Payer Specifications June 2010

Payer Specification June 2010

EPIC, New York State Senior Prescription Plan
P.O. Box 15018
Albany, NY 12212-5018
1-800-634-1340

PAYER: NYS EPIC

  • Processor: Magellan Health Services
  • Information Source: Magellan Health Services
  • Effective as of: June 2008
  • Document Date: June 16, 2010
  • Provider Help Desk Contact Information: <800-634-1340
  • Vendor Certification Help Number: <804-217-7900

Version 5.1 Transactions (some transactions may be required at a future date to be determined):

NCPDP
Lower
Version
Transaction
Code		 NCPDP Lower Version Transaction Name NCPDP V.5.1
Transaction
Code		 NCPDP V.5.1 Transaction Name Transaction Support Requirements
00 Eligibility Verification E1 Eligibility Verification Required <<future date>
01 - 04 Rx Billing B1 Billing Required <<12/16/2004>
11 Rx Reversal B2 Reversal Required <<12/16/2004>
21 - 24 Rx Downtime Billing N/A N/A Not supported in v.5.1.
31 - 34 Rx Re-billing B3 Rebill Required <<12/16/2004>
41 Prior Authorization Request with Request for Payment P1 Prior Authorization Request and Billing Required <<future date>
45 Prior Authorization Inquiry P3 Prior Authorization Inquiry Required <<future date>
46 Prior Authorization Reversal P2 Prior Authorization Reversal Required <<future date>
51 Prior Authorization Request Only P4 Prior Authorization Request Only Required <<future date>>
81 - 84 Rx DUR N1 Information Reporting No planned requirements at this time;
91 - 94 Rx Refill N/A N/A Not supported in v.5.1.
N/A N/A N2 Information Reporting Reversal No planned requirements at this time;
N/A N/A N3 Information Reporting Rebill No planned requirements at this time;
N/A N/A C1 Controlled Substance Reporting No planned requirements at this time;
N/A N/A C2 Controlled Substance Reporting Reversal No planned requirements at this time;
N/A N/A C3 Controlled Substance Reporting Rebill No planned requirements at this time;

Version 5.1 Transaction Segments Mandatory/ Situational/ Not Sent:

NCPDP : Request Segment Matrix Segment Support Requirements
Segment\Transaction Code E1 B1 B2 B3 P1 P2 P3 P4 Some segments may be required at a future date to be determined.
Header M M M M M M M M Required <<12/16/2004>
Patient S S S S S S S S Required <<12/16/2004>
Insurance M M S M M S M M Required <<12/16/2004>
Claim N M M M M M M M Required <<12/16/2004>
Pharmacy Provider S S N S S S S S No planned requirements at this time; may be required at a future date.
Prescriber N M N M S S S S Required <<12/16/2004>
COB/Other Payments N S N S S N S S Required <<12/16/2004>
Worker's Comp N S N S S S S S Not required.
DUR/PPS N S S S S S S S Required <<12/16/2004>
Pricing N M S M M S S S Required <<12/16/2004>
Coupon N S N S S S S S No planned requirements at this time; may be required at a future date.
Compound N S N S S S S S Required <<future date>
PA N S N S M S M M Required <<future date>
Clinical N S N S S N N S Required <<12/16/2004>

Notes:
NCPDP Designations: M = Mandatory; S = Situational; N = Not Sent.
Some segments indicated as "Situational" by NCPDP, may be "Required" to support specific transactions for this program.

Important program highlights for v. 5.1:

The software/certification ID will control whether 5.1 claims will be accepted by the production system. Your software vendor will receive a number upon certification with Magellan Health. This number must be included on the transaction header segment.
On 12/16/2004 on-line compounds will be processed using the Compound Segment.
In cases where a repeating field is Required or Required When, the maximum number of iterations has been indicated.
Magellan Health will edit any/all data elements submitted for valid format and values.
Partial Fills are supported.

Field requirement legend:

Code Description
M Designated as Mandatory in accordance with the NCPDP Telecommunication Implementation Guide Version 5.1. These fields must be sent if the segment is required for the transaction.
S Designated as situational in accordance with the NCPDP Telecommunication Implementation Guide Version 5.1. It is necessary to send these fields in noted situations. Some fields designated as situational by NCPDP may be required for all New York State EPIC transactions.
X***R*** The "R***" indicates that the field is repeating. One of the other designators, 'M', or 'S' will precede it.

Notes:
1. Specific field values that are required for the program are identified as "NYS EPIC Values Supported".
2. There may be additional information regarding field values in the Provider Manual.

Request segment and field requirements:

Transaction Header Segment - Segment Mandatory for all transactions.
Field Field Name Mandatory NYS EPIC Values Supported
101-A1 BIN NUMBER M 012345
102-A2 VERSION/RELEASE NUMBER M 51
103-A3 TRANSACTION CODE M B1, B2, B3
104-A4 PROCESSOR CONTROL NUMBER M P024012345
109-A9 TRANSACTION COUNT M B1 = 1-4
B2 = 1-4
B3 = 1-4
202-B2 SERVICE PROVIDER ID QUALIFIER M 01 = NPI, 07 = NCPDP (NABP) Provider ID
201-B1 SERVICE PROVIDER ID M NPI or NCPDP (NABP) Provider Number <provider specific>
401-D1 DATE OF SERVICE M Format = CCYYMMDD
110-AK SOFTWARE VENDOR/CERTIFICATION ID M Assigned when software vendor is certified with Magellan Health; will reject if missing or not valid.

Patient Segment - Segment Mandatory for these transations: B1 and B3.

Field Field Name Mandatory/
Situational
Not Sent		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M 01 = Patient Segment
331-CX PATIENT ID QUALIFIER S Situational.
332-CY PATIENT ID S Situational.
304-C4 DATE OF BIRTH M Required for this program for eligibility validation.
305-C5 PATIENT GENDER CODE S Required for this program.
310-CA PATIENT FIRST NAME M Required for this program.
311-CB PATIENT LAST NAME M Required for this program.
322-CM PATIENT STREET ADDRESS S Situational.
323-CN PATIENT CITY ADDRESS S Situational.
324-CO PATIENT STATE / PROVINCE ADDRESS S Situational.
325-CP PATIENT ZIP/POSTAL ZONE S Situational.
326-CQ PATIENT PHONE NUMBER S Situational.
307-C7 PATIENT LOCATION S Situational.
333-CZ EMPLOYER ID N Situational.
334-1C SMOKER / NON-SMOKER CODE N Not Sent.
335-2C PREGNANCY INDICATOR N Not Sent.

Insurance Segment - Segment Mandatory for these transactions: E1, B1, and B3.
Field     Field Name Mandatory/
Situational		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M 04 = Insurance Segment
302-C2 CARDHOLDER ID M Required for this program.
NYS EPIC Participant Number <patient specific>
Format = AANNNNNNN
312-CC CARDHOLDER FIRST NAME S Required for this program.
313-CD CARDHOLDER LAST NAME S Required for this program.
314-CE HOME PLAN S Situational.
524-FO PLAN ID S Situational.
309-C9 ELIGIBILITY CLARIFICATION CODE S Situational.
336-8C FACILITY ID S Situational.
301-C1 GROUP ID M Required for this program.
NYEPIC
303-C3 PERSON CODE S Situational.
306-C6 PATIENT RELATIONSHIP CODE S Situational.

Claim Segment - Segment Mandatory for these transations: B1, B2, and B3.
Field Field Name Mandatory/
Situational/
Repeating		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M 07 = Claim Segment
455-EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER M 1 = Rx billing
402-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER M Rx Number
436-E1 PRODUCT/SERVICE ID QUALIFIER M 03 = NDC
407-D7 PRODUCT/SERVICE ID M NDC
456-EN ASSOCIATED PRESCRIPTION/SERVICE REFERENCE # S Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)) and the Prescription/Service Reference Number (402-D2) changed from the "P" (Partial Fill).
Required when the "P" (Partial Fill) is not the original fill and the Prescription/Service Reference Number (402-D2) has not changed.
457-EP ASSOCIATED PRESCRIPTION/SERVICE DATE S Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)).
Required when Associated Prescription/Service Reference Number (456-EN) is used.
Required when the "P" (Partial Fill) transaction is not the original fill.
458-SE PROCEDURE MODIFIER CODE COUNT S Situational.
459-ER PROCEDURE MODIFIER CODE S***R*** Situational, Repeating.
442-E7 QUANTITY DISPENSED M Required for this program; expressed in metric decimal units.
403-D3 FILL NUMBER M Required for this program.
405-D5 DAYS SUPPLY M Required for this program.
406-D6 COMPOUND CODE M Required for this program.
0= Not specified
1 = Not a compound
2 = Compound
408-D8 DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE S Required for this program.
414-DE DATE PRESCRIPTION WRITTEN M Required for this program.
415-DF NUMBER OF REFILLS AUTHORIZED S Required for this program.
419-DJ PRESCRIPTION ORIGIN CODE S Situational.
420-DK SUBMISSION CLARIFICATION CODE S Required when needed to provide additional information for coverage purposes.
'2 - Other Override' required to override select Plan Limitation Exceeded for Maximum Quantity / Day Supply edits as of 11/01/04,
'7 - Medically Necessary' required for OCC 3 claims certifying the prescriber was consulted for this prescription,
'99 - Other' required for OCC 3 claims certifying an attempt was made to contact the prescriber
460-ET QUANTITY PRESCRIBED S Situational.
308-C8 OTHER COVERAGE CODE S Required for this program for COB.
Value of 8 to be used for claims covered by primary insurer.
Value of 3 to be used for claims not covered by primary insurer
Value of 2 not allowed for adjudication <1/16/2006>
Value of 4 and 5 not allowed for adjudication <06/23/2008>
Value of 1 and 7 only allowed with override <11/18/2009>
Value of 6 not allowed for adjudication. <6/8/2010>
429-DT UNIT DOSE INDICATOR S Situational.
453-EJ ORIGINALLY PRESCRIBED PRODUCT/SERVICE ID QUALIFIER S Situational.
445-EA ORIGINALLY PRESCRIBED PRODUCT/SERVICE CODE S Situational.
446-EB ORIGINALLY PRESCRIBED QUANTITY S Situational.
330-CW ALTERNATE ID S Situational.
454-EK SCHEDULED PRESCRIPTION ID NUMBER S Situational.
600-28 UNIT OF MEASURE S Situational.
418-DI LEVEL OF SERVICE S Situational.
461-EU PRIOR AUTHORIZATION TYPE CODE S Required when needed to identify designated prior authorization and/ or override conditions.
462-EV PRIOR AUTHORIZATION NUMBER SUBMITTED S Situational.
463-EW INTERMEDIARY AUTHORIZATION TYPE ID S Situational.
464-EX INTERMEDIARY AUTHORIZATION ID S Situational.
343-HD DISPENSING STATUS S Required when submitting a partial fill or the completion of a partial fill.
344-HF QUANTITY INTENDED TO BE DISPENSED S Required when submitting a partial fill or the completion of a partial fill.
345-HG DAYS SUPPLY INTENDED TO BE DISPENSED S Required when submitting a partial fill or the completion of a partial fill.

Pricing Segment - Segment Mandatory for these transations: B1 and B3.
Field Field Name Mandatory/
Situational
Repeating		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M 11 = Pricing Segment
409-D9 INGREDIENT COST SUBMITTED S Required for this program EXCEPT for
COB - CoPay only Billing - Not submitted or zero.
412-DC DISPENSING FEE SUBMITTED S Required for this program EXCEPT for
COB - CoPay only Billing - Not submitted or zero.
477-BE PROFESSIONAL SERVICE FEE SUBMITTED S Situational.
433-DX PATIENT PAID AMOUNT SUBMITTED S Situational.
438-E3 INCENTIVE AMOUNT SUBMITTED S Situational.
478-H7 OTHER AMOUNT CLAIMED SUBMITTED COUNT S***R*** Max = 3
479-H8 OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER S***R***
Max = 3		 Required for this program.
Use when COB is indicated by 308-C8 = "8". Value = "99" Other
480-H9 OTHER AMOUNT CLAIMED SUBMITTED S***R***
Max = 3		 Required for this program.
Use when COB is indicated by 308-C8 = "8".
Must equal Gross Amount Due (430-DU).
481-HA FLAT SALES TAX AMOUNT SUBMITTED S Situational.
482-GE PERCENTAGE SALES TAX AMOUNT SUBMITTED S Situational.
483-HE PERCENTAGE SALES TAX RATE SUBMITTED S Situational.
484-JE PERCENTAGE SALES TAX BASIS SUBMITTED S Situational.
426-DQ USUAL AND CUSTOMARY CHARGE M Required for this program.
430-DU GROSS AMOUNT DUE M Required for this program.
* Must Match field 480-H9 (Other Amount Claimed Submitted) when COB is indicated by 308-C8 = "8".
423-DN BASIS OF COST DETERMINATION S Situational.

Pharmacy Provider Segment - Segment not required at this time; fields intentionally not listed. Possible future use.
Field Field Name Mandatory NYS EPIC Values Supported
intentionally not listed intentionally not listed intentionally not listed intentionally not listed

Prescriber Segment - Segment Mandatory for these transations: B1 and B3.
Field Field Name Mandatory/
Situational		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M 03 = Prescriber Segment
466-EZ PRESCRIBER ID QUALIFIER M Required for this program.
01 = NPI
08 = State License Number
12 = DEA Number
411-DB PRESCRIBER ID M Required for this program.
NPI, DEA Number, or NYS State License Number
467-1E PRESCRIBER LOCATION CODE S Situational.
427-DR PRESCRIBER LAST NAME S Situational.
498-PM PRESCRIBER PHONE NUMBER S Situational.
468-2E PRIMARY CARE PROVIDER ID QUALIFIER S Situational.
421-DL PRIMARY CARE PROVIDER ID S Situational.
469-H5 PRIMARY CARE PROVIDER LOCATION CODE S Situational.
470-4E PRIMARY CARE PROVIDER LAST NAME S Situational.

COB Segment - Segment not required for CoPay Only Billing (Value "8" in 308-C8) for transactions: B1 and B3. Segment is required for claims denied by primary carrier (308-C8 = 3,5,6,or 7). Where possible this segment is requested for all COB claims to allow for proper Manufacturer Rebate processing.
Field Field Name Mandatory/
Situational
Repeating		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M 05 = Coordination of Benefits/ Other Payments Segment
337-4C COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT M
Max = 3		 Required.
338-5C OTHER PAYER COVERAGE TYPE M***R***
Max = 3		 Required when 431-DV is populated.
01 = Primary
02 = Secondary
03 = Tertiary
339-6C OTHER PAYER ID QUALIFIER S***R***
Max = 3		 Situational, Repeating.
340-7C OTHER PAYER ID S***R***
Max = 3		 Situational, Repeating.
443-E8 OTHER PAYER DATE S***R***
Max = 3		 Situational, Repeating.
341-HB OTHER PAYER AMOUNT PAID COUNT S Required for this program when 431-DV is populated.
342-HC OTHER PAYER AMOUNT PAID QUALIFIER S***R***
Max = 3		 Required for this program when 431-DV is populated.
431-DV OTHER PAYER AMOUNT PAID S***R***
Max = 3		 Provided if possible.
471-5E OTHER PAYER REJECT COUNT S Required for this program when 308-C8 = "3,5,6 and 7"
472-6E OTHER PAYER REJECT CODE S Required for this program when 308-C8 = "3,5,6 and 7"

Worker's Comp Segment - Segment Not Required; fields intentionally not listed.
Field Field Name Mandatory NYS EPIC Values Supported
intentionally not listed intentionally not listed intentionally not listed intentionally not listed

DUR/PPS Segment - Segment Mandatory for these transactions: B1 and B3 if there is DUR information.
Field Field Name Mandatory/
Situational
Repeating		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M 08 = DUR/ PPS Segment
473-7E DUR/PPS CODE COUNTER S***R
Max = 9		 Required when needed to communicate DUR information.
439-E4 REASON FOR SERVICE CODE S***R
Max = 9		 Required when needed to communicate DUR information. See "ProDUR" section in Provider Manual.
440-E5 PROFESSIONAL SERVICE CODE S***R
Max = 9		 Required when needed to communicate DUR information. See "ProDUR" section in Provider Manual.
441-E6 RESULT OF SERVICE CODE S***R
Max = 9		 Required when needed to communicate DUR information. See "ProDUR" section in Provider Manual.
474-8E DUR/PPS LEVEL OF EFFORT S***R
Max = 9		 Situational, Repeating.
475-J9 DUR CO-AGENT ID QUALIFIER S***R
Max = 9		 Situational, Repeating.
476-H6 DUR CO-AGENT ID S***R
Max = 9		 Situational, Repeating.

Clinical Segment - Segment Mandatory for these transactions: B1 and B3 if there is Clinical information.
Field Field Name Mandatory/
Situational
Repeating		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M Required for this program.
491-VE DIAGNOSIS CODE COUNT S Situational.

DUR/PPS Segment - Segment Mandatory for these transactions: B1 and B3 if there is DUR information.
Field Field Name Mandatory/
Situational
Repeating		 NYS EPIC Values Supported
492-WE DIAGNOSIS CODE QUALIFIER S***R*** Situational, Repeating.
424-DO DIAGNOSIS CODE S***R*** Situational, Repeating.
493-XE CLINICAL INFORMATION COUNTER S***R*** Situational, Repeating.
494-ZE MEASUREMENT DATE S***R*** Situational, Repeating.
495-H1 MEASUREMENT TIME S***R*** Situational, Repeating.
496-H2 MEASUREMENT DIMENSION S***R*** Situational, Repeating.
497-H3 MEASUREMENT UNIT S***R*** Situational, Repeating.
499-H4 MEASUREMENT VALUE S***R*** Situational, Repeating.

Compound Segment - Segment Mandatory for these transactions: B1 and B3 if there is Compound information.
Field Field Name Mandatory/
Situational
Repeating		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M 10 = Compound Segment
450-EF COMPOUND DOSAGE FORM DESCRIPTION CODE M Must use valid NCPDP values in this field.
451-EG COMPOUND DISPENSING UNIT FORM INDICATOR M 1 = Each
2 = Grams
3 = Milliliters
452-EH COMPOUND ROUTE OF ADMINISTRATION M Must use valid NCPDP values in this field.
447-EC COMPOUND INGREDIENT COMPONENT COUNT M Count of compound product IDs (both active and inactive) in the compound mixture submitted.
488-RE COMPOUND PRODUCT ID QUALIFIER M***R*** Must use valid NCPDP values in this field.
489-TE COMPOUND PRODUCT ID M***R*** Product identification used in compound.
448-ED COMPOUND INGREDIENT QUANTITY M***R*** Amount in metric decimal units of the product included in the compound mixture.
449-EE COMPOUND INGREDIENT DRUG COST S***R*** Required when used to arrive at final reimbursement.
490-UE COMPOUND INGREDIENT BASIS OF COST DETERMINATION S***R*** Situational, Repeating.

Coupon Segment - Segment not required at this time; fields intentionally not listed.
Field Field Name Mandatory NYS EPIC Values Supported
intentionally not listed intentionally not listed intentionally not listed intentionally not listed

Prior Authorization Segment - Segment not required at this time; fields intentionally not listed.
Field Field Name Mandatory NYS EPIC Values Supported
intentionally not listed intentionally not listed intentionally not listed intentionally not listed

Response segment and field requirements:

PAID (or DUPLICATE OF PAID) Response:
Transaction Header Segment - Segment Mandatory for all transactions.
Field Field Name Mandatory NYS EPIC Values Supported
102-A2 VERSION/RELEASE NUMBER M Same value as in request billing
103-A3 TRANSACTION CODE M Same value as in request billing
109-A9 TRANSACTION COUNT M Same value as in request billing
501-F1 HEADER RESPONSE STATUS M Same value as in request billing
202-B2 SERVICE PROVIDER ID QUALIFIER M Same value as in request billing
201-B1 SERVICE PROVIDER ID M Same value as in request billing
401-D1 DATE OF SERVICE M Same value as in request billing

Response Message Segment - Segment Situational.
Field Field Name Mandatory/
Situational		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M 20 = Response Message Segment
504-F4 MESSAGE S Required when text is needed for clarification or detail.

Response Insurance Segment - Segment Situational.
Field Field Name Mandatory/
Situational		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M 25 = Response Insurance Segment
301-C1 GROUP ID S Required when needed to identify the cardholder or employer group, to identify appropriate group number for billing.
524-FO PLAN ID S Situational.
545-2F NETWORK REIMBURSEMENT ID S Situational.
568-J7 PAYER ID QUALIFIER S Situational.
569-J8 PAYER ID S Situational.

Response Status Segment - Segment Situational.
Field Field Name Mandatory/
Situational/
Repeating		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M 21 = Response Status Segment
112-AN TRANSACTION RESPONSE STATUS M P = Paid
D = Duplicate
503-F3 AUTHORIZATION NUMBER S Returned when needed to identify the transaction.
510-FA REJECT COUNT S Situational.
511-FB REJECT CODE S***R*** Situational, Repeating.
546-4F REJECT FIELD OCCURRENCE INDICATOR S***R*** Situational, Repeating.
547-5F APPROVED MESSAGE CODE COUNT S Situational.
548-6F APPROVED MESSAGE CODE S***R*** Situational, Repeating.
526-FQ ADDITIONAL MESSAGE INFORMATION S Required when additional text is needed for clarification or detail.
549-7F HELP DESK PHONE NUMBER QUALIFIER S Required when the Help Desk Phone Number is used.
03 = Processor/ PBM
550-8F HELP DESK PHONE NUMBER S Required when needed to provide a support telephone number.

Response Claim Segment - Segment Situational.
Field Field Name Mandatory/
Situational/
Repeating		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M 22 = Response Claim Segment
455-EM PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER M 1 = Rx billing <client>
402-D2 PRESCRIPTION/ SERVICE REFERNCE NUMBER M Required for this program.
551-9F PREFERRED PRODUCT COUNT S Situational.
552-AP PREFERRED PRODUCT ID QUALIFIER S***R*** Situational, Repeating.
553-AR PREFERRED PRODUCT ID S***R*** Situational, Repeating.
554-AS PREFERRED PRODUCT INCENTIVE S***R*** Situational, Repeating.
555-AT PREFERRED PRODUCT COPAY INCENTIVE S***R*** Situational, Repeating.
556-AU PREFERRED PRODUCT DESCRIPTION S***R*** Situational, Repeating.

Response Pricing Segment - Segment Optional.
Field Field Name Mandatory/
Situational/
Repeating		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M 23 = Response Pricing Segment
505-F5 PATIENT PAY AMOUNT S Returned when the processor determines that the patient has payment responsibility for part/ the entire claim.
506-F6 INGREDIENT COST PAID S Required when this value is used to arrive at the final reimbursement.
507-F7 DISPENSING FEE PAID S Required when this value is used to arrive at the final reimbursement.
557-AV TAX EXEMPT INDICATOR S Situational.
558-AW FLAT SALES TAX AMOUNT PAID S Situational.
559-AX PERCENTAGE SALES TAX AMOUNT PAID S Situational.
560-AY PERCENTAGE SALES TAX RATE PAID S Situational.
561-AZ PERCENTAGE SALES TAX BASIS PAID S Situational.
521-FL INCENTIVE AMOUNT PAID S Situational.
562-J1 PROFESSIONAL SERVICE FEE PAID S Situational.
563-J2 OTHER AMOUNT PAID COUNT S Situational.
564-J3 OTHER AMOUNT PAID QUALIFIER S***R*** Situational, Repeating.
565-J4 OTHER AMOUNT PAID S***R*** Situational, Repeating.
566-J5 OTHER PAYER AMOUNT RECOGNIZED S Required if Other Payer Amount Submitted is greater than zero (0) and COB/Other Payments Segment is supported.
509-F9 TOTAL AMOUNT PAID S Required when this value is used to arrive at the final reimbursement.
522-FM BASIS OF REIMBURSEMENT DETERMINATION S Required when this value is used to arrive at the final reimbursement.
523-FN AMOUNT ATTRIBUTED TO SALES TAX S Situational.
512-FC ACCUMULATED DEDUCTIBLE AMOUNT S Required when this value is used to arrive at the final reimbursement.
513-FD REMAINING DEDUCTIBLE AMOUNT S Required when this value is used to arrive at the final reimbursement.
514-FE REMAINING BENEFIT AMOUNT S Required when this value is used to arrive at the final reimbursement.
517-FH AMOUNT APPLIED TO PERIODIC DEDUCTIBLE S Required when this value is used to arrive at the final reimbursement.
518-FI AMOUNT OF COPAY/CO-INSURANCE S Required when this value is used to arrive at the final reimbursement.
519-FJ AMOUNT ATTRIBUTED TO PRODUCT SELECTION S Situational.
520-FK AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM S Situational.
346-HH BASIS OF CALCULATION - DISPENSING FEE S Situational.
347-HJ BASIS OF CALCULATION - COPAY S Situational.
348-HK BASIS OF CALCULATION - FLAT SALES TAX S Situational.
349-HM BASIS OF CALCULATION - PERCENTAGE SALES TAX S Situational.

Response DUR / PPS Segment - Segment Optional.
Field Field Name Mandatory/
Situational/
Repeating		 NYS EPIC Values Supported
111-AM SEGMENT IDENTIFICATION M 24 = Response DUR/ PPS Segment
567-J6 DUR/ PPS RESPONSE CODE COUNTER S***R*** Situational, Repeating.
439-E4 REASON FOR SERVICE CODE S***R*** See Provider Manual for allowed values.
528-FS CLINICAL SIGNIFICANCE CODE S***R*** Blank = Not specified
1 = Major
2 = Moderate
3 = Minor
9 = Undetermined
529-FT OTHER PHARMACY INDICATOR S***R*** 0 = Not specified
1 = Your pharmacy
2 = Other pharmacy in same chain
3 = Other pharmacy
530-FU PREVIOUS DATE OF FILL S***R*** Situational, Repeating.
531-FV QUANTITY OF PREVIOUS FILL S***R*** Situational, Repeating.
532-FW DATABASE INDICATOR S***R*** 1 = First DataBank
4 = Processor developed
533-FX OTHER PRESCRIBER INDICATOR S***R*** 0 = Not specified
1 = Same prescriber
2 = Other prescriber
544-FY DUR FREE TEXT MESSAGE S***R*** Required when text is needed for additional clarification.

Response segment and field requirements:

REJECT Response: No Changes have been made to the Reject Response Segment.