SPARK-ITS New Mexico Medicaid D.0 FFS Payer Sheet B1-B3

Transcription

1 SPAK-ITS New exico edicaid D.0 FFS Payer Sheet B1-B3 Expert ode (E) Project anagement ethodology September 2015 Version 1.1

2 erox Corporation, erox and erox and Design are trademarks of erox Corporation in the United States and/or other countries. This document is produced for N edicaid Project and cannot be reproduced or distributed to any third party without prior written consent. No part of this document may be modified, deleted, or expanded by any process or means without prior written permission from erox.

3 evision History Version Number Date Description Author /01/14 Initial document with the incentive amount included for Naloxone (438- E3 and 440-E5 updated) 1.1 7/14/2015 Updated 420-DK with Submission Clarification Codes 47 and 48 added. Christine arshall arvin Boyd Configuration of This Document This document is under full configuration management. See Configuration Items List. edicaid Fee For Service iii

4 Table of Contents evision History... iii Configuration of This Document... iii 1.0 equest (B1/B3) Payer Sheet esponse Payer Sheet esponse Payer Sheet Accepted/ejected esponse.. 20 Accepted/ejected esponse ejected/ejected esponse edicaid Fee For Service iv

5 1.0 equest Claim Billing/Claim ebill (B1/B3) Payer Sheet equest (B1/B3) Payer Sheet GENEAL INFOATION Payer Name: New exico edicaid Plan Name/Group Name: N edicaid Fee BIN: PCN: DNPOD For Service Plan Name/Group Name: N edicaid Fee For Service (test) BIN: Processor: erox Effective as of: 12/11/2011 PCN: DNACCP (after 1/1/2012) PCN: DNDV5S (thru 12/31/2011 for D.Ø testing) NCPDP Telecommunication Standard Version/elease #: D.0 NCPDP External Code List Version Date: arch, 2010 NCPDP Data Dictionary Version Date: October, 2007 Contact/Information Source: Other references such as Provider anuals, Payer phone number, web site, etc. Certification Testing Window: Certification is not required Certification Contact Information: Certification phone number and information Provider elations Help Desk Info: 8ØØ Other versions supported: 5.1 supported through 12/31/2011 OTHE TANSACTIONS SUPPOTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Transaction Code Transaction Name B1 Billing B3 ebilling Payer Column FIELD LEGEND FO COLUNS Value Explanation Payer Situation Column No ANDATOY The Field is mandatory for the in the designated Transaction. EQUIED The Field has been designated with the situation of "equired" for the in the designated Transaction. QUALIFIED EQUIEENT equired when. The situations designated have qualifications for usage ("equired if x", "Not required if y"). No Yes edicaid Fee For Service 5

6 Fields that are not used in the transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template. CLAI BILLING/CLAI EBILL TANSACTION The following lists the segments and fields in a Claim Billing or Claim ebill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Transaction Header This is always sent Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Not used If Situational, Transaction Header Claim Billing/Claim ebill 1Ø1-A1 BIN NUBE Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B1, B3 Claim Billing, Claim ebill 1Ø4-A4 POCESSO CONTOL DNPOD = Use DNDV5S for D.Ø NUBE Production DNDV5S = D.Ø test DNACCP = Test testing through 12/31/2011 1Ø9-A9 TANSACTION COUNT 1 = One Occurrence 2 = Two Occurrences 3 = Three Occurrences 4 = Four Occurrences 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Ø1 National Provider Identifier NPI mandated Ø2/Ø1/2ØØ8 2Ø1-B1 SEVICE POVIDE ID National Provider Identifier (NPI) NPI mandated Ø2/Ø1/2ØØ8 4Ø1-D1 DATE OF SEVICE CCYYDD 11Ø-AK SOFTWAE VENDO/CETIFICATIO N ID ØØØØØØØØØØ Populate with zeros Insurance If Situational, This is always sent Insurance (111-A) = Ø4 3Ø2-C2 CADHOLDE ID 312-CC CADHOLDE FIST 12 characters NAE 313-CD CADHOLDE LAST 15 Characters (5.1 Payer Sheet had 20 edicaid Fee For Service 6

7 Insurance (111-A) = Ø4 NAE 3Ø9-C9 ELIGIBILITY CLAIFICATION CODE Ø=Not specified 1=No Override 2=Override 3Ø1-C1 GOUP ID NEWEED 3Ø6-C6 PATIENT ELATIONSHIP 1 = Cardholder CODE characters but 15 is the max per Standard) Enter 2 when the claim has been denied for eligibility but the provider has documentation showing eligibility has recently been determined. Claim will be held for up to 40 days for eligibility to be updated. Patient If Situational, This is always sent Patient (111-A) = Ø1 Field NCPDP Field Name Value Payer 3Ø4-C4 DATE OF BITH CCYYDD 3Ø5-C5 PATIENT GENDE CODE Ø=Not specified 1=ale 335-2C PEGNANCY INDICATO 2=Female Blank=Not Specified 1=Not pregnant 2=Pregnant PATIENT ESIDENCE Ø=Not specified 3=Nursing Facility 9=Intermediate Care Facility/entally etarded 11=Hospice 15=Correctional Institution equired if pregnant equired to indicate patient residence in any of the facilities indicated Claim If Situational, This is always sent This payer supports partial fills Claim Identification (111- A) = Ø7 edicaid Fee For Service 7

8 Claim Identification (111- A) = Ø7 455-E PESCIPTION/SEVI CE EFEENCE NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVI CE EFEENCE NUBE 436-E1 PODUCT/SEVICE ID QUALIFIE 1 = x Billing Ø3 = National Drug Code 4Ø7-D7 PODUCT/SEVICE ID National Drug Code (NDC) 456-EN ASSOCIATED x number of the PESCIPTION/SEVIC associated partial fill E EFEENCE claim NUBE 457-EP ASSOCIATED PESCIPTION/SEVIC E DATE Used when submitting a claim for a partial fill 442-E7 QUANTITY DISPENSED etric Decimal Quantity 4Ø3-D3 FILL NUBE Ø = Original Dispensing 1-99 = efill number 4Ø5-D5 DAYS SUPPLY 4Ø6-D6 COPOUND CODE Ø = Not specified 1= Not a compound 2 = Compound 4Ø8-D8 414-DE 419-DJ 354-N 42Ø-DK DISPENSE AS WITTEN (DAW)/PODUCT SELECTION CODE DATE PESCIPTION WITTEN PESCIPTION OIGIN CODE SUBISSION CLAIFICATION CODE COUNT SUBISSION CLAIFICATION CODE Ø=Default, no product selection indicated 1=Physician request 7=brand mandated by law CCYYDD 1=Written 2=Telephone 3=Electronic 4=Facsimile 5=Transfer aximum count of 3. 8=Process compound for Approved Ingredients 47=Shortened days supply fill. 48=Fill subsequent to a shortened days supply fill equired for the completion transaction in a partial fill (Dispensing Status (343-HD) = C ). Date of the Associated Prescription/Service eference Number. Code indicating whether or not the prescriber s instructions regarding generic substitution were followed. Value 1 may be used when physician requests meet the edicaid Program standards for a brand being medically necessary. equired effective Ø9/Ø1/2ØØ9 Value Ø (not specified) will not be accepted by N. equired if Submission Clarification Code (42Ø-DK) is used. equired when submitting a claim for a multi line compound that includes nonapproved ingredients or ingredients without an NDC number. Value indicates POVIDE approval to accept reimbursement for covered items only. Used to override plan edicaid Fee For Service 8

9 Claim Identification (111- A) = Ø7 3Ø8-C8 453-EJ 445-EA 461-EU OTHE COVEAGE CODE OIGINALLY PESCIBED PODUCT/SEVICE ID QUALIFIE OIGINALLY PESCIBED PODUCT/SEVICE CODE PIO AUTHOIZATION TYPE CODE Ø=Not Specified 1=No other Coverage 2=Other coverage exists - payment collected 3=Other coverage billed - claim not covered 4=Other coverage exists - payment not collected Ø=Not Specified 1=Prior Authorization 2=edical Certification 462-EV PIO AUTHOIZATION NUBE SUBITTED 343-HD DISPENSING STATUS P = Initial Fill C = Completion Fill 344-HF QUANTITY INTENDED TO BE DISPENSED 345-HG DAYS SUPPLY INTENDED TO BE DISPENSED 995-E2 OUTE OF ADINISTATION SNOED Values equired limitations (refill too soon) when a shortened days supply is being dispensed or a fill subsequent to a shortened days supply is being dispensed. equired when other coverage exists Complete to claim higher dispensing fee when product prescribed is different than the product supplied. equired when claiming a higher dispensing fee and field 445-EA is submitted and a pharmacist dispenses a medication other than the originally prescribed Code of the initially prescribed product or service. Effective 07/01/2010 used to indicate when Product Selection has occurred. See notes regarding Product Selection on page 1Ø. Use 1 in this field when submitting claims for Children s edical Services Use 2 in this field for early efill override when authorized by the POS help desk equired if valid value in Field 461-EU is 1 and a number is required to be submitted equired for the partial fill or the completion fill of a prescription. equired when submitting a claim for a partial fill equired when submitting a claim for a partial fill equired when submitting compounds edicaid Fee For Service 9

10 Pricing If Situational, This is always sent Pricing Identification (111- A) = 11 4Ø9-D9 INGEDIENT COST SUBITTED 412-DC DISPENSING FEE SUBITTED 438-E3 INCENTIVE AOUNT SUBITTED 478-H7 OTHE AOUNT CLAIED SUBITTED COUNT Claim Billing/Claim ebill This field is required to be submitted in D.0 which is a change from 5.1 equired if necessary as component part of Gross Amount Due equired when submitting for vaccine administration or Naloxone escue Kit. Format=s$$$$$$cc Example: If the incentive amount submitted is $37.5Ø, this field would reflect: 375. aximum count of 3. Imp Guide: equired if Other Amount Claimed Submitted Qualifier (479- H8) is used. 479-H8 OTHE AOUNT CLAIED SUBITTED QUALIFIE 48Ø-H9 OTHE AOUNT CLAIED SUBITTED 426-DQ USUAL AND CUSTOAY CHAGE 43Ø-DU GOSS AOUNT DUE 423-DN BASIS OF COST DETEINATION Ø9=Compound Preparation Cost Submitted Ø8=340B/Disproportionate Share Pricing/Public Health Service If a compounding fee is being requested in addition to the dispensing fee enter Ø9. New qualifier value added in D.0 N providers enter compound fee in this field. Amount charged cash customers for the prescription exclusive of sales tax or other amounts claimed. This field is required to be submitted in D.0 which is a change from 5.1 equired to identify 340b acquisition cost. Prescriber If Situational, This is always sent Prescriber (111-A) = Ø3 edicaid Fee For Service 10

11 Prescriber (111-A) = Ø3 466-EZ PESCIBE ID QUALIFIE 411-DB PESCIBE ID Ø1=National Provider Identifier (NPI) National Provider Identifier (NPI) Prescriber NPI is required effective 05/23/2008. NPI mandated 05/23/2008 Coordination of Benefits/Other Payments If Situational, This is situational equired only for secondary, tertiary, etc claims. Scenario 3 - Other Payer Amount Paid, Other Payer-Patient esponsibility Amount, and Benefit Stage epetitions Present (Government Programs) If the Payer supports the Coordination of Benefits/Other Payments, only one scenario method shown above may be supported per template. The template shows the Coordination of Benefits/Other Payments that must be used for each scenario method. The Payer must choose the appropriate scenario method with the segment chart, and delete the other scenario methods with their segment charts. See section Coordination of Benefits (COB) Processing for more information. Coordination of Benefits/Other Payments Identification (111- A) = Ø C COODINATION OF aximum count of BENEFITS/OTHE 9. PAYENTS COUNT 338-5C OTHE PAYE COVEAGE TYPE 339-6C OTHE PAYE ID QUALIFIE Blank=Not Specified Ø1=Primary Ø2=Secondary - Second Ø3=Tertiary - Third Ø4=Quaternary - Fourth Ø5=Quinary - Fifth Ø3=Bank Information Number (BIN) 99=Other Scenario 3 - Other Payer Amount Paid, Other Payer- Patient esponsibility Amount, and Benefit Stage epetitions Present (Government Programs) Submit value 99 and N Carrier code in 340-7C if known. Otherwise use 03 and submit BIN of previous payer in 340-7C. 34Ø-7C OTHE PAYE ID Submit N Carrier Code if known, otherwise submit BIN of previous payer 443-E8 OTHE PAYE DATE CCYYDD equired when there is payment or denial from another source 341-HB OTHE PAYE aximum count of equired if Other Payer edicaid Fee For Service 11

12 Coordination of Benefits/Other Payments Identification (111- A) = Ø5 Scenario 3 - Other Payer Amount Paid, Other Payer- Patient esponsibility Amount, and Benefit Stage epetitions Present (Government Programs) AOUNT PAID COUNT 9. Amount Paid Qualifier (342- HC) is used. 342-HC 431-DV OTHE PAYE AOUNT PAID QUALIFIE OTHE PAYE AOUNT PAID Ø1=Delivery Ø2=Shipping Ø3=Postage Ø4=Administrative Ø5=Incentive Ø6=Cognitive Service Ø7=Drug Benefit Ø9=Compound Preparation Cost 1Ø=Sales Tax equired when there is payment from another source Payer equirement: equired when 308-C8 = 2 equired if other payer has approved payment for some/all of the billing E OTHE PAYE EJECT COUNT 472-6E OTHE PAYE EJECT CODE 353-N 351-NP OTHE PAYE- PATIENT ESPONSIBILITY AOUNT COUNT OTHE PAYE- PATIENT ESPONSIBILITY AOUNT QUALIFIE aximum count of 5. aximum count of 25. Ø1=Amt Applied to Periodic Deductible Ø2=Amt Attributed to Product Selection/Brand Drug Ø3=Amt Attributed to Sales Tax Ø4=Amt Exceeding Periodic Benefit aximum Ø5=Amount of Copay Ø6=Patient Pay Amount Ø7=Amount of Coinsurance Ø8=Amt Attributed to Product Selection/Non-Pref equired if Other Payer eject Code (472-6E) is used. Payer equirement: equired if OCC = 3 equired when the other payer has denied the payment for the billing, designated with Other Coverage Code (3Ø8- C8) = 3 (Other Coverage Billed claim not covered). equired if Other Payer- Patient esponsibility Amount Qualifier (351-NP) is used. equired if Other Payer- Patient esponsibility Amount (352-NQ) is used. Use to indicate patient responsibility amount when 308-C8 = 2 or 4 Submission of Ø3, 09, 13 will result in a Denial Submission of 02, 08, 11 will pay only if DAW=1 Submission of 12 will deny if edicare Part D, pay if other non-edicare insurer Submission of 10 will return to patient for payment edicaid Fee For Service 12

13 Coordination of Benefits/Other Payments Identification (111- A) = Ø5 Formulary Ø9=Amt Attributed to Health Plan Funded Assistance Amount 1Ø= Amt Attributed to Provider Network Selection 11=Amt Attributed to Product Selection/Brand Non-Preferred Formulary Selection 12=Amt Attributed to Coverage Gap 13=Amt Attributed to Processor Fee 352-NQ OTHE PAYE- PATIENT ESPONSIBILITY AOUNT Scenario 3 - Other Payer Amount Paid, Other Payer- Patient esponsibility Amount, and Benefit Stage epetitions Present (Government Programs) equired when Other Coverage Code 308-C8 = 2 or 4 DU/PPS If Situational, This is always sent This is situational DU/PPS (111-A) = Ø E DU/PPS CODE COUNTE aximum of 9 occurrences. equired if DU/PPS is used. 439-E4 EASON FO SEVICE CODE Code identifying the type of utilization conflict detected or the reason for the pharmacist s professional service. 44Ø-E5 POFESSIONAL SEVICE CODE A = edication administration Use A for vaccine administration and naloxone rescue kit incentive amount. ust equal a value of A (edication Administered) when Incentive Amount Submitted (438-E3) is greater than zero (Ø). Payer equirement: Enter one professional service code only, indicating the type of service. N edicaid Valid Values: edicaid Fee For Service 13

14 DU/PPS (111-A) = Ø8 441-E6 ESULT OF SEVICE CODE 474-8E DU/PPS LEVEL OF EFFOT Ø=Not Specified 11=Level 1 (Lowest) 12=Level 2 13=Level 3 14=Level 4 15=Level 5 (Highest) A = edication Administration Action taken by a pharmacist in response to a conflict or the result of a pharmacist s professional service. Code indicating the level of effort as determined by the complexity of decision-making or resources utilized by a pharmacist to perform a professional service. 475-J9 DU CO-AGENT ID QUALIFIE equired if DU Co-Agent ID (476-H6) is used. 476-H6 DU CO-AGENT ID Identifies the co-existing agent contributing to the DU event (drug or disease conflicting with the prescribed drug or prompting pharmacist professional service). Compound If Situational, This is always sent This is situational equired when billing for member that has other coverage (TPL) Compound (111-A) = 1Ø 45Ø-EF COPOUND DOSAGE FO DESCIPTION CODE 451-EG COPOUND DISPENSING UNIT FO INDICATO Ø1=Capsule Ø2=Ointment Ø3=Cream Ø4=Suppository Ø5=Powder Ø6=Emulsion Ø7=Liquid 1Ø=Tablet 11=Solution 12=Suspension 13=Lotion 14=Shampoo 15=Elixir 16=Syrup 17=Lozenge 18=Enema 1=Each 2=Grams 3=illiliters Dosage form of the ete compound mixture edicaid Fee For Service 14

15 Compound (111-A) = 1Ø 447-EC COPOUND INGEDIENT COPONENT COUNT 488-E COPOUND PODUCT ID QUALIFIE 489-TE COPOUND PODUCT ID 448-ED COPOUND INGEDIENT QUANTITY 449-EE COPOUND INGEDIENT DUG COST aximum 25 ients Ø3=NDC NDC 9(7)v999 Count of compound product IDs (both active and inactive) in the compound mixture submitted. Imp Guide: equired if needed for receiver claim determination when multiple products are billed. 49Ø-UE COPOUND INGEDIENT BASIS OF COST DETEINATION Ø8=340B / Disproportionate Share Pricing/Public Health Service Payer equirement: Use to submit 340b acquisition cost if 340b inventory is used for compound ingredient(s). Submit Ø8 to identify 340b acquisition cost eqequest (B1/B3) Payer Sheet est (B1/B3) Payer Sheet ** End of equest (B1/B3) Payer Sheet Template** 2.0 esponse Claim Billing/Claim ebill Payer Sheet esponse Payer Sheet ** Start of esponse (B1/B3) Payer Sheet Template** Payer Name: New exico edicaid Plan Name/Group Name: N edicaid Fee For Service GENEAL INFOATION BIN: 61ØØ84 PCN: DNPOD = Production edicaid Fee For Service 15

16 Plan Name/Group Name: N edicaid Fee For Service (test) BIN: 61ØØ84 PCN: DNACCP = Test (after 1/1/2012) PCN: DNDV5S (thru 12/31/2011 for D.Ø testing) CLAI BILLING/CLAI EBILL PAID (O DUPLICATE OF PAID) ESPONSE The following lists the segments and fields in a Claim Billing or Claim ebill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. esponse Transaction Header This is always sent Accepted/Paid (or Duplicate of Paid) If Situational, esponse Transaction Header 1Ø2-A2 VESION/ELEASE DØ NUBE 1Ø3-A3 TANSACTION CODE B1, B3 1Ø9-A9 TANSACTION COUNT Same value as in request 5Ø1-F1 HEADE ESPONSE A = Accepted STATUS 2Ø2-B2 SEVICE POVIDE Same value as in ID QUALIFIE request 2Ø1-B1 SEVICE POVIDE Same value as in ID request 4Ø1-D1 DATE OF SEVICE Same value as in request Accepted/Paid (or Duplicate of Paid) esponse essage Accepted/Paid (or Duplicate of Paid) If Situational, This is situational sent if required for clarification esponse essage (111-A) = 2Ø Accepted/Paid (or Duplicate of Paid) 5Ø4-F4 ESSAGE Text essage equired if text is needed for clarification or detail. esponse Insurance This is always sent esponse Insurance (111-A) = 25 Accepted/Paid (or Duplicate of Paid) If Situational, Accepted/Paid (or Duplicate of Paid) edicaid Fee For Service 16

17 3Ø1-C1 GOUP ID Used to identify the group number used in claim adjudication. 524-FO PLAN ID Used to identify the actual plan ID that was used in claim adjudication. esponse Status This is always sent Accepted/Paid (or Duplicate of Paid) If Situational, esponse Status (111-A) = AN TANSACTION ESPONSE STATUS P=Paid D=Duplicate of Accepted/Paid (or Duplicate of Paid) 5Ø3-F3 13Ø-UF AUTHOIZATION NUBE ADDITIONAL ESSAGE INFOATION COUNT 17-digit TCN aximum count of 25. equired if Additional essage Information (526- FQ) is used. 132-UH ADDITIONAL ESSAGE INFOATION QUALIFIE equired if Additional essage Information (526- FQ) is used. 526-FQ ADDITIONAL ESSAGE INFOATION equired when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFOATION CONTINUITY equired if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526- FQ) follows it, and the text of the following message is a continuation of the current. esponse Claim This is always sent esponse Claim (111-A) = 22 Accepted/Paid (or Duplicate of Paid) If Situational, Accepted/Paid (or Duplicate of Paid) edicaid Fee For Service 17

18 455-E PESCIPTION/SEVI 1 = x Billing CE EFEENCE NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVI CE EFEENCE NUBE esponse Pricing This is always sent Accepted/Paid (or Duplicate of Paid) If Situational, esponse Pricing (111-A) = 23 5Ø5-F5 PATIENT PAY AOUNT 5Ø6-F6 INGEDIENT COST PAID 5Ø7-F7 DISPENSING FEE PAID 521-FL INCENTIVE AOUNT PAID 559-A PECENTAGE SALES TA AOUNT PAID 563-J2 OTHE AOUNT PAID COUNT aximum count of 3. Accepted/Paid (or Duplicate of Paid) equired if Incentive Amount Submitted (438- E3) is greater than zero (Ø). Populated with zeros equired if Other Amount Paid (565-J4) is used. 564-J3 OTHE AOUNT PAID QUALIFIE 565-J4 OTHE AOUNT PAID Ø9 = Compound Preparation Cost Paid equired if Other Amount Paid (565-J4) is used. equired if this value is used to arrive at the final reimbursement. equired if Other Amount Claimed Submitted (48Ø- H9) is greater than zero (Ø). 566-J5 OTHE PAYE AOUNT ECOGNIZED equired if Other Payer Amount Paid (431-DV) is greater than zero (Ø) and Coordination of Benefits/Other Payments is supported. 5Ø9-F9 TOTAL AOUNT PAID 522-F BASIS OF EIBUSEENT DETEINATION equired if Ingredient Cost Paid (5Ø6-F6) is greater than zero (Ø). 514-FE EAINING BENEFIT Populated with zeros. AOUNT 517-FH AOUNT APPLIED TO Populated with zeros. PEIODIC DEDUCTIBLE 518-FI AOUNT OF COPAY Patient Copay edicaid Fee For Service 18

19 esponse Pricing (111-A) = 23 52Ø-FK AOUNT ECEEDING PEIODIC BENEFIT AIU Accepted/Paid (or Duplicate of Paid) Populated with zeros. esponse DU/PPS Accepted/Paid (or Duplicate of Paid) If Situational, This is situational Sent to provide information about DU conflicts esponse DU/PPS (111-A) = J6 DU/PPS ESPONSE CODE COUNTE 439-E4 EASON FO SEVICE CODE 528-FS CLINICAL SIGNIFICANCE CODE 529-FT 53Ø-FU 531-FV OTHE PHAACY INDICATO PEVIOUS DATE OF FILL QUANTITY OF PEVIOUS FILL aximum 9 occurrences supported. Accepted/Paid (or Duplicate of Paid) equired if eason For Service Code (439-E4) is used. equired if utilization conflict is detected. equired if needed to supply additional information for the equired if needed to supply additional information for the CCYYDD equired if needed to supply additional information for the equired if needed to supply additional information for the 532-FW DATABASE INDICATO 1 = First DataBank a drug database company equired if needed to supply additional information for the 533-F 544-FY OTHE PESCIBE INDICATO DU FEE TET ESSAGE equired if needed to supply additional information for the equired if needed to supply additional information for the edicaid Fee For Service 19

20 3.0 Claim Billing/Claim ebill Accepted/ejected esponse Accepted/ejected esponse CLAI BILLING/CLAI EBILL ACCEPTED/EJECTED ESPONSE esponse Transaction Header This is always sent Accepted/ejected If Situational, esponse Transaction Header 1Ø2-A2 VESION/ELEASE DØ NUBE 1Ø3-A3 TANSACTION CODE B1, B3 1Ø9-A9 TANSACTION COUNT Same value as in request 5Ø1-F1 HEADE ESPONSE A = Accepted STATUS 2Ø2-B2 SEVICE POVIDE ID Same value as in QUALIFIE request 2Ø1-B1 SEVICE POVIDE ID Same value as in request 4Ø1-D1 DATE OF SEVICE Same value as in request Accepted/ejected esponse essage Accepted/ejected If Situational, This is situational sent if required for reject clarification esponse essage (111-A) = 2Ø Accepted/ejected 5Ø4-F4 ESSAGE Text essage equired if text is needed for clarification or detail. edicaid Fee For Service 20

21 esponse Insurance This is always sent This is situational Accepted/ejected If Situational, esponse Insurance (111-A) = 25 Accepted/ejected 3Ø1-C1 GOUP ID Used to identify the actual group ID used during adjudication. 524-FO PLAN ID Used to identify the actual plan ID used during adjudication. esponse Status This is always sent Accepted/ejected If Situational, esponse Status (111-A) = AN TANSACTION = eject ESPONSE STATUS 5Ø3-F3 AUTHOIZATION 17-digit TCN NUBE 546-4F EJECT FIELD OCCUENCE INDICATO 13Ø-UF ADDITIONAL ESSAGE INFOATION COUNT aximum count of 25. Accepted/ejected equired if a repeating field is in error, to identify repeating field occurrence. equired if Additional essage Information (526- FQ) is used. 132-UH ADDITIONAL ESSAGE INFOATION QUALIFIE equired if Additional essage Information (526- FQ) is used. 526-FQ ADDITIONAL ESSAGE INFOATION equired when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFOATION CONTINUITY equired if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526- FQ) follows it, and the text of the following message is a continuation of the current. edicaid Fee For Service 21

22 esponse Claim This is always sent Accepted/ejected If Situational, esponse Claim (111-A) = E 4Ø2-D2 PESCIPTION/SEVI CE EFEENCE NUBE QUALIFIE PESCIPTION/SEVI CE EFEENCE NUBE Accepted/ejected 1 = xbilling For Transaction Code of B1, in the esponse Claim, the Prescription/Service eference Number Qualifier (455-E) is 1 (x Billing). esponse DU/PPS This is situational Accepted/ejected If Situational, esponse DU/PPS (111-A) = J6 DU/PPS ESPONSE CODE COUNTE 439-E4 EASON FO SEVICE CODE 528-FS CLINICAL SIGNIFICANCE CODE 529-FT 53Ø-FU 531-FV OTHE PHAACY INDICATO PEVIOUS DATE OF FILL QUANTITY OF PEVIOUS FILL aximum 9 occurrences supported. 532-FW DATABASE INDICATO 1 = First DataBank a drug database company 533-F OTHE PESCIBE INDICATO Accepted/ejected equired if eason For Service Code (439-E4) is used. equired if utilization conflict is detected. equired if needed to supply additional information for the equired if needed to supply additional information for the CCYYDD equired if needed to supply additional information for the equired if needed to supply additional information for the equired if needed to supply additional information for the equired if needed to supply additional information for the edicaid Fee For Service 22

23 544-FY esponse DU/PPS (111-A) = 24 DU FEE TET ESSAGE Accepted/ejected equired if needed to supply additional information for the Claim Billing/Claim ebill ejected/ejected esponse CLAI BILLING/CLAI EBILL EJECTED/EJECTED ESPONSE esponse Transaction Header This is always sent ejected/ejected If Situational, esponse Transaction Header 1Ø2- VESION/ELEASE DØ A2 NUBE 1Ø3- TANSACTION CODE B1, B3 A3 1Ø9- TANSACTION COUNT Same value as in A9 request 5Ø1- HEADE ESPONSE = ejected F1 STATUS 2Ø2- SEVICE POVIDE ID Same value as in B2 QUALIFIE request 2Ø1- SEVICE POVIDE ID Same value as in B1 request 4Ø1- DATE OF SEVICE Same value as in D1 request ejected/ejected esponse essage ejected/ejected If Situational, This is situational sent if required for reject clarification edicaid Fee For Service 23

24 esponse essage (111-A) = 2Ø ejected/ejected 5Ø4-F4 ESSAGE Text essage equired if text is needed for clarification or detail. esponse Status This is always sent ejected/ejected If Situational, esponse Status (111-A) = AN TANSACTION = eject ESPONSE STATUS 5Ø3-F3 AUTHOIZATION NUBE 51Ø-FA EJECT COUNT aximum count of 5. ejected/ejected 17-digit TCN equired if needed to identify the transaction. 511-FB EJECT CODE 546-4F EJECT FIELD OCCUENCE INDICATO 13Ø-UF ADDITIONAL ESSAGE INFOATION COUNT aximum count of 25. equired if a repeating field is in error, to identify repeating field occurrence. equired if Additional essage Information (526- FQ) is used. 132-UH ADDITIONAL ESSAGE INFOATION QUALIFIE equired if Additional essage Information (526- FQ) is used. 526-FQ ADDITIONAL ESSAGE INFOATION equired when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFOATION CONTINUITY equired if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526- FQ) follows it, and the text of the following message is a continuation of the current. edicaid Fee For Service 24