GENERAL INFORMATION. FIELD LEGEND FOR COLUMNS Payer Usage Column

Transcription

1 Department of Labor United States Department of Labor Division of Energy Employees Occupational Illness Compensation REQUEST CLAI REVERSAL PAYER SHEET ** Start of Request Claim Reversal (B2) Payer Sheet Template** GENERAL INFORATION Payer Name: Department of Labor Date: January 1, 2Ø12 (test) PCN: DRWDPROD = Production PCN: DRWDACCP = 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 RW Required when. The situations designated have qualifications for usage ( Required if x, Not required if y ). NOT USED NA The Field is not used for the Segment in the designated Transaction. Not used are shaded for clarity for the Payer when creating the Template. For the actual Payer Template, not used fields must be deleted from the transaction (the row in the table removed). No Yes No Question What is your reversal window? (If transaction is billed today what is the timeframe for reversal to be submitted?) Specify timeframe Answer Unlimited CLAI REVERSAL TRANSACTION The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Transaction Header Segment Questions Check Claim Reversal 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 1Ø4-A4 PROCESSOR CONTROL NUBER DRWDPROD = Production DRWDACCP = Test. 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1 = National Provider Identifier (NPI). 11Ø-AK SOFTWAREVENDOR/CERTIFICATION ID This will be provided by the provider's software vender Claim Reversal If no number is supplied, populate with zeros

2 Insurance Segment Questions Check Claim Reversal Insurance Segment Segment Identification (111-A) = Ø4 3Ø2-C2 CARDHOLDER ID SSN 3Ø1-C1 GROUP ID OWCP1222 R Claim Reversal Claim Segment Questions Check Claim Reversal Claim Segment Claim Reversal Segment Identification (111-A) = Ø7 455-E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 1 = R 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 pharmacy NUBER 436-E1 PRODUCT/SERVICE ID QUALIFIER Ø3 = NDC 4Ø7-D7 PRODUCT/SERVICE ID NDC Number 4Ø3-D3 FILL NUBER Ø = Original Dispensing 1-99 = Number of refills R Required in D.0 ** End of Request Claim Reversal (B2) Payer Sheet Template**

3 DEPARTENT OF LABOR United States Department of Labor Division of Energy Employees Occupational Illness Compensation CLAI REVERSAL ACCEPTED/APPROVED RESPONSE ** Start of Claim Reversal Response (B2) Payer Sheet Template** GENERAL INFORATION Payer Name: Department of Labor Date: January 1, 2Ø12 (test) PCN: DRWDPROD = Production PCN: DRWDACCP = Test CLAI REVERSAL ACCEPTED/APPROVED RESPONSE The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Response Transaction Header Segment Questions Check Response Transaction Header Segment 1Ø2-A2 VERSION/RELEASE NUBER DØ 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1 = National Provider Identifier (NPI). Response essage Segment Questions Check This Segment is situational Used if necessary to elaborate on Header level rejects. Response essage Segment Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE RW Required if text is needed for clarification or detail. Response Status Segment Questions Check Response Status Segment 112-AN TRANSACTION RESPONSE STATUS A = Approved 5Ø3-F3 AUTHORIZATION NUBER 17-digit DOL TCN R 546-4F REJECT FIELD OCCURRENCE INDICATOR RW Required if a repeating field is in error, to identify repeating field occurrence. 13Ø-UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. RW Required if Additional essage Information 132-UH ADDITIONAL ESSAGE INFORATION QUALIFIER RW Required if Additional essage Information 526-FQ ADDITIONAL ESSAGE INFORATION RW Required when additional text is needed for clarification or detail.

4 Response Status Segment 131-UG ADDITIONAL ESSAGE INFORATION RW CONTINUITY 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 Response Claim Segment 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

5 CLAI REVERSAL ACCEPTED/REJECTED RESPONSE Response Transaction Header Segment Questions Check Claim Reversal - Accepted/Rejected Response Transaction Header Segment 1Ø2-A2 VERSION/RELEASE NUBER DØ 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1 = National Provider Identifier (NPI). Response essage Segment Questions Check Claim Reversal - Accepted/Rejected This Segment is situational Used if necessary to elaborate on Header level rejects. Response essage Segment Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE RW Required if text is needed for clarification or detail. Response Status Segment Questions Check Claim Reversal - Accepted/Rejected Response Status Segment 112-AN TRANSACTION RESPONSE STATUS R = Reject 5Ø3-F3 AUTHORIZATION NUBER R 51Ø-FA REJECT COUNT aximum count of 5. R 511-FB REJECT CODE R 546-4F REJECT FIELD OCCURRENCE INDICATOR RW Required if a repeating field is in error, to identify repeating field occurrence. 13Ø-UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. RW Imp Guide: Required if Additional essage Information 132-UH ADDITIONAL ESSAGE INFORATION QUALIFIER RW Required if Additional essage Information 526-FQ ADDITIONAL ESSAGE INFORATION RW Required when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFORATION CONTINUITY Response Claim Segment Questions Check Claim Reversal - Accepted/Rejected 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 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).

6 Response Claim Segment Segment Identification (111-A) = 22 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE Number assigned by the NUBER pharmacy

7 CLAI REVERSAL REJECTED/REJECTED RESPONSE Response Transaction Header Segment Questions Check Claim Reversal - Rejected/Rejected Response Transaction Header Segment 1Ø2-A2 VERSION/RELEASE NUBER DØ 5Ø1-F1 HEADER RESPONSE STATUS R = Rejected 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1 = National Provider Identifier (NPI). Claim Reversal Rejected/Rejected Response essage Segment Questions Check Claim Reversal Rejected/Rejected This Segment is situational Used if necessary to elaborate on Header level rejects. Response essage Segment Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE RW Required if text is needed for clarification or detail. Response Status Segment Questions Check Claim Reversal - Rejected/Rejected Response Status Segment Claim Reversal Rejected/Rejected 112-AN TRANSACTION RESPONSE STATUS R = Reject 5Ø3-F3 AUTHORIZATION NUBER R 51Ø-FA REJECT COUNT aximum count of 5. R 511-FB REJECT CODE R 546-4F REJECT FIELD OCCURRENCE INDICATOR RW Required if a repeating field is in error, to identify repeating field occurrence. 13Ø-UF ADDITIONAL ESSAGE INFORATION COUNT aximum count of 25. RW Required if Additional essage Information 132-UH ADDITIONAL ESSAGE INFORATION QUALIFIER RW Required if Additional essage Information 526-FQ ADDITIONAL ESSAGE INFORATION RW Imp Guide: Required when additional text is needed for clarification or detail. 131-UG ADDITIONAL ESSAGE INFORATION CONTINUITY RW 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 Claim Reversal (B2) Response Payer Sheet Template** Payer Requirement: (any unique payer requirement(s))