New Plan Notification
Pet Genius The purpose of this document is to alert you to the use of BIN # 015673 by Medical Security Card Company / ScriptSave in partnership with Pet Genius.
Notification is for BIN #015673 and PCN: SS This business is being created for Pet Genius and will be NATIONAL in scope This BIN will be active immediately therefore timely consideration is appreciated Sample Card below
If you have any questions please contact Medical Security Card Company / ScriptSave Pharmacy Help Desk: 1-800-404-1031
Pet Genius NCPDP vD.Ø Payer Sheet Claim Reversal GENERAL INFORMATION Payer Name: Medical Security Card Company Plan Name/Group Name: Pet Genius Plan Name/Group Name: Plan Name/Group Name: Processor: Emdeon Effective as of: Ø7/Ø9/2Ø12
Date: Ø7/Ø1/2Ø12 BIN: Ø15673 BIN: BIN:
PCN: SS PCN: PCN:
NCPDP Telecommunication Standard Version/Release #: D.Ø
NCPDP Data Dictionary Version Date: 9/2Ø1Ø NCPDP External Code List Version Date: 9/2Ø1Ø Contact/Information Source: ScriptSave Provider Contracting:
[email protected] Provider Relations Help Desk Info: ScriptSave Pharmacist Assistance: 8ØØ-4Ø4-1Ø31 Other versions supported: 5.1 Telecommunication Standard Supported until 12/31/2Ø11. Refer to the 5.1 payer sheet.
FIELD LEGEND FOR COLUMNS Payer Situation Column
Payer Usage Column
Value
Explanation
MANDATORY
M
The Field is mandatory for the Segment in the designated Transaction.
No
REQUIRED
R
The Field has been designated with the situation of “Required” for the Segment in the designated Transaction.
No
QUALIFIED REQUIREMENT
RW
“Required when”. The situations designated have qualifications for usage (“Required if x”, “Not required if y”).
Yes
NOT USED
NA
The Field is not used for the Segment in the designated Transaction.
No
Question
Answer
What is your reversal window? (If transaction is billed today what is the timeframe for reversal to be submitted?)
3Ø days from DOS
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 1
Pet Genius NCPDP vD.Ø Payer Sheet Claim Reversal CLAIM REVERSAL TRANSACTION The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø.
Transaction Header Segment Questions
Transaction Header Segment NCPDP Field Name
1Ø1-A1
BIN NUMBER
1Ø2-A2 1Ø3-A3 1Ø4-A4
VERSION/RELEASE NUMBER TRANSACTION CODE PROCESSOR CONTROL NUMBER
1Ø9-A9 2Ø2-B2 2Ø1-B1 4Ø1-D1 11Ø-AK
TRANSACTION COUNT SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE SOFTWARE VENDOR/CERTIFICATION ID
Value refer to values listed in BIN field in General Info DØ B2 refer to values listed in PCN field in General Info 1-4 Ø1 - NPI NPI All Spaces
Claim Segment Questions
Check
This Segment is always sent
X
Field #
Claim Segment Segment Identification (111-AM) = “Ø7” NCPDP Field Name
455-EM
PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER
4Ø2-D2
PRESCRIPTION/SERVICE REFERENCE NUMBER PRODUCT/SERVICE ID QUALIFIER PRODUCT/SERVICE ID FILL NUMBER
436-E1 4Ø7-D7 4Ø3-D3
Claim Reversal If Situational, Payer Situation
X
This Segment is always sent
Field #
Check
Payer Usage M
Claim Reversal Payer Situation
M M M M M M M M
Claim Reversal If Situational, Payer Situation
Claim Reversal
Value 1 = Rx Billing
Payer Usage M
Payer Situation Imp Guide: For Transaction Code of “B2”, in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is “1” (Rx Billing).
M Ø3 - NDC 11 digit NDC New = ØØ (zeros must be sent)
M M R
Imp Guide: Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (4Ø2-D2) occur on the same day
** End of Request Claim Reversal (B2) Payer Sheet Template**
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 2
Pet Genius NCPDP vD.Ø Payer Sheet Claim Reversal Response GENERAL INFORMATION Payer Name: Medical Security Card Company Plan Name/Group Name: Pet Genius Plan Name/Group Name: Plan Name/Group Name:
Date: Ø7/Ø1/2Ø12 BIN: Ø15673 BIN: BIN:
PCN: SS PCN: PCN:
CLAIM REVERSAL ACCEPTED/APPROVED RESPONSE The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Response Transaction Header Segment Questions This Segment is always sent
Field # 1Ø2-A2 1Ø3-A3 1Ø9-A9 5Ø1-F1 2Ø2-B2 2Ø1-B1 4Ø1-D1
Response Transaction Segment NCPDP Field Name
Check X
Value
VERSION/RELEASE NUMBER TRANSACTION CODE TRANSACTION COUNT HEADER RESPONSE STATUS SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE
This Segment is always sent This Segment is situational
5Ø4-F4
Claim Reversal – Accepted/Approved
Header
Response Message Segment Questions
Field #
Claim Reversal – Accepted/Approved If Situational, Payer Situation
DØ B2 Same value as in request A = Accepted Same value as in request Same value as in request Same value as in request Check
X
Response Message Segment Segment Identification (111-AM) = “2Ø” NCPDP Field Name
Payer Usage M M M M M M M
Payer Situation
Claim Reversal – Accepted/Approved If Situational, Payer Situation Provide general information when used for transmission-level messaging. Claim Reversal – Accepted/Approved
Value
Payer Usage RW
MESSAGE
Payer Situation Imp Guide: Required if text is needed for clarification or detail. Payer Requirement: Same As Imp Guide
Response Status Segment Questions
Check X
This Segment is always sent
Field # 112-AN 5Ø3-F3
Claim Reversal – Accepted/Approved If Situational, Payer Situation
Response Status Segment Segment Identification (111-AM) = “21” NCPDP Field Name TRANSACTION RESPONSE STATUS AUTHORIZATION NUMBER
Claim Reversal – Accepted/Approved
Value A = Approved
Payer Usage M R
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 3
Payer Situation
Imp Guide: Required if needed to identify the transaction.
Pet Genius NCPDP vD.Ø Payer Sheet Claim Reversal Response Response Claim Segment Questions This Segment is always sent
Field #
Claim Reversal – Accepted/Approved If Situational, Payer Situation
Check X
Response Claim Segment Segment Identification (111-AM) = “22” NCPDP Field Name
455-EM
PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER
4Ø2-D2
PRESCRIPTION/SERVICE REFERENCE NUMBER
Claim Reversal – Accepted/Approved
Value
Payer Usage M
1 = Rx Billing
Payer Situation Imp Guide: For Transaction Code of “B2”, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is “1” (Rx Billing).
M
CLAIM REVERSAL ACCEPTED/REJECTED RESPONSE Response Transaction Header Segment Questions This Segment is always sent
Field # 1Ø2-A2 1Ø3-A3 1Ø9-A9 5Ø1-F1 2Ø2-B2 2Ø1-B1 4Ø1-D1
Response Transaction Segment NCPDP Field Name
Check X
Value
VERSION/RELEASE NUMBER TRANSACTION CODE TRANSACTION COUNT HEADER RESPONSE STATUS SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE
This Segment is always sent This Segment is situational
5Ø4-F4
Claim Reversal – Accepted/Rejected
Header
Response Message Segment Questions
Field #
Claim Reversal - Accepted/Rejected If Situational, Payer Situation
DØ B2 Same value as in request A = Accepted Same value as in request Same value as in request Same value as in request Check
Payer Usage M M M M M M M
Payer Situation
Claim Reversal - Accepted/Rejected If Situational, Payer Situation
X
Response Message Segment Segment Identification (111-AM) = “2Ø” NCPDP Field Name
Claim Reversal – Accepted/Rejected
Value
Payer Usage RW
MESSAGE
Payer Situation Imp Guide: Required if text is needed for clarification or detail. Payer Requirement: Same As Imp Guide
Response Status Segment Questions
Check
This Segment is always sent
Claim Reversal - Accepted/Rejected If Situational, Payer Situation
X Claim Reversal – Accepted/Rejected
Response Status Segment Segment Identification (111-AM) = “21” “Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 4
Pet Genius NCPDP vD.Ø Payer Sheet Claim Reversal Response Field #
NCPDP Field Name
Value
112-AN 5Ø3-F3 51Ø-FA 511-FB 546-4F
TRANSACTION RESPONSE STATUS AUTHORIZATION NUMBER REJECT COUNT REJECT CODE REJECT FIELD OCCURRENCE INDICATOR
R = Reject
13Ø-UF
ADDITIONAL MESSAGE INFORMATION COUNT
Maximum count of 25.
132-UH
Maximum count of 5.
Payer Usage M R R R RW
Payer Situation
Imp Guide: Required if a repeating field is in error, to identify repeating field occurrence.
RW
Payer Requirement: Same As Imp Guide Imp Guide: Required if Additional Message Information (526-FQ) is used.
ADDITIONAL MESSAGE INFORMATION QUALIFIER
RW
Payer Requirement: Same As Imp Guide Imp Guide: Required if Additional Message Information (526-FQ) is used.
526-FQ
ADDITIONAL MESSAGE INFORMATION
RW
Payer Requirement: Same As Imp Guide Imp Guide: Required when additional text is needed for clarification or detail.
131-UG
ADDITIONAL MESSAGE INFORMATION CONTINUITY
RW
549-7F
HELP DESK PHONE NUMBER QUALIFIER
RW
55Ø-8F
HELP DESK PHONE NUMBER
RW
Payer Requirement: Same As Imp Guide Imp 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 Guide Imp Guide: Required if Help Desk Phone Number (55Ø-8F) is used. Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Same As Imp Guide
Response Claim Segment Questions
Check
This Segment is always sent
Field #
Claim Reversal - Accepted/Rejected If Situational, Payer Situation
X
Response Claim Segment Segment Identification (111-AM) = “22” NCPDP Field Name
455-EM
PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER
4Ø2-D2
PRESCRIPTION/SERVICE REFERENCE NUMBER
Claim Reversal – Accepted/Rejected
Value 1 = RxBilling
Payer Usage M
M
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 5
Payer Situation Imp Guide: For Transaction Code of “B2”, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is “1” (Rx Billing).
Pet Genius NCPDP vD.Ø Payer Sheet Claim Reversal Response CLAIM REVERSAL REJECTED/REJECTED RESPONSE Response Transaction Header Segment Questions This Segment is always sent
Field # 1Ø2-A2 1Ø3-A3 1Ø9-A9 5Ø1-F1 2Ø2-B2 2Ø1-B1 4Ø1-D1
X Claim Reversal – Rejected/Rejected Value
VERSION/RELEASE NUMBER TRANSACTION CODE TRANSACTION COUNT HEADER RESPONSE STATUS SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE
DØ B2 Same value as in request A = Accepted Same value as in request Same value as in request Same value as in request
This Segment is always sent This Segment is situational
5Ø4-F4
Claim Reversal - Rejected/Rejected If Situational, Payer Situation
Response Transaction Header Segment NCPDP Field Name
Response Message Segment Questions
Field #
Check
Check
Payer Usage M M M M M M M
Payer Situation
Claim Reversal – Rejected/Rejected If Situational, Payer Situation
X
Response Message Segment Segment Identification (111-AM) = “2Ø” NCPDP Field Name
Claim Reversal – Rejected/Rejected
Value
Payer Usage RW
MESSAGE
Payer Situation Imp Guide: Required if text is needed for clarification or detail. Payer Requirement: Same As Imp Guide
Response Status Segment Questions
Check
This Segment is always sent
Field # 112-AN 5Ø3-F3 51Ø-FA 511-FB 546-4F
13Ø-UF
X
Response Status Segment Segment Identification (111-AM) = “21” NCPDP Field Name TRANSACTION RESPONSE STATUS AUTHORIZATION NUMBER REJECT COUNT REJECT CODE REJECT FIELD OCCURRENCE INDICATOR
ADDITIONAL MESSAGE INFORMATION COUNT
Claim Reversal - Rejected/Rejected If Situational, Payer Situation
Claim Reversal – Rejected/Rejected
Value R = Reject Maximum count of 5.
Maximum count of 25.
Payer Usage M R R R RW
RW
Payer Situation
Imp Guide: Required if a repeating field is in error, to identify repeating field occurrence. Payer Requirement: Same As Imp Guide Imp Guide: Required if Additional Message Information (526-FQ) is used. Payer Requirement: Same As Imp Guide
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 6
Pet Genius NCPDP vD.Ø Payer Sheet Claim Reversal Response
Field #
Response Status Segment Segment Identification (111-AM) = “21” NCPDP Field Name
Claim Reversal – Rejected/Rejected
Value
Payer Usage RW
132-UH
ADDITIONAL MESSAGE INFORMATION QUALIFIER
526-FQ
ADDITIONAL MESSAGE INFORMATION
RW
131-UG
ADDITIONAL MESSAGE INFORMATION CONTINUITY
RW
549-7F
HELP DESK PHONE NUMBER QUALIFIER
RW
55Ø-8F
HELP DESK PHONE NUMBER
RW
Payer Situation Imp Guide: Required if Additional Message Information (526-FQ) is used. Payer Requirement: Same As Imp Guide Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Same As Imp Guide Imp 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 Guide Imp Guide: Required if Help Desk Phone Number (55Ø-8F) is used. Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Same As Imp Guide
** End of Claim Reversal (B2) Response Payer Sheet Template**
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 7
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill
GENERAL INFORMATION Payer Name: Medical Security Card Company Plan Name/Group Name: Pet Genius Plan Name/Group Name: Plan Name/Group Name: Processor: Emdeon Effective as of: Ø7/Ø9/2Ø12
Date: Ø7/Ø1/2Ø12 BIN: Ø15673 BIN: BIN:
PCN: SS PCN: PCN:
NCPDP Telecommunication Standard Version/Release #: D.Ø
NCPDP Data Dictionary Version Date: 9/2Ø1Ø NCPDP External Code List Version Date: 9/2Ø1Ø Contact/Information Source: ScriptSave Provider Contracting:
[email protected] Provider Relations Help Desk Info: ScriptSave Pharmacist Assistance: 8ØØ-4Ø4-1Ø31 Other versions supported: 5.1 Telecommunication Standard Supported until 12/31/2Ø11. Refer to the 5.1 payer sheet.
OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Transaction Code Transaction Name B1 Billing Transaction B2 Reversal Transaction B3 Rebill Transaction
FIELD LEGEND FOR COLUMNS Payer Usage Column
Value
Explanation
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 and/or Segments that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from this Payer Sheet.
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 1
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill CLAIM BILLING/CLAIM REBILL TRANSACTION The following lists the segments and fields in a Claim Billing or Claim Rebill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø.
Transaction Header Segment Questions
Transaction Header Segment NCPDP Field Name
1Ø1-A1
BIN NUMBER
1Ø2-A2 1Ø3-A3 1Ø4-A4
VERSION/RELEASE NUMBER TRANSACTION CODE PROCESSOR CONTROL NUMBER
1Ø9-A9 2Ø2-B2 2Ø1-B1 4Ø1-D1 11Ø-AK
TRANSACTION COUNT SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE SOFTWARE VENDOR/CERTIFICATION ID
Insurance Segment Questions
3Ø2-C2 3Ø1-C1
Value refer to values listed in BIN field in General Info DØ B1 OR B3 refer to values listed in PCN field in General Info 1-4 Ø1 – NPI NPI ALL SPACES
Check
Payer Usage M
Claim Billing/Claim Rebill Payer Situation
M M M M M M M M
Claim Billing/Claim Rebill If Situational, Payer Situation
X
This Segment is always sent
Field #
Claim Billing/Claim Rebill If Situational, Payer Situation
X
This Segment is always sent
Field #
Check
Insurance Segment Segment Identification (111-AM) = “Ø4” NCPDP Field Name
Claim Billing/Claim Rebill
Value
Payer Usage M R
CARDHOLDER ID GROUP ID
3Ø3-C3
PERSON CODE
R
3Ø6-C6
PATIENT RELATIONSHIP CODE
R
Payer Situation
Imp Guide: Required if necessary for state/federal/regulatory agency programs. Processor Requirement. Use Group Number as printed on ID Card. Imp Guide: Required if needed to uniquely identify the family members within the Cardholder ID. Payer Requirement : Same as Imp Guide Imp Guide: Required if needed to uniquely identify the relationship of the Patient to the Cardholder. Payer Requirement: Same as Imp Guide
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 2
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill Patient Segment Questions
Check X
This Segment is always sent This Segment is situational
Field
Patient Segment Segment Identification (111-AM) = “Ø1” NCPDP Field Name
3Ø4-C4 3Ø5-C5 31Ø-CA
DATE OF BIRTH PATIENT GENDER CODE PATIENT FIRST NAME
311-CB
PATIENT LAST NAME
Claim Billing/Claim Rebill
Value
Payer Usage R R R
Payer Situation
Imp Guide: Required when the patient has a first name.
R
Claim Segment Questions
Check
Claim Billing/Claim Rebill If Situational, Payer Situation
X
This Segment is always sent This payer supports partial fills This payer does not support partial fills
Field #
Claim Billing/Claim Rebill If Situational, Payer Situation
X
Claim Segment Segment Identification (111-AM) = “Ø7” NCPDP Field Name
Claim Billing/Claim Rebill
Value 1 = Rx Billing
Payer Usage M
455-EM
PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER
4Ø2-D2 436-E1 4Ø7-D7 442-E7
PRESCRIPTION/SERVICE REFERENCE NUMBER PRODUCT/SERVICE ID QUALIFIER PRODUCT/SERVICE ID QUANTITY DISPENSED
4Ø3-D3
FILL NUMBER
4Ø5-D5 4Ø6-D6
DAYS SUPPLY COMPOUND CODE
4Ø8-D8
R
414-DE 415-DF
DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE DATE PRESCRIPTION WRITTEN NUMBER OF REFILLS AUTHORIZED
419-DJ
PRESCRIPTION ORIGIN CODE
R
354-NX
SUBMISSION CLARIFICATION CODE COUNT
Payer Situation Imp Guide: For Transaction Code of “B1”, in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is “1” (Rx Billing).
M Ø3 - NDC 11 digit NDC Format 9(7)V999
M M R
New = ØØ (zeros must be sent) Refill = Ø1 - 99
R
1 = Not a Compound 2 = Compound
R R
R R
Maximum count of 3.
RW
Imp Guide: Required if necessary for plan benefit administration. Imp Guide: Required if necessary for plan benefit administration. Imp Guide: Required if Submission Clarification Code (42Ø-DK) is used. Payer Requirement: Same as Imp Guide
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 3
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill
Field # 42Ø-DK
Claim Segment Segment Identification (111-AM) = “Ø7” NCPDP Field Name SUBMISSION CLARIFICATION CODE
Claim Billing/Claim Rebill
Value Ø8 = Process Compound For Approved Ingredients
Payer Usage RW
Payer Situation Imp Guide: Required if clarification is needed and value submitted is greater than zero (Ø). If the Date of Service (4Ø1-D1) contains the subsequent payer coverage date, the Submission Clarification Code (42Ø-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.
3Ø8-C8
OTHER COVERAGE CODE
Ø8 = Billing for patient financial responsibility only
RW
Payer Requirement: Same as Imp Guide Imp 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.
461-EU
PRIOR AUTHORIZATION TYPE CODE 1 = Prior Authorization, if applicable
RW
462-EV
PRIOR AUTHORIZATION NUMBER SUBMITTED
RW
995-E2
ROUTE OF ADMINISTRATION
If applicable to Rx
RW
Payer Requirement: Same as Imp Guide Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility. Payer Requirement: Same as Imp Guide Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility. Payer Requirement: Same As Imp Guide Imp Guide: Required if specified in trading partner agreement. Payer Requirement: When compound code = 2
Pricing Segment Questions
Check
This Segment is always sent
Field #
Claim Billing/Claim Rebill If Situational, Payer Situation
X
Pricing Segment Segment Identification (111-AM) = “11” NCPDP Field Name
4Ø9-D9 412-DC
INGREDIENT COST SUBMITTED DISPENSING FEE SUBMITTED
481-HA
FLAT SALES TAX AMOUNT SUBMITTED
Claim Billing/Claim Rebill
Value
Payer Usage R R
RW
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 4
Payer Situation
Imp Guide: Required if its value has an effect on the Gross Amount Due (43ØDU) calculation. Imp Guide: Required if its value has an effect on the Gross Amount Due (43ØDU) calculation.
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill
Field #
Pricing Segment Segment Identification (111-AM) = “11” NCPDP Field Name
Claim Billing/Claim Rebill
Value
Payer Usage
482-GE
PERCENTAGE SALES TAX AMOUNT SUBMITTED
RW
483-HE
PERCENTAGE SALES TAX RATE SUBMITTED
RW
Payer Situation
Payer Requirement: Same as Imp Guide Imp Guide: Required if its value has an effect on the Gross Amount Due (43ØDU) calculation. Payer Requirement: Same as Imp Guide Imp 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 (559AX).
484-JE
PERCENTAGE SALES TAX BASIS SUBMITTED
RW
Payer Requirement: Same as Imp Guide Imp 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 (559AX).
426-DQ
USUAL AND CUSTOMARY CHARGE
R
43Ø-DU 423-DN
GROSS AMOUNT DUE BASIS OF COST DETERMINATION
R R
Prescriber Segment Questions
Check
Imp Guide: Required if needed for receiver claim/encounter adjudication.
Claim Billing/Claim Rebill If Situational, Payer Situation
X
This Segment is always sent This Segment is situational
Field #
Payer Requirement: Same as Imp. Guide Imp Guide: Required if needed per trading partner agreement.
Prescriber Segment Segment Identification (111-AM) = “Ø3” NCPDP Field Name
466-EZ
PRESCRIBER ID QUALIFIER
411-DB
PRESCRIBER ID
Claim Billing/Claim Rebill
Value
Payer Usage R
Ø1 – NPI 12 - DEA
R
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 5
Payer Situation Imp Guide: Required if Prescriber ID (411DB) is used. Imp Guide: Required if this field could result in different coverage or patient
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill
Field #
Prescriber Segment Segment Identification (111-AM) = “Ø3” NCPDP Field Name
Claim Billing/Claim Rebill
Value
Payer Usage
Payer Situation financial responsibility. Required if necessary for state/federal/regulatory agency programs.
DUR/PPS Segment Questions
Check
This Segment is always sent This Segment is situational
Claim Billing/Claim Re-bill If Situational, Payer Situation
X
DUR/PPS Segment Segment Identification (111-AM) = “Ø8” NCPDP Field Name
Value
473-7E
DUR/PPS CODE COUNTER
Maximum of 9 occurrences.
439-E4
REASON FOR SERVICE CODE
Field #
44Ø-E5
441-E6
474-8E
Claim Billing/Claim Re-bill
Payer Usage R R
PROFESSIONAL SERVICE CODE
RESULT OF SERVICE CODE
DUR/PPS LEVEL OF EFFORT
Payer Situation Imp Guide: Required if DUR/PPS Segment is used. Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.
R
Required if this field affects payment for or documentation of professional pharmacy service. Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.
R
Required if this field affects payment for or documentation of professional pharmacy service. Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.
R
Required if this field affects payment for or documentation of professional pharmacy service. Imp 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.
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 6
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill Compound Segment Questions
Check
This Segment is always sent This Segment is situational
Field # 45Ø-EF 451-EG 447-EC 488-RE 489-TE 448-ED 449-EE
49Ø-UE
Claim Billing/Claim Rebill If Situational, Payer Situation
X
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 COMPOUND INGREDIENT DRUG COST
Claim Billing/Claim Rebill
Value
Payer Usage M
Payer Situation
M Maximum 25 ingredients
M
Ø3 - NDC
M
11 digit NDC
M M R
COMPOUND INGREDIENT BASIS OF COST DETERMINATION
R
Imp Guide: Required if needed for receiver claim determination when multiple products are billed. Imp Guide: Required if needed for receiver claim determination when multiple products are billed.
** End of Request Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template**
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 7
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill Response
GENERAL INFORMATION Payer Name: Medical Security Card Company Plan Name/Group Name: Pet Genius Plan Name/Group Name: Plan Name/Group Name:
Date: Ø7/Ø1/2Ø12 BIN: Ø15673 BIN: BIN:
PCN: SS PCN: PCN:
CLAIM BILLING/CLAIM REBILL PAID (OR DUPLICATE OF PAID) RESPONSE The following lists the segments and fields in a Claim Billing or Claim Rebill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø.
Response Transaction Header Segment Questions
1Ø2-A2 1Ø3-A3 1Ø9-A9 5Ø1-F1 2Ø2-B2 2Ø1-B1 4Ø1-D1
Response Transaction Header Segment NCPDP Field Name
Value
VERSION/RELEASE NUMBER TRANSACTION CODE TRANSACTION COUNT HEADER RESPONSE STATUS SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE
DØ B1, B3 1-4 A = Accepted Same value as in request Same value as in request Same value as in request
Response Message Segment Questions
This Segment is always sent This Segment is situational
Field # 5Ø4-F4
Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
X
This Segment is always sent
Field #
Check
Check
Payer Usage M M M M M M M
Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Payer Situation
Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
X Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Payer Payer Situation Usage Imp Guide: Required if text is needed for RW clarification or detail.
Response Message Segment Segment Identification (111-AM) = “2Ø” NCPDP Field Name Value MESSAGE
Payer Requirement: Same as Imp Guide
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 8
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill Response Response Insurance Segment Questions
This Segment is always sent This Segment is situational
Field # 545-2F
Check
Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
X
Response Insurance Segment Segment Identification (111-AM) = “25” NCPDP Field Name
Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Payer Payer Situation Usage Imp Guide: Required if needed to identify RW the network for the covered member.
Value
NETWORK REIMBURSEMENT ID
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 Questions
Check
X
This Segment is always sent
Field #
Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
Response Status Segment Segment Identification (111-AM) = “21” NCPDP Field Name
112-AN
TRANSACTION RESPONSE STATUS
Ø3-F3
AUTHORIZATION NUMBER
Value P=Paid D=Duplicate of Paid
Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Payer Payer Situation Usage M R
Maximum count of 25.
RW
Imp Guide: Required if needed to identify the transaction. Imp Guide: Required if Additional Message Information (526-FQ) is used.
13Ø-UF
ADDITIONAL MESSAGE INFORMATION COUNT
132-UH
ADDITIONAL MESSAGE INFORMATION QUALIFIER
RW
Payer Requirement: Same as Imp Guide Imp Guide: Required if Additional Message Information (526-FQ) is used.
526-FQ
ADDITIONAL MESSAGE INFORMATION
RW
Payer Requirement: Same as Imp Guide Imp Guide: Required when additional text is needed for clarification or detail.
131-UG
ADDITIONAL MESSAGE INFORMATION CONTINUITY
RW
Payer Requirement: Same as Imp Guide Imp 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 Guide
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 9
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill Response
Field #
Response Status Segment Segment Identification (111-AM) = “21” NCPDP Field Name
549-7F
HELP DESK PHONE NUMBER QUALIFIER
55Ø-8F
HELP DESK PHONE NUMBER
Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Payer Payer Situation Usage Imp Guide: Required if Help Desk Phone RW Number (55Ø-8F) is used.
Value
RW
Payer Requirement: Same as Imp Guide Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Same as Imp Guide
Response Claim Segment Questions
Check
X
This Segment is always sent
Field #
Response Claim Segment Segment Identification (111-AM) = “22” NCPDP Field Name
455-EM
PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER
4Ø2-D2
PRESCRIPTION/SERVICE REFERENCE NUMBER
Response Pricing Segment Questions
Value 1 = RxBilling
Check
Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Payer Payer Situation Usage Imp Guide: For Transaction Code of “B1”, M in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is “1” (Rx Billing). M
Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
X
This Segment is always sent
Field #
Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Payer Payer Situation Usage R R Imp Guide: Required if this value is used R to arrive at the final reimbursement. Imp Guide: Required if the sender (health RW plan) and/or patient is tax exempt and exemption applies to this billing.
Response Pricing Segment Segment Identification (111-AM) = “23” NCPDP Field Name Value
5Ø5-F5 5Ø6-F6 5Ø7-F7
PATIENT PAY AMOUNT INGREDIENT COST PAID DISPENSING FEE PAID
557-AV
TAX EXEMPT INDICATOR
558-AW
FLAT SALES TAX AMOUNT PAID
RW
Payer Requirement: Same as Imp Guide Imp Guide: Required if Flat Sales Tax Amount Submitted (481-HA) is greater than zero (Ø) or if Flat Sales Tax Amount Paid (558-AW) is used to arrive at the final reimbursement. Payer Requirement: Same as Imp Guide
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 10
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill Response
Field # 559-AX
Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Payer Payer Situation Usage Imp Guide: Required if this value is used RW to arrive at the final reimbursement.
Response Pricing Segment Segment Identification (111-AM) = “23” NCPDP Field Name Value PERCENTAGE SALES TAX AMOUNT PAID
Required if Percentage Sales Tax Amount Submitted (482-GE) is greater than zero (Ø). Required if Percentage Sales Tax Rate Paid (56Ø-AY) and Percentage Sales Tax Basis Paid (561-AZ) are used.
56Ø-AY
PERCENTAGE SALES TAX RATE PAID
RW
561-AZ
PERCENTAGE SALES TAX BASIS PAID
RW
521-FL
INCENTIVE AMOUNT PAID
RW
Payer Requirement: Same as Imp Guide Imp Guide: Required if Percentage Sales Tax Amount Paid (559-AX) is greater than zero (Ø). Payer Requirement: Same as Imp. Guide Imp Guide: Required if Percentage Sales Tax Amount Paid (559-AX) is greater than zero (Ø). Payer Requirement: Same as Imp Guide Imp Guide: Required if this value is used to arrive at the final reimbursement. Required if Incentive Amount Submitted (438-E3) is greater than zero (Ø).
RW
Payer Requirement: Same as Imp Guide Imp Guide: Required if Other Amount Paid (565-J4) is used.
OTHER AMOUNT PAID QUALIFIER
RW
Payer Requirement: Same as Imp Guide Imp Guide: Required if Other Amount Paid (565-J4) is used.
OTHER AMOUNT PAID
RW
Payer Requirement: Same as Imp Guide Imp Guide: Required if this value is used to arrive at the final reimbursement.
563-J2
OTHER AMOUNT PAID COUNT
564-J3
565-J4
Maximum count of 3.
Required if Other Amount Claimed Submitted (48Ø-H9) is greater than zero (Ø). Payer Requirement: Same as Imp Guide 5Ø9-F9 522-FM
TOTAL AMOUNT PAID BASIS OF REIMBURSEMENT DETERMINATION
R R
Imp Guide: Required if Ingredient Cost Paid (5Ø6-F6) is greater than zero (Ø). Required if Basis of Cost Determination (423-DN) is submitted on billing.
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 11
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill Response
Field #
Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Payer Payer Situation Usage Imp Guide: Required if Patient Pay RW Amount (5Ø5-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.
Response Pricing Segment Segment Identification (111-AM) = “23” NCPDP Field Name Value
523-FN
AMOUNT ATTRIBUTED TO SALES TAX
517-FH
AMOUNT APPLIED TO PERIODIC DEDUCTIBLE
518-FI
AMOUNT OF COPAY
571-NZ
AMOUNT ATTRIBUTED TO PROCESSOR FEE
RW
575-EQ
PATIENT SALES TAX AMOUNT
RW
574-2Y
PLAN SALES TAX AMOUNT
RW
572-4U
AMOUNT OF COINSURANCE
RW
133-UJ
AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION
RW
134-UK
AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG
RW
135-UM
AMOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORMULARY SELECTION
RW
RW
R
Payer Requirement: Same as Imp Guide Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes deductible Payer Requirement: Same as Imp Guide Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes co-pay as patient financial responsibility. Imp Guide: Required if the customer is responsible for 1ØØ% of the prescription payment and when the provider net sale is less than the amount the customer is expected to pay. Payer Requirement: Same as Imp Guide Imp Guide: Used when necessary to identify the Patient’s portion of the Sales Tax. Provided for informational purposes only. Payer Requirement: Same As Imp Guide Imp Guide: Used when necessary to identify the Plan’s portion of the Sales Tax. Provided for informational purposes only. Payer Requirement: Same As Imp Guide Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes coinsurance as patient financial responsibility. Payer Requirement: Same As Imp Guide Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes an amount that is attributable to a cost share differential due to the selection of one pharmacy over another Payer Requirement: Same As Imp Guide Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes an amount that is attributable to a patient’s selection of a Brand drug. Payer Requirement: Same As Imp Guide Imp Guide: Required if Patient Pay Amount (5Ø5-F5) includes an amount that is attributable to a patient’s selection of a non-preferred formulary product. Payer Requirement: Same As Imp Guide
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 12
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill Response
Field #
Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Payer Payer Situation Usage Imp Guide: Required if Patient Pay RW Amount (5Ø5-F5) includes an amount that is attributable to a patient’s selection of a Brand non-preferred formulary product.
Response Pricing Segment Segment Identification (111-AM) = “23” NCPDP Field Name Value
136-UN
AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NONPREFERRED FORMULARY SELECTION
148-U8
INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT
RW
149-U9
DISPENSING FEE CONTRACTED/REIMBURSABLE AMOUNT
RW
Payer Requirement: Same As Imp Guide Imp 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 Imp 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
Response DUR/PPS Segment Questions
This Segment is always sent This Segment is situational
Field #
Check
Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
X
Response DUR/PPS Segment Segment Identification (111-AM) = “24” NCPDP Field Name
Value
Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Payer Payer Situation Usage Imp Guide: Required if Reason For RW Service Code (439-E4) is used.
567-J6
DUR/PPS RESPONSE CODE COUNTER Maximum 9 occurrences supported.
439-E4
REASON FOR SERVICE CODE
RW
528-FS
CLINICAL SIGNIFICANCE CODE
RW
529-FT
OTHER PHARMACY INDICATOR
RW
Payer Requirement: Same As Imp Guide Imp Guide: Required if utilization conflict is detected. Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same As Imp Guide
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 13
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill Response
Field # 53Ø-FU
Response DUR/PPS Segment Segment Identification (111-AM) = “24” NCPDP Field Name
Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Payer Payer Situation Usage Imp Guide: Required if needed to supply RW additional information for the utilization conflict.
Value
PREVIOUS DATE OF FILL
Required if Quantity of Previous Fill (531FV) is used.
531-FV
QUANTITY OF PREVIOUS FILL
RW
Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to supply additional information for the utilization conflict. Required if Previous Date Of Fill (53Ø-FU) is used.
532-FW
DATABASE INDICATOR
RW
533-FX
OTHER PRESCRIBER INDICATOR
RW
544-FY
DUR FREE TEXT MESSAGE
RW
Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement : Same As Imp Guide Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same As Imp Guide
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 14
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill Response CLAIM BILLING/CLAIM REBILL ACCEPTED/REJECTED RESPONSE Response Transaction Header Segment Questions This Segment is always sent
Check
Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
X
Response Transaction Header Segment Field # 1Ø2-A2 1Ø3-A3 1Ø9-A9 5Ø1-F1 2Ø2-B2 2Ø1-B1 4Ø1-D1
NCPDP Field Name
Value
VERSION/RELEASE NUMBER TRANSACTION CODE TRANSACTION COUNT HEADER RESPONSE STATUS SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE
DØ B1, B3 Same value as in request A = Accepted Same value as in request Same value as in request Same value as in request
Response Message Segment Questions
Check
This Segment is always sent This Segment is situational
Field # 5Ø4-F4
Claim Billing/Claim Rebill Accepted/Rejected Payer Payer Situation Usage M M M M M M M
Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
X
Response Message Segment Segment Identification (111-AM) = “2Ø” NCPDP Field Name
Claim Billing/Claim Rebill Accepted/Rejected Payer Payer Situation Usage Imp Guide: Required if text is needed for RW clarification or detail.
Value
MESSAGE
Payer Requirement: Same As Imp Guide Response Insurance Segment Questions This Segment is always sent This Segment is situational 545-2F
Check
Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
X
NETWORK REIMBURSEMENT ID
R
Imp 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 Questions
Check X
This Segment is always sent
Field # 112-AN 5Ø3-F3
Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
Response Status Segment Segment Identification (111-AM) = “21” NCPDP Field Name TRANSACTION RESPONSE STATUS AUTHORIZATION NUMBER
Value R = Reject
Claim Billing/Claim Rebill Accepted/Rejected Payer Payer Situation Usage M Imp Guide: Required if needed to identify R the transaction.
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 15
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill Response
Field #
Response Status Segment Segment Identification (111-AM) = “21” NCPDP Field Name
Value
51Ø-FA 511-FB 546-4F
REJECT COUNT REJECT CODE REJECT FIELD OCCURRENCE INDICATOR
Maximum count of 5.
13Ø-UF
ADDITIONAL MESSAGE INFORMATION COUNT
Maximum count of 25.
132-UH
Claim Billing/Claim Rebill Accepted/Rejected Payer Payer Situation Usage R R Imp Guide: Required if a repeating field is RW in error, to identify repeating field occurrence.
RW
Payer Requirement: Same As Imp Guide Imp Guide: Required if Additional Message Information (526-FQ) is used.
ADDITIONAL MESSAGE INFORMATION QUALIFIER
RW
Payer Requirement: Same As Imp Guide Imp Guide: Required if Additional Message Information (526-FQ) is used.
526-FQ
ADDITIONAL MESSAGE INFORMATION
RW
Payer Requirement : Same As Imp Guide Imp Guide: Required when additional text is needed for clarification or detail.
131-UG
ADDITIONAL MESSAGE INFORMATION CONTINUITY
RW
549-7F
HELP DESK PHONE NUMBER QUALIFIER
RW
55Ø-8F
HELP DESK PHONE NUMBER
RW
987-MA
URL
RW
Payer Requirement: Same As Imp Guide Imp 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 Guide Imp Guide: Required if Help Desk Phone Number (55Ø-8F) is used. Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to provide a support telephone number to the receiver. Payer Requirement: Same As Imp Guide Imp Guide: Provided for informational purposes only to relay health care communications via the Internet. Payer Requirement: Same As Imp Guide
Response Claim Segment Questions
Check X
This Segment is always sent
Field #
Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
Response Claim Segment Segment Identification (111-AM) = “22” NCPDP Field Name
Value
455-EM
PRESCRIPTION/SERVICE REFERENCE 1 = RxBilling NUMBER QUALIFIER
4Ø2-D2
PRESCRIPTION/SERVICE REFERENCE NUMBER
Claim Billing/Claim Rebill Accepted/Rejected Payer Payer Situation Usage Imp Guide: For Transaction Code of “B1”, M in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is “1” (Rx Billing). M
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 16
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill Response Response DUR/PPS Segment Questions This Segment is always sent This Segment is situational
Field #
Check
Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
X
Response DUR/PPS Segment Segment Identification (111-AM) = “24” NCPDP Field Name
Value
Claim Billing/Claim Rebill Accepted/Rejected Payer Payer Situation Usage Imp Guide: Required if Reason For RW Service Code (439-E4) is used.
567-J6
DUR/PPS RESPONSE CODE COUNTER Maximum 9 occurrences supported.
439-E4
REASON FOR SERVICE CODE
RW
528-FS
CLINICAL SIGNIFICANCE CODE
RW
529-FT
OTHER PHARMACY INDICATOR
RW
53Ø-FU
PREVIOUS DATE OF FILL
RW
Payer Requirement: Same As Imp Guide Imp Guide: Required if utilization conflict is detected. Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to supply additional information for the utilization conflict. Required if Quantity of Previous Fill (531FV) is used.
531-FV
QUANTITY OF PREVIOUS FILL
RW
Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to supply additional information for the utilization conflict. Required if Previous Date Of Fill (53Ø-FU) is used.
532-FW
DATABASE INDICATOR
RW
533-FX
OTHER PRESCRIBER INDICATOR
RW
544-FY
DUR FREE TEXT MESSAGE
RW
Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same As Imp Guide Imp Guide: Required if needed to supply additional information for the utilization conflict. Payer Requirement: Same As Imp Guide
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 17
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill Response
57Ø-NS
Response DUR/PPS Segment Segment Identification (111-AM) = “24” DUR ADDITIONAL TEXT
RW
Claim Billing/Claim Rebill Accepted/Rejected Imp Guide: Required if needed to supply additional information for the utilization conflict.
Payer Requirement: Same As Imp Guide CLAIM BILLING/CLAIM REBILL REJECTED/REJECTED RESPONSE Response Transaction Header Segment Questions This Segment is always sent
Field # 1Ø2-A2 1Ø3-A3 1Ø9-A9 5Ø1-F1 2Ø2-B2 2Ø1-B1 4Ø1-D1
Response Transaction Segment NCPDP Field Name
Check X Header Value
VERSION/RELEASE NUMBER TRANSACTION CODE TRANSACTION COUNT HEADER RESPONSE STATUS SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE
Response Message Segment Questions
DØ B1, B3 Same value as in request R = Rejected Same value as in request Same value as in request Same value as in request Check
This Segment is always sent This Segment is situational
Field # 5Ø4-F4
Claim Billing/Claim Rebill Rejected/Rejected If Situational, Payer Situation
Payer Usage M M M M M M M
Claim Billing/Claim Rebill Rejected/Rejected Payer Situation
Claim Billing/Claim Rebill Rejected/Rejected If Situational, Payer Situation
X
Response Message Segment Segment Identification (111-AM) “2Ø” NCPDP Field Name
Claim Billing/Claim Rebill Rejected/Rejected
= Value
Payer Usage RW
MESSAGE
Payer Situation Imp Guide: Required if text is needed for clarification or detail. Payer Requirement : Same As Imp Guide
Response Status Segment Questions
Check X
This Segment is always sent
Field #
Claim Billing/Claim Rebill Rejected/Rejected If Situational, Payer Situation
Response Status Segment Segment Identification (111-AM) “21” NCPDP Field Name
Claim Billing/Claim Rebill Rejected/Rejected
= Value
112-AN 5Ø3-F3
TRANSACTION RESPONSE STATUS AUTHORIZATION NUMBER
R = Reject
51Ø-FA 511-FB
REJECT COUNT REJECT CODE
Maximum count of 5.
Payer Usage M R R R
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 18
Payer Situation
Imp Guide: Required if needed to identify the transaction.
Pet Genius NCPDP vD.Ø Payer Sheet Claim Billing / Claim Rebill Response
Field # 546-4F
13Ø-UF
132-UH
526-FQ
131-UG
549-7F
55Ø-8F
Response Status Segment Segment Identification (111-AM) “21” NCPDP Field Name
Claim Billing/Claim Rebill Rejected/Rejected
= Value
Payer Usage RW
REJECT FIELD OCCURRENCE INDICATOR
ADDITIONAL MESSAGE INFORMATION COUNT
Maximum count of 25.
ADDITIONAL MESSAGE INFORMATION QUALIFIER
RW
RW
ADDITIONAL MESSAGE INFORMATION
RW
ADDITIONAL MESSAGE INFORMATION CONTINUITY
RW
HELP DESK PHONE NUMBER QUALIFIER
RW
HELP DESK PHONE NUMBER
RW
Payer Situation Imp Guide: Required if a repeating field is in error, to identify repeating field occurrence. Payer Requirement : Same As Imp Guide Imp Guide: Required if Additional Message Information (526-FQ) is used. Payer Requirement: Same As Imp Guide Imp Guide: Required if Additional Message Information (526-FQ) is used. Payer Requirement: Same As Imp Guide Imp Guide: Required when additional text is needed for clarification or detail. Payer Requirement: Same As Imp Guide Imp 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 Guide Imp Guide: Required if Help Desk Phone Number (55Ø-8F) is used. Payer Requirement: Same As Imp Guide Imp 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 Rebill (B1/B3) Payer Sheet Template**
“Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP” 19
