2019 Payer Sheet. Version 4.0 for 2019

Transcription

1 2019 Payer Sheet Version 4.0 for 2019 Effective Date: January 1, 2019

2 Contents Contents... 2 General Information... 3 BIN Information... 3 List for BIN List for BIN List for BIN List for BIN Pharmacy Help Desk Information... 3 Version Information... 6 NCPDP Version D.0 Claims Billing... 7 Request Claim Billing Payer Sheet... 7 General Information... 7 Transactions Supported... 8 Field Legend for Columns... 8 Claims Billing Transaction... 8 Response Claim Billing Payer Sheet General Information Claim Billing Accepted/Paid (or Duplicate of Paid) Response Claim Billing/Rejected Response NCPDP Version D.0 Claim Reversal Request Claim Reversal Payer Sheet General Information Field Legend for Columns Request Claim Reversal Transaction Response Claim Reversal Payer Sheet 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 BIN Number Effective as of NCPDP Version January 1, 2019 D January 1, 2019 D January 1, 2019 D January 1, 2019 D January 1, 2019 D.0 List for BIN List for BIN eridianrx Group ID Line of Business RICH N/A Commercial GVHPCOR N/A Commercial THPCD 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 RCOPSS Commercial RCOPQL Commercial CORGRP EDAVISION Commercial RCOP Commercial List for BIN Group ID Line of Business 9999 Refer to ID Card Commercial Group ID Line of Business NSCRIPT Refer to ID Card Commercial 3

4 List for BIN List for BIN Group ID Line of Business SSR Refer to ID Card Commercial Group ID Line of Business UUHPRx Refer to ID Card Commercial 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 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 4

5 RCOPQL CORGRP UUHPRx : edicaid UUHPRx: HI UUHPRx: HC UUHPRx: Employees UUHPRx: Commercial * 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. 5

6 Version Information Version Date Page Field Notes 1.0 1/1/2017 Payer Sheet for /1/2019 Payer Sheet for /1/2019 Payer Sheet for /1/2019 Payer Sheet for

7 NCPDP Version D.0 Claims Billing Request Claim Billing Payer Sheet General Information **Start of Request Claim Billing (B1) Payer Sheet ** Payer Name: eridianrx BIN: Date: January 1, 2019 THPCD (edicaid) CECOR (Commercial) RICH (Commercial) BAPCOR (Commercial) CONCORR (Commercial) CONR (Commercial) QCPR (Commercial) PERCOR (Commercial) GSR (Commercial) RCOPQL (Commercial) RCOP (Commercial) RCOPSS (Commercial) Payer Name: BIN: Date: January 1, Payer Name: BIN: Date: January 1, 2019 NSCRIPT Payer Name: BIN: Date: January 1, 2019 SSR Effective as of: January 1, 2019 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: (option 5) Other Versions Supported: None 7

8 Transactions Supported Transaction Code B1 B2 Transaction Name Claim Billing Claim Reversal Field Legend for Columns Payer Usage Column Value Explanation andatory Required Qualified Requirement R The field is mandatory for the segment in the designated transaction The field has been designated with the situation of Required for the segment in the designated transaction Required when the situations designated have qualifications for usage ( Required if x, Not required if y ) Payer Situation Column No No 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 , , , , 102-A2 VERSION/RELEASE NUBER D0 103-A3 TRANSACTION CODE B1 104-A4 PROCESSOR CONTROL NUBER Refer to table on page 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 Note: Rebill (B3) not supported Use correct for BIN/Group/Line of Business. Only one transaction allowed in a single transmission 01 = NPI 07 = NCPDP Provider ID 8

9 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 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 Required when necessary to clarify coverage 9

10 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 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 0 = Not specified 1 = Not a Compound 2 = Compound 10

11 408-D8 DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE 0-9 R 414-DE DATE PRESCRIPTION WRITTEN R 415-DF NUBER OF REFILLS AUTHORIZED R 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 mandated by law 8 = No generic in marketplace 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 11 1 = No other coverage 2 = Other coverage exists 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 For Copay Only Billing: Use value 4 when payment was not collected due to previous payers deductible Use value 3 when

12 147-U7 PHARACY SERVICE TYPE R 354-N 420-DK SUBISSION CLARIFICATION CODE COUNT SUBISSION CLARIFICATION CODE Up to 3 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 12 Claim Billing (if situational, Payer Situation) This segment is situational Required if only for secondary, tertiary, claims Claim Billing Scenario 2- Other Coordination of Benefits/Other payer-patient Payments Segment responsibility amount repetitions and (111-A) = 05 benefit stage repetitions only 337-4C COORDIATION OF aximum count BENEFITS/OTHER PAYENTS of 9 COUNT 338-5C OTHER PAYER COVERAGE TYPE C OTHER PAYER ID QUALIFIER 03 R 03 = BIN 340-7C OTHER PAYER ID R 443-E8 OTHER PAYER DATE R 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, 10 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 Required when other payer payment is made 471-5E OTHER PAYER REJECT COUNT aximum count Required when other

13 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 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 DD = Drug Drug TD = Duplicate Therapy S = Drug - Gender 440-E5 PROFESSIONAL SERVICE CODE 441-E6 RESULT OF SERVICE CODE 13

14 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 451-EG COPOUND DOSAGE FOR DESCRIPTION CODE COPOUND DISPENSING UNIT FOR INDICATOR 01-07, , 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 COST DETERINATION **End of Request Claim Billing (B1) Payer Sheet ** R R Blank = Not specified 01 = Capsule 02 = Ointment 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 14

15 Response Claim Billing Payer Sheet **Start of Response Claim Billing (B1) Payer Sheet ** General Information Payer Name: eridianrx BIN: Date: January 1, 2019 CORGRP (Commercial) CECOR (Commercial) RICH (Commercial) BAPCOR (Commercial) CONCORR (Commercial) CONR (Commercial) QCPR (Commercial) PERCOR (Commercial) GSR (Commercial) RCOPQL (Commercial) RCOP (Commercial) RCOPSS (Commercial) Payer Name: BIN: Date: January 1, Payer Name: BIN: Date: January 1, 2019 NSCRIPT Payer Name: BIN: Date: January 1, 2019 SSR Payer Name: BIN: Date: January 1, 2019 UUHPRx Effective January 1, 2019 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: (option 5) Other Versions Supported: None 15

16 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 Claim Billing Accepted/Paid (Or Duplicate of Paid) (if situational, Payer Situation) Claim Billing Response Transaction Header Accepted/Paid (or Segment Duplicate of Paid) 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 01 = NPI 01, 07 QUALIFIER 07 = NCPDP 201-B1 SERVICE PROVIDER ID 401-D1 DATE OF SERVICE Response essage Header Segment Claim Billing Accepted/Paid (Or Duplicate of Questions Paid) (if situational, Payer Situation) This segment is situational When additional text is required for clarification or detail Response essage Segment (111-A) = 20 Claim Billing Accepted/Paid (or Duplicate of Paid) 504-F4 ESSAGE R Response Insurance Header Segment Claim Billing Accepted/Paid (Or Duplicate of Questions Paid) (if situational, Payer Situation) This segment is situational Returned with Cardholder ID differs from Cardholder ID submitted Response Insurance Segment (111-A) = 25 Claim Billing Accepted/Paid (or Duplicate of Paid) 302-C2 CARDHOLDER ID R 16

17 Response Status Segment Questions Claim Billing Accepted/Paid (Or Duplicate of Paid) (if situational, Payer Situation) Response Status Segment (111-A) = 21 Claim Billing Accepted/Paid (or Duplicate of Paid) 112-AN P=Paid TRANSACTION RESPONSE D=Duplicate of STATUS 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 Claim Billing Accepted/Paid (or Duplicate of Paid) 455-E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 1 = Rx Billing 402-D2 PRESCRIPTION/SERVICE REFERENCE NUBER Response Pricing Segment Questions Claim Billing Accepted/Paid (Or Duplicate of Paid) (if situational, Payer Situation) Response Pricing Segment (111-A) = 23 Claim Billing 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 17 Required when ingredient cost paid (506- F6) is greater than zero Returned when applicable

18 518-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 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 Response Pricing Segment Questions Claim Billing Accepted/Paid (Or Duplicate of Paid) (if situational, Payer Situation) Response Pricing Segment (111-A) = 23 Claim Billing 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 Claim Billing Accepted/Paid (or (111-A) = 24 Duplicate of Paid) 567-J6 aximum 9 Required when reason DUR/PPS RESPONSE CODE occurrences for service code (439-E4) COUNTER supported is used 18

19 439-E4 REASON FOR SERVICE CODE Required when utilization conflict is detected 528-FS CLINICAL SIGNIFICANCE CODE Blank, 1,2,3,9 Required when necessary to provide additional information on utilization conflict 529-FT OTHER PHARACY INDICATOR Required when necessary to provide additional information on utilization conflict 530-FU PREVIOUS DATE OF FILL Required when necessary to provide additional information on utilization conflict 531-FV QUANTITY OF PREVIOUS FILL Required when necessary to provide additional information on utilization conflict 532-FW DATABASE INDICATOR Required when necessary to provide additional information on utilization conflict 533-F OTHER PRESCRIBER INDICATOR Required when necessary to provide additional information on utilization conflict 544-FY DUR FREE TET ESSAGE Required when necessary to provide additional information on utilization conflict 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) = NS DUR ADDITIONAL TET Claim Billing Accepted/Paid (or Duplicate of Paid) Required when necessary to provide additional information on utilization conflict 19

20 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 Claim Billing 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 20

21 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 Claim Billing Accepted/Rejected Questions (if situational, Payer Situation) Response Transaction Header Segment Claim Billing 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 Claim Billing Accepted/Rejected 504-F4 ESSAGE R Response Claim Segment Questions Claim Billing Accepted/Rejected (if situational, Payer Situation) Response Claim Segment Claim Billing Accepted/Rejected (111-A) = 22 Imp Guide: For transaction code of B1, in the response 455-E PRESCRIPTION/SERVICE claim segment, the 1 = Rx Billing REFERENCE NUBER QUALIFIER prescription/service reference number qualifier (455-E) is 1 (Rx Billing) 402-D2 PRESCRIPTION/SERVICE REFERENCE NUBER 21

22 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 Claim Billing Accepted/Rejected aximum 9 Required when reason DUR/PPS RESPONSE CODE 567-J6 occurrences for service code (439-E4) COUNTER supported is used 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 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 ** Required when utilization conflict is detected Required when necessary to provide additional information on utilization conflict Required when necessary to provide additional information on utilization conflict Required when necessary to provide additional information on utilization conflict Required when necessary to provide additional information on utilization conflict Required when necessary to provide additional information on utilization conflict Required when necessary to provide additional information on utilization conflict Required when necessary to provide additional information on utilization conflict Required when necessary to provide additional information on utilization conflict 22

23 NCPDP Version D.0 Claim Reversal Request Claim Reversal Payer Sheet **Start of Request Claim Reversal (B2) Payer Sheet ** General Information Payer Name: eridianrx BIN: Date: January 1, 2019 CORGRP ( Commercial) CECOR (Commercial) RICH (Commercial) BAPCOR (Commercial) CONCORR (Commercial) CONR (Commercial) QCPR (Commercial) PERCOR (Commercial) GSR (Commercial) RCOPQL (Commercial) RCOP (Commercial) RCOPSS (Commercial) Payer Name: BIN: Date: January 1, Payer Name: BIN: Date: January 1, 2019 NSCRIPT Payer Name: BIN: Date: January 1, 2019 SSR Payer Name: BIN: Date: January 1, 2019 SSR Effective as of: January 1, 2019 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: (option 5) Other Versions Supported: None 23

24 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 ) 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 24

25 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 , , , , 102-A2 VERSION/RELEASE NUBER D0 103-A3 TRANSACTION CODE B2 301-C1 GROUP ID R As printed on the ID card or as 104-A4 PROCESSOR CONTROL NUBER Refer to table on page 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 communicated Use correct for BIN/Group/Line of Business 01 = NPI 07 = NCPDP Insurance Segment Questions Claim Reversal (if situational, Payer Situation) Insurance Segment (111-A) = 04 Claim Reversal 302-C2 CARDHOLDER ID 25

26 Claim Segment Questions Claim Reversal (if situational, Payer Situation) Claim Segment (111-A) = 07 Claim Reversal 455-E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 01=Rx Billing 402-D2 PRESCRIPTION/SERVICE REFERENCE NUBER 436-E1 PRODUCT/SERVICE ID QUALIFIER 03 National Drug Code 00 ulti- Ingredient Compound 407-D7 PRODUCT/SERVICE ID Valid NDC or 0 if original claim was for a multiingredient compound **End of Request Claim Reversal (B2) Payer Sheet ** ust contain product/service ID from original prescription billing 26

27 Response Claim Reversal Payer Sheet **Start of Claim Reversal Response (B2) Payer Sheet ** General Information Payer Name: eridianrx BIN: Date: January 1, 2019 edavision CORGRP (Commercial) Caidan anagement Company CECOR (Commercial) eridian Commercial /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) RCOP (Commercial) Payer Name: BIN: Date: January 1, Payer Name: BIN: Date: January 1, 2019 NSCRIPT Payer Name: BIN: Date: January 1, 2019 SSR Payer Name: Refer to ember ID Card BIN: Date: January 1, 2019 UUHPRx Effective as of: January 1, 2019 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: (option 5) Other Versions Supported: None Claim Reversal Accepted/Rejected Response 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 27 Claim Reversal Accepted/Approved (if situational, Payer Situation)

28 Response Transaction Header Segment Claim Reversal 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 202-B2 SERVICE PROVIDER ID QUALIFIER 01, B1 SERVICE PROVIDER ID 401-D1 DATE OF SERVICE R = Rejected 01 = NPI 07 = NCPDP Response essage Header Segment Questions This segment is situational Response essage Segment (111-A) = 20 Claim Reversal Accepted/Approved (if situational, Payer Situation) Required when necessary to clarify reversal 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 = Rx Billing 402-D2 PRESCRIPTION/SERVICE REFERENCE NUBER **End of Claim Reversal Response (B2) Payer Sheet ** 28