Pharmacy Online Processing System (POPS) Billing Guide NCPDP Telecommunications Standard D.0 (REV. APRIL 2013) Table of Contents 1.0 Introduction 1 2.0 Claim Submission Formats – B1 and B3 1 2.1 Request Claim Billing/Claim Rebill Payer Sheet 1 2.2 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response 37 2.3 Claim Billing/Claim Rebill Accepted/Rejected Response 44 2.4 Claim Billing/Claim Rebill Rejected/Rejected Response 48 3.0 Claim Submission Format – B2 50 3.1 Request for Claim Reversal Payer Sheet 50 3.2 Claim Reversal Accepted/Approved Response 54 3.3 Claim Reversal Accepted/Rejected Response 56 3.4 Claim Reversal Rejected/Rejected Response 58 4.0 Claim Submission Formats – S1 and S3 59 4.1 Service Billing/Service Rebill Request 59 4.2 Service Billing/Service Rebill Accepted/Paid (or Duplicate of Paid) Response 82 4.3 Service Billing/Service Rebill Accepted/Rejected Response 89 4.4 Service Billing/Service Rebill Rejected/Rejected Response 93 5.0 Claim Submission Format – S2 94 5.1 Service Reversal Request 94 5.2 Service Reversal Accepted/Approved Response 97 5.3 Service Reversal Accepted/Rejected Response 99 5.4 Service Reversal Rejected/Rejected Response 101 6.0 Third-Party Liability (TPL) Billing 103 7.0 90-Day Waiver Procedures 105 8.0 Claims Over $99,999.99 105 9.0 Special Topics and References 105 10.0 Version Table 106 11.0 Where to Get Help 110 Appendix A – Pharmacy 90-Day Waiver Form i 1.0 Introduction Effective January 1, 2012, Xerox State Healthcare (“Xerox”) will accept claims for MassHealth in the National Council for Prescription Drug Programs (NCPDP) version D.0 format. All MassHealth pharmacy claims must be sent via the Pharmacy Online Processing System (POPS). The list of values represented in the vD.0 POPS Billing Guide is found in the NCPDP External Code List dated January 2010. Xerox operates POPS under the general framework of standards and protocols established by NCPDP. Pharmacy providers must work with their software and switch vendors to ensure compliance such that all practice management software must be capable of submitting the following transactions to the MassHealth POPS: B1/B3, S1/S3, B2, and S2. Switches * Emdeon eRX Network: 1-866-379-6389 * RelayHealth: 1-800-388-2316 * QS1: 1-800-231-7776 This billing guide includes the D.0 payer sheets and also contains pertinent information for submitting pharmacy drug and service claims to MassHealth POPS. This document is updated regularly. The revision date above represents the most recent date that this document was updated. Please ensure that you are using the most current version of this document. For detailed information concerning updates to this document, please refer to the version table in Section 10.0 of this document. MassHealth has used NCPDP D.0 payer sheet templates as the basis for our payer sheets. (Materials are reproduced with the consent of the National Council for Prescription Drug Programs, Inc. 2010 NCPDP.) 2.0 Claim Submission Formats – B1 and B3 BIN NUMBER 009555 DESTINATION XEROX STATE HEALTHCARE ACCEPTING CLAIM ADJUDICATION (B1-BILLING AND B3-REBILL TRANSACTIONS) FORMAT NCPDP D.0 2.1 Request Claim Billing/Claim Rebill Payer Sheet Field Legend for Columns Payer Usage Column Value Explanation Payer Situation Column Mandatory M The field is mandatory for the segment in the designated transaction. No Required R The field has been designated with the situation of “required” for the segment in the designated transaction. Yes Qualified Requirement Q The situations designated have qualifications for usage (required if x, not required if y). Yes Qualified Requirement for Medicaid Subrogation Only QM The situations designated have qualifications for usage (required if x, not required if y) for Medicaid subrogation. Yes Informational Only I The field is for informational purposes only for the transaction. Yes Not Used N The field is not used for the segment for the transaction. No Repeating ***R*** The three asterisks, R, and three asterisks designates a field is repeating. Example: Q***R*** means a situationally qualified field that repeats. Example: N***R*** means a not used field that repeats when used. Yes Please Note: Fields that are not used in the claim billing/claim rebill transactions and those that do not have qualified requirements (i.e., not used) for this payer are excluded from the template. Claim Billing/Claim Rebill Transaction The following table lists the segments and fields applicable to MassHealth in a claim billing or claim rebill transaction for the NCPDP version D.0. Claim billing includes pharmacy billing transactions B1 and B3. Transaction Header Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situational This segment is always sent. X Source of certification IDs required in software vendor/certification ID (110-AK) is payer issued. X Source of certification IDs required in software vendor/certification ID (110-AK) is switch/VAN issued. Source of certification IDs required in software vendor/certification ID (110-AK) is not used. Transaction Header Segment Claim Billing/ Claim Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 101-A1 BIN Number 009555 M 9(6) 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code B1, B3 M X(2) 104-A4 Processor Control Number MASSPROD for production transactions M X(10) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M X(1) 202-B2 Service Provider ID Qualifier 01 – National provider identifier M X(2) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) 110-AK Software Vendor/Certification ID M The MassHealth registration number assigned to software as part of initial certification. X(10) Insurance Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. X Insurance Segment Segment Identification (111-AM) = 04 Claim Billing/ Claim Rebill Field # NCPDP FIELD NAME Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 302-C2 Cardholder ID M The 12-digit MassHealth member ID number X(20) 312-CC Cardholder First Name R Refer to Section 9.0 for more information. X(12) 313-CD Cardholder Last Name R Refer to Section 9.0 for more information. X(15) 314-CE Home Plan N 524-FO Plan ID I 309-C9 Eligibility Clarification Code N 301-C1 Group ID MassHealth HSN R Refer to Section 9.0 for more information. X(15) 303-C3 Person Code N 306-C6 Patient Relationship Code 0=Not specified 1=Cardholder N 359-2A Medigap ID QM X(20) 360-2B Medicaid Indicator QM X(2) 361-2D Provider Accept Assignment Indicator Y=Assigned N=Not assigned QM X(1) 997-G2 CMS Part D Defined Qualified Facility Y=CMS-qualified facility N=Not a CMS-qualified assigned QM X(1) 115-N5 Medicaid ID Number QM X(20) 116-N6 Medicaid Agency Number N Patient Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. X This segment is situational. Patient Segment Segment Identification (111-AM) = 01 Claim Billing/Claim Rebill Field NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 331-CX Patient ID Qualifier N X(2) 332-CY Patient ID N 304-C4 Date of Birth CCYYMMDD R Refer to Section 9.0 for more information. 9(8) 305-C5 Patient Gender Code 1=Male 2=Female R Refer to Section 9.0 for more information. 9(1) 310-CA Patient First Name I X(12) 311-CB Patient Last Name I X(15) 322-CM Patient Street Address N 323-CN Patient City Address N 324-CO Patient State / Province Address N 325-CP Patient Zip/Postal Zone N 326-CQ Patient Phone Number N 307-C7 Place of Service (formerly patient location) 1=Pharmacy 2=Unassigned 3=School 4=Homeless Shelter 5=Indian Health Service Free-standing Facility 6=Indian Health Service Provider-based Facility 7=Tribal 638 Free- standing Facility 8=Tribal 638 Provider- based Facility 9-10=Prison/Correctional Facility 11=Office 12=Home 13=Assisted Living Facility 14=Group Home 15=Mobile Unit I 9(2) 307-C7 (cont.) 16=Temporary Lodging 17=Walk-in Retail Health Clinic 18-19=Unassigned 20=Urgent Care Facility 21=Inpatient Hospital 22=Outpatient Hospital 23=Emergency Room – Hospital 24=Ambulatory Surgical Center 25=Birthing Center 26=Military Treatment Facility 27-30=Unassigned 31=Skilled Nursing Facility 32=Nursing Facility 33=Custodial Care Facility 34=Hospice 35-40=Unassigned 41=Ambulance – Land 42=Ambulance – Air or Water 43-48=Unassigned 49=Independent Clinic 50=Federally Qualified Health Center 51=Inpatient Psychiatric Facility 52=Psychiatric Facility – Partial Hospitalization 53=Community Mental Health Center 54=Intermediate Care Facility/Mentally Retarded 55=Residential Substance Abuse Treatment Facility 56=Psychiatric Residential Treatment 57=Non-residential Substance Abuse Treatment Facility 58-59=Unassigned 60 =Mass Immunization Center 61=Comprehensive Inpatient Rehabilitation Facility 62=Comprehensive Outpatient Rehabilitation Facility 63-64=Unassigned 65=End-Stage Renal Disease Treatment Facility 66-70 =Unassigned 71=Public Health Clinic 72=Rural Health Clinic 73-80 =Unassigned 81=Independent Laboratory 82-98=Unassigned 99=Other Place of Service 333-CZ Employer ID N 334-1C Smoker/Nonsmoker Code Yes=Smoker No=Nonsmoker Q X(1) 335-2C Pregnancy Indicator Blank=Not specified 1=Not pregnant 2=Pregnant Q X(1) 350-HN Patient E-Mail Address N 384-4X Patient Residence 1=Home 2=Skilled Nursing Facility 3=Nursing Facility 4=Assisted Living Facility 5=Custodial Care Facility 6=Group Home 11=Hospice 14=Homeless Shelter R 9(2) Claim Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. X This payer supports partial fills. X This payer does not support partial fills. Partial Fills The claim segment describes scenarios about partial fills and completion fills. A partial fill occurs when a pharmacy does not have the full quantity of a drug specified by a prescription to dispense to a patient. The pharmacy dispenses the available quantity. A claim may be submitted for this type of fill, known as a partial fill, whether or not the patient returns to obtain the remainder of the drug quantity (sometimes the patient does not return for the remainder). If the patient does return and receives the remainder of the drug quantity, a claim submitted for this transaction is known as a completion fill. A pharmacy can submit the following types of claims: * partial – whenever there is a partial fill on a covered drug; * completion with a previous partial claim – whenever a partial fill for which a previous claim was submitted has a completion fill; and * completion without a previous partial. The table below lists the fields that are required for partial-fill transactions, completion-fill transactions, or both. Field Name Used with Partial, Completion, or Both 456-EN (Associated prescription/service reference number) Completion 457-EP (Associated prescription/service date) Completion 343-HD (Dispensing status) Both 344-HF (Quantity intended to be dispensed) Both 345-HG (Days’ supply intended to be dispensed) Both Claim Segment Segment Identification (111-AM) = 07 Claim Billing/Claim Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 455-EM Prescription/Service Reference Number Qualifier 1=Rx billing M X(1) 402-D2 Prescription/Service Reference Number M The prescription number assigned must be unique for each member/ drug combination within a dispensing pharmacy. 9(12) 436-E1 Product/Service ID Qualifier 01=Universal Product Code (UPC) 02=Health-related item (HRI) 03=National Drug Code (NDC) M X(2) 407-D7 Product/Service ID M If CC, this field should be zero filled. X(19) 456-EN Associated Prescription/Service Reference Number Q Required if the completion transaction in a partial fill (dispensing status (343- HD) =C (completed)). Required if the dispensing status (343-HD) =P (partial fill) and there are multiple occurrences of partial fills for this prescription. 9(12) 457-EP Associated Prescription/Service Date CCYYMMDD Q Required if the completion transaction in a partial fill (dispensing status (343- HD) =C (completed)). Required if associated prescription/service reference number (456- EN) is used. Required if the dispensing status (343-HD) =P (partial fill) and there are multiple occurrences of partial fills for this prescription. 9(8) 458-SE Procedure Code Count N 459-ER Procedure Modifier Code N 442-E7 Quantity Dispensed Metric decimal quantity R For CC, enter the quantity of the drug in its compounded form. s9(7)v999 403-D3 Fill Number 0=Original dispensing 1 to 11=Refill number R 9(2) 405-D5 Days Supply R On partial-fill transactions, specify only whole days dispensed. 9(3) 406-D6 Compound Code 1=Not a compound 2=Compound code R 9(1) 408-D8 Dispense as Written (DAW)/Product Selection Code 0=No product selection indicated 1=Physician request 5=Brand used as generic R X(1) 414-DE Date Prescription Written CCYYMMDD R 9(8) 415-DF Number of Refills Authorized 0 through 11 R 9(2) 419-DJ Prescription Origin Code 1=Written on tamper- resistant prescription pad 2=Telephone 3=Electronic 4=Facsimile 5=Pharmacy R MassHealth will only recognize and allow the use of value 5 to cover situations defined in the Massachusetts Board of Registration in Pharmacy Regulation. 9(1) 354-NX Submission Clarification Code Count Maximum count of three R 9(1) 420-DK Submission Clarification Code 00=Not specified 01=No override 02=Other Override 03=Vacation Supply – The pharmacist is indicating that the cardholder has requested a vacation supply of the medicine. 04=Lost Prescription – The pharmacist is indicating that the cardholder has requested a replacement of medication that has been lost. 05=Therapy Change – The pharmacist is indicating that the physician has determined that a change in therapy was required; either that the medication was used faster than expected, or a different dosage form is needed, etc. 06=Starter Dose – The pharmacist is indicating that the previous medication was a starter dose and now additional medication is needed to continue treatment. 07=Medically Necessary – The pharmacist is indicating that this medication has been determined by the physician to be medically necessary. 08=Process Compound for Approved Ingredients 09=Encounters 10=Meets Plan Limitations –The pharmacy certifies that the transaction is in compliance with the program’s policies and rules that are specific to the particular product being billed. R***R*** MassHealth requires this field be populated on each claim. Submitters must use value 00=not specified if no other MassHealth supported values apply. MassHealth evaluates the submitted valid values supported in this field periodically and will deny claim submissions if the submitted field is omitted or the value is not supported. Value of 08 allows for processing the compound claim with all (covered and noncovered) ingredients. To select submission clarification code of 08, the compound code value must be 2. 99=Other: drug/product is exempt from Medicare D wrap threshold. 9(2) 420-DK (cont.) Submission Clarification Code 11=Certification on File – The supplier’s guarantee that a copy of the paper certification, signed and dated by the physician, is on file at the supplier’s office. 12=DME Replacement Indicator – Indicator that this certification is for a DME item replacing a previously purchased DME item. 13=Payer-Recognized Emergency/Disaster Assistance Request – The pharmacist is indicating that an override is needed based on an emergency/disaster situation recognized by the payer. 14=Long-Term Care (LTC) Leave of Absence – The pharmacist is indicating that the cardholder requires a short-fill of a prescription due to a leave of absence from the LTC facility. 15=LTC Replacement Medication – Medication has been contaminated during administration in a LTC setting. 16=LTC Emergency Box (kit) or Automated Dispensing Machine – Indicates that the transaction is a replacement supply for doses previously dispensed to the patient after hours. 17=LTC Emergency Supply Remainder – Indicates that the transaction is for the remainder of the drug originally begun from an emergency kit. 420-DK (cont.) Submission Clarification Code 18=LTC Patient Admit/Readmit Indicator – Indicates that the transaction is for a new dispensing of medication due to the patient’s admission or readmission status. 19=remainder billed to a subsequent payer when Medicare Part A expires. Used only in LTC settings. 20=340B – Indicates that, prior to providing service, the pharmacy has determined the product being billed is purchased, pursuant to rights available under Section 340B of the Public Health Act of 1992, including sub-ceiling purchases authorized by Section 340B (a)(10) and those made through the Prime Vendor Program (Section 340B(a)(8)). 21=LTC Dispensing: Seven days or less not applicable – Seven-days or less dispensing is not applicable due to CMS exclusion and/or manufacturer packaging may not be broken or special dispensing methodology (i.e., vacation supply, leave of absence, ebox, splitter dose). Medication quantities are dispensed as billed. 22=LTC Dispensing: Seven days – Pharmacy dispenses medication in seven-day supplies. 23=LTC Dispensing: Four days – Pharmacy dispenses medication in four-day supplies. 420-DK (cont.) Submission Clarification Code 24=LTC Dispensing: Three days – Pharmacy dispenses medication in three-day supplies 25=LTC Dispensing: Two days – Pharmacy dispenses medication in two-day supplies. 26=LTC Dispensing: One day – Pharmacy or remote (multiple shifts) dispenses medication in one-day supplies. 27=LTC Dispensing: 4-3 days – Pharmacy dispenses medication in four-day, then three-day supplies. 28=LTC Dispensing: 2-2- 3 days – Pharmacy dispenses medication in two-day, then two-day, then three-day supplies. 29=LTC Dispensing: Daily and three-day weekend – Pharmacy or remote dispensed daily during the week and combines multiple-days dispensing for weekends. 30=LTC Dispensing: Per shift dispensing – Remote dispensing per shift (multiple med passes). 31=LTC Dispensing: Per med pass dispensing – Remote dispensing per med pass. 32=LTC Dispensing: PRN on-demand – Remote dispensing on demand as needed. 33=LTC Dispensing: Seven-day or less dispensing method not listed above – Cycle not represented in codes 22- 31. 99=Other 308-C8 Other Coverage Code 00=Not specified by patient 01=No other coverage has been identified. 02=Other coverage exists. Payment was collected. 03=Other coverage exists. This claim is not covered. 04=Other coverage exists; payment not collected R MassHealth requires this field be populated on each claim. Submitters must use value 00=not specified by patient if no other MassHealth-supported values apply. MassHealth will reject the claim if a COB segment is submitted and the Other Coverage Code value is not equal to 02, 03, or 04. MassHealth will reject the claim if a COB segment is not submitted and Other Coverage Code value is equal to 02, 03, or 04. A value of 04 must be used only when the other payer has paid $0 because 100% of the allowed amount was applied to the patient responsibility. For multiple other insurances, if different payers returned different outcomes (02 – other coverage exists – payment collected, 04 – other coverage exists – payment not collected, 03 – other coverage exists – claim not covered), then use this hierarchy (02, 04, 03) for determining the value to enter in the other coverage code field. 9(2) 429-DT Special Packaging Indicator (Formerly Unit Dose Indicator) 0=Not specified 1=Not unit dose 2=Manufacturer unit dose 3=Pharmacy unit dose 4=Custom packaging 5=Multi-drug compliance packaging 6=Remote Device Unit Dose - Drug is dispensed at the facility, via a remote device, in a unit of use package. I 9(1) 429-DT (cont.) Special Packaging Indicator (Formerly Unit Dose Indicator) 7=Remote Device Multi- drug Compliance – Drug is dispensed at the facility, via a remote device, with packaging that may contain drugs from multiple manufacturers combined to ensure compliance and safe administration. 8=Manufacturer Unit of Use Package (not unit dose) – Drug is dispensed by pharmacy in original manufacturer’s package and relabeled for use. Applicable in long-term- care claims. 453-EJ Originally Prescribed Product/Service ID Qualifier 01=Universal Product Code (UPC) 02=Health-related item (HRI) 03=National Drug Code (NDC) N 445-EA Originally Prescribed Product/Service Code N 446-EB Originally Prescribed Quantity Q s9(7)v999 330-CW Alternate ID N 454-EK Scheduled Prescription ID Number N 600-28 Unit of Measure EA=Each GM=Grams ML=Milliliters I Not required for compound claim-Use field 451-EG instead. X(2) 418-DI Level of Service 03=Emergency Q 9(2) 461-EU Prior Authorization Type Code 0=Not specified 1=Prior authorization Q 9(1) 462-EV Prior Authorization Number Submitted Q 1) Required entry for claims submitted on behalf of 340B clinics for indirect billing. Authorization number is provided during registration; and 2) Required on B3 transactions for return to stock program. 9(11) 463-EW Intermediary Authorization Type ID N 464-EX Intermediary Authorization ID N 343-HD Dispensing Status Blank=Not specified P=Partial C=Completion Q This field is used and required only for partial- fill/complete actions. A value of P is required along with the quantity and days’ supply intended to be dispensed on the initial fill. A value of C will be required on the completion fill along with the associated pharmacy/service reference number and associated pharmacy/service date. If transaction is a B3-rebill, you cannot submit a dispensing status of P (partial) or C (completion). Values of P and C are valid only for B1. X(1) 344-HF Quantity Intended to be Dispensed Q Required for the partial fill or the completion fill of a prescription. s9(7)v999 345-HG Days Supply Intended to be Dispensed Q Required for the partial fill or the completion fill of a prescription. 9(3) 357-NV Delay Reason Code 1=Proof of eligibility unknown or unavailable. 2=Litigation 3=Authorization delay 4=Delay in certifying provider 5=Delay in supplying billing forms 7=Third-party processing delay 8=Delay in eligibility determination 9=Original claims rejected 10=Administrative delay in the prior approval process. 11=Other 12=Received late with no exceptions. Q Required when needed to specify the reason that submission of the transaction has been delayed. 9(2) 391-MT Patient Assignment Indicator (Direct Member Reimbursement Indicator) N 995-E2 Route of Administration 54471007=Buccal 372449004=Dental 417985001=Enteral 11751009=External 112239003=Inhalation 385218009=Injection 372464004=Intradermal 38239002=Intraperitoneal 47625008=Intravenous 47056001=Irrigation 249376008=Mouth/throat 46713006=Nasal 54485002=Ophthalmic 26643006=Oral 10547007=Otic 37161004=Rectal 419874009=Submucosal 37839007=Sublingual 6064005=Topical 45890007=Transdermal 90028008=Urethral 16857009=Vaginal Q This field should be populated only when billing for a multi-ingredient compound using a valid value recognized by MassHealth. X(11) 996-G1 Compound Type 01=Anti-infective 02=Ionotropic 03=Chemotherapy 04=Pain management 05=TPN/PPN 06=Hydration 07=Ophthalmic 99=Other Q Required when compound code (CC)=2 X(2) 147-U7 Pharmacy Service Type 1=Community/retail pharmacy services 2=Compounding pharmacy services 3=Home infusion therapy provider services 4=Institutional pharmacy services. 5=LTC pharmacy services 6=Mail order pharmacy services 7=Managed care organization pharmacy services 8=Specialty care pharmacy services 99=Other Q Required for members with commercial insurance that use mail order pharmacies. 9(2) Pricing Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. X Pricing Segment Segment Identification (111-AM) = 11 Claim Billing/Claim Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 409-D9 Ingredient Cost Submitted R s9(6)v99 412-DC Dispensing Fee Submitted R s9(6)v99 477-BE Professional Service Fee Submitted N 433-DX Patient Paid Amount Submitted Q When MassHealth is the primary payer, enter the copay amount the pharmacy received from the patient for the prescription dispensed. This field is not used in coordination of benefit transactions. s9(6)v99 438-E3 Incentive Amount Submitted Q When billing for both vaccine serum obtained at a cost to the pharmacy and vaccine administration, use this field for the vaccine administration fee. s9(6)v99 478-H7 Other Amount Claimed Submitted Count Maximum count of three Q Used for return to stock of unused Unit Dose Package Drugs. 9(1) 479-H8 Other Amount Claimed Submitted Qualifier Blank=Not specified 04=Administrative cost Q***R*** MassHealth only supports a value of 04 and this 04 should only be used if the pharmacy participates in the MassHealth Return to Stock program. X(2) 480-H9 Other Amount Claimed Submitted Q***R*** If field 479-H8 is populated with the value of 04, the pharmacy is indicating the claim is for the MassHealth Return to Stock program and must enter the administrative fee in this field. s9(6)v99 481-HA Flat Sales Tax Amount Submitted N 482-GE Percentage Sales Tax Amount Submitted N 483-HE Percentage Sales Tax Rate Submitted N 484-JE Percentage Sales Tax Basis Submitted N 426-DQ Usual And Customary Charge R s9(6)v99 430-DU Gross Amount Due R Whether billing MassHealth as the primary payer or a secondary payer, this amount follows the formula outlined in the D.0 Implementation Guide (Section 28.1.10.1) and adheres to the definition of Usual & Customary Charge defined in the Division of Health Care Finance & Policy regulation. s9(6)v99 423-DN Basis of Cost Determination 00=Default 01=Average wholesale price (AWP) 02=Local wholesaler 03=Direct 04=Estimated acquisition cost (EAC) 05=Acquisition R X(2) 423-DN (cont.) Basis of Cost Determination 06=Maximum allowable cost (MAC) 07=Usual and customary – The pharmacy’s price for the medication for a cash paying person on the day of dispensing. 08=340B/ disproportionate share pricing/public health 09=Other 10=Average sales price (ASP) 11=Average manufacturer price (AMP) 12=Wholesale acquisition cost (WAC) 13=Special patient pricing – The cost calculated by the pharmacy for the drug for this special patient. Pharmacy Provider Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. X The segment is submitted to indicate situations where an authorized pharmacist has entered into written agreements with supervising physicians to engage in Collaborative Drug Therapy Management (CDTM) in the Commonwealth of Massachusetts. Refer to 247 CMR 16.00. MassHealth requires the prescribing pharmacist to be the dispensing pharmacist. Pharmacy Provider Segment Segment Identification (111-AM) = 02 Claim Billing/Claim Refill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 465-EY Provider ID Qualifier 05=National provider identifier (NPI) R X(2) 444-E9 Provider ID R X(15) Prescriber Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. X This segment is situational. Prescriber Segment Segment Identification (111-AM) = 03 Claim Billing/Claim Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 466-EZ Prescriber ID Qualifier 01=National provider identifier (NPI) R X(2) 411-DB Prescriber ID R X(15) 427-DR Prescriber Last Name R X(15) 498-PM Prescriber Phone Number I 9(10) 468-2E Primary Care Provider ID Qualifier Blank=Not specified 01=National provider identifier (NPI) 02=Blue Cross 03=Blue Shield 04=Medicare 05=Medicaid 06=UPIN 07=NCPDP provider ID 08=State license 09=TriCare 10=Health industry number (HIN) 11=Federal tax ID 12=Drug Enforcement Administration (DEA) 13=State issued 14=Plan specific 99=Other I X(2) 421-DL Primary Care Provider ID I X(15) 470-4E Primary Care Provider Last Name I X(15) 364-2J Prescriber First Name I 365-2K Prescriber Street Address N 366-2M Prescriber City Address N 367-2N Prescriber State/Province Address N 368-2P Prescriber Zip/Postal Zone N Coordination of Benefits/Other Payments Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. X Required only for secondary, tertiary, etc., claims. Scenario 1 – Other payer amount paid, repetitions only. Scenario 2 – Other payer-patient responsibility amount repetitions, and benefit stage repetitions only. Scenario 3 – Other payer amount paid, other payer-patient responsibility amount, and benefit stage repetitions present (government programs). X All pharmacy claims submitted to POPS are adjudicated for other insurance coverage, also known as third-party liability (TPL). The billing pharmacy must indicate that the member’s other insurance was billed prior to submitting the claim to MassHealth. Therefore, all billing pharmacies must have online split-billing capability. After billing the primary payer, enter the appropriate information for the required split-billing fields on the claim submission (see below). Coordination of Benefits/Other Payments Segment Segment Identification (111-AM) = 05 Claim Billing/Claim Rebill Scenario 3 – Other Payer Amount Paid, Other Payer- Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 337-4C Coordination of Benefits/Other Payments Count Maximum count of nine M 9(1) 338-5C Other Payer Coverage Type 01=Primary 02=Secondary 03=Tertiary 04=Quaternary-fourth 05=Quinary-fifth 06=Senary-sixth 07=Septenary-seventh 08=Octonary-eighth 09=Nonary-ninth M***R*** X(2) 339-6C Other Payer ID Qualifier 03=BIN 99=Other R***R*** MassHealth accepts BIN on a limited basis. Refer to Section 6.0 TPL Billing for additional information. X(2) 340-7C Other Payer ID R MassHealth accepts BIN on a limited basis. Refer to Section 6.0 TPL Billing for additional information. X(10) 443-E8 Other Payer Date CCYYMMDD R 9(8) 341-HB Other Payer Amount Paid Count Maximum count of nine. Q 9(1) 342-HC Other Payer Amount Paid Qualifier Blank=not specified 01=Delivery Cost – An indicator which signifies the amount claimed for the costs related to the delivery of a product or service. 02=Shipping Cost – The amount claimed for transportation of an item. 03=Postage Cost – The amount claimed for the mailing of an item. 04=Administrative Cost – An indicator conveying the following amount is related to the cost of activities such as utilization review, premium collection, claims processing, quality assurance, and risk management for purposes of insurance. 05=Incentive – An indicator that signifies the dollar amount paid by the other payer, which is related to additional fees or compensations paid as an inducement for an action taken by the provider (e.g., collection of survey data, counseling plan enrollees, vaccine administration). Q***R*** MassHealth requires that one of these occurrences must contain the payment dollars associated with the drug benefit (07=Drug Benefit) X(2) 342-HC (cont.) Other Payer Amount Paid Qualifier 06=Cognitive Service – An indicator that signifies the dollar amount paid by the other payer, which is related to the pharmacist's interaction with a patient or caregiver that is beyond the traditional dispensing/patient instruction activity (e.g., therapeutic regiment review; recommendation for additional, fewer or different therapeutic choices). 07=Drug Benefit – An indicator that signifies the dollar amount paid by the other payer, which is related to the plan's drug benefit. 09=Compound Preparation Cost Submitted – The amount claimed for the preparation of the compound. 10=Sales Tax – An Indicator that signifies the dollar amount paid by the other payer, which is related to sales tax. 431-DV Other Payer Amount Paid s$$$$$$cc Q***R*** s9(6)v99 471-5E Other Payer Reject Count Maximum count of five Q Only populated when claim denies from a prior payer (i.e., Medicare or private). 9(2) 472-6E Other Payer Reject Code Q***R*** MassHealth requires the NCPDP reject code from the other payer when the other payer denies the claim (OCC3). MassHealth periodically notifies submitters of supported values. X(3) 353-NR Other Payer-Patient Responsibility Amount Count Maximum count of 25 Q 9(2) 351-NP Other Payer-Patient Responsibility Amount Qualifier 01=Deductible 04=Benefit Maximum 05=Copay 06=Patient Pay Amount 07=Coinsurance 09=Health Plan Assistance Amount Q***R*** MassHealth only supports the values listed. MassHealth will deny a claim submitted with a qualifier of any other value, even if the corresponding other payer-patient responsibility amount (352- NQ) is $0. If the prior payer returns Patient Responsibility Amounts utilizing component fields, submit a separate occurrence for any non-zero component, with the applicable qualifier (351- NP) and corresponding $$ amount (352-NQ). MassHealth only recognizes the use of qualifier 06- Patient Pay Amount when the prior payer does not return Patient Responsibility Amounts at a component level. When value 09 is submitted, the corresponding other payer-patient responsibility amount (352-NQ) must be a negative amount. X(2) 352-NQ Other Payer-Patient Responsibility Amount Q***R*** s9(8)v99 392-MU Benefit Stage Count Maximum count of four. Q 9(1) 393-MV Benefit Stage Qualifier Blank not specified 01=Deductible 02=Initial benefit 03=Coverage gap (donut hole) 04=Catastrophic coverage Q***R*** X(2) 394-MW Benefit Stage Amount Q***R*** s9(8)v99 Workers’ Compensation Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Workers’ Compensation Segment Segment Identification (111-AM) = 06 Claim Billing/Claim Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 434-DY Date of Injury M 315-CF Employer Name 316-CG Employer Street Address 317-CH Employer City Address 318-CI Employer State/Province Address 319-CJ Employer Zip/Postal Zone 320-CK Employer Phone Number 321-CL Employer Contact Name 327-CR Carrier ID 435-DZ Claim/Reference ID 117-TR Billing Entity Type Indicator 118-TS Pay to Qualifier 119-TT Pay to ID 120-TU Pay to Name 121-TV Pay to Street Address 122-TW Pay to City Address 123-TX Pay to State/Province Address 124-TY Pay to Zip/Postal Zone 125-TZ Generic Equivalent Product ID Qualifier 126-UA Generic Equivalent Product ID DUR/PPS Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. X DUR/PPS Segment Segment Identification (111-AM) = 08 Claim Billing/Claim Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 473-7E DUR/PPS Code Counter Maximum of nine occurrences R 9(1) 439-E4 Reason for Service Code DD=Drug-drug interaction HD=High dose ID=Ingredient duplication TD=Therapeutic duplication ER=Early refill Q***R*** Not required when Professional Service Code (440-E5)=MA 440-E5 Professional Service Code MA= Medication administration M0=Prescriber consulted R0=Pharmacist consulted other source R***R*** . X(2) 441-E6 Result of Service Code 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 Q***R*** Not required when Professional Service Code (440-E5)=MA X(2) 474-8E DUR/PPS Level of Effort 00 =Not specified 11=Level 1 – Less than five min. 12=Level 2 – Less than 15 min. 13=Level 3 – Less than 30 min. 14=Level 4 – Less than one hour 15=Level 5 – Greater than one hour I***R*** 9(2) 475-J9 DUR Coagent ID Qualifier 01=Universal Product Code (UPC) 02=Health-related item (HRI) 03=National Drug Code (NDC) 04=Universal product number (UPN) 05=Department of Defense (DOD) 07=Common procedure terminology (CPT4) I***R*** X(2) 475-J9 (cont.) DUR Coagent ID Qualifier 08=Common Procedure Terminology (CPT5) 09=Health Care Financing Administration Common Procedural Coding System (HCPCS) 11=National Pharmaceutical Product Interface code (NAPPI) 12=International article numbering system (EAN) 13=Drug Identification Number (DIN) 14=Medi-Span GPI 15=First DataBank GCN 16=Medical Economics GPO 17=Medi-Span DDID 18=First DataBank SmartKey 19=Medical Economics GM 20=International Classification of Diseases (ICD9) 21=International Classification of Diseases (ICD10) 23=National Criteria Care Institute (NCCI) 24=The Systematized Nomenclature of Human and Veterinary Medicine (SNOMED) 25=Common Dental Terminology (CDT) 475-J9 (cont.) DUR Coagent ID Qualifier 26=American Psychiatric Association Diagnostic Statistical Manual of Mental Disorders (DSM IV) 99=Other 476-H6 DUR Coagent ID I***R*** X(19) Coupon Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Coupon Segment Segment Identification (111-AM) = 09 Claim Billing/Claim Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 485-KE Coupon Type M X(2) 486-ME Coupon Number M X(15) 487-NE Coupon Value Amount Q s9(6)v99 Compound Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. X Segment is required when provided medication involves the compounding of two or more drugs. Refer to information below for specifics. Compound Claims Pharmacy compound claims must be submitted through POPS for payment. All compounds must be submitted online and must contain more than one ingredient. Each ingredient of the compound must be submitted. * Each compound claim is limited to a maximum of 15 ingredient lines. Providers can submit only a single compound transaction within a single transmission. * Noncovered ingredients will cause a claim to deny. Each ingredient is subjected to the edits and audits within claim adjudication. If a claim is denied because of a noncovered ingredient, the provider may agree to accept payment for the approved ingredients making up the compound. To do this, enter a value of 08 (08=Process Compound for Approved Ingredients) in the Submission Clarification Code (Field 420-DK). This allows the pharmacy to communicate acceptance of payment for approved ingredients only and for the POPS system to process the compound for these approved ingredients. Compound reversals are processed like other D.0 transactions. * Compounds may not be submitted as partial fills. Compound Segment Segment Identification (111-AM) = 10 Claim Billing/Claim Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 450-EF Compound Dosage Form Description Code 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 M X(2) 451-EG Compound Dispensing Unit Form Indicator 1=Each 2=Grams 3=Milliliters M 9(1) 447-EC Compound Ingredient Component Count Maximum 15 ingredients M 9(2) 488-RE Compound Product ID Qualifier 01=Universal Product Code (UPC) 02=Health-related item (HRI) 03=National Drug Code (NDC) (default) M***R*** X(2) 489-TE Compound Product ID M***R*** X(19) 448-ED Compound Ingredient Quantity M***R*** Metric decimal Equivalent s9(7)v999 449-EE Compound Ingredient Drug Cost R***R*** s9(7)v99 490-UE Compound Ingredient Basis Of Cost Determination 00=Default 01=Average wholesale price (AWP) 02=Local wholesaler 03=Direct 04=Estimated acquisition cost (EAC) 05=Acquisition 06=Maximum allowable cost (MAC) 07=Usual and customary (default) 08=340B Drug pricing 09=Other 10=Average sales price (ASP) 11=Average manufacturer price (AMP) 12=Wholesale acquisition cost (WAC) 13=Special patient pricing R***R*** X(2) 362-2G Compound Ingredient Modifier Code Count Maximum count of 10 I 9(2) 363-2H Compound Ingredient Modifier Code I***R*** X(2) Clinical Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. X Clinical Segment Segment Identification (111-AM) = 13 Claim Billing/Claim Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 491-VE Diagnosis Code Count Maximum count of five N 492-WE Diagnosis Code Qualifier N***R*** 424-DO Diagnosis Code N***R*** 493-XE Clinical Information Counter Maximum five occurrences supported Q 9(1) 494-ZE Measurement Date CCYYMMDD Q***R*** 9(8) 495-H1 Measurement Time HHMM Q***R*** 9(4) 496-H2 Measurement Dimension Blank=Not specified 01=Blood pressure (BP) 02=Blood glucose level 03=Temperature 04=Serum creatinine (SCr) 05=HbA1c 06=Sodium (Na+) 07=Potassium (K+) 08=Calcium (Ca++) 09=Serum glutamic- oxaloacetic transaminase (SGOT) 10=Serum glutamic- pyruvic transaminase (SCPT) 11=Alkaline phosphatase 12=Serum theophylline level 13=Serum digoxin level 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) Q***R*** X(2) 496-H2 (cont.) Measurement Dimension 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 497-H3 Measurement Unit 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=Millimeters per minute (ml/min) 13=Percentage (%) 14=Milliequivalent (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 Q***R*** X(2) 499-H4 Measurement Value Blood pressure entered in XXX/YYY format in which XXX=systolic, /=divider, and YYY is diastolic. Temperature entered in XXX.X format always includes decimal point. Request clinical segment. Q***R*** X(15) Additional Documentation Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Additional Documentation Segment Segment Identification (111-AM) = 14 Claim Billing/Claim Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 369-2Q Additional Documentation Type ID M 374-2V Request Period Begin Date 375-2W Request Period Recert/Revised Date 373-2U Request Status 371-2S Length of Need Qualifier 370-2R Length of Need 372-2T Prescriber/Supplier Date Signed 376-2X Supporting Documentation 377-2Z Question Number/Letter Count Maximum count of 50 378-4B Question Number/Letter 379-4D Question Percent Response 380-4G Question Date Response 381-4H Question Dollar Amount Response 382-4J Question Numeric Response 383-4K Question Alphanumeric Response Facility Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Facility Segment Segment Identification (111-AM) = 15 Claim Billing/Claim Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 336-8C Facility ID 385-3Q Facility Name 386-3U Facility Street Address 388-5J Facility City Address 387-3V Facility State/Province Address 389-6D Facility Zip/Postal Zone Narrative Segment Questions Check Claim Billing/Claim Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Narrative Segment Segment Identification (111-AM) = 16 Claim Billing/Claim Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 390-BM Narrative Message ** End of Request Claim Billing/Claim Rebill (B1/B3) Payer Sheet ** 2.2 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response The following table lists the segments and fields in a claim billing or claim rebill response (paid or duplicate of paid) transaction for the NCPDP version D.0. Claim billing includes pharmacy billing transactions B1 and B3. Response Transaction Header Segment Questions Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. X Response Transaction Header Segment Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code B1, B3 M X(2) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M X(1) 501-F1 Header Response Status A=Accepted M X(1) 202-B2 Service Provider ID Qualifier 01 – National provider identifier M X(2) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) Response Message Segment Questions Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. X This segment is situational. Provide general information when used for transmission-level messaging. Response Message Segment Segment Identification (111-AM) = 20 Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 504-F4 Message Q X(200) Response Insurance Segment Questions Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Insurance Segment Segment Identification (111-AM) = 25 Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 301-C1 Group ID MassHealth HSN R Refer to Section 9.0 for more information. X(15) 524-FO Plan ID R 545-2F Network Reimbursement ID N 568-J7 Payer ID Qualifier N 569-J8 Payer ID N 115-N5 Medicaid ID Number N 116-N6 Medicaid Agency Number N 302-C2 Cardholder ID N Response Patient Segment Questions Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Patient Segment Segment Identification (111-AM) = 29 Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 310-CA Patient First Name R X(12) 311-CB Patient Last Name R X(15) 304-C4 Date of Birth CCYYMMDD R 9(8) Response Status Segment Questions Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. X Response Status Segment Segment Identification (111-AM) = 21 Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 112-AN Transaction Response Status P=Paid D=Duplicate of paid M X(1) 503-F3 Authorization Number R X(20) 547-5F Approved Message Code Count Maximum count of five N 548-6F Approved Message Code N***R*** 130-UF Additional Message Information Count Maximum count of eight Q 9(2) 132-UH Additional Message Information Qualifier 01 Q***R*** X(2) 526-FQ Additional Message Information Q***R*** X(40) 131-UG Additional Message Information Continuity + Q***R*** X(1) 549-7F Help Desk Phone Number Qualifier N 550-8F Help Desk Phone Number N Response Claim Segment Questions Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. X Response Claim Segment Segment Identification (111-AM) = 22 Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 455-EM Prescription/Service Reference Number Qualifier 1=Rx billing M X(1) 402-D2 Prescription/Service Reference Number M 9(12) 551-9F Preferred Product Count Maximum count of six N 552-AP Preferred Product ID Qualifier N***R*** 553-AR Preferred Product ID N***R*** 554-AS Preferred Product Incentive N***R*** 555-AT Preferred Product Cost Share Incentive N***R*** 556-AU Preferred Product Description N***R*** Response Pricing Segment Questions Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. X Response Pricing Segment Segment Identification (111-AM) = 23 Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 505-F5 Patient Pay Amount R s9(6)v99 506-F6 Ingredient Cost Paid Q s9(6)v99 507-F7 Dispensing Fee Paid Q s9(6)v99 557-AV Tax Exempt Indicator N 558-AW Flat Sales Tax Amount Paid N 559-AX Percentage Sales Tax Amount Paid N 560-AY Percentage Sales Tax Rate Paid N 561-AZ Percentage Sales Tax Basis Paid N 521-FL Incentive Amount Paid Q 562-J1 Professional Service Paid N 563-J2 Other Amount Paid Count Maximum count of three Q 9(1) 564-J3 Other Amount Paid Qualifier 04=Administrative 09=Compound preparation cost Q***R*** For 04=MassHealth administrative fee associated with return to stock program. For 09=Compound prescription cost, this field contains the additional cost for the dispensing of compounds as per MassHealth regulation. X(2) 565-J4 Other Amount Paid Q***R*** s9(6)v99 566-J5 Other Payer Amount Recognized Q s9(6)v99 509-F9 Total Amount Paid R s9(6)v99 522-FM Basis of Reimbursement Determination R 9(2) 523-FN Amount Attributed to Sales Tax N 512-FC Accumulated Deductible Amount N 513-FD Remaining Deductible Amount N 514-FE Remaining Benefit Amount 999999.00 R s9(6)v99 517-FH Amount Applied to Periodic Deductible N 518-FI Amount of Copay Q s9(6)v99 520-FK Amount Exceeding Periodic Benefit Maximum N 346-HH Basis of Calculation – Dispensing Fee N 347-HJ Basis Of Calculation – Copay 01=Quantity dispensed 02=Quantity intended to be dispensed 03=Usual and customary/prorated 04=Waived due to partial fill 99=Other Q X(2) 348-HK Basis of Calculation – Flat Sales Tax N 349-HM Basis of Calculation – Percentage Sales Tax N 571-NZ Amount Attributed to Processor Fee N 575-EQ Patient Sales Tax Amount N 574-2Y Plan Sales Tax Amount N 572-4U Amount Of Coinsurance N 573-4V Basis Of Calculation – Coinsurance N 392-MU Benefit Stage Count Maximum count of four. Q 9(1) 393-MV Benefit Stage Qualifier Blank=Not specified 01=Deductible 02=Initial benefit 03=Coverage gap (donut hole) 04=Catastrophic coverage Q***R*** X(2) 394-MW Benefit Stage Amount Q***R*** s9(6)v99 577-G3 Estimated Generic Savings N 128-UC Spending Account Amount Remaining N 129-UD Health Plan-Funded Assistance Amount N 133-UJ Amount Attributed to Provider Network Selection N 134-UK Amount Attributed to Product Selection/Brand Drug N 135-UM Amount Attributed to Product Selection/Nonpreferred Formulary Selection N 136-UN Amount Attributed to Product Selection/Brand Nonpreferred Formulary Selection N 137-UP Amount Attributed to Coverage Gap N 148-U8 Ingredient cost contracted/ Reimbursable amount N 149-U9 Dispensing fee contracted/ Reimbursable amount N Response DUR/PPS Segment Questions Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. This segment is situational. X Response DUR/PPS Segment Segment Identification (111-AM) = 24 Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 567-J6 DUR/PPS Response Code Counter Maximum nine occurrences supported. Q 9(1) 439-E4 Reason for Service Code DD=Drug-drug interaction HD=High dose ID=Ingredient duplication TD=Therapeutic duplication ER=Early refill Q***R*** X(2) 528-FS Clinical Significance Code Q***R*** X(1) 529-FT Other Pharmacy Indicator Q***R*** 9(1) 530-FU Previous Date of Fill Q***R*** 9(8) 531-FV Quantity of Previous Fill Q***R*** s9(7)v999 532-FW Database Indicator Q***R*** X(1) 533-FX Other Prescriber Indicator Q***R*** 9(1) 544-FY DUR Free Text Message Q***R*** X(30) 570-NS DUR Additional Text Q***R*** X(100) Response Coordination of Benefits/Other Payers Segment Questions Check Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent.. This segment is situational. X Response Coordination of Benefits/Other Payers Segment Segment Identification (111-AM) = 28 Claim Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 355-NT Other Payer ID Count Maximum count of three M 9(1) 338-5C Other Payer Coverage Type 01=Primary 02=Secondary 03=Tertiary M***R*** X(2) 339-6C Other Payer ID Qualifier Blank=Not specified 03=BIN 99=Other Q***R*** X(2) 340-7C Other Payer ID Q***R*** X(10) 991-MH Other Payer Processor Control Number Q***R*** : X(10) 356-NU Other Payer Cardholder ID N***R*** 992-MJ Other Payer Group ID Q***R*** X(15) 142-UV Other Payer Person Code N***R*** 127-UB Other Payer Help Desk Phone Number N***R*** 143-UW Other Payer Patient Relationship Code N***R*** 144-UX Other Payer Benefit Effective Date N***R*** 145-UY Other Payer Benefit Termination Date N***R*** 2.3 Claim Billing/Claim Rebill Accepted/Rejected Response The following table lists the segments and fields in a claim billing or claim rebill response (accepted or rejected) transaction for the NCPDP version D.0. Claim billing includes pharmacy billing transactions B1 and B3. Response Transaction Header Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. X Response Transaction Header Segment Claim Billing/Claim Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code B1, B3 M X(2) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M X(1) 501-F1 Header Response Status A=Accepted M X(1) 202-B2 Service Provider ID Qualifier M X(15) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) Response Message Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Message Segment Segment Identification (111- AM) = 20 Claim Billing/Claim Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 504-F4 Message Q X(200) Response Insurance Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Insurance Segment Segment Identification (111-AM) = 25 Claim Billing/Claim Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 301-C1 Group ID MassHealth HSN R If the system determined that Health Safety Net was the payer of the claim, then the Group ID (301-C1) within this response transaction will contain a value of HSN. Please check with your software vendor, to ensure that this information is captured in your system and available to payment reconciliation processes. X(15) 524-FO Plan ID Q 545-2F Network Reimbursement ID N 568-J7 Payer ID Qualifier N 569-J8 Payer ID N Response Patient Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Patient Segment Segment Identification (111-AM) = 29 Claim Billing/Claim Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 310-CA Patient First Name Q X(12) 311-CB Patient Last Name Q X(15) 304-C4 Date of Birth CCYYMMDD Q 9(8) Response Status Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation This Segment is always sent. X Response Status Segment Segment Identification (111-AM) = 21 Claim Billing/Claim Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 112-AN Transaction Response Status R=Rejected M X(1) 503-F3 Authorization Number R X(20) 510-FA Reject Count Maximum count of five R 9(2) 511-FB Reject Code R***R*** This field is mandatory when a reject response is returned. X(3) 546-4F Reject Field Occurrence Indicator Q***R*** This is the number of rejected fields. 9(2) 547-5F Approved Message Code Count N 548-6F Approved Message Code N***R*** 130-UF Additional Message Information Count Maximum count of eight Q 9(2) 132-UH Additional Message Information Qualifier 01 Q***R*** X(2) 526-FQ Additional Message Information Q***R*** X(40) 131-UG Additional Message Information Continuity + Q***R*** X(1) 549-7F Help Desk Phone Number Qualifier N 550-8F Help Desk Phone Number N Response Claim Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. X Response Claim Segment Segment Identification (111-AM) = 22 Claim Billing/Claim Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 455-EM Prescription/Service Reference Number Qualifier 1=Rx billing M X(1) 402-D2 Prescription/Service Reference Number M 9(12) 551-9F Preferred Product Count Maximum count of six N 552-AP Preferred Product ID Qualifier N***R*** 553-AR Preferred Product ID N***R*** 554-AS Preferred Product Incentive N***R*** 555-AT Preferred Product Cost Share Incentive N***R*** 556-AU Preferred Product Description N***R*** 114-N4 Medicaid Subrogration Internal Control Number/Transaction Control Number (ICN/TCN) N Response DUR/PPS Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. This segment is situational. X Response DUR/PPS Segment Segment Identification (111-AM) = 24 Claim Billing/Claim Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 567-J6 DUR/PPS Response Code Counter Maximum nine occurrences supported Q 9(1) 439-E4 Reason For Service Code DD=Drug-drug interaction HD=High dose ID=Ingredient duplication TD=Therapeutic duplication ER=Early refill Q***R*** X(2) 528-FS Clinical Significance Code Q***R*** X(1) 529-FT Other Pharmacy Indicator Q***R*** 9(8) 530-FU Previous Date of Fill Q***R*** 9(8) 531-FV Quantity of Previous Fill Q***R*** s9(7)v999 532-FW Database Indicator Q***R*** X(1) 533-FX Other Prescriber Indicator Q***R*** 9(1) 544-FY DUR Free Text Message Q***R*** X(30) 570-NS DUR Additional Text Q***R*** Response Coordination of Benefits/Other Payers Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. This segment is situational. X Response Coordination of Benefits/Other Payers Segment Segment Identification (111-AM) = 28 Claim Billing/Claim Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 355-NT Other Payer ID Count Maximum count of three. M 338-5C Other Payer Coverage Type 01=Primary 02=Secondary 03=Tertiary M***R*** X(2) 339-6C Other Payer ID Qualifier Blank=Not specified 03=BIN 99=Other Q***R*** X(2) 340-7C Other Payer ID Q***R*** X(10) 991-MH Other Payer Processor Control Number Q***R*** X(10) 356-NU Other Payer Cardholder ID N***R*** 992-MJ Other Payer Group ID Q***R*** X(15) 142-UV Other Payer Person Code N***R*** 127-UB Other Payer Help Desk Phone Number N***R*** 143-UW Other Payer Patient Relationship Code N***R*** 144-UX Other Payer Benefit Effective Date N***R*** 145-UY Other Payer Benefit Termination Date N***R*** 2.4 Claim Billing/Claim Rebill Rejected/Rejected Response The following table lists the segments and fields in a claim billing or claim rebill response (rejected/rejected) transaction for the NCPDP version D.0. Claim billing includes pharmacy billing transactions B1 and B3. Response Transaction Header Segment Questions Check Claim Billing/Claim Rebill Rejected/Rejected If Situational, Payer Situation This segment is always sent. X Response Transaction Header Segment Claim Billing/Claim Rebill Rejected/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code B1, B3 M X(2) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M X(1) 501-F1 Header Response Status R=Rejected M X(1) 202-B2 Service Provider ID Qualifier 01 – National provider identifier M X(2) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) Response Message Segment Questions Check Claim Billing/Claim Rebill Rejected/Rejected If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Message Segment Segment Identification (111-AM) = 20 Claim Billing/Claim Rebill Rejected/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M 504-F4 Message Q X(200) Response Status Segment Questions Check Claim Billing/Claim Rebill Rejected/Rejected If Situational, Payer Situation This Segment is always sent. X Response Status Segment Segment Identification (111-AM) = 21 Claim Billing/Claim Rebill Rejected/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 112-AN Transaction Response Status R=Rejected M X(1) 503-F3 Authorization Number R X(20) 510-FA Reject Count Maximum count of five R 9(2) 511-FB Reject Code R***R*** X(3) 546-4F Reject Field Occurrence Indicator Q***R*** X(3) 130-UF Additional Message Information Count Maximum count of eight Q 9(2) 132-UH Additional Message Information Qualifier 01 Q***R*** X(2) 526-FQ Additional Message Information Q***R*** X(40) Response Status Segment Segment Identification (111-AM) = 21 Claim Billing/Claim Rebill Rejected/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 131-UG Additional Message Information Continuity + Q***R*** X(1) 549-7F Help Desk Phone Number Qualifier N 550-8F Help Desk Phone Number N ** End of Response Claim Billing/Claim Rebill (B1/B3) Payer Sheet ** 3.0 Claim Submission Format – B2 BIN NUMBER 009555 DESTINATION XEROX STATE HEALTHCARE ACCEPTING CLAIM ADJUDICATION (B2 REVERSAL TRANSACTIONS) FORMAT NCPDP D.0 3.1 Request for Claim Reversal Payer Sheet Field Legend for Columns Payer Usage Column Value Explanation Payer Situation Column Mandatory M The field is mandatory for the segment in the designated transaction. No Required R The field has been designated with the situation of ‘required’ for the segment in the designated transaction. No Qualified Requirement Q The situations designated have qualifications for usage (required if x, not required if y). Yes Informational Only I The field is for informational purposes only for the transaction. Yes Not Used N The field is not used for the segment for the transaction. No Repeating ***R*** The three asterisks, R, and three asterisks designates a field is repeating. Example: Q***R*** means a situationally qualified field that repeats. Example: N***R*** means a not used field that repeats when used. Yes Claim Reversal Transaction The following table lists the segments and fields in a claim reversal transaction for the NCPDP version D.0. Claim reversal transaction includes pharmacy billing transactions B2. Transaction Header Segment Questions Check Claim Reversal If Situational, Payer Situation This segment is always sent. X Source of certification IDs required in software vendor/certification ID (110-AK) is payer issued. X Source of certification IDs required in software vendor/certification ID (110-AK) is switch/VAN issued. Source of certification IDs required in software vendor/certification ID (110-AK) is not used. Transaction Header Segment Claim Reversal Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 101-A1 BIN Number 009555 M 9(6) 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code B2 M X(2) 104-A4 Processor Control Number MASSPROD for production transactions M X(10) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M For B2/S2 (reversal) transactions, transaction count must be a value of 1, 2, 3, or 4. If this transaction is for a compound claim, the transaction count value must be 1. X(1) 202-B2 Service Provider ID Qualifier 01=National provider identifier (NPI) M X(2) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) 110-AK Software Vendor/Certification ID M The MassHealth registration number assigned to software as part of initial certification. X(10) Insurance Segment Questions Check Claim Reversal If Situational, Payer Situation This segment is always sent. X This segment is situational. Insurance Segment Segment Identification (111-AM) = 04 Claim Reversal Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 302-C2 Cardholder ID M 12-digit MassHealth ID number X(20) 301-C1 Group ID MassHealth HSN R X(15) Claim Segment Questions Check Claim Reversal If Situational, Payer Situation This segment is always sent. X Claim Segment Segment Identification (111-AM) = 07 Claim Reversal Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 455-EM Prescription/Service Reference Number Qualifier 1=Rx billing M X(1) 402-D2 Prescription/Service Reference Number M 9(12) 436-E1 Product/Service ID Qualifier 01=Universal Product Code (UPC) 02=Health-related item (HRI) 03=National Drug Code (NDC) M X(2) 407-D7 Product/Service ID M X(19) 403-D3 Fill Number Q 9(2) 308-C8 Other Coverage Code Q 9(2) 147-U7 Pharmacy Service Type Q Required for members with commercial insurance that use mail order pharmacies. Pricing Segment Questions Check Claim Reversal If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Pricing Segment Segment Identification (111-AM) = 11 Claim Reversal Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 438-E3 Incentive Amount Submitted Q 430-DU Gross Amount Due Coordination of Benefits/Other Payments Segment Questions Check Claim Reversal If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Coordination of Benefits/Other Payments Segment Segment Identification (111-AM) = 05 Claim Reversal Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 337-4C Coordination of Benefits/Other Payments Count Maximum count of nine M 9(1) 338-5C Other Payer Coverage Type M 9(1) DUR/PPS Segment Questions Check Claim Reversal If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. DUR/PPS Segment Segment Identification (111-AM) = 08 Claim Reversal Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 473-7E DUR/PPS Code Counter Maximum of nine occurrences 9(1) 439-E4 Reason for Service Code X(2) 440-E5 Professional Service Code X(2) 441-E6 Result of Service Code X(2) ** End of Request Claim Reversal (B2) Payer Sheet ** 3.2 Claim Reversal Accepted/Approved Response The following table lists the segments and fields in a claim reversal response (accepted/approved) transaction for the NCPDP version D.0. Response Transaction Header Segment Questions Check Claim Reversal – Accepted/Approved If Situational, Payer Situation This segment is always sent. X Response Transaction Header Segment Claim Reversal – Accepted/Approved Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code B2 M X(2) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M For B2 (reversal) transactions, the transaction count will be a value of 1, 2, 3, or 4. If this transaction is for a compound claim, the transaction count value must be 1. X(1) 501-F1 Header Response Status A=Accepted M X(1) 202-B2 Service Provider ID Qualifier 01 – National provider identifier (NPI) M X(2) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) Response Message Segment Questions Check Claim Reversal – Accepted/Approved If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Message Segment Segment Identification (111-AM) = 20 Claim Reversal – Accepted/Approved Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 504-F4 Message Q X(200) Response Status Segment Questions Check Claim Reversal – Accepted/Approved If Situational, Payer Situation This segment is always sent. X Response Status Segment Segment Identification (111-AM) = 21 Claim Reversal – Accepted/Approved Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 112-AN Transaction Response Status A=Approved M X(1) 503-F3 Authorization Number R X(20) 547-5F Approved Message Code Count Maximum count of five N 548-6F Approved Message Code N***R*** 130-UF Additional Message Information Count Maximum count of eight Q 9(2) 132-UH Additional Message Information Qualifier 01 Q***R*** X(2) 526-FQ Additional Message Information Q***R*** X(40) 131-UG Additional Message Information Continuity + Q***R*** X(1) 549-7F Help Desk Phone Number Qualifier N 550-8F Help Desk Phone Number N Response Claim Segment Questions Check Claim Reversal – Accepted/Approved If Situational, Payer Situation This segment is always sent. X Response Claim Segment Segment Identification (111-AM) = 22 Claim Reversal – Accepted/Approved Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 455-EM Prescription/Service Reference Number Qualifier 1=Rx billing M X(1) 402-D2 Prescription/Service Reference Number M 9(12) Response Pricing Segment Questions Check Claim Reversal – Accepted/Approved If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Response Pricing Segment Segment Identification (111-AM) = 23 Claim Reversal – Accepted/Approved Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 521-FL Incentive Amount Paid Q 509-F9 Total Amount Paid 3.3 Claim Reversal Accepted/Rejected Response The following table lists the segments and fields in a claim reversal response (accepted/rejected) transaction for the NCPDP version D.0. Response Transaction Header Segment Claim Reversal – Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code B2 M X(2) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M For B2 (reversal) transactions, the transaction count will be a value of 1, 2, 3, or 4. If this transaction is for a compound claim, the transaction count value must be 1. X(1) 501-F1 Header Response Status A=Accepted M X(1) 202-B2 Service Provider ID Qualifier 01 – National provider identifier (NPI) M X(2) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) Response Message Segment Questions Check Claim Reversal - Accepted/Rejected If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Message Segment Segment Identification (111-AM) = “20” Claim Reversal – Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 504-F4 Message Q X(200) Response Status Segment Questions Check Claim Reversal - Accepted/Rejected If Situational, Payer Situation This segment is always sent. X Response Status Segment Segment Identification (111-AM) = 21 Claim Reversal – Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 112-AN Transaction Response Status R=Rejected M X(1) 503-F3 Authorization Number R X(20) 510-FA Reject Count R 9(2) 511-FB Reject Code R***R*** X(3) 546-4F Reject Field Occurrence Indicator Q***R*** 9(2) 130-UF Additional Message Information Count Maximum count of eight Q 9(2) 132-UH Additional Message Information Qualifier 01 Q***R*** X(2) 526-FQ Additional Message Information Q***R*** X(40) 131-UG Additional Message Information Continuity + Q***R*** X(1) 549-7F Help Desk Phone Number Qualifier N 550-8F Help Desk Phone Number N Response Claim Segment Questions Check Claim Reversal - Accepted/Rejected If Situational, Payer Situation This segment is always sent. X Response Claim Segment Segment Identification (111-AM) = 22 Claim Reversal – Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 455-EM Prescription/Service Reference Number Qualifier 1=Rx billing M For transaction code of B2 in the response claim segment, the prescription/service reference number qualifier (455-EM) is 1 (Rx billing). X(1) 402-D2 Prescription/Service Reference Number M 9(12) 3.4 Claim Reversal Rejected/Rejected Response The following table lists the segments and fields in a claim reversal response (rejected) transaction for the NCPDP version D.0. Response Transaction Header Segment Questions Check Claim Reversal - Rejected/Rejected If Situational, Payer Situation This segment is always sent. X Response Transaction Header Segment Claim Reversal – Rejected/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code B2 M X(2) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M For B2 (reversal) transactions, the transaction count will be a value of 1, 2, 3, or 4. If this transaction is for a compound claim, the transaction count value must be 1. X(1) 501-F1 Header Response Status R=Rejected M X(1) 202-B2 Service Provider ID Qualifier 01 – National provider identifier (NPI) M X(2) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) Response Message Segment Questions Check Claim Reversal – Rejected/Rejected If Situational, Payer Situation This segment is always sent X This segment is situational Response Message Segment Segment Identification (111-AM) = 20 Claim Reversal – Rejected/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 504-F4 Message Q X(200) Response Status Segment Questions Check Claim Reversal - Rejected/Rejected If Situational, Payer Situation This segment is always sent. X Response Status Segment Segment Identification (111-AM) = 21 Claim Reversal – Rejected/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 112-AN Transaction Response Status R=Rejected M X(1) 503-F3 Authorization Number R X(20) 510-FA Reject Count Maximum count of five R 9(2) 511-FB Reject Code R***R*** X(3) 546-4F Reject Field Occurrence Indicator N 130-UF Additional Message Information Count Maximum count of eight Q 9(2) 132-UH Additional Message Information Qualifier 01 Q***R*** X(2) 526-FQ Additional Message Information Q***R*** X(40) 131-UG Additional Message Information Continuity + Q***R*** X(1) 549-7F Help Desk Phone Number Qualifier N 550-8F Help Desk Phone Number N ** End of Claim Reversal (B2) Response Payer Sheet ** 4.0 Claim Submission Formats – S1 and S3 BIN NUMBER 009555 DESTINATION XEROX STATE HEALTHCARE ACCEPTING CLAIM ADJUDICATION (S1 SERVICE BILLING AND S3 SERVICE REBILL TRANSACTIONS) FORMAT NCPDP D.0 4.1 Service Billing/Service Rebill Request Field Legend for Columns Payer Usage Column Value Explanation Payer Situation Column Mandatory M The field is mandatory for the segment in the designated transaction. No Required R The field has been designated with the situation of “required” for the segment in the designated transaction. Yes Qualified Requirement Q The situations designated have qualifications for usage (required if x, not required if y). Yes Qualified Requirement For Medicaid Subrogation Only QM The situations designated have qualifications for usage (required if x, not required if y) for Medicaid subrogation. Yes Informational Only I The field is for informational purposes only for the transaction. Yes Not Used N The field is not used for the segment for the transaction. No Repeating ***R*** The three asterisks, R, and three asterisks designates a field is repeating. Example: Q***R*** means a situationally qualified field that repeats. Example: N***R*** means an unused field that repeats when used. Yes Please Note: Fields that are not used in the service billing/service rebill transactions and those that do not have qualified requirements (i.e., not used) for this payer are excluded from the template. Service Billing/Service Rebill Transaction The following table lists the segments and fields in a service billing or service rebill transaction for the NCPDP version D.0. Service billing includes billing transactions S1 and S3. Transaction Header Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. X Source of certification IDs required in software vendor/certification ID (110-AK) is payer issued. X Source of certification IDs required in software vendor/certification ID (110-AK) is switch/VAN issued. Source of certification IDs required in software vendor/certification ID (110-AK) is not used. Transaction Header Segment Service Billing/Service Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 101-A1 BIN Number 009555 M 9(6) 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code S1, S3 M X(2) 104-A4 Processor Control Number MASSPROD for production transactions M X(10) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M X(1) 202-B2 Service Provider ID Qualifier 01 – National provider identifier(NPI) M X(2) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) 110-AK Software Vendor/Certification ID M The MassHealth registration number assigned to software as part of initial certification. X(10) Insurance Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. X Insurance Segment Segment Identification (111-AM) = 04 Service Billing/Service Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 302-C2 Cardholder ID M The 12-digit MassHealth member ID number X(20) 312-CC Cardholder First Name R Refer to Section 9.0 for more information. X(12) 313-CD Cardholder Last Name R Refer to Section 9.0 for more information. X(15) 314-CE Home Plan N 524-FO Plan ID I 309-C9 Eligibility Clarification Code N 301-C1 Group ID MassHealth HSN R If the system determined that Health Safety Net was the payer of the claim, then the Group ID (301-C1) within this response transaction will contain a value of HSN. Please check with your software vendor to ensure that this information is captured in your system and available to payment reconciliation processes. X(15) 303-C3 Person Code N 306-C6 Patient Relationship Code 0=Not specified 1=Cardholder N 359-2A Medigap ID QM X(20) 360-2B Medicaid Indicator QM X(2) 361-2D Provider Accept Assignment Indicator Y=Assigned N=Not assigned QM X(1) Patient Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. X This segment is situational. Patient Segment Segment Identification (111-AM) = 01 Service Billing/Service Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 331-CX Patient ID Qualifier N 332-CY Patient ID N 304-C4 Date of Birth CCYYMMDD R 9(8) 305-C5 Patient Gender Code 1=Male 2=Female R Refer to Section 9.0 for more information. 9(1) 310-CA Patient First Name I X(12) 311-CB Patient Last Name I X(15) 322-CM Patient Street Address N 323-CN Patient City Address N 324-CO Patient State/Province Address N 325-CP Patient Zip/Postal Zone N 326-CQ Patient Phone Number N 307-C7 Place of Service (formerly patient location) 01=Pharmacy R 9(2) 333-CZ Employer ID N 334-1C Smoker/Nonsmoker Code N 335-2C Pregnancy Indicator Blank=Not specified 1=Not pregnant 2=Pregnant Q X(1) 350-HN Patient E-mail Address N 384-4X Patient Residence 1=Home 2=Skilled nursing facility 3=Nursing facility 4=Assisted living facility 5=Custodial care facility 6=Group home 11=Hospice 14=Homeless shelter R 9(2) Claim Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. X This payer supports partial fills. This payer does not support partial fills. Claim Segment Segment Identification (111-AM) = 07 Service Billing/Service Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 455-EM Prescription/Service Reference Number Qualifier 2=Service billing M X(1) 402-D2 Prescription/Service Reference Number M The service reference number assigned must be unique for each member/ service combination within a dispensing pharmacy. 9(12) 436-E1 Product/Service ID Qualifier 09=HCPCS M X(2) 407-D7 Product/Service ID M For vaccine administration, where the vaccine is obtained at no cost to the pharmacy, enter the HCPCS code for the vaccine administered. X(19) 456-EN Associated Prescription/Service Reference Number N 457-EP Associated Prescription/Service Date N 458-SE Procedure Modifier Code Count Maximum count of 10 Q 9(2) 459-ER Procedure Modifier Code Q***R*** X(2) 442-E7 Quantity Dispensed R s9(7)v999 403-D3 Fill Number N 405-D5 Days Supply R 9(3) 414-DE Date Prescription Written CCYYMMDD Q 9(8) 415-DF Number of Refills Authorized N 460-ET Quantity Prescribed Q s9(7)v99 308-C8 Other Coverage Code 00=Not specified by patient 01=No other coverage has been identified 02=Other coverage exists; payment was collected 03=Other coverage exists; this claim is not covered 04=Other coverage exists; payment not collected Q MassHealth requires this field be populated on each claim. Submitters must use value 00=not specified by patient if no other MassHealth supported values apply. MassHealth will reject the claim if a COB segment is submitted and Other Coverage Code value is not equal to 02, 03, or 04. MassHealth will reject the claim if a COB segment is not submitted and Other Coverage Code value is equal to 02, 03, or 04. A value of 04 must be used only when the other insurer has paid $0 because 100 percent of the allowed amount was applied to the patient responsibility. For multiple other insurances, if different payers returned different outcomes (other coverage exists – payment collected, other coverage exists – payment not collected, other coverage exists – claim not covered), then use this hierarchy (02, 04, 03) for determining the value to enter in the other coverage code field. 9(2) 453-EJ Originally Prescribed Product/Service ID Qualifier N 445-EA Originally Prescribed Product/Service Code N 446-EB Originally Prescribed Quantity N 454-EK Scheduled Prescription ID Number N 418-DI Level of Service 03=Emergency Q 9(2) 461-EU Prior Authorization Type Code 0=Not specified 1=Prior authorization Q 9(1) 462-EV Prior Authorization Number Submitted Q 9(11) 463-EW Intermediary Authorization Type ID N 464-EX Intermediary Authorization ID N 357-NV Delay Reason Code 1=Proof of eligibility unknown or unavailable 2=Litigation 3=Authorization delay 4=Delay in certifying provider 5=Delay in supplying billing forms 7=Third party processing delay 8=Delay in eligibility determination 9=Original claims rejected 10=Administrative delay in the prior approval process 11=Other 12=Received late with no exceptions Q Required when needed to specify the reason that submission of the transaction has been delayed. 9(2) 391-MT Patient Assignment Indicator (Direct Member Reimbursement Indicator) N 147-U7 Pharmacy Service Type 1=Community/retail pharmacy services 2=Compounding pharmacy services 3=Home infusion therapy provider services 4=Institutional pharmacy services. 5=Long term care pharmacy services 6=Mail-order pharmacy services 7=Managed care organization pharmacy services 8=Specialty care pharmacy services 99=Other I Required for members with commercial insurance that use mail order pharmacies 9(2) Pricing Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. X Pricing Segment Segment Identification (111-AM) = 11 Service Billing/Service Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 477-BE Professional Service Fee Submitted R Use this field for the vaccine administration fee when the vaccine serum is obtained at no cost. s9(6)v99 433-DX Patient Paid Amount Submitted Q When MassHealth is the primary payer, enter copay amount the pharmacy received from the patient for the prescription dispensed. This field is not used in coordination of benefit transactions. s9(6)v99 478-H7 Other Amount Claimed Submitted Count Maximum count of three Q 9(1) 479-H8 Other Amount Claimed Submitted Qualifier NR X(2) 480-H9 Other Amount Claimed Submitted NR s9(6)v99 481-HA Flat Sales Tax Amount Submitted N 482-GE Percentage Sales Tax Amount Submitted N 483-HE Percentage Sales Tax Rate Submitted N 426-DQ Usual and Customary Charge R s9(6)v99 430-DU Gross Amount Due R Whether billing MassHealth as the primary payer or as a secondary payer, this amount follows the formula outlined in the D.0 Implementation Guide (Section 28.1.10.1) and adheres to the definition of Usual & Customary Charge defined in the Division of Health Care Finance & Policy regulation. s9(6)v99 Pharmacy Provider Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. X Pharmacy Provider Segment Segment Identification (111-AM) = 02 Service Billing/Service Refill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 465-EY Provider ID Qualifier 05=National provider identifier (NPI) Q X(2) 444-E9 Provider ID Q X(15) Prescriber Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. X Prescriber Segment Segment Identification (111-AM) = 03 Service Billing/Service Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 466-EZ Prescriber ID Qualifier 01=National provider identifier (NPI) R X(2) 411-DB Prescriber ID R X(15) 427-DR Prescriber Last Name R X(15) 498-PM Prescriber Phone Number I 9(10) 468-2E Primary Care Provider ID Qualifier Blank=Not specified 01=National provider identifier (NPI) 02=Blue Cross 03=Blue Shield 04=Medicare 05=Medicaid 06=UPIN 07=NCPDP provider ID 08=State license 09=TriCare 10=Health industry number (HIN) 11=Federal tax ID 12=Drug Enforcement Administration (DEA) 13=State issued 14=Plan specific 99=Other I X(2) 421-DL Primary Care Provider ID I X(15) 470-4E Primary Care Provider Last Name I X(15) 364-2J Prescriber First Name I 365-2K Prescriber Street Address N 366-2M Prescriber City Address N 367-2N Prescriber State/Province Address N 368-2P Prescriber Zip/Postal Zone N Coordination of Benefits/Other Payments Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. X Required only for secondary, tertiary, etc., claims. Scenario 1 – Other payer amount paid repetitions only. Scenario 2 – Other payer-patient responsibility amount repetitions, and benefit stage repetitions only. Scenario 3 – Other payer amount paid, other payer-patient responsibility amount, and benefit stage repetitions present (government programs). X All service claims submitted to POPS are adjudicated for other insurance coverage, also known as third-party liability (TPL). If primary insurance is listed in the MassHealth member eligibility file, the billing entity must indicate that the insurance was billed prior to submitting the claim to MassHealth. Therefore, all billers must have online split-billing capability. After billing the primary payer, enter the appropriate information for the required split-billing fields on the claim submission (see below). Coordination of Benefits/Other Payments Segment Segment Identification (111-AM) = 05 Service Billing/Service Rebill Scenario 3 - Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 337-4C Coordination Of Benefits/Other Payments Count Maximum count of nine M 9(1) 338-5C Other Payer Coverage Type 01=Primary 02=Secondary 03=Tertiary 04=Quaternary – fourth 05=Quinary – fifth 06=Senary – sixth 07=Septenary – seventh 08=Octonary – eighth 09=Nonary – ninth M***R*** X(2) 339-6C Other Payer ID Qualifier 03=BIN 99=Other R***R*** X(2) 340-7C Other Payer ID R***R*** X(10) 443-E8 Other Payer Date CCYYMMDD I***R*** 9(8) 341-HB Other Payer Amount Paid Count Maximum count of nine Q 9(1) 342-HC Other Payer Amount Paid Qualifier Blank=not specified 01=Delivery Cost – An indicator that signifies the amount claimed for the costs related to the delivery of a product or service. 02=Shipping Cost – The amount claimed for transportation of an item. 03=Postage Cost – The amount claimed for the mailing of an item. 04=Administrative Cost – An indicator conveying the following amount is related to the cost of activities such as utilization review, premium collection, claims processing, quality assurance, and risk management for purposes of insurance. 05=Incentive – An indicator that signifies the dollar amount paid by the other payer, which is related to additional fees or compensations paid as an inducement for an action taken by the provider (e.g., collection of survey data, counseling plan enrollees, vaccine administration). 342-HC (cont.) Other Payer Amount Paid Qualifier 06=Cognitive Service – An indicator that signifies the dollar amount paid by the other payer, which is related to the pharmacist's interaction with a patient or caregiver that is beyond the traditional dispensing/ patient instruction activity (e.g., therapeutic regimen review; recommendation for additional, fewer or different therapeutic choices). 07=Drug Benefit – An indicator that signifies the dollar amount paid by the other payer, which is related to the plan's drug benefit. 10=Sales Tax – An indicator that signifies the dollar amount paid by the other payer, which is related to sales tax. Q***R*** X(2) 431-DV Other Payer Amount Paid s$$$$$$cc Q***R*** When payment from other insurance is returned, use value of 07-drug benefit” in Field 342 and put the $$ amount returned (in Field 509) into this field (431). s9(6)v99 471-5E Other Payer Reject Count Maximum count of five Q Only populated when claim denies from prior payer (Medicare or private) 9(2) 472-6E Other Payer Reject Code Q***R*** MassHealth requires the NCPDP reject code from the other payer when the other payer denies the claim (OCC3). X(3) 353-NR Other Payer-Patient Responsibility Amount Count Maximum count of 25 Q***R*** 9(2) 351-NP Other Payer-Patient Responsibility Amount Qualifier 01=Deductible 04=Benefit Maximum 05=Copay 06=Patient Pay Amount 07=Coinsurance 09=Health Plan Assistance Program Q***R*** MassHealth only supports the values listed. MassHealth will deny a claim submitted with a qualifier of any other value, even if the corresponding other payer-patient responsibility amount (352-NQ) is $0. If the prior payer returns Patient Responsibility Amounts utilizing component fields, submit a separate occurrence for any non-zero component, with the applicable qualifier (351-NP) and corresponding $$ amount (352-NQ). MassHealth only recognizes the use of qualifier 06- Patient Pay Amount when the prior payer does not return Patient Responsibility Amounts at a component level. When value 09 is submitted, the corresponding other payer- patient responsibility amount (352-NQ) must be a negative amount. X(2) 352-NQ Other Payer-Patient Responsibility Amount Q***R*** s9(6)V99 392-MU Benefit Stage Count Maximum count of four Q 9(1) 393-MV Benefit Stage Qualifier Blank not specified 01=Deductible 02=Initial benefit 03= Coverage gap (donut hole) 04=Catastrophic coverage Q***R*** X(2) 394-MW Benefit Stage Amount Q***R*** s9(6)V99 Workers’ Compensation Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Workers’ Compensation Segment Segment Identification (111-AM) = 06 Service Billing/Service Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 434-DY Date of Injury M 315-CF Employer Name 316-CG Employer Street Address 317-CH Employer City Address 318-CI Employer State/Province Address 319-CJ Employer Zip/Postal Zone 320-CK Employer Phone Number 321-CL Employer Contact Name 327-CR Carrier ID 435-DZ Claim/Reference ID 117-TR Billing Entity Type Indicator 118-TS Pay to Qualifier 119-TT Pay to ID 120-TU Pay to Name 121-TV Pay to Street Address 122-TW Pay to City Address 123-TX Pay to State/Province Address 124-TY Pay to Zip/Postal Zone 125-TZ Generic Equivalent Product ID Qualifier 126-UA Generic Equivalent Product ID DUR/PPS Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. DUR/PPS Segment Segment Identification (111-AM) = 08 Service Billing/Service Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 473-7E DUR/PPS Code Counter Maximum of nine occurrences R 9(1) 439-E4 Reason for Service Code DD=Drug-drug interaction HD=High dose ID=Ingredient duplication TD=Therapeutic duplication ER=Early refill Q***R*** 440-E5 Professional Service Code MA= Medication administration M0=Prescriber consulted R0=Pharmacist consulted other source Q***R*** . X(2) 441-E6 Result of Service Code 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 Q***R*** X(2) 474-8E DUR/PPS Level of Effort 00=Not specified 11=Level 1 – Less than five mins. 12=Level 2 – Less than 15 min. 13=Level 3 – Less than 30 min. 14=Level 4 – Less than one hour 15=Level 5 – Greater than one hour I***R*** 9(2) 475-J9 DUR Coagent ID Qualifier 01=Universal Product Code (UPC) 02=Health-related item (HRI) 03=National Drug Code (NDC) 04=Universal Product Number (UPN) 05=Department of Defense (DOD) 07=Common procedure terminology (CPT4) 08=Common procedure terminology (CPT5) 09=Health Care Financing Administration Common Procedural Coding System (HCPCS) 11=National Pharmaceutical Product Interface code (NAPPI) 12=International article numbering system (EAN) 13=Drug identification number (DIN) 14=Medi-Span GPI 15=First DataBank GCN 16=Medical economics GPO 17=Medi-Span DDID 18=First DataBank SmartKey 19=Medical economics GM 20=International classification of diseases (ICD-9) 21=International classification of diseases (ICD10) I***R*** X(2) 475-J9 (cont.) DUR Coagent ID Qualifier 23=National Criteria Care Institute (NCCI) 24=The Systematized Nomenclature of Human and Veterinary Medicine (SNOMED) 25=Common dental terminology (CDT) 26=American Psychiatric Association Diagnostic Statistical Manual of Mental Disorders (DSM IV) 99=Other 476-H6 DUR Coagent ID I***R*** X(19) Coupon Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Coupon Segment Segment Identification (111-AM) = 09 Service Billing/Service Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 485-KE Coupon Type M X(2) 486-ME Coupon Number M X(15) 487-NE Coupon Value Amount Q s9(6)v99 Compound Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. 1 This segment is situational. Segment not supported. Compound Segment Segment Identification (111-AM) = 10 Service Billing/Service Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 450-EF Compound Dosage Form Description Code 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 M X(2) Clinical Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. X Clinical Segment Segment Identification (111-AM) = 13 Service Billing/Service Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 491-VE Diagnosis Code Count Maximum count of five N 492-WE Diagnosis Code Qualifier N***R*** 424-DO Diagnosis Code N***R*** 493-XE Clinical Information Counter Maximum five occurrences supported Q 9(1) 494-ZE Measurement Date CCYYMMDD Q***R*** 9(8) 495-H1 Measurement Time HHMM Q***R*** 9(4) 496-H2 Measurement Dimension Blank=Not specified 01=Blood pressure (BP) 02=Blood glucose level 03=Temperature 04=Serum creatinine (SCr) 05=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=Serum theophylline level 13=Serum digoxin level 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) Q***R*** X(2) 496-H2 (cont.) Measurement Dimension 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 497-H3 Measurement Unit 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=Millimeters per minute (ml/min) 13=Percentage (%) 14=Milliequivalent (mEq/ml) 15=International units per liter (IU/l) Q***R*** X(2) 497-H3 (cont.) Measurement Unit 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 499-H4 Measurement Value Blood pressure entered in XXX/YYY format in which XXX=systolic, /=divider, and YYY is diastolic. Temperature entered in XXX.X format always includes decimal point. Request clinical segment. Q***R*** X(15) Additional Documentation Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Additional Documentation Segment Segment Identification (111-AM) = 14 Service Billing/Service Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 369-2Q Additional Documentation Type ID M 374-2V Request Period Begin Date 375-2W Request Period Recert/Revised Date 373-2U Request Status 371-2S Length of Need Qualifier 370-2R Length of Need 372-2T Prescriber/Supplier Date Signed 376-2X Supporting Documentation 377-2Z Question Number/Letter Count Maximum count of 50 378-4B Question Number/Letter 379-4D Question Percent Response 380-4G Question Date Response 381-4H Question Dollar Amount Response 382-4J Question Numeric Response 383-4K Question Alphanumeric Response Facility Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Facility Segment Segment Identification (111-AM) = 15 Service Billing/Service Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 336-8C Facility ID 385-3Q Facility Name 386-3U Facility Street Address 388-5J Facility City Address 387-3V Facility State/Province Address 389-6D Facility Zip/Postal Zone Narrative Segment Questions Check Service Billing/Service Rebill If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Narrative Segment Segment Identification (111-AM) = 16 Service Billing/Service Rebill Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 390-BM Narrative Message ** End of Request Service Billing/Service Rebill (S1/S3) Payer Sheet ** 4.2 Service Billing/Service Rebill Accepted/Paid (or Duplicate of Paid) Response The following table lists the segments and fields in a service billing or service rebill response (paid or duplicate of paid) transaction for the NCPDP version D.0. Service billing includes service billing transactions S1 and S3. Response Transaction Header Segment Questions Check Service Billing/Service Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. X Response Transaction Header Segment Service Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code S1, S3 M X(2) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M X(1) 501-F1 Header Response Status A=Accepted M X(1) 202-B2 Service Provider ID Qualifier 01– National provider identifier (NPI) M X(2) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) Response Message Segment Questions Check Service Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. X This segment is situational. Provide general information when used for transmission-level messaging. Response Message Segment Segment Identification (111-AM) = 20 Service Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 504-F4 Message Q X(200) Response Insurance Segment Questions Check Service Billing/Service Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Insurance Segment Segment Identification (111-AM) = 25 Service Billing/Service Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 301-C1 Group ID MassHealth HSN R X(15) 524-FO Plan ID R 545-2F Network Reimbursement ID N 568-J7 Payer ID Qualifier N 569-J8 Payer ID N 115-N5 Medicaid ID Number N 116-N6 Medicaid Agency Number N 302-C2 Cardholder ID N Response Patient Segment Questions Check Service Billing/Service Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Patient Segment Segment Identification (111-AM) = 29 Service Billing/Claim Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 310-CA Patient First Name R X(12) 311-CB Patient Last Name R X(15) 304-C4 Date of Birth CCYYMMDD R 9(8) Response Status Segment Questions Check Service Billing/Service Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. X Response Status Segment Segment Identification (111-AM) = 21 Service Billing/Service Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 112-AN Transaction Response Status P=Paid D=Duplicate of paid M X(1) 503-F3 Authorization Number R X(20) 547-5F Approved Message Code Count Maximum count of five N 548-6F Approved Message Code N***R*** 130-UF Additional Message Information Count Maximum count of eight Q 9(2) 132-UH Additional Message Information Qualifier 01 Q***R*** X(2) 526-FQ Additional Message Information Q***R*** X(40) 131-UG Additional Message Information Continuity + Q***R*** X(1) 549-7F Help Desk Phone Number Qualifier N Response Claim Segment Questions Check Service Billing/Service Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. X Response Claim Segment Segment Identification (111-AM) = 22 Service Billing/Service Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 455-EM Prescription/Service Reference Number Qualifier 2=Service billing M X(1) 402-D2 Prescription/Service Reference Number M 9(12) 551-9F Preferred Product Count Maximum count of six N 552-AP Preferred Product ID Qualifier N***R*** 553-AR Preferred Product ID N***R*** 554-AS Preferred Product Incentive N***R*** 555-AT Preferred Product Cost Share Incentive N***R*** 556-AU Preferred Product Description N***R*** Response Pricing Segment Questions Check Service Billing/Service Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. X Response Pricing Segment Segment Identification (111-AM) = 23 Service Billing/Service Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 505-F5 Patient Pay Amount R s9(6)v99 506-F6 Ingredient Cost Paid Q s9(6)v99 507-F7 Dispensing Fee Paid Q s9(6)v99 557-AV Tax Exempt Indicator N 558-AW Flat Sales Tax Amount Paid N 559-AX Percentage Sales Tax Amount Paid N 560-AY Percentage Sales Tax Rate Paid N 561-AZ Percentage Sales Tax Basis Paid N 521-FL Incentive Amount Paid Q 562-J1 Professional Service Paid R s9(6)v99 563-J2 Other Amount Paid Count Maximum count of three Q 9(1) 564-J3 Other Amount Paid Qualifier N***R*** 565-J4 Other Amount Paid N***R*** 566-J5 Other Payer Amount Recognized Q s9(6)v99 509-F9 Total Amount Paid R s9(6)v99 522-FM Basis of Reimbursement Determination R 9(2) 523-FN Amount Attributed to Sales Tax N 512-FC Accumulated Deductible Amount N 513-FD Remaining Deductible Amount N 514-FE Remaining Benefit Amount 999999.00 R s9(6)v99 517-FH Amount Applied to Periodic Deductible N 518-FI Amount of Copay Q s9(6)v99 520-FK Amount Exceeding Periodic Benefit Maximum N 346-HH Basis of Calculation – Dispensing Fee N 347-HJ Basis of Calculation – Copay 01=Quantity dispensed 02=Quantity intended to be dispensed 03=Usual and customary/prorated 04=Waived due to partial fill 99=Other Q X(2) 348-HK Basis of Calculation – Flat Sales Tax N 349-HM Basis of Calculation – Percentage Sales Tax N 571-NZ Amount Attributed to Processor Fee N 575-EQ Patient Sales Tax Amount N 574-2Y Plan Sales Tax Amount N 572-4U Amount of Coinsurance N 573-4V Basis of Calculation – Coinsurance N 392-MU Benefit Stage Count Maximum count of four. Q 9(1) 393-MV Benefit Stage Qualifier Blank=Not specified 01=Deductible 02=Initial benefit 03=Coverage gap (donut hole) 04=Catastrophic coverage Q***R*** X(2) 394-MW Benefit Stage Amount Q***R*** s9(6)v99 577-G3 Estimated Generic Savings N 128-UC Spending Account Amount Remaining N 129-UD Health Plan-Funded Assistance Amount N 133-UJ Amount Attributed to Provider Network Selection N 134-UK Amount Attributed to Product Selection/Brand Drug N 135-UM Amount Attributed to Product Selection/Nonpreferred Formulary Selection N 136-UN Amount Attributed to Product Selection/Brand Nonpreferred Formulary Selection N 137-UP Amount Attributed to Coverage Gap N 148-U8 Ingredient Cost Contracted/Reimbursable Amount N 149-U9 Dispensing Fee Contracted/Reimbursable Amount N Response DUR/PPS Segment Questions Check Service Billing/Service Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Response DUR/PPS Segment Segment Identification (111-AM) = 24 Service Billing/Service Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 567-J6 DUR/PPS Response Code Counter Maximum nine occurrences supported Q 9(1) 439-E4 Reason for Service Code DD=Drug-drug interaction HD=High dose ID=Ingredient duplication TD=Therapeutic duplication ER=Early refill Q***R*** X(2) 528-FS Clinical Significance Code Q***R*** X(1) 529-FT Other Pharmacy Indicator Q***R*** 9(1) 530-FU Previous Date of Fill Q***R*** 9(8) 531-FV Quantity of Previous Fill Q***R*** s9(7)v999 532-FW Database Indicator Q***R*** X(1) 533-FX Other Prescriber Indicator Q***R*** 9(1) 544-FY DUR Free Text Message Q***R*** X(30) 570-NS DUR Additional Text Q***R*** X(100) Response Coordination of Benefits/Other Payers Segment Questions Check Service Billing/Service Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation This segment is always sent. This segment is situational. X Response Coordination of Benefits/Other Payers Segment Segment Identification (111-AM) = 28 Service Billing/Service Rebill – Accepted/Paid (or Duplicate of Paid) Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 355-NT Other Payer ID Count Maximum count of three M 9(1) 338-5C Other Payer Coverage Type 01=Primary 02=Secondary 03=Tertiary M***R*** X(2) 339-6C Other Payer ID Qualifier Blank=Not specified 03=BIN 99=Other Q***R*** X(2) 340-7C Other Payer ID Q***R*** X(10) 991-MH Other Payer Processor Control Number Q***R*** X(10) 356-NU Other Payer Cardholder ID N***R*** 992-MJ Other Payer Group ID Q***R*** X(15) 142-UV Other Payer Person Code N***R*** 127-UB Other Payer Help Desk Phone Number N***R*** 143-UW Other Payer Patient Relationship Code N***R*** 144-UX Other Payer Benefit Effective Date N***R*** 145-UY Other Payer Benefit Termination Date N***R*** 4.3 Service Billing/Service Rebill Accepted/Rejected Response The following table lists the segments and fields in a service billing/service rebill response (accepted/rejected) transaction for the NCPDP version D.0. Response Transaction Header Segment Questions Check Service Billing/Service Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. X Response Transaction Header Segment Service Billing/Claim Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code S1, S3 M X(2) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M X(1) 501-F1 Header Response Status A=Accepted M X(1) 202-B2 Service Provider ID Qualifier M X(15) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) Response Message Segment Questions Check Service Billing/Service Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Message Segment Segment Identification (111-AM) = “20” Service Billing/Service Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 504-F4 Message Q X(200) Response Insurance Segment Questions Check Service Billing/Service Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Insurance Segment Segment Identification (111-AM) = 25 Service Billing/Service Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 301-C1 Group ID MassHealth HSN R If the system determined that Health Safety Net was the payer of the claim, then the Group ID (301-C1) within this response transaction will contain a value of HSN. Please check with your software vendor, to ensure that this information is captured in your system and available to payment reconciliation processes. X(15) 524-FO Plan ID N 545-2F Network Reimbursement ID N 568-J7 Payer ID Qualifier N 569-J8 Payer ID N Response Patient Segment Questions Check Service Billing/Service Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Patient Segment Segment Identification (111-AM) = 29 Service Billing/Service Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 310-CA Patient First Name Q X(12) 311-CB Patient Last Name Q X(15) 304-C4 Date of Birth CCYYMMDD Q 9(8) Response Status Segment Questions Check Service Billing/Service Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. X Response Status Segment Segment Identification (111-AM) = 21 Service Billing/Service Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 112-AN Transaction Response Status R=Rejected M X(1) 503-F3 Authorization Number R X(20) 510-FA Reject Count Maximum count of five R 9(2) 511-FB Reject Code R***R*** This field is mandatory when a reject response is returned. X(3) 546-4F Reject Field Occurrence Indicator Q***R*** This is the number of rejected fields. 9(2) 130-UF Additional Message Information Count Maximum count of eight Q 9(2) 132-UH Additional Message Information Qualifier 01 Q***R*** X(2) 526-FQ Additional Message Information Q***R*** X(40) 131-UG Additional Message Information Continuity + Q***R*** X(1) 549-7F Help Desk Phone Number Qualifier N 550-8F Help Desk Phone Number N Response Claim Segment Questions Check Service Billing/Service Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. X Response Claim Segment Segment Identification (111-AM) = “22” Service Billing/Service Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 455-EM Prescription/Service Reference Number Qualifier 2=Service billing M X(1) 402-D2 Prescription/Service Reference Number M 9(12) Response DUR/PPS Segment Questions Check Service Billing/Service Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported Response DUR/PPS Segment Segment Identification (111-AM) = 24 Service Billing/Service Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 567-J6 DUR/PPS Response Code Counter Maximum nine occurrences supported Q 9(1) 439-E4 Reason For Service Code DD=Drug-drug interaction HD=High dose ID=Ingredient duplication TD=Therapeutic duplication ER=Early refill Q***R*** X(2) Response Coordination of Benefits/Other Payers Segment Questions Check Service Billing/Service Rebill Accepted/Rejected If Situational, Payer Situation This segment is always sent. This segment is situational. X Response Coordination of Benefits/Other Payers Segment Segment Identification (111-AM) = 28 Service Billing/Service Rebill Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 355-NT Other Payer ID Count Maximum count of three M 338-5C Other Payer Coverage Type 01=Primary 02=Secondary 03=Tertiary M***R*** X(2) 339-6C Other Payer ID Qualifier Blank=Not specified 03=BIN 99=Other Q***R*** X(2) 340-7C Other Payer ID Q***R*** X(10) 991-MH Other Payer Processor Control Number Q***R*** 356-NU Other Payer Cardholder ID N***R*** 992-MJ Other Payer Group ID Q***R*** X(15) 142-UV Other Payer Person Code N***R*** 127-UB Other Payer Help Desk Phone Number N***R*** 143-UW Other Payer Patient Relationship Code N***R*** 144-UX Other Payer Benefit Effective Date N***R*** 145-UY Other Payer Benefit Termination Date N***R*** 4.4 Service Billing/Service Rebill Rejected/Rejected Response The following table lists the segments and fields in a service billing/service rebill response (rejected/rejected) transaction for the NCPDP version D.0. Response Transaction Header Segment Questions Check Service Billing/Service Rebill Rejected/Rejected If Situational, Payer Situation This segment is always sent. X Response Transaction Header Segment Service Billing/Service Rebill Rejected/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code S1, S3 M X(2) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M X(1) 501-F1 Header Response Status R=Rejected M X(1) 202-B2 Service Provider ID Qualifier 01-National provider identifier (NPI) M X(2) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) Response Message Segment Questions Check Service Billing/Service Rebill Rejected/Rejected If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Message Segment Segment Identification (111- AM) = 20 Service Billing/Service Rebill Rejected/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M 504-F4 Message Q X(200) Response Status Segment Questions Check Service Billing/Service Rebill Rejected/Rejected If Situational, Payer Situation This segment is always sent. X Response Status Segment Segment Identification (111-AM) = 21 Service Billing/Service Rebill Rejected/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 112-AN Transaction Response Status R=Rejected M X(1) 503-F3 Authorization Number R X(20) 510-FA Reject Count Maximum count of five R 9(2) 511-FB Reject Code R***R*** X(3) 546-4F Reject Field Occurrence Indicator Q***R*** X(3) 130-UF Additional Message Information Count Maximum count of eight Q 9(2) 132-UH Additional Message Information Qualifier 01 Q***R*** X(2) 526-FQ Additional Message Information Q***R*** X(40) 131-UG Additional Message Information Continuity + Q***R*** X(1) ** End of Response Service Billing/Service Rebill (S1/S3) Payer Sheet** 5.0 Claim Submission Format – S2 BIN NUMBER 009555 DESTINATION XEROX STATE HEALTHCARE ACCEPTING CLAIM ADJUDICATION (S2 REVERSAL TRANSACTIONS) FORMAT NCPDP D.0 5.1 Service Reversal Request Field Legend for Columns Payer Usage Column Value Explanation Payer Situation Column Mandatory M The field is mandatory for the segment in the designated transaction. No Required R The field has been designated with the situation of “required” for the segment in the designated transaction. No Qualified Requirement Q The situations designated have qualifications for usage (required if x, not required if y). Yes Informational Only I The field is for informational purposes only for the transaction. Yes Not Used N The field is not used for the segment for the transaction. No Repeating ***R*** The three asterisks, R, and three asterisks designates a field is repeating. Example: Q***R*** means a situationally qualified field that repeats. Example: N***R*** means an unused field that repeats when used. Yes Service Reversal Transaction The following table lists the segments and fields in a Claim Reversal Transaction for the NCPDP version D.0. Claim reversal transaction includes service billing transactions S2. Transaction Header Segment Questions Check Service Reversal If Situational, Payer Situation This segment is always sent. X Source of certification IDs required in software vendor/certification ID (110-AK) is payer issued. X Source of certification IDs required in software vendor/certification ID (110-AK) is switch/VAN issued. Source of certification IDs required in software vendor/certification ID (110-AK) is not used. Transaction Header Segment Service Reversal Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 101-A1 BIN Number 009555 M 9(6) 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code S2 M X(2) 104-A4 Processor Control Number MASSPROD for production transactions M X(10) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M For S2 (reversal) transactions, the transaction count must be a value of 1, 2, 3, or 4. If this transaction is for a compound claim, the transaction count value must be 1. X(1) 202-B2 Service Provider ID Qualifier 01=National provider identifier M X(2) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) 110-AK Software Vendor/Certification ID M The MassHealth registration number assigned to software as part of initial certification. X(10) Insurance Segment Questions Check Service Reversal If Situational, Payer Situation This segment is always sent. X This segment is situational. Insurance Segment Segment Identification (111-AM) = 04 Service Reversal Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 302-C2 Cardholder ID M 12-digit MassHealth ID number X(20) 301-C1 Group ID MassHealth HSN R X(15) Claim Segment Questions Check Service Reversal If Situational, Payer Situation This segment is always sent. X Claim Segment Segment Identification (111-AM) = 07 Service Reversal Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 455-EM Prescription/Service Reference Number Qualifier 2=Service billing M X(1) 402-D2 Prescription/Service Reference Number M 9(12) 436-E1 Product/Service ID Qualifier 09=HCPCS M X(2) 407-D7 Product/Service ID M X(19) 403-D3 Fill Number N 308-C8 Other Coverage Code N 147-U7 Pharmacy Service Type N Pricing Segment Questions Check Service Reversal If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Pricing Segment Segment Identification (111-AM) = 11 Service Reversal Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 438-E3 Incentive Amount Submitted 430-DU Gross Amount Due Coordination of Benefits/Other Payments Segment Questions Check Service Reversal If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Coordination of Benefits/Other Payments Segment Segment Identification (111-AM) = 05 Service Reversal Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 337-4C Coordination of Benefits/Other Payments Count Maximum count of nine M 9(1) 338-5C Other Payer Coverage Type M***R*** X(2) DUR/PPS Segment Questions Check Service Reversal If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. DUR/PPS Segment Segment Identification (111-AM) = 08 Service Reversal Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 473-7E DUR/PPS Code Counter Maximum of nine occurrences 9(1) 439-E4 Reason for Service Code X(2) 440-E5 Professional Service Code X(2) 441-E6 Result of Service Code X(2) ** End of Request Service Reversal (S2) Payer Sheet ** 5.2 Service Reversal Accepted/Approved Response The following table lists the segments and fields in a claim reversal response (accepted/approved) transaction for the NCPDP version D.0. Response Transaction Header Segment Questions Check Service Reversal – Accepted/Approved If Situational, Payer Situation This segment is always sent. X Response Transaction Header Segment Service Reversal – Accepted/Approved Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code S2 M X(2) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M For S2 (reversal) transactions, the transaction count will be a value of 1, 2, 3, or 4. If this transaction is for a compound claim, the transaction count value must be 1. X(1) 501-F1 Header Response Status A=Accepted M 202-B2 Service Provider ID Qualifier 01-National provider identifier (NPI) M X(2) 201-B1 Service Provider ID M 401-D1 Date of Service CCYYMMDD M 9(8) Response Message Segment Questions Check Service Reversal – Accepted/Approved If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Message Segment Segment Identification (111-AM) = 20 Service Reversal – Accepted/Approved Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 504-F4 Message Q X(200) Response Status Segment Questions Check Service Reversal – Accepted/Approved If Situational, Payer Situation This segment is always sent. X Response Status Segment Segment Identification (111-AM) = 21 Service Reversal – Accepted/Approved Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 112-AN Transaction Response Status A=Approved M X(1) 503-F3 Authorization Number R X(20) 547-5F Approved Message Code Count Maximum count of five N 548-6F Approved Message Code N***R*** 130-UF Additional Message Information Count Maximum count of eight Q 9(2) 132-UH Additional Message Information Qualifier 01 Q***R*** X(2) 526-FQ Additional Message Information Q***R*** X(40) 131-UG Additional Message Information Continuity + Q***R*** X(1) 549-7F Help Desk Phone Number Qualifier N 550-8F Help Desk Phone Number N 880 -K5 Transaction Reference Number N 993-A7 Internal Control Number N 987-MA URL N Response Claim Segment Questions Check Service Reversal – Accepted/Approved If Situational, Payer Situation This segment is always sent. X Response Claim Segment Segment Identification (111-AM) = 22 Service Reversal – Accepted/Approved Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 455-EM Prescription/Service Reference Number Qualifier 2=Service billing M X(1) 402-D2 Prescription/Service Reference Number M 9(12) Response Pricing Segment Questions Check Service Reversal – Accepted/Approved If Situational, Payer Situation This segment is always sent. This segment is situational. Segment not supported. Response Pricing Segment Segment Identification (111-AM) = 23 Service Reversal – Accepted/Approved Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 521-FL Incentive Amount Paid Q 509-F9 Total Amount Paid 5.3 Service Reversal Accepted/Rejected Response The following table lists the segments and fields in a claim reversal response (accepted/rejected) transaction for the NCPDP version D.0. Response Transaction Header Segment Questions Check Service Reversal - Accepted/Rejected If Situational, Payer Situation This segment is always sent. X Response Transaction Header Segment Service Reversal – Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code S2 M X(2) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M For S2 (reversal) transactions, the transaction count will be a value of 1, 2, 3, or 4. If this transaction is for a compound claim, the transaction count value must be 1. X(1) 501-F1 Header Response Status A=Accepted M X(1) 202-B2 Service Provider ID Qualifier 01-National provider identifier (NPI) M X(2) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) Response Message Segment Questions Check Service Reversal - Accepted/Rejected If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Message Segment Segment Identification (111-AM) = 20 Service Reversal – Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 504-F4 Message Q X(200) Response Status Segment Questions Check Service Reversal - Accepted/Rejected If Situational, Payer Situation This segment is always sent. X Response Status Segment Segment Identification (111-AM) = 21 Service Reversal – Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 112-AN Transaction Response Status R=Rejected M X(1) 503-F3 Authorization Number R X(20) 510-FA Reject Count M R 9(2) 511-FB Reject Code R***R*** X(3) 546-4F Reject Field Occurrence Indicator Q***R*** 9(2) 130-UF Additional Message Information Count Maximum count of eight Q 9(2) 132-UH Additional Message Information Qualifier 01 Q***R*** X(2) 526-FQ Additional Message Information Q***R*** X(40) 131-UG Additional Message Information Continuity + Q***R*** X(1) 549-7F Help Desk Phone Number Qualifier N 550-8F Help Desk Phone Number N Response Claim Segment Questions Check Service Reversal - Accepted/Rejected If Situational, Payer Situation This segment is always sent. X Response Claim Segment Segment Identification (111-AM) = 22 Service Reversal – Accepted/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 455-EM Prescription/Service Reference Number Qualifier 2=Service billing M For transaction code of S2 in the response claim segment, the prescription/service reference number qualifier (455-EM) is 2 (services billing). 402-D2 Prescription/Service Reference Number M 9(12) 5.4 Service Reversal Rejected/Rejected Response Response Transaction Header Segment Questions Check Service Reversal - Rejected/Rejected If Situational, Payer Situation This segment is always sent. X Response Transaction Header Segment Service Reversal – Rejected/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 102-A2 Version/Release Number D0 M X(2) 103-A3 Transaction Code S2 M X(2) 109-A9 Transaction Count 1=One occurrence 2=Two occurrences 3=Three occurrences 4=Four occurrences M For S2 (reversal) transactions, the transaction count will be a value of 1, 2, 3, or 4. If this transaction is for a compound claim, the transaction count value must be 1. X(1) 501-F1 Header Response Status R=Rejected M X(1) 202-B2 Service Provider ID Qualifier 01 – National provider identifier (NPI) M X(2) 201-B1 Service Provider ID M X(15) 401-D1 Date of Service CCYYMMDD M 9(8) Response Message Segment Questions Check Service Reversal – Rejected/Rejected If Situational, Payer Situation This segment is always sent. X This segment is situational. Response Message Segment Segment Identification (111-AM) = 20 Service Reversal – Rejected/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 504-F4 Message Q X(200) Response Status Segment Questions Check Service Reversal - Rejected/Rejected If Situational, Payer Situation This segment is always sent. X Response Status Segment Segment Identification (111-AM) = 21 Service Reversal – Rejected/Rejected Field # NCPDP Field Name Value Payer Usage Payer Situation Field Format 111-AM Segment Identification M X(2) 112-AN Transaction Response Status R=Rejected M X(1) 503-F3 Authorization Number R X(20) 510-FA Reject Count Maximum count of five R 9(2) 511-FB Reject Code R***R*** X(3) 546-4F Reject Field Occurrence Indicator N 130-UF Additional Message Information Count Maximum count of eight Q 9(2) 132-UH Additional Message Information Qualifier 01 Q***R*** X(2) 526-FQ Additional Message Information Q***R*** X(40) 131-UG Additional Message Information Continuity + Q***R*** X(1) 549-7F Help Desk Phone Number Qualifier N 550-8F Help Desk Phone Number N ** End of Service Reversal Response (S2) Payer Sheet ** 6.0 Third-Party Liability (TPL) Billing If the pharmacy becomes aware that the MassHealth member has other pharmacy insurance coverage, the pharmacy must complete the Third-Party Liability (TPL) indicator form and submit it to MassHealth for verification. To access the TPL indicator form, go to www.mass.gov/masshealth. In the lower right panel, under Publications, click on MassHealth Provider Forms. The form will be listed as Third-Party Liability Indicator. Pharmacies submitting claims for members with other insurance will need to submit the claims to all other payers before submitting claims to MassHealth. Also, there are billing requirements for communicating other insurance information to MassHealth, depending on the prior payer and the outcome (paid/denied) of a claim. Further, the outcome of a claim impacts whether the other insurance information represented on a claim can be submitted with a bank information number (BIN) or the MassHealth-specific carrier code assigned to the Pharmacy Benefit Manager (PBM) administering that drug benefit. MassHealth’s TPL carrier code information is available on the Web at www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications then Provider Library. Click on MassHealth Provider Manual Appendices. Choose Appendix C: Third-Party Liability Codes. Claims submitted for services for which a member has other pharmacy coverage insurance will be denied unless the claim has been previously submitted to other payers. In addition, the carrier-code value chosen and submitted in the Other Payer ID (340-7C) field must be consistent with the member’s eligibility (e.g., Medicare vs. Commercial). Claims submitted to MassHealth where the TPL carrier code conflicts with the member’s eligibility cannot be overridden. MassHealth will return an error message similar to: 'SUBMITTED OTHER PAYER ID DOES NOT MEET MASSHEALTH CRITERIA FOR DIRECT TPL OVERRIDE.' If the claim is denied, the billing pharmacy receives NCPDP reject code 41, AE or A6, with an additional explanation of benefits (EOB) reason code and additional message text. Based upon MassHealth regulations at 130 CMR 450.317, MassHealth will pay the lowest of: * the member's liability, as reported in the patient-paid amount by the other insurers including coinsurance, deductibles, and copayments; * the provider's charges minus the other insurer’s payments; or * the maximum allowable amount payable under MassHealth payment methodology minus the other insurer’s payments. For Medicare Part D, refer to MassHealth regulations at 130 CMR 406.414(C) for guidance. Below are some billing scenarios which MassHealth provides for clarification and pharmacy use when submitting claims to MassHealth for members with other insurance. If MassHealth’s, other insurance business rules are not followed, the claim may be denied by MassHealth and the response transaction will include Reject Code 7M – Discrepancy between Other Coverage Code and Other Coverage Information on file. Medicare B For claims approved by the Medicare B processor – Other Payer ID Qualifier must be equal to 99 and the corresponding Other Payer ID must be one of the Medicare B carrier codes listed in Appendix C. For claims denied by the Medicare B processor – Other Payer ID Qualifier must be equal to 99 and the corresponding Other Payer ID must be one of the Medicare B carrier codes listed in Appendix C. Note: Only a Medicare B carrier code may be used to override a member’s B coverage when there is no claim payment. Medicare C or D For claims approved by the Medicare C or D processor – Other Payer ID Qualifier must be equal to 99 and the corresponding Other Payer ID must be one of the Medicare C or D carrier codes listed in Appendix C. For claims denied by the Medicare C or D processor – Other Payer ID Qualifier must be equal to 99 and the corresponding Other Payer ID must be one of the Medicare C or D carrier codes listed in Appendix C, assuming the claim meets the MassHealth One-Time Supplies requirement. Note: 1. Only a Medicare C or D carrier code may be used to override a member’s C or D coverage when there is no payment. 2. Medications excluded from Medicare D Drug Program will continue to be covered for MassHealth members who are dually eligible for both Medicare and MassHealth and when the drug is covered by MassHealth. Claims submitted to MassHealth for these excluded medications do not require the completion of a Coordination of Benefits/Other Payment Segment. Commercial For claims approved by the Commercial processor – Other Payer ID Qualifier must be equal to 99 and the corresponding Other Payer ID must be one the Commercial codes listed in Appendix C; or the Other Payer ID Qualifier must be equal to 03 and the corresponding Other Payer ID (BIN) must be known to the Pharmacy Online Processing System (POPS) system. Note: Any known carrier code or BIN can be used to override any coverage type when there is payment for the other payer. For claims denied by the Commercial processor – Other Payer ID Qualifier must be equal to 99 and the corresponding Other Payer ID must be one the Commercial codes listed in Appendix C; or the Other Payer ID Qualifier must be equal to 03 and the corresponding Other Payer ID (BIN) must be known to the Pharmacy Online Processing System (POPS) system. Note: Only a commercial carrier code may be used to override a member’s commercial coverage when there is no payment. If additional assistance is required, please contact the Xerox Pharmacy Technical Help Desk at 1-866-246-8503. 7.0 90-Day Waiver Procedures POPS claims received more than 90 days, but less than 12 months, from the date of service will receive NCPDP reject code 81 (claim exceeds filing limit). The billing pharmacy can obtain a 90-day waiver form from the Xerox Pharmacy Technical Help Desk at 1-866-246-8503. This form is included in Appendix A of this document and can be photocopied. The completed form and supporting information can also be faxed to Xerox at 1-866-566-9315. If approved, the billing pharmacy will receive notification that the claim can be submitted to POPS. Please Note: TPL or split-bill claims submitted within 90 days of the primary carrier’s EOB date do not require a 90-day waiver. Providers may apply for a 90-day waiver only in the following circumstances. * Reprocessing of a claim (originally paid or denied) * Retroactive member enrollment * Retroactive provider enrollment Claims older than 12 months are not considered for “90-day waivers.” A review of these claims may be requested by completing the Request for Claim Review form located in the Provider Online Service Center portal. Additionally the Final Deadline Appeal Unit has adopted the industry standard claim review form: www.mass.gov/eohhs/docs/masshealth/bull-2012/all-226.pdf. 8.0 Claims Over $99,999.99 Claims greater than $99,999.99 can be billed online, but these claims will require MassHealth approval. Providers must contact the Xerox Pharmacy Technical Help Desk at 1-866-246-8503 to initiate the request. 9.0 Special Topics and References Cardholder First Name: Claims must contain the member’s first name (field #312-CC). When a claim for a member is received in POPS without the cardholder first name field populated, the pharmacy system will reject that claim and send a message back to the pharmacy. Cardholder Last Name: Claims must contain the member’s last name (field #313-CD). When a claim for a member is received in POPS without the cardholder last name field populated, the pharmacy system will reject that claim and send a message back to the pharmacy. Group ID: Claims must contain a Group ID (field #301-C1) of either MassHealth or HSN: Pharmacies enrolled in the Health Safety Net (HSN) program and dispensing medications or OTC products to HSN-eligible members (MassHealth aid categories AP, AQ, HA, HB, HC, or HD) must submit claims with a Group ID value (field #301-C1) of HSN for those claims. When a claim for a member with a HSN aid category is received in POPS with a Group ID value (field # 301-C1) of MassHealth, POPS will return a reject code of 65 – Patient Not Covered, with a response message similar to ‘RESUBMIT CLAIM WITH HSN AS THE GROUP ID.’ Date of Birth: Claims must contain the member’s date of birth (field # 304-C4). When a claim for a member is received in POPS with a non-matching date of birth, the pharmacy system will reject that claim and send a message back to the pharmacy. Patient Gender Code: Claims must contain the member’s gender code (field # 305-C5). When a claim for a member is received in POPS without the gender code field populated, the pharmacy system will reject the claim and send a message back to the pharmacy. Pharmacies may use the MassHealth Eligibility Verification System (EVS) or contact the Xerox Technical Help Desk at 1-866-246-8503 to understand the on-file demographics (e.g., date of birth) for the MassHealth or Health Safety Net member. Please note that Xerox cannot change a member’s demographic information. Instead, the MassHealth member must contact MassHealth Customer Service Team (CST) at 1-800-841-2900 for assistance (Hours: Monday – Friday, excluding holidays, 8:00 A.M. – 5:00 P.M.). The Health Safety Net (HSN) member must contact 1-877-910-2100 for assistance (Hours: Monday – Friday, excluding holidays, 8:00 A.M. – 5:00 P.M.). Pharmacies with questions involving Health Safety Net members should contact the HSN Help Desk at 1-800-609- 7232 for assistance (Hours: Monday – Friday, excluding holidays, 8:00 A.M. – 5:00 P.M). Other: Some aspects of the billing process are of a narrower perspective than is the target of this billing guide. As such, the more commonly mentioned ones are identified below and an authoritative source of information is identified. Topic Reference Return to Stock MassHealth pharmacy regulations at 130 CMR 406.446 MassHealth 340B Program MassHealth pharmacy regulations at 130 CMR 406.404 To view the MassHealth pharmacy regulations, go to www.mass.gov/masshealth. Click on MassHealth Regulations under Publications in the lower right panel. Click on MassHealth Provider Regulations then scroll down the page to the pharmacy regulations. 10.0 Version Table Vers ion Date Section Description 1.0 2001 Original document created Internal document developed 2.0 10/03 First major revision of publication Implemented NCPDP version 5.1 format. Internal document developed 3.0 11/06 Section 3.7 payment segment updated. Deleted text in Sections 7 (Payer Sheet E1) and 8 (Response E1). First production version issued. 4.0 08/07 Sections 2.1, 2.4, 2.7, 2.10, 3.1-3.2, 4.1, and 5.1.1 have been updated with new NPI information. Production version issued 5.0 07/08 Sections 2.4 and 2.6 have been updated to reflect two new CMS initiatives – Tamper-proof prescription pads and NPI. Production version issued 6.0 03/09 Sections 2.0, 2.4, and 9.0 have been updated to reflect changes in Coverage Code 4. This code is no longer permitted. There will be a change to the current software to reflect this code removal. Production version issued 7.0 05/09 Various segments in Sections 2.0, 3.0, and 4.0 have been updated to reflect software changes in support for NewMMIS go live. Section 9.0 has also been updated to provide links to the TPL indicator form and carrier code information. Production version issued 8.0 08/09 Section 9.0 TPL billing code descriptions revised 9.0 02/10 New Section 13.0 – Pharmacy Administered Flu Vaccines was added to the billing guide. Two field value changes were made to Section 2.9 – DUR/PPS Segment 08, and Section 3.1.4 – Response Pricing Segment 23, to reflect the new Section 13.0. These two section changes also apply to Payer sheet B1/B3. Production version issued 10.0 08/10 Appendix B has been updated. Production version issued 11.0 11/10 Section 8.0 – Temporary ID Cards/Newborn IDs has been removed and all subsequent sections have been renumbered. Section 12.0 – Pharmacy Administered Flu Vaccines has been updated. Section 14.0 – Where to Get Help has been updated. Section 15.0 – Appendix B has been removed. Production version issued 12.0 06/11 Full document revision to reflect NCPDP Telecommunications Standard D. 0. Billing Guide for NCPDP version D.0 effective January 1, 2012 12.1 08/11 Changes to the following fields. * 109-A9 * 338-5C * 339-G3 * 351-NP * 423-DN * 490-UE * 524-FO Billing Guide for NCPDP version D.0 effective January 1, 2012 12.2 10/11 Changes to the following fields. * 334-1C * 342-HC * 361-2D * 564-J3 * 565-J4 * 997-G2 Correction to supported status of S1/S3 transaction, Prescriber Segment Questions Billing Guide for NCPDP version D.0 effective January 1, 2012 13.0 1/12 Changes to the following fields. * 441-E6 * 439-E4 * 405-D5 * 442-E7 Billing Guide for NCPDP version D.0 effective January 1, 2012 13.1 5/12 Changes to the following fields. * 995-E2 * 339-6C * 340-7C Changes to the following sections. Section 6.0: TPL Billing Section 9.0: Special Topics and References Section 11.0: Where to Get Help 430-DU 471-5E Revisions to Route of Administration values Updates and clarifications for TPL Billing * Added words to 339-6C and 340-7C that cross- reference to 6.0 TPL Billing. * Revised Section 6.0 and added additional specifics for various other insurance scenarios in support of the transition to NCPDP D.0 transmission standard. Added some words regarding Date of Birth claim rejections and steps to resolve any issues. Deleted reference and fax number for ID Card Request Forms since this process is no longer valid. Reworded ‘Payer description’ and removed term “downstream’ Reworded ‘Payer description’ and removed term “upstream’ 14.0 3/2013 312-CC 313-CD 301-C1 304-C4 305-C5 402-D2 406-D6 420-DK 308-C8 479-H8 480-H9 423-DN 351-NP 475-J9 Section 6.0 Section 9.0 Added words to indicate a cross-reference to Section 9.0 Added words to indicate a cross-reference to Section 9.0 Added words to inbound segment instructions to indicate a cross-reference to Section 9.0; added words to response segment instructions to assist pharmacies to resolve rejections for an incorrect group ID value for HSN members. Added words to indicate a cross-reference to Section 9.0 Added words to indicate a cross-reference to Section 9.0 Added words to clarify that each prescription/service reference number assigned by a pharmacy must be unique Deleted value 0=Not specified. Not a valid value Added clarification words Added clarification words Added clarification words Added clarification words Changed Payer Usage from ‘Q’ to ‘R’ Added new valid value and added clarification words Deleted value 22. Not a valid value Added clarification words Added clarification words 11.0 Where to Get Help Billing and Claims Xerox Pharmacy Technical Help Desk: 1-866-246-8503 (available 24/7) Xerox Provider Relations : 617-423-9845 Xerox Provider Relations: thomas.lawson@xerox.com Member Eligibility MassHealth Customer Service: 1-800-841-2900 Automated Voice Response (AVR) : 1-800-554-0042 HSN Help Desk at 1-800-609-7232 Hours: Monday – Friday, excluding holidays, 8:00 A.M. – 5:00 P.M Pharmacy Prior Authorization University of Massachusetts Medical School Phone: 1-800-745-7318 Fax: 1-877-208-7428 Drug Utilization Review (DUR) Program Commonwealth Medicine University of Massachusetts Medical School P.O. Box 2586 Worcester, MA 01613-2586 Non-Pharmacy Prior Authorization Prior authorization requests for non-pharmacy services, including nutritional products, enteral products, diapers, medical/hospital equipment, private-duty nursing, and personal care attendants should be sent to the following address. MassHealth Prior Authorization Unit P.O. Box 9154 Hingham, MA 02043-9154 Phone: 1-800-862-8341 Fax: 617-847-3795 Provider Enrollment and Credentialing MassHealth Provider Enrollment and Credentialing P.O. Box 9118 Hingham, MA 02043-9118 Phone: 1-800-841-2900 Fax: 617-988-8974 Hours: Monday-Friday 8:00 A.M. – 5:00 P.M. (excluding holidays) E-mail: providersupport@mahealth.net Appendix A Commonwealth of Massachusetts Executive Office of Health and Human Services POPS Billing Guide May 2012 Version 13.1 2 - -- Pharmacy Online Processing System (POPS) Billing Guide April 2013 –Version 14.0 Pharmacy Online Processing System (POPS) Billing Guide April 2013 – Version 14.0 2 2 The Commonwealth of Massachusetts – Executive Office of Health and Human Services Pharmacy Online Processing System (POPS) Billing Guide April 2013 – Version 14.0 1