Envisionxptions Comprehensive D.Ø heet General Information Name: ENVIIN/X PTIN evision Date: 12/12/2017 Plan Name/Group Name: AmWIN Commercial BIN: Ø11289 PCN: N/A Plan Name/Group Name: AmWIN - Williamson County BIN: Ø13492 PCN: N/A Plan Name/Group Name: AmWIN QHP BIN: Ø14848 PCN: EDD Plan Name/Group Name: AmWINx (Effective 1/1/2018) BIN: Ø15185 PCN: CPATD Processor: ENVIIN/X PTIN Effective as of: 1/1/2017 Contact/Information ource: www.envisionrx.com NCPDP Telecommunication Version/elease #: D.Ø Transaction Code: B1 & B2 *Please contact AmWIN at 1-855-693-3921 for all questions pertaining to the AmWIN Plan Names/Groups Names. Name: ENVIIN/X PTIN evision Date: 12/12/2017 Plan Name/Group Name: Part D BIN: Ø12312 PCN: PATD Plan Name/Group Name: Commercial BIN: ØØ9893 PCN: IX Plan Name/Group Name: FamilyWize BIN: 61Ø194 PCN: FW Plan Name/Group Name: VDCX BIN: 61Ø272 PCN: IX Plan Name/Group Name: Tri County chools Ins. Group (TCIG) Plan Name/Group Name: Costco Employees BIN: Ø13477 BIN: Ø15342 PCN: IX PCN: CTEP Plan Name/Group Name: NYPD BIN: ØØ9893 PCN: AEØ2 Plan Name/Group Name: Delta Care BIN: Ø16473 PCN: N/A Plan Name/Group Name: Careington BIN: 61Ø3Ø3 PCN: AEØ2 Plan Name/Group Name: Cogent Works BIN: Ø17134 PCN: IX Plan Name/Group Name: assachusetts edicaid BIN: 61Ø342 PCN: BCAID (asshealth) Plan Name/Group Name: Total Health Care edicaid and Healthy ichigan Plan BIN: 61Ø342 PCN: IX Plan Name/Group Name: Health Choice Arizona/Utah edicaid BIN: 61Ø342 PCN: IX Plan Name/Group Name: Health Choice Integrated Care BIN: 61Ø342 PCN: HCICNA Plan Name/Group Name: Health Choice Generations BIN: Ø12312 PCN: PATD Plan Name/Group Name: Health Choice Insurance Company BIN: ØØ9893 PCN: IX Plan Name/Group Name: IAI BIN: ØØ9893 PCN: IX Envisionx ptions heet D.0. 122017 v31 800.361.4542 envisionrx.com 1
Plan Name/Group Name: New Benefits BIN: 61Ø346 PCN: N/A Plan Name/Group Name: nex BIN: 637639 PCN: IX/ AEØ2 Plan Name/Group Name: edtrak BIN: Ø14244 PCN: DCAE2/ IX Plan Name/Group Name: XEZPAY BIN: Ø18Ø75 PCN: XEP Plan Name/Group Name: Envision edical olutions (E) BIN: ØØ9893 PCN: DCAE1 Plan Name/Group Name: edicare Card ystem (C) BIN: Ø12312 *All B1 and B2 transactions need to PCN: PATD be submitted with the Group Number. Plan Name/Group Name: edicare Card ystem (C) BIN: ØØ9893 *All B1 and B2 transactions need to PCN: IX be submitted with the Group Number. Plan Name/Group Name: Envision ave BIN: 61Ø288 PCN: DCAE1/ IX Plan Name/Group Name: rchestrax BIN: Ø18687 PCN: CHETA Plan Name/Group Name: ite Aid x avings Program BIN: Ø18852 PCN: AD Plan Name/Group Name: Ameritas BIN: Ø17529 PCN: AX Plan Name/Group Name: Popupx BIN: Ø198Ø2 PCN: DCAE1/ IX Processor: ENVIIN/X PTIN Effective as of: 1/1/2015 Contact/Information ource: www.envisionrx.com Pharmacy Help Desk NCPDP Telecommunication Version/elease #: D.Ø Phone:1-800-361-4542 Transaction Code: B1 & B2 Billing Transaction \ egments and Fields The following lists the segments available in a Billing Transaction. The document also lists values as defined under Version D.Ø. The Transaction Header egment is mandatory. The egment ummaries included below list the mandatory data fields. =andatory - The Field is mandatory for the egment in the designated transaction. =equired - The Field has been designated with the situation of "equired" for the segment in the designated Transaction. Envisionx ptions heet D.0. 122017 v31 800.361.4542 envisionrx.com 2
=ptional / = ituational - The situations designated have qualifications for usage ther Transaction Information aximum Number of Transactions upported per transmission eversal Window CB Processing 18Ø days old Can vary by group NCPDP ption 2 (PPA) ** Indicates Government entity requiring NCPDP CB processing ption 3; ee General Information, Plan and Group listing for applicable Group Number, BIN and PCN combinations 4 Certification equirements Certification is not required. Transaction Header egment: andatory 1Ø1-A1 BIN Number 1Ø2-A2 Version/elease Number D.Ø 1Ø3-A3 Transaction Code B1 or B2 1Ø4-A4 Processor Control Number 1Ø9-A9 Transaction Count 1-4 2Ø2-B2 ervice Provider ID Qualifier Ø1 aximum of 4 transactions per transmission 2Ø1-B1 ervice Provider ID NPI EQUIED 4Ø1-D1 Date of ervice CCYYDD 11Ø-AK oftware Vendor/Certification ID Field # 111-A NCPDP Field Name egment Identification Patient egment: andatory Value Ø1 331-CX Patient ID Qualifier Envisionx ptions heet D.0. 122017 v31 800.361.4542 envisionrx.com 3
332-CY Patient ID 3Ø4-C4 Date of Birth CCYYDD Patient Gender 3Ø5-C5 Code 1- ALE 2- FEALE 3Ø7-C7 Place of ervice 31Ø-CA Patient First Name 311-CB Patient Last Name 322-C Patient treet Address 323-CN Patient City Address 324-C 325-CP Patient tate/province Address Patient Zip/Postal Zone ust be valid two character alphabetic state code The ZIP code must be a valid 5 or 9 digit UP ZIP code and must not include hyphens or all zeros in 6th through 9th positions. 326-CQ Patient Phone No. If present, must be 1Ø digit numeric 333-CZ Employer ID 335-2C Pregnancy Indicator If present, valid values = null, 1,2 35Ø-HN Patient Email Address 384-4X Patient esidence Home : 1 Long Term Care : 3,4,6,9 and 11 Pharmacy Provider egment: andatory 111-A egment Identification Ø2 465-EY Provider ID Qualifier Valid value = Ø5 444-E9 Provider ID ust be valid NPI Envisionx ptions heet D.0. 122017 v31 800.361.4542 envisionrx.com 4
Prescriber egment: equired 111-A egment Identification Ø3 466-EZ Prescriber ID Qualifier Ø1 411-DB Prescriber ID 427-D Prescriber Last Name 498-P Prescriber Phone Number Ø1 National Provider Identifier ( NPI) NPI (prescribing physician) must be 1Ø digits If present, must be 1Ø digit numeric 468-2E Primary Care Provider ID Qualifier 421-DL Primary Care Provider ID 47Ø-4E Primary Care Provider Last Name 364-2J Prescriber First Name 365-2K Prescriber treet Address 366-2 Prescriber City Address Prescriber tate/providence 367-2N Address 368-2P Prescriber Zip/Postal Zone Ø1 If present, value must = Ø1 ust be valid NPI If 468-2E is present and =Ø1 If present, must be valid two character alphabetic state code If 368-2P is present, ZIP code must be a valid 5 or 9 digit UP ZIP code, must not include hyphens or all zeros in 6th through 9th positions. Insurance egment: andatory 111-A egment Identification Ø4 3Ø2-C2 Cardholder ID 312-CC Cardholder First Name 313-CD Cardholder Last Name 314-CE Home Plan Envisionx ptions heet D.0. 122017 v31 800.361.4542 envisionrx.com 5
524-F Plan ID 3Ø9-C9 Eligibility Clarification Code 336-8C Facility ID 3Ø1-C1 Group ID 3Ø3-C3 Person Code Ø1 ALL (with noted exceptions) 3Ø6-C6 Patient elationship Code 1 All edicare Part D are 36Ø-2B edicaid Indicator 361-2D 997-G2 ust be present with valid T codes Provider Accept Assignment Indicator Y, N ust be present and = Y or N C Part D Defined Qualified Facility Y, N If present, must = Y or N 115-N5 edicaid ID Number 116-N6 edicare Agency Number Claim egment: equired 111-A egment Identification Ø7 455-E Prescription/ervice ef No. Qualifier 1 ust = 1 4Ø2-D2 Prescription/ervice ef No. ax 12 digits 436-E1 Product/ervice ID Qualifier ØØ,Ø3 4Ø7-D7 Product/ervice ID 456-EN 457-EP ØØ if Compound Code in 4Ø6-D6 = 2 NDC; If 436-E1 = ØØ, then must submit Ø Associated Prescription/ervice ef No. ust be present if 343-HD = C Associated Prescription/erv. Date 458-E Procedure odifier Code Count 1-1Ø CCYYDD / ust be present if 343-HD = C and 456-EN is present If present, must = total # of group occurrences 459-E Procedure odifier Code ust be present if 459-E 442-E7 Quantity Dispensed ust be present and > Ø Envisionx ptions heet D.0. 122017 v31 800.361.4542 envisionrx.com 6
4Ø3-D3 Fill Number Ø,1-99 The values defined for this field are Ø = riginal fill, 1-99 = refill 4Ø5-D5 Days upply ust be present and > Ø 4Ø6-D6 Compound Code 1,2 4Ø8-D8 DAW / Prod election Code Ø-5,7,9 6,8 Not allowed 414-DE Date Prescription Written CCYYDD 1=Not a Compound, 2=Compound, If 2 is submitted, then compound segment is required. 415-DF Number of efills Authorized If present, must = Ø,1-99 419-DJ Prescription rigin Code 1-5 1=Written, 2=Telephonic, 3=Electronic, 4=Facsimile, 5=Pharmacy 354-NX ubmission Clarification Code Count 1-3 ust be present if 42Ø-DK is used 42Ø-DK ubmission Clarification Code If 384-4X = 3,4,6,9 or 11 then 42Ø- DK must be 16 or 21-36*Per C mandate effective 2/28/13. Code of 2Ø is populated if 34Øb Left blank intentionally Claim egment: equired (cont.) 3Ø8-C8 429-DT 453-EJ 445-EA 446-EB 6ØØ-28 418-DI ther Coverage Code pecial Packaging Indicator rig Prescribed Prod/erv ID Qualifier rig Prescribed Prod/erv Code riginally Prescribed Quantity Unit of easure Level of ervice ØØ, Ø1, Ø2, Ø3, Ø4, Ø8 Ø3 If 3Ø8-C8 = Ø2, Ø3, Ø4, Ø8, CB segment** must be submitted If present, values accepted are Ø- 5 ust be present if 455-EA is used ust be present if 453-EJ is used If present. ust be EA,G.L If present, must be Ø,1-6 Envisionx ptions heet D.0. 122017 v31 800.361.4542 envisionrx.com 7
461-EU 462-EV 463-EW 464-EX Prior Authorization Type Code Prior Authorization No. ubmitted Intermediary Authorization Type ID Intermediary Authorization ID 343-HD Dispensing tatus P, C 344-HF 345-HG Quantity Intended to be Dispensed Days upply Intended to be Dispensed ay be equired if ubmitting Prior Auth ay be equired if ubmitting Prior Auth not in either If present, P= Partial, C= Completion ust be present and > Ø if 343-HD = P or C ust be present and > Ø if 343-HD = P or C 357-NV Delay eason Code 391-T Patient Assignment Indicator Y,N ust be present and Y or N 995-E2 oute of Administration 996-G1 Compound Type 147-U7 Pharmacy ervice Type etail: Ø1 Home Infusion: Ø3 Long Term Care : Ø5 Workers Compensation egment: ptional 111-A egment Identification Ø6 434-DY Date of Injury CCYYDD 315-CF Employer Name 316-CG Employer treet Address 317-CH Employer City Address 318-CI Employer tate/province Address 319-CJ Employer Zip/Postal Zone The ZIP code must be a valid 5 or 9 digit UP ZIP code and must not include hyphens or all zeros in 6 th through 9 th positions. Envisionx ptions heet D.0. 122017 v31 800.361.4542 envisionrx.com 8
32Ø-CK Employer Phone Number 321-CL Employer Contact Name 327-C Carrier ID 435-DZ Claim eference/id 117-T Billing Entity Type Indicator 118-T Pay To Qualifier 119-TT Pay To ID 12Ø-TU Pay To Name 121-TV Pay To treet Address 122-TW Pay To City 123-TX Pay To tate/province Address 124-TY Pay To Zip/Postal Zone 125-TZ Generic Equivalent Product ID Qualifier 126-UA Generic Equivalent Product ID CB/ther Payments egment: ituational *equired when other insurance processing is involved 111-A egment Identification Ø5 337-4C Coordination of Benefits/ther Payments Count 1-9 338-5C ther Coverage Type 339-6C ther ID Qualifier 34Ø-7C ther ID ust = total # of group occurrences that follow ust be present with values = Ø1- Ø9 If 338-5C is populated then values = Ø1, Ø2, Ø3,Ø4, Ø5, 1C, 1D, 99 ust be populated with ther ID 443-E8 ther Date CCYYDD 341-HB ther Amount Paid Count 1-9 If present, must be = total # of group occurrences, 342-HC and 431-DV 342-HC ther Amount Paid Qualifier If present, must be values = Ø1- Ø7, Ø9, 1Ø when 341-HB is used Envisionx ptions heet D.0. 122017 v31 800.361.4542 envisionrx.com 9
431-DV ther Amount Paid 471-5E ther eject Count 472-6E ther eject Code 993-A7 Internal Control Number ther - Patient 353-N esponsibility Amount Count 1-25 351-NP 352-NQ ther - Patient esponsibility Amount Qualifier ther - Patient esponsibility Amount 392-U Benefit tage Count 1-4 Ø1, Ø2, Ø3, Ø4, 5Ø, 61, 62, 7Ø, 393-V Benefit tage Qualifier 8Ø, 9Ø 394-W Benefit tage Amount DU/PP egment: equired 111-A egment Identification Ø8 473-7E DU / PP Code Counter 1-9 439-E4 eason for ervice Code 44Ø-E5 Professional ervice Code **ust be present for Government CB Processing ust be present when 472-6E is used Values are = ECL Appendix 1; ust be present when 3Ø8-C8 = 3 equired if 3Ø8-C8 = Ø2** or Ø8. equired if 351-NP is populated equired if 3Ø8-C8 = Ø2** or Ø8.If present, must =, Ø1-13, must be present when 352-NQ is used. equired if 3Ø8-C8 = Ø2** or Ø8.equired if 351-NP is If present, must = total # of group occurrences that follow, 393-V, 394-W, must be present when 394-W is used ust be present when 394-W is used ust be present when 393-V is used ubmitted when requested by processor ubmitted when requested by processor ubmit A when provider billing Vaccine Admin Fees Envisionx ptions heet D.0. 122017 v31 800.361.4542 envisionrx.com 10
441-E6 esult of ervice Code 474-8E DU/PP Level of Effort 475-J9 DU Co-Agent ID Qualifier 476-H6 DU Co-Agent ID ubmitted when requested by processor Compound egment: ptional *equired when submitting a compound formulation with multiple active ingredients 111-A egment Identification 1Ø 45Ø-EF 451-EG 447-EC Compound Dosage Form Description Code Compound Dispensing Unit Form Indicator Compound Ingredient Component Count 488-E Compound Product ID Qualifier 489-TE Compound Product ID 448-ED Compound Ingredient Quantity 449-EE Compound Ingredient Drug Cost ust be present 49Ø-UE 362-2G Compound Ingredient Basis of Cost Determination Compound Ingredient odifier Count 363-2H Compound Ingredient odifier If 4Ø6-D6 = 2, then segment is required ubmit Ø8 to identify 340b acquisition cost Coupon egment: ptional 111-A egment Identification Ø9 485-KE Coupon Type 486-E Coupon Number Envisionx ptions heet D.0. 122017 v31 800.361.4542 envisionrx.com 11
487-NE Coupon Value Amount Pricing egment: andatory 111-A egment Identification 11 4Ø9-D9 Ingredient Cost ubmitted ust be present 412-DC Dispensing Fee ubmitted 438-E3 Incentive Amount ubmitted Incentive Amount used when billing Vaccine Admin Fees. Enter Vaccine Admin Fee amount provider is billing. Field 44Ø-E5 UT also be populated for claim to pay 478-H7 479-H8 48Ø-H9 481-HA 482-GE 483-HE 484-JE ther Amount Claimed ubmitted Count ther Amount Claimed ubmitted Qualifier ther Amount Claimed ubmitted Flat ales Tax Amount ubmitted Percentage ales Tax Amount ubmitted Percentage ales Tax ate ubmitted Percentage ales Tax Basis ubmitted 426-DQ Usual and Customary Charge 43Ø-DU Gross Amount Due 423-DN Basis of Cost Determination ubmit Ø8 to identify 340b acquisition cost Envisionx ptions heet D.0. 122017 v31 800.361.4542 envisionrx.com 12
Clinical egment: equired 111-A egment Identification 13 491-VE Diagnosis Code Count 1-9 492-WE Diagnosis Code Qualifier 424-D Diagnosis Code 493-XE Clinical Information Counter 494-ZE easurement Date CCYYDD 495-H1 easurement Time HH 496-H2 easurement Dimension 497-H3 easurement Unit 499-H4 easurement Value Additional Information: Zip Codes: If the zip code is 98765-4321, this field would reflect: 987654321. If the zip code is 98765, this field would reflect: 98765 left justified Envisionx ptions heet D.0. 122017 v31 800.361.4542 envisionrx.com 13