NetCard Systems P.O. Box 4517 Centennial, CO 80112 PAYER SPECIFICATION SHEET Segment and Field Requirements by Transaction Type Plan Information Payer Name: NetCard Systems Date: 03/15/16 Plan Name: NetCard Systems/Welldyne/RxWest BIN: 008878 PCN: CB8 Plan Name: Pharmastrategies BIN: 014856 PCN: None Plan Name: Pharmastrategies BIN: 015383 PCN: None Plan Name: UFCW BIN: 008878 PCN: UFCW Plan Name: Unite Here Health BIN: 008878 PCN: TCN Plan Name: RxedSaver BIN: 018034 PCN: WDF Plan Name: Connect Health Solutions BIN: 018506 PCN: None Plan Name: Strategy Corp BIN: 008878 PCN: 11330 Processor: OptumRx Effective: 01/01/13 Telecommunication Standard Version/Release #: D.0 Provider Support: 1 888 886 5822. For questions regarding ember Eligibility, Prior Authorizations or Claim Rejections you may also call 1 800 479 2000 Certification Contact Information: D.0certification@sxc.com Segment and Field Requirements by Transaction Type: Billing (B1), Reversal (), and Rebilling (B3) Transaction Data Elements ( andatory, R Required, Required When) TRANSACTION SEGENT NAE ANDATY ANDATY 101 A1 BIN See above for BINs 102 A2 VERSION/RELEASE NUBER D.0 103 A3 TRANSACTION CODE 104 A4 PROCESS CONTROL NUBER REQUIRED FRO ID CARD 109 A9 TRANSACTION 1 4 (UP TO 4 TRANSACTIONS PER TRANSISSION) ACCEPTED 202 SERVICE PROVIDER ID 01 (NATIONAL PROVIDER ID) 201 B1 SERVICE PROVIDER ID VALUE F THE
IN 202 ABOVE 401 D1 DATE OF SERVICE YYYYDD 110 AK SOFTWARE VEND/CERTIFICATION ID USE VALUE F SWITCH S REQUIREENTS. IF SUBITTING CLAI WITHOUT A SWITCH INSURANCE SEGENT 111 A SEGENT INDENTIFICATION 04 SUBIT ONLY IF SEGENT IS TRANSITTED 115 N5 EDICAID ID NUBER 301 C1 GROUP ID USE IF PATIENT IS COVERED UNDER E THAN ONE PLAN 302 C2 CARDHOLDER ID FRO ID CARD 303 C3 PERSON CODE WHEN PROVIDED ON ID CARD 306 C6 PATIENT RELATIONSHIP CODE 1 =CARDHOLDER 2 = SPOUSE 3 = CHILD 4 = OTHER 360 2B EDICAID INDICAT 361 2D PROVIDER ACCEPT ASSINGENT INDICAT 997 G2 CS PART D DEFINED QUALIFIED FACILITY PATIENT SEGENT 111 A SEGENT IDENTIFICATION 01 - SUBIT ONLY IF SEGENT IS TRANSITTED 310 CA PATIENT FIRST NAE R REQUIRED F TWINS, ETC. 311 CB PATIENT LAST NAE R 305 C5 PATIENT GENDER CODE 304 C4 DATE OF BIRTH R 322 C PATIENT STREET ADDRESS 322 CN PATIENT CITY ADDRESS 324 CO PATIENT STATE/PROVIDENCE ADDRESS 325 CP PATIENT ZIP/POSTALZONE 307 C7 PLACE OF SERVICE 335 2C PREGNANCY INDICAT 384-4X PATIENT RESIDENCE CLAI SEGENT 111 A SEGENT IDENTIFICATION 07 SUBIT ONLY IF THE SEGENT IS TRANSITTED 455 E PRESCRIPTION/SERVICE 01 RX BILLING REFERENCE NUBER 402 D2 PRESCRIPTION /SERVICE REFERENCE NUBER PRODUCT/SERVICE ID 436 E1 REQUIRED UP TO 12 DIGITS SUPPTED 03 NATIONAL DRUG CODE
407 D7 PRODUCT/SERVICE ID NDC NUBER/F ULTI INGREDIENT COPOUNDS, SUBIT 00000 00 0000 442 E7 QUANTITY DISPENSED R B1 AND B3 CLAIS 405 D5 DAYS SUPPLY R B1 AND B3 CLAIS 403-D3 FILL NUBER R CLAIS 406-D6 COPOUND CODE R CLAIS. USE 2 IF PRODUCT IS A COPOUND. THE COPOUND SEGENT IS ALSO REQUIRED IF A COPOUND CODE OF 2 IS 408-D8 DISPENSE AS WRITTEND (DAW) R 0-B1 AND B3 CLAIS 414-DE DATE PRESCRIPTION WAS WRITTEN R CLAIS 415-DF NUBER OF REFILLS AUTHIZED 420-DK SUBISSION CLARIFICATION CODE USE VALUE 8 WHEN ACCEPTING PAYENT ONLY F COVERED PRODUCTS IN ULTI-INGREDIENT COPOUND. USE VALUE 19 WHEN SUBITTING AN LTC SPLIT BILLING CLAIS THAT IS THE BALANCE OF A CLAI TO EDICARE PART A. 308-C8 OTHER COVERAGE CODE IF OTHER COVERAGE EXISTS, THE APPLICABLE VALUE UST BE SUBITED WITH REQUIRED COB SEGENT (S). 0= NON SPECIFIED. 1= NO OTHER COVERAGE IDENTIFIED. 2 = OTHER COVERAGE EXISTS PYNT COLLECTED. 3 = OTHER COVERAGE EXISTS THIS CLAI NOT COVERED. 4 = OTHER COVERAGE EXISTS, PAYENT NOT COLLECTED. 5 = ANAGED CARE PLAN DENIAL. 6 = OTHER COVERAGE DENIED NOT A PARTICIPATION PROVIDER. 7 = OTHER COVERAGE EXISTS NOT IN EFFECT AT TIE OF SERVICE. 8 = CLAI IS BILLING F A COPAY. 429-DT UNIT DOSE INDICAT
357-NV DELAY REASON CODE 995-E2 ROUTE OF ADINISTRATION 996-G1 COPOUND TYPE 147-U7 PHARACY SERVICE TYPE 453-EJ IG PRESCRIBED PRODUCT/SERVICE ID 445-EA IGINALLY PRESCRIBED PRODUCT.SERVICE CODE 461-EU PRI AUTHIZATION TYPE CODE 462-EV PRI AUTHIZATION NUBER 354-NX SUBISSION CLARIFICATION CODE VARIES BY PLAN PRESCRIBER SEGENT NAE ANDATY ANDATY 111-A SEGENT IDENTIFICATION SUBIT ONLY IF SEGENT IS TRANSITTED 466-EZ PRESCRIBER ID QUALIFER 12-DEA. PREFER USE OF 12,13,14 411-D8 PRESCRIBER ID 427-DR PRESCRIBER LAST NAE 498-P PRESCRIBER PHONE NUBER WHEN REQUIRED BY PAN COB/OTHER PAYENTS SEGENT SCENARIO 1 OTHER PAYER AOUNT PAID REPETITIONS ONLY NAE ANDATY 111 A SEGENT IDENTIFICATION ANDATY COB/OTHER PAYENTS SEGENT
337 4C CODINATION OF BENEFITS/OTHER PAYENTS REQUIRED IF SEGENT. AX =3 338 5C OTHER PAYER COVERAGE TYPE 339 6C OTHER PAYER ID 03 = BIN 340-7C OTHER PAYER ID BIN OF OTHER PAYER 443-E8 OTHER PAYER DATE 341-HB OTHER PAYER AOUNT PAID # OF OCCURRENCES 342-HC OTHER PAYER AOUNT PAID 431-DV OTHER PAYER AOUNT PAID ENTER COUPON VALUE 471-5E OTHER PAYER REJECT 472-6E OTHER PAYER REJECT CODE COB/OTHER PAYENTS SEGENT SCENARIO 2 OTHER PAYER PATIENT REPITITIONS AND BENEFIT STAGE REPETITIONS ONLY ANDATY ANDATY NAE 111-A SEGENT IDENTIFICATION 337-4C 338-5C 339-6C CODINATION OF BENEFITS/OTHER PAYENTS 05= TRANSIT ONLY IF THE SEGENT IS TRANSITTED OTHER PAYER COVERAGE TYPE OTHER PAYER ID 340-7C OTHER PAYER ID 443-E8 OTHER PAYER DATE 471-5E OTHER PAYER REJECT 472-6E OTHER PAYER REJECT CODE 353-NR OTHER PAYER-PATIENT 351-NP OTHER PAYER-PATIENT 352-NQ OTHER PAYER-PATIENT 392-U BENEFIT STAGE 393-V BENEFIT STAGE 394-W BENEFIT STAGE AOUNT COB/OTHER PAYENTS SEGENT SCENARIO 3 OTHER PAYER AOUNT PAID, OTHER PAYER-PATIENT, AND BENEFIT STAGE REPETITIONS PRESENT (GOVERNENT PROGRAS)
NAE ANDATY 111-A SEGENT INDICAT 337-4C CODINATION OF BENEFITS/OTHER PAYENTS ANDATY 05= TRANSIT ONLY IF THE SEGENT IS TRANSITTED 338-5C OTHER PAYER COVERAGE TYPE 339-6C OTHER PAYER ID 340-7C OTHER PAYER ID 443-E8 OTHER PAYER DATE 341-HB OTHER PAYER AOUNT PAID 342-HC OTHER PAYER AOUNT PAID 431-DV OTHER PAYER AOUNT PAID 471-5E OTHER PAYER REJECT 472-6E OTHER PAYER REJECT CODE 353-NR OTHER PAYER-PATIENT 352-NP OTHER PAYER-PATIENT 352-NQ OTHER PAYER-PATIENT 392-U BENEFIT STAGE 393-V BENEFIT STAGE 394-W BENEFIT STAGE AOUNT WKERS COPENSATION SEGENT NAE ANDATY ANDATY 111-A SEGENT IDENTIFICATION SUBIT ONLY IF THE SEGENT IS TRANSITTED. 434-DY DATE OF INJURY R REQUIRED IF SEGENT IS. 315-CF EPLOYER NAE VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 316-CG EPLOYER STREET ADDRESS VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS.
317-CH EPLOYER CITY ADDRESS VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 318-CI EPLOYER STATE/PROVINCE ADDRESS VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 319-CJ EPLOYER ZIP/POSTAL ZONE VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 32O-CK EPLOYER PHONE NUBER VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 321-CL EPLOYER CONTACT NAE VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 327-CR CARRIER ID VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 435-DZ CLAI REFERENCE ID R REQUIRED IF SEGENT IS 117-TR BILLING ENTITY TYPE INDICAT VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 118-TS PAY TO VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 119-TT PAY TO ID VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 12O-TU PAY TO NAE VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 121-TV PAY TO STREET ADDRESS VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 122-TW PAY TO CITY ADDRESS VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 123-TX PAY TO STATE/PROVINCE ADDRESS VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 124-TY PAY TO ZIP/POSTAL ZONE VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 125-TZ GENERIC EQUIVALENT PRODUCT ID VARIES BY PLAN. SEE ONLINE RESPONSE F DETAILS. 126-UA GENERIC EQUIVALENT PRODUCT ID VARIES BY PLAN. PRICING SEGENT B1&B3 ANDATY ANDATY NAE 111-A SEGENT IDENTIFICATION PRICING SEGENT 409-D9 INGREDIENT COST R 426-DQ USUAL AND CUSTOARY CHARGE R 430-DU GROSS AOUNT DUE R R 412-DC DISPENSING FEE 433-DX PATIENT PAID AOUNT
481-HA FLAT SALES TAX AOUNT IF SALES TAX IS REQUIRED 482-GE PERCENTAGE SALES TAX AOUNT IF SALES TAX IS REQUIRED 483-HE PERCENTAGE SALES TAX RATE IF SALES TAX IS REQUIRED 484-JE PERCENTAGE SALES TAX BASIS IF SALES TAX IS REQUIRED 423-DN BASIS OF COST DETERINATION 478-H7 OTHER AOUNT CLAI AOUNT 479-H8 OTHER AOUNT CLAIED 480-H9 OTHER AOUNT CLAIED DUR/PPS SEGENT NAE B1&B3 ANDATY ANDATY 111-A SEGENT IDENTIFICATION SUBIT ONLY IF THE SEGENT IS TRANSITTED 473-7E DUR/PPS CODE ER R R REQUIRED IF SEGENT IS 439-E4 REASON F SERVICE CODE R R REQUIRED IF SEGENT IS 440-ES PROFESSIONAL SERVICE CODE R R REQUIRED IF SEGENT IS 441-E6 RESULT OF SERVICE CODE R R REQUIRED IF SEGENT IS 474-8E REQUIRED IF SEGENT IS DUR/PPS LEVEL OF EFFT R R 475-J9 DUR CO-AGENT ID 476-H6 DUR CO-AGENT CODE COPOUND SEGENT 450-EF 451-EG NAE COPOUND DOSAGE F DESCRIPTION CODE COPOUND DISPENSING UNIT F INDICAT ANDATY ANDATY 1=EACH, 2= GRAS, 3= ILLILITERS
447-EC 488-RE COPOUND INGREDIENT COPONENT COPOUND PRODUCT ID 489-TE COPOUND PRODUCT ID 448-ED 449-EE 490-UE 362-2G 363-2H COPOUND INGREDIENT QUANTITY COPOUND INGREDIENT DRUG COST COPOUND INGREDIENT BASIS OF COST DETERINATION COPOUND INGREDIENT ODIFIER CODE COPOUND INGREDIENT ODIFIER CODE AX 25 INGREDIENTS 03 - NDC AT LEAST 2 INGREDIENTS AND 2 NDC S REQUIRED WHEN COPOUND INGREDIENT ODIFIER CODE (363-2H) IS SENT REQUIRED IF NECESSARY F STATE/FEDERAL REGULATY AGENCY PROGRAS COUPON SEGENT: USE OF THE COUPON SEGENT DATA ELEENTS IS NOT SUPPTED. SUBIT VALUE OF COUPON IN COB SEGENT OTHER PAYER AOUNT. *********OTHER TRANSACTIONAL INFATION******** AXIU NUBER OF TRANSACTIONS SUPPTED PER TRANSISSION 4 TRANSACTIONSF TRANSISSION. ONLY 01 F A TRANSACTION REVERSAL WINDOW 14 DAYS PRESCRIBER ID DEA # IS THE PREFFERED ENTRY F PRESCRIBER ID PHARACY CONTRACT REGISTRATION REQUIRED. CONTACT 866-813-3743 VEND CERTIFICATION REQUIRED NOT REQUIRED PLAN SPECIFIC HELP DESK 888-479-2000 PHARACY HELP DESK 888-886-5822