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1 New York State Department of Health (NYS DOH) Office of Health Insurance Programs (OHIP) New York State Department of Health (NYS DOH) Office of Health Insurance Programs (OHIP) New York State New York State Department of Health (NYS DOH) Office of Health Insurance Programs (OHIP) Department of Health (NYS DOH) Office of Health Insurance Programs (OHIP) Standard Companion Guide Transaction Information emedny Instructions related to Transactions based on NCPDP Telecommunications Implementation Guide, version D.0 and related documents New York State Department Of Companion Guide Version Number: 1.5 Health Office December of 20, 2017 Health Insurance Programs National Council for Prescription Drug Programs (NCPDP) NYSDOH 1 emedny

2 Table of Contents NCPDP National Council for Prescription Drug Programs... 5 INTODUCTION... 5 COMPANION GUIDE DISCLAIME:... 6 CG MODIFICATION TACKING:... 6 NYS MEDICAID NOTE:... 6 PUPOSE... 7 SYSTEM AVAILABILITY... 7 NCPDP D.0 TANSACTIONS SUPPOTED by NYSDOH... 7 ELIGIBILITY VEIFICATION EQUEST... 9 ELIGIBILITY VEIFICATION EQUEST ( Payer Sheet )... 9 ELIGIBILITY VEIFICATION ESPONSE Eligibility VEIFICATION ESPONSE (Transmission Accepted / Transaction Approved) 11 ELIGIBILITY VEIFICATION ESPONSE (Transmission Accepted / Transaction ejected) ELIGIBILITY VEIFICATION ESPONSE (Transmission ejected / Transaction ejected) CLAIM BILLING / CLAIM EBILL CLAIM BILLING / CLAIM EBILL EQUEST ( Payer Sheet ) CLAIM BILLING / CLAIM EBILL ESPONSE CLAIM BILLING / CLAIM EBILL ESPONSE (Accepted/Captured (or Duplicate of Captured)) CLAIM BILLING / CLAIM EBILL ESPONSE (Transmission Accepted / Transaction ejected) CLAIM BILLING / CLAIM EBILLESPONSE (Transmission ejected / Transaction ejected) CLAIM EVESAL CLAIM EVESAL EQUEST ( Payer Sheet ) CLAIM EVESAL ESPONSE CLAIM EVESAL ESPONSE (Accepted/Captured (or Duplicate of Captured)) CLAIM EVESAL ESPONSE (Transmission Accepted / Transaction ejected) CLAIM EVESAL ESPONSE (Transmission ejected / Transaction ejected) INFOMATION EPOTING / INFOMATION EBILL INFOMATION EPOTING / INFOMATION EBILL EQUEST (Payer Sheet) INFOMATION EPOTING / INFOMATION EBILL ESPONSE INFOMATION EPOTING / INFOMATION EBILL ESPONSE (Accepted/Captured (or Duplicate of Captured)) INFOMATION EPOTING / INFOMATION EBILL (Transmission Accepted / Transaction ejected) INFOMATION EPOTING / INFOMATION EBILL (Transmission ejected / Transaction ejected) INFOMATION EPOTING EVESAL INFOMATION EPOTING EVESAL EQUEST ( Payer Sheet ) INFOMATION EPOTING EVESAL ESPONSE NYSDOH 2 emedny

3 INFOMATION EPOTING EVESAL ESPONSE (Accepted/Captured (or Duplicate of Captured)) INFOMATION EPOTING EVESAL ESPONSE (Transmission Accepted / Transaction ejected) INFOMATION EPOTING EVESAL ESPONSE (Transmission ejected / Transaction ejected) SEVICE BILLING / SEVICE EBILL SEVICE BILLING / SEVICE EBILL EQUEST ( Payer Sheet ) SEVICE BILLING / SEVICE EBILL ESPONSE SEVICE BILLING / SEVICE EBILL ESPONSE (Accepted/Captured (or Duplicate of Captured)) SEVICE BILLING / SEVICE EBILL ESPONSE (Transmission Accepted / Transaction ejected) SEVICE BILLING / SEVICE EBILL ESPONSE (Transmission ejected / Transaction ejected) SEVICE EVESAL SEVICE EVESAL EQUEST ( Payer Sheet ) SEVICE EVESAL ESPONSE SEVICE EVESAL ESPONSE (Accepted/Captured (or Duplicate of Captured)) SEVICE EVESAL ESPONSE (Transmission Accepted / Transaction ejected) SEVICE EVESAL ESPONSE (Transmission ejected / Transaction ejected) PIO AUTHOIZATION EQUEST / BILLING EQUEST PIO AUTHOIZATION EQUEST / BILLING EQUEST ( Payer Sheet ) PIO AUTHOIZATION EQUEST / BILLING EQUEST ESPONSE PIO AUTHOIZATION EQUEST / BILLING EQUEST ESPONSE (Accepted/Captured (or Duplicate of Captured)) PIO AUTHOIZATION EQUEST / BILLING EQUEST ESPONSE (Transmission Accepted / Transaction ejected) PIO AUTHOIZATION EQUEST / BILLING EQUEST ESPONSE (Transmission ejected / Transaction ejected) PIO AUTHOIZATION EVESAL PIO AUTHOIZATION EVESAL ( Payer Sheet ) PIO AUTHOIZATION EVESAL ESPONSE PIO AUTHOIZATION EVESAL ESPONSE (Accepted/Captured (or Duplicate of Captured)) PIO AUTHOIZATION EVESAL ESPONSE (Transmission Accepted / Transaction ejected) PIO AUTHOIZATION EVESAL ESPONSE (Transmission ejected / Transaction ejected) PIO AUTHOIZATION EQUEST ONLY PIO AUTHOIZATION EQUEST ONLY EQUEST ( Payer Sheet ) PIO AUTHOIZATION EQUEST ONLY ESPONSE PIO AUTHOIZATION EQUEST ONLY ESPONSE (Captured (or Duplicate of Captured) PIO AUTHOIZATION EQUEST ONLY ESPONSE (Transmission Accepted / Transaction ejected) NYSDOH 3 emedny

4 PIO AUTHOIZATION EQUEST ONLY ESPONSE (Transmission ejected / Transaction ejected) NCPDP 1.2 Batch Transactions NCPDP 1.2 Batch Transaction ecord Structure TANSMISSION / SENDE TO ECEIVE / ECOD STUCTUE NYSDOH 4 emedny

5 NCPDP NATIONAL COUNCIL FO PESCIPTION DUG POGAMS INTODUCTION The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carry provisions for administrative simplification. This requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard. The National Council for Prescription Drug Programs (NCPDP) is a non-profit organization formed in It is dedicated to the development and dissemination of voluntary consensus standards that are necessary to transfer information that is used to administer the prescription drug benefit program. efer to the NCPDP Telecommunication Version D documents Telecommunication Standard Implementation Guide Version D.0, Data Dictionary, External Code List, and Version D Editorial Document for more detailed information on field values and segments. The following information is intended to serve only as a Companion Guide to the aforementioned NCPDP Telecommunications Standard Version D.0 Documents. The use of this Companion Guide is solely for the purpose of clarification. The information describes specific requirements to be used for processing data. This Companion Guide supplements, but does not contradict any requirements in the NCPDP Telecommunications Standard Version D.0 Implementation Guide and related documents. To request a copy of the NCPDP Standard Formats or for more information contact the National Council for Prescription Drug Programs, Inc. at The contact information is as follows: National Council for Prescription Drug Programs 9240 East aintree Drive Scottsdale, AZ Phone: (480) Fax (480) Materials eproduced With the Consent of National Council for Prescription Drug Programs, Inc NCPDP NYSDOH 5 emedny

6 COMPANION GUIDE DISCLAIME: The New York State Department of Health (NYSDOH) has provided this Payer Sheet Companion Guide for the NCPDP transactions to assist Providers, Clearinghouses and all Covered Entities in preparing HIPAA compliant transactions. This document was prepared using the Telecommunication Standard Implementation Guide Version D.0, Data Dictionary, External Code List, and Version D Editorial Document. NYSDOH does not offer individual training to assist Providers in the use of the NCPDP transactions. The information provided herein is believed to be true and correct based on the aforementioned NCPDP Telecommunication Standard Version D.0 Implementation Guide and the related documents. The HIPAA regulations are continuing to evolve. Therefore, NYS Medicaid makes no guarantee, expressed or implied, as to the accuracy of the information provided herein. Furthermore, this is a living document and the information provided herein is subject to change as NYSDOH policy changes or as HIPAA legislation is updated or revised. CG MODIFICATION TACKING: >V1.5 - emedny Standard Companion Guide publication updates Publication Date: 12/20/2017 eplace references to BIN with IIN Update General Information sections >V1.4 - emedny Standard Companion Guide publication updates Publication Date: 11/10/2016 eplace references to CSC with emedny >V1.3 - emedny Standard Companion Guide publication updates Publication Date: 10/01/2015 Update diagnosis code information regarding ICD10 implementation >V1.2 - emedny Standard Companion Guide publication updates Publication Date: 05/22/2014 Add additional accepted code set values to 351-NP Specify accepted values in 308-C8 >V1.1 - emedny Standard Companion Guide publication corrections Publication Date: 01/20/2012 Add COB/Other Payments Segment to Claim eversal (B2) & Service eversal (S2) equest Add ICD code reporting format comment to 424-DO transmit ICD with decimal point implied. Chg. reporting note on 419-DJ Codes 0 thru 4 are accepted. >V1.0 - emedny Standard Companion Guide initial publication Publication Date: 04/22/2011 NYS MEDICAID NOTE: Under HIPAA the National Council for Prescription Drug Programs (NCPDP) Telecommunication Standard Implementation Guide Version D.0, Data Dictionary, and External Code List, has been adopted by Health and Human Services as standard transactions for etail Pharmacy. This Companion Guide, which is provided by the New York State Department of Health (NYSDOH), outlines the required format for the New York State Medicaid etail Pharmacy transactions. It is important that Providers study the Companion Guide and become familiar with the data that will be expected by NYS Medicaid in transmission of a Pharmacy Transaction. NYSDOH 6 emedny

7 This Companion Guide does not modify the standards; rather, it puts forth the subset of information from the NCPDP Telecommunications Standard Version D.0 Implementation Guide, Data Dictionary, External Code List, and Version D.0 Editorial Updates that will be required for processing transactions. It is important that providers use this Companion Guide as a supplement to the NCPDP Standard D.0 documents. Within the IG, there are data elements, which have many different qualifiers available for use. Each qualifier identifies a different piece of information. This document omits code qualifiers that are not necessary for NYS Medicaid processing. Although not all available codes are listed in this document, NYSDOH will accept any codes named or listed in the NCPDP Data Dictionary and External Code List. When necessary, NYS Medicaid notes are included under to describe the NYSDOH specific requirements. Although not all IG items are listed in the Companion Guide, NYS Medicaid will accept and capture the data from all transactions that comply with the HIPAA IG. Providers are required to use the NCPDP Telecommunication Standard Implementation Guide Version D.0, the Data Dictionary, and the External Code List, (ECL) to understand the positioning, format and usage of the transaction and data elements. Please refer to the Technical Supplementary Companion Guide for Information about transaction header structures, transaction size limits, electronic communications methods, and enrollment. This document is available for download at Providers with questions regarding HIPAA compliance billing please call EMEDNY s support unit at Pharmacy Providers can acquire the aforementioned NCPDP documents from PUPOSE This guide is intended to provide guidelines to software vendors, switching companies and pharmacy providers as they implement the NCPDP D.0 Standard. The information included in this companion guide is separated into two sections; the D.0 transactions supported by NYSDOH and the 1.2 Batch transaction record structure. The 1.2 section of this document is only pertinent to those entities that will be sending batch transactions to NYSDOH. SYSTEM AVAILABILITY The New York State Medicaid NCPDP transaction submission system is available to providers 24 hours a day, seven days a week. NCPDP D.0 TANSACTIONS SUPPOTED BY NYSDOH NYSDOH 7 emedny

8 E1 B1 B2 B3 N1 N2 N3 P1 P2 P4 S1 S2 S3 Transaction Name Eligibility Claim Billing Claim eversal Claim ebill Information eporting Information eporting eversal Information eporting ebill Prior Authorization equest & Billing Prior Authorization eversal Prior Authorization equest Only Service Billing Service eversal Service ebill NYSDOH does not support the following transactions: C1, C2, C3, D1, and P3. NYSDOH does not support/require the following segments: Coupon and Workers Comp. Transaction Format Information New York State Medicaid will only accept NCPDP Telecommunication Standard Version D.0 with the implementation of the New York State Medicaid system on Jan. 1 st Please refer to the NCPDP D.0 Implementation Guide, Data Dictionary and External Code List to understand the positioning, format and use of the data elements. NYSDOH 8 emedny

9 ELIGIBILITY VEIFICATION EQUEST ELIGIBILITY VEIFICATION EQUEST ( Payer Sheet ) ** Start of equest Eligibility Verification Segments (E1) Payer Sheet ** GENEAL INFOMATION Payer Name: New York State Department of Health (NYSDOH) Date: 04/22/2011 Plan Name/Group Name: NYS Medicaid IIN: PCN: NYS Medicaid ID Processor: emedny Effective as of: 07/21/2011 NCPDP Telecommunication Standard Version/elease #: D.0 NCPDP Data Dictionary Version Date: 10/2017 NCPDP External Code List Version Date: 10/2017 Contact/Information Source: Provider Manuals available at General Website Provider elations Help Desk Info: OTHE TANSACTIONS SUPPOTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Transaction Name B1 Claim Billing B2 Claim eversal B3 Claim ebill N1 Information eporting N2 Information eporting eversal N3 Information eporting ebill P1 Prior Authorization equest & Billing P2 Prior Authorization eversal P4 Prior Authorization equest Only S1 Service Billing S2 Service eversal S3 Service ebill FIELD LEGEND FO COLUMNS Payer Column Value Explanation Column MANDATOY M The Field is mandatory for the Segment in the designated Transaction. No EQUIED The Field has been designated with the situation of No "equired" for the Segment in the designated Transaction. QUALIFIED EQUIEMENT W equired when. The situations designated have qualifications for usage ("equired if x", "Not required if y"). Yes Fields that are not used in the Eligibility Verification equest transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template. ELIGIBILITY VEIFICATION EQUEST TANSACTION The following lists the segments and fields in an Eligibility Verification equest Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Transaction Header Segment Questions Check Eligibility Verification equest Source of certification IDs required in Software Vendor/Certification ID (110-AK) is Payer Issued Source of certification IDs required in Software Vendor/Certification ID (110-AK) is Switch/VAN issued Source of certification IDs required in Software Vendor/Certification ID (110-AK) is Not used NYSDOH 9 emedny

10 Transaction Header Segment Eligibility Verification equest 101-A1 IIN NUMBE M IIN for NYS Medicaid 102-A2 VESION/ELEASE NUMBE D0 M 103-A3 TANSACTION CODE E1 M 104-A4 POCESSO CONTOL NUMBE The PCN 10 Character formats: M 3 Character ETIN: (PIC (1), PIC (2), PIC (4), PIC (3)) 4 Character ETIN: (PIC (2), PIC (4), PIC (4)) The Processor Control Number field has two formats. Providers with a 3 character or a 4 character Electronic Transmitter Identification Number (ETIN). 3 Character ETIN: The ead Certification Indicator (PIC (01)), the Pharmacist's Initials (PIC (02)), Provider Personal Identification Number (PIN) (PIC (04)) and the Provider ETIN (PIC (03)). 4 Character ETIN: The Pharmacist's Initials (PIC (02)), Provider Personal Identification Number (PIN) (PIC (04)) and the ETIN (PIC (04)). 109-A9 TANSACTION COUNT 01 = One occurrence M 202-B2 SEVICE POVIDE ID QUALIFIE 01 = National Provider ID M 201-B1 SEVICE POVIDE ID M 401-D1 DATE OF SEVICE M 110-AK SOFTWAE VENDO/CETIFICATION ID Blank fill M Blank fill Insurance Segment Questions Check Eligibility Verification equest Insurance Segment Segment Identification (111-AM) = 04 Eligibility Verification equest 302-C2 CADHOLDE ID M The 8 character alpha numeric Member Number. Patient Segment Questions Check Eligibility Verification equest This Segment is situational Patient Segment Eligibility Verification equest Segment Identification (111-AM) = 01 Field NCPDP Field Name Value Payer 304-C4 DATE OF BITH 305-C5 PATIENT GENDE CODE 1 = Male 2 = Female 310-CA PATIENT FIST NAME Imp Guide: equired when the patient has a first name. 311-CB PATIENT LAST NAME Payer equirement: ** End of equest Eligibility Verification equest (E1) Payer Sheet ** NYSDOH 10 emedny

11 ELIGIBILITY VEIFICATION ESPONSE ** Start of Eligibility Verification esponse (E1) Payer Sheet ** GENEAL INFOMATION Payer Name: New York State Department of Health (NYSDOH) Date: 04/22/2011 Plan Name/Group Name: NYS Medicaid IIN: PCN: NYS Medicaid ID Eligibility VEIFICATION ESPONSE (Transmission Accepted / Transaction Approved) ELIGIBILITY VEIFICATION ESPONSE (TANSMISSION ACCEPTED/TANSACTION APPOVED) esponse Transaction Header Segment Questions Check Eligibility Verification esponse (Transmission Accepted/Transaction Approved) esponse Transaction Header Segment 102-A2 VESION/ELEASE NUMBE D0 M 103-A3 TANSACTION CODE E1 M 109-A9 TANSACTION COUNT Same value as in request M 501-F1 HEADE ESPONSE STATUS A = Accepted M 202-B2 SEVICE POVIDE ID QUALIFIE Same value as in request M 201-B1 SEVICE POVIDE ID Same value as in request M 401-D1 DATE OF SEVICE Same value as in request M Eligibility Verification esponse (Transmission Accepted/Transaction Approved) esponse Message Header Segment Questions Check Eligibility Verification esponse (Transmission Accepted/Transaction Approved) This Segment is situational Provide general information when used for transmission-level messaging. esponse Message Segment Segment Identification (111-AM) = 20 Eligibility Verification esponse (Transmission Accepted/Transaction Approved) NYSDOH 11 emedny

12 esponse Message Segment Segment Identification (111-AM) = F4 MESSAGE Medicaid Number (8) Filler Value = Space (1) County Code = (2) Field Separator Value = * (1) Anniversary Mo. = (2) (values: 01 12) Filler Value = Space (1) Patient Gender code = (1) (values: M or F) Year of Birth = (3) (Format = CYY) Filler Value = Space (1) Category of Assistance = (1) Filler Value = Space (1) e-certification Month = (2) (values: 01 12) Filler Value = Space (1) Office Number (3) Field Separator Value = & (1) Service Date = (8) (Format = CCYYMMDD) Total bytes = 37 Eligibility Verification esponse (Transmission Accepted/Transaction Approved) Imp Guide: equired if text is needed for clarification or detail. Payer equirement: esponse Status Segment Questions Check Eligibility Verification esponse (Transmission Accepted/Transaction Approved) esponse Status Segment Segment Identification (111-AM) = AN TANSACTION ESPONSE STATUS A=Approved M 130-UF ADDITIONAL MESSAGE INFOMATION Maximum count of 25. COUNT Value = 3 Eligibility Verification esponse (Transmission Accepted/Transaction Approved) Imp Guide: equired if Additional Message Information (526-FQ) is used. 132-UH ADDITIONAL MESSAGE INFOMATION QUALIFIE Payer equirement: NYSDOH will return a count of 3. Value = 01 Imp Guide: equired if Additional Message Information (526-FQ) is used. 526-FQ ADDITIONAL MESSAGE INFOMATION MEVS esponse Code (3) Space field separator (1) Utilization Threshold Code (2) Separator Value = $ (1) Maximum Per Unit Price (9) " Separator Value = % (1) Co-Payment Code (3) Space field separator (1) Co-Payment Met Date (8) Separator Value of (=) (1) Medicare Coverage Code (2) Space field separator (1) HIC Number 1 st 7 bytes (7) Payer equirement: NYSDOH will return a qualifier of 01 Imp Guide: equired when additional text is needed for clarification or detail. Payer equirement: ADDITIONAL MESSAGE 01 = (40 bytes) NYSDOH 12 emedny

13 esponse Status Segment Segment Identification (111-AM) = UG ADDITIONAL MESSAGE INFOMATION CONTINUITY Eligibility Verification esponse (Transmission Accepted/Transaction Approved) + Imp Guide: equired if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current. 132-UH ADDITIONAL MESSAGE INFOMATION QUALIFIE Payer equirement: NYSDOH will return a + Value = 02 Imp Guide: equired if Additional Message Information (526-FQ) is used. 526-FQ ADDITIONAL MESSAGE INFOMATION HIC Number last 5 bytes (5) Separator Value = # (1) 1 st Insurance Carrier Code (6) Separator Value = / (1) 1 st Insurance Coverage Codes (14) Separator Value (1) 2 nd Insurance Carrier Code (6) Separator Value = / (1) 2 nd Insur.Coverage Codes (5) 131-UG ADDITIONAL MESSAGE INFOMATION CONTINUITY Payer equirement: NYSDOH will return a qualifier of 02 Imp Guide: equired when additional text is needed for clarification or detail. Payer equirement: ADDITIONAL MESSAGE 02 = (40 bytes) + Imp Guide: equired if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current. 132-UH ADDITIONAL MESSAGE INFOMATION QUALIFIE Payer equirement: NYSDOH will return a + Value = 03 Imp Guide: equired if Additional Message Information (526-FQ) is used. 526-FQ ADDITIONAL MESSAGE INFOMATION 2 nd Insur.Coverage Codes (9) Separator Value = + (1) Indication of Additional Coverage (2) Separator Value = * (1) Exception Codes: "xx xx xx xx" (11) Total (24) Payer equirement: NYSDOH will return a qualifier of 03 Imp Guide: equired when additional text is needed for clarification or detail. Payer equirement: ADDITIONAL MESSAGE 03 = (24 bytes) ELIGIBILITY VEIFICATION ESPONSE (Transmission Accepted / Transaction ejected) ELIGIBILITY VEIFICATION ESPONSE (TANSMISSION ACCEPTED/TANSACTION EJECTED) esponse Transaction Header Segment Questions Check Eligibility Verification esponse (Transmission Accepted/Transaction ejected) esponse Transaction Header Segment Eligibility Verification esponse (Transmission Accepted/Transaction ejected) NYSDOH 13 emedny

14 esponse Transaction Header Segment 102-A2 VESION/ELEASE NUMBE D0 M 103-A3 TANSACTION CODE E1 M 109-A9 TANSACTION COUNT Same value as in request M 501-F1 HEADE ESPONSE STATUS A = Accepted M 202-B2 SEVICE POVIDE ID QUALIFIE Same value as in request M 201-B1 SEVICE POVIDE ID Same value as in request M 401-D1 DATE OF SEVICE Same value as in request M Eligibility Verification esponse (Transmission Accepted/Transaction ejected) esponse Status Segment Questions Check Eligibility Verification esponse (Transmission Accepted/Transaction ejected) esponse Status Segment Segment Identification (111-AM) = AN TANSACTION ESPONSE STATUS = eject M 510-FA EJECT COUNT Maximum count of FB EJECT CODE 130-UF ADDITIONAL MESSAGE INFOMATION Maximum count of 25. COUNT Value = 1 Eligibility Verification esponse (Transmission Accepted/Transaction ejected) Imp Guide: equired if Additional Message Information (526-FQ) is used. 132-UH ADDITIONAL MESSAGE INFOMATION QUALIFIE Payer equirement: NYSDOH will return a count of 1. Value = 01 Imp Guide: equired if Additional Message Information (526-FQ) is used. Payer equirement: NYSDOH will return a message code FQ ADDITIONAL MESSAGE INFOMATION MEVS Denial Code = (3) Imp Guide: equired when additional text is needed for clarification or detail. Payer equirement: NYSDOH will return a MEVS Denial Code. NYSDOH 14 emedny

15 ELIGIBILITY VEIFICATION ESPONSE (Transmission ejected / Transaction ejected) ELIGIBILITY VEIFICATION ESPONSE (TANSMISSION EJECTED/ TANSACTION EJECTED) esponse Transaction Header Segment Questions Check Eligibility Verification esponse ejected/ejected esponse Transaction Header Segment 102-A2 VESION/ELEASE NUMBE D0 M 103-A3 TANSACTION CODE E1 M 109-A9 TANSACTION COUNT Same value as in request M 501-F1 HEADE ESPONSE STATUS = ejected M 202-B2 SEVICE POVIDE ID QUALIFIE Same value as in request M 201-B1 SEVICE POVIDE ID Same value as in request M 401-D1 DATE OF SEVICE Same value as in request M Eligibility Verification esponse ejected/ejected esponse Status Segment Questions Check Eligibility Verification esponse ejected/ejected esponse Status Segment Segment Identification (111-AM) = 21 Eligibility Verification esponse ejected/ejected 112-AN TANSACTION ESPONSE STATUS = eject M 510-FA EJECT COUNT Maximum count of FB EJECT CODE NYSDOH will return 1 to 5 eject codes. ** End of esponse Eligibility Verification esponse (E1) Payer Sheet ** NYSDOH 15 emedny

16 CLAIM BILLING / CLAIM EBILL CLAIM BILLING / CLAIM EBILL EQUEST ( Payer Sheet ) ** Start of equest Claim Billing/Claim ebill (B1/B3) Payer Sheet ** GENEAL INFOMATION Payer Name: New York State Department of Health (NYSDOH) Date: 04/22/2011 Plan Name/Group Name: NYS Medicaid IIN: PCN: NYS Medicaid ID Processor: emedny Effective as of: 07/21/2011 NCPDP Telecommunication Standard Version/elease #: D.0 NCPDP Data Dictionary Version Date: 10/2017 NCPDP External Code List Version Date: 10/2017 Contact/Information Source: Provider Manuals available at General Website Provider elations Help Desk Info: OTHE TANSACTIONS SUPPOTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Transaction Name B2 Claim eversal E1 Eligibility Verification N1 Information eporting N2 Information eporting eversal N3 Information eporting ebill P1 Prior Authorization equest & Billing P2 Prior Authorization eversal P4 Prior Authorization equest Only S1 Service Billing S2 Service eversal S3 Service ebill FIELD LEGEND FO COLUMNS Payer Column Value Explanation Column MANDATOY M The Field is mandatory for the Segment in the designated Transaction. No EQUIED The Field has been designated with the situation of "equired" for the Segment in the designated Transaction. QUALIFIED EQUIEMENT W equired when. The situations designated have qualifications for usage ("equired if x", "Not required if y"). Fields that are not used in the Claim Billing/Claim ebill transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template. No Yes CLAIM BILLING/CLAIM 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.0. Transaction Header Segment Questions Check Claim Billing/Claim ebill Source of certification IDs required in Software Vendor/Certification ID (110-AK) is Payer Issued Source of certification IDs required in Software Vendor/Certification ID (110-AK) is Switch/VAN issued Source of certification IDs required in Software Vendor/Certification ID (110-AK) is Not used Transaction Header Segment Claim Billing/Claim ebill NYSDOH 16 emedny

17 101-A1 IIN NUMBE M IIN for NYS Medicaid 102-A2 VESION/ELEASE NUMBE D0 M 103-A3 TANSACTION CODE B1, B3 M 104-A4 POCESSO CONTOL NUMBE The PCN 10 Character formats: M 3 Character ETIN: (PIC (1), PIC (2), PIC (4), PIC (3)) 4 Character ETIN: (PIC (2), PIC (4), PIC (4)) The Processor Control Number field has two formats. Providers with a 3 character or a 4 character Electronic Transmitter Identification Number (ETIN). 3 Character ETIN: The ead Certification Indicator (PIC (01)), the Pharmacist's Initials (PIC (02)), Provider Personal Identification Number (PIN) (PIC (04)) and the Provider ETIN (PIC (03)). 109-A9 TANSACTION COUNT 01 = One occurrence M 02 = Two occurrences 03 = Three occurrences 04 = Four occurrences 202-B2 SEVICE POVIDE ID QUALIFIE 01 = National Provider ID M 4 Character ETIN: The Pharmacist's Initials (PIC (02)), Provider Personal Identification Number (PIN) (PIC (04)) and the ETIN (PIC (04)). 201-B1 SEVICE POVIDE ID M 401-D1 DATE OF SEVICE M 110-AK SOFTWAE VENDO/CETIFICATION ID Blank fill M Blank fill Insurance Segment Questions Check Claim Billing/Claim ebill Insurance Segment Claim Billing/Claim ebill Segment Identification (111-AM) = C2 CADHOLDE ID M The 8 character alpha numeric Member Number. 309-C9 ELIGIBILITY CLAIFICATION CODE 2 = Override W Imp Guide: equired if needed for receiver inquiry validation and/or determination, when eligibility is not maintained at the dependent level. equired in special situations as defined by the code to clarify the eligibility of an individual, which may extend coverage. Payer equirement: equired when indicating an eligibility override as follows: Code '2' indicates: an eligibility override for spend down/ excess income when the member's liability has been met, but there is a time lag in updating the eligibility system. a nursing home override Patient Segment Questions Check Claim Billing/Claim ebill This Segment is situational Patient Segment Segment Identification (111-AM) = 01 Claim Billing/Claim ebill NYSDOH 17 emedny

18 Field NCPDP Field Name Value Payer 304-C4 DATE OF BITH 305-C5 PATIENT GENDE CODE 1 = Male 2 = Female 310-CA PATIENT FIST NAME W Imp Guide: equired when the patient has a first name. 311-CB PATIENT LAST NAME 307-C7 PLACE OF SEVICE All code set values supported CMS Maintained code set. Imp Guide: equired if this field could result in different coverage, pricing, or patient financial responsibility C PEGNANCY INDICATO Blank=Not Specified, 1=Not pregnant, 2=Pregnant W Imp Guide: equired if pregnancy could result in different coverage, pricing, or patient financial responsibility. equired if required by law as defined in the HIPAA final Privacy regulations section definitions (45 CF Parts 160 and 164 Standards for Privacy of Individually Identifiable Health Information; Final ule- Thursday, December 28, 2000, page and following, and Wednesday, August 14, 2002, page and following.) Payer equirement: equired when the member is known to be pregnant. Claim Segment Questions Check Claim Billing/Claim ebill This payer supports partial fills This payer does not support partial fills Claim Segment Claim Billing/Claim ebill Segment Identification (111-AM) = EM PESCIPTION/SEVICE EFEENCE NUMBE QUALIFIE 1 = x Billing M Imp Guide: For Transaction Code of B1, in the Claim Segment, the Prescription/Service eference Number Qualifier (455-EM) is 1 (x Billing). 402-D2 PESCIPTION/SEVICE EFEENCE NUMBE The prescription number assigned by the pharmacy. M 436-E1 PODUCT/SEVICE ID QUALIFIE 00 = Not Specified 03 = NDC 09 = HCPCS M If billing for a multi-ingredient prescription, Product/Service ID Qualifier (436-E1) is zero ( 00 ). NYSDOH requires one of these codes. 407-D7 PODUCT/SEVICE ID M If billing for a multi-ingredient prescription, Product/Service ID (407-D7) is zero. (Zero means 0.) NYSDOH requires an NDC code, a HCPCS Code, or 0 (zero). 458-SE POCEDUE MODIFIE CODE COUNT Maximum count of 10. W Imp Guide: equired if Procedure Modifier Code (459-E) is used. Payer equirement: NYSDOH will map up to 4 modifiers. NYSDOH 18 emedny

19 Claim Segment Claim Billing/Claim ebill Segment Identification (111-AM) = E POCEDUE MODIFIE CODE W Imp Guide: equired to define a further level of specificity if the Product/Service ID (407-D7) indicated a Procedure Code was submitted. equired if this field could result in different coverage, pricing, or patient financial responsibility. 442-E7 QUANTITY DISPENSED 403-D3 FILL NUMBE 00 = New Prescription 01 = First efill 02 = Second efill 03 = Third efill 04 = Fourth efill 05 = Fifth efill 405-D5 DAYS SUPPLY 406-D6 COMPOUND CODE 1 = Not Compound 2 = Compound 408-D8 DISPENSE AS WITTEN (DAW)/PODUCT 0 = No Product Selection SELECTION CODE Indicated 1= Substitute Not Allowed by Prescriber 4 = Sub Allowed-Generic Drug Not in Stock 5 = Sub Allowed-Brand Drug Dispensed as Generic 7 = Sub Not Allowed-Brand Drug Mandated by Law 8 = Sub Allowed-Generic Drug Not Avail. in Market 9 = Sub Allowed By Prescriber- Plan equests Brand 414-DE DATE PESCIPTION WITTEN 415-DF NUMBE OF EFILLS AUTHOIZED 00 = No efill Authorized 01 = 1 efill 02 = 2 efills 03 = 3 efills 04 = 4 efills 05 = 5 efills 419-DJ PESCIPTION OIGIN CODE Code values 0, 1, 2, 3, and 4 are accepted. Payer equirement: NYSDOH will map up to 4 modifiers. NYSDOH allows a maximum of 5 refills. NYSDOH requires one of the listed codes to process a claim. Imp Guide: equired if necessary for plan benefit administration. Payer equirement: NYSDOH allows a maximum of 5 refills. Imp Guide: equired if necessary for plan benefit administration. 354-N SUBMISSION CLAIFICATION CODE COUNT Payer equirement: NYS DOH will use code 3 for administration of the e-prescribing incentive. Maximum count of 3. W Imp Guide: equired if Submission Clarification Code (420-DK) is used. Payer equirement: NYSDOH will process up to three occurrences of the codes listed. NYSDOH 19 emedny

20 Claim Segment Segment Identification (111-AM) = DK SUBMISSION CLAIFICATION CODE 01 = No Override W 02 = Other Override 05 = Therapy Change 06 = Starter Dose 07 = Medically Necessary 08 = Process Compound for Approved Ingredients 09 = Encounters 10 = Meets Plan Limitations (when instructed by NYSDOH) 20 = 340B Drugs 99 = Other Claim Billing/Claim ebill Imp Guide: equired if clarification is needed and value submitted is greater than zero (0). If the Date of Service (401-D1) contains the subsequent payer coverage date, the Submission Clarification Code (420-DK) is required with value of 19 (Split Billing indicates the quantity dispensed is the remainder billed to a subsequent payer when Medicare Part A expires. Used only in longterm care settings) for individual unit of use medications. 308-C8 OTHE COVEAGE CODE Accepted Values: 1 = Not Specified 2= Other Coverage Exists- Payment Collected 3= Other Coverage Exists- This Claim Not Covered 4=Other Coverage Exists- Payment Not Collected W Payer equirement: equired if clarification is needed when value submitted is greater than zero (0). For 340B Drugs, NYSDOH requires the use of value 20, in addition to value of 08 in field 423-DN Basis of Cost Determination. Imp Guide: equired if needed by receiver, to communicate a summation of other coverage information that has been collected from other payers. equired for Coordination of Benefits. Payer equirement: equired when other insurance coverage exists. 454-EK SCHEDULED PESCIPTION ID NUMBE Imp Guide: equired if necessary for state/federal/regulatory agency programs. Payer equirement: NYSDOH requires the Prescription Pad Serial Number from the Official NYS Prescription blank. When the following scenarios exist, use the following values in lieu of reporting the Official Prescription Form Serial Number: 461-EU PIO AUTHOIZATION TYPE CODE 00 = Not Specified 01 = Prior Authorization 04 = Exempt Copay a/o Coinsur. W Prescriptions received via Fax or electronically, use EEEEEEEE. Prescriptions on carve-out drugs for Nursing Home patients, use NNNNNNNN. Prescriptions written by Out of State Prescribers, use ZZZZZZZZ. Oral Prescriptions, use Imp Guide: equired if this field could result in different coverage, pricing, or patient financial responsibility. 462-EV PIO AUTHOIZATION NUMBE SUBMITTED W Payer equirement: equired when the claim requires Prior Authorization/Approval, or is copay exempt. Imp Guide: equired if this field could result in different coverage, pricing, or patient financial responsibility. Payer equirement: equired when a Prior Authorization/Approval number has been assigned for this claim. NYSDOH 20 emedny

21 Claim Segment Claim Billing/Claim ebill Segment Identification (111-AM) = NV DELAY EASON CODE All code set values W Imp Guide: equired when needed to specify the reason that submission of the transaction has been delayed. 995-E2 OUTE OF ADMINISTATION All code set values W Imp Guide: equired if specified in trading partner agreement. Payer equirement: equired when billing compound drugs. 996-G1 COMPOUND TYPE All code set values W Imp Guide: equired if specified in trading partner agreement. Payer equirement: equired when billing compound drugs. Pricing Segment Questions Check Claim Billing/Claim ebill Pricing Segment Claim Billing/Claim ebill Segment Identification (111-AM) = D9 INGEDIENT COST SUBMITTED 433-D PATIENT PAID AMOUNT SUBMITTED W Imp Guide: equired if this field could result in different coverage, pricing, or patient financial responsibility. Payer equirement: equired when the member has made payment toward this claim. 426-DQ USUAL AND CUSTOMAY CHAGE Imp Guide: equired if needed per trading partner agreement. Payer equirement: equired. 430-DU GOSS AMOUNT DUE 423-DN BASIS OF COST DETEMINATION All code set values Imp Guide: equired if needed for receiver claim/encounter adjudication. Payer equirement: For 340B Drugs, NYSDOH requires the use of value 08, in addition to value 20 in field 420-DK Submission Clarification Code. Pharmacy Provider Segment Questions Check Claim Billing/Claim ebill This Segment is situational Pharmacy Provider Segment Claim Billing/Claim ebill Segment Identification (111-AM) = EY POVIDE ID QUALIFIE 05 NPI Imp Guide: equired if Provider ID (444-E9) is used. Payer equirement: NYSDOH requires the NPI qualifier. NYSDOH 21 emedny

22 Pharmacy Provider Segment Claim Billing/Claim ebill Segment Identification (111-AM) = E9 POVIDE ID Imp Guide: equired if necessary for state/federal/regulatory agency programs. equired if necessary to identify the individual responsible for dispensing of the prescription. equired if needed for reconciliation of encounter-reported data or encounter reporting. Payer equirement: NYSDOH requires the NPI of the dispensing pharmacist. Prescriber Segment Questions Check Claim Billing/Claim ebill This Segment is situational Prescriber Segment Claim Billing/Claim ebill Segment Identification (111-AM) = EZ PESCIBE ID QUALIFIE 01 NPI Imp Guide: equired if Prescriber ID (411-DB) is used. Payer equirement: NYSDOH requires the NPI qualifier. 411-DB PESCIBE ID Imp Guide: equired if this field could result in different coverage or patient financial responsibility. equired if necessary for state/federal/regulatory agency programs. Payer equirement: NYSDOH requires the NPI of the prescriber E PIMAY CAE POVIDE ID QUALIFIE 01 NPI W Imp Guide: equired if Primary Care Provider ID (421-DL) is used. Payer equirement: equired when the member is restricted to a primary care provider other than the prescriber. 421-DL PIMAY CAE POVIDE ID W Imp Guide: equired if needed for receiver claim/encounter determination, if known and available. equired if this field could result in different coverage or patient financial responsibility. equired if necessary for state/federal/regulatory agency programs. Payer equirement: equired when the member is restricted to a primary care provider other than the prescriber. NYSDOH 22 emedny

23 Coordination of Benefits/Other Payments Segment Questions Check Claim Billing/Claim ebill This Segment is situational equired only for secondary, tertiary, etc claims. Scenario 1 - Other Payer Amount Paid epetitions Only Scenario 2 - Other Payer-Patient esponsibility Amount epetitions and Benefit Stage epetitions Only 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 Segment, only one scenario method shown above may be supported per template. The template shows the Coordination of Benefits/Other Payments Segment 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. Coordination of Benefits/Other Payments Segment Segment Identification (111-AM) = C COODINATION OF BENEFITS/OTHE Maximum count of 9. M PAYMENTS COUNT 338-5C OTHE PAYE COVEAGE TYPE All code set values supported M 339-6C OTHE PAYE ID QUALIFIE 03 = Issuer Identification No. (IIN) 05 = Medicare Carrier No. 99 = Other Claim Billing/Claim ebill Scenario 3 - Other Payer Amount Paid, Other Payer-Patient esponsibility Amount, and Benefit Stage epetitions Present (Government Programs) W Imp Guide: equired if Other Payer ID (340-7C) is used. Payer equirement: equired when another payer has adjudicated this claim. NYS DOH recognizes the listed codes C OTHE PAYE ID W Imp Guide: equired if identification of the Other Payer is necessary for claim/encounter adjudication. Payer equirement: equired when another payer has adjudicated this claim. NYS DOH requires: When field 339-6C contains 03 (IIN) previously known as BIN, enter the 6-digit numeric Issuer Identification Number. When field 339-6C contains 05 - (Medicare Part B), enter the Medicare Part B Carrier Number. When field 339-6C contains 99 - (Other), enter 13 for Medicare MCO. 443-E8 OTHE PAYE DATE W Imp Guide: equired if identification of the Other Payer Date is necessary for claim/encounter adjudication. Payer equirement: equired when another payer has adjudicated this claim. 341-HB OTHE PAYE AMOUNT PAID COUNT Maximum count of 9. W Imp Guide: equired if Other Payer Amount Paid Qualifier (342-HC) is used. Payer equirement: equired when another payer has adjudicated this claim. 342-HC OTHE PAYE AMOUNT PAID QUALIFIE All code set values supported W Imp Guide: equired if Other Payer Amount Paid (431-DV) is used. Payer equirement: equired when another payer has adjudicated this claim. NYSDOH 23 emedny

24 Coordination of Benefits/Other Payments Segment Segment Identification (111-AM) = 05 Claim Billing/Claim ebill Scenario 3 - Other Payer Amount Paid, Other Payer-Patient esponsibility Amount, and Benefit Stage epetitions Present (Government Programs) 431-DV OTHE PAYE AMOUNT PAID W Imp Guide: equired if other payer has approved payment for some/all of the billing. Not used for patient financial responsibility only billing. Not used for non-governmental agency programs if Other Payer-Patient esponsibility Amount (352-NQ) is submitted. Payer equirement: equired when another payer has adjudicated this claim E OTHE PAYE EJECT COUNT Maximum count of 5. W Imp Guide: equired if Other Payer eject Code (472-6E) is used E OTHE PAYE EJECT CODE W Imp Guide: equired when the other payer has denied the payment for the billing, designated with Other Coverage Code (308-C8) = 3 (Other Coverage Billed claim not covered). 353-N 351-NP 352-NQ OTHE PAYE-PATIENT ESPONSIBILITY AMOUNT COUNT OTHE PAYE-PATIENT ESPONSIBILITY AMOUNT QUALIFIE OTHE PAYE-PATIENT ESPONSIBILITY AMOUNT Maximum count of 25. W Imp Guide: equired if Other Payer-Patient esponsibility Amount Qualifier (351-NP) is used. Accepted code set values: 01 = Deductible Amount 04 = Amount reported from previous payer as Exceeding Periodic Benefit Maximum. 05 = Copay Amount 06 = Patient Pay Amount 07 = Coinsurance Amount. 09 = Health Plan Assistance Amount 12 = Coverage Gap Amount W W Imp Guide: equired if Other Payer-Patient esponsibility Amount (352-NQ) is used. Payer equirement: Values qualified by accepted values other than 01, 05 or 07 will be summed as Payer Other Amount. Values not accepted will result in preadjudication rejection. The amount qualified by 09 = Health Plan Assistance Amount should be submitted as a negative amount. Imp Guide: equired if necessary for patient financial responsibility only billing. equired if necessary for state/federal/regulatory agency programs. Not used for non-governmental agency programs if Other Payer Amount Paid (431- DV) is submitted. Payer equirement: equired when reporting Deductible, Coinsurance, Co-pay, or Other Patient esponsibility amounts. DU/PPS Segment Questions Check Claim Billing/Claim ebill This Segment is situational DU/PPS Segment Claim Billing/Claim ebill Segment Identification (111-AM) = E DU/PPS CODE COUNTE Maximum of 9 occurrences. W Imp Guide: equired if DU/PPS Segment is used. NYSDOH 24 emedny

25 DU/PPS Segment Claim Billing/Claim ebill Segment Identification (111-AM) = E4 EASON FO SEVICE CODE All code set values supported W Imp Guide: equired if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. equired if this field affects payment for or documentation of professional pharmacy service. Payer equirement. equired when sending a DU override of a previously denied claim. 440-E5 POFESSIONAL SEVICE CODE All code set values supported W Imp Guide: equired if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. equired if this field affects payment for or documentation of professional pharmacy service. Payer equirement: NYS DOH will ignore this when processing the claim. 441-E6 ESULT OF SEVICE CODE All code set values supported W Imp Guide: equired if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Compound Segment Questions Check Claim Billing/Claim ebill This Segment is situational equired if this field affects payment for or documentation of professional pharmacy service. Payer equirement: equired when sending a DU override of a previously denied claim. Compound Segment Claim Billing/Claim ebill Segment Identification (111-AM) = EF COMPOUND DOSAGE FOM M DESCIPTION CODE 451-EG COMPOUND DISPENSING UNIT FOM M INDICATO 447-EC COMPOUND INGEDIENT COMPONENT Maximum 25 ingredients M COUNT 488-E COMPOUND PODUCT ID QUALIFIE 03 = NDC M NYSDOH expects NDC s to be reported. 489-TE COMPOUND PODUCT ID M NYSDOH will process NDC s on claim. 448-ED COMPOUND INGEDIENT QUANTITY M 449-EE COMPOUND INGEDIENT DUG COST Imp Guide: equired if needed for receiver claim determination when multiple products are billed. 490-UE COMPOUND INGEDIENT BASIS OF COST DETEMINATION Payer equirement: equired. Imp Guide: equired if needed for receiver claim determination when multiple products are billed. Payer equirement: equired. NYSDOH 25 emedny

26 Clinical Segment Questions Check Claim Billing/Claim ebill This Segment is situational equired when billing for items that are part of the Preferred Diabetic Supply Program. Clinical Segment Claim Billing/Claim ebill Segment Identification (111-AM) = VE DIAGNOSIS CODE COUNT Maximum count of 5. Imp Guide: equired if Diagnosis Code Qualifier (492-WE) and Diagnosis Code (424-DO) are used. 492-WE DIAGNOSIS CODE QUALIFIE For Dates of Service Prior to 9/30/2015 NYSDOH expects 01 = ICD9 coding. Payer equirement: equired. Imp Guide: equired if Diagnosis Code (424- DO) is used. Payer equirement: equired. For Dates of Service On or After 10/01/2015 NYSDOH expects 02 = ICD10 coding. 424-DO DIAGNOSIS CODE ICD9 or ICD10 code identifying diagnosis of the patient. Do not transmit the decimal point for ICD codes, decimal point is implied. Imp Guide: equired if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. equired if this field affects payment for professional pharmacy service. equired if this information can be used in place of prior authorization. equired if necessary for state/federal/regulatory agency programs. Payer equirement: equired. ** End of equest Claim Billing/Claim ebill (B1/B3) Payer Sheet ** NYSDOH 26 emedny

27 CLAIM BILLING / CLAIM EBILL ESPONSE CLAIM BILLING / CLAIM EBILL ESPONSE (Accepted/Captured (or Duplicate of Captured)) ** Start of esponse Claim Billing/Claim ebill (B1/B3) Payer Sheet ** GENEAL INFOMATION Payer Name: New York State Department of Health (NYSDOH) Date: 04/22/2011 Plan Name/Group Name: NYS Medicaid IIN: PCN: NYS Medicaid ID CLAIM BILLING/CLAIM EBILL CAPTUED (O DUPLICATE OF CAPTUED) ESPONSE The following lists the segments and fields in a Claim Billing or Claim ebill response (Captured or Duplicate of Captured) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. esponse Transaction Header Segment Questions Check Claim Billing/Claim ebill Accepted/Captured (or Duplicate of Captured) esponse Transaction Header Segment Claim Billing/Claim ebill Accepted/Captured (or Duplicate of Captured) 102-A2 VESION/ELEASE NUMBE D0 M 103-A3 TANSACTION CODE B1, B3 M 109-A9 TANSACTION COUNT Same value as in request M 501-F1 HEADE ESPONSE STATUS A = Accepted M 202-B2 SEVICE POVIDE ID QUALIFIE Same value as in request M 201-B1 SEVICE POVIDE ID Same value as in request M 401-D1 DATE OF SEVICE Same value as in request M esponse Message Header Segment Questions Check Claim Billing/Claim ebill Accepted/Captured (or Duplicate of Captured) This Segment is situational. esponse Message Segment Segment Identification (111-AM) = 20 Claim Billing/Claim ebill Accepted/Captured (or Duplicate of Captured) NYSDOH 27 emedny

28 esponse Message Segment Segment Identification (111-AM) = F4 MESSAGE Medicaid Number (8) W Filler Value = Space (1) County Code = (2) Field Separator Value = * (1) Anniversary Mo. = (2) (values: 01 12) Filler Value = Space (1) Patient Gender code = (1) (values: M or F) Year of Birth = (3) (Format = CYY) Filler Value = Space (1) Category of Assistance = (1) Filler Value = Space (1) e-certification Month = (2) (values: 01 12) Filler Value = Space (1) Office Number (3) Field Separator Value = & (1) Service Date = (8) (Format = CCYYMMDD) Total bytes = 37 Claim Billing/Claim ebill Accepted/Captured (or Duplicate of Captured) Imp Guide: equired if text is needed for clarification or detail. Payer equirement: NYSDOH will provide the defined information in this field. ESPONSE CAPTUED MAP (37bytes) esponse Status Segment Questions Check Claim Billing/Claim ebill Accepted/Captured (or Duplicate of Captured) esponse Status Segment Segment Identification (111-AM) = 21 Claim Billing/Claim ebill Accepted/Captured (or Duplicate of Captured) 112-AN TANSACTION ESPONSE STATUS A=Approved M NYSDOH will return C C=Captured 503-F3 AUTHOIZATION NUMBE Imp Guide: equired if needed to identify the transaction. Payer equirement: NYSDOH will return: spaces when captured. 130-UF ADDITIONAL MESSAGE INFOMATION COUNT Maximum count of 25. Value = 3 NO CLAIM TO FA when the claim has NOT been captured. Imp Guide: equired if Additional Message Information (526-FQ) is used. 132-UH ADDITIONAL MESSAGE INFOMATION QUALIFIE Payer equirement: NYSDOH will return a count of 3. Value = 01 Imp Guide: equired if Additional Message Information (526-FQ) is used. Payer equirement: NYSDOH will return a qualifier of 01 NYSDOH 28 emedny