2018 Payer Sheet NCPDP Version D.0. Version 1.0 for 2018

Transcription

1 2018 Sheet NCPDP Version D.0 For all EDICARE serviced plans Version 1.0 for 2018 Effective Date: January 1, 2018

2 Contents General Information... 3 PB Information... 3 eridianrx edicare PCN List for Part B vs. D Adjudication Process... 4 Pharmacy Help Desk Information... 5 Version Information... 5 NCPDP VERSION D.0 Template... 6 Request Sheet Template... 6 General Information... 6 Transactions Supported... 7 Field Legend for Columns... 8 Transaction... 9 Response Sheet Template General Information Accepted/Paid (or Duplicate of Paid) Response /Rejected Response NCPDP Version D.0 Claim Reversal Template Request Claim Reversal Sheet Template General Information Field Legend for Columns Request Claim Reversal Transaction Response Claim Reversal Sheet Template General Information Claim Reversal Accepted/Rejected Response

3 General Information PB Information /Processor Name: BIN Number: Effective as of: NCPDP Version: eridianrx January 1, 2018 D.0 eridianrx edicare PCN List for 2018 eridianhealth - edicare PCN Plan/Group Group ID Line of Business Description HPCR eridiancare N/A edicare HPCRB* eridiancare N/A edicare B vs. D ichigan: eridian Easy, eridian Elite, eridian Essential, eridian Extra & eridian Enhanced Indiana: eridian Essential Ohio: eridian Essential, eridian Enhanced & eridian Extra *Please see Part B vs D Adjudication Process below HPILSNP eridiancare N/A edicare eridian Elite, eridian Essential & eridian Edge of Illinois HPILSNPB* eridiancare N/A edicare B vs. D HPILCOP eridiancomplete N/A edicare/edicaid HPILCOPB* eridiancomplete N/A edicare/edicaid B vs. D HPICOP eridiancomplete N/A edicare/edicaid *Please see Part B vs D Adjudication Process below eridiancomplete (AI) for Illinois *Please see Part B vs D Adjudication Process below eridiancomplete (P) for ichigan HPICOPB* eridiancomplete N/A edicare/edicaid B vs. D *Please see Part B vs D Adjudication Process below 3

4 RiverSpring - edicare PCN Plan/Group Group ID Line of Business Description RSNY RiverSpring FIDA N/A edicare/edicaid edicare Fully Integrated Dual Advantage plan for New York RSNYB* RiverSpring FIDA N/A edicare/edicaid RSNY RiverSpring STAR N/A edicare RSNYB* RiverSpring STAR N/A edicare *Please see Part B vs D Adjudication Process below edicare Advantage Institutional Special Needs Plan for New York *Please see Part B vs D Adjudication Process below *Part B vs. D Adjudication Process Claims for medications designated as B vs D by edicare that are submitted using a Part D PCN will return a rejection code 75 Prior Authorization Required. The rejection will include a secondary message explaining that the medication is B vs. D and instructing the pharmacist to contact eridianrx. If, upon investigation, it is determined that the medication can be passed through the member s Part D benefit, eridianrx will provide prior authorization for the claim to adjudicate. As a convenience to pharmacies, for B vs. D medications that are determined to fall under the member s Part B (edical) benefit, eridianrx may establish prior authorization and instruct the pharmacy to re-submit the claim using the Part B PCN associated with the member s PCN (shown with asterisk in PCN list). This will allow the claim to adjudicate through the PB without requiring the pharmacy to work through the member s Part B Health Plan. Important Exceptions: This Part B utility is not available for PDP benefit plans This Part B utility is ONLY for medications designated B vs. D by edicare. Part B medications must be processed through the member s Part B benefit 4

5 Pharmacy Help Desk Information: Inquiries to eridianrx may be directed to our 24 Hour Pharmacy Assistance Center.** All calls are toll free. eridianhealth edicare ichigan Phone: Fax: E-ail: eridian Easy, eridian Elite, eridian Essential, eridian Extra & eridian Enhanced eridiancomplete Indiana eridian Essential Ohio eridian Essential, eridian Enhanced & eridian Extra Illinois Phone: Fax: E-ail: eridian Elite, eridian Essential & eridian Edge eridiancomplete RiverSpring edicare New York Phone: Fax: E-ail RiverSpring Health Plans Version Information VER. DATE PAGE FIELD NOTES /01/2018 EDICARE Sheet Release for

6 NCPDP VERSION D.0 Template Request Sheet Template General Information ** Start of Request (B1) Sheet Template** Name: eridianrx BIN: Date: January 1, 2018 Plan Name/Group Name ichigan eridian Easy eridian Elite eridian Essential eridian Enhanced eridian Extra (HO SNP) PCN HPCR (edicare) HPCRB (edicare Part B)* eridiancomplete (I Health Link) eridiancomplete (I Health Link) Illinois eridian Elite eridian Essential eridian Edge eridian Complete Indiana eridian Essential Ohio eridian Essential eridian Enhanced eridian Extra New York RiverSpring FIDA RiverSpring STAR HPILSNP(edicare) HPILSNPB (edicare Part B)* HPILCOP (AI) HPILCOPB (edicare Part B) HPCR (edicare) HPCRB (edicare Part B)* HPCR (edicare) HPCRB (edicare Part B)* RSNY (edicare) RSNYB (edicare Part B)* Effective as of: January 1, 2018 NCPDP Telecommunication Standard Version/Release #: D.0 NCPDP Data Dictionary Version Date: arch NCPDP External Code List Version Date: arch Contact/Information Source: eridianrx 1 Campus artius, Suite 750, Detroit, I Provider Relations Help Desk Info: Other versions supported: None * To be used ONLY for billing edicare Part B edications through PB. 6

7 Transactions Supported Transaction Code B1 B2 Transaction Name Claim Reversal 7

8 Field Legend for Columns Column Value Explanation Column ANDATORY 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 No QUALIFIED REQUIREENT Required when the situations designated have qualifications for usage ("Required if x", "Not required if y") Yes 8

9 Transaction The following lists the segments and fields in a Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Transaction Header Segment Questions If Situational, Transaction Header Segment 101-A1 BIN NUBER A2 VERSION/RELEASE NUBER D0 103-A3 TRANSACTION CODE B1 Note: Rebill (B3) not supported 104-A4 PROCESSOR CONTROL NUBER Refer to PCN table on Use correct PCN for Group/Line of page 3. Business. 109-A9 TRANSACTION COUNT 1 Only one Transaction allowed in a single 202-B2 SERVICE PROVIDER ID QUALIFIER 01, = NPI 07 = NCPDP Provider ID 201-B1 SERVICE PROVIDER ID 401-D1 DATE OF SERVICE 110-AK SOFTWARE BLANKS Insurance Segment Questions If Situational, Insurance Segment Segment Identification (111-A) = C1 Group ID 302-C2 CARDHOLDER ID As printed on the ID card or as Communicated 312-CC CARDHOLDER FIRST NAE Required for PCN CECOR 313-CD CARDHOLDER LAST NAE Required for PCN CECOR 306-C6 PATIENT RELATIONSHIP CODE Required for PCN CECOR 997-G2 CS Part D Defined Qualified Facility Y=Yes, N=No Required to request Long Term Care Part D processing rules to be followed 9

10 Patient Segment Questions If Situational, Patient Segment Segment Identification (111-A) = 01 Field NCPDP Field Name Value 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 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 R 10

11 Claim Segment Questions If Situational, Claim Segment Segment Identification (111- A) = E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 01 = Rx Billing Imp Guide: For Transaction Code of B1, in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 1 (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 408-D8 DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE 0 thru 9 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 andated by Law 8 = No Generic in arketplace 9 = Plan Requested Brand 414-DE DATE PRESCRIPTION WRITTEN R 415-DF NUBER OF REFILLS R 11

12 419-DJ PRESCRIPTION ORIGIN CODE 1,2,3,4 R 308-C8 OTHER COVERAGE CODE 0, 1, 2, 3, 4 R 1 = Written 2 = Telephone 3 = Electronic 4 = Facsimile 0 = 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 147-U7 PHARACY SERVICE TYPE R 354-N SUBISSION CLARIFICATION CODE COUNT Up to 3 Field is Required when Patient Residence (384-4) = DK SUBISSION CLARIFICATION CODE 3, 4, 5, 7, 13, 16, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 Field is Required when Patient Residence (384-4) = 3 or 9 12

13 Pricing Segment Questions If Situational, Pricing Segment Segment Identification (111-A) = 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 If Situational, Prescriber Segment Segment Identification (111-A) = EZ PRESCRIBER ID QUALIFIER 01, 12 R 01 = NPI 12 = DEA 411-DB PRESCRIBER ID R Coordination of Benefits/Other Payments Segment If Situational, This segment is situational Required only for secondary, tertiary, claims. Coordination of Benefits/Other Payments Segment Segment Identification (111-A) = C COORDIATION OF BENEFITS/OTHER aximum count of 9 Scenario 1- Other Amount Paid (OPAP) Repetitions and Benefit Stage Repetitions Only 13

14 338-5C OTHER PAYER COVERAGE TYPE 01 thru C OTHER PAYER ID QUALIFIER 03 R 03 = BIN 340-7C OTHER PAYER ID R 443-E8 OTHER PAYER DATE R 341-HB OTHER PAYER AOUNT PAID COUNT aximum of 9 Required when 431-DV is used 342-HC OTHER PAYER AOUNT PAID QUALIFIER 01, 02, 03, 04, 05, 06, 07, 09 Required when 431-DV is used 01 Delivery 02 Shipping 03 Postage 04 Admin 05 Incentive 06 Cognitive 07 Drug Benefit 09 Compound Prep 431-DV OTHER PAYER AOUNT PAID 471-5E OTHER PAYER REJECT COUNT aximum count of Required when other payer payment is made Required when Other Coverage Code (308-C8) = E OTHER PAYER REJECT CODE 60, 61, 65, 66, 67, 68, 69, 70, 76, AA, 1, RN Required when Other Coverage Code (308-C8) = 3 14

15 DUR/PPS Segment Questions This segment is situational If Situational, When necessary to provide information on potential drug interactions DUR/PPS Segment Segment Identification (111-A) = E DUR/PPS CODE COUNTER aximum of 9 occurrences 439-E4 REASON FOR SERVICE CODE DD, TD, S 440-E5 PROFESSIONAL SERVICE CODE DD = Drug Drug TD = Duplicate Therapy S = Drug - Gender 441-E6 RESULT OF SERVICE CODE Compound Segment Questions If Situational, This segment is situational For billing of compound medications. Compound Segment Segment Identification (111-A) = EF COPOUND DOSAGE FOR DESCRIPTION CODE 01-07, 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 15

16 451-EG COPOUND DISPENSING UNIT FOR INDICATOR 1, 2, 3 1 = Each 2 = Grams 3 = illiliters 447-EC COPOUND INGREDIENT COPONENT COUNT aximum 25 ingredients 488-RE COPOUND PRODUCT ID QUALIFIER 489-TE COPOUND PRODUCT ID 448-ED COPOUND INGREDIENT QUANTITY 449-EE COPOUND INGREDIENT DRUG COST R Enter ingredient cost for each product in the compound 490-UE COPOUND INGREDIENT BASIS OF COST DETERINATION R Clinical Segment Questions If Situational, This segment is situational Required for all edicare transactions. Clinical Segment Segment Identification (111-A) = VE DIAGNOSIS CODE COUNT aximum count of 5 R 492-WE DIAGNOSIS CODE QUALIFIER R 424-DO DIAGNOSIS CODE R ** End of Request (B1) Sheet Template** 16

17 Response Sheet Template ** Start of Response (B1) Sheet Template** General Information Name: eridianrx BIN: Date: January 1, 2018 Plan Name/Group Name ichigan eridian Easy eridian Elite eridian Essential eridian Enhanced eridian Extra (HO SNP) eridiancomplete (I Health Link) Illinois eridian Elite eridian Essential eridian Edge eridiancomplete PCN HPCR (edicare) HPCRB (edicare Part B)* HPICOP (P) HPICOPB (edicare Part B)* HPILSNP (edicare) HPILSNPB (edicare Part B)* HPILCOP (AI) HPILCOPB (edicare Part B)* Indiana eridian Essential HPCR (edicare) HPCRB (edicare Part B)* Ohio eridian Essential eridian Enhanced eridian Extra HPCR (edicare) HPCRB (edicare Part B)* New York RiverSpring FIDA RiverSpring STAR RSNY (edicare) RSNYB - (edicare Part B)* Effective as of: January 1, 2018 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:

18 Other versions supported: None * To be used ONLY for billing edicare Part B edications through PB. 18

19 Accepted/Paid (or Duplicate of Paid) Response The following lists the segments and fields in a Accepted/Paid (or Duplicate of Paid) Response Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Response Transaction Header Segment Questions Accepted/Paid (or Duplicate of Paid) If Situational, Response Transaction Header Segment - Accepted/Paid (or 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 QUALIFIER 01, B1 SERVICE PROVIDER ID 401-D1 DATE OF SERVICE 01 = NPI 07 = NCPDP Response essage Header Segment Questions Accepted/Paid (or Duplicate of Paid) If Situational, This segment is situational When additional text is required for clarification or detail Response essage Segment Segment Identification (111-A) = 20 - Accepted/Paid (or Duplicate of Paid) 504-F4 ESSAGE R 19

20 Response Insurance Header Segment Questions This segment is situational Accepted/Paid (or Duplicate of Paid) If Situational, Returned when cardholder ID differs from cardholder ID submitted Response Insurance Segment Segment Identification (111-A) = 302-C2 CARDHOLDER ID R Accepted/Paid (or Duplicate of Paid) Response Status Segment Questions Accepted/Paid (or Duplicate of Paid) Response Status Segment Segment Identification (111-A) = 112-AN TRANSACTION RESPONSE STATUS P=Paid D=Duplicate of Paid 503-F3 AUTHORIZATION NUBER R Accepted/Paid (or Duplicate of Paid) Response Claim Segment Questions Accepted/Paid (or Duplicate of Paid) If Situational, Response Claim Segment Segment Identification (111-A) = E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 1 = RxBilling Accepted/Paid (or Duplicate of Paid) 402-D2 PRESCRIPTION/SERVICE REFERENCE NUBER 20

21 Response Pricing Segment Questions Accepted/Paid (or Duplicate of Paid) If Situational, Response Pricing Segment Segment Identification (111-A) = F5 PATIENT PAY AOUNT R 506-F6 INGREDIENT COST PAID R 507-F7 DISPENSING FEE PAID R 557-AV TA EEPT INDICATOR 04 R 521-FL INCENTIVE AOUNT PAID Accepted/Paid (or Duplicate of Paid) 04 = Neither /Plan nor Patient are liable for tax Required when Professional Service Code = A 566-J5 OTHER PAYER AOUNT RECOGNIZED Required when Other Coverage Code = 2, 3, F9 TOTAL AOUNT PAID R 522-F BASIS OF REIBURSEENT DETERINATION Required when Ingredient Cost Paid (506-F6) is greater than zero 517-FH AOUNT APPLIED TO PERIODIC DEDUCTIBLE Returned when applicable 518-FI AOUNT OF COPAY Returned when applicable 572-4U AOUNT OF COINSURANCE Returned when applicable 392-U BENEFIT STAGE COUNT aximum count of 4 Returned when applicable 393-V BENEFIT STAGE QUALIFIER Returned when applicable 394-W BENEFIT STAGE AOUNT Returned when applicable 133-UJ AOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION Returned when applicable 21

22 Response Pricing Segment Segment Identification (111-A) = UK 135-U 136-UN 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 Accepted/Paid (or Duplicate of Paid) Returned when applicable Returned when applicable Returned when applicable 137-UP AOUNT ATTRIBUTED TO COVERAGE GAP Returned when applicable 148-U8 INGREDIENT COST CONTRACTED/REIBURSABLE AOUNT Required when Other Coverage Code (308-C8) = U9 DISPENSING FEE CONTRACTED/REIBURSABLE AOUNT Required when Other Coverage Code (308-C8) = 2 Response DUR/PPS Segment Questions Accepted/Paid (or Duplicate of Paid) If Situational, This segment is situational Required when DUR warning is indicated Response DUR/PPS Segment Segment Identification (111-A) = 24 Accepted/Paid (or Duplicate of Paid) 567-J6 DUR/PPS RESPONSE CODE COUNTER aximum 9 occurrences supported Required when Reason For Service Code (439-E4) is used 439-E4 REASON FOR SERVICE CODE 528-FS CLINICAL SIGNIFICANCE CODE Blank, 1,2,3 9 Required when utilization conflict is detected Required when necessary to provide additional information on utilization conflict 22

23 529-FT OTHER PHARACY INDICATOR 530-FU PREVIOUS DATE OF FILL 531-FV QUANTITY OF PREVIOUS FILL 532-FW DATABASE INDICATOR 533-F OTHER PRESCRIBER INDICATOR 544-FY DUR FREE TET ESSAGE 570-NS DUR ADDITIONAL TET 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 23

24 Response Coordination of Benefits/Other s Segment Questions Accepted/Paid (or Duplicate of Paid) If Situational, This segment is situational For claims where other payer information is indicated Response Coordination of Benefits/Other s Segment Segment Identification (111-A) = NT OTHER PAYER ID COUNT aximum count of C OTHER PAYER COVERAGE TYPE 339-6C OTHER PAYER ID QUALIFIER 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 Accepted/Paid (or Duplicate of Paid) 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 Required when secondary coverage is indicated for the member For informational purposes For informational purposes For informational purposes For informational purposes 24

25 /Rejected Response The following lists the segments and fields in a /Rejected Response Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0 Response Transaction Header Segment Questions Response Transaction Header Segment - Accepted/Rejected If Situational, - Accepted/Rejected 102-A2 VERSION/RELEASE NUBER D0 103-A3 TRANSACTION CODE B1 Note: Rebill (B3) not supported 109-A9 TRANSACTION COUNT 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 Only one transaction per transmission Response essage Segment Questions - Accepted/Rejected If Situational, This segment is situational When required to clarify response Response essage Segment Segment Identification (111-A) = F4 ESSAGE R - Accepted/Rejected 25

26 Response Claim Segment Questions - Accepted/Rejected If Situational, Response Claim Segment Segment Identification (111-A) = E 402-D2 PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUBER 1 = RxBilling - Accepted/Rejected Imp Guide: For Transaction Code of B1, in the Response Claim Segment, the Prescription/Service 26

27 Response DUR/PPS Segment Questions - Accepted/Rejected If Situational, This segment is situational When DUR warning is indicated Response DUR/PPS Segment Segment Identification (111-A) = 24 - Accepted/Rejected 567-J6 DUR/PPS RESPONSE CODE COUNTER aximum 9 occurrences supported Required when Reason For Service Code (439-E4) 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 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 ** End of Response (B1) Sheet Template** 27

28 NCPDP Version D.0 Claim Reversal Template Request Claim Reversal Sheet Template ** Start of Request Claim Reversal (B2) Sheet Template** General Information Name: eridianrx BIN: Date: January 1, 2018 Plan Name/Group Name PCN ichigan eridian Easy eridian Elite eridian Essential eridian Enhanced eridian Extra (HO SNP) eridiancomplete (I Health Link) HPCR (edicare) HPCRB (edicare Part B)* HPICOP (P) HPICOPB (edicare Part B)* Illinois eridian Elite eridian Essential eridian Edge eridiancomplete HPILSNP (edicare) HPILSNPB (edicare Part B)* HPILCOP (AI) HPILCOPB (edicare Part B) Indiana eridian Essential HPCR (edicare) HPCRB (edicare Part B)* Ohio eridian Essential eridian Enhanced eridian Extra HPCR (edicare) HPCRB (edicare Part B)* New York RiverSpring FIDA RiverSpring STAR RSNY (Dual Eligible) RSNYB (edicare Part B) Effective as of: January 1, 2018 NCPDP Telecommunication Standard Version/Release #: D.0 NCPDP Data Dictionary Version Date: arch 2010 NCPDP External Code List Version Date: arch

29 Contact/Information Source: eridianrx 1 Campus artius, Suite 750, Detroit, I Provider Relations Help Desk Info: Other versions supported: None * To be used ONLY for billing edicare Part B edications through PB. 29

30 Field Legend for Columns Column ANDATORY REQUIRED QUALIFIED REQUIREENT Value R Explanation 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 Question Answer What is your reversal window? (If transaction is billed today what is the timeframe for reversal to be submitted?) 60 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.0 Transaction Header Segment Questions Claim Reversal If Situational, Transaction Header Segment 101-A1 BIN NUBER Claim Reversal 102-A2 VERSION/RELEASE NUBER D0 103-A3 TRANSACTION CODE B2 104-A4 PROCESSOR CONTROL NUBER Refer to PCN table on page 3. Use correct PCN for Group/Line of Business 109-A9 TRANSACTION COUNT B2 SERVICE PROVIDER ID QUALIFIER 01, = NPI 07 = NCPDP 201-B1 SERVICE PROVIDER ID 401-D1 DATE OF SERVICE 30

31 Transaction Header Segment Field# NCPDP Field Name Value Claim Reversal 110-AK SOFTWARE VENDOR/CERTIFICATION ID Blanks 31

32 Insurance Segment Questions Claim Reversal If Situational, Insurance Segment Segment Identification (111-A) = C2 CARDHOLDER ID Claim Reversal Claim Segment Questions Claim Reversal If Situational, Claim Segment Segment Identification (111-A) = E 402-D2 PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUBER 01=RxBilling Claim Reversal 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 multi-ingredient compound ust contain product/service ID from original prescription billing ** End of Request Claim Reversal (B2) Sheet Template** 32

33 Response Claim Reversal Sheet Template General Information **Start of Claim Reversal Response (B2) Sheet Template** Name: eridianrx BIN: Date: January 1, 2018 Plan Name/Group Name PCN ichigan eridian Easy eridian Elite eridian Essential eridian Enhanced eridian Extra (HO SNP) eridiancomplete (I Health Link) Illinois eridian Elite eridian Essential eridian Edge eridiancomplete Indiana HPCR (edicare) HPCRB (edicare Part B)* HPICOP (P) HPICOPB (edicare Part B)* HPILSNP (edicare) HPILSNPB (edicare Part B)* HPILCOP (edicare) HPILCOPB (edicare Part B)* eridian Essential HPCR (edicare) HPCRB (edicare Part B)* Ohio eridian Essential eridian Enhanced eridian Extra New York RiverSpring FIDA RiverSpring STAR HPCR (edicare) HPCRB (edicare Part B)* RSNY (edicare) RSNYB - (edicare Part B)* Effective as of: January 1, 2018 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: Other versions supported: None * To be used ONLY for billing edicare Part B edications through PB. 33

34 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 Claim Reversal Accepted/Approved If Situational, Response Transaction Header 102-A2 VERSION/RELEASE NUBER D0 103-A3 TRANSACTION CODE B2 109-A9 TRANSACTION COUNT F1 HEADER RESPONSE STATUS A, R 202-B2 SERVICE PROVIDER ID QUALIFIER 01, B1 SERVICE PROVIDER ID 401-D1 DATE OF SERVICE Claim Reversal Accepted/Approved A = Accepted R = Rejected 01 = NPI 07 = NCPDP Response essage Header Segment Questions Claim Reversal Accepted/Approved If Situational, This segment is situational x Required when necessary to clarify reversal Response essage Segment Segment Identification (111-A) = F4 ESSAGE Claim Reversal Accepted/Approved 34

35 Response Status Segment Questions Claim Reversal Accepted/Approved If Situational, Response Status Segment Segment Identification (111-A) = AN TRANSACTION RESPONSE STATUS A, R Claim Reversal Accepted/Approved A = Accepted R = Rejected Response Claim Segment Questions Claim Reversal Accepted/Approved If Situational, Response Claim Segment Segment Identification (111-A) = 22 Claim Reversal Accepted/Approved 455-E 402-D2 PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUBER 1 = RxBilling **End of Claim Reversal Response (B2) Sheet Template** 35