NCPDP Version D.0 and 1.2 Transactions Payer Sheets

NCPDP Version D.0and 1.2 Transactions Payer Sheets ________________________________________________________________________________

© 2011 Hewlett-Packard Development Company, L.P.

NCPDP Version D.0 and 1.2 Transactions Payer Sheets Standard Companion Guide Transaction Information December 21, 2011 Version 2.2

NCPDP Version D.0and 1.2 Transactions Payer Sheets ________________________________________________________________________________

© 2011 Hewlett-Packard Development Company, L.P.

NCPDP Version D.0 Transactions Payer Sheets

i Created 12/21/2011 Version 2.2

Revis ion His to ry

Document Version Number

Revision Date

Revision Page Numbers

Reason for Revision

Version 1.0 June 18, 2010 Full manual Creation of manual Version 2.0 May 01, 2011 11, 12, 22, 52-54 Updated the comment section for 338-5C

Added fields 471-5E and 472-6E Added 1.2 batch transaction payer sheets

Version 2.1 November 1, 2011 11,12, 23, 24

10, 22

9, 21

Added co-pay fields 353-NR, 351-NR, and 352-NQ to COB segment Updated comments section for 430-DU Updated comments se-C8

Version 2.2 December 21, 2011 Full manual

Added separate payer sheets for Medicare D Secondary B1 and B3 claims Removed 5.1 copay terminology


ii Created 12/21/2011 Version 2.2

Table of Contents 1. NCPDP vD.0 Transaction Set Information ............................................................................. 22. NCPDP vD.0 Transaction Set Specifications ........................................................................ 53. NCPDP vD.0 Request Data Element Descriptions ............................................................... 64. NCPDP vD.0 Response Data Element Descriptions .......................................................... 555. NCPDP v1.2 Transaction Set Specifications ....................................................................... 786. NCPDP v1.2 Transaction Data Element Descriptions ....................................................... 79


1 Created 12/21/2011 Version 2.2

Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc.

2008 NCPDP

NCPDP is a registered trademark of the National Council for Prescription Drug Programs, Inc. Versions D.0 and their predecessors include proprietary material which is protected under the U.S. Copyright Law, and all rights remain with NCPDP.

NCPDP Version D.0 defines the data structure and content of single point-of-sale (POS) transmissions only.

These specifications cover the minimum required fields per the NCPDP D.0 standards as well as the required fields needed for Kansas Medical Assistance Program (KMAP) claims processing. Even though a segment or field may not be covered in this document, it does not mean the segment or field cannot be sent. All records, segments, and fields that are allowed for NCPDP D.0 will be accepted, but only those segments and fields pertinent to claims processing will be utilized in the KMAP claims system.

The code values listed in the payer sheets are based on the January 2010 External Code List.



1. NCPDP vD.0 Transaction Set Information

General Transaction Formatting Information

The first segment of every transmission (request or response) is the Header Segment. This is the only segment that does not have a segment identification since it is a fixed field and length segment. After the Header Segment, other segments are included, according to the particular transaction type. Every other segment has an identifier to denote the particular segment for parsing. Segments may appear in any order after the Header Segment, according to whether the segment occurs at the transmission or transaction level. Segments are not allowed to repeat within a transaction. Segments may occur more than once only in a multitransaction transmission.

In the Header Segment, all fields are required positionally and filled to their maximum designation. This is a fixed segment. If a required field is not used, it must be filled with spaces or zeroes, as appropriate. The fields within the Header Segment do not use field separators.

Other segments may have both required and optional fields. Optional fields in a segment are submitted after the required fields. Both types of fields must be preceded by a field separator and the field’s identifier. Optional fields may appear in any order except for those designated with a qualifier or in a repeating group. The required and optional fields may be truncated to the actual size used.

Parsing is accomplished with the use of separators. Version D.0 uses three separators. • Segment separator Hex 1E (Dec 30)

• Group separator Hex 1D (Dec 29)

• Field separator Hex 1C (Dec 28)

A transmission consists of one or more transactions separated by group separators. All transmissions, whether for one, two, three, or four transactions, use group separators to denote the start of a transaction with the following exception: the Eligibility Verification transmission, which does not use a group separator.

Within a transaction, appropriate segments are included. Segments are delineated with the usage of segment separators. Segments are also identified with the usage of a segment identification in the first position of each segment. One or many segments may be included in each transaction. Field separators are used to delineate fields in the segments.



The general syntax of a transmission request and response will appear as follows:

Header Segment Header Segment fields

Segment Separator Required fields within segment as appropriate, with field separators Optional Segment fields with field separators


Group Separator Segment Separator

Required fields within segment as appropriate, with field separators Optional Segment fields with field separators


Variable Usage Guidelines • Leading zeroes and trailing blanks may be omitted from some data fields.

• Alphanumeric fields default to spaces when empty, not null characters.

• Numeric fields default to zeroes.

• Dollar fields default to zeroes; however, dollar fields are always signed. The least significant digit of a dollar field must always be an overpunch sign, not a digit.

Overpunch Sign The purpose of using overpunch signs in dollar fields is to allow the representation of positive and negative dollar amounts without expanding the size of the field (that is, to hold the plus or minus character). The overpunch sign replaces the right most character in a dollar field. The signed value designates the positive or negative status of the numeric value. The dollar field of $99.95 would be represented as 999E with truncation. A negative dollar amount of $2.50 would be represented as 25} with truncation.



UN I T SI G N E D PO S I T I V E SI G N E D NE G A T I V E

GRAPHIC OCT DEC HEX GRAPHIC OCT DEC HEX 0 { 173 123 7B } 175 125 7D

1 A 101 65 41 J 112 74 4A

2 B 102 66 42 K 113 75 4B

3 C 103 67 43 L 114 76 4C

4 D 104 68 44 M 115 77 4D

5 E 105 69 45 N 116 78 4E

6 F 106 70 46 O 117 79 4F

7 G 107 71 47 P 120 80 50

8 H 110 72 48 Q 121 81 51

9 I 111 73 49 R 122 82 52

Note: This table shows ASCII values.

Implied Decimal Points In the D.0 standard, only patient clinical value fields will contain decimal points. All other decimal points are implied. For example, patient diagnosis codes should be formatted with explicit decimal points. Note: Decimal points in dollar fields are implied.

Truncation To truncate a field using the D.0 format:

• Numeric (N or D): Remove leading zeroes

• Alphanumeric (A): Remove trailing spaces

Note: Do not truncate or eliminate any fields in the required header segments.



2. NCPDP vD.0 Transaction Set Specifications

Following is a list of the data elements, field names, and field positions for the Kansas Rx–POS system claims using the NCPDP version D.0 format. Standard COBOL documentation is used for transaction descriptions. The following definitions are given to ensure consistency of interpretation:

• Field – The NCPDP D.0 data element identifier for a given transaction.

• Field Name – The short definition, name, or literal constant of the data located within the transaction at the positions indicated.

• Picture (Pic) – The COBOL “PICTURE” clause that describes how the data is presented on the transmission.

X = An alphanumeric character 9 = A numeric character S = A numeric value sign (+ or –) V = An implied decimal point ( ) = The character in front of the left parenthesis is repeated the number of times

between the parentheses; for example, X(5) represents the same PICTURE as XXXXX

• Type – The type of data in the field.

A = Alphanumeric – Always left–justified and space filled; A–Z, 0–9, and printable characters.

D = Signed Numeric – Always right–justified, zero always positive, zero filled dollar – cents amount with two positions to the right of the implied decimal point, all other positions to the left of the implied decimal point and have default values of zeroes when used for dollar fields (sign is internal and trailing).

Example: A D field with a length of 8 is represented as $$$$$$cc.

N = Unsigned Numeric – Always right–justified and zero filled.

Format: 9(7)V999 Example: 9999999.999

• Value – If a particular value is expected for Rx–POS, that value is given.

• Comments – NCPDP vD.0 is a variable length format standard. Therefore, with the exception of the header fields (which are always required), a transaction will contain only those elements that are necessary. The “Comments” portion indicates whether a field is required and any new rules on how to bill. Required fields may be mandatory by the NCPDP D.0 standard and/or required by the processor (HP Enterprise Services).



3. NCPDP vD.0 Request Data Element Descriptions

Claim Request NCPDP Telecommunication Standard Version D.0: Claim Billing Field Field Name Pic Type Value Comments Transaction Header Segment: Required (in all cases) 101–A1

BIN Number 9(6) N ‘610517’ – KS Medicaid Mandatory

102–A2

Version/Release Number

X(2) A ‘D0’ – Version D.0 Mandatory

103–A3

Transaction Code X(2) A ‘B1’ – Billing Mandatory

104–A4

Processor Control Number

X(10) A Spaces Mandatory

109–A9

Transaction Count X(1) A ‘1’ – One occurrence ‘2’ – Two occurrences ‘3’ – Three occurrences ‘4’ – Four occurrences Maximum of one allowed for compound transactions. A value > ‘1’ applies to all transaction codes except ‘E’ and ‘P’ transactions.

Mandatory

202–B2

Service Provider ID Qualifier

X(2) A ‘01’ – National Provider ID Mandatory

201–B1

Service Provider ID

X(15) A Ten-character National Provider ID

Mandatory

401–D1

Date of Service 9(8) N Format – CCYYMMDD CC – Century YY – Year MM – Month DD – Day

Mandatory

110–AK

Software Vendor/ Certification ID


Insurance Segment: Required 111–AM

Segment Identification

X(2) A ‘04’ – Insurance Mandatory

302–C2

Cardholder ID X(20) A Cardholder ID Kansas: 11-digit Medicaid Beneficiary ID number

Mandatory

312–CC

Cardholder First Name

X(12) A Cardholder’s first name Required

313–CD

Cardholders Last Name

X(15) A Cardholder’s last name Required



NCPDP Telecommunication Standard Version D.0: Claim Billing Field Field Name Pic Type Value Comments 301–C1

Group ID X(15) A Pay to provider number For Batch encounter requests, specify the 10-character provider ID or the managed care organization (MCO).

Required when known

Patient Segment: Required 111-AM


X(2) A ‘01’ – Patient Mandatory

304-C4

Date of Birth 9(8) R Patient’s Date of Birth Required

305-C5

Patient Gender Code

9(1) R ‘0’ – Not Specified ‘1’ – Male ‘2’ – Female

Required

310-CA

Patient First Name X(12) Q Patient’s First Name Required when known

311-CB

Patient Last Name X(15) R Patient’s Last Name Required

335-2C

Pregnancy Indicator

X(1) Q ‘1’ – Not Pregnant ‘2’ – Pregnant ‘Blank’ – Not Specified

Required when known

Claim Segment: Required 111–AM


X(2) A ‘07’ – Claim Mandatory

455–EM

Prescription/ Service Reference Number Qualifier

X(1) A ‘1’ – Rx billing Mandatory

402–D2

Prescription/ Service Reference Number

9(12) N Prescription number Mandatory

436–E1

Product/Service ID Qualifier

X(2) A ‘03’ – National Drug Code (NDC)

Mandatory

407–D7

Product/Service ID X(19) A National Drug Code (NDC) Kansas: 11 characters

Mandatory

442–E7

Quantity Dispensed

9(7)V9(3) N Kansas: Maximum of 9(6).9(3) allowed. 999999.999

Required

403–D3

Fill Number 9(2) N ‘00’ – Original dispensing ‘01’-‘99’ – Refill number

Required

405–D5

Days Supplied 9(3) N Estimated number of days the prescription will last

Required

406–D6

Compound Code 9(1) N ‘0’ – Not Specified ‘1’ – Not a Compound ‘2’ – Compound

Required



NCPDP Telecommunication Standard Version D.0: Claim Billing Field Field Name Pic Type Value Comments 408–D8

Dispense as Written Code (Product Selection Code)

X(1) A ‘0’ – No product selection indicated ‘1’ – Substitution not allowed by prescriber ‘2’ – Substitution allowed – patient requested 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 ‘8’ – Substitution allowed – generic drug not available in marketplace ‘9’ – Substitution allowed – by prescriber but plan requests brand

Required

414–DE

Date Prescription Written

9(8) N Format – CCYYMMDD CC – Century YY – Year MM – Month DD – Day

Required

419-DJ

Prescription Origin Code

9(1) Q 0 – Not Known 1 – Written 2 – Telephone 3 – Electronic 4 – Facsimile 5 - Pharmacy

Required

354-NX

Submission Clarification Code Count

9(1) Q ‘1’ Required if submission clarification code (420-DK) is used.



NCPDP Telecommunication Standard Version D.0: Claim Billing Field Field Name Pic Type Value Comments 420–DK

Submission Clarification Code

9(2) N ‘1’ – No Override ‘2’ – Other Override ‘3’ – Vacation Supply ‘4’ – Lost Prescription ‘5’ – Therapy Change ‘6’ – Starter Dose ‘7’ – Medically Necessary ‘8’ – Process Compound For Approved Ingredients ‘9’ – Encounters ‘10’ – Meets Plan Limitations ’11’ – Certification on File ‘12’ – DME Replacement Indicator ‘13’– Payer-Recognized Emergency/Disaster Assistance Request ‘14’ – Long Term Care Leave of Absence ‘15’ – Long Term Care Replacement Medication ‘16’ – Long Term Care Emergency box (kit) or automated dispensing machine ‘17’ – Long Term Care Emergency supply remainder ‘18’ – Long Term Care Patient Admit/Readmit Indicator ‘19’ – Split Billing ‘99’ – Other

Required if clarification is needed and value submitted is greater than zero (0). Occurs the number of times identified in Submission Clarification Code Count (354-NX).

308–C8

Other Coverage Code

9(2) N ‘00’ – Not specified ‘01’ – No other coverage ‘02’ – Other coverage exists – payment collected ‘03’ – Other coverage exists – claim not covered ‘04’ – Other coverage exists – payment not collected

Required

418–DI

Level of Service 9(2) N ‘00’ – Not specified ‘01’ – Patient consultation ‘02’ – Home delivery ‘03’ – Emergency ‘04’ – 24 hour service ‘05’ – Patient consultation regarding generic product selection ‘06’ – In home service

Required when known



NCPDP Telecommunication Standard Version D.0: Claim Billing Field Field Name Pic Type Value Comments 461–EU

Prior Authorization Type Code

9(2) N ‘0’ – Not specified ‘1’ – Prior authorization ‘2’ – Medical certification ‘3’ – Early periodic screening diagnosis treatment (EPSDT) ‘4’ – Exemption from co-pay ‘5’ – Exemption from Rx ‘6’ – Family plan indicator ‘7’ – Aid to Families with Dependent Children (AFDC) ‘8’ – Payer defined exemption ‘9’ – Emergency Preparedness

Required when known

462–EV

Prior Authorization Number Submitted

9(11) N Prior authorization number Required when known

Pricing Segment: Required 111–AM


X(2) A ‘11’ – Pricing Mandatory

409-D9

Ingredient Cost Submitted

S9(6)v99 R 999999.99 Claim Billing/Encounter: Required

426–DQ

Usual and Customary Charge

S9(6)V9(2) D s$$$$$$cc Required

430–DU

Gross Amount Due


Prescriber Segment: Required

111–AM


X(2) A ‘03’ – Prescriber Mandatory when segment is present

466–EZ

Prescriber ID Qualifier

X(2) A ‘01’ – National Provider Identification (NPI)

Required

411–DB

Prescriber Identification

X(15) A Prescriber identification code

Required

COB/Other Payments Segment: Optional 111–AM


X(2) A ‘05’ – Coordination of benefits/other payments

Mandatory when segment is present

337–4C

Coordination of Benefits/Other Payments Count

9(1) N ‘1’ – ‘9’ Mandatory when segment is present



NCPDP Telecommunication Standard Version D.0: Claim Billing Field Field Name Pic Type Value Comments 338–5C

Other Payer Coverage Type

X(2) A Blank Not Specified ’01’ Primary – First ’02’ Secondary – Second ’03’ Tertiary – Third ’04’ Quaternary – Fourth ’05’ Quinary – Fifth ’06’ Senary – Sixth ’07’ Septenary - Seventh ’08’ Octonary – Eighth ’09’ Nonary – Ninth


341–HB

Other Payer Amount Paid Count

9(1) N ‘1’ – ‘9’ Required when known

342–HC

Other Payer Amount Paid Qualifier

X(2) A ‘01’ – Delivery ‘02’ – Shipping ‘03’ – Postage ‘04’ – Administrative ‘05’ – Incentive ‘06’ – Cognitive service ‘07’ – Drug benefit

Required when known

431–DV

Other Payer Amount Paid

S9(6)V9(2) D s$$$$$$cc Required when known

471–5E

Other Payer Reject Count

9(2) Q Claim Billing/Encounter: Maximum count 5.

Required if Other Payer Reject Code (472-6E) is used.

472–6E

Other Payer Reject Code

X(3) Q This field must only contain the NCPDP Reject Code (511-FB) values.

Required when the other payer has denied the payment for the billing.

DUR/PPS Segment: Optional 111–AM


X(2) A ‘08’ – DUR/PPS Mandatory when segment is present

473–7E

DUR/PPS Code Counter

9(1) N ‘1’ – Maximum of one allowed

Required when known

439–E4

Reason for Service Code

X(2) A ‘DC’ – Drug – disease (inferred) ‘DD’ – Drug – drug interaction ‘ER’ – Overuse ‘HD’ – High dose ‘LD’ – Low dose ‘LR’ – Underuse ‘MC’ – Drug – disease (reported) ‘MN’ – Insufficient duration ‘MX’ – Excessive duration ‘PA’ – Drug – age ‘PG’ – Drug – pregnancy ‘TD’ – Therapeutic

Required when known



NCPDP Telecommunication Standard Version D.0: Claim Billing Field Field Name Pic Type Value Comments 440–E5

Professional Service Code

X(2) A ‘00’ – No intervention ‘M0’ – Prescriber consulted ‘P0’ – Patient consulted ‘R0’ – Pharmacist consulted other source ‘TC’ – Payer/processor consulted Example:

Required when known

If the pharmacist spoke with the patient as a result of a conflict code being transmitted on a prescription, the field would reflect P0.

441–E6

Result of Service Code

X(2) A ‘1A’ – Filled as is, false positive ‘1B’ – Filled prescription as is ‘1C’ – Filled, with different dose ‘1D’ – Filled, with different directions ‘1E’ – Filled, with different drug ‘1F’ – Filled, with different quantity ‘1G’ – Filled, with prescriber approval ‘2A’ – Prescription not filled ‘2B’ – Not filled, directions clarified

Required when known

Compound Segment: Optional 111–AM


X(2) A ‘10’ – Compound Field 406–D6 in the claim segment must be = ‘2’


450–EF

Compound Dosage Form Description Code

X(2) A Blank – Not specified ‘01’ – Capsule ‘02’ – Ointment ‘03’ – Cream ‘04’ – Suppository ‘05’ – Powder ‘06’ – Emulsion ‘07’ – Liquid ‘10’ – Tablet ‘11’ – Solution ‘12’ – Suspension ‘13’ – Lotion ‘14’ – Shampoo ‘15’ – Elixir ‘16’ – Syrup ‘17’ – Lozenge ‘18’ – Enema


451–EG

Compound Dispensing Unit Form Indicator

9(1) N ‘1’ – Each ‘2’ – Grams ‘3’ – Milliliters




NCPDP Telecommunication Standard Version D.0: Claim Billing Field Field Name Pic Type Value Comments 447–EC

Compound Ingredient Component Count


488–RE

Compound Product ID Qualifier


Required when segment is present (repeating)

489–TE

Compound Product ID

X(19) A National Drug Code (NDC) Kansas: 11 characters


448–ED

Compound Ingredient Quantity

9(7)V9(3) N Compound ingredient quantity 9999999.999


490–UE

Compound Ingredient Basis of Cost Determination

X(2) AN Blank – Not specified ‘01’ – Average wholesale price (AWP) ‘02’ – Local wholesaler ‘03’ – Direct ‘04’ – Estimated acquisition cost (EAC) ‘05’ – Acquisition ‘06’ – Maximum allowable cost (MAC) ‘07’ – Usual & Customary ‘08’ – 340B /Disproportionate Share Pricing/Public Health Service ‘09’ – Other ’10 – ASP (Average Sales Price) ‘11’ – AMP (Average Manufacturer Price) ‘12’ – WAC (Wholesale Acquisition Cost)

Required when segment is present

Clinical Segment: Optional 111–AM


X(2) A ‘13’ – Clinical Mandatory when segment is present

491–VE

Diagnosis Code Count


Required when known

492–WE

Diagnosis Code Qualifier

X(2) A ‘01’ – International Classification of Diseases (ICD9)

Required when known

424–DO

Diagnosis Code X(15) A Three- to seven-digit alphanumeric code

Required when known



NCPDP Telecommunication Standard Version D.0: Claim Billing Field Field Name Pic Type Value Comments 493–XE

Clinical Information Counter

9(1) N Comments

: Fields in the logical set/grouping may include:

494–ZE – Measurement Date 495–H1 – Measurement Time 496–H2 – Measurement Dimension 497–H3 – Measurement Unit 499–H4 – Measurement Value

Required when known. Maximum 5 occurrences supported.

494–ZE

Measurement Date


Required when known

495–H1

Measurement Time

9(4) N Format – HHMM HH – Hour MM – Minute Time clinical information was collected or measured.

Required when known



NCPDP Telecommunication Standard Version D.0: Claim Billing Field Field Name Pic Type Value Comments 496–H2

Measurement Dimension

X(2) A Blank – Not specified ‘01’ – Blood pressure (BP) ‘02’ – Blood glucose ‘03’ – Temperature ‘04’ – Serum creatinine (SCr) ‘05’ – Glycosylated hemoglobin (HbA1c) ‘06’ – Sodium (Na+) ‘07’ – Potassium (K+) ‘08’ – Calcium (Ca++) ‘09’ – Serum glutamic–oxaloacetic transaminase (SGOT) ‘10’ – Serum glutamic–pyruvic transaminase (SGPT) ‘11’ – Alkaline phosphatase ‘12’ – Theophylline ‘13’ – Digoxin ‘14’ – Weight ‘15’ – Body surface area (BSA) ‘16’ – Height ‘17’ – Creatinine clearance (CrCl) ‘18’ – Cholesterol ‘19’ – Low density lipoprotein (LDL) ‘20’ – High density lipoprotein (HDL) ‘21’ – Triglycerides (TG) ‘22’ – Bone mineral density (BMD) T–Score ‘23’ – Prothrombin time (PT) ‘24’ – Hemoglobin (Hb; Hgb) ‘25’ – Hematocrit (Hct) ‘26’ – White blood cell count (WBC) ‘27’ – Red blood cell count (RBC) ‘28’ – Heart rate ‘29’ – Absolute neutrophil count (ANC) ‘30’ – Activated partial thromboplastin time (APTT) ’31’ – CD4 count ‘32’ – Partial thromboplastin time (PTT) ‘33’ – T–cell count ‘34’ – International normalized ratio (INR) ‘99’ – Other

Required when known



NCPDP Telecommunication Standard Version D.0: Claim Billing Field Field Name Pic Type Value Comments 497–H3

Measurement Unit X(2) A Blank – Not specified ‘01’ – Inches (in) ‘02’ – Centimeters (cm) ‘03’ – Pounds (lb) ‘04’ – Kilograms (kg) ‘05’ – Celsius (C) ‘06’ – Fahrenheit (F) ‘07’ – Meters squared (m2) ‘08’ – Milligrams per deciliter (mg/dl) ‘09’ – Units per milliliter (U/ml) ‘10’ – Millimeters of mercury (mmHg) ‘11’ – Centimeters squared (cm2) ‘12’ – Milliliters per minute (ml/min) ‘13’ – Percent (%) ‘14’ – Milliequivalents per milliliter (mEq/ml) ‘15’ – International units per liter (IU/L) ‘16’ – Micrograms per milliliter (mcg/ml) ‘17’ – Nanograms per milliliter (ng/ml) ‘18’ – Milligrams per milliliter (mg/ml) ‘19’ – Ratio ‘20’ – SI units ‘21’ – Millimoles (mmol/l) ‘22’ – Seconds ‘23’ – Grams per deciliter (g/dl) ‘24’ – Cells per cubic millimeter (cells/cu mm) ‘25’ – 1,000,000 cells per cubic millimeter (million cells/cu mm) ‘26’ – Standard deviation ‘27’ – Beats per minute

Required when known

499–H4

Measurement Value

X(15) A Actual value of clinical information. Blood pressure format – XXX/YYY XXX – systolic / – divider YYY – diastolic Temperature format – XXX.X (always include decimal point)

Required when known



Medicare D Secondary Claim Request NCPDP Telecommunication Standard Version D.0: Medicare D Secondary Claim Request Field Field Name Pic Type Value Comments Transaction Header Segment: Required (in all cases) 101–A1

BIN Number 9(6) N ‘610517’ – KS Medicaid Mandatory

102–A2

Version/Release Number


103–A3

Transaction Code X(2) A ‘B1’ – Billing Mandatory

104–A4

Processor Control Number


109–A9

Transaction Count X(1) A ‘1’ – One occurrence ‘2’ – Two occurrences ‘3’ – Three occurrences ‘4’ – Four occurrences Maximum of one allowed for compound transactions. A value > ‘1’ applies to all transaction codes except ‘E’ and ‘P’ transactions.

Mandatory

202–B2

Service Provider ID Qualifier


201–B1

Service Provider ID


Mandatory

401–D1

Date of Service 9(8) N Format – CCYYMMDD CC – Century YY – Year MM – Month DD – Day

Mandatory

110–AK

Software Vendor/ Certification ID


Insurance Segment: Required 111–AM


X(2) A ‘04’ – Insurance Mandatory

302–C2

Cardholder ID X(20) A Cardholder ID Kansas: 11-digit Medicaid Beneficiary ID number

Mandatory

312–CC

Cardholder First Name

X(12) A Cardholder’s first name Required

313–CD

Cardholders Last Name

X(15) A Cardholder’s last name Required

301–C1

Group ID X(15) A Pay to provider number For batch encounter requests, specify the 10-character provider ID or the managed care organization (MCO).

Required when known



Patient Segment: Required 111-AM


X(2) A ‘01’ – Patient Mandatory

304-C4

Date of Birth 9(8) R Patient’s Date of Birth Required

305-C5

Patient Gender Code


Required

310-CA

Patient First Name X(12) Q Patient’s First Name Required when known

311-CB

Patient Last Name X(15) R Patient’s Last Name Required

335-2C

Pregnancy Indicator

X(1) Q ‘1’ – Not Pregnant ‘2’ – Pregnant ‘Blank’ – Not Specified

Required when known

Claim Segment: Required 111–AM


X(2) A ‘07’ – Claim Mandatory

455–EM

Prescription/ Service Reference Number Qualifier


402–D2

Prescription/ Service Reference Number


436–E1

Product/Service ID Qualifier


Mandatory

407–D7

Product/Service ID X(19) A National Drug Code (NDC) Kansas: 11 characters

Mandatory

442–E7

Quantity Dispensed


Required

403–D3

Fill Number 9(2) N ‘00’ – Original dispensing ‘01’-‘99’ – Refill number

Required

405–D5

Days Supplied 9(3) N Estimated number of days the prescription will last

Required

406–D6

Compound Code 9(1) N ‘0’ – Not Specified ‘1’ – Not a Compound ‘2’ – Compound

Required



408–D8

Dispense as Written Code (Product Selection Code)

X(1) A ‘0’ – No product selection indicated ‘1’ – Substitution not allowed by prescriber ‘2’ – Substitution allowed – patient requested 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 ‘8’ – Substitution allowed – generic drug not available in marketplace ‘9’ – Substitution allowed – by prescriber but plan requests brand

Required

414–DE

Date Prescription Written


Required

419-DJ

Prescription Origin Code

9(1) Q 0 – Not Known 1 – Written 2 – Telephone 3 – Electronic 4 – Facsimile 5 - Pharmacy

Required

354-NX

Submission Clarification Code Count

9(1) Q ‘1’ Required if submission clarification code (420-DK) is used.



420–DK

Submission Clarification Code



308–C8

Other Coverage Code

9(2) N ‘08’ – Claim is billing for patient financial responsibility only

Mandatory

Submit the Medicare Part D patient responsibility in the Other Payer-Patient Responsibility Amount field (352-NQ) along with a ‘06’ in the Other Payer-Patient Responsibility Amount Qualifier field (351-NP) and a ‘08’ in the Other Coverage Code field (308-C8).

418–DI

Level of Service 9(2) N ‘00’ – Not specified ‘01’ – Patient consultation ‘02’ – Home delivery ‘03’ – Emergency ‘04’ – 24 hour service ‘05’ – Patient consultation regarding generic product selection ‘06’ – In home service

Required when known



461–EU

Prior Authorization Type Code

9(2) N ‘0’ – Not specified ‘1’ – Prior authorization ‘2’ – Medical certification ‘3’ – Early periodic screening diagnosis treatment (EPSDT) ‘4’ – Exemption from co-pay ‘5’ – Exemption from Rx ‘6’ – Family plan indicator ‘7’ – Aid to Families with Dependent Children (AFDC) ‘8’ – Payer defined exemption ‘9’ – Emergency Preparedness

Required when known

462–EV

Prior Authorization Number Submitted


Pricing Segment: Required 111–AM


X(2) A ‘11’ – Pricing Mandatory

409-D9

Ingredient Cost Submitted

S9(6)v99 R 999999.99 Claim Billing/Encounter: Required

426–DQ

Usual and Customary Charge


430–DU

Gross Amount Due


Prescriber Segment: Required

111–AM


X(2) A ‘03’ – Prescriber Mandatory when segment is present

466–EZ

Prescriber ID Qualifier

X(2) A ‘01’ – National Provider Identification (NPI)

Required

411–DB

Prescriber Identification


Required

COB/Other Payments Segment: Optional 111–AM


X(2) A ‘05’ – Coordination of benefits/other payments


337–4C

Coordination of Benefits/Other Payments Count




338–5C

Other Payer Coverage Type

X(2) A 01’ – ‘09’ Blank Not Specified Ø1 Primary – First Ø2 Secondary – Second Ø3 Tertiary – Third Ø4 Quaternary – Fourth Ø5 Quinary – Fifth Ø6 Senary – Sixth Ø7 Septenary - Seventh Ø8 Octonary – Eighth Ø9 Nonary – Ninth


341–HB

Other Payer Amount Paid Count


342–HC

Other Payer Amount Paid Qualifier


Required when known

431–DV

Other Payer Amount Paid

S9(6)V9(2) D s$$$$$$cc Required when known

471–5E

Other Payer Reject Count



472–6E

Other Payer Reject Code



353-NR

Other Payer-Patient Responsibility Amount Count

9(1) Q ‘1’ - Maximum count of 25. Required

351-NP

Other Payer-Patient Responsibility Amount Qualifier

X(2) Q***R***

‘06’ – Patient Pay Amount

Required


352-NQ

Other Payer-Patient Responsibility Amount

S9(6)V9(2) Q***R***

s$$$$$$cc Required


DUR/PPS Segment: Optional 111–AM


X(2) A ‘08’ – DUR/PPS Mandatory when segment is present

473–7E

DUR/PPS Code Counter


Required when known



439–E4

Reason for Service Code


Required when known

440–E5

Professional Service Code


Required when known


441–E6

Result of Service Code


Required when known

Compound Segment: Optional 111–AM


X(2) A ‘10’ – Compound Field 406–D6 in the claim segment must be = ‘2’




450–EF

Compound Dosage Form Description Code



451–EG

Compound Dispensing Unit Form Indicator



447–EC

Compound Ingredient Component Count


488–RE

Compound Product ID Qualifier



489–TE

Compound Product ID



448–ED

Compound Ingredient Quantity



490–UE

Compound Ingredient Basis of Cost Determination

X(2) AN Blank – Not specified ‘01’ – Average wholesale price (AWP) ‘02’ – Local wholesaler ‘03’ – Direct ‘04’ – Estimated acquisition cost (EAC) ‘05’ – Acquisition ‘06’ – Maximum allowable cost (MAC) ‘07’ – Usual & Customary ‘08’ – 340B /Disproportionate Share Pricing/Public Health Service ‘09’ – Other ’10 – ASP (Average Sales Price) ‘11’ – AMP (Average Manufacturer Price) ‘12’ – WAC (Wholesale Acquisition Cost)




Clinical Segment: Optional 111–AM


X(2) A ‘13’ – Clinical Mandatory when segment present

491–VE

Diagnosis Code Count


Required when known

492–WE



Required when known

424–DO

Diagnosis Code X(15) A Three- to seven-digit alphanumeric code

Required when known

493–XE

Clinical Information Counter

9(1) N Comments



Required when known. Maximum 5 occurrences supported.

494–ZE

Measurement Date


Required when known

495–H1

Measurement Time

9(4) N Format – HHMM HH – Hour MM – Minute Time clinical information was collected or measured.

Required when known



496–H2

Measurement Dimension


Required when known



497–H3

Measurement Unit X(2) A Blank – Not specified ‘01’ – Inches (in) ‘02’ – Centimeters (cm) ‘03’ – Pounds (lb) ‘04’ – Kilograms (kg) ‘05’ – Celsius (C) ‘06’ – Fahrenheit (F) ‘07’ – Meters squared (m2) ‘08’ – Milligrams per deciliter (mg/dl) ‘09’ – Units per milliliter (U/ml) ‘10’ – Millimeters of mercury (mmHg) ‘11’ – Centimeters squared (cm2) ‘12’ – Milliliters per minute (ml/min) ‘13’ – Percent (%) ‘14’ – Milliequivalents per milliliter (mEq/ml) ‘15’ – International units per liter (IU/L) ‘16’ – Micrograms per milliliter (mcg/ml) ‘17’ – Nanograms per milliliter (ng/ml) ‘18’ – Milligrams per milliliter (mg/ml) ‘19’ – Ratio ‘20’ – SI units ‘21’ – Millimoles (mmol/l) ‘22’ – Seconds ‘23’ – Grams per deciliter (g/dl) ‘24’ – Cells per cubic millimeter (cells/cu mm) ‘25’ – 1,000,000 cells per cubic millimeter (million cells/cu mm) ‘26’ – Standard deviation ‘27’ – Beats per minute

Required when known

499–H4

Measurement Value


Required when known



Claim Reversal NCPDP Telecommunication Standard Version D.0: Claim Reversal

Field Field Name Pic Type Value Comments Transaction Header Segment: Required (in all cases) 101–A1 BIN Number 9(6) N ‘610517’ – KS Medicaid Mandatory

102–A2 Version/Release Number


103–A3 Transaction Code

X(2) A ‘B2’ – Reversal Mandatory

104–A4 Processor Control Number


109–A9 Transaction Count

X(1) A ‘1’ – One occurrence ‘2’ – Two occurrences ‘3’ – Three occurrences ‘4’ – Four occurrences A value > ‘1’ applies to all transaction codes except ‘E’ and ‘P’ transactions.

Mandatory

202–B2 Service Provider ID Qualifier


201–B1 Service Provider ID


Mandatory

401–D1 Date of Service 9(8) N Format – CCYYMMDD CC – Century YY – Year MM – Month DD – Day

Mandatory

110–AK Software Vendor/ Certification ID


Claim Segment: Required 111–AM Segment

Identification X(2) A ‘07’ – Claim Mandatory

455–EM Prescription/ Service Reference Number Qualifier


402–D2 Prescription/ Service Reference Number


436–E1 Product/Service ID Qualifier

X(2) A ‘03’ – NDC Mandatory

407–D7 Product/Service ID


Mandatory



Claim Rebill NCPDP Telecommunication Standard Version D.0: Claim Rebill




103–A3 Transaction Code X(2) A ‘B3’ – Rebill Mandatory



109–A9 Transaction Count X(1) A ‘1’ – One occurrence ‘2’ – Two occurrences ‘3’ – Three occurrences ‘4’ – Four occurrences Maximum of one allowed for compound transactions. A value > ‘1’ applies to all transaction codes except ‘E’ and ‘P’ transactions.

Mandatory




X(15) A Ten-character National Provider ID.

Mandatory


Mandatory



Insurance Segment: Required 111–AM Segment

Identification X(2) A ‘04’ – Insurance Mandatory

302–C2 Cardholder ID X(20) A Cardholder ID Kansas: 11-digit Medicaid Beneficiary ID number

Mandatory

312–CC Cardholder First Name

X(12) A Cardholder’s First Name Required

313–CD Cardholders Last Name

X(15) A Cardholder’s Last Name Required

301–C1 Group ID X(15) A Pay to Provider Number For batch encounter requests, specify the 10-character provider ID or the managed care organization (MCO).

Required when known

Patient Segment: Optional (segment only present if 335–2C is populated) 111–AM Segment

Identification X(2) A ‘01’ – Patient Mandatory when segment is

present



NCPDP Telecommunication Standard Version D.0: Claim Rebill Field Field Name Pic Type Value Comments

304–C4 Date of Birth 9(8) R Patient’s Date of Birth Required

305–C5 Patient Gender Code


Required

310–CA Patient First Name

X(12) Q Patient’s First Name Required when patient has a first name.

311–CB Patient Last Name X(15) R Patient’s Last Name Required

335–2C Pregnancy Indicator

X(1) A ‘1’ – Not pregnant ‘2’ – Pregnant

Required when known





402–D2 Prescription/ Service Reference Number Qualifier




Mandatory



Mandatory

442–E7 Quantity Dispensed


Required

403–D3 Fill Number 9(2) N ‘00’ – Original dispensing ‘01’ – ‘99’ – Refill number

Required

405–D5 Days Supplied 9(3) N Estimated number of days the prescription will last

Required

406–D6 Compound Code 9(1) N ‘0’ – Not Specified ‘1’ – Not a compound ‘2’ – Compound

Required




408–D8 Dispense as Written Code (Product Selection Code)

X(1) A ‘0’ – No product selection indicated ‘1’ – Substitution not allowed by prescriber ‘2’ – Substitution allowed – patient requested 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 requests brand

Required

414–DE Date Prescription Written


Required

419-DJ Prescription Origin Code

9(1) Q 0 – Not Known 1 – Written 2 – Telephone 3 – Electronic 4 – Facsimile 5 – Pharmacy

Required

354–NX Submission Clarification Code Count

9(1) Q ‘1’ Required if Submission Clarification Code (420–DK) is used.




420–DK Submission Clarification Code



308–C8 Other Coverage Code

9(2) N ‘00’ – Not specified ‘01’ – No other coverage ‘02’ – Other coverage exists – payment collected ‘03’ – Other coverage exists – claim not covered ‘04’ – Other coverage exists – payment not collected

Required

418–DI Level of Service 9(2) N ‘00’ – Not specified ‘01’ – Patient consultation ‘02’ – Home delivery ‘03’ – Emergency ‘04’ – 24 hour service ‘05’ – Patient consultation regarding generic product selection ‘06’ – In–home service

Required when known




461–EU Prior Authorization Type Code

9(2) N ‘0’ – Not specified ‘1’ – Prior authorization ‘2’ – Medical certification ‘3’ – EPSDT (Early Periodic Screening Diagnosis treatment) ‘4’ – Exemption from co-pay ‘5’ – Exemption from Rx ‘6’ – Family Plan Indicator ‘7’ – AFDC (Aid to Families with Dependent Children) ‘8’ – Payer defined Exemption ‘9’ – Emergency Preparedness

Required when known

462–EV Prior Authorization Number Submitted


Pricing Segment: Required 111–AM Segment

Identification X(2) A ‘11’ – Pricing Mandatory

409-D9 Ingredient Cost Submitted

S9(6)v99 R Ingredient Cost Required

426–DQ Usual and Customary Charge


430–DU Gross Amount Due


Prescriber Segment 111–AM Segment

Identification X(2) A ‘03’ – Prescriber Mandatory when segment is

present

466–EZ Prescriber ID Qualifier

X(2) A ‘01’ – National Provider Identification

Required

411–DB Prescriber Identification


Required

COB Other Payment Segment: Optional 111–AM Segment

Identification X(2) A ‘05’ – Coordination of

benefits/other payments Mandatory when segment is present

337–4C Coordination of Benefits/Other Payments Count


338–5C Other Payer Coverage Type

X(2) A Blank Not Specified ‘01’ Primary – First ‘02’ Secondary – Second ‘03’ Tertiary – Third ‘04’ Quaternary – Fourth ‘05’ Quinary – Fifth ‘06’ Senary – Sixth ‘07’ Septenary - Seventh ‘08’ Octonary – Eighth ‘09’ Nonary – Ninth





341–HB Other Payer Amount Paid Count


342–HC Other Payer Amount Paid Qualifier


Required when known (repeating)

431–DV Other Payer Amount Paid

s9(6)V9(2) D s$$$$$$cc Required when known (repeating)

471–5E Other Payer Reject Count



472–6E Other Payer Reject Code



DUR PPS Segment: Optional 111–AM Segment

Identification X(2) A ‘08’ – DUR/PPS Mandatory when segment is

present

473–7E DUR/PPS Code Counter


Required when known

439–E4 Reason for Service Code


Required when known

440–E5 Professional Service Code


Required when known





441–E6 Result of Service Code


Required when known

Compound Segment: Optional 111–AM Segment

Identification X(2) A ‘10’ – Compound

Field 406–D6 in the claim segment must be = ‘2’


450–EF Compound Dosage Form Description Code



451–EG Compound Dispensing Unit Form Indicator



447–EC Compound Ingredient Component Count


488–RE Compound Product ID Qualifier



489–TE Compound Product ID



448–ED Compound Ingredient Quantity






490–UE Compound Ingredient Basis of Cost Determination

X(2) A Blank – Not specified ‘01’ – Average wholesale price (AWP) ‘02’ – Local wholesaler ‘03’ – Direct ‘04’ – Estimated acquisition cost (EAC) ‘05’ – Acquisition ‘06’ – Maximum allowable cost (MAC) ‘07’ – Usual & Customary ‘09’ – Other


Clinical Segment: Optional 111–AM Segment

Identification X(2) A ‘13’ – Clinical Mandatory when segment is

present

491–VE Diagnosis Code Count

9(1) N ‘1’ – Maximum of 1 allowed Required when known

492–WE



Required when known

424–DO Diagnosis Code X(15) A Three- to seven-digit alphanumeric code

Required when known

493–XE Clinical Information Counter

9(1) N Comments



Required when known

494–ZE Measurement Date


Required when known

495–H1 Measurement Time

9(4) N Format - HHMM HH – Hour MM – Minute Time clinical information was collected or measured.

Required when known




496–H2 Measurement Dimension


Required when known




497–H3 Measurement Unit X(2) A Blank – Not specified ‘01’ – Inches (in) ‘02’ – Centimeters (cm) ‘03’ – Pounds (lb) ‘04’ – Kilograms (kg) ‘05’ – Celsius (C) ‘06’ – Fahrenheit (F) ‘07’ – Meters squared (m2) ‘08’ – Milligrams per deciliter (mg/dl) ‘09’ – Units per milliliter (U/ml) ‘10’ – Millimeters of mercury (mmHg) ‘11’ – Centimeters squared (cm2) ‘12’ – Milliliters per minute (ml/min) ‘13’ – Percent (%) ‘14’ – Milliequivalents per milliliter (mEq/ml) ‘15’ – International units per liter (IU/L) ‘16’ – Micrograms per milliliter (mcg/ml) ‘17’ – Nanograms per milliliter (ng/ml) ‘18’ – Milligrams per milliliter (mg/ml) ‘19’ – Ratio ‘20’ – SI units ‘21’ – Millimoles (mmol/l) ‘22’ – Seconds ‘23’ – Grams per deciliter (g/dl) ‘24’ – Cells per cubic millimeter (cells/cu mm) ‘25’ – 1,000,000 cells per cubic millimeter (million cells/cu mm) ‘26’ – Standard deviation ‘27’ – Beats per minute

Required when known

499–H4 Measurement Value


Required when known



Medicare D Secondary Claim Rebill NCPDP Telecommunication Standard Version D.0: Medicare D Secondary Claim Rebill




103–A3 Transaction Code X(2) A ‘B3’ – Rebill Mandatory



109–A9 Transaction Count X(1) A ‘1’ – One occurrence ‘2’ – Two occurrences ‘3’ – Three occurrences ‘4’ – Four occurrences Maximum of one allowed for compound transactions. A value > ‘1’ applies to all transaction codes except ‘E’ and ‘P’ transactions.

Mandatory




X(15) A Ten-character National Provider ID.

Mandatory


Mandatory






Mandatory

312–CC Cardholder First Name

X(12) A Cardholder’s First Name Required

313–CD Cardholders Last Name

X(15) A Cardholder’s Last Name Required

301–C1 Group ID X(15) A Pay to Provider Number For batch encounter requests, specify the 10-character provider ID or the managed care organization (MCO).

Required when known

Patient Segment: Optional (segment only present if 335–2C is populated) 111–AM Segment

Identification X(2) A ‘01’ – Patient Mandatory when segment is

present



NCPDP Telecommunication Standard Version D.0: Medicare D Secondary Claim Rebill Field Field Name Pic Type Value Comments

304–C4 Date of Birth 9(8) R Patient’s Date of Birth Required



Required

310–CA Patient First Name

X(12) Q Patient’s First Name Required when patient has a first name.

311–CB Patient Last Name X(15) R Patient’s Last Name Required

335–2C Pregnancy Indicator

X(1) A ‘1’ – Not pregnant ‘2’ – Pregnant

Required when known





402–D2 Prescription/ Service Reference Number Qualifier




Mandatory



Mandatory



Required

403–D3 Fill Number 9(2) N ‘00’ – Original dispensing ‘01’ – ‘99’ – Refill number

Required

405–D5 Days Supplied 9(3) N Estimated number of days the prescription will last

Required


Required




408–D8 Dispense as Written Code (Product Selection Code)

X(1) A ‘0’ – No product selection indicated ‘1’ – Substitution not allowed by prescriber ‘2’ – Substitution allowed – patient requested 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 requests brand

Required

414–DE Date Prescription Written


Required

419-DJ Prescription Origin Code

9(1) Q 0 – Not Known 1 – Written 2 – Telephone 3 – Electronic 4 – Facsimile 5 – Pharmacy

Required

354–NX Submission Clarification Code Count

9(1) Q ‘1’ Required if Submission Clarification Code (420–DK) is used.




420–DK Submission Clarification Code



308–C8 Other Coverage Code

9(2) N ‘08’ – Claim is billing for patient financial responsibility only

Mandatory


418–DI Level of Service 9(2) N ‘00’ – Not specified ‘01’ – Patient consultation ‘02’ – Home delivery ‘03’ – Emergency ‘04’ – 24 hour service ‘05’ – Patient consultation regarding generic product selection ‘06’ – In–home service

Required when known




461–EU Prior Authorization Type Code

9(2) N ‘0’ – Not specified ‘1’ – Prior authorization ‘2’ – Medical certification ‘3’ – EPSDT (Early Periodic Screening Diagnosis treatment) ‘4’ – Exemption from co-pay ‘5’ – Exemption from Rx ‘6’ – Family Plan Indicator ‘7’ – AFDC (Aid to Families with Dependent Children) ‘8’ – Payer defined Exemption ‘9’ – Emergency Preparedness

Required when known

462–EV Prior Authorization Number Submitted


Pricing Segment: Required 111–AM Segment

Identification X(2) A ‘11’ – Pricing Mandatory

409-D9 Ingredient Cost Submitted

S9(6)v99 R Ingredient Cost Required

426–DQ Usual and Customary Charge


430–DU Gross Amount Due


Prescriber Segment 111–AM Segment

Identification X(2) A ‘03’ – Prescriber Mandatory when segment is

present

466–EZ Prescriber ID Qualifier

X(2) A ‘01’ – National Provider Identification

Required

411–DB Prescriber Identification


Required

COB Other Payment Segment: Optional 111–AM Segment

Identification X(2) A ‘05’ – Coordination of

benefits/other payments Mandatory when segment is present

337–4C Coordination of Benefits/Other Payments Count

9(1) N ‘1’ – ‘9’


338–5C Other Payer Coverage Type

X(2) A Blank Not Specified ‘01’ Primary – First ‘02’ Secondary – Second ‘03’ Tertiary – Third ‘04’ Quaternary – Fourth ‘05’ Quinary – Fifth ‘06’ Senary – Sixth ‘07’ Septenary - Seventh ‘08’ Octonary – Eighth ‘09’ Nonary – Ninth





341–HB Other Payer Amount Paid Count


342–HC Other Payer Amount Paid Qualifier


Required when known (repeating)

431–DV Other Payer Amount Paid

s9(6)V9(2) D s$$$$$$cc Required when known (repeating)

471–5E Other Payer Reject Count



472–6E Other Payer Reject Code



353-NR Other Payer-Patient Responsibility Amount Count

9(1) Q Maximum count of 25 Required

351-NP Other Payer-Patient Responsibility Amount Qualifier

X(2) Q***R***

‘06’ – Patient Pay Amount Required


352-NQ Other Payer-Patient Responsibility Amount

S9(6)V9(2) Q***R***

s$$$$$$cc Required


DUR PPS Segment: Optional 111–AM Segment

Identification X(2) A ‘08’ – DUR/PPS Mandatory when segment is

present

473–7E DUR/PPS Code Counter


Required when known






Required when known

440–E5 Professional Service Code


Required when known


441–E6 Result of Service Code


Required when known

Compound Segment: Optional 111–AM Segment

Identification X(2) A ‘10’ – Compound

Field 406–D6 in the claim segment must be = ‘2’





450–EF Compound Dosage Form Description Code



451–EG Compound Dispensing Unit Form Indicator



447–EC Compound Ingredient Component Count


488–RE Compound Product ID Qualifier



489–TE Compound Product ID



448–ED Compound Ingredient Quantity



490–UE Compound Ingredient Basis of Cost Determination

X(2) A Blank – Not specified ‘01’ – Average wholesale price (AWP) ‘02’ – Local wholesaler ‘03’ – Direct ‘04’ – Estimated acquisition cost (EAC) ‘05’ – Acquisition ‘06’ – Maximum allowable cost (MAC) ‘07’ – Usual & Customary ‘09’ – Other


Clinical Segment: Optional 111–AM Segment

Identification X(2) A ‘13’ – Clinical Mandatory when segment is

present

491–VE Diagnosis Code Count

9(1) N ‘1’ – Maximum of 1 allowed Required when known

492–WE



Required when known

424–DO Diagnosis Code X(15) A Three- to seven-digit alphanumeric code

Required when known




493–XE Clinical Information Counter

9(1) N Comments



Required when known

494–ZE Measurement Date


Required when known

495–H1 Measurement Time

9(4) N Format - HHMM HH – Hour MM – Minute Time clinical information was collected or measured.

Required when known




496–H2 Measurement Dimension


Required when known




497–H3 Measurement Unit X(2) A Blank – Not specified ‘01’ – Inches (in) ‘02’ – Centimeters (cm) ‘03’ – Pounds (lb) ‘04’ – Kilograms (kg) ‘05’ – Celsius (C) ‘06’ – Fahrenheit (F) ‘07’ – Meters squared (m2) ‘08’ – Milligrams per deciliter (mg/dl) ‘09’ – Units per milliliter (U/ml) ‘10’ – Millimeters of mercury (mmHg) ‘11’ – Centimeters squared (cm2) ‘12’ – Milliliters per minute (ml/min) ‘13’ – Percent (%) ‘14’ – Milliequivalents per milliliter (mEq/ml) ‘15’ – International units per liter (IU/L) ‘16’ – Micrograms per milliliter (mcg/ml) ‘17’ – Nanograms per milliliter (ng/ml) ‘18’ – Milligrams per milliliter (mg/ml) ‘19’ – Ratio ‘20’ – SI units ‘21’ – Millimoles (mmol/l) ‘22’ – Seconds ‘23’ – Grams per deciliter (g/dl) ‘24’ – Cells per cubic millimeter (cells/cu mm) ‘25’ – 1,000,000 cells per cubic millimeter (million cells/cu mm) ‘26’ – Standard deviation ‘27’ – Beats per minute

Required when known

499–H4 Measurement Value


Required when known



Eligibility Request NCPDP Telecommunication Standard Version D.0: Eligibility Request

Field Field Name Pic Type Value Comments Transaction Header Segment: Required (in all cases) 101–A1 Bin Number 9(6) N ‘610517’ – KS Medicaid Mandatory




X(2) A ‘E1’ – Eligibility verification Mandatory




X(1) N ‘1’ – One occurrence Mandatory





Mandatory


Mandatory


X(10) A Spaces

Mandatory

Patient Segment: Optional 111–AM Segment

Identification X(2) A ‘01’ – Patient Mandatory

331–CX Patient ID Qualifier

X(2) A Blank – Not specified ‘01’ – Social Security number ’02’ – Driver’s license number ‘03’ – U.S. military ID ‘99’ – Other

Required when known

332–CY ID assigned to the patient

X(20) A Comments:

This field is used to uniquely identify the patient for purposes other than billing.

Qualified by Patient ID Qualifier (331–CX).

Required when known

304–C4 Date of Birth 9(8) N Format – CCYYMMDD CC – Century YY – Year MM – Month DD – Day

Required when known


9(1) N ‘0’ – Not specified ‘1’ – Male ‘2’ – Female

Required when known





NCPDP Telecommunication Standard Version D.0: Eligibility Request Field Field Name Pic Type Value Comments


Mandatory

Prior Authorization Inquiry NCPDP Telecommunication Standard Version D.0: Prior Authorization Inquiry





X(2) A ‘P3’ – PA inquiry Mandatory




X(1) A ‘1’ – One occurrence Mandatory





Mandatory


Mandatory






Mandatory

Prior Authorization Segment: Required 111–AM Segment

Identification X(2) A ‘12’ – Prior authorization Mandatory

498–PA Request Type X(1) A ‘1’ – Initial ‘2’ – Reauthorization ‘3’ – Deferred

Mandatory

498–PB Request Period Date–Begin


Mandatory



NCPDP Telecommunication Standard Version D.0: Prior Authorization Inquiry Field Field Name Pic Type Value Comments

498–PC Request Period Date–End


Mandatory

498–PD Basis of Request X(2) A ‘ME’ – Medical exception ‘PR’ – Plan requirement ‘PL’ – Increase plan limitation

Mandatory

498–PY Prior Authorization Number–Assigned

9(11) N Assigned prior authorization number

Required

Prior Authorization Request NCPDP Telecommunication Standard Version D.0: Prior Authorization Request





X(2) A ‘P4’ – PA request only Mandatory




X(1) A '1' – One occurrence Mandatory





Mandatory


Mandatory






Mandatory





NCPDP Telecommunication Standard Version D.0: Prior Authorization Request Field Field Name Pic Type Value Comments





436-E1 Product/Service ID Qualifier

X(2) ‘03” – National Drug Code (NDC)

Required



Mandatory



Required

405–D5 Days Supplied 9(3) N Estimated number of days the prescription will last.

Required


Required

408–D8 Dispensed as Written (DAW)

X(1) A ‘0’ – No product selection indicated ‘1’ – Substitution not allowed by prescriber ‘2’ – Substitution allowed – patient requested 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’ – Plan Mandates Brand

Required

415–DF Number of Refills Authorized

9(2) N ‘0’ – Not specified ‘1’-‘98’ – Number of refills ‘99’ – As needed/Refills unlimited

Required

460–ET Quantity Prescribed

9(7)V999 N 9999999.999 Required

429–DT Unit Dose Indicator

9(1) N ‘0’ – Not specified ‘1’ – Not unit dose ‘2’ – Manufacturer unit dose ‘3’ – Pharmacy unit dose

Required



NCPDP Telecommunication Standard Version D.0: Prior Authorization Request Field Field Name Pic Type Value Comments

Prior Authorization Segment: Required 111–AM Segment

Identification X(2) A ‘12' – Prior authorization Mandatory

498–PA Request Type X(1) A ‘1’ – Initial ‘2’ – Reauthorization ‘3’ – Deferred

Mandatory

498–PB Request Period Date–Begin


Mandatory

498–PC Request Period Date–End


Mandatory

498–PD Basis or Request X(2) A ‘ME’ – Medical exception ‘PR’ – Plan requirement ‘PL’ – Increase plan limitation

Mandatory



4. NCPDP vD.0 Response Data Element Descriptions

Claim Billing Paid Response NCPDP Telecommunication Standard Version D.0: Claim Billing Paid Response

Field Field Name Pic Type Value Comments Response Header Segment: Required



103–A3 Transaction Code X(2) A ‘B1’ – Billing Mandatory


X(1) A ‘1’ – One occurrence ‘2’ – Two occurrences ‘3’ – Three occurrences ‘4’ – Four occurrences

Mandatory

501–F1 Header Response Status

X(1) A ‘A’ – Accepted Mandatory


X(2) A ‘01’ - National Provider ID Mandatory


X(15) A Provider ID will be returned with the ID received on the request.

Mandatory


Mandatory

Response Message Segment: Optional 111–AM Segment

Identification X(2) A ‘20’ – Response message Mandatory

504–F4 Message X(200) A This field will contain response specific text.

Required

Response Status Segment: Required 111–AM Segment

Identification X(2) A ‘21’ – Response status Mandatory

112–AN Transaction Response Status

X(1) A ‘P’ – Paid Mandatory

503–F3 Authorization Number

X(20) A 13-character internal control number (ICN) for the original claim

Required

526–FQ Additional Message Information

X(200) A Used if additional message is needed.

Required

If additional message is needed

Response Claim Segment: Required 111–AM Segment

Identification X(2) A ‘22’ – Response claim Mandatory





NCPDP Telecommunication Standard Version D.0: Claim Billing Paid Response Field Field Name Pic Type Value Comments



Response Pricing Segment: Required 111–AM Segment

Identification X(2) A ‘23’ – Response pricing Mandatory

505–F5 Patient Pay Amount

S9(6)V99 D s$$$$$$cc Required

507–F7 Dispensing Fee Paid


509–F9 Total Amount Paid


566-J5 Other Payer Amount Recognized


518–FI Amount of Co-pay/Coinsurance


Response DUR/PPS Segment: Optional (Only required if DUR info is sent in response) 111–AM Segment

Identification X(2) A ‘24’ – Response DUR/PPS Mandatory when known

567–J6 DUR/PPS Response Code Counter

9(1) N Counter number for each DUR/PPS response set/logical grouping.

Required when known


X(2) A Accepted values available in NCPDP D.0 guide.

Required when known

528–FS Clinical Significance Code

X(1) A Blank – Not specified ‘1’ – Major ‘2’ – Moderate ‘3’ – Minor

Required when known

529–FT Other Pharmacy Indicator

9(1) N ‘0’ – Not specified ‘1’ – Your pharmacy ‘2’ – Other pharmacy in same chain ‘3’ – Other pharmacy

Required when known

530–FU Previous Date of Fill


Required when known

531–FV Quantity of Previous Fill

9(7)V999 N 9999999.999 Required when known

532–FW Database Indicator

X(1) A ‘1’ – First Databank Required when known

533–FX Other Prescriber Indicator

9(1) N ‘0’ – Not specified ‘1’ – Same prescriber ‘2’ – Other prescriber

Required when known

544–FY DUR Free Text Message

X(30) A Additional DUR message if needed.

Required when known



Medicare D Secondary Claim Billing Paid Response NCPDP Telecommunication Standard Version D.0: Medicare D Secondary Claim Billing Paid Response




103–A3 Transaction Code X(2) A ‘B1’ – Billing Mandatory



Mandatory




X(2) A ‘01’ - National Provider ID Mandatory



Mandatory


Mandatory




Required







Required



Required


















522-FM Basis of Reimbursement Determination

9(2) N 14 – Other Payer Patient Responsibility Amount

Required

518–FI Amount of Co-pay/Coinsurance






Required when known



Required when known



Required when known



Required when known



Required when known







Required when known



Required when known



Claim Billing Rejected Response NCPDP Telecommunication Standard Version D.0:Claim Billing Rejected Response

Field Field Name Pic Type Value Comments Response Header Segment: Required 102–A2 Version/Release

Number X(2) A ‘D0’ – Version D.0 Mandatory


X(2) A ‘B1’ – Billing Mandatory



Mandatory







Mandatory


Mandatory




Required




X(1) A ‘R’ – Rejected Mandatory



Required

510–FA Reject Count 9(2) N Reject Count Required

511–FB Reject Code X(3) A See Appendix F – Reject Code Listing in the NCPDP D.0 Data Dictionary.

Required



Required






NCPDP Telecommunication Standard Version D.0:Claim Billing Rejected Response Field Field Name Pic Type Value Comments









Required when known



Required when known



Required when known



Required when known



Required when known


9(7)V999

N 9999999.999 9(7)V999

Required when known





Required when known



Required when known

Claim Reversal Approved Response NCPDP Telecommunication Standard Version D.0:Claim Reversal Approved Response







NCPDP Telecommunication Standard Version D.0:Claim Reversal Approved Response Field Field Name Pic Type Value Comments



Mandatory




X(2) A ‘01’ – National Provider ID

Mandatory



Mandatory


Mandatory




Required

Response Status Segment: Optional 111–AM Segment



X(1) A ‘A’ – Approved Mandatory


X(20) A 13-character internal control number (ICN) for original claim

Required



Required








Response DUR PPS Segment: Required 111–AM Segment




Required when known



NCPDP Telecommunication Standard Version D.0:Claim Reversal Approved Response Field Field Name Pic Type Value Comments



Required when known



Required when known



Required when known



Required when known







Required when known



Required when known

Claim Reversal Rejected Response NCPDP Telecommunication Standard Version D.0: Claim Reversal Rejected Response







Mandatory







Mandatory


Mandatory



NCPDP Telecommunication Standard Version D.0: Claim Reversal Rejected Response Field Field Name Pic Type Value Comments




Required

Response Status Segment: Optional 111–AM Segment






Required

510–FA Reject Count 9(2) N Reject count Required


Required



Required








Response DUR PPS Segment: Required 111–AM Segment




Required when known



Required when known



Required when known



Required when known



NCPDP Telecommunication Standard Version D.0: Claim Reversal Rejected Response Field Field Name Pic Type Value Comments



Required when known


9(7)V999 N 9999999.999

Required when known





Required when known



Required when known



Claim Rebill Paid Response NCPDP Telecommunication Standard Version D.0: Claim Rebill Paid Response




X(2) A ‘B3’ – Rebill Mandatory



Mandatory





Mandatory



Mandatory


Mandatory




Required







Required



Required








NCPDP Telecommunication Standard Version D.0: Claim Rebill Paid Response Field Field Name Pic Type Value Comments











566-J5 Other Payer Amount Recognized


518–FI Amount of Co-pay/ Coinsurance


Response DUR/PPS Segment: Optional (only required if DUR information is sent in response) 111–AM Segment




Required when known



Required when known



Required when known



Required when known



Required when known







Required when known



Required when known



Medicare D Secondary Claim Rebill Paid Response NCPDP Telecommunication Standard Version D.0: Medicare D Secondary Claim Rebill Paid Response







Mandatory





Mandatory



Mandatory


Mandatory




Required







Required



Required












522-FM Basis of Reimbursement Determination

9(2) N 14 – Other Payer Patient Responsibility Amount

Required







518–FI Amount of Co-pay/ Coinsurance


Response DUR/PPS Segment: Optional (only required if DUR information is sent in response) 111–AM Segment




Required when known



Required when known



Required when known



Required when known



Required when known







Required when known



Required when known



Claim Rebill Rejected Response NCPDP Telecommunication Standard Version D.0: Claim Rebill Rejected Response







Mandatory


X(1) A 'A' – Accepted Mandatory



Mandatory



Mandatory


Mandatory




Required




X(1) A ‘R' – Rejected Mandatory



Required

510–FA Reject Count 9(2) N Reject Count Required


Required



Required






NCPDP Telecommunication Standard Version D.0: Claim Rebill Rejected Response Field Field Name Pic Type Value Comments









Required when known


X(2) A Accepted values available in NCPDP 5D.0 guide.

Required when known



Required when known



Required when known



Required when known







Required when known



Required when known

Eligibility Verification Approved Response NCPDP Telecommunication Standard Version D.0: Eligibility Verification Approved Response


Number X(2) A ‘D0' – Version D.0 Mandatory


X(2) A ‘E1’ – Eligibility verification Mandatory



NCPDP Telecommunication Standard Version D.0: Eligibility Verification Approved Response Field Field Name Pic Type Value Comments


X(1) A ‘1’ – One occurrence Mandatory







Mandatory


Mandatory





549–7F Help Desk Phone Number Qualifier

X(2) A Blank – Not specified ‘03’ – Processor/PBM

Required when known

550–8F Help Desk Phone Number

X(18) A ‘7852745969’ Format – AAAEEENNNNXXXXXXXX AAA – Area code EEE – Exchange code NNNN – Number XXXXXXXX – Extension

Required when known

Eligibility Verification Rejected Response NCPDP Telecommunication Standard Version D.0: Eligibility Verification Rejected Response



103–A3 Transaction Code X(2) A ‘E1’ – Eligibility verification Mandatory

109–A9 Transaction Count X(1) A ‘1’– One occurrence Mandatory





Mandatory

201–B1 Service Provider ID X(15) A Provider ID will be returned with the ID received on the request.

Mandatory



NCPDP Telecommunication Standard Version D.0: Eligibility Verification Rejected Response Field Field Name Pic Type Value Comments


Mandatory





510–FA Reject Count 9(2) A ‘1’ – One occurrence Required


Required

549–7F Help Desk Phone Number Qualifier

X(2) A Blank – Not specified ‘03’ – Processor/PBM

Required when known

550–8F Help Desk Phone Number

X(18) A ‘7852745969’ Format – AAAEEENNNNXXXXXXXX AAA – Area code EEE – Exchange code NNNN – Number XXXXXXXX – Extension

Required when known

PA Inquiry Approved Response NCPDP Telecommunication Standard Version D.0: PA Inquiry Approved Response



103–A3 Transaction Code X(2) A ‘P3’ – PA inquiry Mandatory

109–A9 Transaction Count X(1) A ‘1’ – One occurrence Mandatory





Mandatory



Mandatory


Mandatory





NCPDP Telecommunication Standard Version D.0: PA Inquiry Approved Response Field Field Name Pic Type Value Comments


Required






X(20) A Authorization number Required



Required








Response Prior Authorization Segment: Required 111–AM Segment

Identification X(2) A ‘26’ – Response prior

authorization Required

498–RA Prior Authorization Quantity

9(7)V999 N 9999999.999 Required

498–RB Prior Authorization Dollars Authorized


498–PX Prior Authorization Quantity Accumulated

9(7)V999 N 9999999.999

Required

498–PY Prior Authorization Number – Assigned


Required

PA Inquiry Rejected Response NCPDP Telecommunication Standard Version D.0: PA Inquiry Rejected Response



103–A3 Transaction Code X(2) A ‘P3’ – PA inquiry Mandatory






NCPDP Telecommunication Standard Version D.0: PA Inquiry Rejected Response Field Field Name Pic Type Value Comments



Mandatory



Mandatory


Mandatory


Identification X(2) A ‘20' – Response message Mandatory


Required







Required



Required



Required








PA Request Captured Response NCPDP Telecommunication Standard Version D.0: PA Request Captured Response



103–A3 Transaction Code X(2) A ‘P4’ – PA request only Mandatory




NCPDP Telecommunication Standard Version D.0: PA Request Captured Response Field Field Name Pic Type Value Comments







Mandatory


Mandatory



504–F4 Message X(1)–X(200)

A This field will contain response specific text.

Required


Identification X(2) A ‘21’ – Response status Required


X(1) A ‘C’ – Captured Required


X(20) A Authorization number Required



Required








Response Prior Authorization Segment: Required 111–AM Segment

Identification X(2) A ‘26’ – Response prior

authorization Required

498–PY Prior Authorization Number – Assigned


Required



PA Request Rejected Response NCPDP Telecommunication Standard Version D.0: PA Request Rejected Response



103–A3 Transaction Code X(2) A ‘P4’ – PA request only Mandatory






Mandatory



Mandatory


Mandatory




Required







Required



Required



Required



Identification X(2) A ‘22’ – Request claim Mandatory







Transmission Rejected, Transaction Rejected Response NCPDP Telecommunication Standard Version D.0: Transaction Rejected Response



X(2) A Same value as in request Required

103–A3 Transaction Code X(2) A Same value as in request Required

109–A9 Transaction Count X(1) A Same value as in request Required


X(1) A ‘R’ – Rejected Required


X(2) A Same value as in request Required

201–B1 Service Provider ID X(15) A Same value as in request Required

401–D1 Date of Service 9(8) N Same value as in request Required


Identification X(2) A ‘20’ – Response message

segment Required

When segment present

504–F4 Message X(200) A Additional transaction information

Required

When segment present


Identification X(2) A ‘21’ Response status Required


X(1) A ‘R’ – Rejected Required

1 per transaction

510–FA Reject Count 9(2) N Required

511–FB Reject Code X(3) A Required


X(200) A Required




5. NCPDP v1.2 Transaction Set Specifications

Following is a list of the data elements, field names, and field positions for the Kansas Rx–POS system claims using the NCPDP version 1.2 format.

Standard COBOL documentation is used for transaction descriptions. The following definitions are given to ensure consistency of interpretation:

• Field – The NCPDP v1.2 data element identifier for a given transaction.

• Field Name – The short definition, name, or literal constant of the data located within the transaction at the positions indicated.

• Picture (Pic) – The COBOL “PICTURE” clause that describes how the data is presented on the transmission.

X = An alphanumeric character 9 = A numeric character S = A numeric value sign (+ or –) V = An implied decimal point ( ) = The character in front of the left parenthesis is repeated the number of times

between the parentheses; for example, X(5) represents the same PICTURE as XXXXX

• Type – The type of data in the field.

A = Alphanumeric – Always left–justified and space filled; A–Z, 0–9, and printable characters.

D = Signed Numeric – Always right–justified, zero always positive, zero filled dollar – cents amount with two positions to the right of the implied decimal point, all other positions to the left of the implied decimal point and have default values of zeroes when used for dollar fields (sign is internal and trailing).

Example: A D field with a length of 8 is represented as $$$$$$cc.

N = Unsigned Numeric – Always right–justified and zero filled.

Format: 9(7)V999 Example: 9999999.999

• Value – If a particular value is expected for Rx–POS, that value is given.

• Comments – NCPDP v1.2 is a fixed–format standard. Therefore, all of the segments and fields within the 1.2 standard are required.



6. NCPDP v1.2 Transaction Data Element Descriptions

Only one Version 1.2 Transaction Header and Trailer Record per batch transmission file NCPDP Telecommunication Standard Version 1.2: Batch Transaction

Field Field Name Pic Type Value Comments Header Record Definition: Required 880–K4 Text Indicator X(1) A Start of Text (STX) –X‘02’ Required

701 Segment Identifier

X(2) A ‘00’ – File header Required

880–K6 Transmission Type

X(1) A ‘T’ – Transaction ‘R’ – Response ‘E’ – Error

Required

880–K1 Sender ID X(24) A Sender ID Required

806–5C Batch Number 9(7) N Assigned by the sender and must match the Transaction Trailer Batch Number field.

Required

880–K2 Creation Date 9(8) N Date Filled Format – CCYYMMDD CC – Century YY – Year MM – Month DD – Day

Required

880–K3 Creation Time 9(4) N Time Filled Format – HHMM HH – Hour MM – Minute

Required

702 File Type X(1) A ‘P’ – Production ‘T’ – Test

Required


X(2) A ‘12’ – Version 1.2 Required

880–K7 Receiver ID X(24) A Receiver ID – Kansas Medical Assistance Program BIN # – ‘610517’

Required

880–K4 Text Indicator X(1) A End of text (ETX) –X‘03’ Required

Detail Data Record Definition: Required 880–K4 Text Indicator X(1) A Start of text (STX) – X‘02’ Required


X(2) A ‘G1’ – Detail data record Required

880–K5 Transaction Reference Number

X(10) A The transaction reference number is assigned by the pharmacy and is used to explicitly tie a response back to the original claim.

Required

NCPDP Version D.0 Data Record

NCPDP Version D.0 Transmission. The data record to be transmitted in this batch standard will follow the NCPDP Telecommunication Standard Version D.0. Length will vary.



NCPDP Telecommunication Standard Version 1.2: Batch Transaction Field Field Name Pic Type Value Comments

880–K4 Text Indicator X(1) A End of text (ETX) – X‘03’ Required

Detail Data Record Definition: Required 880–K4 Text Indicator X(1) A Start of text (STX) – X‘02’ Required


X(2) A ‘99’ – File trailer Required

806–5C Batch Number 9(7) N Assigned by the sender and must match the Transaction Header Batch Number field.

Required

751 Record Count 9(10) N Count of Version 1.2 Batch records (one Version 1.2 Batch Transaction Header, one too many Version 1.2 Batch Transaction Detail Data Records, and one Version 1.2 Batch Transaction Trailer) The record count field includes the total number of Version 1.2 records in the batch, including the header and trailer records. The maximum number of records in a file is 9,999,999,999 including one Transaction Header and one Transaction Trailer.

Required

504–F4 Message X(35) A The message field can be used to further explain the reasons why the entire batch is in error or any other information that needs to be sent regarding the batch. This field should only contain informational data and should not contain required data.

Required

880–K4 Text Indicator X(1) A End of text (ETX) – X‘03’ Required

Documents

NCPDP Version D.0 and 1.2 Transactions Payer Sheets