2018 Payer Sheet NCPDP Version D.0. Version 3.0 for 2018

Transcription

1 2018 Payer Sheet NCPDP Version D.0 Version 3.0 for 2018 Effective Date: January 1, 2018

2 Contents Contents... 2 General Information... 3 BIN Information... 3 List for BIN List for BIN List for BIN List for BIN List for BIN Pharmacy Help Desk Information... 4 Version Information... 5 NCPDP Version D.0 Claims Billing Template... 6 Request Claim Billing Payer Sheet Template... 6 General Information... 6 Transactions Supported... 6 Field Legend for Columns... 6 Claims Billing Transaction... 7 Response Claim Billing Payer Sheet Template General Information Claim Billing Accepted/Paid (or Duplicate of Paid) Response Claim Billing/Rejected Response NCPDP Version D.0 Claim Reversal Template Request Claim Reversal Payer Sheet Template General Information Field Legend for Columns Request Claim Reversal Transaction Response Claim Reversal Payer Sheet Template General Information Claim Reversal Accepted/Rejected Response Note: For all eridianrx EDICARE serviced plans, please refer to the EDICARE payer sheet available on the Documents and Forms page of our website: 2

3 General Information BIN Information List for BIN BIN Number Effective as of NCPDP Version January 1, 2018 D January 1, 2018 D January 1, 2018 D January 1, 2018 D January 1, 2018 D.0 eridianrx Group ID Line of Business HPCD N/A edicaid HPILCD N/A edicaid THPCD N/A edicaid RICH N/A Commercial GVHPCOR N/A Commercial BAPCOR N/A Commercial CECOR N/A Commercial CONCORR N/A Commercial CONR N/A Commercial QCPR N/A Commercial PERCOR N/A Commercial GSR N/A Commercial PC N/A Commercial SKPC N/A Commercial RCOPSS Commercial RCOPQL Commercial List for BIN Group ID Line of Business 9999 Refer to ID Card Commercial List for BIN Group ID Line of Business NSCRIPT Refer to ID Card Commercial List for BIN Group ID Line of Business SSR Refer to ID Card Commercial 3

4 List for BIN Group ID Line of Business RCDPHH Refer to ID Card edicaid Pharmacy Help Desk Information Inquiries to eridianrx may be directed to our 24 hour Pharmacy Assistance Center. All calls are toll-free. eridianrx Phone Fax HPCD (edicaid) HPILCD (edicaid) RICH THPCD GVHPCOR BAPCOR CECOR * cmcpharmacyteam@meridianrx.com CONCORR CONR m.white@conciergecorrections.com s.carrier@concierge-rx.com PERCOR info@meridianrx.com QCPR info@meridianrx.com GSR info@meridianrx.com RCOP info@meridianrx.com RCDP info@meridianrx.com RCOPQL info@meridianrx.com * Caidan anagement Company phone operation hours are onday Friday from 8 a.m. to 10 p.m. and Saturday Sunday from 10 a.m. to 6:30 p.m. 4

5 Version Information Version Date Page Field Notes 1.0 1/1/2017 Payer Sheet for /1/2018 Payer Sheet for

6 NCPDP Version D.0 Claims Billing Template Request Claim Billing Payer Sheet Template General Information **Start of Request Claim Billing (B1) Payer Sheet Template** Payer Name: eridianrx BIN: Date: January 1, 2018 HPCD (edicaid) HPILCD (edicaid) THPCD (edicaid) CECOR (Commercial) RICH (Commercial) BAPCOR (Commercial) CONCORR (Commercial) CONR (Commercial) QCPR (Commercial) PERCOR (Commercial) GSR (Commercial) RCOPQL (Commercial) PC (Commercial) SKPC (Commercial) Payer Name: BIN: Date: January 1, Payer Name: BIN: Date: January 1, 2018 NSCRIPT Payer Name: BIN: Date: January 1, 2018 SSR Payer Name: BIN: Date: January 1, 2018 RCDPHH Effective as of: January 1, 2018 NCPDP Telecommunication Standard Version/Release #: D.0 NCPDP Data Dictionary Version Date: arch 2010 NCPDP External Code List Version Date: arch 2010 Contact/Information Source: eridianrx, 1 Campus artius, Suite 750, Detroit, I Provider Relations Help Desk Info: Other Versions Supported: None Transactions Supported Transaction Code B1 B2 Transaction Name Claim Billing Claim Reversal Field Legend for Columns 6

7 Payer Usage Column Value Explanation Payer Situation Column andatory 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 Claims Billing Transaction The following lists the segments and fields in a Claim Billing Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Transaction Header Segment Questions Claim Billing (if situational, Payer Situation) Transaction Header Segment Claim Billing 101-A1 BIN NUBER , , , , A2 VERSION/RELEASE NUBER D0 103-A3 TRANSACTION CODE B1 Note: Rebill (B3) not supported 104-A4 PROCESSOR CONTROL NUBER Use correct for Refer to table BIN/Group/Line of on page 3 Business. Only one Transaction 109-A9 TRANSACTION COUNT 1 allowed in a single transmission 202-B2 SERVICE PROVIDER ID QUALIFIER 01, = NPI 07 = NCPDP Provider ID 201-B1 SERVICE PROVIDER ID 401-D1 DATE OF SERVICE 110-AK SOFTWARE VENDOR/CERTIFICATION ID BLANKS Insurance Segment Questions Claim Billing (if situational, Payer Situation) Insurance Segment (111-A) = 04 Claim Billing 301-C1 Group ID R As printed on the ID card or as communicated 302-C2 CARDHOLDER ID 312-CC CARDHOLDER FIRST NAE Required for Caidan anagement 313-CD CARDHOLDER LAST NAE Required for Caidan anagement 306-C6 PATIENT RELATIONSHIP CODE Required for Caidan anagement 7

8 Patient Segment Questions Claim Billing (if situational, Payer Situation) Patient Segment (111-A) = 01 Claim Billing 304-C4 DATE OF BIRTH R 305-C5 PATIENT GENDER CODE 1, 2 R 310-CA PATIENT FIRST NAE R 311-CB PATIENT LAST NAE R 322-C PATIENT STREET ADDRESS R 323-CN PATIENT CITY ADDRESS R 324-CO PATIENT STATE / PROVINCE ADDRESS R 325-CP PATIENT ZIP/POSTAL ZONE R 307-C7 PLACE OF SERVICE Required for Home Infusion and LTC patients 350-HN PATIENT E-AIL ADDRESS For informational purposes only PATIENT RESIDENCE to clarify coverage Pricing Segment Questions Claim Billing (if situational, Payer Situation) Pricing Segment (111-A) = 11 Claim Billing 409-D9 INGREDIENT COST SUBITTED R 412-DC DISPENSING FEE SUBITTED R 438-E3 INCENTIVE AOUNT SUBITTED Required when applicable 426-DQ USUAL AND CUSTOARY CHARGE R 430-DU GROSS AOUNT DUE R Prescriber Segment Questions Claim Billing (if situational, Payer Situation) Prescriber Segment (111-A) = 03 Claim Billing 466-EZ PRESCRIBER ID QUALIFIER 01, 12 R 01 = NPI 12 = DEA 411-DB PRESCRIBER ID R Claim Segment Questions Claim Billing (if situational, Payer Situation) Claim Segment (111-A) = 07 Claim Billing 8

9 455-E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 01 = Rx Billing 402-D2 PRESCRIPTION/SERVICE REFERENCE NUBER 436-E1 PRODUCT/SERVICE ID QUALIFIER 03 NDC Number 407-D7 PRODUCT/SERVICE ID = anufacturer assigned number DDDD = Drug ID PP = Package size Zero filled if product is a Compound. 442-E7 QUANTITY DISPENSED R 403-D3 FILL NUBER R 405-D5 DAYS SUPPLY R 406-D6 COPOUND CODE 0, 1, 2 R 408-D8 DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE 0 thru 9 R 414-DE DATE PRESCRIPTION WRITTEN R 415-DF NUBER OF REFILLS AUTHORIZED R 0 = Not specified 1 = Not a Compound 2 = Compound 0 = No Product Selection Indicated 1 = Prescriber DAW 2 = Patient Selection 3 = Pharmacist Selection 4 = No Generic Available at Pharmacy 5 = Brand Dispensed as Generic 6 = Override 7 = Brand andated by Law 8 = No Generic in arketplace 9 = Plan Requested Brand Claim Segment Questions Claim Billing (if situational, Payer Situation) Claim Segment (111-A) = 07 Claim Billing 419-DJ PRESCRIPTION ORIGIN CODE 1,2,3,4 R 1 = Written 2 = Telephone 3 = Electronic 4 = Facsimile 308-C8 OTHER COVERAGE CODE 1, 2, 3, 4, 8 R 1 = No other coverage 2 = Other coverage exists 9

10 payment collected 3 = Other coverage billed claim not covered. 4 = Other coverage exists payment not collected 8 = Claim is billing for patient financial responsibility only 147-U7 PHARACY SERVICE TYPE R 354-N SUBISSION CLARIFICATION CODE COUNT Up to DK SUBISSION CLARIFICATION CODE For Copay Only Billing: Use value 4 when payment was not collected due to previous payers deductible Use value 3 when payment was not collected from previous payer Use value 8 when payment was collected from previous payer and the claim is billing for copay only Field is Required when Patient Residence (384-4) = 3 Field is Required for 340B Claim Submissions Field is Required when Patient Residence (384-4) = 3 Value 20 Required for 340B Claim Submissions Coordination of Benefits/Other Payments Segment Questions Claim Billing (if situational, Payer Situation) This segment is situational Required if only for secondary, tertiary, claims Coordination of Benefits/Other Payments Segment (111-A) = 05 Claim Billing Scenario 2- Other Payer- Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only 337-4C COORDIATION OF BENEFITS/OTHER aximum count PAYENTS COUNT of C OTHER PAYER COVERAGE TYPE 01 thru C OTHER PAYER ID QUALIFIER 03 R 03 = BIN 340-7C OTHER PAYER ID R 443-E8 OTHER PAYER DATE R 10

11 341-HB 342-HC OTHER PAYER AOUNT PAID COUNT OTHER PAYER AOUNT PAID QUALIFIER aximum of 9 01, 02, 03, 04, 05, 06, 07, 09 Required if Other Payer Amount Paid Qualifier (342-HC) is used Required if Other Payer Amount Paid (431-DV) is used 431-DV OTHER PAYER AOUNT PAID 471-5E OTHER PAYER REJECT COUNT aximum count of E OTHER PAYER REJECT CODE 353-NR 351-NP 352-NQ OTHER PAYER-PATIENT RESPONSIBILITY AOUNT COUNT OTHER PAYER-PATIENT RESPONSIBILITY AOUNT QUALIFIER OTHER PAYER-PATIENT RESPONSIBILITY AOUNT aximum count of 25 01, 02, 04, 05, 06, 07, 08, 09, 11 Required when other payer payment is made Required when Other Payer Reject Code (472-6E) is used Required when Other Coverage Code (308-C8) = 3 Required when Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used Required when Other Payer-Patient Responsibility Amount (352-NQ) is used Necessary for Patient Financial Responsibility Only Billing DUR/PPS Segment Questions Claim Billing (if situational, Payer Situation) This segment is situational When necessary to provide information on potential drug interactions DUR/PPS Segment (111-A) = 08 Claim Billing 473-7E DUR/PPS CODE COUNTER aximum of 9 occurrences 439-E4 REASON FOR SERVICE CODE DD, TD, S 440-E5 PROFESSIONAL SERVICE CODE 441-E6 RESULT OF SERVICE CODE 11 DD = Drug Drug TD = Duplicate Therapy S = Drug - Gender Compound Segment Questions Claim Billing (if situational, Payer Situation) This segment is situational For billing of compound medications Compound Segment (111-A) = 10 Claim Billing 450-EF COPOUND DOSAGE FOR DESCRIPTION CODE 01-07, Blank = Not Specified 01 = Capsule 02 = Ointment

12 451-EG COPOUND DISPENSING UNIT FOR INDICATOR 1, 2, EC COPOUND INGREDIENT aximum 25 COPONENT COUNT ingredients 488-RE COPOUND PRODUCT ID QUALIFIER 489-TE COPOUND PRODUCT ID 448-ED COPOUND INGREDIENT QUANTITY 449-EE 490-UE COPOUND INGREDIENT DRUG COST COPOUND INGREDIENT BASIS OF R COST DETERINATION **End of Request Claim Billing (B1) Payer Sheet Template** R 03 = Cream 04 = Suppository 05 = Powder 06 = Emulsion 07 = Liquid 10 = Tablet 11 = Solution 12 = Suspension 13 = Lotion 14 = Shampoo 15 = Elixir 16 = Syrup 17 = Lozenge 1 = Each 2 = Grams 3 = illiliters Enter ingredient cost for each product in the compound 12

13 Response Claim Billing Payer Sheet Template General Information **Start of Response Claim Billing (B1) Payer Sheet Template** Payer Name: eridianrx BIN: Date: January 1, 2018 HPCD (edicaid) HPILCD (edicaid) THPCD (edicaid) CECOR (Commercial) RICH (Commercial) BAPCOR (Commercial) CONCORR (Commercial) CONR (Commercial) QCPR (Commercial) PERCOR (Commercial) GSR (Commercial) RCOPQL (Commercial) Payer Name: BIN: Date: January 1, Payer Name: BIN: Date: January 1, 2018 NSCRIPT Payer Name: BIN: Date: January 1, 2018 SSR Payer Name: BIN: Date: January 1, 2018 RCDPHH Effective as of: January 1, 2018 NCPDP Telecommunication Standard Version/Release #: D.0 NCPDP Data Dictionary Version Date: arch 2010 NCPDP External Code List Version Date: arch 2010 Contact/Information Source: eridianrx, 1 Campus artius, Suite 750, Detroit, I Provider Relations Help Desk Info: Other Versions Supported: None Claim Billing Accepted/Paid (or Duplicate of Paid) Response The following lists the segments and fields in a Claim Billing Accepted/Paid (or Duplicate of Paid) Response Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Response Transaction Header Segment Questions 13 Claim Billing Accepted/Paid (Or Duplicate of Paid) (if situational, Payer Situation) Response Transaction Header Accepted/Paid (or Segment Duplicate of Paid)

14 102-A2 VERSION/RELEASE NUBER D0 103-A3 TRANSACTION CODE B1 Note: Rebill (B3) not supported 109-A9 TRANSACTION COUNT 1 Only one transaction per transmission 501-F1 HEADER RESPONSE STATUS A = Accepted 202-B2 SERVICE PROVIDER ID QUALIFIER 01, = NPI 07 = NCPDP 201-B1 SERVICE PROVIDER ID 401-D1 DATE OF SERVICE Response essage Header Segment Questions Claim Billing Accepted/Paid (Or Duplicate of This segment is situational Response essage Segment (111-A) = Paid) (if situational, Payer Situation) When additional text is required for clarification or detail Accepted/Paid (or Duplicate of Paid) 504-F4 ESSAGE R Response Insurance Header Segment Questions This segment is situational Response Insurance Segment (111-A) = 25 Claim Billing Accepted/Paid (Or Duplicate of Paid) (if situational, Payer Situation) Returned with Cardholder ID differs from Cardholder ID submitted Accepted/Paid (or Duplicate of Paid) 302-C2 CARDHOLDER ID R Response Status Segment Questions Claim Billing Accepted/Paid (Or Duplicate of Paid) (if situational, Payer Situation) Response Status Segment (111-A) = 21 Accepted/Paid (or Duplicate of Paid) 112-AN TRANSACTION RESPONSE STATUS P=Paid D=Duplicate of Paid 503-F3 AUTHORIZATION NUBER R Response Claim Segment Questions Claim Billing Accepted/Paid (Or Duplicate of Paid) (if situational, Payer Situation) Response Claim Segment (111-A) = 22 Accepted/Paid (or Duplicate of Paid) 455-E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 1 = RxBilling 402-D2 PRESCRIPTION/SERVICE REFERENCE

15 NUBER Response Pricing Segment Questions Claim Billing Accepted/Paid (Or Duplicate of Paid) (if situational, Payer Situation) Response Pricing Segment (111-A) = 23 Accepted/Paid (or Duplicate of Paid) 505-F5 PATIENT PAY AOUNT R 506-F6 INGREDIENT COST PAID R 507-F7 DISPENSING FEE PAID R 557-AV TA EEPT INDICATOR 04 R 04 = Neither Payer/Plan nor Patient are liable for tax 521-FL INCENTIVE AOUNT PAID Required when Professional Service Code = A 566-J5 OTHER PAYER AOUNT Required when Other RECOGNIZED Coverage Code = 2, 3, F9 TOTAL AOUNT PAID R 522-F 517-FH BASIS OF REIBURSEENT DETERINATION AOUNT APPLIED TO PERIODIC DEDUCTIBLE 518-FI AOUNT OF COPAY 572-4U AOUNT OF COINSURANCE 392-U BENEFIT STAGE COUNT aximum count of V BENEFIT STAGE QUALIFIER 394-W BENEFIT STAGE AOUNT 133-UJ 134-UK 135-U 136-UN 137-UP AOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION AOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG AOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORULARY SELECTION AOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NON-PREFERRED FORULARY SELECTION AOUNT ATTRIBUTED TO COVERAGE GAP Required when Ingredient Cost Paid (506-F6) is greater than zero Returned when applicable Returned when applicable Returned when applicable Returned when applicable Returned when applicable Returned when applicable Returned when applicable Returned when applicable Returned when applicable Returned when applicable Returned when applicable 15

16 Response Pricing Segment Questions 16 Claim Billing Accepted/Paid (Or Duplicate of Paid) (if situational, Payer Situation) Response Pricing Segment (111-A) = 23 Accepted/Paid (or Duplicate of Paid) 148-U8 INGREDIENT COST CONTRACTED/REIBURSABLE AOUNT Required when Other Coverage Code (308-C8) = 2 or U9 DISPENSING FEE CONTRACTED/REIBURSABLE AOUNT Required when Other Coverage Code (308-C8) = 2 or 8 Response DUR/PPS Segment Questions Claim Billing Accepted/Paid (Or Duplicate of Paid) (if situational, Payer Situation) This segment is situational Required when DUR warning is indicated Response DUR/PPS Segment (111-A) = 24 Accepted/Paid (or Duplicate of Paid) 567-J6 DUR/PPS RESPONSE CODE COUNTER aximum 9 occurrences supported 439-E4 REASON FOR SERVICE CODE 528-FS CLINICAL SIGNIFICANCE CODE Blank, 1,2,3,9 529-FT OTHER PHARACY INDICATOR 530-FU PREVIOUS DATE OF FILL 531-FV QUANTITY OF PREVIOUS FILL 532-FW DATABASE INDICATOR Required when Reason For Service Code (439-E4) is used Required when utilization is detected 533-F OTHER PRESCRIBER INDICATOR 544-FY DUR FREE TET ESSAGE

17 Response DUR/PPS Segment Questions 17 Claim Billing Accepted/Paid (Or Duplicate of Paid) (if situational, Payer Situation) This segment is situational Required when DUR warning is indicated Response DUR/PPS Segment (111-A) = 24 Accepted/Paid (or Duplicate of Paid) 570-NS DUR ADDITIONAL TET Response Coordination of Benefits/Other Payers Segment Questions This segment is situational Response Coordination of Benefits/Other Payers Segment (111-A) = 28 Claim Billing Accepted/Paid (Or Duplicate of Paid) (if situational, Payer Situation) For claims where other payer information is indicated Accepted/Paid (or Duplicate of Paid) 355-NT OTHER PAYER ID COUNT aximum count of C OTHER PAYER COVERAGE TYPE 339-6C OTHER PAYER ID QUALIFIER Required when secondary coverage is indicated for the member 340-7C OTHER PAYER ID 991-H OTHER PAYER PROCESSOR CONTROL NUBER 356-NU OTHER PAYER CARDHOLDER ID 992-J OTHER PAYER GROUP ID 142-UV OTHER PAYER PERSON CODE 127-UB 143-UW 144-U 145-UY OTHER PAYER HELP DESK PHONE NUBER OTHER PAYER PATIENT RELATIONSHIP CODE OTHER PAYER BENEFIT EFFECTIVE DATE OTHER PAYER BENEFIT TERINATION DATE Required when secondary coverage is indicated for the member Required when secondary coverage is indicated for the member Required when secondary coverage is indicated for the member Required when secondary coverage is indicated for the member Required when secondary coverage is indicated for the member For informational purposes For informational purposes For informational purposes For informational purposes

18 Claim Billing/Rejected Response The following lists the segments and fields in a Claim Billing/Rejected Response Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Response Transaction Header Segment Questions Claim Billing Accepted/Rejected (if situational, Payer Situation) Response Transaction Header Segment Accepted/Rejected 102-A2 VERSION/RELEASE NUBER D0 103-A3 TRANSACTION CODE B1 Note: Rebill (B3) not supported 109-A9 TRANSACTION COUNT 1 Only one transaction per transmission. 501-F1 HEADER RESPONSE STATUS R = Rejected 202-B2 SERVICE PROVIDER ID QUALIFIER Same value as in request 201-B1 SERVICE PROVIDER ID Same value as in request 401-D1 DATE OF SERVICE Same value as in request Response essage Segment Questions Claim Billing Accepted/Rejected (if situational, Payer Situation) This segment is situational When required to clarify response Response essage Segment (111-A) = 20 Accepted/Rejected 504-F4 ESSAGE R Response Claim Segment Questions Claim Billing Accepted/Rejected (if situational, Payer Situation) Response Claim Segment Accepted/Rejected (111-A) = 22 Imp Guide: For Transaction Code of B1, in the Response Claim 455-E PRESCRIPTION/SERVICE REFERENCE Segment, the 1 = RxBilling NUBER QUALIFIER Prescription/Service Reference Number Qualifier (455-E) is 1 (Rx Billing) 402-D2 PRESCRIPTION/SERVICE REFERENCE NUBER 18

19 Response SUR/PPS Segment Questions Claim Billing Accepted/Rejected (if situational, Payer Situation) This segment is situational When DUR warning is indicated Response DUR/PPS Segment (111-A) = 24 Accepted/Rejected 567-J6 aximum 9 Required when Reason DUR/PPS RESPONSE CODE occurrences For Service Code (439-E4) COUNTER supported is used 439-E4 REASON FOR SERVICE CODE Required when utilization is detected 528-FS CLINICAL SIGNIFICANCE CODE Blank, 1,2,3,9 529-FT OTHER PHARACY INDICATOR 530-FU PREVIOUS DATE OF FILL 531-FV QUANTITY OF PREVIOUS FILL 532-FW DATABASE INDICATOR 1= First Databank 2=edispan 533-F OTHER PRESCRIBER INDICATOR 544-FY DUR FREE TET ESSAGE 570-NS DUR ADDITIONAL TET **End of Response Claim Billing (B1) Payer Sheet Template** 19

20 NCPDP Version D.0 Claim Reversal Template Request Claim Reversal Payer Sheet Template General Information **Start of Request Claim Reversal (B2) Payer Sheet Template** Payer Name: eridianrx BIN: Date: January 1, 2018 HPCD (edicaid) HPILCD (edicaid) THPCD (edicaid) CECOR (Commercial) RICH (Commercial) BAPCOR (Commercial) CONCORR (Commercial) CONR (Commercial) QCPR (Commercial) PERCOR (Commercial) GSR (Commercial) RCOPQL (Commercial) Payer Name: BIN: Date: January 1, Payer Name: BIN: Date: January 1, 2018 NSCRIPT Payer Name: BIN: Date: January 1, 2018 SSR Payer Name: BIN: Date: January 1, 2018 RCDPHH Effective as of: January 1, 2018 NCPDP Telecommunication Standard Version/Release #: D.0 NCPDP Data Dictionary Version Date: arch 2010 NCPDP External Code List Version Date: arch 2010 Contact/Information Source: eridianrx, 1 Campus artius, Suite 750, Detroit, I Provider Relations Help Desk Info: Other Versions Supported: None Field Legend for Columns Payer Usage Column Value Explanation andatory The field is mandatory for the segment in the designated transaction Required R The field has been designated with the situation of "Required" for the segment in the designated transaction Qualified Requirement Required when the situations designated have qualifications for usage ( Required if x, Not required if y ) 20

21 Question What is your reversal window? (If transaction is billed today what is the timeframe for reversal to be submitted?) Answer 60 days from the date of service Request Claim Reversal Transaction The following lists the segments and fields in a Request Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Transaction Header Segment Questions Claim Reversal (if situational, Payer Situation) Transaction Header Segment Claim Reversal 101-A1 BIN NUBER , , , , A2 VERSION/RELEASE NUBER D0 103-A3 TRANSACTION CODE B2 301-C1 GROUP ID R As printed on the ID card or as communicated 104-A4 PROCESSOR CONTROL NUBER Use correct for Refer to table BIN/Group/Line of on page 3. Business 109-A9 TRANSACTION COUNT B2 SERVICE PROVIDER ID QUALIFIER 01, B1 SERVICE PROVIDER ID 401-D1 DATE OF SERVICE 110-AK SOFTWARE VENDOR/CERTIFICATION ID Blanks 01 = NPI 07 = NCPDP Insurance Segment Questions Claim Reversal (if situational, Payer Situation) Insurance Segment (111-A) = 04 Claim Reversal 302-C2 CARDHOLDER ID Claim Segment Questions Claim Reversal (if situational, Payer Situation) Claim Segment (111-A) = 07 Claim Reversal 455-E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 01=RxBilling 402-D2 PRESCRIPTION/SERVICE REFERENCE NUBER 21

22 436-E1 PRODUCT/SERVICE ID QUALIFIER 407-D7 PRODUCT/SERVICE ID 03 National Drug Code 00 ulti- Ingredient Compound Valid NDC or 0 if original claim was for a multiingredient compound ust contain product/service ID from original prescription billing **End of Request Claim Reversal (B2) Payer Sheet Template** 22

23 Response Claim Reversal Payer Sheet Template General Information Claim Reversal Accepted/Rejected Response **Start of Claim Reversal Response (B2) Payer Sheet Template** Payer Name: eridianrx BIN: Date: January 1, 2018 eridian Health Plan of ichigan HPCD (edicaid) eridian Health Plan of Illinois HPILCD (edicaid) Trusted Health Plan of Washington DC THPCD (edicaid) Caidan anagement Company CECOR (Commercial) eridianchoice/bronson Healthcare RICH (Commercial) Bridgestone BAPCOR (Commercial) Concierge Corrections CONCORR (Commercial) Concierge Rx CONR (Commercial) Quality Care Partners (QCP) QCPR (Commercial) Perry Corporation (PERRY protech) PERCOR (Commercial) Group anagement Services (GS) GSR (Commercial) Quicken Loans RCOPQL (Commercial) Payer Name: BIN: Date: January 1, Payer Name: BIN: Date: January 1, 2018 NSCRIPT Payer Name: BIN: Date: January 1, 2018 SSR Payer Name: BIN: Date: January 1, 2018 RCDPHH Effective as of: January 1, 2018 NCPDP Telecommunication Standard Version/Release #: D.0 NCPDP Data Dictionary Version Date: arch 2010 NCPDP External Code List Version Date: arch 2010 Contact/Information Source: eridianrx, 1 Campus artius, Suite 750, Detroit, I Provider Relations Help Desk Info: Other Versions Supported: None The following lists the segments and fields in a Claim Reversal (Accepted/Rejected) Response Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Response Transaction Header Segment Questions Claim Reversal Accepted/Approved (if situational, Payer Situation) Response Transaction Header Claim Reversal 23

24 Segment Accepted/Approved 102-A2 VERSION/RELEASE NUBER D0 103-A3 TRANSACTION CODE B2 109-A9 TRANSACTION COUNT F1 HEADER RESPONSE STATUS A, R A = Accepted R = Rejected 202-B2 SERVICE PROVIDER ID QUALIFIER 01, = NPI 07 = NCPDP 201-B1 SERVICE PROVIDER ID 401-D1 DATE OF SERVICE Claim Reversal Accepted/Approved (if situational, Payer Situation) This segment is situational to clarify reversal Response essage Header Segment Questions Response essage Segment (111-A) = 20 Claim Reversal Accepted/Approved 504-F4 ESSAGE Response Status Segment Questions Claim Reversal Accepted/Approved (if situational, Payer Situation) Response Status Segment Claim Reversal Accepted/Approved (111-A) = AN TRANSACTION RESPONSE STATUS A, R A = Accepted R = Rejected Response Claim Segment Questions Claim Reversal Accepted/Approved (if situational, Payer Situation) Response Claim Segment Claim Reversal Accepted/Approved (111-A) = E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 1 = RxBilling 402-D2 PRESCRIPTION/SERVICE REFERENCE NUBER **End of Claim Reversal Response (B2) Payer Sheet Template** 24