NCPDP VERSION D.0 CLAIM BILLING MEDICAID/COMMERCIAL REQUEST CLAIM BILLING PRIMARY PAYER SHEET

Transcription

1 NCPDP VESION D.0 CLAI BILLING EDICAID/COECIAL EQUEST CLAI BILLING PIAY PAYE SHEET GENEAL INFOATION Payer Name: Envolve Pharmacy Solutions Date: Plan Name/Group Name: Commercial/Non edicare D Plans BIN: ØØ8Ø19 PCN: Plan Name/Group Name: agnolia Health Plan - SCAN BIN: PCN: A371 Plan Name/Group Name: agnolia Health Plan - CHIP BIN: PCN: A372 Processor: Envolve Pharmacy Solutions Effective as of: 10/1/2018 NCPDP Telecommunication Standard Version/elease #: D.0 NCPDP Data Dictionary Version Date: July 2007 NCPDP External Code List Version Date: October 2013 Contact/Information Source: ITS Service Desk (800) Certification Testing Window: Certification Contact Information: Provider elations Help Desk Info: (800) OTHE TANSACTIONS SUPPOTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Transaction Code Transaction Name B1 Billing B2 eversal Payer Column ANDATOY EQUIED QUALIFIED EQUIEENT FIELD LEGEND FO COLUNS Value Explanation Column The Field is mandatory for the Segment in the designated Transaction. No The Field has been designated with the situation of "equired" for the Segment in the designated Transaction. equired when. The situations designated have qualifications for usage ("equired if x", "Not required if y"). No Yes Fields that are not used in the Claim Billing transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template. CLAI BILLING TANSACTION Transaction Header Segment Questions Check Claim Billing Vendor/Certification ID (11Ø-AK) is Payer Issued Vendor/Certification ID (11Ø-AK) is Switch/VAN issued Vendor/Certification ID (11Ø-AK) is Not used Transaction Header Segment 1Ø1-A1 BIN NUBE BIN listed in General Information 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B1 1Ø4-A4 POCESSO CONTOL NUBE See General Information 1Ø9-A9 TANSACTION COUNT 1-4 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Ø1=NPI Ø7=NCPDP# 2Ø1-B1 SEVICE POVIDE ID aterials eproduced With the Consent of Page: 1

2 Transaction Header Segment 4Ø1-D1 DATE OF SEVICE 11Ø-AK SOFTWAE VENDO/CETIFICATION ID Software Vendor ID; Will not cause failure Insurance Segment Questions Check Claim Billing Insurance Segment Segment Identification (111-A) = Ø4 3Ø2-C2 CADHOLDE ID 312-CC CADHOLDE FIST NAE 313-CD CADHOLDE LAST NAE 524-FO PLAN ID 3Ø1-C1 GOUP ID 3Ø3-C3 PESON CODE 3Ø6-C6 PATIENT ELATIONSHIP CODE Needed for Worker s Comp and POS Eligibility Needed to identify specific multi-birth dependent. Patient Segment Questions Check Claim Billing If Situational, Patient Segment Segment Identification (111-A) = Ø1 Field NCPDP Field Name Value Payer 3Ø4-C4 DATE OF BITH Patient s Date of Birth 3Ø5-C5 31Ø-CA 311-CB PATIENT GENDE CODE PATIENT FIST NAE PATIENT LAST NAE 335-2C PEGNANCY INDICATO Claim Segment Questions Check Claim Billing This payer supports partial fills This payer does not support partial fills aterials eproduced With the Consent of Page: 2

3 Claim Segment Segment Identification (111-A) = Ø7 455-E PESCIPTION/SEVICE EFEENCE 1 = x Billing NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE NUBE 436-E1 PODUCT/SEVICE ID QUALIFIE Ø1=UPC Ø2=HI Ø3=NDC 4Ø7-D7 PODUCT/SEVICE ID 442-E7 QUANTITY DISPENSED 4Ø3-D3 FILL NUBE 4Ø5-D5 DAYS SUPPLY 4Ø6-D6 COPOUND CODE 1 = Not a Compound 2 = Compound 4Ø8-D8 DISPENSE AS WITTEN (DAW)/PODUCT 0,1,2,3,4,5,6,7,8,9 SELECTION CODE 414-DE DATE PESCIPTION WITTEN 415-DF NUBE OF EFILLS AUTHOIZED 419-DJ PESCIPTION OIGIN CODE 0,1,2,3,4,5 354-N 42Ø-DK SUBISSION CLAIFICATION CODE COUNT SUBISSION CLAIFICATION CODE aximum count of 3. 3Ø8-C8 OTHE COVEAGE CODE 0 = Unspecified 1 = No other coverage 3 = Other Coverage Billed-claim not covered 418-DI LEVEL OF SEVICE 0 = Unspecified 3= Emergency 461-EU PIO AUTHOIZATION TYPE CODE 462-EV PIO AUTHOIZATION NUBE SUBITTED 995-E2 OUTE OF ADINISTATION 996-G1 COPOUND TYPE Payer equirement: equired if Submission Clarification Code is sent. Informational; will not cause failure if not Informational; will not cause failure if not Pricing Segment Questions Check Claim Billing Pricing Segment Segment Identification (111-A) = 11 4Ø9-D9 INGEDIENT COST SUBITTED 412-DC DISPENSING FEE SUBITTED Imp Guide: equired if its value has an effect on the Gross Amount Due (43Ø-DU) 433-D PATIENT PAID AOUNT SUBITTED Imp Guide: equired if this field could result in different coverage, pricing, or patient financial responsibility. 438-E3 INCENTIVE AOUNT SUBITTED Imp Guide: equired if its value has an effect on the Gross Amount Due (43Ø-DU) 481-HA FLAT SALES TA AOUNT SUBITTED Imp Guide: equired if its value has an effect on the Gross Amount Due (43Ø-DU) aterials eproduced With the Consent of Page: 3

4 Pricing Segment Segment Identification (111-A) = GE 483-HE PECENTAGE SALES TA AOUNT SUBITTED PECENTAGE SALES TA ATE SUBITTED Imp Guide: equired if its value has an effect on the Gross Amount Due (43Ø-DU) Imp Guide: equired if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Basis Submitted (484-JE) are used. equired if this field could result in different pricing. 484-JE PECENTAGE SALES TA BASIS SUBITTED equired if needed to calculate Percentage Sales Tax Amount Paid (559-A). Imp Guide: equired if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax ate Submitted (483-HE) are used. equired if this field could result in different pricing. 426-DQ USUAL AND CUSTOAY CHAGE 43Ø-DU GOSS AOUNT DUE 423-DN BASIS OF COST DETEINATION equired if needed to calculate Percentage Sales Tax Amount Paid (559-A). Prescriber Segment Questions Check Claim Billing If Situational, Prescriber Segment Segment Identification (111-A) = Ø3 466-EZ PESCIBE ID QUALIFIE 01 = NPI, 12 = DEA, 05 = edicaid, 08 = State Lic., 14 = Plan specific, 99 = Other 411-DB PESCIBE ID 427-D PESCIBE LAST NAE 498-P PESCIBE PHONE NUBE 364-2J PESCIBE FIST NAE 367-2N PESCIBE STATE/POVINCE ADDESS 468-2E PIAY CAE POVIDE ID QUALIFIE 01 = NPI, 12 = DEA, 05 = edicaid, 08 = State Lic, 14 = Plan Specific, 99 = Other 421-DL PIAY CAE POVIDE ID 47Ø-4E PIAY CAE POVIDE LAST NAE equired if needed for Prescriber ID equired if needed for Prescriber ID equired if needed for Prescriber ID aterials eproduced With the Consent of Page: 4

5 Compound Segment Questions Check Claim Billing If Situational, This Segment is situational Only required if at least one ingredient sent and compound type in claim segment exists Compound Segment Segment Identification (111-A) = 1Ø 45Ø-EF COPOUND DOSAGE FO DESCIPTION CODE 451-EG COPOUND DISPENSING UNIT FO INDICATO 447-EC COPOUND INGEDIENT COPONENT aximum 25 ingredients COUNT 488-E COPOUND PODUCT ID QUALIFIE Ø1=UPC Ø2=HI Ø3=NDC 489-TE COPOUND PODUCT ID 448-ED COPOUND INGEDIENT QUANTITY 449-EE COPOUND INGEDIENT DUG COST 49Ø-UE COPOUND INGEDIENT BASIS OF COST DETEINATION 362-2G COPOUND INGEDIENT ODIFIE CODE COUNT aximum count of 1Ø. equired when Compound Ingredient odifier Code (363-2H) is sent H COPOUND INGEDIENT ODIFIE CODE Clinical Segment Questions Check Claim Billing If Situational, This Segment is situational This segment may be required as determined by benefit design. Clinical Segment Segment Identification (111-A) = VE DIAGNOSIS CODE COUNT aximum count of WE DIAGNOSIS CODE QUALIFIE Ø1=ICD9 424-DO DIAGNOSIS CODE aterials eproduced With the Consent of Page: 5