Payer Specifications D.0

EPIC, New York State Senior Prescription Plan
P.O. Box 15018
Albany, NY 12212-5018
1-800-634-1340

This document contains the specifications of six templates:

Start of Request Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template

General Information Column Information
Payer Name:New York EPIC
Date:01/01/2013
Plan Name/Group Name:New York EPIC
BIN:012345
PCN:P024012345
Processor:Processor/Fiscal Intermediary
Effective as of:01/01/2013
NCPDP Telecommunication Standard Version/Release #:D.0
NCPDP Data Dictionary Version Date:June 2010
NCPDP External Code List Version Date:June 2010
Contact/Information Source:Magellan Health Services — Albany, NY
Certification Testing Window:TBD (to be determined)
Certification Contact Information:804-217-7900
Provider Relations Help Desk Information:866-254-1669
Other versions supported:NCPDP Telecommunication version 5.1 until TBD

Other Transactions Supported

Payer: Please list each transaction supported with the segments, fields and pertinent information on each transaction.

Transaction CodeTransaction Name
B1Claim Billing
B2Claim Reversal
B3Claim Re-bill

Field Legend for Columns:

Payer Usage Column Value Explanation Payer Situation Column
MANDATORYM The field is mandatory for the Segment in the designated Transaction. No
RequiredR The field has been designated with the situation of "Required" for the Segment in the designated Transaction. No
Qualified RequirementRW "Required When." The situations designated have qualifications for usage ("Required when x,"Not Required when y"). Yes
Repeating Field *** The "***" indicates that the field is repeating. One of the other designators, "M", "R" or "RW" will precede it. Yes

Note: Fields that are not used in the Claim Billing/Claim Re-bill transactions and those that do not have qualified requirements (.i.e., not used) for this payer are excluded from the template.

Claim Billing/Claim Re-bill Transaction

The following lists the segments and fields in a Claim Billing or Claim Re-bill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0.

Transaction Header Segment - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
101-A1 BIN NUMBER 012345 M 012345 — New York EPIC
102-A2 VERSION/RELEASE NUMBER D.0 M Mandatory
103-A3 TRANSACTION CODE B1 Billing
B2 Reversal
B3 Re-bill
M Mandatory
104-A4 PROCESSOR CONTROL NUMBER P024012345 M Mandatory
109-A9 TRANSACTION COUNT 01 = One occurrence
02 = Two occurrences
03 = Three occurrences
04 = Four occurrences
M Mandatory
202-B2 SERVICE PROVIDER ID QUALIFIER 01 = National Provider Identifier (NPI) M Mandatory
201-B1 SERVICE PROVIDER ID NPI M Mandatory
401-D1 DATE OF SERVICE Format = CCYYMMDD M Mandatory
110-AK SOFTWARE VENDOR/CERTIFICATION ID Assigned by Magellan Health Services. M Assigned by Magellan Health Services.

Patient Segment (111-AM="01") - Required for these transactions: B1 and B3.
Field # NCPDP Field Name Value Payer Usage Payer Situation
304-C4 DATE OF BIRTH Format = CCYYMMDD R Required for this program.
305-C5 PATIENT GENDER CODE 1 = Male
2 = Female
R Required for this program.
310-CA PATIENT FIRST NAME Required for this program R Required for this program.
311-CB PATIENT LAST NAME Required for this program R Required for this program.

Insurance Segment (111-AM="04") - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
302-C2 CARDHOLDER ID EPIC Cardholder ID M NY EPIC Number <patient specific>
Format = EPNNNNNNN
312-CC CARDHOLDER FIRST NAME Required for this program. R Required for this program.
313-CD CARDHOLDER LAST NAME Required for this program. R Required for this program.
301-C1 GROUP ID NY EPIC M NY EPIC

Claim Segment (111-AM = "07") - This segment is always sent and the Payer supports partial fills.
Field # NCPDP Field Name Value Payer Usage Payer Situation
455-EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER 1 = Rx billing M For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing).
402-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER Mandatory M Mandatory
436-E1 PRODUCT/SERVICE ID QUALIFIER 03 = National Drug Code (NDC)
00 = Compound
M Mandatory
407-D7 PRODUCT/SERVICE ID Mandatory M One "0" when submitting compound
456-EN ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)).
Required when the Dispensing Status (343-HD) = "P" (Partial Fill) and there are multiple occurrences of partial fills for this prescription.
RW Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)).
Required when the Dispensing Status (343-HD) = "P" (Partial Fill) and there are multiple occurrences of partial fills for this prescription.
457-EP ASSOCIATED PRESCRIPTION/SERVICE DATE Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)).
Required when Associated Prescription/Service Reference Number (456-EN) is used.
Required when the Dispensing Status (343-HD) = "P" (Partial Fill) and there are multiple occurrences of partial fills for this prescription.
RW Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)).
Required when Associated Prescription/Service Reference Number (456-EN) is used.
Required when the Dispensing Status (343-HD) = "P" (Partial Fill) and there are multiple occurrences of partial fills for this prescription.
442-E7 QUANTITY DISPENSED Required for this program. R Required for this program.
403-D3 FILL NUMBER 0 = Original Dispensing
1-99 = Refill number - Number of the replenishment
R Required for this program.
405-D5 DAYS SUPPLY Required for this program. R Required for this program.
406-D6 COMPOUND CODE 1 = Not a compound
2 = Compound
R Required for this program.
408-D8 DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE 0 = No Product Selection Indicated
1 = Substitution Not Allowed by Prescriber
2 = Substitution Allowed - Patient Requested Product Dispensed
3 = Substitution Allowed - Pharmacist Selected Product Dispensed
4 = Substitution Allowed - Generic Drug Not in Stock
5 = Substitution Allowed - Brand Drug Dispensed as Generic
6 = Override
7 = Substitution Not Allowed - Brand Drug Mandated by Law
8 = Substitution Allowed - Generic Drug Not Available in Marketplace
9 = Substitution Allowed by Prescriber but Plan Requests Brand - Patient's Plan Requested Brand Product to be Dispensed
R Required for this program.
414-DE DATE PRESCRIPTION WRITTEN Format = CCYYMMDD R Required for this program.
415-DF NUMBER OF REFILLS AUTHORIZED 0 - No refills authorized
1-99 = Authorized Refill number - with 99 being as needed, refills unlimited
RW Required when necessary for plan benefit administration.
354-NX SUBMISSION CLARIFICATION CODE COUNT Maximum count of 3. RW Required when Submission Clarification Code (420-DK) is used.
420-DK SUBMISSION CLARIFICATION CODE '2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits
'7 = Medically Necessary' required for FluMist age limit overrides
'8 = Process Compound For Approved Ingredients' required to override and accept payments only for covered items within a compound
R '2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits
'7 = Medically Necessary' required for FluMist age limit overrides
'8 = Process Compound For Approved Ingredients' required to override and accept payments only for covered items within a compound
308-C8 OTHER COVERAGE CODE 3 = Other Coverage Billed — Claim not Covered
8 = Claim is billing for patient financial responsibility only
R 3 = Other Coverage Billed — Claim not Covered
8 = Claim is billing for patient financial responsibility only
343-HD DISPENSING STATUS P = Partial Fill
C = Completion of Partial Fill
R Required for the partial fill or the completion fill of a prescription.
344-HF QUANTITY INTENDED TO BE DISPENSED Required for this program. R Required for the partial fill or the completion fill of a prescription.
345-HG DAYS SUPPLY INTENDED TO BE DISPENSED Required for this program. R Required for the partial fill or the completion fill of a prescription.
357-NV DELAY REASON CODE 1 = Proof of eligibility unknown or unavailable
2 = Litigation
3 = Authorization delays
4 = Delay in certifying provider
5 = Delay in supplying billing forms
6 = Delay in delivery of custom-made appliances
7 = Third-party processing delay
8 = Delay in eligibility determination
9 = Original claims rejected or denied due to a reason unrelated to the billing limitation rules
10 = Administration delay in the prior approval process
11 = Other
12 = Received late with no exceptions
13 = Substantial damage by fire, etc to provider records
14 = Theft, sabotage/other willful acts by employee
RW Required when needed to specify the reason that submission of the transaction has been delayed.
995-E2 ROUTE OF ADMINISTRATION SNOMED RW Required when specified in trading partner agreement
Payer Requirement: (any unique payer requirement(s))
996-G1 COMPOUND TYPE 01 = Anti-infective
02 = Ionotropic
03 = Chemotherapy
04 = Pain management
05 = TPN/PPN (Hepatic, Renal, Pediatric) Total Parenteral Nutrition/ Peripheral Parenteral Nutrition
06 = Hydration
07 = Ophthalmic
99 = Other
RW Required when submitting new compound.
Payer Requirement: Same as implementation guide: Same as Imp Guide.

Pricing Segment (111-AM="11") - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
409-D9 INGREDIENT COST SUBMITTED Mandatory M Mandatory
412-DC DISPENSING FEE SUBMITTED Mandatory M Mandatory
478-H7 OTHER AMOUNT CLAIMED SUBMITTED COUNT Maximum count of 3. RW*** Required when Other Amount Claimed Submitted Qualifier (479-H8) is used.
479-H8 OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER 99 = Other RW*** Required when Other Amount Claimed Submitted (480-H9) is used.
480-H9 OTHER AMOUNT CLAIMED SUBMITTED Required when its value has an effect on the Gross Amount Due (430-DU) calculation. RW*** Required when its value has an effect on the Gross Amount Due (430-DU) calculation.
426-DQ USUAL AND CUSTOMARY CHARGE Required when needed per trading partner agreement. RW Required when needed per trading partner agreement.
430-DU GROSS AMOUNT DUE Mandatory M Mandatory

Prescriber Segment (111-AM = "03") - Segment Required for B1 and B3 transactions.
Field # NCPDP Field Name Value Payer Usage Payer Situation
466-EZ PRESCRIBER ID QUALIFIER 01 = National Provider Identifier (NPI)
08 = State License Number
12 = Drug Enforcement Administration (DEA) Number
M Mandatory
411-DB PRESCRIBER ID NPI
State License
DEA Number
M Format:
NPI = NNNNNNNNN
State License = NNNNNNN
DEA Number = AANNNNNNN

COB/Other Payments Segment (111-AM = "05") - Segment is situational. Required only for secondary, tertiary, etc., claims. Required for B1 and B3 transactions when there is other payer information. Scenario 2 - Other Payer-Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only.
Field # NCPDP Field Name Value Payer Usage Payer Situation
337-4C COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT Maximum count of 9. M Mandatory
338-5C OTHER PAYER COVERAGE TYPE Blank = Not Specified
01 = Primary — First
02 = Secondary — Second
03 = Tertiary — Third
M*** Mandatory
339-6C OTHER PAYER ID QUALIFIER 03 = Bank Information Number (BIN) Card Issuer ID RW Required when Other Payer ID (340-7C) is used.
340-7C OTHER PAYER ID Other Payer Bank Information Number (BIN) R Required for this program.
443-E8 OTHER PAYER DATE Required for this program. R Required for this program.
471-5E OTHER PAYER REJECT COUNT Maximum count of 5. RW Required when the Other Payer Reject Code (472-6E) is used.
472-6E OTHER PAYER REJECT CODE NCPDP Reject Code (511-FB) values RW Required for this program when the Other Coverage Code (308-C8) of "3" is used.
353-NR OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT Maximum count of 25. RW Required when Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used.
351-NP OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER Blank = Not Specified
01 = Amount Applied to Periodic Deductible (517-FH) as reported by previous payer
02 = Amount attributed to Product Selection/Brand Drug (134-UK) as reported by previous payer
03 = Amount Attributed to Sales Tax (5123-FN) as reported by previous payer
04 = Amount Exceeding Periodic Benefit Maximum (520-FK) as reported by previous payer
05 = Amount of Co-pay (518-FI) as reported by previous payer
07 = Amount of Coinsurance (572-4U) as reported by previous payer
08 = Amount Attributed to Product Selection/Non-Preferred Formulary Selection (135-UM) as reported by previous payer
09 = Amount Attributed to Health Plan Assistance Amount (129-UD) as reported by previous payer
10 = Amount Attributed to Provider Network Selection (133-UJ) as reported to previous payer
11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) as reported by previous payer
12 = Amount Attributed to Coverage Gap (137-UP) that was collected from the patient due to a coverage gap
13 = Amount Attributed to Processor Fee (571-NZ) as reported by previous payer
RW Required when Other Payer-Patient Responsibility Amount (352-NQ) is used.These values will be the only ones accepted by EPIC. Any other values will deny.
352-NQ OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT Required when necessary for patient financial responsibility only billing.
Not used when Other Payer Amount Paid (431-DV) is submitted.
RW Required when necessary for patient financial responsibility only billing.
Not used when Other Payer Amount Paid (431-DV) is submitted.
392-MU BENEFIT STAGE COUNT Maximum count of 4. RW Required when Benefit Stage Amount (394-MW) is used.
393-MV BENEFIT STAGE QUALIFIER 01 = Deductible
02 = Initial Benefit
03 = Coverage Gap
04 = Catastrophic Coverage
RW Required when Benefit Stage Amount (394-MW) is used.
394-MW BENEFIT STAGE AMOUNT Required when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. This field is required when the plan is a participant in a Medicare Part D program that requires reporting of benefit stage specific financial amounts. RW Required when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. This field is required when the plan is a participant in a Medicare Part D program that requires reporting of benefit stage specific financial amounts.

DUR/PPS Segment (111-AM = "08") - Segment Mandatory for B1 and B3 transactions when there is DUR information.
Field # NCPDP Field Name Value Payer Usage Payer Situation
473-7E DUR/PPS CODE COUNTER Maximum of 9 occurrences. RW*** Required when DUR/PPS Segment is used.
439-E4 REASON FOR SERVICE CODE Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.
Required when this field affects payment for or documentation of professional pharmacy service.
RW*** Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.
Required when this field affects payment for or documentation of professional pharmacy service.
440-E5 PROFESSIONAL SERVICE CODE Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.
Required when this field affects payment for or documentation of professional pharmacy service.
RW*** Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.
Required when this field affects payment for or documentation of professional pharmacy service.
441-E6 RESULT OF SERVICE CODE 00 = Not Specified
1A = Filled As Is, False Positive
1B = Filled Prescription As Is
1C = Filled, With Different Dose
1D = Filled, With Different Directions
1E = Filled, With Different Drug
1F = Filled, With Different Quantity
1G = Filled, With Prescriber Approval
1H = Brand-to-Generic Change
1J = Rx-to-OTC Change
1K = Filled with Different Dosage Form
2A = Prescription Not Filled
2B = Not Filled, Directions Clarified
3A = Recommendation Accepted
3B = Recommendation Not Accepted
3C = Discontinued Drug
3D = Regimen Changed
3E = Therapy Changed
3F = Therapy Changed
3G = Drug Therapy Unchanged
3H = Follow-Up/Report
3J = Patient Referral
3K = Instructions Understood
3M = Compliance Aid Provided
3N = Medication Administered
4A = Prescribed with acknowledgements
RW*** Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.
Required when this field affects payment for or documentation of professional pharmacy service.

Compound Segment - Segment Mandatory for these transactions: B1 and B3 when there is Compound information.
Field # NCPDP Field Name Value Payer Usage Payer Situation
450-EF COMPOUND DOSAGE FORM DESCRIPTION CODE Blank = Not Specified
01 = Capsule
02 = Ointment
03 = Cream
04 = Suppository
05 = Powder
06 = Emulsion
07 = Liquid
10 = Tablet
11 = Solution
12 = Suspension
13 = Lotion
14 = Shampoo
15 = Elixir
16 = Syrup
17 = Lozenge
18 = Enema
M Mandatory
451-EG COMPOUND DISPENSING UNIT FORM INDICATOR 1 = Each
2 = Grams
3 = Milliliters
M Mandatory
447-EC COMPOUND INGREDIENT COMPONENT COUNT Maximum of 25 ingredients. M Mandatory
488-RE COMPOUND PRODUCT ID QUALIFIER 03 M 03 = National Drug Code (NDC) - Formatted 11 digits (N)
489-TE COMPOUND PRODUCT ID Mandatory M Mandatory
448-ED COMPOUND INGREDIENT QUANTITY Amount expressed in metric decimal units of the product included in the compound. M Mandatory
449-EE COMPOUND INGREDIENT DRUG COST Enter the ingredient drug cost for each product used in making the compound. RW Required when needed for receiver claim determination when multiple products are billed.
490-UE COMPOUND INGREDIENT BASIS OF COST DETERMINATION 00 = Default
01 = AWP
02 = Local Wholesaler
03 = Direct
04 = EAC (Estimated Acquisition Cost)
05 = Acquisition
06 = MAC (Maximum Allowable Cost)
07 = Usual & Customary
08 = 340B/Disproportionate Share Pricing
09 = Other
10 = ASP (Average Sales Price)
11 = AMP (Average Manufacturer Price)
12 = WAC (Wholesale Acquisition Cost)
13 = Special Patient Pricing
M Mandatory
362-2G COMPOUND INGREDIENT MODIFIER CODE COUNT Maximum count of 10. RW Required when Compound Ingredient Modifier Code (363-2H) is sent.
363-2H COMPOUND INGREDIENT MODIFIER CODE HCPCS R Required for this program.

Clinical Segment - Segment is situational; Segment may be required at a future date for B1 and B3 transactions when Designated Clinical Information is needed for drug coverage consideration; fields intentionally not listed.
Field # NCPDP Field Name Value Payer Usage Payer Situation
intentionally not listed intentionally not listed intentionally not listed intentionally not listed intentionally not listed

End of Request Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template

Start of Response Claim Billing/Claim Re-bill Accepted/Paid (or Duplicate of Paid)(B1/B3) Payer Sheet Template

General Information Column Information
Payer Name:New York EPIC
Date:01/01/2013
Plan Name/Group Name:New York EPIC
BIN:012345
PCN:P024012345
Processor:Processor/Fiscal Intermediary
Effective as of:01/01/2013
NCPDP Telecommunication Standard Version/Release #:D.0
NCPDP Data Dictionary Version Date:June 2010
NCPDP External Code List Version Date:June 2010
Contact/Information Source:Magellan Health Services — Albany, NY
Certification Testing Window:TBD (to be determined)
Certification Contact Information:804-217-7900
Provider Relations Help Desk Information:866-254-1669
Other versions supported:NCPDP Telecommunication version 5.1 until TBD

Claim Billing/Claim Re-bill Paid (or Duplicate of Paid) Response

The 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.0.

Response Transaction Header Segment - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
102-A2 VERSION/RELEASE NUMBER D0 M Mandatory
103-A3 TRANSACTION CODE B1
B3
M Mandatory
109-A9 TRANSACTION COUNT Same value as in request M Mandatory
501-F1 HEADER RESPONSE STATUS A = Accepted M Mandatory
202-B2 SERVICE PROVIDER ID QUALIFIER Same value as in request M Mandatory
201-B1 SERVICE PROVIDER ID Same value as in request M Mandatory
401-D1 DATE OF SERVICE Same value as in request M Mandatory

Response Message Segment (111-AM = "20")- This segment is Situational. Provide general information when used for transmission-level messaging.
Field # NCPDP Field Name Value Payer Usage Payer Situation
504-F4 MESSAGE Required when text is needed for clarification or detail. RW Required when text is needed for clarification or detail.

Response Insurance Segment (111-AM = "25") - This segment is situational.
Field # NCPDP Field Name Value Payer Usage Payer Situation
301-C1 GROUP ID Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. RW Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.
524-FO PLAN ID Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. RW Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.
545-2F NETWORK REIMBURSEMENT ID Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. RW Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.
568-J7 PAYER ID QUALIFIER Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. RW Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.
569-J8 PAYER ID Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. RW Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.
302-C2 CARDHOLDER ID Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. RW Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.

Patient Segment (111-AM="29") - This segment is situational.
Field # NCPDP Field Name Value Payer Usage Payer Situation
310-CA PATIENT FIRST NAME Required when known. RW Required when known.
311-CB PATIENT LAST NAME Required when known. RW Required when known.
304-C4 DATE OF BIRTH Format = CCYYMMDD RW Required when known.

Response Status Segment (111-AM = "21") - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
112-AN TRANSACTION RESPONSE STATUS P = Paid
D = Duplicate
M Mandatory
503-F3 AUTHORIZATION NUMBER Required when needed to identify the transaction. RW Required when needed to identify the transaction.
547-5F APPROVED MESSAGE CODE COUNT Maximum count of 5. RW Required when Approved Message Code (548-6F) is used.
548-6F APPROVED MESSAGE CODE Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. RW Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity.
130-UF ADDITIONAL MESSAGE INFORMATION COUNT Maximum count of 25. RW Required when Additional Message Information (526-FQ) is used.
132-UH ADDITIONAL MESSAGE INFORMATION QUALIFIER Required when Additional Message Information (526-FQ) is used. RW Required when Additional Message Information (526-FQ) is used.
526-FQ ADDITIONAL MESSAGE INFORMATION Required when additional text is needed for clarification or detail. RW Required when additional text is needed for clarification or detail.
131-UG ADDITIONAL MESSAGE INFORMATION CONTINUITY Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQW) follows it, and the text of the following message is a continuation of the current. RW Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQW) follows it, and the text of the following message is a continuation of the current.
549-7F HELP DESK PHONE NUMBER QUALIFIER Required when Help Desk Phone Number (550-8F) is used. RW Required when Help Desk Phone Number (550-8F) is used.
550-8F HELP DESK PHONE NUMBER Required when needed to provide a support telephone number. RW Required when needed to provide a support telephone number.

Response Claim Segment (111-AM = "22") - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
455-EM PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER 1 = Rx billing M Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing)
402-D2 PRESCRIPTION/ SERVICE REFERNCE NUMBER Mandatory M Mandatory
551-9F PREFERRED PRODUCT COUNT Maximum count of 6. RW Required when Preferred Product ID (553-AR) is used.
552-AP PREFERRED PRODUCT ID QUALIFIER Required when Preferred Product ID (553-AR) is used. RW Required when Preferred Product ID (553-AR) is used.
553-AR PREFERRED PRODUCT ID Required when a product preference exists that needs to be communicated to the receiver via an ID. RW Required when a product preference exists that needs to be communicated to the receiver via an ID.
554-AS PREFERRED PRODUCT INCENTIVE Required when there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). RW Required when there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU).
555-AT PREFERRED PRODUCT COST SHARE INCENTIVE Required when there is a known patient financial responsibility incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). RW Required when there is a known patient financial responsibility incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU).
556-AU PREFERRED PRODUCT DESCRIPTION Required when a product preference exists that either cannot be communicated by the Preferred Product ID (553-AR) or to clarify the Preferred Product ID (553-AR). RW Required when a product preference exists that either cannot be communicated by the Preferred Product ID (553-AR) or to clarify the Preferred Product ID (553-AR).

Response Pricing Segment (111-AM = "23") - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
505-F5 PATIENT PAY AMOUNT Required for this program. R Required for this program.
506-F6 INGREDIENT COST PAID Required for this program. R Required for this program.
507-F7 DISPENSING FEE PAID Required when this value is used to arrive at the final reimbursement. RW Required when this value is used to arrive at the final reimbursement.
557-AV TAX EXEMPT INDICATOR Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. RW Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing.
558-AW FLAT SALES TAX AMOUNT PAID Required when Flat Sales Tax Amount Submitted (481-HA) is greater than zero (0) or when Flat Sales Tax Amount Paid (558-AW) is used to arrive at the final reimbursement. RW Required when Flat Sales Tax Amount Submitted (481-HA) is greater than zero (0) or when Flat Sales Tax Amount Paid (558-AW) is used to arrive at the final reimbursement.
559-AX PERCENTAGE SALES TAX AMOUNT PAID Required when this value is used to arrive at the final reimbursement.
Required when Percentage Sales Tax Amount Submitted (482-GE) is greater than zero (0).
Required when Percentage Sales Tax Rate Paid (560-AY) and Percentage Sales Tax Basis Paid (561-AZ) are used.
RW Required when this value is used to arrive at the final reimbursement.
Required when Percentage Sales Tax Amount Submitted (482-GE) is greater than zero (0).
Required when Percentage Sales Tax Rate Paid (560-AY) and Percentage Sales Tax Basis Paid (561-AZ) are used.
560-AY PERCENTAGE SALES TAX RATE PAID Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). RW Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0).
561-AZ PERCENTAGE SALES TAX BASIS PAID Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). RW Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0).
521-FL INCENTIVE AMOUNT PAID Required when this value is used to arrive at the final reimbursement.
Required when Incentive Amount Submitted (438-E3) is greater than zero (0).
RW Required when this value is used to arrive at the final reimbursement.
Required when Incentive Amount Submitted (438-E3) is greater than zero (0).
563-J2 OTHER AMOUNT PAID COUNT Maximum count of 3. RW Required when Other Amount Paid (565-J4) is used.
564-J3 OTHER AMOUNT PAID QUALIFIER Required when Other Amount Paid (565-J4) is used. RW Required when Other Amount Paid (565-J4) is used.
565-J4 OTHER AMOUNT PAID Required when this value is used to arrive at the final reimbursement.
Required when Other Amount Claimed Submitted (480-H9) is greater than zero (0).
RW Required when this value is used to arrive at the final reimbursement.
Required when Other Amount Claimed Submitted (480-H9) is greater than zero (0).
566-J5 OTHER PAYER AMOUNT RECOGNIZED Required when this value is used to arrive at the final reimbursement.
Required when Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported.
RW Required when this value is used to arrive at the final reimbursement.
Required when Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported.
509-F9 TOTAL AMOUNT PAID Required for this program. R Required for this program.
522-FM BASIS OF REIMBURSEMENT DETERMINATION Required when Ingredient Cost Paid (506-F6) is greater than zero (0).
Required when Basis of Cost Determination (432-DN) is submitted on billing.
RW Required when Ingredient Cost Paid (506-F6) is greater than zero (0).
Required when Basis of Cost Determination (432-DN) is submitted on billing.
523-FN AMOUNT ATTRIBUTED TO SALES TAX Required when Patient Pay Amount (505-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. RW Required when Patient Pay Amount (505-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.
512-FC ACCUMULATED DEDUCTIBLE AMOUNT Provided for informational purposes only. RW Provided for informational purposes only.
513-FD REMAINING DEDUCTIBLE AMOUNT Provided for informational purposes only. RW Provided for informational purposes only.
514-FE REMAINING BENEFIT AMOUNT Provided for informational purposes only. RW Provided for informational purposes only.
517-FH AMOUNT APPLIED TO PERIODIC DEDUCTIBLE Required when Patient Pay Amount (505-F5) includes deductible. RW Required when Patient Pay Amount (505-F5) includes deductible.
518-FI AMOUNT OF COPAY/CO-INSURANCE Required when Patient Pay Amount (5o5-F5) includes co-pay as patient financial responsibility. RW Required when Patient Pay Amount (5o5-F5) includes co-pay as patient financial responsibility.
520-FK AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM Required when Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. RW Required when Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum.
346-HH BASIS OF CALCULATION - DISPENSING FEE Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill). RW Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill).
347-HJ BASIS OF CALCULATION - COPAY Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill). RW Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill).
348-HK BASIS OF CALCULATION - FLAT SALES TAX Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Flat Sales Tax Amount Paid (558-AW) is greater than zero (0). RW Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Flat Sales Tax Amount Paid (558-AW) is greater than zero (0).
349-HM BASIS OF CALCULATION - PERCENTAGE SALES TAX Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). RW Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0).
571-NZ AMOUNT ATTRIBUTED TO PROCESSOR FEE Required when the customer is responsible for 100 percent of the prescription payment and when the provider net sale is less than the amount the customer is expected to pay. RW Required when the customer is responsible for 100 percent of the prescription payment and when the provider net sale is less than the amount the customer is expected to pay.
575-EQ PATIENT SALES TAX AMOUNT Required when necessary to identify the Patient's portion of the Sales Tax. RW Required when necessary to identify the Patient's portion of the Sales Tax.
574-2Y PLAN SALES TAX AMOUNT Required when necessary to identify the Plan's portion of the Sales Tax. RW Required when necessary to identify the Plan's portion of the Sales Tax.
572-4U AMOUNT OF COINSURANCE Required when Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. RW Required when Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility.
573-4V BASIS OF CALCULATION-COINSURANCE Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill). RW Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill).
392-MU BENEFIT STAGE COUNT Maximum count of 4. RW Required when Benefit Stage Amount (394-MW) is used.
393-MV BENEFIT STAGE QUALIFIER Required when Benefit Stage Amount (394-MW) is used. RW Required when Benefit Stage Amount (394-MW) is used.
394-MW BENEFIT STAGE AMOUNT Required when a Medicare Part D payer applies financial amounts to Medicare Part D beneficiary benefit stages. This field is required when the plan is a participant in a Medicare Part D program that requires reporting of benefit stage specific financial amounts.
Required when necessary for state/federal/regulatory agency programs.
RW Required when a Medicare Part D payer applies financial amounts to Medicare Part D beneficiary benefit stages. This field is required when the plan is a participant in a Medicare Part D program that requires reporting of benefit stage specific financial amounts.
Required when necessary for state/federal/regulatory agency programs.
577-G3 ESTIMATED GENERIC SAVINGS Required when a patient selected the brand drug and a generic form of the drug was available. It will contain an estimate of the difference between the cost of the brand drug and the generic drug, when the brand drug is more expensive than the generic. RW Required when a patient selected the brand drug and a generic form of the drug was available. It will contain an estimate of the difference between the cost of the brand drug and the generic drug, when the brand drug is more expensive than the generic.
128-UC SPENDING ACCOUNT AMOUNT REMAINING This dollar amount will be provided, when known, to the receiver when the transaction had spending account dollars reported as part of the patient pay amount. RW This dollar amount will be provided, when known, to the receiver when the transaction had spending account dollars reported as part of the patient pay amount.
129-UD HEALTH PLAN-FUNDED ASSISTANCE AMOUNT Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. RW Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero.
133-UJ AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a cost share differential due to the selection of one pharmacy over another. RW Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a cost share differential due to the selection of one pharmacy over another.
134-UK AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. RW Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug.
135-UM AMOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORMULARY SELECTION Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a non-preferred formulary product. RW Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a non-preferred formulary product.
136-UN AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NON-PREFERRED FORMULARY SELECTION Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand non-preferred formulary product. RW Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand non-preferred formulary product.
137-UP AMOUNT ATTRIBUTED TO COVERAGE GAP Required when the patient's financial responsibility is due to the coverage gap. RW Required when the patient's financial responsibility is due to the coverage gap.
148-U8 INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT 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. RW 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.
149-U9 DISPENSING FEE CONTRACTED/REIMBURSABLE AMOUNT 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. RW 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.

Response DUR / PPS Segment (111-AM = "24") - This segment is situational.
Field # NCPDP Field Name Value Payer Usage Payer Situation
567-J6 DUR/ PPS RESPONSE CODE COUNTER Maximum of 9 occurrences. RW Required when Reason For Service Code (439-E4) is used.
439-E4 REASON FOR SERVICE CODE Required when utilization conflict is detected. RW Required when utilization conflict is detected.
528-FS CLINICAL SIGNIFICANCE CODE Required when needed to supply additional information for the utilization conflict. RW Required when needed to supply additional information for the utilization conflict.
529-FT OTHER PHARMACY INDICATOR Required when needed to supply additional information for the utilization conflict. RW Required when needed to supply additional information for the utilization conflict.
530-FU PREVIOUS DATE OF FILL Required when Quantity of Previous Fill (531-FV) is used. RW Required when Quantity of Previous Fill (531-FV) is used.
531-FV QUANTITY OF PREVIOUS FILL Required when Previous Date Of Fill (530-FU) is used. RW Required when Previous Date Of Fill (530-FU) is used.
532-FW DATABASE INDICATOR Required when needed to supply additional information for the utilization conflict. RW Required when needed to supply additional information for the utilization conflict.
533-FX OTHER PRESCRIBER INDICATOR Required when needed to supply additional information for the utilization conflict. RW Required when needed to supply additional information for the utilization conflict.
544-FY DUR FREE TEXT MESSAGE Required when needed to supply additional information for the utilization conflict. RW Required when needed to supply additional information for the utilization conflict.
570-NS DUR ADDITIONAL TEXT Required when needed to supply additional information for the utilization conflict. RW Required when needed to supply additional information for the utilization conflict.

Response COB / Other Payers Segment (111-AM = "28") - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
355-NT OTHER PAYER ID COUNT Maximum count of 3. M Mandatory
338-5C OTHER PAYER COVERAGE TYPE Mandatory M Mandatory
339-6C OTHER PAYER ID QUALIFIER Required when Other Payer ID (340-7C) is used. RW Required when Other Payer ID (340-7C) is used.
340-7C OTHER PAYER ID Required when other insurance information is available for coordination of benefits. RW Required when other insurance information is available for coordination of benefits.
991-MH OTHER PAYER PROCESSOR CONTROL NUMBER Required when other insurance information is available for coordination of benefits. RW Required when other insurance information is available for coordination of benefits.
356-NU OTHER PAYER CARDHOLDER ID Required when other insurance information is available for coordination of benefits. RW Required when other insurance information is available for coordination of benefits.
992-MJ OTHER PAYER GROUP ID Required when other insurance information is available for coordination of benefits. RW Required when other insurance information is available for coordination of benefits.
142-UV OTHER PAYER PERSON CODE Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. RW Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer.
127-UB OTHER PAYER HELP DESK PHONE NUMBER Required when needed to provide a support telephone number of the other payer to the receiver. RW Required when needed to provide a support telephone number of the other payer to the receiver.
143-UW OTHER PAYER PATIENT RELATIONSHIP CODE Required when needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. RW Required when needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer.
144-UX OTHER PAYER BENEFIT EFFECTIVE DATE Required when other coverage is known, which is after the Date of Service submitted. RW Required when other coverage is known, which is after the Date of Service submitted.
145-UY OTHER PAYER BENEFIT TERMINATION DATE Required when other coverage is known, which is after the Date of Service submitted. RW Required when other coverage is known, which is after the Date of Service submitted.

End of Response Claim Billing/Claim Re-bill Accepted/Paid (or Duplicate of Paid)(B1/B3) Payer Sheet Template

Start of Request Claim Reversal (B2) Payer Sheet Template

General Information Column Information
Payer Name:New York EPIC
Date:01/01/2013
Plan Name/Group Name:New York EPIC
BIN:012345
PCN:P024012345
Processor:Processor/Fiscal Intermediary
Effective as of:01/01/2013
NCPDP Telecommunication Standard Version/Release #:D.0
Contact/Information Source:Magellan Health Services — Albany, NY
Certification Contact Information:804-217-7900
Provider Relations Help Desk Information:866-254-1669
Reversal Window (If transaction is billed today, what is the
timeframe for reversal to be submitted?):
365 days

Claim Reversal Transaction

The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0.

Transaction Header Segment - This segment is always sent. Source of certification IDs required in Software Vendor/Certification ID (110-AK) is Payer Issued.
Field # NCPDP Field Name Value Payer Usage Payer Situation
101-A1 BIN NUMBER 012345 M 012345 — New York EPIC
102-A2 VERSION/RELEASE NUMBER D.0 M Mandatory
103-A3 TRANSACTION CODE B2 Reversal M Mandatory
104-A4 PROCESSOR CONTROL NUMBER P024012345 M Mandatory
109-A9 TRANSACTION COUNT Mandatory M Mandatory
202-B2 SERVICE PROVIDER ID QUALIFIER 01 = National Provider Identifier (NPI) M Mandatory
201-B1 SERVICE PROVIDER ID National Provider Identifier (NPI) M Mandatory
401-D1 DATE OF SERVICE Format = CCYYMMDD M Mandatory
110-AK SOFTWARE VENDOR/CERTIFICATION ID Assigned by Magellan Health Services. M Assigned by Magellan Health Services.

Insurance Segment (111-AM="04") - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
302-C2 CARDHOLDER ID EPIC Cardholder ID M NY EPIC Number <patient specific>
Format = EPNNNNNNN
301-C1 GROUP ID NY EPIC RW Required when needed to match the reversal to the original billing transaction

Claim Segment (111-AM = "07") - This segment is always sent and the Payer supports partial fills.
Field # NCPDP Field Name Value Payer Usage Payer Situation
455-EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER 1 = Rx billing M For Transaction Code of "B2", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing).
402-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER Mandatory M Mandatory
436-E1 PRODUCT/SERVICE ID QUALIFIER 00 = Compound
03 = National Drug Code (NDC)
M If reversal is for multi-ingredient prescription, the value must be 00.
407-D7 PRODUCT/SERVICE ID NDC - for non-compound claims
'0' - for compound claims
M Mandatory

Pricing Segment (111-AM = "11") - This segment is always sent; intentionally not listed.
Field # NCPDP Field Name Value Payer Usage Payer Situation
intentionally not listed intentionally not listed intentionally not listed intentionally not listed intentionally not listed

Coordination of Benefits/Other Payments Segment (111-AM = "05") - This segment is situational; intentionally not listed.
Field # NCPDP Field Name Value Payer Usage Payer Situation
intentionally not listed intentionally not listed intentionally not listed intentionally not listed intentionally not listed


DUR/PPS Segment (111-AM = "08") - This segment is situational; intentionally not listed.
Field # NCPDP Field Name Value Payer Usage Payer Situation
intentionally not listed intentionally not listed intentionally not listed intentionally not listed intentionally not listed

End of Request Claim Reversal (B2) Payer Sheet Template

Start of Response Claim Reversal (B2) Accepted/Approved Payer Sheet Template

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.0.

Transaction Header Segment - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
102-A2 VERSION/RELEASE NUMBER D.0 M Mandatory
103-A3 TRANSACTION CODE B2 Reversal M Mandatory
109-A9 TRANSACTION COUNT Same value as in request M Mandatory
501-F1 HEADER RESPONSE STATUS A = Accepted M Mandatory
202-B2 SERVICE PROVIDER ID QUALIFIER Same value as in request M Mandatory
201-B1 SERVICE PROVIDER ID Same value as in request M Mandatory
401-D1 DATE OF SERVICE Same value as in request
Format = CCYYMMDD
M Mandatory

Response Message Segment (111-AM = "20")- This segment is Situational. Provide general information when used for transmission-level messaging.
Field # NCPDP Field Name Value Payer Usage Payer Situation
504-F4 MESSAGE Required when text is needed for clarification or detail. RW Required when text is needed for clarification or detail.

Response Status Segment (111-AM = "21") - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
112-AN TRANSACTION RESPONSE STATUS A = Approved M Mandatory
503-F3 AUTHORIZATION NUMBER Required when needed to identify the transaction. RW Required when needed to identify the transaction.
547-5F APPROVED MESSAGE CODE COUNT Maximum count of 5. RW*** Required when Approved Message Code (548-6F) is used.
548-6F APPROVED MESSAGE CODE Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. RW*** Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity.
130-UF ADDITIONAL MESSAGE INFORMATION COUNT Maximum count of 25. RW*** Required when Additional Message Information (526-FQ) is used.
132-UH ADDITIONAL MESSAGE INFORMATION QUALIFIER Required when Additional Message Information (526-FQ) is used. RW*** Required when Additional Message Information (526-FQ) is used.
526-FQ ADDITIONAL MESSAGE INFORMATION Required when additional text is needed for clarification or detail. RW*** Required when additional text is needed for clarification or detail.
131-UG ADDITIONAL MESSAGE INFORMATION CONTINUITY Required only when 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. RW*** Required only when 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.
549-7F HELP DESK PHONE NUMBER QUALIFIER Required when Help Desk Phone Number (550-8F) is used. RW Required when Help Desk Phone Number (550-8F) is used.
550-8F HELP DESK PHONE NUMBER Required when needed to provide a support telephone number. RW Required when needed to provide a support telephone number.

Response Claim Segment (111-AM = "22") - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
455-EM PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER 1 = Rx billing M Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing)
402-D2 PRESCRIPTION/ SERVICE REFERNCE NUMBER Mandatory M Mandatory

Response Pricing Segment (111-AM = "23") - This segment is situational.
Field # NCPDP Field Name Value Payer Usage Payer Situation
509-F9 TOTAL AMOUNT PAID Required when any other payment fields sent by the sender. RW Required when any other payment fields sent by the sender.

End of Response Claim Reversal (B2) Accepted/Approved Payer Sheet Template

Start of Response Claim Reversal (B2) Accepted/Rejected Payer Sheet Template

Claim Reversal Accepted/Rejected Response

Transaction Header Segment - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
102-A2 VERSION/RELEASE NUMBER D.0 M Mandatory
103-A3 TRANSACTION CODE B2 = Reversal M Mandatory
109-A9 TRANSACTION COUNT Same value as in request M Mandatory
501-F1 HEADER RESPONSE STATUS A = Accepted M Mandatory
202-B2 SERVICE PROVIDER ID QUALIFIER 01 = National Provider Identifier M Mandatory
201-B1 SERVICE PROVIDER ID Same value as in request M Mandatory
401-D1 DATE OF SERVICE Same value as in request
Format = CCYYMMDD
M Mandatory

Response Message Segment (111-AM = "20")- This segment is Situational.
Field # NCPDP Field Name Value Payer Usage Payer Situation
504-F4 MESSAGE Required when text is needed for clarification or detail. RW Required when text is needed for clarification or detail.

Response Status Segment (111-AM = "21") - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
112-AN TRANSACTION RESPONSE STATUS R = Rejected M Mandatory
503-F3 AUTHORIZATION NUMBER Required for this program. R Required for this program.
510-FA REJECT COUNT Maximum count of 5. R Required for this program.
511-FB REJECT CODE Required for this program. R Required for this program.
546-4F REJECT FIELD OCCURRENCE INDICATOR Required when a repeating field is in error, to identify repeating field occurrence. RW*** Required when a repeating field is in error, to identify repeating field occurrence.
130-UF ADDITIONAL MESSAGE INFORMATION COUNT Maximum count of 25. RW*** Required when Additional Message Information (526-FQ) is used.
132-UH ADDITIONAL MESSAGE INFORMATION QUALIFIER Required when Additional Message Information (526-FQ) is used. RW*** Required when Additional Message Information (526-FQ) is used.
526-FQ ADDITIONAL MESSAGE INFORMATION Required when additional text is needed for clarification or detail. RW*** Required when additional text is needed for clarification or detail.
131-UG ADDITIONAL MESSAGE INFORMATION CONTINUITY Required only when 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. RW*** Required only when 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.
549-7F HELP DESK PHONE NUMBER QUALIFIER Required when Help Desk Phone Number (550-8F) is used. RW Required when Help Desk Phone Number (550-8F) is used.
550-8F HELP DESK PHONE NUMBER Required when needed to provide a support telephone number. RW Required when needed to provide a support telephone number.

Response Claim Segment (111-AM = "22") - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
455-EM PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER 1 = Rx billing M Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing)
402-D2 PRESCRIPTION/ SERVICE REFERNCE NUMBER Mandatory M Mandatory

End of Response Claim Reversal (B2) Accepted/Rejected Payer Sheet Template

Start of Response Claim Reversal (B2) Rejected/Rejected Payer Sheet Template

Claim Reversal Rejected/Rejected Response

Transaction Header Segment - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
102-A2 VERSION/RELEASE NUMBER D.0 M Mandatory
103-A3 TRANSACTION CODE B2 = Reversal M Mandatory
109-A9 TRANSACTION COUNT Same value as in request M Mandatory
501-F1 HEADER RESPONSE STATUS A = Accepted M Mandatory
202-B2 SERVICE PROVIDER ID QUALIFIER 01 = National Provider Identifier M Mandatory
201-B1 SERVICE PROVIDER ID Same value as in request M Mandatory
401-D1 DATE OF SERVICE Same value as in request
Format = CCYYMMDD
M Mandatory

Response Message Segment (111-AM = "20")- This segment is Situational.
Field # NCPDP Field Name Value Payer Usage Payer Situation
504-F4 MESSAGE Required when text is needed for clarification or detail. RW Required when text is needed for clarification or detail.

Response Status Segment (111-AM = "21") - This segment is always sent.
Field # NCPDP Field Name Value Payer Usage Payer Situation
112-AN TRANSACTION RESPONSE STATUS R = Rejected M Mandatory
503-F3 AUTHORIZATION NUMBER Required for this program. R Required for this program.
510-FA REJECT COUNT Maximum count of 5. R Required for this program.
511-FB REJECT CODE Required for this program. R Required for this program.
546-4F REJECT FIELD OCCURRENCE INDICATOR Required when a repeating field is in error, to identify repeating field occurrence. RW*** Required when a repeating field is in error, to identify repeating field occurrence.
130-UF ADDITIONAL MESSAGE INFORMATION COUNT Maximum count of 25. RW*** Required when Additional Message Information (526-FQ) is used.
132-UH ADDITIONAL MESSAGE INFORMATION QUALIFIER Required when Additional Message Information (526-FQ) is used. RW*** Required when Additional Message Information (526-FQ) is used.
526-FQ ADDITIONAL MESSAGE INFORMATION Required when additional text is needed for clarification or detail. RW*** Required when additional text is needed for clarification or detail.
131-UG ADDITIONAL MESSAGE INFORMATION CONTINUITY Required only when 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. RW*** Required only when 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.
549-7F HELP DESK PHONE NUMBER QUALIFIER Required when Help Desk Phone Number (550-8F) is used. RW Required when Help Desk Phone Number (550-8F) is used.
550-8F HELP DESK PHONE NUMBER Required when needed to provide a support telephone number. RW Required when needed to provide a support telephone number.

End of Response Claim Reversal (B2) Rejected/Rejected Payer Sheet Template