MedImpact CO FFS Medicaid Payer Sheet
MedImpact Colorado Medicaid Payer Sheet
NCPDP Version D.Ø
Table of Contents
- General Information
- Claim Billing Request Transaction
- Emergency Preparedness
- Vaccine Billing
- Claim Response Transaction (Accepted/Paid or Dup. of Paid)
- Claim Response Transaction (Accepted/Rejected)
- Claim Response Transaction (Rejected/Rejected)
- Claim Reversal Request Transaction
- Claim Reversal Response Transaction (Accepted/Approved)
- Claim Reversal Response Transaction (Accepted/Rejected)
- Claim Reversal Response Transaction (Rejected/Rejected)
- Revision History
General Information
| Payer Name | MedImpact Healthcare Systems, Inc. Colorado Medicaid |
| Publication Date | January 30, 2026 |
| BIN(s) | 018902 |
| PCN(s) | P303018902 |
| Processor | MedImpact Healthcare Systems, Inc. |
| Effective as of | April 1, 2026 |
| NCPDP Telecommunication Standard Version | D.Ø |
| NCPDP Data Dictionary Version Date | August of 2007 |
| NCPDP External Code List Version Date | October 15, 2024 |
| Contact/Information Source | www.medimpact.com |
| Provider Relations Help Desk Info | 888-672-7203 starting 4/1 Prior to 4/1 for questions please contact MedImpact at COFFSTeam@medimpact.com |
| Other Versions Supported | Only D.Ø |
Claim Billing Request Transaction
Transaction Header Segment – Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 1Ø1-A1 | BIN NUMBER | 018902 | M | |
| 1Ø2-A2 | VERSION / RELEASE NUMBER | D.Ø | M | |
| 1Ø3-A3 | TRANSACTION CODE | B1 | M | B3 (Rebill) is not supported |
| 1Ø4-A4 | PROCESSOR CONTROL NUMBER | P303018902 | M | |
| 1Ø9-A9 | TRANSACTION COUNT | M | Per D.Ø standard, up to 4 transactions supported, except for compounds, which allow only 1. | |
| 2Ø2-B2 | SERVICE PROVIDER ID QUALIFIER | 01=NPI | M | NPI Only |
| 2Ø1-B1 | SERVICE PROVIDER ID | M | ||
| 4Ø1-D1 | DATE OF SERVICE | M | ||
| 11Ø-AK | SOFTWARE VENDOR / CERTIFICATION ID | M | Leave blank if unknown |
Insurance Segment (111-AM = “Ø4”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 3Ø2-C2 | CARDHOLDER ID | M | CO Medicaid identification number | |
| 3Ø9-C9 | ELIGIBILITY CLARIFICATION CODE | RW | Required when needed to clarify member eligibility. | |
| 312-CC | CARDHOLDER FIRST NAME | |||
| 313-CD | CARDHOLDER LAST NAME | |||
| 3Ø1-C1 | GROUP ID | COMEDICAID | R | |
| 3Ø3-C3 | PERSON CODE | RW | Use value printed on card to identify specific person when cardholder ID is for family. | |
| 3Ø6-C6 | PATIENT RELATIONSHIP CODE | |||
| 36Ø-2B | MEDICAID INDICATOR | RW |
Patient Segment (111-AM = “Ø1”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 3Ø4-C4 | DATE OF BIRTH | R | ||
| 3Ø5-C5 | PATIENT GENDER CODE | R | ||
| 31Ø-CA | PATIENT FIRST NAME | R | ||
| 311-CB | PATIENT LAST NAME | R | ||
| 322-CM | PATIENT STREET ADDRESS | RW | ||
| 323-CN | PATIENT CITY ADDRESS | RW | ||
| 324-CO | PATIENT STATE / PROVINCE ADDRESS | RW | ||
| 325-CP | PATIENT ZIP / POSTAL ZONE | RW | When submitted value should only contain numeric characters. A dash is not allowed. | |
| 3Ø7-C7 | PLACE OF SERVICE | RW | ||
| 384-4X | PATIENT RESIDENCE | RW | Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility. Required when LTC processing edits and payment are desired. | |
| 335-2C | PREGNANCY INDICATOR | RW | Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility. |
Claim Segment (111-AM = “Ø7”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 455-EM | PRESCRIPTION / SERVICE REFERENCE NUMBER QUALIFIER | 1 = Rx Billing | M | |
| 4Ø2-D2 | PRESCRIPTION / SERVICE REFERENCE NUMBER | M | ||
| 436-E1 | PRODUCT / SERVICE ID QUALIFIER | 03 = NDC | M | For multi-ingredient compounds this should be 00 (two zeros). |
| 4Ø7-D7 | PRODUCT / SERVICE ID | M | For multi-ingredient compounds this should be 0 (one zero). | |
| 442-E7 | QUANTITY DISPENSED | R | ||
| 4Ø3-D3 | FILL NUMBER | R | ||
| 4Ø5-D5 | DAYS SUPPLY | R | ||
| 4Ø6-D6 | COMPOUND CODE | R | ||
| 4Ø8-D8 | DISPENSE AS WRITTEN (DAW) / PRODUCT SELECTION CODE | R | Values other than 0, 1, 8 and 9 will deny. | |
| 414-DE | DATE PRESCRIPTION WRITTEN | R | ||
| 415-DF | NUMBER OF REFILLS AUTHORIZED | R | Required for all transactions. CII Claim will deny when value is greater than zero. | |
| 419-DJ | PRESCRIPTION ORIGIN CODE | R | Required for all prescriptions regardless of whether NEW or REFILL. | |
| 354-NX | SUBMISSION CLARIFICATION CODE COUNT | Maximum count of 3 | RW | Required if Submission Clarification Code (42Ø-DK) is used. |
| 42Ø-DK | SUBMISSION CLARIFICATION CODE | RW | Required to indicate the need for special handling to override normal processing. 20 - must be submitted when 340B drugs are dispensed to Managed Medicaid and Fee-For-Service Medicaid members. |
Claim Segment (111-AM = “Ø7”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 46Ø-ET | QUANTITY PRESCRIBED | RW | Imp Guide: Required when the transmission is for a Schedule I drug as defined in 21 CFR 1308.12 and per CMS-0055-F (Compliance Date 9/21/2020. Refer to the Version D.Ø Editorial Document). Payer Requirement: Effective 9/21/2020, field is required for Schedule II drugs | |
| 3Ø8-C8 | OTHER COVERAGE CODE | RW | Required for Coordination of Benefits or non-primary claim submissions. 8 is not accepted and will result in a denial. | |
| 429-DT | SPECIAL PACKAGING INDICATOR | RW | Required for LTC claims for brand oral solid drugs. | |
| 6ØØ-28 | UNIT OF MEASURE | R | ||
| 418-DI | LEVEL OF SERVICE | RW | ||
| 461-EU | PRIOR AUTHORIZATION TYPE CODE | RW | Required to indicate the need for special handling. | |
| 462-EV | PRIOR AUTHORIZATION NUMBER SUBMITTED | RW | Required to indicate the need for special handling to override a normal processing rejection. | |
| 995-E2 | ROUTE OF ADMINISTRATION | SNOMED Code | RW | Required when needed by plan for proper adjudication. See Plan Profile Sheets. |
| 996-G1 | COMPOUND TYPE | RW | Required when billing for a compound. | |
| 147-U7 | PHARMACY SERVICE TYPE | RW | Required for Mail Order, LTC, and Specialty pharmacies for proper reimbursement. |
Pricing Segment (111-AM = “11”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 4Ø9-D9 | INGREDIENT COST SUBMITTED | R | ||
| 412-DC | DISPENSING FEE SUBMITTED | RW | Required if necessary as a component of Gross Amount Due | |
| 433-DX | PATIENT PAID AMOUNT SUBMITTED | Not Used | This field is not used for COB billing. Claim will deny if value is other than $0. | |
| 438-E3 | INCENTIVE AMOUNT SUBMITTED | RW | Required when pharmacy is entitled to a Vaccine Administration Fee. | |
| 478-H7 | OTHER AMOUNT CLAIMED SUBMITTED COUNT | RW | ||
| 479-H8 | OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER | RW | ||
| 48Ø-H9 | OTHER AMOUNT CLAIMED SUBMITTED | RW | ||
| 481-HA | FLAT SALES TAX AMOUNT SUBMITTED | RW | Flat Sales Tax Amount should be submitted when a governing jurisdiction requires the collection of a fixed amount for all applicable prescriptions. Required when flat sales tax is applicable to product dispensed. |
Pricing Segment (111-AM = “11”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 482-GE | PERCENTAGE SALES TAX AMOUNT SUBMITTED | RW | Required when percentage sales tax is applicable to product dispensed. Pharmacy is responsible for submission of accurate percentage tax values for use in payment calculation. NOTE: For payment of Percentage Tax, all 3 Percentage Tax fields must be submitted: - PERCENTAGE SALES TAX AMOUNT SUBMITTED - PERCENTAGE SALES TAX RATE SUBMITTED - PERCENTAGE SALES TAX BASIS SUBMITTED | |
| 483-HE | PERCENTAGE SALES TAX RATE SUBMITTED | RW | Required when sales tax is applicable to product dispensed to provide the rate for use in payment calculation. | |
| 484-JE | PERCENTAGE SALES TAX BASIS SUBMITTED | RW | Required when sales tax is applicable to product dispensed to provide the basis for use in payment calculation. | |
| 426-DQ | USUAL AND CUSTOMARY CHARGE | R | Required on all claim submissions. In the case of a Vaccine where the product is also administered to the patient, U&C value should include the Administration Fee so any comparison to Usual and Customary calculates correctly. |
Pricing Segment (111-AM = “11”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 43Ø-DU | GROSS AMOUNT DUE | R | Must summarize according to NCPDP criteria. Ingredient Cost Submitted (4Ø9-D9) + Dispensing Fee Submitted (412-DC) + Flat Sales Tax Amt Submitted (481-HA) + Percentage Sales Tax Amt Submitted (482-GE) + Incentive Amount Submitted (438-E3) + Other Amount Claimed (48Ø- H9) | |
| 423-DN | BASIS OF COST DETERMINATION | RW | Imp Guide: Required if needed for receiver claim/encounter adjudication. 05 (Acquisition) 08 (340B/Disproportionate Share Pricing/Public Health Service required when billing 340B transactions. |
Prescriber Segment (111-AM = “Ø3”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 466-EZ | PRESCRIBER ID QUALIFIER | 01 = National Provider Identifier (NPI) | R | Required to identify the prescriber of the product dispensed. |
| 411-DB | PRESCRIBER ID | R | Required to identify the prescriber of the product dispensed. | |
| 427-DR | PRESCRIBER LAST NAME | RW | Required to identify the prescriber of the product dispensed. | |
| 498-PM | PRESCRIBER PHONE NUMBER | |||
| 468-2E | PRIMARY CARE PROVIDER ID QUALIFIER | |||
| 421-DL | PRIMARY CARE PROVIDER ID | |||
| 47Ø-4E | PRIMARY CARE PROVIDER LAST NAME | |||
| 364-2J | PRESCRIBER FIRST NAME | |||
| 365-2K | PRESCRIBER STREET ADDRESS | |||
| 366-2M | PRESCRIBER CITY ADDRESS | |||
| 367-2N | PRESCRIBER STATE / PROVINCE ADDRESS | |||
| 368-2P | PRESCRIBER ZIP / POSTAL ZONE | When submitted value should only contain numeric characters. A dash is not allowed. |
Coordination of Benefits/Other Payments Segment (OPAP) (111-AM = “Ø5”) Situational
Required only for secondary, tertiary, etc. claims. Will reject if the Segment is sent on primary claim
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 337-4C | COORDINATION OF BENEFITS / OTHER PAYMENTS COUNT | Maximum count of 9 | M | |
| 338-5C | OTHER PAYER COVERAGE TYPE | M | ||
| 339-6C | OTHER PAYER ID QUALIFIER | 03 = BIN Number | R | |
| 34Ø-7C | OTHER PAYER ID | R | If no BIN exists due to billing of a non-online payer, please use value 999999 as the BIN of the Other Payer. | |
| 443-E8 | OTHER PAYER DATE | R | ||
| 341-HB | OTHER PAYER AMOUNT PAID COUNT | Maximum count of 9 | RW | Imp Guide: Required if Other Payer Amount Paid Qualifier (342-HC) is used. Required with Other Coverage Code 2 or 4. |
| 342-HC | OTHER PAYER AMOUNT PAID QUALIFIER | RW | Imp Guide: Required if Other Payer Amount Paid (431-DV) is used. Required with Other Coverage Code 2 or 4. | |
| 431-DV | OTHER PAYER AMOUNT PAID | Required even if the value is zero. | RW | Required with Other Coverage Code 2 or 4. OCC=2: Submit amount > $0.00 OCC=4: Submit amount = $0.00 OCC=4: Negative value is accepted and treated as zero. |
| 353-NR | OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT | Maximum count of 25 | RW | Imp Guide: Required if Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. Required with Other Coverage Code 2 or 4. |
Coordination of Benefits/Other Payments Segment (OPAP) (111-AM = “Ø5”) Situational
Required only for secondary, tertiary, etc. claims. Will reject if the Segment is sent on primary claim
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 351-NP | OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER | RW | Imp Guide: Required if Other Payer-Patient Responsibility Amount (352- NQ) is used. Required with Other Coverage Code 2 or 4. | |
| 352-NQ | OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT | RW | Required with Other Coverage Code 2 or 4. | |
| 471-5E | OTHER PAYER REJECT COUNT | Maximum count of 5 | RW | Required with Other Coverage Code 3. |
| 472-6E | OTHER PAYER REJECT CODE | NCPDP Reject Codes | RW | Required with Other Coverage Code 3. |
DUR/PPS Segment (111-AM = “Ø8”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 473-7E | DUR / PPS CODE COUNTER | Maximum count of 9 | R | |
| 439-E4 | REASON FOR SERVICE CODE | RW | Payer Requirement: Required when needed by plan for proper adjudication. | |
| 44Ø-E5 | PROFESSIONAL SERVICE CODE | RW | Payer Requirement: Required when needed by plan for proper adjudication. | |
| 441-E6 | RESULT OF SERVICE CODE | RW | Payer Requirement: Required when needed by plan for proper adjudication. | |
| 474-8E | DUR/PPS LEVEL OF EFFORT | RW | Payer Requirement: Required when needed by plan for proper adjudication. | |
| 475-J9 | DUR CO-AGENT ID QUALIFIER | S | ||
| 476-H6 | DUR CO-AGENT ID | S |
Compound Segment (111-AM = “1Ø”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 45Ø-EF | COMPOUND DOSAGE FORM DESCRIPTION CODE | M | ||
| 451-EG | COMPOUND DISPENSING UNIT FORM INDICATOR | M | ||
| 447-EC | COMPOUND INGREDIENT COMPONENT COUNT | Maximum 25 ingredients | M | |
| 488-RE | COMPOUND PRODUCT ID QUALIFIER | 03 = NDC | M | |
| 489-TE | COMPOUND PRODUCT ID | M | ||
| 448-ED | COMPOUND INGREDIENT QUANTITY | M | ||
| 449-EE | COMPOUND INGREDIENT DRUG COST | R | ||
| 49Ø-UE | COMPOUND INGREDIENT BASIS OF COST DETERMINATION | R |
Clinical Segment (111-AM = “13”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 491-VE | DIAGNOSIS CODE COUNT | Maximum count of 5 | RW | |
| 492-WE | DIAGNOSIS CODE QUALIFIER | 02 = ICD-10 | RW | |
| 424-DO | DIAGNOSIS CODE | RW | Decimal point should not be included in the ICD-10 value. |
Emergency Preparedness
In the event of a ‘declared emergency’, the following guidelines will be followed:
Patient Segment (111-AM = “Ø1”)
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 322-CM | PATIENT STREET ADDRESS | RW | ||
| 323-CN | PATIENT CITY ADDRESS | RW | ||
| 324-CO | PATIENT STATE / PROVINCE ADDRESS | RW | ||
| 325-CP | PATIENT ZIP / POSTAL ZONE | RW | When submitted value should only contain numeric characters. A dash is not allowed. |
NOTE: Patient Segment is for the demographic information from which the patient has been displaced. This may/may not be where the patient is residing during the emergency.
Claim Segment (111-AM = “Ø7”)
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 42Ø-DK | SUBMISSION CLARIFICATON CODE | 13 = Payer- Recognized Emergency / Disaster Assistance Request | RW | The pharmacist is indicating that an override is needed based on an emergency/disaster situation recognized by the payer. |
Prescriber Segment (111-AM = “Ø3”)
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 411-DB | PRESCRIBER ID | RW | In a ‘declared emergency situation’ when the pharmacist prescribes, the organizational (type 2) NPI of the pharmacy may be submitted. |
Vaccine Billing
If a pharmacy is contracted for vaccine billing, the following guidelines will be followed:
Claim Segment (111-AM = “Ø7”)
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 455-EM | PRESCRIPTION / SERVICE REFERENCE NUMBER QUALIFIER | 1 = Rx Billing | R | |
| 4Ø2-D2 | PRESCRIPTION / SERVICE REFERENCE NUMBER | R | ||
| 436-E1 | PRODUCT / SERVICE QUALIFIER | 03 = NDC | R | |
| 4Ø7-D7 | PRODUCT / SERVICE ID | R |
NOTE: Other claim segment fields are required per normal claim billing.
Pricing Segment (111-AM = “11”)
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 4Ø9-D9 | INGREDIENT COST SUBMITTED | R | ||
| 412-DC | DISPENSING FEE SUBMITTED | RW | ||
| 438-E3 | INCENTIVE AMOUNT SUBMITTED | RW | This should be the contracted Administration Fee. | |
| 43Ø-DU | GROSS AMOUNT DUE | R | This must be the sum of Ingredient Cost Submitted (4Ø9-D9) + Dispensing Fee Submitted (412-DC) + Flat Sales Tax Amt Submitted (481-HA) + Percentage Sales Tax Amt Submitted (482-GE) + Incentive Amount Submitted (438-E3) + Other Amount Claimed (48Ø- H9) | |
| 426-DQ | USUAL AND CUSTOMARY CHARGE | R | U&C must include the Vaccine Administration Fee so lesser than logic works properly. |
DUR/PPS Segment (111-AM = “Ø8”)
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 473-7E | DUR / PPS CODE COUNTER | 1 | RW | |
| 44Ø-E5 | PROFESSIONAL SERVICE CODE | MA – Medication Administered | RW | If this is not submitted the Administrative Fee will be ignored. |
Claim Response Transaction (Accepted/Paid or Dup. of Paid)
Transaction Header Segment – Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 1Ø2-A2 | VERSION / RELEASE NUMBER | DØ | M | |
| 1Ø3-A3 | TRANSACTION CODE | B1 | M | |
| 1Ø9-A9 | TRANSACTION COUNT | Same value as in request. | M | |
| 5Ø1-F1 | HEADER RESPONSE STATUS | A = Accepted | M | |
| 2Ø2-B2 | SERVICE PROVIDER ID QUALIFIER | Same value as in request. | M | |
| 2Ø1-B1 | SERVICE PROVIDER ID | Same value as in request. | M | |
| 4Ø1-D1 | DATE OF SERVICE | Same value as in request. | M |
Response Message Segment (111-AM = “2Ø”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 5Ø4-F4 | MESSAGE | RW | When claim(s) are PAID, transmission related messaging may be sent for pharmacy review. |
Response Insurance Segment (111-AM = “25”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 3Ø1-C1 | GROUP ID | RW | ||
| 524-FO | PLAN ID | RW | ||
| 545-2F | NETWORK REIMBURSEMENT ID | RW | ||
| 568-J7 | PAYER ID QUALIFIER | RW | ||
| 569-J8 | PAYER ID | RW |
Response Patient Segment (111-AM = “29”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 31Ø-CA | PATIENT FIRST NAME | RW | Returned when enrollment file match occurs to indicate the First Name on the file for the Member ID. | |
| 311-CB | PATIENT LAST NAME | RW | Returned when enrollment file match occurs to indicate the Last Name on the file for the Member ID. | |
| 3Ø4-C4 | DATE OF BIRTH | RW |
Response Status Segment (111-AM = “21”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 112-AN | TRANSACTION RESPONSE STATUS | P = Paid D = Duplicate of Paid | M | |
| 5Ø3-F3 | AUTHORIZATION NUMBER | RW | When calling the Help Desk, this ID is the fastest means to identify the claim. | |
| 547-5F | APPROVED MESSAGE CODE COUNT | Maximum count of 5 | RW | |
| 548-6F | APPROVED MESSAGE CODE | RW | Used for Transition of Care messaging when applicable. | |
| 13Ø-UF | ADDITIONAL MESSAGE INFORMATION COUNT | Maximum count of 25 | RW | |
| 132-UH | ADDITIONAL MESSAGE INFORMATION QUALIFIER | 01 – 09 for the number of lines of messaging 10 – Next Refill Date (format CCYYMMDD) 19 – Remaining Quantity; Remaining amount of a maximum quantity limit based on quantity amounts accumulated. | RW | |
| 526-FQ | ADDITIONAL MESSAGE INFORMATION | RW | ||
| 131-UG | ADDITIONAL MESSAGE INFORMATION CONTINUITY | RW | ||
| 987-MA | URL | RW | Future Use |
Response Claim Segment (111-AM = “22”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 455-EM | PRESCRIPTION / SERVICE REFERENCE NUMBER QUALIFIER | 1 = Rx Billing | M | |
| 4Ø2-D2 | PRESCRIPTION / SERVICE REFERENCE NUMBER | M |
Response Pricing Segment (111-AM = “23”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 5Ø5-F5 | PATIENT PAY AMOUNT | R | ||
| 5Ø6-F6 | INGREDIENT COST PAID | R | ||
| 5Ø7-F7 | DISPENSING FEE PAID | RW | ||
| 557-AV | TAX EXEMPT INDICATOR | RW | ||
| 558-AW | FLAT SALES TAX AMOUNT PAID | RW | ||
| 559-AX | PERCENTAGE SALES TAX AMOUNT PAID | RW | ||
| 56Ø-AY | PERCENTAGE SALES TAX RATE PAID | RW | ||
| 561-AZ | PERCENTAGE SALES TAX BASIS PAID | RW | ||
| 521-FL | INCENTIVE AMOUNT PAID | RW | ||
| 563-J2 | OTHER AMOUNT PAID COUNT | Maximum count of 3 | RW | Returned when values related to the following reimbursements are returned. |
| 564-J3 | OTHER AMOUNT PAID QUALIFIER | RW | Values provided per trading partner agreements. | |
| 565-J4 | OTHER AMOUNT PAID | RW | ||
| 566-J5 | OTHER PAYER AMOUNT RECOGNIZED | RW | Returned on COB payment response when OPAP dollars used to reduce primary claim payment. | |
| 5Ø9-F9 | TOTAL AMOUNT PAID | R | ||
| 522-FM | BASIS OF REIMBURSEMENT DETERMINATION | RW |
Response Pricing Segment (111-AM = “23”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| COMPONENTS OF PATIENT PAY AMOUNT | ||||
| 523-FN | AMOUNT ATTRIBUTED TO SALES TAX | RW | ||
| 517-FH | AMOUNT APPLIED TO PERIODIC DEDUCTIBLE | RW | ||
| 518-FI | AMOUNT OF COPAY | RW | ||
| 52Ø-FK | AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM | RW | ||
| 571-NZ | AMOUNT ATTRIBUTED TO PROCESSOR FEE | RW | ||
| 572-4U | AMOUNT OF COINSURANCE | RW | ||
| 129-UD | HEALTH PLAN-FUNDED ASSISTANCE AMOUNT | 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 | ||
| 136-UN | AMOUNT ATTRIBUTED TO PRODUCT SELECTION / BRAND NON-PREFERRED FORMULARY SELECTION | RW | ||
| 137-UP | AMOUNT ATTRIBUTED TO COVERAGE GAP | RW | ||
| INFORMATIONAL FIELDS | ||||
| 512-FC | ACCUMULATED DEDUCTIBLE AMOUNT | RW | When applicable, the amount that has accumulated toward the deductible. | |
| 513-FD | REMAINING DEDUCTIBLE AMOUNT | RW | When applicable, the amount of deductible that remains to be met. | |
| 514-FE | REMAINING BENEFIT AMOUNT | RW | When applicable, the amount of benefit that has not yet been met. | |
| 575-EQ | PATIENT SALES TAX AMOUNT | RW | ||
| 574-2Y | PLAN SALES TAX AMOUNT | RW | ||
Response Pricing Segment (111-AM = “23”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 148-U8 | INGREDIENT COST CONTRACTED / REIMBURSABLE AMOUNT | RW | Returned when payment is based on Patient Responsibility COB or Patient Pay Amount. | |
| 149-U9 | DISPENSING FEE CONTRACTED / REIMBUSABLE AMOUNT | RW | Returned when payment is based on Patient Responsibility COB or Patient Pay Amount. | |
| 577-G3 | ESTIMATED GENERIC SAVINGS | RW | ||
| 128-UC | SPENDING ACCOUNT AMOUNT REMAINING | RW |
Response DUR/PPS Segment (111-AM = “24”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 567-J6 | DUR / PPS RESPONSE CODE COUNTER | Maximum of 9 occurrences | RW | |
| 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 | ||
| 531-FV | QUANTITY OF PREVIOUS FILL | RW | ||
| 532-FW | DATABASE INDICATOR | RW | ||
| 533-FX | OTHER PRESCRIBER INDICATOR | RW | ||
| 544-FY | DUR FREE TEXT MESSAGE | RW | ||
| 57Ø-NS | DUR ADDITIONAL TEXT | RW |
Response Coordination of Benefits/Other Payers Segment (111-AM = “28”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 355-NT | OTHER PAYER ID COUNT | Maximum count of 3 | M | |
| 338-5C | OTHER PAYER COVERAGE TYPE | M | ||
| 339-6C | OTHER PAYER ID QUALIFIER | 03 = BIN | RW | |
| 34Ø-7C | OTHER PAYER ID | RW | ||
| 991-MH | OTHER PAYER PROCESSOR CONTROL NUMBER | RW | ||
| 356-NU | OTHER PAYER CARDHOLDER ID | RW | ||
| 992-MJ | OTHER PAYER GROUP ID | RW | ||
| 142-UV | OTHER PAYER PERSON CODE | RW | ||
| 127-UB | OTHER PAYER HELP DESK PHONE NUMBER | RW | ||
| 143-UW | OTHER PAYER PATIENT RELATIONSHIP CODE | RW | ||
| 144-UX | OTHER PAYER BENEFIT EFFECTIVE DATE | RW | ||
| 145-UY | OTHER PAYER BENEFIT TERMINATION DATE | RW |
Claim Response Transaction (Accepted/Rejected)
Transaction Header Segment – Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 1Ø2-A2 | VERSION / RELEASE NUMBER | DØ | M | |
| 1Ø3-A3 | TRANSACTION CODE | B1 | M | |
| 1Ø9-A9 | TRANSACTION COUNT | Same value as in request. | M | |
| 5Ø1-F1 | HEADER RESPONSE STATUS | A = Accepted | M | |
| 2Ø2-B2 | SERVICE PROVIDER ID QUALIFIER | Same value as in request. | M | |
| 2Ø1-B1 | SERVICE PROVIDER ID | Same value as in request. | M | |
| 4Ø1-D1 | DATE OF SERVICE | Same value as in request. | M |
Response Message Segment (111-AM = “2Ø”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 5Ø4-F4 | MESSAGE | RW | When claim(s) are REJECTED, transmission related messaging may be sent for pharmacy review. |
Response Insurance Segment (111-AM = “25”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 3Ø1-C1 | GROUP ID | RW | ||
| 524-FO | PLAN ID | RW | ||
| 545-2F | NETWORK REIMBURSEMENT ID | RW |
Response Patient Segment (111-AM = “29”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 31Ø-CA | PATIENT FIRST NAME | RW | Returned when enrollment file match occurs to indicate the First Name on the file for the Member ID. | |
| 311-CB | PATIENT LAST NAME | RW | Returned when enrollment file match occurs to indicate the Last Name on the file for the Member ID. | |
| 3Ø4-C4 | DATE OF BIRTH | RW |
Response Status Segment (111-AM = “21”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 112-AN | TRANSACTION RESPONSE STATUS | R = Reject | M | |
| 5Ø3-F3 | AUTHORIZATION NUMBER | RW | When calling the Help Desk, this ID is the fastest means to identify the claim. | |
| 51Ø-FA | REJECT COUNT | Maximum count of 5 | R | |
| 511-FB | REJECT CODE | R | ||
| 546-4F | REJECT FIELD OCCURRENCE INDICATOR | RW | MedImpact will be using the Reject Occurrence Indicator to indicate repeating field rejections. - In the case of COMPOUNDS this will be used to indicate an ingredient level rejection. Example: Reject Code 70 with the Occurrence Indicator of 3 will indicate that the Product submitted as the third ingredient is Not Covered / Plan Benefit Exclusion. - In the case of COB, this will direct the provider to the PAYER LOOP in error. |
Response Status Segment (111-AM = “21”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 13Ø-UF | ADDITIONAL MESSAGE INFORMATION COUNT | Maximum count of 25 | RW | |
| 132-UH | ADDITIONAL MESSAGE INFORMATION QUALIFIER | 01 – 09 for the number of lines of messaging 10 – Next Refill Date (format CCYYMMDD) 19 – Remaining Quantity; Remaining amount of a maximum quantity limit based on quantity amounts accumulated. | RW | |
| 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 | ||
| 987-MA | URL | RW | Future Use |
Response Claim Segment (111-AM = “22”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 455-EM | PRESCRIPTION / SERVICE REFERENCE NUMBER QUALIFIER | 1 = Rx Billing | M | |
| 4Ø2-D2 | PRESCRIPTION / SERVICE REFERENCE NUMBER | M |
Response DUR/PPS Segment (111-AM = “24”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 567-J6 | DUR / PPS RESPONSE CODE COUNTER | Maximum of 9 occurrences | RW | |
| 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 | ||
| 531-FV | QUANTITY OF PREVIOUS FILL | RW | ||
| 532-FW | DATABASE INDICATOR | RW | ||
| 533-FX | OTHER PRESCRIBER INDICATOR | RW | ||
| 544-FY | DUR FREE TEXT MESSAGE | RW | ||
| 57Ø-NS | DUR ADDITIONAL TEXT | RW |
Response Coordination of Benefits/Other Payer Segment (111-AM = “28”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 335-NT | OTHER PAYER ID COUNT | Maximum count of 3 | M | |
| 338-5C | OTHER PAYER COVERAGE TYPE | M | ||
| 339-6C | OTHER PAYER ID QUALIFIER | 03 = BIN Number | RW | |
| 34Ø-7C | OTHER PAYER ID | RW | ||
| 991-MH | OTHER PAYER PROCESSOR CONTROL NUMBER | RW | ||
| 356-NU | OTHER PAYER CARDHOLDER ID | RW | ||
| 992-MJ | OTHER PAYER GROUP ID | RW | ||
| 142-UV | OTHER PAYER PERSON CODE | RW | ||
| 127-UB | OTHER PAYER HELP DESK PHONE NUMBER | RW | ||
| 143-UW | OTHER PAYER PATIENT RELATIONSHIP CODE | RW | ||
| 144-UX | OTHER PAYER BENEFIT EFFECTIVE DATE | RW | ||
| 145-UY | OTHER PAYER BENEFIT TERMINATION DATE | RW |
Claim Response Transaction (Rejected/Rejected)
Transaction Header Segment – Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 1Ø2-A2 | VERSION / RELEASE NUMBER | DØ | M | |
| 1Ø3-A3 | TRANSACTION CODE | B1 | M | |
| 1Ø9-A9 | TRANSACTION COUNT | Same value as in request. | M | |
| 5Ø1-F1 | HEADER RESPONSE STATUS | R = Rejected | M | |
| 2Ø2-B2 | SERVICE PROVIDER ID QUALIFIER | Same value as in request. | M | |
| 2Ø1-B1 | SERVICE PROVIDER ID | Same value as in request. | M | |
| 4Ø1-D1 | DATE OF SERVICE | Same value as in request. | M |
Response Message Segment (111-AM = “2Ø”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 5Ø4-F4 | MESSAGE | RW | When claim(s) are REJECTED, transmission related messaging may be sent for pharmacy review. |
Response Status Segment (111-AM = “21”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 112-AN | TRANSACTION RESPONSE STATUS | R = Reject | M | |
| 5Ø3-F3 | AUTHORIZATION NUMBER | RW | When calling Help Desk, this ID is the fastest means to identify the claim. | |
| 51Ø-FA | REJECT COUNT | Maximum count of 5 | R | |
| 511-FB | REJECT CODE | R | ||
| 546-4F | REJECT FIELD OCCURRENCE INDICATOR | RW | ||
| 13Ø-UF | ADDITIONAL MESSAGE INFORMATION COUNT | Maximum count of 25 | RW | When supplied, count will equal the number of sets associated with UH, FQ and UG fields. |
| 132-UH | ADDITIONAL MESSAGE INFORMATION QUALIFIER | 01 – 09 for the number of lines of messaging 10 – Next Refill Date (format CCYYMMDD) 19 – Remaining Quantity; Remaining amount of a maximum quantity limit based on quantity amounts accumulated. | RW | |
| 526-FQ | ADDITIONAL MESSAGE INFORMATION | RW | ||
| 131-UG | ADDITIONAL MESSAGE INFORMATION CONTINUITY | RW |
Claim Reversal Request Transaction
Reversals must be submitted with the same Rx number as was submitted on the original paid claim.
Reversals of COB claims should be performed in the correct “back out order”, meaning LAST claim billed must be reversed first until getting to the primary claim or a claim to be re-submitted.
- If a claim has been billed as Primary, Secondary, or Tertiary and the pharmacy wishes to reprocess the secondary claim, the tertiary claim must be reversed first, then the secondary reversal. At this point the pharmacy may reprocess the secondary claim as required (the tertiary claim as well).
- The reversal of a COB claim must contain the COB segment with Other Payer Coverage Type so in the case where MedImpact is the payer of more than one claim for the Pharmacy, Rx, Date of Service and Fill Number, the claim for reversal can be correctly identified.
Transaction Header Segment – Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 1Ø1-A1 | BIN NUMBER | 018902 | M | |
| 1Ø2-A2 | VERSION / RELEASE NUMBER | DØ | M | |
| 1Ø3-A3 | TRANSACTION CODE | B2 | M | |
| 1Ø4-A4 | PROCESSOR CONTROL NUMBER | P303018902 | M | Should be same value as submitted on B1 claim. |
| 1Ø9-A9 | TRANSACTION COUNT | 1 through 4 supported | M | |
| 2Ø2-B2 | SERVICE PROVIDER ID QUALIFIER | 01 = NPI | M | |
| 2Ø1-B1 | SERVICE PROVIDER ID | M | ||
| 4Ø1-D1 | DATE OF SERVICE | M | ||
| 11Ø-AK | SOFTWARE VENDOR / CERTIFICATION ID | Blanks | M |
Insurance Segment (111-AM = “Ø4”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 3Ø2-C2 | CARDHOLDER ID | M | Value submitted on claim should be included on reversal. | |
| 3Ø1-C1 | GROUP ID | COMEDICAID | R | Value submitted on claim should be included on reversal. |
| 3Ø6-C6 | PATIENT RELATIONSHIP CODE |
Claim Segment (111-AM = “Ø7”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 455-EM | PRESCRIPTION / SERVICE REFERENCE NUMBER QUALIFIER | 1 = Rx Billing | M | |
| 4Ø2-D2 | PRESCRIPTON / SERVICE REFERENCE NUMBER | M | ||
| 436-E1 | PRODUCT / SERVICE ID QUALIFIER | 03 = NDC | M | |
| 4Ø7-D7 | PRODUCT / SERVICE ID | M | ||
| 4Ø3-D3 | FILL NUMBER | R | Used as a ‘tie break’ if multiple fills of the same Rx/DOS allowed. | |
| 3Ø8-C8 | OTHER COVERAGE CODE | RW | Required when reversing a COB claim. Used as a ‘tie break’ if multiple fills of same Rx/DOS allowed. | |
| 147-U7 | PHARMACY SERVICE TYPE | RW |
Pricing Segment (111-AM = “11”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 4Ø9-D9 | INGREDIENT COST SUBMITTED | |||
| 412-DC | DISPENSING FEE SUBMITTED | |||
| 438-E3 | INCENTIVE AMOUNT SUBMITTED | |||
| 426-DQ | USUAL AND CUSTOMARY CHARGE | |||
| 43Ø-DU | GROSS AMOUNT DUE | |||
| 423-DN | BASIS OF COST DETERMINATION |
Coordination of Benefit/Other Payment Segment (111-AM = “Ø5”) Situational
Required for reversal of a COB claim
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 337-4C | COORDINATION OF BENEFITS / OTHER PAYMENTS COUNT | Maximum count of 9 | RW | Required when original claim was COB. |
| 338-5C | OTHER PAYER COVERAGE TYPE | RW | Required when original claim was COB. | |
| 339-6C | OTHER PAYER ID QUALIFIER | |||
| 34Ø-7C | OTHER PAYER ID | |||
| 443-E8 | OTHER PAYER DATE | |||
| 341-HB | OTHER PAYER AMOUNT PAID COUNT | |||
| 342-HC | OTHER PAYER AMOUNT PAID QUALIFIER | |||
| 431-DV | OTHER PAYER AMOUNT PAID | |||
| 471-5E | OTHER PAYER REJECT COUNT | |||
| 472-6E | OTHER PAYER REJECT CODE | |||
| 353-NR | OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT | |||
| 351-NP | OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER | |||
| 352-NQ | OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT |
Claim Reversal Response Transaction (Accepted/Approved)
Transaction Header Segment – Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 1Ø2-A2 | VERSION / RELEASE NUMBER | DØ | M | |
| 1Ø3-A3 | TRANSACTION CODE | B2 | M | |
| 1Ø9-A9 | TRANSACTION COUNT | Same value as in request. | M | |
| 5Ø1-F1 | HEADER RESPONSE STATUS | A = Accepted | M | |
| 2Ø2-B2 | SERVICE PROVIDER ID QUALIFIER | Same value as in request. | M | |
| 2Ø1-B1 | SERVICE PROVIDER ID | Same value as in request. | M | |
| 4Ø1-D1 | DATE OF SERVICE | Same value as in request. | M |
Response Message Segment (111-AM = “2Ø”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 5Ø4-F4 | MESSAGE | RW | When reversals are successful, transmission related messaging may be sent for pharmacy review. |
Response Status Segment (111-AM = “21”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 112-AN | TRANSACTION RESPONSE STATUS | A = Approved | M | |
| 5Ø3-F3 | AUTHORIZATION NUMBER | RW | When calling Help Desk, this ID is the fastest means to identify the claim. | |
| 13Ø-UF | ADDITIONAL MESSAGE INFORMATION COUNT | Maximum count of 25 | RW | |
| 132-UH | ADDITIONAL MESSAGE INFORMATION QUALIFIER | 01 – 09 for the number of lines of messaging 10 – Next Refill Date (format CCYYMMDD) 19 – Remaining Quantity; Remaining amount of a maximum quantity limit based on quantity amounts accumulated. | RW | |
| 526-FQ | ADDITIONAL MESSAGE INFORMATION | RW | ||
| 131-UG | ADDITIONAL MESSAGE INFORMATION CONTINUITY | RW |
Response Claim Segment (111-AM = “22”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 455-EM | PRESCRIPTION / SERVICE REFERENCE NUMBER QUALIFIER | 1 = Rx Billing | M | |
| 4Ø2-D2 | PRESCRIPTION/SERVICE REFERENCE NUMBER | M |
Claim Reversal Response Transaction (Accepted/Rejected)
Transaction Header Segment – Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 1Ø2-A2 | VERSION / RELEASE NUMBER | DØ | M | |
| 1Ø3-A3 | TRANSACTION CODE | B2 | M | |
| 1Ø9-A9 | TRANSACTION COUNT | Same value as in request. | M | |
| 5Ø1-F1 | HEADER RESPONSE STATUS | A = Accepted | M | |
| 2Ø2-B2 | SERVICE PROVIDER ID QUALIFIER | Same value as in request. | M | |
| 2Ø1-B1 | SERVICE PROVIDER ID | Same value as in request. | M | |
| 4Ø1-D1 | DATE OF SERVICE | Same value as in request. | M |
Response Message Segment (111-AM = “2Ø”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 5Ø4-F4 | MESSAGE | RW | When reversals are REJECTED, transmission related messaging may be sent for pharmacy review. |
Response Status Segment (111-AM = “21”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 112-AN | TRANSACTION RESPONSE STATUS | R = Reject | M | |
| 5Ø3-F3 | AUTHORIZATION NUMBER | RW | When calling Help Desk, this ID is the fastest means to identify the claim. | |
| 51Ø-FA | REJECT COUNT | Maximum count of 5 | R | |
| 511-FB | REJECT CODE | R | ||
| 546-4F | REJECT FIELD OCCURRENCE INDICATOR | RW | ||
| 13Ø-UF | ADDITIONAL MESSAGE INFORMATION COUNT | Maximum count of 25 | RW | |
| 132-UH | ADDITIONAL MESSAGE INFORMATION QUALIFIER | 01 – 09 for the number of lines of messaging 10 – Next Refill Date (format CCYYMMDD) 19 – Remaining Quantity; Remaining amount of a maximum quantity limit based on quantity amounts accumulated. | RW | |
| 526-FQ | ADDITIONAL MESSAGE INFORMATION | RW | ||
| 131-UG | ADDITIONAL MESSAGE INFORMATION CONTINUITY | RW |
Response Claim Segment (111-AM = “22”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 455-EM | PRESCRIPTION / SERVICE REFERENCE NUMBER QUALIFIER | 1 = Rx Billing | M | |
| 4Ø2-D2 | PRESCRIPTION/SERVICE REFERENCE NUMBER | M |
Claim Reversal Response Transaction (Rejected/Rejected)
Transaction Header Segment – Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 1Ø2-A2 | VERSION / RELEASE NUMBER | DØ | M | |
| 1Ø3-A3 | TRANSACTION CODE | B2 | M | |
| 1Ø9-A9 | TRANSACTION COUNT | Same value as in request. | M | |
| 5Ø1-F1 | HEADER RESPONSE STATUS | R = Rejected | M | |
| 2Ø2-B2 | SERVICE PROVIDER ID QUALIFIER | Same value as in request. | M | |
| 2Ø1-B1 | SERVICE PROVIDER ID | Same value as in request. | M | |
| 4Ø1-D1 | DATE OF SERVICE | Same value as in request. | M |
Response Message Segment (111-AM = “2Ø”) Situational
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 5Ø4-F4 | MESSAGE | RW | When claim transmission is REJECTED, contains information to further explain the reason for the rejection. |
Response Status Segment (111-AM = “21”) Mandatory
| Field # | NCPDP Field Name | Value | Payer Usage | Payer Situation |
|---|---|---|---|---|
| 112-AN | TRANSACTION RESPONSE STATUS | R = Reject | M | |
| 5Ø3-F3 | AUTHORIZATION NUMBER | RW | When calling Help Desk, this ID is the fastest means to identify the claim. | |
| 51Ø-FA | REJECT COUNT | Maximum count of 5 | R | |
| 511-FB | REJECT CODE | R | ||
| 546-4F | REJECT FIELD OCCURRENCE INDICATOR | RW | ||
| 13Ø-UF | ADDITIONAL MESSAGE INFORMATION COUNT | Maximum count of 25 | RW | |
| 132-UH | ADDITIONAL MESSAGE INFORMATION QUALIFIER | 01 – 09 for the number of lines of messaging 10 – Next Refill Date (format CCYYMMDD) 19 – Remaining Quantity; Remaining amount of a maximum quantity limit based on quantity amounts accumulated. | RW | |
| 526-FQ | ADDITIONAL MESSAGE INFORMATION | RW | ||
| 131-UG | ADDITIONAL MESSAGE INFORMATION CONTINUITY | RW |
Revision History
| Revision Date | Version | Summary of Changes |
|---|---|---|
| May 19, 2025 | 1.0 | Created |