Pharmacy Manual & Payer Sheets 7101 College Blvd., Ste Pharmacy Help Desk: Overland Park, KS Fax:

Transcription

1 Publication Date: February 10, 2017 Pharmacy Manual & Sheets 7101 College Blvd., Ste Pharmacy Help Desk: Overland Park, KS Fax:

2 OVERVIEW MedTrak Services is a pharmacy benefit management company committed to providing the best possible service to the pharmacies in its participating pharmacy networks. The MedTrak Participating Pharmacy Manual provides information on the administrative policies and procedures pharmacies should follow in providing pharmacy services to MedTrak's eligible members. However, it should be noted that the on-line claims processing system reflects the most current plan benefits and takes precedence over any printed material. Section 1 provides Information about MedTrak's claims processing system. Section 2 gives general information about MedTrak's plan benefit designs.

3 MedTrak Services NCPDP Commercial Sheet SECTION 1: CLAIMS PROCESSING SYSTEM Help Desk-MedTRAK (BIN ) For questions related to eligibility, claims or claim payments, the pharmacy should call the MedTrak Help Desk. The MedTrak Help Desk is open Monday through Friday from 8:00 a.m. (CDT) to 9:00 p.m. (CDT) and Saturday from 9:00 a.m. (CDT) to 6:00 p.m. (CDT). The main toll-free phone number is (600) , but pharmacies should always call the MedTrak toll-free phone number that is printed on the Member Identification Card. After normal Help Desk hours, a voice mail system records messages. A Customer Service Representative will respond to these messages at the start of the next business day. Tria Help Desk (BIN ) For questions related to eligibility, claims or claim payments, the pharmacy should call the Tria Help Desk. The Tria Help Desk is open Monday through Thursday from 8:00 a.m. (CDT) to 9:00 p.m. (CDT), Friday from 8:00 a.m. (CDT) to 7:00 p.m. (CDT) and Saturday from 9:00 a.m. (CDT) to 5:00 p.m. (CDT). The main toll-free phone number is (888) , but pharmacies should always call the Tria toll-free phone number that is printed on the Member Identification Card. After normal Help Desk hours, a voice mail system records messages. A Customer Service Representative will respond to these messages at the start of the next business day. Member Identification All eligible members using a participating retail pharmacy must present a Member Identification Card before the pharmacy dispenses their prescription(s). The Member Identification Cards include, among other things, the MedTrak logo, ANSI BIN, toll-free phone number, Rx Group Number, Group Name, Cardholder ID Number, and Cardholder Name. When eligible members order prescriptions from a participating mail order pharmacy, they must register with the pharmacy and. in the process; indicate they are an eligible member of MedTrak. Point-of-Sale Certification MedTrak's claims processor is Laker Software. A pharmacy system vendor must receive system certification from the claims processor before a pharmacy using that system can submit claims electronically. The pharmacy should contact its pharmacy system vendor if there are questions about how to submit claims. Point-of-Sale Hook-Up In order to establish on-line capabilities with MedTrak's claims processor, the pharmacy, or its pharmacy system vendor, should contact the communication network vendor to obtain the phone number that allows the pharmacy access to the claims processor for submitting claims. MedTrak accepts claims from the following communication network vendors: Relay Health ( ), Emdeon ( ), QS1 ( ), and ERx ( ). On-Line Claims Submission Participating pharmacies must submit claims via electronic transmission for all covered medications dispensed to eligible members. This includes covered medications for which the usual and customary charge is less than the copayment and no reimbursement is due the pharmacy. Pharmacies must submit claims via electronic transmission within 14 days of the date of service using NCPDP Version 5.1 claims. With each claim, the pharmacy must submit: ANSI BIN (or UN), which is

4 MedTrak Services NCPDP Commercial Sheet NCPDP Processor Number, which is (optional). Eligible member information, which includes, at a minimum, the individual's group number, cardholder ID number, person code (or dependent code), member last name, member first name, relationship to cardholder code, gender code and date of birth. The group number and cardholder ID number appear on the identification card. Pharmacy identifier, which is the pharmacy's NPI number. Prescriber identifier, which is the prescriber's NPI number. Prescription information, which includes, at a minimum, the prescription written date, prescription filled date, prescription number, number of refills authorized, drug product NDC, metric quantity, days' supply, compound code (if applicable), PSC, ingredient cost, dispensing fee, tax (if applicable), total charge (ingredient cost + dispensing fee + tax), and U&C. Usual and Customary Charge Special Claims Submission Requirements When submitting a claim, the pharmacy must submit its usual and customary charge. The usual and customary charge is the lowest prescription price, including discounts, charged to a cash-paying patron for that drug on that day. Discounts to be reflected in a pharmacy's usual and customary charge include: Discounts to senior citizens Discounts to frequent shoppers Discounts for members of special programs Professional discounts Discounts due to competitive pricing (e.g., price matching) Any other special discounts to attract patrons Compounds When submitting a claim for a compounded medication (i.e., two or more ingredients), the pharmacy should initially enter the NDC and quantity of the most expensive ingredient. The claim should be marked as a compound, followed by entry of drug and pricing information for each ingredient to include, but not limited to, NDC number, quantity, ingredient cost, Usual and Customary charge, and gross amount due. Product Selection Codes (PSC's) The following PSC's must be used appropriately when a pharmacy submits a claim to MedTrak: PSC=0 - No Product Selection Indicated. This PSC should be used when the drug product is a generic, or when the drug product is a single-source brand (where generic substitution is, by definition, not possible). PSC=1 - Physician-Selected Product. This PSC should be used when the physician requests the branded version of a multiple-source drug product. PSC=2 - Patient-Selected Product. This PSC should be used when the patient requests the branded version of a multiple-source drug product. PSC=3 - Pharmacist-Selected Product. This PSC should be used when, at the pharmacist's discretion, the branded version of a multiple-source drug product is dispensed. 4

5 MedTrak Services NCPDP Commercial Sheet PSC=4 - Generic Out of Stock. This PSC should be used when no generic drug product-is-available to-the pharmacy from-its suppliers. PSC=5 - Brand Product Selected as Generic PSC=6 Override PSC=7 - Product Mandated by Law PSC=8 - Product Not Available PSC=9-Other Some pharmacy benefit plans require that, if the branded version of a multiple- source drug product is dispensed, the eligible member pays the copayment plus the calculated cost difference between the brand and the generic drug products. The pharmacy should always rely on the POS response to determine what copayment should be collected from the eligible member. NOTE: The pharmacy's use of PSC's is subject to audit by MedTrak. Prior Authorization Based on specific plan design, some claims may require MedTrak authorization before the claim will process as paid. The following represent some common POS messages a pharmacy might receive in these situations: Reject 79, RTS (refill too soon) Reject 76, Plan Limitations Exceeded MQ (maximum quantity) Reject 76, Plan Limitations Exceeded MD (maximum dollars) Reject 60, OTC drugs not covered Reject 54, Non-matched NDC number MedTrak will respond quickly and appropriately to a pharmacy's request to approve a claim requiring prior authorization. This PA process will be expedited if the pharmacy contacts MedTrak directly, as soon as possible, regarding the rejected claim. MedTrak reserves the right to disallow any pharmacy's request for prior authorization. PEA Numbers All DEA Numbers submitted with claims by a pharmacy must pass the U.S. Drug Enforcement Administration's check-digit verification algorithm. NPI Numbers Ail NPI numbers submitted by a pharmacy must pass the CMS check-digit verification algorithm. On-Line Claims Response AIJ claims submitted by a pharmacy are subject to system edits before a determination of payment is made. If a claim passes all edits, the claim response will contain an acceptance message consisting of the approved copayment or deductible to be paid by the eligible member and a claim reference number. If, on the other, hand,, a claim fails an edit, the claim response will contain a rejection message consisting of a denial code, reason for denial and a claim reference number. Whether a claim is approved or denied by MedTrak, the pharmacist must exercise professional judgment in 5

6 MedTrak Services NCPDP Commercial Sheet determining whether to dispense a particular medication. Approval or denial of a claim by MedTrak relates only to whether a drug product is covered as a plan benefit, and does not preclude the pharmacist from dispensing the drug if the patient requests the drug and is willing to pay the pharmacy's usual and customary charge for the drug. On-Line Drug Utilization Review MedTrak currently supplies on-line drug utilization review (DUR) messages in its claim response to participating pharmacies. The following types of DUR messages may be sent: Therapeutic duplication Drug to drug interaction Drug regimen compliance e Drug to inferred health state Dosage range Drug overuse edit Drug to age edit Drug to sex edit Preferred formulary Pharmacists with questions regarding DUR messages are encouraged to call the MedTrak Help Desk. DUR information from MedTrak is limited to information contained in the claims processor's current participant database. Therefore, DUR messages relate only to other claims processed by or through the claims processor's system. These DUR messages are only one of several tools pharmacists should use in the dispensing process. On-Line Claims Reversals A pharmacy must submit a reversal to a claim previously accepted on-line when an eligible member fails to pick up a filled prescription within 90 days of the claim submission date. If a pharmacy needs to resubmit a claim previously accepted on-line, the pharmacy must first submit a reversal within 9Q days of the claim submission date. Signature Log All participating retail pharmacies must maintain a signature log (hard-copy or electronic) that includes the plan sponsor name, prescription number, and date of receipt of each covered medication dispensed to an eligible member. The eligible member, or his/her representative, must sign the log for each covered medication he/she receives. Reporting MedTrak will send the following documents for payment and reconciliation assistance for each participating pharmacy: Payment check or electronic funds transfer Pharmacy Remittance Report. This report lists all paid claims, reversed claims, and denied claims for the processing period (available electronically in H1PAA- approved format). The claims processing payment period is twice monthly on the 15th and the last day of the month. Claims payments and supporting documents are sent no more than 30 days after invoice payment to MedTrak. 6

7 MedTrak Services NCPDP Commercial Sheet Pricing Each-submitted claim will be priced using the specific guidelines established by the plan sponsor. The source of drug product AWP prices is Medi-Span. Prices are effective on the date the prescription is filled. Claims Adjustments Adjustments to paid or denied claims are possible. The pharmacy should submit documentation to MedTrak supporting the pharmacy's request for corrections and a copy of the Pharmacy Remittance Report highlighting the claims on which adjustments are being requested. Universal Claim Form Although MedTrak requires pharmacies to submit claims electronically through the POS system, an isolated instance may occur from time to time when a pharmacy must submit a claim by completing and sending a Universal Claim Form (UCF). The pharmacy should follow the steps outlined below when sending a UCF for payment consideration: The UCF must be an original form obtained from NCPDP, with all required data fields completed clearly and legibly. The UCF should be mailed to: MedTrak Services 7101 College Blvd., Suite 1000 Overland Park, KS Pharmacy Audits MedTrak is obligated to conduct audits of pharmacy records to insure compliance with the Pharmacy Services Agreement. A participating pharmacy may be selected for an on-site audit based on such factors as prescription volume, use of generics, dispensing of controlled substances, average prescription quantity, average prescription cost, and average number of prescriptions per eligible member. In addition, service complaints from eligible members, plan sponsors, and other pharmacies may trigger an audit. When selected for an audit, MedTrak will notify the pharmacy in writing. A random selection of claims information submitted to MedTrak will be generated in a report. The auditor will review actual pharmacy files for the prescriptions contained within the report. Prescriptions will be reviewed to determine how they were written in comparison to how the respective claims were submitted to MedTrak and what is documented in the signature log. If MedTrak suspects that the pharmacy has acted fraudulently, the auditor may request supplier invoices and patron cash register receipts. The auditor may also look for any notes or changes made to prescription orders received from physicians and may contact physicians to verify what was actually prescribed. Any discrepancies found by the auditor will be pointed out to an on-site pharmacist at the completion of the audit. These discrepancies will be logged on an audit "checklist" and will be signed by both the auditor and the pharmacist. Trouble-Shooting If the pharmacy system is unable to make a connection with the claims processor's computer system, the pharmacy should contact its communication network vendor (or switch). For questions about eligibility, claims, and claims payments, the pharmacy should call the MedTrak Help Desk. Written inquiries may be directed to: MedTrak Services 7101 College Blvd., Suite 1000 Overland Park, KS

8 MedTrak Services NCPDP Commercial Sheet SECTION 2: PLAN INFORMATION Participating Pharmacy Network Any pharmacy that has a fully executed Pharmacy Services Agreement, signed by both the pharmacy and MedTrak, is considered a MedTrak participating pharmacy. General Plan Design The following is a general discussion of MedTrak's plan design. Individual plans may vary. The pharmacy should refer to the on-line claims response to verify the plan specifications that apply to a particular drug claim. Inclusions: The following items are typically covered: Federal legend drugs Compounded medications in which at least one ingredient is a legend drug Injectable Anti-Diabetics (OTC Insulin-Rx required) Exclusions: The following items are typically not covered: Abortifacients Anabolic steroids (Testosterone for male hypogonadism)» Anti-Obesity/Anorexiant drugs Blood sera Botox Contraceptive implants and topicals (luds and diaphragms» Cosmetic drugs (Rogaine, Propecia) Diabetic administration supplies (Pumps/supplies with the exception of Insulin syringes/needles) Diagnostic test supplies Emergency contraceptives Erectile dysfunction drugs (ED)-P5 inhibitors (Cialis, Levitra, Viagra) Fertility agents Fluoride preparations Growth stimulating products «Homeopathic drugs Inhaler devices Legend drugs with over-the-counter equivalents Needles and syringes (except insulin needles and syringes) Nutritional and dietary supplements Over-the-counter drugs (except insulin) Therapeutic devices or appliances and other non-medicinal substances Vaccines /Serums/Toxoids/AIIergens Charges for injection or administration of a drug Drugs dispensed to replace lost, stolen, broken or thrown away medications Drugs entirely consumed at the time and place of prescribing 8

9 MedTrak Services NCPDP Commercial Sheet Prescriptions dispensed without charge to eligible members due to Workers' Compensation laws {exception: Workers' Compensation plans) & Experimental drugs or drugs labeled, "Caution - Limited by federal law to investigational use" Medication to be taken by or administered to an eligible member while a patient in a licensed hospital, nursing home, or similar situation, which operates or allows to be operated on its premises a facility for dispensing pharmaceuticals Refills in excess of the number specified or authorized by the physician or any refill dispensed after one year from the physician's original order. Mailing and delivery charges Prior Authorization Some medications may require prior authorization by MedTrak. Dispensing Limits For each covered medication dispensed at a participating pharmacy, the pharmacist should exercise sound professional judgment regarding drug dispensing practices and act in accordance with all state and federal regulations. In general, the quantity dispensed will not exceed the quantity prescribed. In addition, the quantity dispensed will usually not exceed a 34-day supply for acute medications and a 90-day supply for maintenance medications. Maintenance Medications Maintenance medications are drugs which, when used regularly by individuals with chronic medical conditions, will prevent debilitating diseases. Prescriptions for maintenance medications may qualify for a maximum dispensing quantity of 90 days. However, not all dosage forms of maintenance medications qualify for a 90-day supply (e.g., topical products, sublingual tablets, suppositories, ophthalmic products, inhalers, etc.). Types of Member-Pav Programs Shared-Pay Program. The participating pharmacy submits its clairn(s) electronically to MedTrak. The eligible member pays all applicable deductibles and copayments at the participating pharmacy. Through MedTrak, the plan sponsor pays the pharmacy any pharmacy reimbursement due. Full-Pay Funded Program. The participating pharmacy submits the eligible member's claim(s) electronically to MedTrak. The eligible member pays the total pharmacy reimbursement at the participating pharmacy. MedTrak sends the claim(s) to the plan sponsor's claims administrator. The claims administrator pays the eligible member any pharmacy reimbursement due. Deductible Within shared-pay programs, there can be an individual or a family deductible. In these cases, the eligible member pays one hundred (100) percent of the total pharmacy reimbursement for each covered medication until the applicable deductible is satisfied. Copayment Within shared-pay programs, once any applicable deductible is satisfied and for the remainder of the calendar or the contract year, the eligible member pays the applicable copayment for each covered medication. The copayment can be a fee that varies for generic, branded and formulary drug products; or it can be a percentage of the total pharmacy reimbursement, which also may vary for generic, branded and formulary drug products; or it can be a combination of these two alternatives. 9

10 MedTrak Services NCPDP Commercial Sheet Benefit Maximum Within shared-pay programs, a predetermined ceiling can be set on covered medication claims expense of member-out-of-pocket costs for-an-individual or-a-family. If an individual or a family reaches this benefit maximum during the calendar or the contract year, the benefit can be modified or terminated. Mandatory Generic Program For shared-pay programs, if the medication prescribed is available as a generic but the pharmacy dispenses the brand, the eligible member must pay the applicable copayment for the branded drug product plus the difference in product cost between the branded and the generic drug products. Out-of-Network An eligible member may get a prescription filled at a non-participating pharmacy, but he/she must pay the non-participating pharmacy's usual and customary charge for the prescription. The eligible member must then submit a claim to receive reimbursement for shared-pay programs may be at the non- participating pharmacy's usual and customary charge Jess any applicable deductible and/or copayment, or at the total pharmacy reimbursement less any applicable deductible and/or copayment. Drug Utilization Review In addition to On-Line Drug Utilization Review, which is discussed in Section 1 of this Manual, MedTrak also reviews retrospectively the drug utilization by plan sponsors' eligible members. When a potential drug utilization problem is identified by MedTrak, MedTrak contacts the appropriate participating pharmacy, determines the severity of the problem, and discusses with a pharmacist the best course of action for resolving it. The pharmacy is expected to cooperate with and support MedTrak's drug utilization review programs. Formulary Management MedTrak promotes its formulary to physicians, participating pharmacies and eligible members, it also monitors compliance with the formulary. When a non-formulary drug is dispensed, MedTrak may contact the participating pharmacy and discuss with a pharmacist the feasibility of substituting a therapeutic equivalent. The pharmacy is expected to cooperate with and support MedTrak's formulary programs to the extent possible. 10

11 MedTrak Services NCPDP Commercial Sheet ** Start of Request Claim Billing (B1/B3) Sheet ** General Information Name: MedTrak Services Date: 02/10/2017 Plan Name/Group Name: Commercial-MedTrak BIN: PCN: Blank Fill Plan Name/Group Name: Tria Incentive Plan BIN: PCN: Blank Fill Processor: Laker Software Effective as of: 1(1/2012 NCPDP Telecommunication Standard Version/Release #: D.O NCPDP Data Dictionary Version Date: Date of Publication NCPDP External Code List Version Date: July 2011 Contact/Information Source: Erika Timmons Certification Testing Window: 11/1/ /15/2011 Certification Contact Information: Erika Timmons Provider Relations Help Desk Info Other versions supported: 5.1 Telecommunication Standard will be supported until 1/1/2012 OTHER TRANSACTIONS SUPPORTED : Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Transaction Code B1 B2 Billing Transaction Billing Reversal Transaction Name FIELD LEGEND FOR COLUMNS Column Value Explanation Situation Column MANDATORY M The Field is mandatory for the Segment in the designated Transaction. No REQUIRED R The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. No QUALIFIED REQUIREMENT "Required when". The situations designated have qualifications for usage ("Required if x", "Not required if y"). Yes 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. CLAIM BILLING/CLAIM REBILL TRANSACTION The following lists the segments and fields in a Claim Billing or Claim Rebill Transaction for the NCPDP Telecommunication standard Implementation Guide Version D.0.. Transaction Header Segment Questions Check Source of certification IDs required in Software Vendor/Certification ID (110-AK) is 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 Situation 101-A1 BIN NUMBER See Values in General Information M 102-A2 VERSION/RELEASE NUMBER D0 M 103-A3 TRANSACTION CODE B1, B3 M 104-A4 PROCESSOR CONTROL NUMBER See PCN under general information M 109-A9 TRANSACTION COUNT 1-4 M 202-B2 SERVICE PROVIDER ID QUALIFIER 01 M 201-B1 SERVICE PROVIDER ID NPI M 401-D1 DATE OF SERVICE M 110-AK SOFTWARE VENDOR/CERTIFICATION ID M Blank Fill 11

12 MedTrak Services NCPDP Commercial Sheet Insurance Segment Questions Check Insurance Segment Segment Identification (111-AM) = "04" 302-C2 CARDHOLDER ID M 312-CC CARDHOLDER FIRST NAME R 313-CD CARDHOLDER LAST NAME R 301-C1 GROUP ID 303-C3 PERSON CODE 306-C6 PATIENT RELATIONSHIP CODE 1= Cardholder 2= Spouse 3= Chile 4= Other 360-2B MEDICAID INDICATOR 115-N5 MEDICAID ID NUMBER R Situation Imp Guide: Required if necessary for state/federal/regulatory agency programs when the cardholder has a first name. Requirement: First Name is required Imp Guide: Required if necessary for state/federal/regulatory agency programs. Requirement: Last Name is required Imp Guide: Required if necessary for state/federal/regulatory agency programs. Required if needed for pharmacy claim processing and payment. Requirement: Required When supplied on ID Card Imp Guide: Required if needed to uniquely identify the family members within the Cardholder ID. Requirement: Required when on ID card Imp Guide: Required if needed to uniquely identify the relationship of the Patient to the Cardholder. Imp Guide: Required, if known, when patient has Medicaid coverage. Requirement: Required when Medicaid policy is available Imp Guide: Required, if known, when) patient has Medicaid coverage. Requirement: Required when Medicaid policy is available Insurance Segment Questions Check This Segment is situational Patient Segment Segment Identification (111-AM) = "01" Field NCPDP Field Name Value Situation 304-C4 DATE OF BIRTH R 305-C5 PATIENT GENDER CODE 1 = MALE 2= FEMALE 310-CA PATIENT FIRST NAME R 311-C8 PATIENT LAST NAME R 322-CM PATIENT STREET ADDRESS R 323-CN PATIENT CITY ADDRESS R 324-CO PATIENT STATE / PROVINCE ADDRESS R 325-CP PATIENT ZIP/POSTAL ZONE R 326-CQ PATIENT PHONE NUMBER R R Imp Guide: Required when the patient has a first name. 12

13 MedTrak Services NCPDP Commercial Sheet Field NCPDP Field Name Value 335-2C PREGNANCY INDICATOR 350-HN PATIENT ADDRESS Situation Imp Guide: Required if pregnancy could result in different coverage, pricing, or patient financial responsibility. Required if "required by law" as defined in the HIPAA final Privacy regulations section definitions (45 CFR Parts 160 and 164 Standards for Privacy of Individually Identifiable Health Information; Final Rule- Thursday, December 28, 2000, page and following, and Wednesday, August 14, 2002, page and Following.) Requirement: Submit if available Imp Guide: May be submitted for the receiver to relay patient health care communications via the Internet when provided by the patient. Requirement: Required when available Claim Segment Questions Check Claim Billings/Claim Rebill This payer supports partial fills. Partial Fill is not supported for Compounds This payer does not support partial fills Claim Segment Segment Identification (111-AM) = "07" 455-EM 402-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUMBER 1 = Rx Billing M 436-E1 PRODUCT/SERVICE ID QUALIFIER 03= National Drug Code M 407-D7 PRODUCT/SERVICE ID M M Situation Imp Guide: For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Imp Guide: Required if the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). 456-EN ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER Required if the Dispensing Status (343- HD) = "P" (Partial Fill) and there are multiple occurrences of partial fills for this prescription. Requirement: Required when completing a partial fill Imp Guide: Required if the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). 457-EP ASSOCIATED PRESCRIPTION/SERVICE DATE Required if Associated Prescription/Service Reference Number (456-EN) is used. Required if the Dispensing Status (343- HD) = "P" (Partial Fill) and there are multiple occurrences of partial fills for this prescription. 442-E7 QUANTITY DISPENSED R Requirement: Required when completing a partial fill 13

14 MedTrak Services NCPDP Commercial Sheet Claim Segment Segment Identification (111-AM) = "07" 403-D3 FILL NUMBER R 405-D5 DAYS SUPPLY R 406-D6 COMPOUND CODE 408-D8 DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE 01 = Not a Compound 02 = Compound 414-DE DATE PRESCRIPTION WRITTEN R 415-DF NUMBER OF REFILLS AUTHORIZED R 419-DJ PRESCRIPTION ORIGIN CODE R 354-N SUBMISSION CLARIFICATION CODE COUNT Maximum count of DK SUBMISSION CLARIFICATION CODE 308-C8 OTHER COVERAGE CODE 429-DT SPECIAL PACKAGING INDICATOR 418-DI LEVEL OF SERVICE 461-EU PRIOR AUTHORIZATION TYPE CODE R R Situation Imp Guide: Required if necessary for plan benefit administration. Requirement: PRN = 99, otherwise max 12 Imp Guide: Required if necessary for plan benefit administration. Imp Guide: Required if Submission Clarification Code (420-DK) is used. Requirement: Submit when available. Imp Guide: Required 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 long-term care settings) for individual unit of use medications. Requirement: Submit when available Imp Guide: Required if needed by receiver, to communicate a summation of other coverage information that has been collected from other payers. Required for Coordination of Benefits. Requirement: Required when other Paver is identified Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility. Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility. Requirement: Submit when available Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility. Requirement: Submit when Prior authorization is required for payment 14

15 MedTrak Services NCPDP Commercial Sheet Claim Segment Segment Identification (111-AM) = "07" 462-EV PRIOR AUTHORIZATION NUMBER SUBMITTED 343-HD DISPENSING STATUS 344-HF 345-HG QUANTITY INTENDED TO BE DISPENSED DAYS SUPPLY INTENDED TO BE DISPENSED 357-NV DELAY REASON CODE 995-E2 ROUTE OF ADMINISTRATION Situation Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility. Requirement: Submit when Prior authorization is required for payment Imp Guide: Required for the partial fill or the completion fill of a prescription. Requirement: Required for partial fills Imp Guide: Required for the partial fill or he completion fill of a prescription. Requirement: Required for partial fills Imp Guide: Required for the partial fill or the completion fill of a prescription. Requirement: Required for partial fills Imp Guide: Required when needed to specify the reason that submission of the transaction has been delayed. Requirement: when transaction is delayed Imp Guide: Required if specified in trading partner agreement. Requirement: Required for compound code G1 COMPOUND TYPE 1- Anti-infective 2- Ionotropic 3- Chemotherapy 4- Pain Management 5- TPN/PPN 6- Hydration 7- Ophthalmic 99- Not Defined Imp Guide: Required if specified in trading partner agreement. Requirement: Required for compound code U7 PHARMACY SERVICE TYPE 1- Community/Retail Pharmacy services 2- Compounding Pharmacy 3- Home Infusion 4- Institutional Pharmacy 5- LTC pharmacy 6- Mail order 7- Managed Care Org 8- Specialty Care Pharmacy 99. Other R Imp Guide: Required when the submitter must clarify the type of services being performed as a condition for proper reimbursement by the payer. Requirement: Refer to 15

16 MedTrak Services NCPDP Commercial Sheet Pricing Segment Questions Check Pricing Segment Segment Identification (111-AM) = "11" Situation 409-D9 INGREDIENT COST SUBMITTED R 412-DC DISPENSING FEE SUBMITTED R 433-D PATIENT PAID AMOUNT SUBMITTED R Imp Guide: Required if its value has an effect on the Gross Amount Due (430- DU) calculation. Requirement: Submit when available Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility. 438-E3 INCENTIVE AMOUNT SUBMITTED 481-HA FLAT SALES TA AMOUNT SUBMITTED 482-GE PERCENTAGE SALES TA AMOUNT SUBMITTED Requirement: Submit when COB claim Imp Guide: Required if its value has an effect on the Gross Amount Due (430- DU) calculation. Requirement: Required when requesting administration fee payment Imp Guide: Required if its value has an effect on the Gross Amount Due (430- DU) calculation. Requirement: Required if sales tax is submitted Imp Guide: Required if its value has an effect on the Gross Amount Due (430- DU) calculation. Requirement: Required if sales tax is submitted Imp Guide: Required if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Basis Submitted (484-JE) are used. 483-HE PERCENTAGE SALES TA RATE SUBMITTED Required if this field could result in different pricing. Required if needed to calculate Percentage Sales Tax Amount Paid (559- A). Requirement: Required if sales lax is submitted Imp Guide: Required if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Rate Submitted (483-HE) are used. 484-JE PERCENTAGE SALES TA BASIS SUBMITTED Required if this field could result in different pricing. Required if needed to calculate Percentage Sales Tax Amount Paid (559- A). 426-DQ USUAL AND CUSTOMARY CHARGE R 430-DU GROSS AMOUNT DUE R 423-DN BASIS OF COST DETERMINATION Requirement: Required if sales tax is submitted Imp Guide: Required if needed per trading partner agreement. Imp Guide: Required if needed for receiver claim/encounter adjudication. Requirement: Submit when available 16

17 MedTrak Services NCPDP Commercial Sheet Prescriber Segment Questions Check This Segment is situational Prescriber Segment Segment Identification (111-AM) = "03" 466-EZ PRESCRIBER ID QUALIFIER R 411-DB PRESCRIBER ID R 427-DR PRESCRIBER LAST NAME R 498-PM PRESCRIBER PHONE NUMBER R 364-2J PRESCRIBER FIRST NAME 365-2K PRESCRIBER STREET ADDRESS 366-2M PRESCRIBER CITY ADDRESS 367-2N PRESCRIBER STATE/PROVINCE ADDRESS 368-2P PRESCRIBER ZIP/POSTAL ZONE Situation Imp Guide: Required if Prescriber ID (411- DB) is used. Imp Guide: Required if this field could result in different coverage or patient financial responsibility. Required if necessary for state/federal/regulatory agency programs. Imp Guide: Required when the Prescriber ID (411-DB) is not known. Required if needed for Prescriber ID (411- DB) validation/clarification. Imp Guide: Required if needed for Workers' Compensation. Required if needed to assist in identifying the prescriber. Required if needed for Prior Authorization process. Imp Guide: Required if needed to assist in identifying the prescriber. Required if necessary for state/federal/regulatory agency programs. Requirement: submit when available Imp Guide: Required if needed to assist in identifying the prescriber. Required if necessary for state/federal/regulatory agency programs. Requirement: submit when available Imp Guide: Required if needed to assist in identifying the prescriber. Required if necessary for state/federal/regulatory agency programs. Requirement: submit when Imp Guide: Requited if needed to assist in identifying the prescriber. Required if necessary for state/federal/regulatory agency programs. Requirement: submit when available Imp Guide: Required if needed to assist in identifying the prescriber. Required if necessary for state/federal/regulatory agency programs. Requirement: submit when available 17

18 MedTrak Services NCPDP Commercial Sheet Coordination of Benefits/Other Payments Segment Questions Check This Segment is situational Required only for secondary, tertiary, etc claims. Scenario 1 - Other Amount Paid Repetitions Only Scenario 2 - Other -Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only Scenario 3 - Other Amount Paid, Other - Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) If the 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 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 Segment Segment Identification (111-AM) = "05" 337-4C COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT Maximum count of C OTHER PAYER COVERAGE TYPE M 339-6C OTHER PAYER ID QUALIFIER M 340-7C OTHER PAYER ID M 443-E8 OTHER PAYER DATE R 341-HB OTHER PAYER AMOUNT PAID COUNT Maximum count of 9. R 342-HC OTHER PAYER AMOUNT PAID QUALIFIER Blank= Not specified 02= Shipping 03= Postage 04= Administrative 05= Incentive 06= Cognitive Service 07= Drug Benefit 08= Sum of all Reimbursement 98= Coupon 99= Other 431-DV OTHER PAYER AMOUNT PAID 471-5E OTHER PAYER REJECT COUNT Maximum count of E OTHER PAYER REJECT CODE 353-NR OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT M R Scenario 1 - Other Amount Paid Repetitions Only Situation Imp Guide: Required if Other ID (340-7C) is used. Imp Guide: Required if identification of the Other is necessary for claim/encounter adjudication. Imp Guide: Required if identification of the Other Date is necessary for claim/encounter adjudication. Imp Guide: Required if Other Amount Paid Qualifier (342-HC) is used. Imp Guide: Required if Other Amount Paid (431-DV) is used. Imp Guide: Required 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 -Patient Responsibility Amount (352-NQ) is submitted. Imp Guide: Required if Other Reject Code (472-6E) is used. Requirement: Required when claims rejected by other payer Imp Guide: Required when the other layer has denied the payment for the lilting. Requirement: Required when claim s rejected by other payer Maximum Count of 25 1 (for other payer-patient Responsibility) 18

19 MedTrak Services NCPDP Commercial Sheet Coordination of Benefits/Other Payments Segment Segment Identification (111-AM) = "05" 351 -NP 351 -NQ OTHER PATIENT RESPONSIBILITY AMOUNT QUALIFIER OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT Scenario 1 - Other Amount Paid Repetitions Only 06 Situation Enter Co-pay Primary Worker s Compensation Segment Questions This Segment is situational Applies for Workers Comp claims Workers' Compensation Segment Segment Identification (111-AM) = "06" Situation 434-DY DATE OF INJURY M 315-CF EMPLOYER NAME 316-CG EMPLOYER STREET ADDRESS 317-CH EMPLOYER CITY ADDRESS 318-CI EMPLOYER STATE/PROVINCE ADDRESS 319-CJ EMPLOYER ZIP/POSTAL ZONE 327-CR CARRIER ID 435-DZ CLAIM/REFERENCE ID 117-TR BILLING ENTITY TYPE INDICATOR R Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition. Requirement: Submit when available Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition. Requirement: Submit when available Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition. Requirement: Submit when available Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition. Requirement: Submit when available Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition. Requirement: Submit when available Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition. Requirement: Submit when available Imp Guide: Required if needed to process a claim/encounter for a work related injury or condition. Requirement: Submit when available 19

20 MedTrak Services NCPDP Commercial Sheet Prescriber Segment Questions Check This Segment is situational Based on Pharmacy determination for clinical or vaccine processing. DUR/PPS Segment Segment Identification f111-am) = "08" 473-7E DUR/PPS CODE COUNTER Maximum of 9 occurrences. Situation Imp Guide: Required if DUR/PPS Segment is used. Requirement: Required if DUR/PPS segment is used Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. 439-E4 REASON FOR SERVICE CODE Required if this field affects payment for or documentation of professional pharmacy service. Requirement: Required if request for service payment is submitted Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. 440-E5 PROFESSIONAL SERVICE CODE Required if this field affects payment for or documentation of professional pharmacy service. Requirement: Required when medication is being administered Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. 441-E6 RESULT OF SERVICE CODE 474-8E DUR/PPS LEVEL OF EFFORT 475-J9 DUR CO-AGENT ID QUALIFIER 476-H6 DUR CO-AGENT ID Required if this field affects payment for or documentation of professional pharmacy service. Requirement: Required if request for service payment is submitted Imp Guide: Required if this field could resutt in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required if this field affects payment for or documentation of professional pharmacy service. Requirement: required when describing effort Imp Guide: Required if DUR Co-Agent ID (476-H6) is used. Requirement: Required when available Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required if this field affects payment for or documentation of professional pharmacy service. Requirement: Required when available 20

21 MedTrak Services NCPDP Commercial Sheet Coupon Segment Questions Check This Segment is situational Coupon Segment Segment Identification (111-AM) = "09" 485-KE COUPON TYPE M 486-ME COUPON NUMBER M 487-NE COUPON VALUE AMOUNT R Situation Imp Guide: Required if needed for receiver claim/encounter determination when a coupon value is known. Required if this field could result in different pricing and/or patient financial responsibility. Requirement: submit when coupon is used Compound Segment Questions Check This Segment is situational This segment is required when submitting a claim for mufti-ingredient j claim transaction (406-D6 = 2) Compound Segment Segment identification (111-AM) - "10" 450-EF 451-EG 447-EC COMPOUND DOSAGE FORM DESCRIPTION CODE COMPOUND DISPENSING UNIT FORM INDICATOR COMPOUND INGREDIENT COMPONENT COUNT Maximum 25 ingredients 488-RE COMPOUND PRODUCT ID QUALIFIER M 489-TE COMPOUND PRODUCT ID M 448-ED COMPOUND INGREDIENT QUANTITY M 449-EE COMPOUND INGREDIENT DRUG COST 490-UE COMPOUND INGREDIENT BASIS OF COST DETERMINATION M M M Situation Imp Guide: Required if needed for receiver claim determination when multiple products are billed. Requirement: Required when compound code 2 is used Imp Guide: Required if needed for receiver claim determination when multiple products are billed. Requirement: Required when compound code 2 is used 21

22 MedTrak Services NCPDP Commercial Sheet Clinical Segment Questions Check This Segment is situational When Diagnosis is available Clinical Segment Segment Identification (111-AM) = "13" Situation 491-VE DIAGNOSIS CODE COUNT Maximum count of WE DIAGNOSIS CODE QUALIFIER Imp Guide: Required if Diagnosis Code Qualifier (492-WE) and Diagnosis Code (424-DO) are used. Requirement: Submit when available Imp Guide: Required if Diagnosis Code (424-DO) is used. Requirement: Submit when available Imp Guide: Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. 424-DO DIAGNOSIS CODE Required if this field affects payment for professional pharmacy service. Required if this information can be used in place of prior authorization. Requited if necessary for state/federal; regulatory agency programs. Requirement: Submit when available ** End of Request Claim Billing (B1/B3) Sheet ** 1.1 Response Sheet Template Accepted/Paid (or Duplicate of Paid) Response **Start of Response Claim Billing/Claim (B1/B3 Sheet** Name: MedTrak Services Date: 10/18/11 Plan Name/Group Name: Commercial BIN: / PCN: Blank Fill Plan Name/Group Name: Medicare Wrap Plans BIN: PCN: Blank Fill CLAIM BILLING/CLAIM REBILL PAID (OR DUPLICATE OF PAID) RESPONSE The following lists the segments and fields in a Claim Billing or Claim Rebill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Response Transaction Header Segment Check - Accepted/Paid (or Duplicate of Paid) Response Transaction Header Segment - Accepted/Paid (or Duplicate of Paid) Situation 102-A2 VERSION/RELEASE NUMBER D0 M 103-A3 TRANSACTION CODE B1, B3 M 109-A9 TRANSACTION COUNT Same value as in request M 501-F1 HEADER RESPONSE STATUS A = Accepted M 202-B2 SERVICE PROVIDER ID QUALIFIER Same value as in request M 201-B1 SERVICE PROVIDER ID Same value as in request M 401-D1 DATE OF SERVICE Same value as in request M 22

23 MedTrak Services NCPDP Commercial Sheet Response Message Segment Question Check - Accepted/Paid (or Duplicate of Paid) This Segment is situational Provided when text is needed for clarification or detail. Response Message Segment Segment identification (111-AM) = "20" 504-F4 MESSAGE - Accepted/Paid (or Duplicate of Paid) Situation Imp Guide: Required if text is needed for clarification or detail. Requirement: Response Insurance Segment Question Check - Accepted/Paid (or Duplicate of Paid) This Segment is situational Response Insurance Segment Segment Identification (111-AM) = "25" - Accepted/Paid (or Duplicate of Paid) Situation 301-C1 GROUP ID Imp Guide: Required if needed to identify the actual cardholder or employer group, to identify appropriate group R number, when available. Required to identify the actual group that was used when multiple group coverages exist. 568-J7 PAYER ID QUALIFIER R Imp Guide: Required if ID (569- J8) is used. 569-J8 PAYER ID R Imp Guide: Required to identify the ID of the payer responding. Response Status Segment Question Check - Accepted/Paid (or Duplicate of Paid) Response Status Segment Segment Identification (111-AM) = "21" 112-AN TRANSACTION RESPONSE STATUS P=Paid D=Duplicate of Paid - Accepted/Paid (or Duplicate of Paid) Situation 503-F3 AUTHORIZATION NUMBER R Imp Guide: Required if needed to identify the transaction. 526-FQ ADDITIONAL MESSAGE INFORMATION M Imp Guide: Required when additional text is needed for clarification or detail. Response Claim Segment Question Check - Accepted/Paid (or Duplicate of Paid) Response Claim Segment Segment Identification (111-AM) - "22" 455-EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER 402-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER 1 Rx Billing M M - Accepted/Paid (or Duplicate of Paid) Situation Imp Guide: For Transaction Code of "B1", in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1' (Rx Billing). 23

24 MedTrak Services NCPDP Commercial Sheet Response Pricing Segment Question Check - Accepted/Paid (or Duplicate of Paid) Response Pricing Segment Segment Identification (111-AM) = "23" 505-F5 PATIENT PAY AMOUNT R 506-F6 INGREDIENT COST PAID R - Accepted/Paid (or Duplicate of Paid) Situation 507-F7 DISPENSING FEE PAID R Imp Guide: Required if this value is used to arrive at the final reimbursement. 557-AV TA EEMPT INDICATOR Imp Guide: Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. 509-F9 TOTAL AMOUNT PAID R Requirement : When available Response Pricing Segment Segment Identification (111-AM) - "23" Field it NCPDP Field Name Value 522-FM BASIS OF REIMBURSEMENT DETERMINATION - Accepted/Paid (or Duplicate of Paid) Situation Imp Guide: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Required if Basis of Cost Determination (432-DN) is submitted on billing. Requirement: When available 523-FN AMOUNT ATTRIBUTED TO SALES TA Imp Guide: Required if Patient Pay Amount (505-F5) includes sales tax that is the financial responsibility of the member but is not also included in any of the other fields that add up to Patient Pay Amount. 517-FH AMOUNT APPLIED TO PERIODIC DEDUCTIBLE Paver Requirement: When available Imp Guide: Required if Patient Pay Amount (505-F5) includes deductible 518-FI AMOUNT OF COPAY Imp Guide: Required if Patient Pay Amount (505-F5) includes copay as patient financial responsibility. 520-FK AMOUNT ECEEDING PERIODIC BENEFIT MAIMUM Imp Guide: Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. 134-UK AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG Requirement: When available Imp Guide: Required if Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a Brand drug. Paver Requirement: When available Response DUR/PPS Segment Question Check - Accepted/Paid (or Duplicate of Paid) The Segment is situational Response DUR/PPS Segment Segment identification (111-AM) = "24" 567-J6 DUR/PPS RESPONSE CODE COUNTER Maximum 9 occurrences supported. - Accepted/Paid (or Duplicate of Paid) Situation Imp Guide: Required if Reason For Service Code (439-E4) is used. 439-E4 REASON FOR SERVICE CODE Imp Guide: Required if utilization conflict is detected. 24