Payor Specification Information

Transcription

1 Payor Specification Information for Pharmacies Participating in the First Health x Network First Health x is implementing NCPDP v.5.1 effective ctober 16, Please note that v.5.1 functionality will be introduced incrementally. Designated transactions and segments will be required on the implementation date; others will be required at a future date to be determined. First Health is providing this information to facilitate a pharmacy's ability to conduct NCPDP v.5.1 transactions after ctober 16, First Health Attention: Pharmacy Network 750 iver Point Drive West Sacramento, CA FirstHealthx@firsthealth.com First Health Group Corp. All rights reserved. First Health and the heart logo are registered service marks of First Health Group Corp. Proprietary. Do not disclose without written permission. 8/2003

2 General Information PAY: First Health x Processor: First Health x Information Source: First Health Group Corp. Effective as of: ctober 16, 2003 Document Date: August 20, 2003 Claim Submission/Adjudication Help Number: NCPDP v.5.1 Payor Specification Implementation Help Please call the toll-free phone number on the back of Number: (630) the plan member s ID card. ther versions supported: NCPDP v.3.2 and 3A through ctober 16, Please detailed questions regarding these payor specifications to: FirstHealthx@firsthealth.com Version 5.1 Transactions NCPDP v.5.1 Transaction Code NCPDP v.5.1 Transaction Name Transaction Support equirements E1 Eligibility Verification equired B1 Billing equired B2 eversal equired B3 e-bill equired P1 Prior Authorization equest and Billing equired P2 Prior Authorization eversal equired P3 Prior Authorization Inquiry equired P4 Prior Authorization equest nly equired NCPDP equest Segment Matrix Transaction Code Segment E1 B1 B2 B3 P1 P2 P3 P4 Header M M M M M M M M Patient Insurance M M M M M M Claim N M M M M M M M Pharmacy Provider N Prescriber N N CB/ther Payments N N N Workers Comp N N DU/PPS N Pricing N M M M Coupon N N Compound N N PA N N M M M Clinical N N N N Proprietary. Do not disclose without written permission of First Health. 1

3 NCPDP Designations: M= Mandatory; = ptional; N = Not Sent. NTE: Some segments indicated as ptional by NCPDP, may be equired to support specific transactions for First Health x claims processing. NCPDP esponse Segment Matrix Transaction Paid or Duplicate of Paid Segment E1 B1 B2 B3 P1 P2 P3 P4 esp Header N M N M M N M N Header esponse Status (5Ø1-F1) A A A A esp Message N N N N esp Insurance N N N N esp Status N M N M M N M N Transaction esponse Status (112-AN) P,D P,D P,D P,D esp Claim N M N M M N M N esp Pricing N M N M M N M N esp DU/PPS N N N N esp Prior Auth N N N N M N M N M = Mandatory; = ptional; conditional based on data content; N = Not Sent A = Accepted; P = Paid; D = Duplicate Submission and response requirements are shown for each segment as Mandatory (M), ptional (), or Not Sent (N). Valid values are shown for each transaction type in the Header and Transaction esponse Status fields (5Ø1- F1 and 112-AN). NCPDP esponse Segment Matrix Transaction ejected Segment E1 B1 B2 B3 P1 P2 P3 P4 esp Header M M M M M M M M Header esponse Status (5Ø1-F1) A A A A A A A A esp Message esp Insurance N N N esp Status M M M M M M M M Transaction esponse Status (112-AN)) esp Claim N M M M M M M M esp Pricing N N N N N N N N esp DU/PPS N N N esp Prior Auth N N N N N N N N esp Header M M M M M M M M M = Mandatory; = ptional; conditional based on data content; N = Not Sent A = Accepted; = ejected Submission and response requirements are shown for each segment as Mandatory (M), ptional (), or Not Sent (N). Valid values are shown for each transaction type in the Header and Transaction esponse Status fields (5Ø1- F1 and 112-AN). Proprietary. Do not disclose without written permission of First Health. 2

4 Field equirement Legend Code M W X****** Description Designated as MANDATY in accordance with the NCPDP Telecommunication Implementation Guide Version 5.1. These fields must be sent if the segment is required for the transaction. Designated as optional in accordance with the NCPDP Telecommunication Implementation Guide Version 5.1, but designated as EQUIED by First Health x. These fields must be sent if the segment is required for the transaction. EQUIED data elements may not always be used in adjudication. Designated as optional in accordance with the NCPDP Telecommunication Implementation Guide Version 5.1, but designated as EQUIED WHEN by First Health x. These fields must be sent if the condition described is met and the segment is required for the transaction. EQUIED WHEN data elements may not always be used in claims adjudication. Designated as optional in accordance with the NCPDP Telecommunication Implementation Guide Version 5.1, but designated as PTINAL/NT EQUIED by First Health x. It is not necessary to send these fields. If data are sent for ptional fields, the data must be submitted in the valid NCPDP format or the claim may reject. The *** indicates that the field is repeating. ne of the other designators, M,, W or will precede it. NTES: 1. Specific field values that are required for the program are identified as First Health x Values Supported. 2. Fields listed as ptional/not equired at this time may be required in the future. Proprietary. Do not disclose without written permission of First Health. 3

5 equest Segments and Field equirements TANSACTIN HEADE SEGMENT Segment MANDATY For All Transactions Field Field Name M,, W, First Health x Values Supported 1Ø1-A1 BIN NUMBE M Ø2-A2 VESIN/ELEASE NUMBE M 51 1Ø3-A3 TANSACTIN CDE M E1, B1, B2, B3, P1, P2, P3 and P4 1Ø4-A4 PCESS CNTL NUMBE M Ø9-A9 TANSACTIN CUNT M 1-4 except multi-ingredient compound (when implemented) = 1 2Ø2-B2 SEVICE PVIDE ID QUALIFIE M Ø7 = NCPDP (NABP) Provider ID 2Ø1-B1 SEVICE PVIDE ID M NCPDP (NABP) Provider Number provider specific> 4Ø1-D1 DATE F SEVICE M Format = CCYYMMDD 11Ø-AK SFTWAE VEND/CETIFICATIN ID M If no Software Vendor/Certification ID is submitted, at least 10 spaces must be entered. PATIENT SEGMENT Segment EQUIED For E1, B1, B3, P1, P3 and P4 Segment PTINAL For B2 and P2 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 01=Patient Segment 331-CX PATIENT ID QUALIFIE 332-CY PATIENT ID 3Ø4-C4 DATE F BITH equired for eligibility validation 3Ø5-C5 PATIENT GENDE CDE equired for eligibility validation 31Ø-CA PATIENT FIST NAME equired for eligibility validation 311-CB PATIENT LAST NAME equired for eligibility validation 322-CM PATIENT STEET ADDESS 323-CN PATIENT CITY ADDESS 324-C PATIENT STATE/PVINCE ADDESS 325-CP PATIENT ZIP/PSTAL ZNE 326-CQ PATIENT PHNE NUMBE 3Ø7-C7 PATIENT LCATIN 333-CZ EMPLYE ID 334-1C SMKE/NN-SMKE CDE 335-2C PEGNANCY INDICAT Proprietary. Do not disclose without written permission of First Health. 4

6 INSUANCE SEGMENT Segment MANDATY For E1, B1, B3, P1, P3 and P4 Segment PTINAL For B2 and P2 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 04=Insurance Segment 3Ø2-C2 CADHLDE ID M 312-CC CADHLDE FIST NAME 313-CD CADHLDE LAST NAME 314-CE HME PLAN 524-F PLAN ID 3Ø9-C9 ELIGIBILITY CLAIFICATIN CDE 336-8C FACILITY ID 3Ø1-C1 GUP ID equired 3Ø3-C3 PESN CDE 3Ø6-C6 PATIENT ELATINSHIP CDE equired CLAIM SEGMENT Segment MANDATY For B1, B2, B3, P1, P2, P3 and P4 Segment NT SENT For E1 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 07=Claim Segment 455-EM PESCIPTIN/SEVICE EFEENCE M 1=X Billing NUMBE QUALIFIE 4Ø2-D2 PESCIPTIN/SEVICE EFEENCE M NUMBE 436-E1 PDUCT/SEVICE ID QUALIFIE M 03=NDC 4Ø7-D7 PDUCT/SEVICE ID M NDC 456-EN ASSCIATED PESCIPTIN/SEVICE EFEENCE # 457-EP ASSCIATED PESCIPTIN/SEVICE DATE 458-SE PCEDUE MDIFIE CDE CUNT 459-E PCEDUE MDIFIE CDE 442-E7 QUANTITY DISPENSED Must be metric decimal 4Ø3-D3 FILL NUMBE 4Ø5-D5 DAYS SUPPLY 4Ø6-D6 CMPUND CDE 0=Not specified 1=Not a compound 2=Compound 4Ø8-D8 DISPENSE AS WITTEN (DAW)/PDUCT SELECTIN CDE 414-DE DATE PESCIPTIN WITTEN 415-DF NUMBE F EFILLS AUTHIZED 419-DJ PESCIPTIN IGIN CDE 42Ø-DK SUBMISSIN CLAIFICATIN CDE 46Ø-ET QUANTITY PESCIBED 3Ø8-C8 THE CVEAGE CDE 429-DT UNIT DSE INDICAT CLAIM SEGMENT table continued on next page. Proprietary. Do not disclose without written permission of First Health. 5

7 CLAIM SEGMENT (Continued) Segment MANDATY For B1, B2, B3, P1, P2, P3 and P4 Segment NT SENT For E1 Field Field Name M,, W, First Health x Values Supported 453-EJ IGINALLY PESCIBED PDUCT/SEVICE ID QUALIFIE 445-EA IGINALLY PESCIBED PDUCT/SEVICE CDE 446-EB IGINALLY PESCIBED QUANTITY 33Ø-CW ALTENATE ID 454-EK SCHEDULED PESCIPTIN ID NUMBE 6ØØ-28 UNIT F MEASUE 418-DI LEVEL F SEVICE 461-EU PI AUTHIZATIN TYPE CDE 462-EV PI AUTHIZATIN NUMBE SUBMITTED 463-EW INTEMEDIAY AUTHIZATIN TYPE ID 464-EX INTEMEDIAY AUTHIZATIN ID 343-HD DISPENSING STATUS Not supported. 344-HF QUANTITY INTENDED T BE Not supported. DISPENSED 345-HG DAYS SUPPLY INTENDED T BE Not supported. DISPENSED PHAMACY PVIDE SEGMENT Segment NT EQUIED at this time; fields intentionally not listed. Possible future use. PESCIBE SEGMENT Segment EQUIED For B1, B3, P1, P3 and P4 Segment PTINAL For P2 Segment NT SENT For E1 and B2 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 03=Prescriber Segment 466-EZ PESCIBE ID QUALIFIE DB PESCIBE ID DEA required E PESCIBE LCATIN CDE 427-D PESCIBE LAST NAME 498-PM PESCIBE PHNE NUMBE 468-2E PIMAY CAE PVIDE ID QUALIFIE 421-DL PIMAY CAE PVIDE ID 469-H5 PIMAY CAE PVIDE LCATIN CDE 47Ø-4E PIMAY CAE PVIDE LAST NAME Proprietary. Do not disclose without written permission of First Health. 6

8 CB SEGMENT WKES CMP SEGMENT Segment NT EQUIED at this time; fields intentionally not listed. Possible future use. Segment NT EQUIED at this time; fields intentionally not listed. Possible future use. DU/PPS SEGMENT Segment PTINAL For B1, B2, B3, P1, P2, P3 and P4 Segment NT SENT For E1 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 08=DU/PPS Segment 473-7E DU/PPS CDE CUNTE W*** Max = E4 EASN F SEVICE CDE W*** 44Ø-E5 PFESSINAL SEVICE CDE Max = 9 W*** Max = E6 ESULT F SEVICE CDE W*** Max = E DU/PPS LEVEL F EFFT 475-J9 DU C-AGENT ID QUALIFIE 476-H6 DU C-AGENT ID PICING SEGMENT Segment MANDATY For B1, B3 and P1 Segment EQUIED For P3 and P4 Segment PTINAL For B2 and P2 Segment NT SENT For E1 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 11=Pricing Segment 4Ø9-D9 INGEDIENT CST SUBMITTED 412-DC DISPENSING FEE SUBMITTED 477-BE PFESSINAL SEVICE FEE Not supported SUBMITTED 433-DX PATIENT PAID AMUNT SUBMITTED 438-E3 INCENTIVE AMUNT SUBMITTED Not supported 478-H7 THE AMUNT CLAIMED Not supported SUBMITTED CUNT 479-H8 THE AMUNT CLAIMED Not supported SUBMITTED QUALIFIE 48Ø-H9 THE AMUNT CLAIMED Not supported SUBMITTED 481-HA FLAT SALES TAX AMUNT SUBMITTED 482-GE PECENTAGE SALES TAX AMUNT W equired in States with sales tax SUBMITTED 483-HE PECENTAGE SALES TAX ATE W equired in States with sales tax SUBMITTED 484-JE PECENTAGE SALES TAX BASIS W equired in States with sales tax SUBMITTED 426-DQ USUAL AND CUSTMAY CHAGE M 43Ø-DU GSS AMUNT DUE 423-DN BASIS F CST DETEMINATIN Proprietary. Do not disclose without written permission of First Health. 7

9 CUPN SEGMENT Segment NT EQUIED at this time; fields intentionally not listed. Possible future use. CMPUND SEGMENT Segment NT EQUIED at this time; fields intentionally not listed. Possible future use. PI AUTHIZATIN Segment Segment MANDATY For P1, P3 and P4 Segment PTINAL For B1, B3 and P2 Segment NT SENT For E1and B2 Field Field Name M,, W, First Health x Values Supported 111- SEGMENT IDENTIFICATIN M 12=Prior Authorization Segment AM 498-PA EQUEST TYPE M 498-PB EQUEST PEID DATE-BEGIN M 498-PC EQUEST PEID DATE-END M 498-PD BASIS F EQUEST M 498-PE AUTHIZED EPESENTATIVE FIST NAME 498-PF AUTHIZED EPESENTATIVE LAST NAME 498-PG AUTHIZED EPESENTATIVE STEET ADDESS 498-PH AUTHIZED EPESENTATIVE CITY ADDESS 498-PJ AUTHIZED EPESENTATIVE STATE/PVINCE ADDESS 498-PK AUTHIZED EPESENTATIVE ZIP/PSTAL ZNE 498-PY PI AUTHIZATIN NUMBE- -ASSIGNED 5Ø3-F3 AUTHIZATIN NUMBE 498-PP PI AUTHIZATIN SUPPTING DCUMENTATIN CLINICAL SEGMENT Segment PTINAL For B1, B3, P1and P4 Segment NT SENT For E1, B2, P2 and P3 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 13=Clinical Segment 491-VE DIAGNSIS CDE CUNT 492-WE DIAGNSIS CDE QUALIFIE 424-D DIAGNSIS CDE 493-XE CLINICAL INFMATIN CUNTE 494-ZE MEASUEMENT DATE 495-H1 MEASUEMENT TIME 496-H2 MEASUEMENT DIMENSIN 497-H3 MEASUEMENT UNIT 499-H4 MEASUEMENT VALUE Proprietary. Do not disclose without written permission of First Health. 8

10 esponse Segments and Field equirements Paid or Duplicate of Paid TANSACTIN HEADE SEGMENT Segment MANDATY For All Transactions Field Field Name M,, W, First Health x Values Supported 1Ø2-A2 VESIN/ELEASE NUMBE M Same value as in request billing 1Ø3-A3 TANSACTIN CDE M Same value as in request billing 1Ø9-A9 TANSACTIN CUNT M Same value as in request billing 5Ø1-F1 HEADE ESPNSE STATUS M A 2Ø2-B2 SEVICE PVIDE ID QUALIFIE M Same value as in request billing 2Ø1-B1 SEVICE PVIDE ID M Same value as in request billing 4Ø1-D1 DATE F SEVICE M Same value as in request billing ESPNSE MESSAGE SEGMENT Segment PTINAL For All Transactions Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 20=esponse Message Segment 5Ø4-F4 MESSAGE ESPNSE INSUANCE SEGMENT Segment PTINAL For E1, B1, B3, P1, P3 and P4 Segment NT SENT for B2 and P2 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 25=esponse Insurance Segment 3Ø1-C1 GUP ID 524-F PLAN ID 545-2F NETWK EIMBUSEMENT ID 568-J7 PAY ID QUALIFIE 569-J8 PAY ID ESPNSE STATUS SEGMENT Segment MANDATY For All Transactions Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 21=esponse Status Segment 112-AN TANSACTIN ESPNSE STATUS M 5Ø3-F3 AUTHIZATIN NUMBE 547-5F APPVED MESSAGE CDE CUNT 548-6F APPVED MESSAGE CDE ****** 526-FQ ADDITINAL MESSAGE INFMATIN 549-7F HELP DESK PHNE NUMBE QUALIFIE 55Ø-8F HELP DESK PHNE NUMBE Proprietary. Do not disclose without written permission of First Health. 9

11 ESPNSE CLAIM SEGMENT Segment MANDATY For B1, B2, B3, P1, P2, P3 and P4 Segment NT SENT For E1 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 22=esponse Claim Segment 455-EM PESCIPTIN/SEVICE EFENCE M NUMBE QUALIFIE 4Ø2-D2 PESCIPTIN/SEVICE EFENCE M NUMBE 551-9F PEFEED PDUCT CUNT 552-AP PEFEED PDUCT ID QUALIFIE ****** 553-A PEFEED DUCT ID ****** 554-AS PEFEED PDUCT INCENTIVE ****** 555-AT PEFEED PDUCT C-PAY ****** INCENTIVE 556-AU PEFEED PDUCT DESCIPTIN ****** ESPNSE PICING SEGMENT Segment MANDATY For B1and B3 Segment PTINAL For P1, P3 and P4 Segment NT SENT For E1, B2 and P2 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 23=esponse Pricing Segment 5Ø5-F5 PATIENT PAY AMUNT W eturned when the processor determines that the patient has payment responsibility for part/all of the claim. 5Ø6-F6 INGEDIENT CST PAID W eturned when the processor determines that the patient has payment responsibility for part/all of the claim. 5Ø7-F7 DISPENSING FEE PAID W eturned when the processor determines that the patient has payment responsibility for part/all of the claim. 557-AV TAX EXEMPT INDICAT 558-AW FLAT SALES TAX AMUNT PAID 559-AX PECENTAGE SALES TAX AMUNT W equired in states with sales tax PAID 56Ø-AY PECENTAGE SALES TAX ATE PAID W equired in states with sales tax 561-AZ PECENTAGE SALES TAX BASIS W equired in states with sales tax PAID 521-FL INCENTIVE AMUNT PAID 562-J1 PEFESSINAL SEVICE FEE PAID 563-J2 THE AMUNT PAID CUNT 564-J3 THE AMUNT PAID QUALIFIE 565-J4 THE AMUNT PAID 566-J5 THE PAY AMUNT ECGNIZED 5Ø9-F9 TTAL AMUNT PAID 522-FM BASIS F EIMBUSEMENT DETEMINATIN 523-FN AMUNT ATTIBUTED T SALES TAX ESPNSE PICING SEGMENT table continued on next page. Proprietary. Do not disclose without written permission of First Health. 10

12 ESPNSE PICING SEGMENT (continued) Segment MANDATY For B1and B3 Segment PTINAL For P1, P3 and P4 Segment NT SENT For E1, B2 and P2 Field Field Name M,, W, First Health x Values Supported 512-FC ACCUMULATED DEDUCTIBLE AMUNT 513-FD EMAINING DEDUCTIBLE AMUNT 514-FE EMAINING BENEFIT AMUNT 517-FH AMUNT APPLIED T PEIDIC W DEDUCTIBLE eturned when the processor determines that the patient has payment responsibility for part/all of the claim. 518-FI AMUNT F C-PAY/CINSUANCE W eturned when the processor determines that the patient has payment responsibility for part/all of the claim. 519-FJ AMUNT ATTIBUTED T PDUCT SELECTIN 52Ø-FK AMUNT EXCEEDING PEIDIC BENEFIT MAXIMUM 346-HH BASIS F CALCULATIN DISPENSING FEE 347-HJ BASIS F CALCULATIN C-PAY 348-HK BASIS F CALCULATIN FLAT SALES TAX 349-HM BASIS F CALCULATIN PECENTAGE SALES TAX ESPNSE DU/PPS SEGMENT Segment PTINAL For B1, B3, P1, P3 and P4 Segment NT SENT For E1, B2 and P2 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 24=esponse DU/PPS Segment 567-J6 DU/PPS ESPNSE CDE CUNTE ****** 439-E4 EASN F SEVICE CDE ****** 528-FS CLINICAL SIGNIFICANCE CDE ****** 529-FT THE PHAMACY INDICAT ****** 53Ø-FU PEVIUS DATE F FILL ****** 531-FV QUANTITY F PEVIUS FILL ****** 532-FW DATABASE INDICAT ****** 533-FX THE PESCIBE INDICAT ****** 544-FY DU FEE TEXT MESSAGE ****** Proprietary. Do not disclose without written permission of First Health. 11

13 ESPNSE PI AUTHIZATIN SEGMENT Segment MANDATY For P1 and P4 Segment PTINAL For P3 Segment NT SENT For E1, B1, B2, B3 and P2 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 12=esponse Prior Auth Segment 498-P PI AUTHIZATIN PCESSED DATE 498-PS PI AUTHIZATIN EFFECTIVE DATE 498-PT PI AUTHIZATIN EXPIATIN DATE 498-A PI AUTHIZATIN QUANTITY 498-B PI AUTHIZATIN DLLAS AUTHIZED 498-PW PI AUTHIZATIN NUMBE F EFILLS AUTHIZED 498-PX PI AUTHIZATIN QUANTITY ACCUMULATED 498-PY PI AUTHIZATIN NUMBE ASSIGNED Proprietary. Do not disclose without written permission of First Health. 12

14 esponse Segments and Field equirements Transaction ejected TANSACTIN HEADE SEGMENT Segment MANDATY For All Transactions Field Field Name M,, W, First Health x Values Supported 1Ø2-A2 VESIN/ELEASE NUMBE M Same value as in request billing 1Ø3-A3 TANSACTIN CDE M Same value as in request billing 1Ø9-A9 TANSACTIN CUNT M Same value as in request billing 5Ø1-F1 HEADE ESPNSE STATUS M A 2Ø2-B2 SEVICE PVIDE ID QUALIFIE M Same value as in request billing 2Ø1-B1 SEVICE PVIDE ID M Same value as in request billing 4Ø1-D1 DATE F SEVICE M Same value as in request billing ESPNSE MESSAGE SEGMENT Segment PTINAL For All Transactions Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 20=esponse Message Segment 5Ø4-F4 MESSAGE ESPNSE INSUANCE SEGMENT Segment PTINAL For B1, B3, P1, P3 and P4 Segment NT SENT For E1, B2 and P2 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 25=esponse Insurance Segment 3Ø1-C1 GUP ID 524-F PLAN ID 545-2F NETWK EIMBUSEMENT ID 568-J7 PAY ID QUALIFIE 569-J8 PAY ID ESPNSE STATUS SEGMENT Segment MANDATY For All Transactions Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 21=esponse Status Segment 112-AN TANSACTIN ESPNSE STATUS M 5Ø3-F3 AUTHIZATIN NUMBE 51Ø-FA EJECT CUNT 511-FB EJECT CDE 546-4F EJECT FIELD CCUENCE W INDICAT 547-5F APPVED MESSAGE CDE CUNT 548-6F APPVED MESSAGE CDE 526-FQ ADDITINAL MESSAGE INFMATIN 549-7F HELP DESK PHNE NUMBE QUALIFIE 55Ø-8F HELP DESK PHNE NUMBE Proprietary. Do not disclose without written permission of First Health. 13

15 ESPNSE CLAIM SEGMENT Segment MANDATY For B1, B2, B3, P1, P2, P3 and P4 Segment NT SENT For E1 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 07=esponse Claim Segment 455-EM PESCIPTIN/SEVICE EFENCE M NUMBE QUALIFIE 4Ø2-D2 PESCIPTIN/ SEVICE EFENCE M NUMBE 551-9F PEFEED PDUCT CUNT 552-AP PEFEED PDUCT ID QUALIFIE ****** 553-A PEFEED DUCT ID ****** 554-AS PEFEED PDUCT INCENTIVE ****** 555-AT PEFEED PDUCT C-PAY ****** INCENTIVE 556-AU PEFEED PDUCT DESCIPTIN ****** ESPNSE DU/PPS SEGMENT Segment PTINAL For B1, B3, P1, P3 and P4 Segment NT SENT For E1, B2 and P2 Field Field Name M,, W, First Health x Values Supported 111-AM SEGMENT IDENTIFICATIN M 08=esponse DU/PPS Segment 567-J6 DU/PPS ESPNSE CDE CUNTE ****** 439-E4 EASN F SEVICE CDE ****** 528-FS CLINICAL SIGNIFICANCE CDE ****** 529-FT THE PHAMACY INDICAT ****** 53Ø-FU PEVIUS DATE F FILL ****** 531-FV QUANTITY F PEVIUS FILL ****** 532-FW DATABASE INDICAT ****** 533-FX THE PESCIBE INDICAT ****** 544-FY DU FEE TEXT MESSAGE ****** Proprietary. Do not disclose without written permission of First Health. 14