DAT A ELE MENT REQUES T FORM (DERF)/ EXTERNAL CODE LIST (ECL) National Council for Prescription Drug Programs Please refer to instructions below before completing DERF #: 001172 ECL #: 000152 RECEIPT DATE: 12/18/13 WG MTG REVIEW DATE(S): 02/05-07/14 REFERENCES OTHER SDO DATA DICTIONARY (LIST SDO, STANDARD AND VERSION): DESCRIBE THE BUSINESS NEED OR PURPOSE ADDRESSED BY THIS DERF/ECL SUBMISSION (REQUIRED): FINAL DERF RESOLUTION DERF ECL Emergency ECL Approved No Modifications Approved With Modifications Denied Pended 1 2 3 (No further action) Withdrawn WG1 Compound Billing Solutions Task Group reported to WG1 during the November 2013 WG meetings of new Reject Code values they would be bringing forward for the February 2014 WG meetings. They also provided a guidance chapter they had written and asked participants to review. The new Reject Code values are being brought forward with this DERF for the WG to approve. Included as background is the guidance chapter that will be requested to be added to the Version D Editorial document. The second modification is to include the compounder in the DUR/PPS Level Of Effort value definitions since the compounder is not always the pharmacist. See below. There are two actions with this DERF: 1. Approval of two new Reject Codes 2. Approval of verbiage change in values of 474-8E - DUR/PPS Level Of Effort (The approval of the Version D Editorial is not a DERF action, but a WG1 action.) NEW DATA ELEMENT (DERF ONLY) Proposed Name (required): Size (required): Format (required): Segment for the New Data Element (required for Telecom, XML Standard): Definition (required): Codes/Values every code/value must include a definition (Use attachments if necessary): (Staff will determine actual code or value) Value Suggested Value Description (required) Value Description Definition (required) Value Limitations (not required) List new reject code (s) below in Change Existing Data Element. Proposed XML Tag (required if data element is in an XML standard): Number of Repetitions for New Data Element (required if repeating data element): Standards to be used in (list all that apply): Fill out Transaction Usage section next. CHANGE EXISTING DATA ELEMENT (ALL INFORMATION IS REQUIRED FOR CHANGES) Field Number (Telecom): 511 ID: FB Name: Reject Code XML Tag (XML Standard based)) Name: Requested change to (choose at least one): Size Format Values Definition Name Summarize Proposed Changes (Use attachments if necessary): Codes/Values every code/value change must include a definition (Use attachments if necessary): Value Suggested Value Description (required) Value Description Definition (required) Value Limitations (not required) Reject Codes staff assigns all values and creates standard reject codes for new fields. Value Suggested Value Description (required) Value Limitation or Explanation (not required) Xxx (TBD) Compound contains unidentifiable ingredient(s); Submission Clarification Code override not allowed Yyy (TBD) Compound contains not covered ingredient(s); Submission Clarification Code override not allowed CHANGE EXISTING DATA ELEMENT (ALL INFORMATION IS REQUIRED FOR CHANGES) Field Number (Telecom): 474-8E ID: 8E Name: DUR/PPS Level Of Effort XML Tag (XML Standard based)) Name: Revised: February 2013 Page: 1
Requested change to (choose at least one): Size Format Values Definition Name Summarize Proposed Changes (Use attachments if necessary): Codes/Values every code/value change must include a definition (Use attachments if necessary): Value Suggested Value Description (required) Value Description Definition (required) Value Limitations (not required) Reject Codes staff assigns all values and creates standard reject codes for new fields. Value Suggested Value Description (required) Value Limitation or Explanation (not required) Ø 11 12 13 14 15 Not Specified Level 1 (Lowest) = Straightforward: Service involves minimal diagnosis or treatment options, minimal amount or complexity of data considered, and minimal risk; AND/OR Requires 1 to 4 MINUTES of the pharmacist s/compounder s time. Level 2 (Low Complexity) = Service involves limited diagnosis or treatment options, limited amount or complexity of data considered, and low risk; AND/OR Requires 5 to 14 MINUTES of the pharmacist s/compounder s time. Level 3 (Moderate Complexity) = Service involves moderate diagnosis or treatment options, moderate amount or complexity of data considered, and moderate risk; AND/OR Requires 15 to 29 MINUTES of the pharmacist s/compounder s time. Level 4 (High Complexity) = Service involves multiple diagnosis or treatment options, extensive amount or complexity of data considered, and high risk; AND/OR Requires 30 to 59 minutes of the pharmacist s/compounder s time. Level 5 (Highest) = Comprehensive = Service involves extensive diagnosis or treatment options, exceptional amount or complexity of data considered, and very high risk; AND/OR Counseling or coordination of care dominated the encounter and requires equal to or greater than 60 minutes of the pharmacist s/compounder s time. (No change) Standards the existing data element appears (list all that apply from the Data Dictionary): Fill out Transaction Usage section next DATA ELEMENT TRANSACTION USAGE Transaction Usage - Which transaction(s) is the field used in? (check all that applies) (Use attachments if necessary): (required for Telecom or Batch Standard) --- Used in all Telecom transactions as applicable rejection. Telecom or Batch Transactions Used in transaction (Y/N)? If Used = Yes (Y), Situation must be provided. Eligibility Verification Claim Billing/Rebill/Encounter Service Billing/Rebill Predetermination of Benefits Claim Reversal Service Reversal Prior Authorization Request and Billing (Claim) Prior Authorization Request and Billing (Service) Prior Authorization Reversal (Claim) Prior Authorization Reversal (Service) Prior Authorization Inquiry Prior Authorization Request Only (Claim) Prior Authorization Request Only (Service) Information Reporting/Rebill (Claim) Information Reporting/Rebill (Service) Information Reporting Reversal (Claim) Information Reporting Reversal (Service) Controlled Substance Reporting/Rebill (specify non-prescription or general) Controlled Substance Reporting Reversal (specify non-prescription or general) Revised: February 2013 Page: 2
Transaction Usage - Which transaction(s) is the field used in (check all that apply)? (Use attachments if necessary): (required for XMLStandard) Transport Transactions Used in transaction (Y/N)? If Used = Yes (Y), Situation must be provided. Error Status Verify Get Message Password Change SCRIPT Transactions Used in transaction (Y/N)? If Used = Yes (Y), Situation must be provided. New Prescription Request Refill Request/Response or Resupply Prescription Change Request/Response Prescription Fill Status Notification Cancel Prescription Request/Response Medication History Request/Response Drug Administration Specialized Transactions Used in transaction (Y/N)? If Used = Yes (Y), Situation must be provided. Census MTM TRANSACTION USAGE For standards other than Telecom, Batch, or XML, please include attachments as needed. DESCRIBE HOW THE NEW/REVISED DATA ELEMENT WILL BE USED: SEE ATTACHED DESCRIBE ANTICIPATED IMPACTS/IMPLEMENTATION CONSIDERATIONS: SUBMITTER (THIS SECTION MUST BE COMPLETED) Name: Ashley Maples/Mike Moore/Nick Calla Work Group submitting DERF: Task Group submitting DERF: WG1 Compound Billing Solutions Task Group Title: Company: Express Scripts, Kroger, Community Specialty Pharmacy Network email: AHMaples@express-scripts.com, michael.moore@kroger.com, ncalla@cspnrx.com Address: City/State/Zip: FOR MC MAINTENANCE AND CONTROL USE ONLY Work Groups that may be impacted (check all appropriate boxes): WG1 Telecommunication WG11 eprescribing & Related Transactions WG2 Product Identification WG14 Long Term Care WG3 Standard Identifiers WG16 Property and Casualty/Workers Compensation WG7 Manufacturer Rebates WG17 Pharmaceutical Pedigree and Traceability WG9 Government Programs WG45 External Standards Assessment, Harmonization, and Implementation Guidance WG10 Professional Pharmacy Services MC Maintenance and Control Other Return completed form by email, mail or fax: Revised: February 2013 Page: 3 Fax: Phone: Signature: submitted electronically Date: 12/18/2013 TELECOMMUNICATION STANDARD ONLY REQUESTING EMERGENCY ECL CHANGE associated to Regulatory/Legislative Compliance If approved, the request will appear in the next ECL publication. There will be a minimum of 180 days required before the implementation of an emergency ECL change. Please see the attached Publication Release/ Implementation Dates Chart. DERF/ECL INSTRUCTIONS Reason for Emergency Change / Reference to Regulation or Legislation Date Needed By: (no earlier than 180 days from the ECL Publication) Please refer to the following instructions when completing this DERF/ECL form. Use additional attachments when necessary to provide complete information. Incomplete forms will be returned for additional information prior to processing. This form is used for multiple purposes. 1) To add/modify a data element to the Data Dictionary. 2) To add/modify a data element code to the External Code List (ECL). 3) To add/modify information in a standard or implementation guide. D E S C R I B E T H E B U S I N E S S N E E D O R P U R P O S E A D D R E S S E D B Y T H I S D E R F / E C L This section should explain, in detail, what the requester would like changed, added, or deleted and the technical and/or reasons why the modifications are necessary. The written explanation should give the readers an understanding as to what the requester is attempting to accomplish. D E S C R I B E I N F O R M A T I O N N E E D E D F O R A D D S /CH A N G E S (DERF only:) Use the NEW data element section to indicate the proposed field name, the size (length, including decimals, if applicable), and the format (numeric, alpha/numeric, dollar). For a NEW data element to the Telecommunications Standard, include the proposed Segment the element would be added to. Include a definition of the field. If applicable, every value/code requested must contain a definition. For the Telecommunication or Batch Standard, specify the situation in which this new field would be used. (DERF or ECL:)To change a data element, complete the CHANGE existing data element section, indicating the current data dictionary information. Check what information is changing: field size (length), format (numeric, alpha/numeric, dollar), adding or changing a value, field name or definition. Summarize all changes that are being requested. EMERGENCY ECL REQUESTS via a DERF form PERTAIN ONLY TO THE TELECOMMUNICATION STANDARD. Used for regulatory and legislative changes which require the addition of a value(s) to be implemented prior to the scheduled annual implementation date of the next ECL Publication. There will be a minimum of 180 days post ECL publication required, before the implementation of an emergency ECL change. D E S C R I B E H O W T H E D AT A E L E M E N T W I L L B E U SED This section needs a detailed description of how and where the data element or value change will be used in the processes governed by the specified standards. For example: If the data element is referenced in multiple standards, is the usage consistent? Will this data element or value change cause a drug claim to reject? How will the data element impact an individual s enrollment status? If the data element has a specified list of values, who will be responsible for maintaining the list? D E S C R I B E T H E I M P A C T S A N D I M P L E M E N T AT I O N C O N S I D E R AT I O N I N V O L V E D I N R E Q U E S T I N G T H AT T H I S I N F O R M AT I O N B E I N C L U D E D I N N C P D P S T A N D A R D S This section is intended to obtain information about the level of consideration given to the operational impacts of including this data element addition/change in the affected standard(s). Is this the most appropriate source for the data element? Are there legislative and/or legal time frames/requirements? Are there specific implementation considerations that should be documented in an implementation guide?
NCPDP, 9240 E. Raintree Drive, Scottsdale, Arizona 85260-7519 email DERF@NCPDP.org fax (480) 767-1042 phone (480) 477-1000 WG This section is used by NCPDP Staff Only DERF MODIFICATIONS (Actions Taken by WG(s) Review) DERF/ ECL STATUS: Approved/Reviewed with no modifications Approved/Reviewed with modifications (complete modifications below) Pended by work group Reason: Denied by Work Group Withdrawn by submitter Changed ECL to DERF (also check appropriate DERF status) Reason: Vote Pink Yellow Green Total Approved Opposed Modifications: MC DERF/ ECL STATUS: Approved/Reviewed with no further modifications Approved/Reviewed with further modifications (complete modifications below) Vote Pink Yellow Green Total Approved Opposed Modifications: To be added to the Version D Editorial: Compound Ingredient Product Identifier and Qualifier Use As of xx/xxxx new Reject Code (511-FB) values are available: xxx (Compound contains unidentifiable ingredient(s); Submission Clarification Code override not allowed) yyy (Compound contains not covered ingredient(s); Submission Clarification Code override not allowed) These new Reject Codes can be used to reject compounds at the claim level. This Reject Code value notifies the pharmacy that the processor does not recognize or does not cover one or more ingredient(s) of the compound. The pharmacy cannot resubmit the claim with a Submission Clarification Code to override this edit. If this Reject Code value is received, in order to service the patient, the pharmacy and the payer will need to collaborate according to trading partner agreement. This guidance is not indicating this value must be used, but if the processor will not process the claim with the ingredient(s) that to them are unidentifiable, the use of this Reject Code value lets the pharmacy know to not attempt to retry sending the compound claim by using the Submission Clarification Code 8 as an override. Revised: February 2013 Page: 4
Note that when Reject Code value xxx or yyy are sent, the most specific ingredient-level Reject Code(s) and corresponding Reject Field Occurrence Indicator (546-4F) should also be included to help identify the ingredient(s) in question. Example 1: Pharmacy submits the claim with industry-recognized valid product IDs and the corresponding qualifiers but the processor does not support a qualifier value A claim with 4 ingredients: 3 products are recognized that are covered and payable and 1 product and qualifier pair is not supported by the processor (ex: UPC, a device identified by HRI) Notes: 1. The pharmacy knows the valid products that are being submitted. 2. The processor may choose to a. ignore the products for which they do not support the qualifier value, or b. reject for the products for which they do not support the qualifier value 3. Although the pharmacist has the choice of removing an ingredient from the claim before adjudication processing occurs in order to service the patient, this practice is not recommended and these examples are not providing any guidance as to whether that should or should not happen. In order to service the patient, the pharmacy and the payer should collaborate according to their trading partner agreement. Recommendation Option 1: 1. Pharmacy submits the claim described above. 2. The processor processes the claim a. The plan design may allow the submitted ingredients from the pharmacist and pay the claim. (It is possible the claim may be subject to a retrospective audit review.) 3. Processor sends the accepted response to the pharmacy. Recommendation Option 2: 1. Pharmacy submits the claim described above. 2. The processor processes the claim a. For the 1 product and qualifier pair that is not supported by the processor i. If the processor cannot pay the claim because the 1 product and qualifier pair is not supported (e.g. concern of inability to perform DUR checking, safety, etc. of the unknown ingredient) 1. The processor should use Reject Code xxx (Compound contains unidentifiable ingredient(s); Submission Clarification Code override not allowed) on the claim level along with the most specific ingredient-level Reject Code (such as 8Z, 8J, 515, etc.) and corresponding Reject Field Occurrence Indicator (546-4F). a. It is not suggested to return 21 (M/I Product/Service ID) because it is not specific enough. 3. Processor sends the claim level reject response to the pharmacy. In order to service the patient, the pharmacy and the payer need to collaborate according to trading partner agreement because the processor does not support resubmission with Submission Clarification Code 8 for override. Recommendation Option 3: 1. Pharmacy submits the claim described above. 2. The processor processes the claim a. For the 1 product and qualifier pair that is not supported by the processor i. If the processor cannot pay the claim because the 1 product and qualifier pair is not supported but plan design allows for exclusion of the unknown ingredient 1. The processor should use Reject Code 515 (Compound Product ID Qualifier Submitted Not Supported) and corresponding Reject Field Occurrence Indicator (546-4F). a. It is not suggested to return 21 (M/I Product/Service ID) because the 515 more clearly indicates that the qualifier value submitted is not supported by this processor. 3. Processor sends the ingredient level reject response to the pharmacy. 4. Pharmacy resubmits the claim with the Submission Clarification Code 8 (Process compound for approved ingredients). Revised: February 2013 Page: 5
5. Upon receipt of the claim with Submission Clarification Code 8, the processor should have logic to ignore ingredients with valid qualifier values they do not support to allow further processing of the claim. Note, the claim may still reject for other reasons, but not for the 1 product and qualifier pair that is not supported by the processor. For Example 1 (only pertinent segments and fields are shown): Pharmacy submission Example 1 Recommendation Option 1/Option 2/Option 3 step 1 CLAIM SEGMENT 111-AM SEGMENT IDENTIFICATION M Ø7 CLAIM SEGMENT 436-E1 PRODUCT/SERVICE ID M ØØ Default for multi-ingredient compounds 4Ø7-D7 PRODUCT/SERVICE ID M Ø Default for multi-ingredient compounds 442-E7 DISPENSED R 3ØØØØ 3Ø.ØØØ grams 4Ø3-D3 FILL NUMBER R 1 First dispensing for Rx# 4Ø5-D5 DAYS SUPPLY R 3Ø 3Ø Days supply 4Ø6-D6 COMPOUND CODE R 2 Compounded Rx 4Ø8-D8 DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE R Ø No product selection indicated 414-DE DATE PRESCRIPTION WRITTEN R 2Ø13Ø915 September 15, 2Ø13 415-DF NUMBER OF REFILLS AUTHORIZED Q 5 5 Refills 419-DJ PRESCRIPTION ORIGIN CODE Q 1 Written prescription 3Ø8-C8 OTHER COVERAGE CODE Q 1 No other coverage 429-DT SPECIAL PACKAGING INDICATOR Q 1 Not unit dose 6ØØ-28 UNIT OF MEASURE Q GM Grams 995-E2 ROUTE OF ADMINISTRATION Q 6Ø64ØØ5 Topical COMPOUND SEGMENT 111-AM SEGMENT IDENTIFICATION M 1Ø COMPOUND SEGMENT 45Ø-EF COMPOUND DOSAGE FORM M Ø3 Cream DESCRIPTION CODE 451-EG COMPOUND DISPENSING UNIT M 2 Grams FORM INDICATOR 447-EC COMPOUND INGREDIENT M Ø4 4 Ingredients COMPONENT COUNT 489-TE COMPOUND PRODUCT ID M 3982261ØØØ1 Progesterone Powder M 1666ØØØØ 1.666 (grams) Q 85G $8.57 DETERMINATION M Ø1 UPC 489-TE COMPOUND PRODUCT ID M 23513Ø71ØØ2 DHEA Cream M 2895ØØØØØ 28.95 (grams) Q 85G $8.57 DETERMINATION 489-TE COMPOUND PRODUCT ID M 38779Ø769Ø5 Pregnenolone Powder M 9ØØØØØØ Ø.9ØØ (grams) Q 84H $8.48 DETERMINATION 489-TE COMPOUND PRODUCT ID M ØØ574Ø46ØØ5 Testosterone Powder M 15ØØØØØ.15Ø (grams) Q 84H $8.48 Revised: February 2013 Page: 6
DETERMINATION Processor Response Example 1 Recommendation Option 1 step 2 paid claim 112-AN TRANSACTION RESPONSE STATUS M P Paid 5Ø3-F3 AUTHORIZATION NUMBER Q 1234567891234 56789 13Ø-UF ADDITIONAL MESSAGE INFORMATION COUNT R 1 1 occurrence 132-UH 526-FQ ADDITIONAL MESSAGE INFORMATION ADDITIONAL MESSAGE INFORMATION R Ø1 Used for first line of free form text with no predefined structure. Q TRANSACTION For illustrative purposes only. Up to 4Ø Bytes MESSAGE TEXT RESPONSE PRICING SEGMENT 111-AM SEGMENT IDENTIFICATION M 23 RESPONSE PRICING SEGMENT applicable fields as needed OR Processor Response Example 1 Recommendation Option 2 step 2.a.i. If the processor cannot pay the claim because the 1 product and qualifier pair is not supported (e.g. concern of inability to perform DUR, safety, etc. of the unknown ingredient) 112-AN TRANSACTION RESPONSE STATUS M R Rejected 51Ø-FA REJECT COUNT R 2 2 Reject Codes follow 511-FB REJECT CODE R xxx Compound contains unidentifiable ingredient(s); Submission Clarification Code override not allowed 511-FB REJECT CODE R 8Z Product/Service ID Qualifier Value Not Supported 546-4F REJECT FIELD OCCURRENCE INDICATOR R 2 (Ingred #2: DHEA CRE) OR Processor Response Example 1 Recommendation Option 3 step 2.a.i. If the processor cannot pay the claim because the 1 product and qualifier pair is not supported (e.g. plan design allows exclusion of the unknown ingredient) 112-AN TRANSACTION RESPONSE STATUS M R Rejected 51Ø-FA REJECT COUNT R 1 1 Reject Code follows 511-FB REJECT CODE R 515 Compound Product ID Qualifier Submitted Not Supported 546-4F REJECT FIELD OCCURRENCE INDICATOR R 2 Ingred #2: DHEA CRE Revised: February 2013 Page: 7
Pharmacy Resubmission Example 1 Recommendation Option 3 step 4 Submission Clarification Code 8 (Process compound for approved ingredients) CLAIM SEGMENT 111-AM SEGMENT IDENTIFICATION M Ø7 CLAIM SEGMENT 455-EM 4Ø2-D2 354-NX 42Ø-DK PRESCRIPTION/SERVICE PRESCRIPTION/SERVICE Same fields as above submitted and SUBMISSION CLARIFICATION CODE COUNT SUBMISSION CLARIFICATION CODE R 1 One occurrence Q 8 Process Compound For Approved Ingredients COMPOUND SEGMENT 111-AM SEGMENT IDENTIFICATION M 1Ø COMPOUND SEGMENT 45Ø-EF COMPOUND DOSAGE FORM M C91187 Topical cream DESCRIPTION CODE 451-EG COMPOUND DISPENSING UNIT M 2 Grams FORM INDICATOR 447-EC COMPOUND INGREDIENT M Ø4 4 Ingredients COMPONENT COUNT Same fields as above submitted Processor Response Example 1 Recommendation Option 3 step 5 Processor ignores ingredients with valid qualifier values they do not support 112-AN TRANSACTION RESPONSE STATUS M P Paid et cetera Example 2: Pharmacy submits the claim with industry-recognized valid product IDs and the corresponding qualifiers. A claim with 4 ingredients: 3 products are recognized that are covered and payable and 1 product is recognized and not covered (ex: a non-formulary cream base, non-covered HRIs (non-covered qualifier)) Notes: 1. The pharmacy knows the valid product that is submitted. 2. The processor may choose to a. ignore the not covered products or b. reject at the ingredient level for the product they recognize but do not cover 3. Although the pharmacist has the choice of removing an ingredient from the claim before adjudication processing occurs in order to service the patient, this practice is not recommended and these examples are not providing any guidance as to whether that should or should not happen. In order to service the patient, the pharmacy and the payer should collaborate according to their trading partner agreement. 4. In this example, the term unpayable means the processor is unable to return a Paid response. Recommendation Option 1: 1. Pharmacy submits the claim described above. 2. The processor processes the claim. a. For the 1 product and qualifier pair that is recognized but not covered by the processor, Revised: February 2013 Page: 8
i. The processor should use the appropriate Reject Codes for that ingredient (e.g. MR (Product Not on Formulary), 7Ø (Product/Service Not Covered-Plan Benefit Exclusion), etc..) along with Reject Field Occurrence Indicator (546-4F) to identify the ingredient rejected. ii. OR Reject Code 9Y (Compound Product ID Qualifier Submitted Not Covered) could be used if appropriate to relay that products with this qualifier value are not covered along with Reject Field Occurrence Indicator (546-4F) to identify the ingredient rejected. iii. If and only if the Processor considers the recognized, but not covered ingredient to render the entire claim unpayable they should return Reject Code yyy (Compound contains not covered ingredient(s); Submission Clarification Code override not allowed) on the claim level along with the most specific ingredientlevel Reject Code (such as 8Z, 8J, 515, etc.) and corresponding Reject Field Occurrence Indicator (546-4F). 3. Processor sends the reject response to the pharmacy. 4. If the reject codes are all at the ingredient level, the pharmacy can attempt to resubmit the claim with the Submission Clarification Code 8 (Process compound for approved ingredients). 5. Unless the not covered ingredient is considered by the processor to render the entire claim unpayable, upon receipt of the claim with Submission Clarification Code 8, the processor should have logic to ignore ingredients with valid qualifier values that they do not support/cover to allow further processing of the claim. Note the claim may still reject for other reasons, but not for the product and qualifier pairs that are not covered by the processor. For Example 2 (only pertinent segments and fields are shown): Pharmacy submission Example 2 Recommendation Option 1 step 1 CLAIM SEGMENT 111-AM SEGMENT IDENTIFICATION M Ø7 CLAIM SEGMENT 436-E1 PRODUCT/SERVICE ID M ØØ Default for multi-ingredient compounds 4Ø7-D7 PRODUCT/SERVICE ID M Ø Default for multi-ingredient compounds 442-E7 DISPENSED R 3ØØØØ 3Ø.ØØØ grams 4Ø3-D3 FILL NUMBER R 1 First dispensing for Rx# 4Ø5-D5 DAYS SUPPLY R 3Ø 3Ø Days supply 4Ø6-D6 COMPOUND CODE R 2 Compounded Rx 4Ø8-D8 DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE R Ø No product selection indicated 414-DE DATE PRESCRIPTION WRITTEN R 2Ø13Ø915 September 15, 2Ø13 415-DF NUMBER OF REFILLS AUTHORIZED Q 5 5 Refills 419-DJ PRESCRIPTION ORIGIN CODE Q 1 Written prescription 3Ø8-C8 OTHER COVERAGE CODE Q 1 No other coverage 429-DT SPECIAL PACKAGING INDICATOR Q 1 Not unit dose 6ØØ-28 UNIT OF MEASURE Q GM Grams 995-E2 ROUTE OF ADMINISTRATION Q 6Ø64ØØ5 Topical COMPOUND SEGMENT 111-AM SEGMENT IDENTIFICATION M 1Ø COMPOUND SEGMENT 45Ø-EF COMPOUND DOSAGE FORM M Ø3 Cream DESCRIPTION CODE 451-EG COMPOUND DISPENSING UNIT M 2 Grams FORM INDICATOR 447-EC COMPOUND INGREDIENT M Ø4 4 Ingredients COMPONENT COUNT 489-TE COMPOUND PRODUCT ID M 629911Ø49Ø2 Estradiol Powder M Ø3ØØØØØ.Ø3Ø (grams) Q 26{ $2.6Ø DETERMINATION 489-TE COMPOUND PRODUCT ID M 387791969Ø8 Emu Oil M 3ØØØØØØØ 3.ØØØ (grams) Revised: February 2013 Page: 9
Q 9{ $.9Ø DETERMINATION 489-TE COMPOUND PRODUCT ID M 519273655ØØ Versabase Liquid Transdermal M 27ØØØØØØØ 27.ØØØ (grams) Q 29H $2.98 DETERMINATION M Ø2 HRI 489-TE COMPOUND PRODUCT ID M Ø829Ø3Ø96Ø4 10ML Syringe MIS Luer-Lok M 3ØØØØØØØ 3.ØØØ (mls) Q 15{ $1.5Ø 49Ø-UE COMPOUND INGREDIENT BASIS OF DETERMINATION Q Ø1 AWP Processor Response Example 2 Recommendation Option 2 step 2.a.i the processor cannot pay the claim because the 1 product and qualifier pair is recognized and not covered 112-AN TRANSACTION RESPONSE STATUS M R Rejected 51Ø-FA REJECT COUNT R 1 1 Reject Code follow 511-FB REJECT CODE R MR Product Not on Formulary 546-4F REJECT FIELD OCCURRENCE INDICATOR R 2 (Ingred #2: Emu Oil) OR Processor Response Example 2 Recommendation Option 2 step 2.a.ii the processor cannot pay the claim because the 1 product and qualifier pair is recognized and not covered and the recognized, but not covered ingredient renders the entire claim unpayable 112-AN TRANSACTION RESPONSE STATUS M R Rejected 51Ø-FA REJECT COUNT R 1 1 Reject Code follow 511-FB REJECT CODE R yyy Compound contains not covered ingredient(s); Submission Clarification Code override not allowed 546-4F REJECT FIELD OCCURRENCE INDICATOR R 2 (Ingred #2: Emu Oil) Pharmacy Resubmission Example 2 Recommendation Option 2 step 4 with the Submission Clarification Code 8 (Process compound for approved ingredients) if appropriate CLAIM SEGMENT 111-AM SEGMENT IDENTIFICATION M Ø7 CLAIM SEGMENT Same fields as above Revised: February 2013 Page: 10
354-NX 42Ø-DK submitted and SUBMISSION CLARIFICATION CODE COUNT SUBMISSION CLARIFICATION CODE R 1 One occurrence Q 8 Process Compound For Approved Ingredients COMPOUND SEGMENT 111-AM SEGMENT IDENTIFICATION M 1Ø COMPOUND SEGMENT 45Ø-EF COMPOUND DOSAGE FORM M Ø3 Cream DESCRIPTION CODE 451-EG COMPOUND DISPENSING UNIT M 2 Grams FORM INDICATOR 447-EC COMPOUND INGREDIENT M Ø4 4 Ingredients COMPONENT COUNT Same fields as above submitted Processor Response Example 2 Recommendation Option 2 step 5 paid claim 112-AN TRANSACTION RESPONSE STATUS M P Paid et cetera Revised: February 2013 Page: 11