MONTANA MEDICAID/MONTANA MENTAL HEALTH REQUEST CLAIM REVERSAL PAYER SHEET ** Start of Request Claim Reversal (B2) Payer Sheet Template**

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1 ONTANA EDICAID/ONTANA ENTAL HEALTH REQUEST CLAI REVERSAL PAYER SHEET ** Start of Request (B2) Payer Sheet Template** GENERAL INFORATION Payer Name: ontana edicaid Date: January 1, 2Ø12 Plan Name/Group Name: ontana edicaid/ontana ental Health BIN: 61ØØ84 Services (HSP) Plan Name/Group Name: ontana edicaid/ontana ental Health BIN: 61ØØ84 Services (HSP) (test) PCN: DRTPROD = Production PCN: DRTACCP = Test FIELD LEGEND FOR COLUNS Payer 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. QUALIFIED REQUIREENT Required when. The situations designated have qualifications for usage ( Required if x, Not required if y ). No Yes Question What is your reversal window? (If transaction is billed today what is the timeframe for reversal to be submitted?) Answer 365 days CLAI REVERSAL TRANSACTION The following lists the segments and fields in a Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Transaction Header Segment Questions Check Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Not used Transaction Header Segment 1Ø1-A1 BIN NUBER Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B2 1Ø4-A4 PROCESSOR CONTROL NUBER DRTPROD = Production This is the same for T ental Health DRTACCP = Test 1Ø9-A9 TRANSACTION COUNT 1 = One Occurrence Count of transactions in the transmission. 2 = Two Occurrences 3 = Three Occurrences 4 = Four Occurrences 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1 = National Provider NPI mandatory 05/23/2008 Identifier (NPI) 2Ø1-B1 SERVICE PROVIDER ID NPI Number NPI mandatory 05/23/2008 4Ø1-D1 DATE OF SERVICE CCYYDD 11Ø-AK SOFTWARE VENDOR/CERTIFICATION ID This will be provided by the provider's software vender If no number is supplied, populate with zeros Insurance Segment Questions Check Insurance Segment Segment Identification (111-A) = Ø4 3Ø2-C2 CARDHOLDER ID Use client s 9-digit ID number

2 Insurance Segment Segment Identification (111-A) = Ø4 3Ø1-C1 GROUP ID edicaid: 15Ø9Ø4Ø R HSP: ØØ642Ø642Ø Claim Segment Questions Check Claim Segment Segment Identification (111-A) = Ø7 455-E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 1 = Rx Billing For Transaction Code of B2, in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 1 (Rx Billing). 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE Number assigned by the NUBER pharmacy 436-E1 PRODUCT/SERVICE ID QUALIFIER Ø3 = National Drug Code 4Ø7-D7 PRODUCT/SERVICE ID NDC Number 4Ø3-D3 FILL NUBER Ø = Original Dispensing 1-99 = Number of refills R 3Ø8-C8 OTHER COVERAGE CODE 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 Required when submitting a claim for a recipient who has other coverage. Values 5, 6, 7, and 8 are not allowed in D.Ø Pricing Segment Questions Check Pricing Segment Segment Identification (111-A) = 11 Coordination of Benefits/Other Payments Segment Questions This Segment is situational Check Coordination of Benefits/Other Payments Segment Segment Identification (111-A) = Ø C COORDINATION OF BENEFITS/OTHER aximum count of 9. PAYENTS COUNT 338-5C OTHER PAYER COVERAGE TYPE DUR/PPS Segment Segment Identification (111-A) = Ø E DUR/PPS CODE COUNTER aximum of 9 occurrences. R Required when submitting this segment 439-E4 REASON FOR SERVICE CODE See Attached list of valid values 44Ø-E5 PROFESSIONAL SERVICE CODE See Attached list of valid values Required when there is a conflict to resolve or reason for service to be explained. Required when there is a professional service to be

3 DUR/PPS Segment Segment Identification (111-A) = Ø8 441-E6 RESULT OF SERVICE CODE See Attached list of valid values identified. Required when There is a result of service to be submitted. ** End of Request (B2) Payer Sheet Template** RESPONSE CLAI REVERSAL PAYER SHEET TEPLATE CLAI REVERSAL ACCEPTED/APPROVED RESPONSE ** Start of Response (B2) Payer Sheet Template** GENERAL INFORATION Payer Name: ontana edicaid Date: January 1, 2Ø12 Plan Name/Group Name: ontana edicaid/ontana ental Health BIN: 61ØØ84 Services (HSP) Plan Name/Group Name: ontana edicaid/ontana ental Health BIN: 61ØØ84 Services (HSP) (test) PCN: DRTPROD = Production PCN: DRTACCP = Test CLAI REVERSAL ACCEPTED/APPROVED RESPONSE The following lists the segments and fields in a response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Response Transaction Header Segment Questions Check Accepted/Approved Response Transaction Header Segment 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B2 1Ø9-A9 TRANSACTION COUNT Same value as in request 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Same value as in request 2Ø1-B1 SERVICE PROVIDER ID Same value as in request 4Ø1-D1 DATE OF SERVICE CCYYDD Accepted/Approved Response Status Segment Questions Check Accepted/Approved Response Status Segment 112-AN TRANSACTION RESPONSE STATUS A = Approved Accepted/Approved 5Ø3-F3 AUTHORIZATION NUBER 17-digit T TCN R 13Ø-UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. Required if Additional essage Information 132-UH ADDITIONAL ESSAGE INFORATION QUALIFIER Required if Additional essage Information 526-FQ ADDITIONAL ESSAGE INFORATION Required when additional text is needed for clarification or detail.

4 Response Status Segment 131-UG ADDITIONAL ESSAGE INFORATION CONTINUITY Accepted/Approved Required if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526-FQ) follows it, and the text of the following message is a continuation of the current. Response Claim Segment Questions Check Accepted/Approved Response Claim Segment Accepted/Approved Segment Identification (111-A) = E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 1 = RxBilling For Transaction Code of B2, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 1 (Rx Billing). 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUBER Number assigned by the pharmacy CLAI REVERSAL ACCEPTED/REJECTED RESPONSE Response Transaction Header Segment Questions Check - Accepted/Rejected Response Transaction Header Segment 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B2 1Ø9-A9 TRANSACTION COUNT Same value as in request 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Same value as in request 2Ø1-B1 SERVICE PROVIDER ID Same value as in request 4Ø1-D1 DATE OF SERVICE CCYYDD Accepted/Rejected Response essage Segment Questions Check - Accepted/Rejected This Segment is situational Used if necessary to elaborate on Header level rejects. Response essage Segment Accepted/Rejected Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE Required if text is needed for clarification or detail. Response Status Segment Questions Check - Accepted/Rejected Response Status Segment 112-AN TRANSACTION RESPONSE STATUS R = Reject 5Ø3-F3 AUTHORIZATION NUBER 17-digit T TCN R 51Ø-FA REJECT COUNT aximum count of 5. R Accepted/Rejected

5 Response Status Segment Accepted/Rejected 511-FB REJECT CODE R 546-4F REJECT FIELD OCCURRENCE INDICATOR Required if a repeating field is in error, to identify repeating field occurrence. 13Ø-UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. Imp Guide: Required if Additional essage Information 132-UH ADDITIONAL ESSAGE INFORATION QUALIFIER Required if Additional essage Information 526-FQ ADDITIONAL ESSAGE INFORATION Required when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFORATION CONTINUITY Imp Guide: Required if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526-FQ) follows it, and the text of the following message is a continuation of the current. Response Claim Segment Questions Check - Accepted/Rejected Response Claim Segment Accepted/Rejected Segment Identification (111-A) = E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 1 = RxBilling For Transaction Code of B2, in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-E) is 1 (Rx Billing). 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUBER Number assigned by the pharmacy CLAI REVERSAL REJECTED/REJECTED RESPONSE Response Transaction Header Segment Questions Check - Rejected/Rejected Response Transaction Header Segment 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B2 1Ø9-A9 TRANSACTION COUNT Same value as in request 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Same value as in request 2Ø1-B1 SERVICE PROVIDER ID Same value as in request 4Ø1-D1 DATE OF SERVICE CCYYDD Rejected/Rejected Response essage Segment Questions Check Rejected/Rejected This Segment is situational Used if necessary to elaborate on Header level rejects. Response essage Segment Rejected/Rejected Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE Required if text is needed for clarification or detail.

6 Response Status Segment Questions Check - Rejected/Rejected Response Status Segment Rejected/Rejected 112-AN TRANSACTION RESPONSE STATUS R = Reject 5Ø3-F3 AUTHORIZATION NUBER 17-digit T TCN R 51Ø-FA REJECT COUNT aximum count of 5. R 511-FB REJECT CODE R 546-4F REJECT FIELD OCCURRENCE INDICATOR Required if a repeating field is in error, to identify repeating field occurrence. 13Ø-UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. Required if Additional essage Information 132-UH ADDITIONAL ESSAGE INFORATION QUALIFIER Required if Additional essage Information 526-FQ ADDITIONAL ESSAGE INFORATION Imp Guide: Required when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFORATION CONTINUITY Imp Guide: Required if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526-FQ) follows it, and the text of the following message is a continuation of the current. ** End of (B2) Response Payer Sheet Template**