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

Transcription

1 Envolve Pharmacy Solutions NCPDP D.0 EPS-CNC Primary Sheet NCPDP VESION D.0 CLAI BILLING EDICAID/COECIAL EQUEST CLAI BILLING PIAY PAYE SHEET GENEAL INFOATION Name: Envolve Pharmacy Solutions Date: Plan Name/Group Name: edicaid/commercial/non edicare D Plans Plan Name/Group Name: agnolia Health Plan Plan Name/Group Name: agnolia Health Plan - CHIP SCHIP Plan Name/Group Name: Centene Corp. BIN: Ø16788 Processor: Envolve Pharmacy Solutions Effective as of: 4/1/2015 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 : Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Transaction Code Transaction Name B1 Billing B2 eversal FIELD LEGEND FO COLUNS Explanation Column Column ANDATOY The Field is mandatory for the Segment in the designated Transaction. EQUIED The Field has been designated with the situation of "equired" for the Segment in the designated Transaction. No QUALIFIED EQUIEENT equired when. The situations designated have qualifications for usage ("equired if x", "Not required if y"). Yes No Fields that are not used in the 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 Vendor/Certification ID (11Ø-AK) is Issued Vendor/Certification ID (11Ø-AK) is Switch/VAN issued Vendor/Certification ID (11Ø-AK) is Not used 1Ø1-A1 1Ø2-A2 1Ø3-A3 1Ø4-A4 1Ø9-A9 2Ø2-B2 Transaction Header Segment BIN NUBE VESION/ELEASE NUBE TANSACTION CODE POCESSO CONTOL NUBE TANSACTION COUNT SEVICE POVIDE ID QUALIFIE 2Ø1-B1 4Ø1-D1 SEVICE POVIDE ID DATE OF SEVICE DØ B1 1-4 Ø1=NPI Ø7=NCPDP# BIN listed in General Information See General Information aterials eproduced With the Consent of Page: 1

2 Envolve Pharmacy Solutions NCPDP D.0 EPS-CNC Primary Sheet 11Ø-AK Transaction Header Segment SOFTWAE VENDO/CETIFICATION ID Insurance Segment Questions Insurance Segment Segment Identification (111-A) = Ø4 3Ø2-C2 CADHOLDE ID 312-CC CADHOLDE FIST NAE 313-CD CADHOLDE LAST NAE 524-FO 3Ø1-C1 3Ø3-C3 3Ø6-C6 PLAN ID GOUP ID PESON CODE PATIENT ELATIONSHIP CODE Patient Segment Segment Identification (111-A) = Ø C PEGNANCY INDICATO PATIENT ESIDENCE Ø1=HOE Ø2=SKILLED NUSING FACILITY Ø3=NUSING FACILITY Ø4=ASSISTED LIVING FACILITY Ø5=CUSTODIAL CAE FACILITY Ø6=GOUP HOE Ø7=INPATIENT PSYCHIATIC FACILITY Ø9=INTEEDIATE CAE FACILITY/ENTALLY ETADED 11=HOSPICE 12=PSYCHIATIC ESIDENTIAL TEATENT FACILITY 13=COPEHENSIVE INPATIENT EHABILITATION FACILITY Claim Segment Questions This payer supports partial fills This payer does not support partial fills Needed for Worker s Comp and POS Eligibility Needed to identify specific multi-birth dependent. 31Ø-CA PATIENT FIST NAE PATIENT LAST NAE Otherwise will not cause Otherwise will not cause If Situational, 3Ø4-C4 DATE OF BITH 3Ø5-C5 PATIENT GENDE CODE 311-CB Patient Segment Questions Field Software Vendor ID; Will not cause failure Patient s Date of Birth Group/plan dependent; otherwise will not cause equired for HS-IN only Claim Segment Segment Identification (111-A) = Ø7 aterials eproduced With the Consent of Page: 2

3 Envolve Pharmacy Solutions NCPDP D.0 EPS-CNC Primary Sheet 455-E Claim Segment Segment Identification (111-A) = Ø7 436-E1 PESCIPTION/SEVICE EFEENCE NUBE QUALIFIE PESCIPTION/SEVICE EFEENCE NUBE PODUCT/SEVICE ID QUALIFIE 4Ø7-D7 442-E7 4Ø3-D3 PODUCT/SEVICE ID QUANTITY DISPENSED FILL NUBE 4Ø5-D5 4Ø6-D6 DAYS SUPPLY COPOUND CODE 4Ø8-D8 DISPENSE AS WITTEN (DAW)/PODUCT SELECTION CODE DATE PESCIPTION WITTEN NUBE OF EFILLS AUTHOIZED PESCIPTION OIGIN CODE 4Ø2-D2 414-DE 415-DF 419-DJ 354-N 42Ø-DK SUBISSION CLAIFICATION CODE COUNT SUBISSION CLAIFICATION CODE 3Ø8-C8 OTHE COVEAGE CODE 1 = x Billing Ø1=UPC Ø2=HI Ø3=NDC 1 = Not a Compound 2 = Compound 0,1,2,3,4,5,6,7,8,9 0,1,2,3,4,5 aximum count of 3. 0 = Unspecified 1 = No other coverage 3 = Other Coverage Billedclaim not covered 0 = Unspecified 3= Emergency equirement: equired if Submission Clarification Code is sent. 418-DI LEVEL OF SEVICE 461-EU PIO AUTHOIZATION TYPE CODE 462-EV 995-E2 PIO AUTHOIZATION NUBE SUBITTED OUTE OF ADINISTATION Informational; will not cause 996-G1 COPOUND TYPE Informational; will not cause Pricing Segment Questions Pricing Segment Segment Identification (111-A) = 11 Imp Guide: equired if its value has an effect on the Imp Guide: equired if this field could result in different coverage, pricing, or patient financial responsibility. Imp Guide: equired if its value has an effect on the 4Ø9-D9 INGEDIENT COST SUBITTED 412-DC DISPENSING FEE SUBITTED 433-D PATIENT PAID AOUNT SUBITTED 438-E3 INCENTIVE AOUNT SUBITTED 481-HA FLAT SALES TA AOUNT SUBITTED 482-GE PECENTAGE SALES TA AOUNT SUBITTED Imp Guide: equired if its value has an effect on the Imp Guide: equired if its value has an effect on the aterials eproduced With the Consent of Page: 3

4 Envolve Pharmacy Solutions NCPDP D.0 EPS-CNC Primary Sheet 483-HE Pricing Segment Segment Identification (111-A) = 11 PECENTAGE SALES TA ATE SUBITTED 484-JE 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. 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. PECENTAGE SALES TA BASIS SUBITTED equired if this field could result in different pricing. equired if needed to calculate Percentage Sales Tax Amount Paid (559-A). 426-DQ USUAL AND CUSTOAY CHAGE 43Ø-DU GOSS AOUNT DUE 423-DN BASIS OF COST DETEINATION Prescriber Segment Questions Prescriber Segment Segment Identification (111-A) = Ø3 466-EZ PESCIBE ID QUALIFIE 411-DB PESCIBE ID If Situational, 01 = NPI, 12 = DEA, 05 = edicaid, 08 = State Lic., 14 = Plan specific, 99 = Other 427-D PESCIBE LAST NAE 498-P PESCIBE PHONE NUBE 364-2J PESCIBE FIST NAE 367-2N 468-2E PESCIBE STATE/POVINCE ADDESS PIAY CAE POVIDE ID QUALIFIE 421-DL PIAY CAE POVIDE ID 47Ø-4E PIAY CAE POVIDE LAST NAE 01 = NPI, 12 = DEA, 05 = edicaid, 08 = State Lic, 14 = Plan Specific, 99 = Other equired if needed for Prescriber ID clarification. equired if needed for Prescriber ID clarification. equired if needed for Prescriber ID clarification. aterials eproduced With the Consent of Page: 4

5 Envolve Pharmacy Solutions NCPDP D.0 EPS-CNC Primary Sheet Compound Segment Questions This Segment is situational If 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 COUNT 488-E COPOUND PODUCT ID QUALIFIE 489-TE COPOUND PODUCT ID 448-ED COPOUND INGEDIENT QUANTITY 449-EE COPOUND INGEDIENT DUG COST aximum 25 ingredients This Segment is situational Clinical Segment Segment Identification (111-A) = VE DIAGNOSIS CODE COUNT 492-WE DIAGNOSIS CODE QUALIFIE Ø1=UPC Ø2=HI Ø3=NDC 49Ø-UE COPOUND INGEDIENT BASIS OF COST DETEINATION 362-2G COPOUND INGEDIENT ODIFIE aximum count of 1Ø. CODE COUNT 363-2H COPOUND INGEDIENT ODIFIE CODE Clinical Segment Questions equired when Compound Ingredient odifier Code (363-2H) is sent. If Situational, This segment may be required as determined by benefit design. aximum count of 5. Ø1=ICD9 424-DO DIAGNOSIS CODE aterials eproduced With the Consent of Page: 5