Version 1.2 for 2Ø15

Transcription

1 MERIDIANRx 2Ø15 Payer Sheet NCPDP Version D.Ø Version 1.2 for 2Ø15 Release Date: May 28, 2Ø15 Effective Date: January 1, 2Ø15

2 Contents GENERAL INFORMATION... 3 BIN INFORMATION... 3 PCN LIST FOR BIN 61Ø PCN LIST FOR BIN Ø17Ø76 PBA-R... 3 PHARMACY HELP DESK INFORMATION:... 4 VERSION INFORMATION... 5 NCPDP VERSION D.Ø CLAIM BILLING TEMPLATE... 6 REQUEST CLAIM BILLING PAYER SHEET TEMPLATE... 6 General Information... 6 Transactions Supported... 6 Field Legend for Columns... 6 Claim 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.Ø 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 MeridianRx MEDICARE serviced plans, please refer to the MEDICARE payer sheet available on the Documents and Forms page of our website: MeridianRx_2015_Payer_Sheet_v1.2 2 May 28, 2Ø15

3 General Information BIN Information Payer/Processor Name: BIN Number: Effective as of: NCPDP Version: MeridianRx 61Ø241 January Ø1, 2Ø15 D.Ø PBA-Rx Ø17Ø76 January Ø1, 2Ø15 D.Ø PCN List for BIN 61Ø241 Meridian Health Plan - Medicaid HPMMCD Meridian Health Plan of Michigan Medicaid Meridian Health Plan of Michigan Medicaid MHPILMCD Meridian Health Plan of Illinois Medicaid Meridian Health Plan of Illinois Medicaid MHPNHMCD Meridian Health Plan of New Hampshire Medicaid MeridianRx Meridian Health Plan of New Hampshire Medicaid GVHPCOR Grand Valley Health Plan Commercial Grand Valley Health Plan MRMIMCH Meridian Choice/Bronson Health Commercial Meridian Choice/Bronson Health Exchange for Michigan THPMCD Trusted Health Medicaid Medicaid Trusted Health Medicaid Washington, DC BAPMCOR Bridgestone Commercial Bridgestone CMEMCOR Caidan Management Company Commercial Commercial pharmacy benefit plan for Caidan Management Company. CONCORR CONR Concierge Corrections Concierge Rx Commercial Refer to Member ID card for plan information QCPR Quality Care Partners Commercial Refer to Member ID card for plan information PERCOR PERRY protech Commercial Refer to Member ID card for plan information GMSR Group Management Services (GMS) Commercial Refer to Member ID card for plan information PCN List for BIN Ø17Ø76 PBA-Rx PBA-Rx 9999 IBEW Local 617 Commercial IBEW Local Health & Welfare Trust Fund MeridianRx_2015_Payer_Sheet_v1.2 3 May 28, 2Ø15

4 Pharmacy Help Desk Information: Inquiries to MeridianRx may be directed to our 24 Hour Pharmacy Assistance Center**. All calls are toll free. Meridian Health Plan - Medicaid Michigan Phone Fax Meridian Health Plan of Michigan Ø7Ø info@meridianrx.com Illinois Phone Fax Meridian Health Plan of Illinois Ø-1688 Toll-free: Ø-1695 info@meridianrx.com Local: MeridianRx Meridian Choice Phone Fax Meridian Choice/Bronson Health System (855) info@meridianrx.com Trusted Health Plan Phone Fax Washington DC info@meridianrx.com Medicaid Grand Valley Health Plan Phone Fax Michigan Ø info@gvhp.com Bridgestone Phone Fax Ohio/Tennessee info@meridianrx.com Caidan Management Phone Fax Caidan Management Company** cmcpharmacyteam@meridianrx.com Concierge Phone Fax Concierge Corrections Concierge Rx 517-9Ø Ø Ø8 m.white@conciergecorrections.com s.carrier@concierge-rx.com Perry Corporation Phone Fax Perry protech Ø Ø236 QCP Phone Fax Quality Care Partners Ø Ø232 GMS Phone Fax Group Management Services (GMS) Ø Ø197 info@meridianrx.com PBA-Rx IBEW Local 617 Phone Fax Commercial 877-2ØØ info@meridianrx.com ** Caidan Management Company phone operation hours are: Monday thru Friday: 8am to 1Øpm Saturday & Sunday: 1Øam to 6:3Øpm All times US Eastern Standard. MeridianRx_2015_Payer_Sheet_v1.2 4 May 28, 2Ø15

5 Version Information VER. DATE PAGE FIELD NOTES 1.Ø 12/Ø1/2Ø14 Payer Sheet Release for 2Ø Ø4/Ø1/2Ø15 Various Various Added ConciergeRx PCN and associated information. 1.2 Ø6/Ø1/2Ø15 Various Various Added GMS PCN and associated information. MeridianRx_2015_Payer_Sheet_v1.2 5 May 28, 2Ø15

6 NCPDP VERSION D.Ø Claim Billing Template Request Claim Billing Payer Sheet Template ** Start of Request Claim Billing (B1) Payer Sheet Template** General Information Payer Name: MeridianRx BIN: 61Ø241 Date: January Ø1, 2Ø15 Plan Name/Group Name PCN Meridian Health Plan of Michigan HPMMCD (Medicaid) Meridian Health Plan of Illinois Medicaid MHPILMCD (Medicaid) Meridian Health Plan of New Hampshire MHPNHMCD (Medicaid) Trusted Health Plan Washington DC Medicaid THPMCD (Medicaid) Caidan Management Company CMEMCOR (Commercial) Meridian Choice/Bronson Health MRMIMCH (Commercial) Bridgestone BAPMCOR (Commercial) Concierge Corrections Concierge Rx CONCORR (Commercial) CONR (Commercial) QCP QCPR (Commercial) Perry Corporation PERCOR (Commercial) Group Management Services GMSR (Commercial) Payer Name: PBA-Rx BIN: Ø17Ø76 Date: January Ø1, 2Ø15 Plan Name/Group Name PCN IBEW Local (Commercial) Effective as of: January 1, 2Ø15 NCPDP Telecommunication Standard Version/Release #: D.Ø NCPDP Data Dictionary Version Date: March 2Ø1Ø NCPDP External Code List Version Date: March 2Ø1Ø Contact/Information Source: MeridianRx 1ØØ1 Woodward Avenue, Suite 7ØØ, Detroit, MI Provider Relations Help Desk Info: Other versions supported: None Transactions Supported Transaction Code B1 B2 Field Legend for Columns Payer Column Transaction Name Claim Billing Claim Reversal Value Explanation Column MANDATORY M 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 QUALIFIED REQUIREMENT RW Required when the situations designated have qualifications for usage ("Required if x", "Not required if y") No Yes MeridianRx_2015_Payer_Sheet_v1.2 6 May 28, 2Ø15

7 Claim Billing Transaction The following lists the segments and fields in a Claim Billing Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Transaction Header Segment Questions Check Claim Billing Transaction Header Segment Claim Billing 1Ø1-A1 BIN NUMBER 61Ø241, Ø17Ø76 M 1Ø2-A2 VERSION/RELEASE NUMBER DØ M 1Ø3-A3 TRANSACTION CODE B1 M Note: Rebill (B3) not supported 1Ø4-A4 PROCESSOR CONTROL NUMBER Refer to PCN table on page 3. M Use correct PCN for BIN/Group/Line of Business. 1Ø9-A9 TRANSACTION COUNT 1 M Only one Transaction allowed in a single transmission 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1, Ø7 M Ø1 = NPI Ø7 = NCPDP Provider ID 2Ø1-B1 SERVICE PROVIDER ID M 4Ø1-D1 DATE OF SERVICE M 11Ø-AK SOFTWARE VENDOR/CERTIFICATION ID BLANKS M Insurance Segment Questions Check Claim Billing Insurance Segment Segment Identification (111-AM) = Ø4 3Ø2-C2 CARDHOLDER ID M Claim Billing 312-CC CARDHOLDER FIRST NAME RW Required for Caidan Management 313-CD CARDHOLDER LAST NAME RW Required for Caidan Management 3Ø6-C6 PATIENT RELATIONSHIP CODE RW Required for Caidan Management Patient Segment Questions Check Claim Billing Patient Segment Segment Identification (111-AM) = Ø1 Field NCPDP Field Name Value Payer 3Ø4-C4 DATE OF BIRTH R 3Ø5-C5 PATIENT GENDER CODE 1, 2 R 31Ø-CA PATIENT FIRST NAME R 311-CB PATIENT LAST NAME R 322-CM PATIENT STREET ADDRESS R 323-CN PATIENT CITY ADDRESS R 324-CO PATIENT STATE / PROVINCE ADDRESS R 325-CP PATIENT ZIP/POSTAL ZONE R Claim Billing 3Ø7-C7 PLACE OF SERVICE RW Required for Home Infusion and LTC patients 35Ø-HN PATIENT ADDRESS RW For informational purposes only PATIENT RESIDENCE RW Required when necessary to clarify coverage. MeridianRx_2015_Payer_Sheet_v1.2 7 May 28, 2Ø15

8 Claim Segment Questions Check Claim Billing Claim Segment Claim Billing Segment Identification (111-AM) = Ø7 455-EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER Ø1 = Rx Billing M Imp Guide: For Transaction Code of B1, in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is 1 (Rx Billing). 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE M NUMBER 436-E1 PRODUCT/SERVICE ID QUALIFIER Ø3 M NDC Number 4Ø7-D7 PRODUCT/SERVICE ID M MMMMM = Manufacturer assigned number DDDD = Drug ID PP = Package size Zero filled if product is a Compound. 442-E7 QUANTITY DISPENSED R 4Ø3-D3 FILL NUMBER R 4Ø5-D5 DAYS SUPPLY R 4Ø6-D6 COMPOUND CODE Ø, 1, 2 R Ø = Not specified 1 = Not a Compound 2 = Compound 4Ø8-D8 DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE 414-DE DATE PRESCRIPTION WRITTEN R 415-DF NUMBER OF REFILLS AUTHORIZED R Ø thru 9 R Ø = 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 419-DJ PRESCRIPTION ORIGIN CODE 1,2,3,4 R 1 = Written 2 = Telephone 3 = Electronic 4 = Facsimile 3Ø8-C8 OTHER COVERAGE CODE Ø, 1, 2, 3, 4, 8 R Ø = Not Specified 1 = No other coverage identified 2 = Other coverage exists payment collected. 3 = Other coverage exists this claim not covered. 4 = Other coverage exists payment not collected 8 = Claim is billing for copay only 147-U7 PHARMACY SERVICE TYPE R 354-N SUBMISSION CLARIFICATION CODE COUNT 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 Up to 3 RW Field is Required when Patient Residence (384-4) = 3 Field is Required for 34ØB Claim Submissions 42Ø-DK SUBMISSION CLARIFICATION CODE RW Field is Required when Patient Residence (384-4) = 3 Value 2Ø Required for 34ØB Claim Submissions MeridianRx_2015_Payer_Sheet_v1.2 8 May 28, 2Ø15

9 Pricing Segment Questions Check Claim Billing Pricing Segment Segment Identification (111-AM) = 11 4Ø9-D9 INGREDIENT COST SUBMITTED R 412-DC DISPENSING FEE SUBMITTED R Claim Billing 438-E3 INCENTIVE AMOUNT SUBMITTED RW Required when applicable 426-DQ USUAL AND CUSTOMARY CHARGE R 43Ø-DU GROSS AMOUNT DUE R Prescriber Segment Questions Check Claim Billing Prescriber Segment Claim Billing Segment Identification (111-AM) = Ø3 466-EZ PRESCRIBER ID QUALIFIER Ø1, 12 R Ø1 = NPI 12 = DEA 411-DB PRESCRIBER ID R Coordination of Benefits/Other Payments Segment Check Claim Billing Questions This Segment is situational Required only for secondary, tertiary, claims. Coordination of Benefits/Other Payments Segment Segment Identification (111-AM) = Ø5 Claim Billing 337-4C COORDIATION OF BENEFITS/OTHER Maximum count of 9. M PAYMENTS COUNT 338-5C OTHER PAYER COVERAGE TYPE Ø1 thru Ø9 M 339-6C OTHER PAYER ID QUALIFIER Ø3 R Ø3 = BIN 34Ø-7C OTHER PAYER ID R 443-E8 OTHER PAYER DATE R Scenario 2- Other Payer-Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only 341-HB OTHER PAYER AMOUNT PAID COUNT Maximum of 9 RW Required when 431-DV is used 342-HC OTHER PAYER AMOUNT PAID QUALIFIER Ø1, Ø2, Ø3, Ø4, Ø5, Ø6, Ø7, Ø9 RW Required when 431-DV is used Ø1 Delivery Ø2 Shipping Ø3 Postage Ø4 Admin Ø5 Incentive Ø6 Cognitive Ø7 Drug Benefit Ø9 Compound Prep 431-DV OTHER PAYER AMOUNT PAID RW Required when other payer payment is made 471-5E OTHER PAYER REJECT COUNT Maximum count of 5. RW Required when Other Coverage Code (3Ø8- C8) = E OTHER PAYER REJECT CODE 6Ø, 61, 65, 66, 67, 68, 69, 7Ø, 76, AA, M1, RN RW Required when Other Coverage Code (3Ø8- C8) = NR OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT Maximum count of 25. RW Required when Other Coverage Code (3Ø8- C8) = NP 352-NQ OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT Ø1, Ø2, Ø4, Ø5, Ø6, Ø7, Ø8, Ø9, 11 RW RW Required when Other Coverage Code (3Ø8- C8) = 8 Required when Other Coverage Code (3Ø8- C8) = 8 MeridianRx_2015_Payer_Sheet_v1.2 9 May 28, 2Ø15

10 DUR/PPS Segment Questions Check Claim Billing This Segment is situational When necessary to provide information on potential drug interactions DUR/PPS Segment Segment Identification (111-AM) = Ø E DUR/PPS CODE COUNTER Maximum of 9 occurrences RW Claim Billing 439-E4 REASON FOR SERVICE CODE DD, TD, S RW DD = Drug Drug TD = Duplicate Therapy S = Drug - Gender 44Ø-E5 PROFESSIONAL SERVICE CODE RW 441-E6 RESULT OF SERVICE CODE RW Compound Segment Questions Check Claim Billing This Segment is situational For billing of compound medications. Compound Segment Segment Identification (111-AM) = 1Ø 45Ø-EF COMPOUND DOSAGE FORM Ø1 - Ø7, M DESCRIPTION CODE 1Ø EG COMPOUND DISPENSING UNIT FORM INDICATOR Claim Billing Blank = Not Specified Ø1 = Capsule Ø2 = Ointment Ø3 = Cream Ø4 = Suppository Ø5 = Powder Ø6 = Emulsion Ø7 = Liquid 1Ø = Tablet 11 = Solution 12 = Suspension 13 = Lotion 14 = Shampoo 15 = Elixir 16 = Syrup 17 = Lozenge 1, 2, 3 M 1 = Each 2 = Grams 3 = Milliliters Maximum 25 ingredients M 447-EC COMPOUND INGREDIENT COMPONENT COUNT 488-RE COMPOUND PRODUCT ID QUALIFIER M 489-TE COMPOUND PRODUCT ID M 448-ED COMPOUND INGREDIENT QUANTITY M 449-EE COMPOUND INGREDIENT DRUG COST R Enter ingredient cost for each product in the compound 49Ø-UE COMPOUND INGREDIENT BASIS OF COST DETERMINATION R ** End of Request Claim Billing (B1) Payer Sheet Template** MeridianRx_2015_Payer_Sheet_v May 28, 2Ø15

11 Response Claim Billing Payer Sheet Template ** Start of Response Claim Billing (B1) Payer Sheet Template** General Information Payer Name: MeridianRx BIN: 61Ø241 Date: January Ø1, 2Ø15 Plan Name/Group Name PCN Meridian Health Plan of Michigan HPMMCD (Medicaid) Meridian Health Plan of Illinois Medicaid MHPILMCD (Medicaid) Meridian Health Plan of New Hampshire MHPNHMCD (Medicaid) Trusted Health Plan Washington DC Medicaid THPMCD (Medicaid) Caidan Management Company CMEMCOR (Commercial) Meridian Choice/Bronson Health MRMIMCH (Commercial) Bridgestone BAPMCOR (Commercial) Concierge Corrections Concierge Rx CONCORR (Commercial) CONR (Commercial) QCP QCPR (Commercial) Perry Corporation PERCOR (Commercial) Group Management Services GMSR (Commercial) Payer Name: PBA-Rx BIN: Ø17Ø76 Date: January Ø1, 2Ø15 Plan Name/Group Name PCN IBEW Local (Commercial) Effective as of: January 1, 2Ø15 NCPDP Telecommunication Standard Version/Release #: D.Ø NCPDP Data Dictionary Version Date: March 2Ø1Ø NCPDP External Code List Version Date: March 2Ø1Ø Contact/Information Source: MeridianRx 1ØØ1 Woodward Avenue, Suite 7ØØ, Detroit, MI 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.Ø. Response Transaction Header Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of Paid) Response Transaction Header Segment Claim Billing - Accepted/Paid (or Duplicate of Paid) 1Ø2-A2 VERSION/RELEASE NUMBER DØ M 1Ø3-A3 TRANSACTION CODE B1 M Note: Rebill (B3) not supported 1Ø9-A9 TRANSACTION COUNT 1 M Only one transaction per transmission 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted M 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1, Ø7 M Ø1 = NPI Ø7 = NCPDP 2Ø1-B1 SERVICE PROVIDER ID M 4Ø1-D1 DATE OF SERVICE M Response Message Header Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of Paid) This Segment is situational When additional text is required for clarification or detail Response Message Segment Segment Identification (111-AM) = 2Ø 5Ø4-F4 MESSAGE R Claim Billing - Accepted/Paid (or Duplicate of Paid) MeridianRx_2015_Payer_Sheet_v May 28, 2Ø15

12 Response Insurance Header Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of Paid) This Segment is situational Returned when Cardholder ID differs from Cardholder ID Submitted. Response Insurance Segment Segment Identification (111-AM) = 25 3Ø2-C2 CARDHOLDER ID R Claim Billing Accepted/Paid (or Duplicate of Paid) Response Status Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of Paid) Response Status Segment Segment Identification (111-AM) = AN TRANSACTION RESPONSE STATUS P=Paid M D=Duplicate of Paid 5Ø3-F3 AUTHORIZATION NUMBER R Claim Billing Accepted/Paid (or Duplicate of Paid) Response Claim Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of Paid) Response Claim Segment Segment Identification (111-AM) = EM PRESCRIPTION/SERVICE REFERENCE 1 = RxBilling M NUMBER QUALIFIER 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER M Claim Billing Accepted/Paid (or Duplicate of Paid) Response Pricing Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of Paid) Response Pricing Segment Segment Identification (111-AM) = 23 Claim Billing Accepted/Paid (or Duplicate of Paid) 5Ø5-F5 PATIENT PAY AMOUNT R 5Ø6-F6 INGREDIENT COST PAID R 5Ø7-F7 DISPENSING FEE PAID R 557-AV TA EEMPT INDICATOR Ø4 R Ø4 = Neither Payer/Plan nor Patient are liable for tax 521-FL INCENTIVE AMOUNT PAID RW Required when Professional Service Code = MA 566-J5 OTHER PAYER AMOUNT RECOGNIZED RW Required when Other Coverage Code = 2, 3, 4 5Ø9-F9 TOTAL AMOUNT PAID R 522-FM BASIS OF REIMBURSEMENT DETERMINATION RW Required when Ingredient Cost Paid (5Ø6- F6) is greater than zero 517-FH AMOUNT APPLIED TO PERIODIC RW Returned when applicable DEDUCTIBLE 518-FI AMOUNT OF COPAY RW Returned when applicable 572-4U AMOUNT OF COINSURANCE RW Returned when applicable 392-MU BENEFIT STAGE COUNT Maximum count of 4 RW Returned when applicable 393-MV BENEFIT STAGE QUALIFIER RW Returned when applicable 394-MW BENEFIT STAGE AMOUNT RW Returned when applicable 133-UJ AMOUNT ATTRIBUTED TO PROVIDER RW Returned when applicable NETWORK SELECTION 134-UK AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG RW Returned when applicable MeridianRx_2015_Payer_Sheet_v May 28, 2Ø15

13 Response Pricing Segment Segment Identification (111-AM) = UM AMOUNT ATTRIBUTED TO PRODUCT RW SELECTION/NON-PREFERRED FORMULARY SELECTION 136-UN AMOUNT ATTRIBUTED TO PRODUCT RW SELECTION/BRAND NON-PREFERRED FORMULARY SELECTION 137-UP AMOUNT ATTRIBUTED TO COVERAGE RW GAP 148-U8 INGREDIENT COST RW CONTRACTED/REIMBURSABLE AMOUNT 149-U9 DISPENSING FEE RW CONTRACTED/REIMBURSABLE AMOUNT Claim Billing Accepted/Paid (or Duplicate of Paid) Returned when applicable Returned when applicable Returned when applicable Required when Other Coverage Code (3Ø8- C8) = 2 or 8 Required when Other Coverage Code (3Ø8- C8) = 2 or 8 Response DUR/PPS Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of Paid) This Segment is situational Required when DUR warning is indicated. Response DUR/PPS Segment Segment Identification (111-AM) = 24 Claim Billing Accepted/Paid (or Duplicate of Paid) 567-J6 DUR/PPS RESPONSE CODE COUNTER Maximum 9 occurrences supported RW Required when Reason For Service Code (439-E4) is used. 439-E4 REASON FOR SERVICE CODE RW Required when utilization conflict is detected 528-FS CLINICAL SIGNIFICANCE CODE Blank, 1,2,3 9 RW Required when necessary to provide additional information on utilization conflict. 529-FT OTHER PHARMACY INDICATOR RW Required when necessary to provide additional information on utilization conflict. 53Ø-FU PREVIOUS DATE OF FILL RW Required when necessary to provide additional information on utilization conflict. 531-FV QUANTITY OF PREVIOUS FILL RW Required when necessary to provide additional information on utilization conflict. 532-FW DATABASE INDICATOR RW Required when necessary to provide additional information on utilization conflict. 533-F OTHER PRESCRIBER INDICATOR RW Required when necessary to provide additional information on utilization conflict. 544-FY DUR FREE TET MESSAGE RW Required when necessary to provide additional information on utilization conflict. 57Ø-NS DUR ADDITIONAL TET RW Required when necessary to provide additional information on utilization conflict. MeridianRx_2015_Payer_Sheet_v May 28, 2Ø15

14 Response Coordination of Benefits/Other Payers Segment Questions Check Claim Billing Accepted/Paid (or Duplicate of Paid) This Segment is situational For claims where other payer information is indicated Response Coordination of Benefits/Other Payers Segment Segment Identification (111-AM) = 28 Claim Billing Accepted/Paid (or Duplicate of Paid) 355-NT OTHER PAYER ID COUNT Maximum count of 3 M 338-5C OTHER PAYER COVERAGE TYPE M 339-6C OTHER PAYER ID QUALIFIER RW Required when secondary coverage is indicated for the member. 34Ø-7C OTHER PAYER ID RW Required when secondary coverage is indicated for the member. 991-MH OTHER PAYER PROCESSOR CONTROL NUMBER RW Required when secondary coverage is indicated for the member. 356-NU OTHER PAYER CARDHOLDER ID RW Required when secondary coverage is indicated for the member. 992-MJ OTHER PAYER GROUP ID RW Required when secondary coverage is indicated for the member. 142-UV OTHER PAYER PERSON CODE RW Required when secondary coverage is indicated for the member. 127-UB OTHER PAYER HELP DESK PHONE RW For informational purposes NUMBER 143-UW OTHER PAYER PATIENT RELATIONSHIP RW For informational purposes CODE 144-U OTHER PAYER BENEFIT EFFECTIVE RW For informational purposes DATE 145-UY OTHER PAYER BENEFIT TERMINATION DATE RW For informational purposes MeridianRx_2015_Payer_Sheet_v May 28, 2Ø15

15 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.Ø. Response Transaction Header Segment Questions Check Claim Billing - Accepted/Rejected Response Transaction Header Segment Claim Billing - Accepted/Rejected 1Ø2-A2 VERSION/RELEASE NUMBER DØ M 1Ø3-A3 TRANSACTION CODE B1 M Note: Rebill (B3) not supported 1Ø9-A9 TRANSACTION COUNT 1 M Only one transaction per transmission. 5Ø1-F1 HEADER RESPONSE STATUS R = Rejected M 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Same value as in request M 2Ø1-B1 SERVICE PROVIDER ID Same value as in request M 4Ø1-D1 DATE OF SERVICE Same value as in request M Response Message Segment Questions Check Claim Billing - Accepted/Rejected This Segment is situational When required to clarify response Response Message Segment Segment Identification (111-AM) = 2Ø 5Ø4-F4 MESSAGE R Claim Billing - Accepted/Rejected Response Claim Segment Questions Check Claim Billing - Accepted/Rejected Response Claim Segment Claim Billing - Accepted/Rejected Segment Identification (111-AM) = EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER 1 = RxBilling M Imp Guide: For Transaction Code of B1, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is 1 (Rx Billing) 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER M MeridianRx_2015_Payer_Sheet_v May 28, 2Ø15

16 Response DUR/PPS Segment Questions Check Claim Billing - Accepted/Rejected This Segment is situational When DUR warning is indicated Response DUR/PPS Segment Claim Billing - Accepted/Rejected Segment Identification (111-AM) = J6 DUR/PPS RESPONSE CODE COUNTER Maximum 9 occurrences supported RW Required when Reason For Service Code (439-E4) is used 439-E4 REASON FOR SERVICE CODE RW Required when utilization conflict is detected 528-FS CLINICAL SIGNIFICANCE CODE Blank, 1,2,3,9 RW Required when necessary to provide additional information on utilization conflict 529-FT OTHER PHARMACY INDICATOR RW Required when necessary to provide additional information on utilization conflict 53Ø-FU PREVIOUS DATE OF FILL RW Required when necessary to provide additional information on utilization conflict 531-FV QUANTITY OF PREVIOUS FILL RW Required when necessary to provide additional information on utilization conflict 532-FW DATABASE INDICATOR 1= First Databank 2=Medispan RW Required when necessary to provide additional information on utilization conflict 533-F OTHER PRESCRIBER INDICATOR RW Required when necessary to provide additional information on utilization conflict 544-FY DUR FREE TET MESSAGE RW Required when necessary to provide additional information on utilization conflict 57Ø-NS DUR ADDITIONAL TET RW Required when necessary to provide additional information on utilization conflict ** End of Response Claim Billing (B1) Payer Sheet Template** MeridianRx_2015_Payer_Sheet_v May 28, 2Ø15

17 NCPDP Version D.Ø Claim Reversal Template Request Claim Reversal Payer Sheet Template ** Start of Request Claim Reversal (B2) Payer Sheet Template** General Information Payer Name: MeridianRx BIN: 61Ø241 Date: January Ø1, 2Ø15 Plan Name/Group Name PCN Meridian Health Plan of Michigan HPMMCD (Medicaid) Meridian Health Plan of Illinois Medicaid MHPILMCD (Medicaid) Meridian Health Plan of New Hampshire MHPNHMCD (Medicaid) Trusted Health Plan Washington DC Medicaid THPMCD (Medicaid) Caidan Management Company CMEMCOR (Commercial) Meridian Choice/Bronson Health MRMIMCH (Commercial) Bridgestone BAPMCOR (Commercial) Concierge Corrections Concierge Rx CONCORR (Commercial) CONR (Commercial) QCP QCPR (Commercial) Perry Corporation PERCOR (Commercial) Group Management Services GMSR (Commercial) Payer Name: PBA-Rx BIN: Ø17Ø76 Date: January Ø1, 2Ø15 Plan Name/Group Name PCN IBEW Local (Commercial) Effective as of: January 1, 2Ø15 NCPDP Telecommunication Standard Version/Release #: D.Ø NCPDP Data Dictionary Version Date: March 2Ø1Ø NCPDP External Code List Version Date: March 2Ø1Ø Contact/Information Source: MeridianRx 1ØØ1 Woodward Avenue, Suite 7ØØ, Detroit, MI Provider Relations Help Desk Info: Other versions supported: None Field Legend for Columns Payer Value Explanation Column MANDATORY M 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 RW Required when the situations designated have qualifications for usage Question What is your reversal window? (If transaction is billed today what is the timeframe for reversal to be submitted?) Answer 6Ø Days from 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.Ø. Transaction Header Segment Questions Check Claim Reversal Transaction Header Segment Claim Reversal 1Ø1-A1 BIN NUMBER 61Ø241, Ø17Ø76 M 1Ø2-A2 VERSION/RELEASE NUMBER DØ M 1Ø3-A3 TRANSACTION CODE B2 M 1Ø4-A4 PROCESSOR CONTROL NUMBER Refer to PCN table on page 3. M Use correct PCN for BIN/Group/Line of Business 1Ø9-A9 TRANSACTION COUNT 1 M 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1, Ø7 M Ø1 = NPI Ø7 = NCPDP 2Ø1-B1 SERVICE PROVIDER ID M 4Ø1-D1 DATE OF SERVICE M 11Ø-AK SOFTWARE VENDOR/CERTIFICATION ID Blanks M MeridianRx_2015_Payer_Sheet_v May 28, 2Ø15

18 Insurance Segment Questions Check Claim Reversal Insurance Segment Segment Identification (111-AM) = Ø4 3Ø2-C2 CARDHOLDER ID M Claim Reversal Claim Segment Questions Check Claim Reversal Claim Segment Segment Identification (111-AM) = Ø7 455-EM PRESCRIPTION/SERVICE REFERENCE Ø1=RxBilling M NUMBER QUALIFIER 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE M NUMBER 436-E1 PRODUCT/SERVICE ID QUALIFIER Ø3 National Drug Code M ØØ Multi-Ingredient Compound 4Ø7-D7 PRODUCT/SERVICE ID Valid NDC M or Ø if original claim was for a multi-ingredient compound Claim Reversal Must contain product/service ID from original prescription billing ** End of Request Claim Reversal (B2) Payer Sheet Template** MeridianRx_2015_Payer_Sheet_v May 28, 2Ø15

19 Response Claim Reversal Payer Sheet Template **Start of Claim Reversal Response (B2) Payer Sheet Template** General Information Payer Name: MeridianRx BIN: 61Ø241 Date: January Ø1, 2Ø15 Plan Name/Group Name PCN Meridian Health Plan of Michigan HPMMCD (Medicaid) Meridian Health Plan of Illinois Medicaid MHPILMCD (Medicaid) Meridian Health Plan of New Hampshire MHPNHMCD (Medicaid) Trusted Health Plan Washington DC Medicaid THPMCD (Medicaid) Caidan Management Company CMEMCOR (Commercial) Meridian Choice/Bronson Health MRMIMCH (Commercial) Bridgestone BAPMCOR (Commercial) Concierge Corrections Concierge Rx CONCORR (Commercial) CONR (Commercial) QCP QCPR (Commercial) Perry Corporation PERCOR (Commercial) Group Management Services GMSR (Commercial) Payer Name: PBA-Rx BIN: Ø17Ø76 Date: January Ø1, 2Ø15 Plan Name/Group Name PCN IBEW Local (Commercial) Effective as of: January 1, 2Ø15 NCPDP Telecommunication Standard Version/Release #: D.Ø NCPDP Data Dictionary Version Date: March 2Ø1Ø NCPDP External Code List Version Date: March 2Ø1Ø Contact/Information Source: MeridianRx 1ØØ1 Woodward Avenue, Suite 7ØØ, Detroit, MI Provider Relations Help Desk Info: 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.Ø. Response Transaction Header Segment Questions Check Claim Reversal Accepted/Approved Response Transaction Header Segment Claim Reversal Accepted/Approved 1Ø2-A2 VERSION/RELEASE NUMBER DØ M 1Ø3-A3 TRANSACTION CODE B2 M 1Ø9-A9 TRANSACTION COUNT 1 M 5Ø1-F1 HEADER RESPONSE STATUS A, R M A = Accepted R = Rejected 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1, Ø7 M Ø1 = NPI Ø7 = NCPDP 2Ø1-B1 SERVICE PROVIDER ID M 4Ø1-D1 DATE OF SERVICE M Response Message Header Segment Questions Check Claim Reversal Accepted/Approved This Segment is situational x Required when necessary to clarify reversal. Response Message Segment Segment Identification (111-AM) = 2Ø 5Ø4-F4 MESSAGE M Claim Reversal Accepted/Approved MeridianRx_2015_Payer_Sheet_v May 28, 2Ø15

20 Response Status Segment Questions Check Claim Reversal Accepted/Approved Response Status Segment Claim Reversal Accepted/Approved Segment Identification (111-AM) = AN TRANSACTION RESPONSE STATUS A, R M A = Accepted R = Rejected Response Claim Segment Questions Check Claim Reversal Accepted/Approved Response Claim Segment Segment Identification (111-AM) = EM PRESCRIPTION/SERVICE REFERENCE 1 = RxBilling M NUMBER QUALIFIER 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER M Claim Reversal Accepted/Approved **End of Claim Reversal Response (B2) Payer Sheet Template** MeridianRx_2015_Payer_Sheet_v May 28, 2Ø15