OptumRx NCPDP Version D.0 Payer Sheet. Medicare Only

Transcription

1 OptumRx NCPDP Version D.0 Payer heet edicare Only Payer Name: OptumRx Date: 01/01/2018 OptumRx Part-D and APD Plans BIN: PCN: 9999 Part-D WRAP Plans BIN: PCN: 8888 PCN: 8500 OptumRx (This represents former informedrx) BIN: Ø1Ø868 61Ø623 61Ø593 PCN: CTRXEDD HFHCR OptumRx (This represents former informedrx) BIN: 61ØØ11 PCN: 987Ø2 ACC_TBG CCACARE CORCARE COTROOP CTRXEDD PHPEDD PREDD HPPARTD CUCAID ECN FRH HAPEDD HCACARE HTHPRING LCL172 XCFLH PD Ø21ØØØØØ LCL44Ø LEAREGWP NC1 NC2 NC3 NHCPDP OPH Ø211ØØØØ Ø212ØØØØ C1 C2 C3 H1 TCHPCARE UE7316 WAGEGWP OptumRx (This represents former CatalystRx) BIN: Ø Ø PCN: Ø Ø594ØØØØ Ø595ØØØØ 59ØØØØØ 59ØØØØ1 591ØØØØ ØØØØ 597ØØØØ CCOKD CTRXEDD Kaiser (ED D) BIN: PCN: COC COCN COC GAC HIC AC ACA NCC NWC CC Health Choice anagement BIN PCN: HEAEDD Healthmarkets (HIC) BIN: Ø1639Ø PCN: Ø128 C Classicare BIN: Ø15764 PCN: Ø Catamaran / eniorscript ervices BIN: Ø1317Ø PCN: Not Required Cigna edicare Part-D BIN: Ø17Ø1Ø PCN: CIHCARE Processor: OptumRx Effective as of: 01/01/2013 NCPDP Telecommunication tandard Version/Release #: D.0 NCPDP Data Dictionary Version Date: October 2016 NCPDP External Code List Version Date: October 2016 Website Contract Information: Provider Relations Ø1 Provider Relations Provider.relations@optum.com Website Certification Testing Window: Certification not required Help Desk Information: AARP edicarecomplete and UnitedHealthcare edicarecomplete Plans: AARP edicarerx, United edicarerx, UnitedHealthcare edicarerx Plans: UnitedHealthcare edicaid Plans: All other Plans: Other versions supported: ONLY D.0 EDD P IPLY TOTAL

2 CLAI BILLING/CLAI REBILL TRANACTION Transaction Header egment 1Ø1-A1 BIN NUBER (see above) 1Ø2-A2 VERION/RELEAE NUBER DØ 1Ø3-A3 TRANACTION CODE B1, B3 1Ø4-A4 PROCEOR CONTROL NUBER ee above 1Ø9-A9 TRANACTION COUNT Up to 4 2Ø2-B2 ERVICE PROVIDER ID QUALIFIER 01 NPI ONLY 2Ø1-B1 ERVICE PROVIDER ID 10 digit NPI number 4Ø1-D1 DATE OF ERVICE 11Ø-AK OFTWARE VENDOR/CERTIFICATION ID O Insurance egment egment Identification (111-A) = Ø4 3Ø2-C2 CARDHOLDER ID 312-CC CARDHOLDER FIRT NAE 313-CD CARDHOLDER LAT NAE 314-CE HOE PLAN O 524-FO PLAN ID O 3Ø1-C1 GROUP ID Always required. Refer to ember ID Card. 3Ø3-C3 PERON CODE Varies by plan 3Ø6-C6 PATIENT RELATIONHIP CODE Varies by plan 359-2A EDIGAP ID O 36Ø-2B EDICAID INDICATOR O 361-2D PROVIDER ACCEPT AIGNENT O INDICATOR 997-G2 C PART D DEFINED QUALIFIED FACILITY RW 115-N5 EDICAID ID NUBER O Required when submitting LT C hort Cycle claims. Patient egment egment Identification (111-A) = Ø1 Field NCPDP Field Name Value Payer 331-CX PATIENT ID QUALIFIER O 332-CY PATIENT ID O 3Ø4-C4 DATE OF BIRTH R 3Ø5-C5 PATIENT GENDER CODE R 31Ø-CA PATIENT FIRT NAE R 311-CB PATIENT LAT NAE R 322-C PATIENT TREET ADDRE O 323-CN PATIENT CITY ADDRE O 324-CO PATIENT TATE / PROVINCE ADDRE O 325-CP PATIENT ZIP/POTAL ZONE O 326-CQ PATIENT PHONE NUBER O 3Ø7-C7 PLACE OF ERVICE R Required when submitting a Part D Home Infusion (HI) Claim: PO code 12 for Home Required when submitting other Part D Claims (not HI): PO code 01 Pharmacy. 333-CZ EPLOYER ID O 384-4X PATIENT REIDENCE R Required when submitted and LTC or HI claim. Claims for members in an LTC should use 03

3 Patient egment egment Identification (111-A) = Ø1 Field NCPDP Field Name Value Payer Home Infusion should use 01 Claim egment egment Identification (111-A) = Ø7 455-E PRECRIPTION/ERVICE REFERENCE Ø1 = Rx Billing NUBER QUALIFIER 4Ø2-D2 PRECRIPTION/ERVICE REFERENCE NUBER 436-E1 PRODUCT/ERVICE ID QUALIFIER 4Ø7-D7 PRODUCT/ERVICE ID 442-E7 QUANTITY DIPENED R 4Ø3-D3 FILL NUBER R 4Ø5-D5 DAY UPPLY R 4Ø6-D6 COPOUND CODE R 4Ø8-D8 DIPENE A WRITTEN (DAW)/PRODUCT R ELECTION CODE 414-DE DATE PRECRIPTION WRITTEN R 415-DF NUBER OF REFILL AUTHORIZED O 419-DJ PRECRIPTION ORIGIN CODE R Always required 354-NX UBIION CLARIFICATION CODE COUNT 42Ø-DK UBIION CLARIFICATION CODE O aximum count of 3. O Required if ubmission Clarification Code (42Ø-DK) is used. 3Ø8-C8 OTHER COVERAGE CODE RW Required for Coordination of Benefits. 429-DT PECIAL PACKAGING INDICATOR RW Required for LTC hort Cycle Dispensing 453-EJ ORIGINALLY PRECRIBED PRODUCT/ERVICE ID QUALIFIER O Required if Originally Prescribed Product/ervice Code (455-EA) is used. 445-EA ORIGINALLY PRECRIBED O PRODUCT/ERVICE CODE 446-EB ORIGINALLY PRECRIBED QUANTITY O 418-DI LEVEL OF ERVICE O 461-EU PRIOR AUTHORIZATION TYPE CODE RW Varies by plan 462-EV PRIOR AUTHORIZATION NUBER RW UBITTED 995-E2 ROUTE OF ADINITRATION O 996-G1 COPOUND TYPE O Varies by plan 147-U7 PHARACY ERVICE TYPE R The following PT Codes should be submitted on each Part D Claim: LTC Pharmacy ervices = 05 Home Infusion Pharmacy ervices = 03 Institutional Pharmacy ervices = 04 ail Order Pharmacy ervices = 06 pecialty Pharmacy ervices = 08 Retail Pharmacy ervices = 01 Default (processes as Retail: = 00, 02, 07 )

4 Prescriber egment egment Identification (111-A) = Ø3 466-EZ PRECRIBER ID QUALIFIER 411-DB PRECRIBER ID NPI should be submitted whenever possible 427-DR PRECRIBER LAT NAE O 498-P PRECRIBER PHONE NUBER O 468-2E PRIARY CARE PROVIDER ID QUALIFIER O 421-DL PRIARY CARE PROVIDER ID O 47Ø-4E PRIARY CARE PROVIDER LAT NAE O 364-2J PRECRIBER FIRT NAE O 365-2K PRECRIBER TREET ADDRE O PRECRIBER CITY ADDRE O 367-2N PRECRIBER TATE/PROVINCE O ADDRE 368-2P PRECRIBER ZIP/POTAL ZONE O Coordination of Benefits/Other Payments egment egment Identification (111-A) = Ø C COORDINATION OF BENEFIT/OTHER aximum count of 9. R PAYENT COUNT 338-5C OTHER PAYER COVERAGE TYPE R 339-6C OTHER PAYER ID QUALIFIER R 34Ø-7C OTHER PAYER ID R 443-E8 OTHER PAYER DATE R ituational 341-HB OTHER PAYER AOUNT PAID COUNT aximum count of 9. RW Required if Other Payer Amount Paid Qualifier (342-HC) is used. 342-HC OTHER PAYER AOUNT PAID QUALIFIER RW Required if Other Payer Amount Paid (431- DV) is used. 431-DV OTHER PAYER AOUNT PAID 471-5E OTHER PAYER REJECT COUNT aximum count of 5. RW Required if Other Payer Reject Code (472-6E) is used E OTHER PAYER REJECT CODE RW Required 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). Pricing egment egment Identification (111-A) = 11 4Ø9-D9 INGREDIENT COT UBITTED R 412-DC DIPENING FEE UBITTED R 433-DX PATIENT PAID AOUNT UBITTED O 438-E3 INCENTIVE AOUNT UBITTED O 478-H7 OTHER AOUNT CLAIED UBITTED aximum count of 3. COUNT 479-H8 OTHER AOUNT CLAIED UBITTED QUALIFIER 48Ø-H9 OTHER AOUNT CLAIED UBITTED O 481-HA FLAT ALE TAX AOUNT UBITTED O 482-GE 483-HE 484-JE PERCENTAGE ALE TAX AOUNT UBITTED PERCENTAGE ALE TAX RATE UBITTED PERCENTAGE ALE TAX BAI UBITTED O This segment is always sent Required if Other Amount Claimed ubmitted (48Ø-H9) is used.

5 Pricing egment egment Identification (111-A) = DQ UUAL AND CUTOARY CHARGE 43Ø-DU GRO AOUNT DUE R 423-DN BAI OF COT DETERINATION R This segment is always sent Compound egment Optional egment egment Identification (111-A) = 1Ø Required for Compounds 45Ø-EF COPOUND DOAGE FOR DECRIPTION CODE RW Required when compound is being submitted. 451-EG COPOUND DIPENING UNIT FOR RW INDICATOR 447-EC COPOUND INGREDIENT COPONENT aximum 25 ingredients RW COUNT 488-RE COPOUND PRODUCT ID QUALIFIER RW 489-TE COPOUND PRODUCT ID RW 448-ED COPOUND INGREDIENT QUANTITY RW 449-EE COPOUND INGREDIENT DRUG COT RW Required if needed for receiver claim determination when multiple products are billed. 49Ø-UE COPOUND INGREDIENT BAI OF COT DETERINATION 362-2G COPOUND INGREDIENT ODIFIER CODE COUNT 363-2H COPOUND INGREDIENT ODIFIER CODE RW Imp Guide: Required if needed for receiver claim determination when multiple products are billed. aximum count of 1Ø. O Imp Guide: Required when Compound Ingredient odifier Code (363-2H) is sent. O Clinical egment egment Identification (111-A) = VE DIAGNOI CODE COUNT aximum count of 5. O Imp Guide: Required if Diagnosis Code Qualifier (492-WE) and Diagnosis Code (424-DO) are used. 492-WE DIAGNOI CODE QUALIFIER O Imp Guide: Required if Diagnosis Code (424- DO) is used. 424-DO DIAGNOI CODE O

6 CLAI BILLING/CLAI REBILL PAID (OR DUPLICATE OF PAID) REPONE Response Transaction Header egment 1Ø2-A2 VERION/RELEAE NUBER DØ 1Ø3-A3 TRANACTION CODE B1, B3 1Ø9-A9 TRANACTION COUNT ame value as in request 5Ø1-F1 HEADER REPONE TATU A = Accepted 2Ø2-B2 ERVICE PROVIDER ID QUALIFIER ame value as in request 2Ø1-B1 ERVICE PROVIDER ID ame value as in request 4Ø1-D1 DATE OF ERVICE ame value as in request Accepted/Paid (or Duplicate of Paid) Response essage egment egment Identification (111-A) = 2Ø 5Ø4-F4 EAGE Accepted/Paid (or Duplicate of Paid) Response Insurance egment egment Identification (111-A) = 25 Accepted/Paid (or Duplicate of Paid) 3Ø1-C1 GROUP ID R 524-FO PLAN ID Part-D Commercial 3Ø2-C2 CARDHOLDER ID Imp Guide: Required if the identification to be used in future transactions is different than what was submitted on the request. Response Patient egment egment Identification (111-A) = 29 31Ø-CA PATIENT FIRT NAE 311-CB PATIENT LAT NAE 3Ø4-C4 DATE OF BIRTH Accepted/Paid (or Duplicate of Paid) Response tatus egment egment Identification (111-A) = AN TRANACTION REPONE TATU P=Paid D=Duplicate of Paid 5Ø3-F3 AUTHORIZATION NUBER R 547-5F APPROVED EAGE CODE COUNT aximum count of F APPROVED EAGE CODE 13Ø-UF ADDITIONAL EAGE INFORATION aximum count of 25. COUNT 132-UH ADDITIONAL EAGE INFORATION QUALIFIER 526-FQ ADDITIONAL EAGE INFORATION 131-UG ADDITIONAL EAGE INFORATION CONTINUITY Accepted/Paid (or Duplicate of Paid) Response Claim egment egment Identification (111-A) = E PRECRIPTION/ERVICE REFERENCE NUBER QUALIFIER Accepted/Paid (or Duplicate of Paid) 1 = RxBilling Imp Guide: For Transaction Code of B1, in the Response Claim egment, the Prescription/ervice Reference Number Qualifier (455-E) is 1 (Rx Billing).

7 Response Claim egment egment Identification (111-A) = 22 Accepted/Paid (or Duplicate of Paid) 4Ø2-D2 PRECRIPTION/ERVICE REFERENCE NUBER 551-9F PREFERRED PRODUCT COUNT aximum count of 6. Future capabilities 552-AP PREFERRED PRODUCT ID QUALIFIER Future capabilities 553-AR PREFERRED PRODUCT ID Future capabilities 554-A PREFERRED PRODUCT INCENTIVE Future capabilities 555-AT PREFERRED PRODUCT COT HARE Future capabilities INCENTIVE 556-AU PREFERRED PRODUCT DECRIPTION Future capabilities Response Pricing egment egment Identification (111-A) = 23 5Ø5-F5 PATIENT PAY AOUNT R 5Ø6-F6 INGREDIENT COT PAID R 5Ø7-F7 DIPENING FEE PAID R 558-AW FLAT ALE TAX AOUNT PAID 559-AX PERCENTAGE ALE TAX AOUNT PAID 56Ø-AY PERCENTAGE ALE TAX RATE PAID 561-AZ PERCENTAGE ALE TAX BAI PAID 521-FL INCENTIVE AOUNT PAID 563-J2 OTHER AOUNT PAID COUNT aximum count of J3 OTHER AOUNT PAID QUALIFIER 565-J4 OTHER AOUNT PAID 566-J5 OTHER PAYER AOUNT RECOGNIZED 5Ø9-F9 TOTAL AOUNT PAID R 522-F BAI OF REIBUREENT DETERINATION 523-FN AOUNT ATTRIBUTED TO ALE TAX 512-FC ACCUULATED DEDUCTIBLE AOUNT 513-FD REAINING DEDUCTIBLE AOUNT 514-FE REAINING BENEFIT AOUNT 517-FH AOUNT APPLIED TO PERIODIC DEDUCTIBLE 518-FI AOUNT OF COPAY 52Ø-FK AOUNT EXCEEDING PERIODIC BENEFIT AXIU 572-4U AOUNT OF COINURANCE 392-U BENEFIT TAGE COUNT aximum count of V BENEFIT TAGE QUALIFIER 394-W BENEFIT TAGE AOUNT 577-G3 ETIATED GENERIC AVING 128-UC PENDING ACCOUNT AOUNT REAINING 133-UJ AOUNT ATTRIBUTED TO PROVIDER NETWORK ELECTION 134-UK AOUNT ATTRIBUTED TO PRODUCT ELECTION/BRAND DRUG 135-U AOUNT ATTRIBUTED TO PRODUCT ELECTION/NON-PREFERRED FORULARY ELECTION 136-UN AOUNT ATTRIBUTED TO PRODUCT ELECTION/BRAND NON-PREFERRED FORULARY ELECTION 137-UP AOUNT ATTRIBUTED TO COVERAGE GAP Accepted/Paid (or Duplicate of Paid) Response DUR/PP egment egment Identification (111-A) = 24 ituation egment Accepted/Paid (or Duplicate of Paid)

8 567-J6 DUR/PP REPONE CODE COUNTER aximum 9 occurrences supported. 439-E4 REAON FOR ERVICE CODE 528-F CLINICAL IGNIFICANCE CODE 529-FT OTHER PHARACY INDICATOR 53Ø-FU PREVIOU DATE OF FILL 531-FV QUANTITY OF PREVIOU FILL 532-FW DATABAE INDICATOR 533-FX OTHER PRECRIBER INDICATOR 544-FY DUR FREE TEXT EAGE 57Ø-N DUR ADDITIONAL TEXT Response Coordination of Benefits/Other Payers egment egment Identification (111-A) = 28 ituation egment 355-NT OTHER PAYER ID COUNT aximum count of C OTHER PAYER COVERAGE TYPE 339-6C OTHER PAYER ID QUALIFIER 34Ø-7C OTHER PAYER ID 991-H OTHER PAYER PROCEOR CONTROL NUBER 356-NU OTHER PAYER CARDHOLDER ID 992-J OTHER PAYER GROUP ID 142-UV OTHER PAYER PERON CODE 127-UB OTHER PAYER HELP DEK PHONE NUBER 143-UW OTHER PAYER PATIENT RELATIONHIP CODE 144-UX OTHER PAYER BENEFIT EFFECTIVE DATE 145-UY OTHER PAYER BENEFIT TERINATION DATE Accepted/Paid (or Duplicate of Paid)

9 CLAI BILLING/CLAI REBILL REJECTED/REJECTED REPONE CLAI BILLING/CLAI REBILL REJECTED/REJECTED REPONE Response Transaction Header egment 1Ø2-A2 VERION/RELEAE NUBER DØ 1Ø3-A3 TRANACTION CODE B1, B3 1Ø9-A9 TRANACTION COUNT ame value as in request 5Ø1-F1 HEADER REPONE TATU R = Rejected 2Ø2-B2 ERVICE PROVIDER ID QUALIFIER ame value as in request 2Ø1-B1 ERVICE PROVIDER ID ame value as in request 4Ø1-D1 DATE OF ERVICE ame value as in request Rejected/Rejected Response essage egment egment Identification (111-A) = 2Ø ituation egment 5Ø4-F4 EAGE Rejected/Rejected Response tatus egment egment Identification (111-A) = AN TRANACTION REPONE TATU R = Reject 5Ø3-F3 AUTHORIZATION NUBER 51Ø-FA REJECT COUNT aximum count of 5. R 511-FB REJECT CODE R 546-4F REJECT FIELD OCCURRENCE INDICATOR 13Ø-UF ADDITIONAL EAGE INFORATION aximum count of 25. COUNT 132-UH ADDITIONAL EAGE INFORATION QUALIFIER 526-FQ ADDITIONAL EAGE INFORATION 131-UG ADDITIONAL EAGE INFORATION CONTINUITY Rejected/Rejected

10 CLAI REVERAL TRANACTION The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication tandard Implementation Guide Version D.Ø. Transaction Header egment 1Ø1-A1 BIN NUBER ee B1 information 1Ø2-A2 VERION/RELEAE NUBER DØ 1Ø3-A3 TRANACTION CODE B2 1Ø4-A4 PROCEOR CONTROL NUBER ee B1 information 1Ø9-A9 TRANACTION COUNT 1 2Ø2-B2 ERVICE PROVIDER ID QUALIFIER NPI 2Ø1-B1 ERVICE PROVIDER ID 01 4Ø1-D1 DATE OF ERVICE 11Ø-AK OFTWARE VENDOR/CERTIFICATION ID Blanks Claim Rev ersal Insurance egment egment Identification (111-A) = Ø4 3Ø2-C2 CARDHOLDER ID 3Ø1-C1 GROUP ID Claim Rev ersal Claim egment egment Identification (111-A) = Ø7 455-E PRECRIPTION/ERVICE REFERENCE 1 NUBER QUALIFIER 4Ø2-D2 PRECRIPTION/ERVICE REFERENCE NUBER 436-E1 PRODUCT/ERVICE ID QUALIFIER 4Ø7-D7 PRODUCT/ERVICE ID 4Ø3-D3 FILL NUBER 3Ø8-C8 OTHER COVERAGE CODE Claim Rev ersal Coordination of Benefits/Other ituational egment Payments egment egment Identification (111-A) = Ø C COORDINATION OF BENEFIT/OTHER aximum count of 9. PAYENT COUNT 338-5C OTHER PAYER COVERAGE TYPE Claim Rev ersal DUR/PP egment ituational egment egment Identification (111-A) = Ø E DUR/PP CODE COUNTER aximum of 9 occurrences. 439-E4 REAON FOR ERVICE CODE 44Ø-E5 PROFEIONAL ERVICE CODE 441-E6 REULT OF ERVICE CODE 474-8E DUR/PP LEVEL OF EFFORT Claim Rev ersal

11 CLAI REVERAL ACCEPTED/APPROVED REPONE Response Transaction Header egment 1Ø2-A2 VERION/RELEAE NUBER DØ 1Ø3-A3 TRANACTION CODE B2 1Ø9-A9 TRANACTION COUNT ame value as in request 5Ø1-F1 HEADER REPONE TATU A = Accepted 2Ø2-B2 ERVICE PROVIDER ID QUALIFIER ame value as in request 2Ø1-B1 ERVICE PROVIDER ID ame value as in request 4Ø1-D1 DATE OF ERVICE ame value as in request Claim Rev ersal Accepted/Approved Response essage egment Claim Rev ersal Accepted/Approved egment Identification (111-A) = 2Ø 5Ø4-F4 EAGE R Reversal Accepted Response tatus egment egment Identification (111-A) = AN TRANACTION REPONE TATU A = Approved 5Ø3-F3 AUTHORIZATION NUBER R Claim Rev ersal Accepted/Approved Response Claim egment egment Identification (111-A) = E PRECRIPTION/ERVICE REFERENCE 1 = RxBilling NUBER QUALIFIER 4Ø2-D2 PRECRIPTION/ERVICE REFERENCE NUBER Claim Rev ersal Accepted/Approved

12 CLAI REVERAL REJECTED REPONE Response Transaction Header egment 1Ø2-A2 VERION/RELEAE NUBER DØ 1Ø3-A3 TRANACTION CODE B2 1Ø9-A9 TRANACTION COUNT ame value as in request 5Ø1-F1 HEADER REPONE TATU A = Accepted 2Ø2-B2 ERVICE PROVIDER ID QUALIFIER ame value as in request 2Ø1-B1 ERVICE PROVIDER ID ame value as in request 4Ø1-D1 DATE OF ERVICE ame value as in request Claim Rev ersal Accepted/Rejected Response essage egment Claim Rev ersal Accepted/Rejected egment Identification (111-A) = 2Ø 5Ø4-F4 EAGE R Reversal Not Processed Response tatus egment egment Identification (111-A) = AN TRANACTION REPONE TATU R = Reject 5Ø3-F3 AUTHORIZATION NUBER R 51Ø-FA REJECT COUNT aximum count of 5. R 511-FB REJECT CODE R Response Claim egment egment Identification (111-A) = E PRECRIPTION/ERVICE REFERENCE 1 = RxBilling NUBER QUALIFIER 4Ø2-D2 PRECRIPTION/ERVICE REFERENCE NUBER Claim Rev ersal Accepted/Rejected Claim Rev ersal Accepted/Rejected