AETNA NCPDP D.Ø CLAIM BILLING (B1) COMMERCIAL PAYER SHEET

Transcription

1 AETNA NCPDP D.Ø CLAIM BILLING (B1) COMMECIAL PAYE SHEET IMPLEMENTATION GUIDE FO VESION D.Ø VESION 2.Ø June 2Ø12 TABLE OF CONTENTS

2 1. NCPDP VESION D CLAIM BILLING COMMECIAL EQUEST CLAIM BILLING COMMECIAL PAYE SHEET ESPONSE CLAIM BILLING COMMECIAL PAYE SHEET Commercial Accepted/Paid (or Duplicate of Paid) esponse Commercial Accepted/ejected esponse Commercial ejected/ejected esponse FEQUENTLY ASKED QUESTIONS APPENDI A. HISTOY OF IMPLEMENTATION GUIDE CHANGES VESION 1.Ø VESION 2.Ø... 18

3 1. NCPDP VESION D CLAIM BILLING COMMECIAL 1.1 EQUEST CLAIM BILLING COMMECIAL PAYE SHEET ** Start of equest (B1) Payer Sheet ** GENEAL INFOMATION Payer Name: Aetna Date: June 2012 Plan Name/Group Name: All BIN: 61Ø5Ø2 PCN: Processor: Aetna Pharmacy Management Effective as of: Fall 2011 (equired 1/1/2Ø12) NCPDP Telecommunication Standard Version/elease #: D.Ø NCPDP Data Dictionary Version Date: October 2011 NCPDP External Code List Version Date: October 2011 Contact/Information Source: NCPDPD.0Questions@aetna.com Provider elations Help Desk Info: 8ØØ OTHE TANSACTIONS SUPPOTED Transaction Code B2 Transaction Name Billing eversal FIELD LEGEND FO COLUMNS Payer Column Value Explanation Column MANDATOY M The Field is mandatory for the Segment in the designated Transaction. No EQUIED The Field has been designated with the situation of No "equired" for the Segment in the designated Transaction. QUALIFIED EQUIEMENT equired when. The situations designated have Yes qualifications for usage ("equired if x", "Not required if y"). NOT USED NA The field is not used. Do not submit. No OPTIONAL O The field is optional. Yes Fields that are defined as NOT USED in the D.Ø implementation guide should not be submitted. If a field that is defined as NOT USED is submitted, the transaction will be rejected. Fields that are defined as Optional in the D.Ø Implementation guide are not required for Aetna Processing however if they are submitted they must conform to NCPDP format. All Character fields will be checked for length limitations and the exceeding characters will be truncated. Example: A field can hold 2 Chars. If the value received for the field is ABC, the value will be truncated to 2 Chars and send AB. NOTE: Aetna only supports B1 and B2 Transactions. CLAIM BILLING TANSACTION 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 Payer Issued Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Switch/VAN issued Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Not used

4 Transaction Header Segment 1Ø1-A1 BIN NUMBE 61Ø5Ø2 M 1Ø2-A2 VESION/ELEASE NUMBE DØ M 1Ø3-A3 TANSACTION CODE B1 M 1Ø4-A4 POCESSO CONTOL NUMBE M 1Ø9-A9 TANSACTION COUNT 1-4 1=One Occurrence 2=Two Occurrences 3=Three Occurrences 4=Four Occurrences 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Ø1 Ø1 = NPI 2Ø1-B1 SEVICE POVIDE ID NPI M 4Ø1-D1 DATE OF SEVICE M 11Ø-AK SOFTWAE VENDO/CETIFICATION ID M Insurance Segment Questions Check M If COMPOUND CODE (4Ø6-D6) = 2, TANSACTION COUNT (1Ø9-A9) must = 1. M Insurance Segment Segment Identification (111-AM) = Ø4 3Ø2-C2 CADHOLDE ID M 336-8C FACILITY ID NA 3Ø1-C1 GOUP ID 3Ø3-C3 PESON CODE 3Ø6-C6 PATIENT ELATIONSHIP CODE The Group number from the member's ID card must be entered exactly as written on the card, excluding dashes and spaces. Patient Segment Questions Check This Segment is situational Patient Segment Segment Identification (111-AM) = Ø1 Field NCPDP Field Name Value Payer 3Ø4-C4 DATE OF BITH 3Ø5-C5 PATIENT GENDE CODE 31Ø-CA PATIENT FIST NAME 311-CB PATIENT LAST NAME 334-1C SMOKE/NON-SMOKE CODE NA

5 Claim Segment Questions Check This payer supports partial fills This payer does not support partial fills Claim Segment Segment Identification (111-AM) = Ø7 455-EM PESCIPTION/SEVICE EFEENCE 1 = x Billing M NUMBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE M NUMBE 436-E1 PODUCT/SEVICE ID QUALIFIE ØØ, Ø3 ØØ-Not Specified M Use ØØ when Compound Code (4Ø6-D6) = 2 Use Ø3 when Compound Code (4Ø6-D6) = 1 Ø3-National Drug Code (NDC) 4Ø7-D7 PODUCT/SEVICE ID M Use Ø when Compound Code (4Ø6-D6) = E7 QUANTITY DISPENSED Must be greater than zero 4Ø3-D3 FILL NUMBE Ø - Original dispensing efill number 4Ø5-D5 DAYS SUPPLY 4Ø6-D6 COMPOUND CODE 1, 2 4Ø8-D8 DISPENSE AS WITTEN (DAW)/PODUCT SELECTION CODE 1 = Not a Compound 2 = Compound Ø - No Product Selection Indicated 1 - Substitution Not Allowed by Prescriber 2 - Substitution Allowed-Patient equested Product Dispensed 3 - Substitution Allowed- Pharmacist Selected Product Dispensed 4 - Substitution Allowed-Generic Drug Not in Stock 5 - Substitution Allowed-Brand Drug Dispensed as a Generic 6 - Override 7 - Substitution Not Allowed-Brand Drug Mandated by Law 8 - Substitution Allowed-Generic Drug Not Available in Marketplace 9 - Substitution Allowed By Prescriber but Plan equests Brand 414-DE DATE PESCIPTION WITTEN 419-DJ PESCIPTION OIGIN CODE Ø 4 When claim is for a Multi-Source Brand the Dispense As Written cannot be Ø. If the DAW submitted is Ø the claim will reject. Ø - Not Known 1 - Written 2 - Telephone 3 - Electronic 4 - Facsimile 354-N SUBMISSION CLAIFICATION CODE 1, 2 or 3. equired when Submission Clarification Code COUNT is used 42Ø-DK SUBMISSION CLAIFICATION CODE 8 equired when pharmacist approves to process Compound for approved ingredients 8=Process Compound For only. Approved Ingredients 46Ø-ET QUANTITY PESCIBED NA 3Ø8-C8 OTHE COVEAGE CODE Ø - Not Specified by patient See COB Payer Sheet for COB values. 1 - No other coverage 418-DI LEVEL OF SEVICE 3 - Emergency equired when filling an emergency prescription.

6 Claim Segment Segment Identification (111-AM) = Ø7 88Ø-K5 TANSACTION EFEENCE NUMBE NA 995-E2 OUTE OF ADMINISTATION O 996-G1 COMPOUND TYPE equired when Compound Code (4Ø6-D6) = U7 PHAMACY SEVICE TYPE O Pricing Segment Questions Check Pricing Segment Segment Identification (111-AM) = 11 4Ø9-D9 INGEDIENT COST SUBMITTED 412-DC DISPENSING FEE SUBMITTED 477-BE POFESSIONAL SEVICE FEE NA SUBMITTED 478-H7 OTHE AMOUNT CLAIMED SUBMITTED COUNT Ø, 1, 2, 3 equired if Other Amount Claimed Submitted Qualifier (479-H8) is used. 479-H8 OTHE AMOUNT CLAIMED SUBMITTED QUALIFIE Ø1 to Ø4, 99 equired when Other Amount Claimed Submitted Qualifier and Other Amount Claimed Submitted Amount are used. equired if Other Amount Claimed Submitted (48Ø-H9) is used. (Blank is not allowed) Ø1 - Delivery Cost Ø2 - Shipping Cost Ø3 - Postage Cost Ø4 - Administrative Cost 99 - Other equired when Other Amount Claimed Submitted Count and Other Amount Claimed Submitted Amount are used. 48Ø-H9 OTHE AMOUNT CLAIMED SUBMITTED equired if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. equired when Other Amount Claimed Submitted Count and Other Amount Claimed Submitted Qualifier are used. 481-HA FLAT SALES TA AMOUNT SUBMITTED equired if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. 482-GE PECENTAGE SALES TA AMOUNT SUBMITTED equired if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. equired when Percentage Sales Tax ate Submitted and Percentage Sales Tax Basis Submitted are used. equired when percentage sales tax applies to the claim. 483-HE PECENTAGE SALES TA ATE SUBMITTED Note: This currently applies to the following states: MN, IL, and LA equired if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Basis Submitted (484-JE) are used. 484-JE PECENTAGE SALES TA BASIS SUBMITTED Ø2, Ø3 Ø2 - Ingredient Cost Ø3 - Ingredient Cost + Dispensing Fee equired if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax ate Submitted (483-HE) are used.

7 Pricing Segment Segment Identification (111-AM) = DQ USUAL AND CUSTOMAY CHAGE 43Ø-DU GOSS AMOUNT DUE Value in this field must balance with all submitted amount fields. 423-DN BASIS OF COST DETEMINATION Ø1-13 Ø1 - AWP (Average Wholesale Price) Ø2 - Local Wholesaler Ø3 - Direct Ø4 - EAC (Estimated Acquisition Cost) Ø5 - Acquisition Ø6 - MAC (Maximum Allowable Cost) Ø7 - Usual & Customary Ø8-34ØB / Disproportionate Share Pricing/Public Health Service Ø9 - Other 1Ø - ASP (Average Sales Price) 11 - AMP (Average Manufacturer Price) 12 - WAC (Wholesale Acquisition Cost) 13 - Special Patient Pricing The cost calculated by the pharmacy for the drug for this special patient. Prescriber Segment Questions Check This Segment is situational Prescriber Segment Segment Identification (111-AM) = Ø3 466-EZ PESCIBE ID QUALIFIE Ø1, Ø8, 12 Ø1=National Provider Identifier (NPI) Ø8=State License 12=Drug Enforcement Administration (DEA) 411-DB PESCIBE ID 367-2N PESCIBE STATE/POVINCE ADDESS 467-1E PESCIBE LOCATION CODE NA

8 DU/PPS Segment Questions Check This Segment is situational DU/PPS Segment Segment Identification (111-AM) = Ø E DU/PPS CODE COUNTE Maximum of 9 occurrences. equired if DU/PPS Segment is used. 439-E4 EASON FO SEVICE CODE equired when used for DU conflict resolution (drug/drug interactions or therapeutic duplication) 44Ø-E5 POFESSIONAL SEVICE CODE equired when used for DU conflict resolution 441-E6 ESULT OF SEVICE CODE equired when used for DU conflict resolution 474-8E DU/PPS LEVEL OF EFFOT Ø, equired when Compound Code (4Ø6-D6) = 2 Ø - Not Specified 11 - Level 1 (Lowest) 12 - Level Level Level Level 5 (Highest) Coupon Segment Questions Check This Segment is situational Coupon Segment Segment Identification (111-AM) = Ø9 485-KE COUPON TYPE M 486-ME COUPON NUMBE M Compound Segment Questions Check This Segment is situational Compound Segment Segment Identification (111-AM) = 1Ø 45Ø-EF COMPOUND DOSAGE FOM M DESCIPTION CODE 451-EG COMPOUND DISPENSING UNIT FOM M INDICATO 447-EC COMPOUND INGEDIENT COMPONENT Maximum 25 ingredients M COUNT 488-E COMPOUND PODUCT ID QUALIFIE Ø3-National Drug Code (NDC) M 489-TE COMPOUND PODUCT ID M 448-ED COMPOUND INGEDIENT QUANTITY Must be greater than zero. M 449-EE COMPOUND INGEDIENT DUG COST Must be greater than zero. 49Ø-UE COMPOUND INGEDIENT BASIS OF COST DETEMINATION Ø1 - AWP (Average Wholesale Price) Ø2 - Local Wholesaler Ø3 - Direct Ø4 - EAC (Estimated Acquisition Cost)

9 Compound Segment Segment Identification (111-AM) = 1Ø Ø5 - Acquisition Ø6 - MAC (Maximum Allowable Cost) Ø7 - Usual & Customary Ø8-34ØB /Disproportionate Share Pricing/Public Health Service Ø9 - Other 1Ø - ASP (Average Sales Price) 11 - AMP (Average Manufacturer Price) 12 - WAC (Wholesale Acquisition Cost) 13 - Special Patient Pricing The cost calculated by the pharmacy for the drug for this special patient. Clinical Segment Questions Check This Segment is situational Clinical Segment Segment Identification (111-AM) = VE DIAGNOSIS CODE COUNT 492-WE DIAGNOSIS CODE QUALIFIE 424-DO DIAGNOSIS CODE O 493-E CLINICAL INFOMATION COUNTE O 494-ZE MEASUEMENT DATE O 495-H1 MEASUEMENT TIME O 496-H2 MEASUEMENT DIMENSION O 497-H3 MEASUEMENT UNIT O 499-H4 MEASUEMENT VALUE O ** End of equest (B1) Payer Sheet ** 1.2 ESPONSE CLAIM BILLING COMMECIAL PAYE SHEET CLAIM BILLING COMMECIAL ACCEPTED/PAID (O DUPLICATE OF PAID) ESPONSE ** Start of esponse (B1) Payer Sheet ** GENEAL INFOMATION Payer Name: Aetna Date: July 2Ø11 Plan Name/Group Name: All BIN: 61Ø5Ø2 PCN: CLAIM BILLING PAID (O DUPLICATE OF PAID) ESPONSE The following lists the segments and fields in a response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø.

10 esponse Transaction Header Segment Questions Check Accepted/Paid (or Duplicate of Paid) esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUMBE DØ M 1Ø3-A3 TANSACTION CODE B1 M 1Ø9-A9 TANSACTION COUNT Same value as in request M 5Ø1-F1 HEADE ESPONSE STATUS A = Accepted M 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request M 2Ø1-B1 SEVICE POVIDE ID Same value as in request M 4Ø1-D1 DATE OF SEVICE Same value as in request M Accepted/Paid (or Duplicate of Paid) esponse Message Segment Questions Check Accepted/Paid (or Duplicate of Paid) This Segment is situational If transmission level messaging applies. esponse Message Segment Segment Identification (111-AM) = 2Ø 5Ø4-F4 MESSAGE O Accepted/Paid (or Duplicate of Paid) esponse Insurance Segment Questions Check Accepted/Paid (or Duplicate of Paid) This Segment is situational esponse Insurance Segment Segment Identification (111-AM) = 25 Accepted/Paid (or Duplicate of Paid) 3Ø1-C1 GOUP ID 524-FO PLAN ID O Will send back if available 568-J7 PAYE ID QUALIFIE Ø3 Ø3 = Bank Identification Number (BIN) 569-J8 PAYE ID 61Ø5Ø2 3Ø2-C2 CADHOLDE ID O Will Send back the ID that is used in Adjudication, only if different than what was submitted on request. esponse Patient Segment Questions Check Accepted/Paid (or Duplicate of Paid) This Segment is situational When the submitted Patient First Name and/or Last Name are different than what is on the member record. esponse Patient Segment Segment Identification (111-AM) = 29 31Ø-CA PATIENT FIST NAME 311-CB PATIENT LAST NAME 3Ø4-C4 DATE OF BITH Accepted/Paid (or Duplicate of Paid)

11 esponse Status Segment Questions Check Accepted/Paid (or Duplicate of Paid) esponse Status Segment Segment Identification (111-AM) = AN TANSACTION ESPONSE STATUS P=Paid M D=Duplicate of Paid 5Ø3-F3 AUTHOIZATION NUMBE Accepted/Paid (or Duplicate of Paid) 13Ø-UF ADDITIONAL MESSAGE INFOMATION COUNT Maximum count of 9. equired if Additional Message Information (526-FQ) is used. 132-UH ADDITIONAL MESSAGE INFOMATION QUALIFIE equired if Additional Message Information (526-FQ) is used. 526-FQ ADDITIONAL MESSAGE INFOMATION equired when additional text is needed for clarification or detail. 131-UG ADDITIONAL MESSAGE INFOMATION CONTINUITY equired if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current F HELP DESK PHONE NUMBE Ø3. QUALIFIE 55Ø-8F HELP DESK PHONE NUMBE 8ØØ esponse Claim Segment Questions Check Accepted/Paid (or Duplicate of Paid) esponse Claim Segment Segment Identification (111-AM) = EM PESCIPTION/SEVICE EFEENCE 1 = xbilling M NUMBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE M NUMBE Accepted/Paid (or Duplicate of Paid) esponse Pricing Segment Questions Check Accepted/Paid (or Duplicate of Paid) esponse Pricing Segment Segment Identification (111-AM) = 23 Accepted/Paid (or Duplicate of Paid) 5Ø5-F5 PATIENT PAY AMOUNT 5Ø6-F6 INGEDIENT COST PAID 5Ø7-F7 DISPENSING FEE PAID 558-AW FLAT SALES TA AMOUNT PAID equired if Flat Sales Tax Amount Submitted (481-HA) is greater than zero (Ø).

12 esponse Pricing Segment Segment Identification (111-AM) = A PECENTAGE SALES TA AMOUNT PAID Accepted/Paid (or Duplicate of Paid).equired if Percentage Sales Tax Amount Submitted (482-GE) is greater than zero (Ø). equired if Percentage Sales Tax ate Paid (56Ø-AY) and Percentage Sales Tax Basis Paid (561-AZ) are used. 56Ø-AY PECENTAGE SALES TA ATE PAID equired if Percentage Sales Tax Amount Paid (559-A) is greater than zero (Ø). 561-AZ PECENTAGE SALES TA BASIS PAID equired if Percentage Sales Tax Amount Paid (559-A) is greater than zero (Ø). 521-FL INCENTIVE AMOUNT PAID equired if Incentive Amount Submitted (438-E3) is greater than zero (Ø). 563-J2 OTHE AMOUNT PAID COUNT Maximum count of 3. equired if Other Amount Paid (565-J4) is used. 564-J3 OTHE AMOUNT PAID QUALIFIE equired if Other Amount Paid (565-J4) is used. 565-J4 OTHE AMOUNT PAID equired if Other Amount Claimed Submitted (48Ø-H9) is greater than zero (Ø). 5Ø9-F9 TOTAL AMOUNT PAID 522-FM BASIS OF EIMBUSEMENT DETEMINATION 512-FC ACCUMULATED DEDUCTIBLE AMOUNT eturned if known or if applicable. 513-FD EMAINING DEDUCTIBLE AMOUNT eturned if known or if applicable. 514-FE EMAINING BENEFIT AMOUNT eturned if known or if applicable. 517-FH AMOUNT APPLIED TO PEIODIC eturned if known and impacts Patient Pay.. DEDUCTIBLE 518-FI AMOUNT OF COPAY eturned if known and impacts Patient Pay. 52Ø-FK AMOUNT ECEEDING PEIODIC eturned if known and impacts Patient Pay. BENEFIT MAIMUM 572-4U AMOUNT OF COINSUANCE eturned if known and impacts Patient Pay. 129-UD HEALTH PLAN-FUNDED ASSISTANCE eturned if known and impacts Patient Pay.. AMOUNT 134-UK AMOUNT ATTIBUTED TO PODUCT SELECTION/BAND DUG eturned if known and impacts Patient Pay. esponse DU/PPS Segment Questions Check Accepted/Paid (or Duplicate of Paid) This Segment is situational If DU information applies. esponse DU/PPS Segment Segment Identification (111-AM) = J6 DU/PPS ESPONSE CODE COUNTE Maximum 9 occurrences supported. Accepted/Paid (or Duplicate of Paid) equired if eason For Service Code (439-E4) is used. 439-E4 EASON FO SEVICE CODE equired if utilization conflict is detected. 528-FS CLINICAL SIGNIFICANCE CODE equired if needed to supply additional 529-FT OTHE PHAMACY INDICATO equired if needed to supply additional

13 esponse DU/PPS Segment Segment Identification (111-AM) = 24 Accepted/Paid (or Duplicate of Paid) 53Ø-FU PEVIOUS DATE OF FILL equired if needed to supply additional 531-FV QUANTITY OF PEVIOUS FILL Imp Guide: equired if needed to supply additional 532-FW DATABASE INDICATO equired if needed to supply additional 533-F OTHE PESCIBE INDICATO equired if needed to supply additional 544-FY DU FEE TET MESSAGE equired if needed to supply additional 57Ø-NS DU ADDITIONAL TET equired if needed to supply additional CLAIM BILLING COMMECIAL ACCEPTED/EJECTED ESPONSE CLAIM BILLING COMMECIAL ACCEPTED/EJECTED ESPONSE esponse Transaction Header Segment Questions Check Accepted/ejected esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUMBE DØ M 1Ø3-A3 TANSACTION CODE B1 M 1Ø9-A9 TANSACTION COUNT Same value as in request M 5Ø1-F1 HEADE ESPONSE STATUS A = Accepted M 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request M 2Ø1-B1 SEVICE POVIDE ID Same value as in request M 4Ø1-D1 DATE OF SEVICE Same value as in request M Accepted/ejected esponse Message Segment Questions Check Accepted/ejected This Segment is situational If transmission level messaging applies. esponse Message Segment Segment Identification (111-AM) = 2Ø 5Ø4-F4 MESSAGE O Accepted/ejected esponse Insurance Segment Questions Check Accepted/ejected This Segment is situational esponse Insurance Segment Accepted/ejected Segment Identification (111-AM) = 25 3Ø1-C1 GOUP ID 524-FO PLAN ID O Will send back if available

14 esponse Insurance Segment Segment Identification (111-AM) = J7 PAYE ID QUALIFIE Ø3 Accepted/ejected Ø3 = Bank Identification Number (BIN) 569-J8 PAYE ID 61Ø5Ø2 3Ø2-C2 CADHOLDE ID O Will Send back the ID that is used in Adjudication, only if different than what was submitted on request. esponse Patient Segment Questions Check Accepted/ejected This Segment is situational When the submitted Patient First Name and/or Last Name are different than Is on the member record. esponse Patient Segment Segment Identification (111-AM) = 29 31Ø-CA PATIENT FIST NAME Accepted/ejected 311-CB PATIENT LAST NAME 3Ø4-C4 DATE OF BITH esponse Status Segment Questions Check Accepted/ejected esponse Status Segment Segment Identification (111-AM) = AN TANSACTION ESPONSE STATUS = eject M 5Ø3-F3 AUTHOIZATION NUMBE 51Ø-FA EJECT COUNT Maximum count of 5. M 511-FB EJECT CODE M 546-4F EJECT FIELD OCCUENCE INDICATO Accepted/ejected equired if a repeating field is in error, to identify repeating field occurrence. 13Ø-UF ADDITIONAL MESSAGE INFOMATION COUNT Maximum count of 9. equired if Additional Message Information (526-FQ) is used. 132-UH ADDITIONAL MESSAGE INFOMATION QUALIFIE equired if Additional Message Information (526-FQ) is used. 526-FQ ADDITIONAL MESSAGE INFOMATION equired when additional text is needed for clarification or detail. 131-UG ADDITIONAL MESSAGE INFOMATION CONTINUITY equired if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current F HELP DESK PHONE NUMBE Ø3 QUALIFIE 55Ø-8F HELP DESK PHONE NUMBE 8ØØ

15 esponse Claim Segment Questions Check Accepted/ejected esponse Claim Segment Segment Identification (111-AM) = EM PESCIPTION/SEVICE EFEENCE 1 = xbilling M NUMBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE M NUMBE Accepted/ejected esponse DU/PPS Segment Questions Check Accepted/ejected This Segment is situational If DU information applies. esponse DU/PPS Segment Accepted/ejected Segment Identification (111-AM) = J6 DU/PPS ESPONSE CODE COUNTE Maximum 9 occurrences. equired if eason For Service Code (439- E4) is used. 439-E4 EASON FO SEVICE CODE equired if utilization conflict is detected. 528-FS CLINICAL SIGNIFICANCE CODE equired if needed to supply additional 529-FT OTHE PHAMACY INDICATO equired if needed to supply additional 53Ø-FU PEVIOUS DATE OF FILL equired if needed to supply additional 531-FV QUANTITY OF PEVIOUS FILL equired if needed to supply additional 532-FW DATABASE INDICATO equired if needed to supply additional 533-F OTHE PESCIBE INDICATO equired if needed to supply additional 544-FY DU FEE TET MESSAGE equired if needed to supply additional 57Ø-NS DU ADDITIONAL TET equired if needed to supply additional CLAIM BILLING COMMECIAL EJECTED/EJECTED ESPONSE CLAIM BILLING COMMECIAL EJECTED/EJECTED ESPONSE esponse Transaction Header Segment Questions Check ejected/ejected esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUMBE DØ M 1Ø3-A3 TANSACTION CODE B1 M 1Ø9-A9 TANSACTION COUNT Same value as in request M ejected/ejected

16 esponse Transaction Header Segment 5Ø1-F1 HEADE ESPONSE STATUS = ejected M 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request M 2Ø1-B1 SEVICE POVIDE ID Same value as in request M 4Ø1-D1 DATE OF SEVICE Same value as in request M ejected/ejected esponse Message Segment Questions Check ejected/ejected This Segment is situational If transmission level messaging applies. esponse Message Segment Segment Identification (111-AM) = 2Ø 5Ø4-F4 MESSAGE O ejected/ejected esponse Status Segment Questions Check ejected/ejected esponse Status Segment Segment Identification (111-AM) = AN TANSACTION ESPONSE STATUS = eject M 5Ø3-F3 AUTHOIZATION NUMBE 51Ø-FA EJECT COUNT Maximum count of 5. M 511-FB EJECT CODE M 546-4F EJECT FIELD OCCUENCE INDICATO ejected/ejected equired if a repeating field is in error, to identify repeating field occurrence. 13Ø-UF ADDITIONAL MESSAGE INFOMATION COUNT Maximum count of 9. equired if Additional Message Information (526-FQ) is used. 132-UH ADDITIONAL MESSAGE INFOMATION QUALIFIE equired if Additional Message Information (526-FQ) is used. 526-FQ ADDITIONAL MESSAGE INFOMATION equired when additional text is needed for clarification or detail. 131-UG ADDITIONAL MESSAGE INFOMATION CONTINUITY equired if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current F HELP DESK PHONE NUMBE Ø3 QUALIFIE 55Ø-8F HELP DESK PHONE NUMBE 8ØØ ** End of esponse (B1) Payer Sheet **

17 2. FEQUENTLY ASKED QUESTIONS

18 3. APPENDI A. HISTOY OF IMPLEMENTATION GUIDE CHANGES 3.1 VESION 1.Ø July Initial Creation of Aetna NCPDP D.Ø (B1) Commercial Payer Sheet. 3.2 VESION 2.Ø June Modified ECL version to October 2011 from March Modified NCPDP Data Dictionary Version Date to October 2011 from March Added 367-2N PESCIBE STATE/POVINCE ADDESS as a required field to the Prescriber Segment.