HAWAII MEDICAID. REQUEST CLAIM REVERSAL PAYER SHEET TEMPLATE ** Start of Request Claim Reversal (B2) Payer Sheet Template** GENERAL INFORMATION

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1 HAWAII EDICAID REQUEST CLAI REVERSAL PAYER SHEET TEPLATE ** Start of Request (B2) Payer Sheet Template** GENERAL INFORATION Payer Name: Hawaii edicaid Fee for Service Date: January 1, 2Ø12 Plan Name/Group Name: Hawaii edicaid BIN: 61ØØ84 PCN: DRHIPROD = Production Plan Name/Group Name: Hawaii edicaid (test) BIN: 61ØØ84 PCN: DRHIACCP = 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 ). No Yes Question What is your reversal window? (If transaction is billed today what is the timeframe for reversal to be submitted?) Specify timeframe 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 DRHIPROD = Production DRHIACCP = Test. 1Ø9-A9 TRANSACTION 1 = One Occurrence 2Ø2-B2 SERVICE PROVIDER ID Ø1 = National Provider Identifier 2Ø1-B1 SERVICE PROVIDER ID NPI Number 4Ø1-D1 DATE OF SERVICE CCYYDD 11Ø-AK SOFTWAREVENDOR/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 1Ø digit Hawaii edicaid ID Number 3Ø1-C1 GROUP ID HAWAII1ØØØ R OYS members use -

2 Insurance Segment Segment Identification (111-A) = Ø4 HAWAII2ØØØ Claim Segment Questions Check Claim Segment Segment Identification (111-A) = Ø7 455-E PRESCRIPTION/SERVICE REFERENCE NUBER 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 Ø3 = NDC 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 RW Required when submitting a claim for a recipient who has other coverage. Values 5, 6 and 7 are not allowed in D.Ø ** 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: Hawaii edicaid Fee for Service Date: January 1, 2Ø12 Plan Name/Group Name: Hawaii edicaid BIN: 61ØØ84 PCN: DRDPROD = Production Plan Name/Group Name: Hawaii edicaid (test) BIN: 61ØØ84 PCN: DRDACCP = 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. Questions Check 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B2 1Ø9-A9 TRANSACTION 1 = One Occurrence 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 2Ø2-B2 SERVICE PROVIDER ID Ø1 = National Provider Identifier 2Ø1-B1 SERVICE PROVIDER ID NPI Number 4Ø1-D1 DATE OF SERVICE CCYYDD

3 Questions Check Segment Identification (111-A) = AN TRANSACTION RESPONSE STATUS A = Approved 5Ø3-F3 AUTHORIZATION NUBER 17-digit HI TCN R 13Ø-UF ADDITIONAL ESSAGE INFORATION aximum count of 25. RW Required if Additional essage Information 132-UH ADDITIONAL ESSAGE INFORATION 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 RW 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 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 Questions Check - Accepted/Rejected 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B2 1Ø9-A9 TRANSACTION 1 = One Occurrence 5Ø1-F1 HEADER RESPONSE STATUS A = Accepted 2Ø2-B2 SERVICE PROVIDER ID Ø1 = National Provider Identifier 2Ø1-B1 SERVICE PROVIDER ID NPI Number 4Ø1-D1 DATE OF SERVICE CCYYDD Accepted/Rejected Response essage Segment Questions Check - Accepted/Rejected This Segment is situational Segment sent if required for reject clarification Response essage Segment Segment Identification (111-A) = 2Ø

4 5Ø4-F4 ESSAGE RW Required if text is needed for clarification or detail. Questions Check - Accepted/Rejected Segment Identification (111-A) = 21 Accepted/Rejected 112-AN TRANSACTION RESPONSE STATUS R = Reject 5Ø3-F3 AUTHORIZATION NUBER R 51Ø-FA REJECT aximum count of 5. R 511-FB REJECT CODE R 13Ø-UF ADDITIONAL ESSAGE INFORATION aximum count of 25. RW Imp Guide: Required if Additional essage Information 132-UH ADDITIONAL ESSAGE INFORATION 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 Response Claim Segment Questions Check - 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 Accepted/Rejected Segment Identification (111-A) = E PRESCRIPTION/SERVICE REFERENCE NUBER 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 REJECTED/REJECTED RESPONSE Questions Check - Rejected/Rejected 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B2 1Ø9-A9 TRANSACTION 1 = One Occurrence 5Ø1-F1 HEADER RESPONSE STATUS R = Rejected 2Ø2-B2 SERVICE PROVIDER ID Ø1 = National Provider Identifier 2Ø1-B1 SERVICE PROVIDER ID NPI Number 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 Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE RW Required if text is needed for clarification or detail. Questions Check - Rejected/Rejected Rejected/Rejected Segment Identification (111-A) = AN TRANSACTION RESPONSE STATUS R = Reject 5Ø3-F3 AUTHORIZATION NUBER R 51Ø-FA REJECT aximum count of 5. R 511-FB REJECT CODE R 13Ø-UF ADDITIONAL ESSAGE INFORATION aximum count of 25. RW Required if Additional essage Information 132-UH ADDITIONAL ESSAGE INFORATION 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 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 (B2) Response Payer Sheet Template** Payer Requirement: (any unique payer requirement(s))