RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET ACCEPTED/PAID (OR DUPLICATE OF PAID) AND CAPTURED (OR DUPLICATE OF CAPTURED)

Transcription

1 ESPONSE CLAI BILLING NON-EDICAE D PAYE SHEET ACCEPTED/PAID (O DUPLICATE OF PAID) AND CAPTUED (O DUPLICATE OF CAPTUED) GENEAL INFOATION Payer Name: Envolve Pharmacy Solutions Date: 10/1/2018 Plan Name/Group Name: Commercial/Non edicare D Plans BIN: ØØ8Ø19 PCN: Plan Name/Group Name: agnolia Health Plan - SCAN BIN: Ø20545 PCN: A371 Plan Name/Group Name: agnolia Health Plan - CHIP BIN: Ø20545 PCN: A372 esponse Transaction Header Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE Same value as in request billing 1Ø3-A3 TANSACTION CODE Same value as in request billing 1Ø9-A9 TANSACTION COUNT Same value as in request billing 5Ø1-F1 HEADE ESPONSE STATUS A = Accepted 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request billing 2Ø1-B1 SEVICE POVIDE ID Same value as in request billing 4Ø1-D1 OF SEVICE Same value as in request billing esponse essage Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of Will not be supplied when message is blank. esponse essage Segment Segment Identification (111-A) = 2Ø Claim Billing Accepted/Paid (or 5Ø4-F4 ESSAGE Will not be supplied when message is blank. esponse Insurance Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of esponse Insurance Segment Segment Identification (111-A) = 25 3Ø1-C1 GOUP ID esponse Status Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of Page: 1

2 esponse Status Segment Segment Identification (111-A) = AN TANSACTION ESPONSE STATUS P=Paid D=Duplicate of Paid C=Capture Q=Duplicate of Capture 5Ø3-F3 AUTHOIZATION 13Ø-UF ADDITIONAL ESSAGE INFOATION aximum count of 25. Only when Additional essage COUNT 132-UH ADDITIONAL ESSAGE INFOATION Only when Additional essage QUALIFIE 526-FQ ADDITIONAL ESSAGE INFOATION Only when not blank. 131-UG ADDITIONAL ESSAGE INFOATION Only when not blank. CONTINUITY esponse Claim Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of esponse Claim Segment Segment Identification (111-A) = E PESCIPTION/SEVICE EFEENCE Same value as in request billing QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE Same value as in request billing esponse Pricing Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of esponse Pricing Segment Segment Identification (111-A) = 23 5Ø5-F5 PATIENT PAY AOUNT 5Ø6-F6 INGEDIENT COST PAID 5Ø7-F7 DISPENSING FEE PAID Imp Guide: equired if this value is used 558-AW FLAT SALES TA AOUNT PAID Imp Guide: equired if Flat Sales Tax Amount Submitted (481-HA) is greater than zero (Ø) or if Flat Sales Tax Amount Paid (558-AW) is used to arrive at the final reimbursement. 559-A PECENTAGE SALES TA AOUNT PAID Imp Guide: equired if this value is used equired if Percentage Sales Tax Amount Submitted (482-GE) is greater than zero (Ø). equired if Percentage Sales Tax ate Paid (56Ø-AY) and Percentage Sales Tax Basis Paid (561-AZ) are used. 56Ø-AY PECENTAGE SALES TA ATE PAID Imp Guide: equired if Percentage Sales Tax Amount Paid (559-A) is greater than zero (Ø). Page: 2

3 esponse Pricing Segment Segment Identification (111-A) = AZ PECENTAGE SALES TA BASIS PAID Imp Guide: equired if Percentage Sales Tax Amount Paid (559-A) is greater than zero (Ø). 563-J2 OTHE AOUNT PAID COUNT aximum count of 3. Imp Guide: equired if Other Amount Paid (565-J4) is used. 564-J3 OTHE AOUNT PAID QUALIFIE Imp Guide: equired if Other Amount Paid (565-J4) is used. 565-J4 OTHE AOUNT PAID Imp Guide: equired if this value is used equired if Other Amount Claimed Submitted (48Ø-H9) is greater than zero (Ø) 566-J5 OTHE PAYE AOUNT ECOGNIZED Imp Guide: equired if this value is used equired if Other Payer Amount Paid (431-DV) is greater than zero (Ø) and Coordination of Benefits/Other Payments Segment is 521-FL INCENTIVE AOUNT PAID Imp Guide: equired if this value is used 5Ø9-F9 TOTAL AOUNT PAID 522-F BASIS OF EIBUSEENT DETEINATION 523-FN AOUNT ATTIBUTED TO SALES TA 512-FC ACCUULATED DEDUCTIBLE AOUNT 513-FD EAINING DEDUCTIBLE AOUNT equired if Incentive Amount Submitted (438-E3) is greater than zero (Ø). 514-FE EAINING BENEFIT AOUNT 517-FH AOUNT APPLIED TO PEIODIC DEDUCTIBLE 518-FI AOUNT OF COPAY 52Ø-FK AOUNT ECEEDING PEIODIC BENEFIT AIU 572-4U AOUNT OF COINSUANCE Imp Guide: equired if Patient Pay Amount (5Ø5-F5) includes coinsurance as patient financial responsibility. 134-UK AOUNT ATTIBUTED TO PODUCT SELECTION/BAND DUG Imp Guide: equired if Patient Pay Amount (5Ø5-F5) includes an amount that is attributable to a patient s selection of a Brand drug. 137-UP AOUNT ATTIBUTED TO COVEAGE GAP Imp Guide: equired when the patient s financial responsibility is due to the coverage gap. esponse DU/PPS Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of esponse DU/PPS Segment Segment Identification (111-A) = J6 DU/PPS ESPONSE CODE COUNTE aximum 9 occurrences Page: 3

4 esponse DU/PPS Segment Segment Identification (111-A) = E4 EASON FO SEVICE CODE 528-FS CLINICAL SIGNIFICANCE CODE 529-FT OTHE PHAACY INDICATO 53Ø-FU PEVIOUS OF FILL 531-FV QUANTITY OF PEVIOUS FILL 532-FW DATABASE INDICATO 533-F OTHE PESCIBE INDICATO 544-FY DU FEE TET ESSAGE 57Ø-NS DU ADDITIONAL TET Imp Guide: equired if needed to supply additional information for the utilization conflict. esponse Coordination of Benefits/Other Payers Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of aximum of 3 esponse Coordination of Benefits/Other Payers Segment Segment Identification (111-A) = NT OTHE PAYE ID COUNT aximum 3 occurrences 338-5C OTHE PAYE COVEAGE TYPE ****** 339-6C OTHE PAYE ID QUALIFIE 34Ø-7C OTHE PAYE ID 991-H OTHE PAYE POCESSO CONTOL 356-NU OTHE PAYE CADHOLDE ID 992-J OTHE PAYE GOUP ID 142-UV OTHE PAYE PESON CODE 143-UW OTHE PAYE PATIENT ELATIONSHIP CODE 144-U OTHE PAYE BENFIT EFFECTIVE 145-UY OTHE PAYE BENEFIT TEINATION Page: 4

5 Claim Billing Accepted Transmission/ejected esponse esponse Transaction Header Segment Questions Check esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE Same value as in request billing 1Ø3-A3 TANSACTION CODE Same value as in request billing 1Ø9-A9 TANSACTION COUNT Same value as in request billing 5Ø1-F1 HEADE ESPONSE STATUS A = Accepted 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request billing 2Ø1-B1 SEVICE POVIDE ID Same value as in request billing 4Ø1-D1 OF SEVICE Same value as in request billing esponse essage Segment Questions Check Will not be supplied when message is blank. esponse essage Segment Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE Will not be supplied when message is blank. esponse Insurance Segment Questions Check Will be supplied when payer has matched the patient to an eligible member. esponse Insurance Segment Segment Identification (111-A) = 25 3Ø1-C1 GOUP ID esponse Status Segment Questions Check esponse Status Segment Segment Identification (111-A) = AN TANSACTION ESPONSE STATUS = eject 51Ø-FA EJECT COUNT aximum count of FB EJECT CODE 546-4F EJECT FIELD OCCUENCE INDICATO Imp Guide: equired if a repeating field is in error, to identify repeating field occurrence. 13Ø-UF ADDITIONAL ESSAGE INFOATION COUNT aximum count of 25. Only when Additional essage 132-UH ADDITIONAL ESSAGE INFOATION QUALIFIE Only when Additional essage 526-FQ ADDITIONAL ESSAGE INFOATION Only when not blank 131-UG ADDITIONAL ESSAGE INFOATION CONTINUITY Only when not blank. esponse Claim Segment Questions Check Page: 5

6 esponse Claim Segment Segment Identification (111-A) = E PESCIPTION/SEVICE EFEENCE Same value as in request billing QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE Same value as in request billing esponse Coordination of Benefits/Other Payers Segment Questions Check aximum Count of 3 esponse Coordination of Benefits/Other Payers Segment Segment Identification (111-A) = NT OTHE PAYE ID COUNT aximum 3 occurrences 338-5C OTHE PAYE COVEAGE TYPE ****** 339-6C OTHE PAYE ID QUALIFIE 34Ø-7C OTHE PAYE ID 991-H OTHE PAYE POCESSO CONTOL 356-NU OTHE PAYE CADHOLDE ID 992-J OTHE PAYE GOUP ID 142-UV OTHE PAYE PESON CODE 143-UW OTHE PAYE PATIENT ELATIONSHIP CODE 144-U OTHE PAYE BENFIT EFFECTIVE 145-UY OTHE PAYE BENEFIT TEINATION Claim Billing Accepted/ejected CLAI BILLING EJECTED TANSISSION/EJECTED ESPONSE esponse Transaction Header Segment Questions Check Claim Billing ejected/ejected esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE Same value as in request billing 1Ø3-A3 TANSACTION CODE Same value as in request billing 1Ø9-A9 TANSACTION COUNT Same value as in request billing 5Ø1-F1 HEADE ESPONSE STATUS = ejected 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request billing 2Ø1-B1 SEVICE POVIDE ID Same value as in request billing 4Ø1-D1 OF SEVICE Same value as in request billing Claim Billing ejected/ejected esponse essage Segment Questions Check Claim Billing ejected/ejected Will not be supplied when message is blank esponse essage Segment Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE Claim Billing ejected/ejected esponse Status Segment Questions Check Claim Billing ejected/ejected Page: 6

7 esponse Status Segment Segment Identification (111-A) = AN TANSACTION ESPONSE STATUS = eject 51Ø-FA EJECT COUNT aximum count of FB EJECT CODE 546-4F EJECT FIELD OCCUENCE INDICATO Claim Billing ejected/ejected Will be supplied only when applicable esponse Coordination of Benefits/Other Payers Segment Questions Check Claim Billing ejected/ejected aximum Count of 3 esponse Coordination of Benefits/Other Payers Segment Segment Identification (111-A) = NT OTHE PAYE ID COUNT aximum 3 occurrences 338-5C OTHE PAYE COVEAGE TYPE ****** 339-6C OTHE PAYE ID QUALIFIE 34Ø-7C OTHE PAYE ID 991-H OTHE PAYE POCESSO CONTOL 356-NU OTHE PAYE CADHOLDE ID 992-J OTHE PAYE GOUP ID 142-UV OTHE PAYE PESON CODE 143-UW OTHE PAYE PATIENT ELATIONSHIP CODE 144-U OTHE PAYE BENFIT EFFECTIVE 145-UY OTHE PAYE BENEFIT TEINATION Claim Billing ejected/ejected Page: 7