN NUMBER VERSION/RELEASE NUMBER TRANSACTION CODE PROCESSOR CONTROL NUMBER
610593 DØ B1,B2, B3 SXC
Payer Usage M M M M
1Ø9-A9 2Ø2-B2
TRANSACTION COUNT SERVICE PROVIDER ID QUALIFIER
Up to 4 allowed Use 01 - NPI ID
M M
2Ø1-B1 4Ø1-D1 11Ø-AK
SERVICE PROVIDER ID DATE OF SERVICE SOFTWARE VENDOR/CERTIFICATION ID
NPI ID CCYYMMDD Use value for Switch’s requirements.
M M M
Insurance Segment
Check
This Segment is situational
Field #
X
Insurance Segment Segment Identification (111-AM) = “Ø4” NCPDP Field Name
3Ø2-C2 312-CC 313-CD 314-CE 524-FO 3Ø9-C9
CARDHOLDER ID CARDHOLDER FIRST NAME CARDHOLDER LAST NAME HOME PLAN PLAN ID ELIGIBILITY CLARIFICATION CODE
3Ø1-C1 3Ø3-C3 3Ø6-C6
GROUP ID PERSON CODE PATIENT RELATIONSHIP CODE
Field 331-CX 332-CY 3Ø4-C4 3Ø5-C5
Value
X
Patient Segment Segment Identification (111-AM) = “Ø1” NCPDP Field Name PATIENT ID QUALIFIER PATIENT ID DATE OF BIRTH PATIENT GENDER CODE
Required for B1 & B3 Transactions. Not required for B2 Claim Billing/Claim Rebill
Check
This Segment is always sent
SXC – Production SXCTEST - Test
Claim Billing/Claim Rebill
Payer Usage M RW RW RW RW RW M RW RW
Patient Segment
Claim Billing/Claim Rebill Payer Situation
Value
Payer Situation Payer Requirement: Required from ID Card Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: As needed to override reject Payer Requirement: Required from ID Card Payer Requirement: Required from ID Card Payer Requirement: Complete if present
Claim Billing/Claim Rebill Required for B1, B2 & B3 Transactions. Segment required to Locate patient Claim Billing/Claim Rebill Payer Usage R R R R
Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP”
Payer Situation Payer Requirement: Required Payer Requirement: Required Payer Requirement: Required Payer Requirement: Required
31Ø-CA 311-CB 322-CM 323-CN 324-CO 325-CP 326-CQ 333-CZ 335-2C 384-4X
PATIENT FIRST NAME PATIENT LAST NAME PATIENT STREET ADDRESS PATIENT CITY ADDRESS PATIENT STATE / PROVINCE ADDRESS PATIENT ZIP/POSTAL ZONE PATIENT PHONE NUMBER EMPLOYER ID PREGNANCY INDICATOR PATIENT RESIDENCE
Claim Segment
Check
This Segment is always sent This payer does not support partial fills
Field # 455-EM
R R RW RW RW RW RW RW RW RW
X
Claim Segment Segment Identification (111-AM) = “Ø7” NCPDP Field Name
Claim Billing/Claim Rebill If Situational, Payer Situation Required for B1 B2 & B3 Transactions.
Claim Billing/Claim Rebill Value
Payer Usage M
01
436-E1
PRODUCT/SERVICE ID QUALIFIER
03
4Ø7-D7 456-EN
458-SE
PRODUCT/SERVICE ID ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER ASSOCIATED PRESCRIPTION/SERVICE DATE PROCEDURE MODIFIER CODE COUNT
459-ER
PROCEDURE MODIFIER CODE
RW
442-E7
QUANTITY DISPENSED
RW
4Ø3-D3
FILL NUMBER
RW
4Ø5-D5
DAYS SUPPLY
RW
4Ø6-D6
COMPOUND CODE
RW
4Ø8-D8
DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE DATE PRESCRIPTION WRITTEN
RW
415-DF 419-DJ 354-NX
NUMBER OF REFILLS AUTHORIZED PRESCRIPTION ORIGIN CODE SUBMISSION CLARIFICATION CODE COUNT
RW R RW
42Ø-DK
SUBMISSION CLARIFICATION CODE
3Ø8-C8
OTHER COVERAGE CODE
429-DT 453-EJ
SPECIAL PACKAGING INDICATOR ORIGINALLY PRESCRIBED PRODUCT/SERVICE ID QUALIFIER
457-EP
414-DE
Maximum count of 1Ø.
RW
Payer Requirement: Complete if present
RW
Payer Requirement: Complete only if 459-ER PROCEDURE MODIFIER CODE is completed Payer Requirement: Complete ONLY is instructed by Help Desk Payer Requirement: Required for B1 & B3 claims Payer Requirement: Required for B1 & B3 claims Payer Requirement: Required for B1 & B3 claims Payer Requirement: Required for B1 & B3 claims Use “1” if product not a compound “2” if product is a compound Payer Requirement: Required for B1 & B3 claims Payer Requirement: Required for B1 & B3 claims Payer Requirement: Complete if present Payer Requirement: Required Payer Requirement: Complete only if 42Ø-DK SUBMISSION CLARIFICATION CODE is completed Payer Requirement: As needed to override reject Payer Requirement: Required if COB Segment Used Payer Requirement: Complete if present Payer Requirement: Complete if present Partial Fills not supported
RW
Maximum count of 3.
Payer Situation
Payer Requirement: Only value of “01” is accepted M Payer Requirement: Supports 12-digit RxNum Rx Number Example: 000001234567 (leading zeros) M Payer Requirement: Only value of 03 accepted M RW Payer Requirement: Complete if present
PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUMBER
4Ø2-D2
Payer Requirement: Required Payer Requirement: Required Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present
RW R RW RW
Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP”
Field # 445-EA 446-EB 454-EK 6ØØ-28 418-DI 461-EU 462-EV
Claim Segment Segment Identification (111-AM) = “Ø7” NCPDP Field Name
Claim Billing/Claim Rebill Value
ORIGINALLY PRESCRIBED PRODUCT/SERVICE CODE ORIGINALLY PRESCRIBED QUANTITY
Payer Usage RW
Payer Situation
RW
Payer Requirement: Complete if present. Partial Fills not supported Payer Requirement: Complete if present Partial Fills not supported Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: As needed or instructed by Help Desk Payer Requirement: Complete if present
RW
464-EX
SCHEDULED PRESCRIPTION ID NUMBER UNIT OF MEASURE LEVEL OF SERVICE PRIOR AUTHORIZATION TYPE CODE PRIOR AUTHORIZATION NUMBER SUBMITTED INTERMEDIARY AUTHORIZATION TYPE ID INTERMEDIARY AUTHORIZATION ID
RW
Payer Requirement: Complete if present
343-HD
DISPENSING STATUS
RW
Payer Requirement: Partial Fills not supported
344-HF
QUANTITY INTENDED TO BE DISPENSED
RW
Payer Requirement: Partial Fills not supported
345-HG
DAYS SUPPLY INTENDED TO BE DISPENSED ROUTE OF ADMINISTRATION
RW
Payer Requirement: Partial Fills not supported
RW
Payer Requirement: Required If 406-D6 Compound Code is a “2”
463-EW
995-E2
Pricing Segment
RW RW RW RW
Check
This Segment is always sent
Field #
X
Pricing Segment Segment Identification (111-AM) = “11” NCPDP Field Name
Claim Billing/Claim Rebill Required for B1 & B3 Transactions. Not required for B2 Claim Billing/Claim Rebill
Value
Payer Usage R R RW
4Ø9-D9 412-DC 433-DX
INGREDIENT COST SUBMITTED DISPENSING FEE SUBMITTED PATIENT PAID AMOUNT SUBMITTED
438-E3 481-HA
INCENTIVE AMOUNT SUBMITTED FLAT SALES TAX AMOUNT SUBMITTED
RW RW
482-GE
PERCENTAGE SALES TAX AMOUNT SUBMITTED PERCENTAGE SALES TAX RATE SUBMITTED
RW
484-JE
PERCENTAGE SALES TAX BASIS SUBMITTED
RW
426-DQ 43Ø-DU 423-DN
USUAL AND CUSTOMARY CHARGE GROSS AMOUNT DUE BASIS OF COST DETERMINATION
R R RW
483-HE
RW
Payer Situation
Payer Requirement: Submit only if Actual payment to pharmacy before submission Should use fields 351-NP and 352-NQ for Patient responsibility Payer Requirement: Complete if present Payer Requirement: Required in applicable locations Payer Requirement: Required in applicable locations Payer Requirement: Required if 482-GE PERCENTAGE SALES TAX AMOUNT SUBMITTED is submitted. Payer Requirement: Required if 482-GE PERCENTAGE SALES TAX AMOUNT SUBMITTED and Percentage Sales Tax Rate Submitted (483-HE) are submitted Payer Requirement: Required Payer Requirement: Required Payer Requirement: Complete if present
Pharmacy Provider Segment
Check
Claim Billing/Claim Rebill
This Segment is situational – Not required
X
Required for B1 & B3 Transactions. Not required for B2
Pharmacy Provider Segment Segment Identification (111-AM) = “Ø2” Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP”
Claim Billing/Claim Rebill
Field #
NCPDP Field Name
Value
465-EY
PROVIDER ID QUALIFIER
Payer Usage RW
444-E9
PROVIDER ID
RW
Prescriber Segment
Check
466-EZ 411-DB 427-DR 498-PM 468-2E 421-DL 47Ø-4E
Prescriber Segment Segment Identification (111-AM) = “Ø3” NCPDP Field Name
337-4C
Claim Billing/Claim Rebill
Claim Billing/Claim Rebill Value
PRESCRIBER ID QUALIFIER PRESCRIBER ID PRESCRIBER LAST NAME PRESCRIBER PHONE NUMBER PRIMARY CARE PROVIDER ID QUALIFIER PRIMARY CARE PROVIDER ID PRIMARY CARE PROVIDER LAST NAME
01
Coordination of Benefits/Other Payments Segment This Segment is situational
Field #
Payer Requirement: Required if Provider ID (444-E9) is Submitted. Payer Requirement: Complete if present and segment is used
Required for B1 & B3 Transactions. Not required for B2
This Segment is situational
Field #
Payer Situation
Coordination of Benefits/Other Payments Segment Segment Identification (111-AM) = “Ø5” NCPDP Field Name
Payer Usage M M RW RW RW RW RW
Payer Situation Payer Requirement: Required.- Use only 01 Payer Requirement: NPI ID Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present
Required only If other payer was primary, secondary or Tertiary Required for B1 B2 & B3 Transactions. Claim Billing/Claim Rebill
Value Maximum count of 3.
Payer Usage M
Payer Situation
338-5C
COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT OTHER PAYER COVERAGE TYPE
339-6C 34Ø-7C
OTHER PAYER ID QUALIFIER OTHER PAYER ID
RW RW
443-E8
OTHER PAYER DATE
RW
Payer Requirement: Date of Service of other payer claim
341-HB
OTHER PAYER AMOUNT PAID COUNT
RW
Payer Requirement: If Other Coverage Code is 2 or 4; # of claims paid
342-HC
OTHER PAYER AMOUNT PAID QUALIFIER
RW
431-DV
OTHER PAYER AMOUNT PAID
RW
471-5E
OTHER PAYER REJECT COUNT
472-6E
OTHER PAYER REJECT CODE
353-NR
OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT
Payer Requirement: Required if Other Coverage Code is 2 or 4; Payer Requirement: Required if Other Coverage Code is 2 or 4; COB Amount- Do Not leave this field Blank Payer Requirement: Required if Other Coverage Code is 3. # of claims rejected by other payer Payer Requirement: Required if Other Coverage Code is 3. NCPDP Reject Code received from other payer Payer Requirement: Required if Other Payer Responsibility Amount Qualifier is used Maximum 25
M
Maximum count of 9.
Maximum count of 5.
RW
RW
Maximum count of 25.
RW
Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP”
01 if other payer was Primary, 02 if other payer was Secondary, 03 if other payer was Tertiary Payer Requirement: Use 03 - BIN Payer Requirement: Other Payer BIN
Field #
Coordination of Benefits/Other Payments Segment Segment Identification (111-AM) = “Ø5” NCPDP Field Name
351-NP
OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER
352-NQ
OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT
Claim Billing/Claim Rebill
Value
Payer Usage RW
RW
DUR/PPS Segment
Check
Payer Situation Payer Requirement: Required if Other Payer Responsibility Amount is used Use Blank, 01…13 accepted. Payer Requirement: Required if Other Coverage Code is 2,4; Do not leave this field Blank
Claim Billing/Claim Rebill
This Segment is situational
Field #
DUR/PPS Segment Segment Identification (111-AM) = “Ø8” NCPDP Field Name
Claim Billing/Claim Rebill Value Maximum of 9 occurrences.
Payer Usage RW
473-7E
DUR/PPS CODE COUNTER
439-E4
REASON FOR SERVICE CODE
RW
44Ø-E5
PROFESSIONAL SERVICE CODE
RW
441-E6
RESULT OF SERVICE CODE
RW
474-8E 475-J9 476-H6
DUR/PPS LEVEL OF EFFORT DUR CO-AGENT ID QUALIFIER DUR CO-AGENT ID
RW RW RW
Compound Segment
Check
This Segment is situational
Field # 45Ø-EF 451-EG 447-EC 488-RE 489-TE 448-ED 449-EE 49Ø-UE
Compound Segment Segment Identification (111-AM) = “1Ø” NCPDP Field Name COMPOUND DOSAGE FORM DESCRIPTION CODE COMPOUND DISPENSING UNIT FORM INDICATOR COMPOUND INGREDIENT COMPONENT COUNT COMPOUND PRODUCT ID QUALIFIER COMPOUND PRODUCT ID COMPOUND INGREDIENT QUANTITY
Claim Billing/Claim Rebill If Situational, Payer Situation Compound code is 02 Required for B1 & B3 Transactions. Not required for B2
Value
Payer Usage M
Payer Situation
M Maximum 25 ingredients
M M M M RW RW
Check
This Segment is situational
Payer Requirement: Required if segment used. Up to 9 occurrences are supported. Payer Requirement: Required if segment used. DD, ID, and TD accepted. Payer Requirement: Required if segment used. MR, MO, and RO accepted. Payer Requirement: Required if segment used. 1B, 1C, 1D, and 3E accepted. Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present
Claim Billing/Claim Rebill
COMPOUND INGREDIENT DRUG COST COMPOUND INGREDIENT BASIS OF COST DETERMINATION
Clinical Segment
Payer Situation
Payer Requirement: 03 Required Payer Requirement: NDC of each ingredient Payer Requirement: Quantity of each ingredient Payer Requirement: Complete if present Payer Requirement: Complete if present
Claim Billing/Claim Rebill If Situational, Payer Situation Submitted Only for B1 or B3 Transactions if required for specific claim.
Clinical Segment Segment Identification (111-AM) = “13” Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP”
Claim Billing/Claim Rebill
Field #
NCPDP Field Name
Value Maximum count of 5.
Payer Usage RW RW RW RW
Payer Situation Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present
491-VE 492-WE 424-DO 493-XE
DIAGNOSIS CODE COUNT DIAGNOSIS CODE QUALIFIER DIAGNOSIS CODE CLINICAL INFORMATION COUNTER
494-ZE
MEASUREMENT DATE
RW
Payer Requirement: Complete if present
495-H1 496-H2 497-H3 499-H4
MEASUREMENT TIME MEASUREMENT DIMENSION MEASUREMENT UNIT MEASUREMENT VALUE
RW RW RW RW
Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present Payer Requirement: Complete if present
Maximum 5 occurrences supported.
GENERAL INFORMATION Live Date:
06/15/2008 (Payer Sheet revisions 09/126/11)
Maximum prescriptions per transaction:
4
Plan specific information, customer service:
(800)-462-5449 NHP Member Services Unit
Technical assistance, pharmacy help desk:
(800) 918-7545 SXC Health Solutions, Inc.
Vendor certification required:
Yes
Pharmacy Registration with Payer Required:
No
Switch Support:
NDC Health Emdeon/WebMD eRx
Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP”
