Payer Specifications D.0

• Payer Specifications D.0 is also available in Portable Document Format (PDF, 740 KB, 18 pg.)

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

This document contains the specifications of six templates:

• Request Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template
• Response Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template
• Request Claim Reversal (B2) Payer Sheet Template
• Response Claim Reversal Accepted/Approved (B2) Payer Sheet Template
• Response Claim Reversal Accepted/Rejected (B2) Payer Sheet Template
• Response Claim Reversal Rejected/Rejected (B2) Payer Sheet Template

Start of Request Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template

General Information Column	Information
Payer Name:	New York EPIC
Date:	10/16/2014
Plan Name/Group Name:	New York EPIC
BIN:	012345
PCN:	P024012345
Processor:	Processor/Fiscal Intermediary
Effective as of:	10/18/2014
NCPDP Telecommunication Standard Version/Release #:	D.0
NCPDP Data Dictionary Version Date:	June 2010
NCPDP External Code List Version Date:	June 2010
Contact/Information Source:	Magellan Health Services — Albany, NY
Certification Testing Window:	TBD (to be determined)
Certification Contact Information:	804-217-7900
Provider Relations Help Desk Information:	866-254-1669
Other versions supported:	NCPDP Telecommunication version 5.1 until TBD

Other Transactions Supported

Payer: Please list each transaction supported with the segments, fields and pertinent information on each transaction.

Transaction Code	Transaction Name
B1	Claim Billing
B2	Claim Reversal
B3	Claim Re-bill

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	RW	"Required When." The situations designated have qualifications for usage ("Required when x,"Not Required when y").	Yes
Repeating Field	***	The "***" indicates that the field is repeating. One of the other designators, "M", "R" or "RW" will precede it.	Yes

Note: Fields that are not used in the Claim Billing/Claim Re-bill transactions and those that do not have qualified requirements (.i.e., not used) for this payer are excluded from the template.

Claim Billing/Claim Re-bill Transaction

The following lists the segments and fields in a Claim Billing or Claim Re-bill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0.

Transaction Header Segment - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
101-A1	BIN NUMBER	012345	M	012345 — New York EPIC
102-A2	VERSION/RELEASE NUMBER	D.0	M	Mandatory
103-A3	TRANSACTION CODE	B1 Billing B2 Reversal B3 Re-bill	M	Mandatory
104-A4	PROCESSOR CONTROL NUMBER	P024012345	M	Mandatory
109-A9	TRANSACTION COUNT	01 = One occurrence 02 = Two occurrences 03 = Three occurrences 04 = Four occurrences	M	Mandatory
202-B2	SERVICE PROVIDER ID QUALIFIER	01 = National Provider Identifier (NPI)	M	Mandatory
201-B1	SERVICE PROVIDER ID	NPI	M	Mandatory
401-D1	DATE OF SERVICE	Format = CCYYMMDD	M	Mandatory
110-AK	SOFTWARE VENDOR/CERTIFICATION ID	Assigned by Magellan Health Services.	M	Assigned by Magellan Health Services.

Patient Segment (111-AM="01") - Required for these transactions: B1 and B3.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
304-C4	DATE OF BIRTH	Format = CCYYMMDD	R	Required for this program.
305-C5	PATIENT GENDER CODE	1 = Male 2 = Female	R	Required for this program.
310-CA	PATIENT FIRST NAME	Required for this program	R	Required for this program.
311-CB	PATIENT LAST NAME	Required for this program	R	Required for this program.

Insurance Segment (111-AM="04") - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
302-C2	CARDHOLDER ID	EPIC Cardholder ID	M	NY EPIC Number <patient specific> Format = EPNNNNNNN
312-CC	CARDHOLDER FIRST NAME	Required for this program.	R	Required for this program.
313-CD	CARDHOLDER LAST NAME	Required for this program.	R	Required for this program.
301-C1	GROUP ID	NY EPIC	M	NY EPIC

Claim Segment (111-AM = "07") - This segment is always sent and the Payer supports partial fills.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
455-EM	PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER	1 = Rx billing	M	For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing).
402-D2	PRESCRIPTION/SERVICE REFERENCE NUMBER	Mandatory	M	Mandatory
436-E1	PRODUCT/SERVICE ID QUALIFIER	03 = National Drug Code (NDC) 00 = Compound	M	Mandatory
407-D7	PRODUCT/SERVICE ID	Mandatory	M	One "0" when submitting compound
456-EN	ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER	Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). Required when the Dispensing Status (343-HD) = "P" (Partial Fill) and there are multiple occurrences of partial fills for this prescription.	RW	Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). Required when the Dispensing Status (343-HD) = "P" (Partial Fill) and there are multiple occurrences of partial fills for this prescription.
457-EP	ASSOCIATED PRESCRIPTION/SERVICE DATE	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 Dispensing Status (343-HD) = "P" (Partial Fill) and there are multiple occurrences of partial fills for this prescription.	RW	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 Dispensing Status (343-HD) = "P" (Partial Fill) and there are multiple occurrences of partial fills for this prescription.
442-E7	QUANTITY DISPENSED	Required for this program.	R	Required for this program.
403-D3	FILL NUMBER	0 = Original Dispensing 1-99 = Refill number - Number of the replenishment	R	Required for this program.
405-D5	DAYS SUPPLY	Required for this program.	R	Required for this program.
406-D6	COMPOUND CODE	1 = Not a compound 2 = Compound	R	Required for this program.
408-D8	DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE	0 = No Product Selection Indicated 1 = Substitution Not Allowed by Prescriber 2 = Substitution Allowed - Patient Requested Product Dispensed 3 = Substitution Allowed - Pharmacist Selected Product Dispensed 4 = Substitution Allowed - Generic Drug Not in Stock 5 = Substitution Allowed - Brand Drug Dispensed as Generic 6 = Override 7 = Substitution Not Allowed - Brand Drug Mandated by Law 8 = Substitution Allowed - Generic Drug Not Available in Marketplace 9 = Substitution Allowed by Prescriber but Plan Requests Brand - Patient's Plan Requested Brand Product to be Dispensed	R	Required for this program.
414-DE	DATE PRESCRIPTION WRITTEN	Format = CCYYMMDD	R	Required for this program.
415-DF	NUMBER OF REFILLS AUTHORIZED	0 - No refills authorized 1-99 = Authorized Refill number - with 99 being as needed, refills unlimited	RW	Required when necessary for plan benefit administration.
354-NX	SUBMISSION CLARIFICATION CODE COUNT	Maximum count of 3.	RW	Required when Submission Clarification Code (420-DK) is used.
420-DK	SUBMISSION CLARIFICATION CODE	'2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits '7 = Medically Necessary' required for FluMist age limit overrides '8 = Process Compound For Approved Ingredients' required to override and accept payments only for covered items within a compound	R	'2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits '7 = Medically Necessary' required for FluMist age limit overrides '8 = Process Compound For Approved Ingredients' required to override and accept payments only for covered items within a compound
308-C8	OTHER COVERAGE CODE	3 = Other Coverage Billed — Claim not Covered 8 = Claim is billing for patient financial responsibility only	R	3 = Other Coverage Billed — Claim not Covered 8 = Claim is billing for patient financial responsibility only
343-HD	DISPENSING STATUS	P = Partial Fill C = Completion of Partial Fill	R	Required for the partial fill or the completion fill of a prescription.
344-HF	QUANTITY INTENDED TO BE DISPENSED	Required for this program.	R	Required for the partial fill or the completion fill of a prescription.
345-HG	DAYS SUPPLY INTENDED TO BE DISPENSED	Required for this program.	R	Required for the partial fill or the completion fill of a prescription.
357-NV	DELAY REASON CODE	1 = Proof of eligibility unknown or unavailable 2 = Litigation 3 = Authorization delays 4 = Delay in certifying provider 5 = Delay in supplying billing forms 6 = Delay in delivery of custom-made appliances 7 = Third-party processing delay 8 = Delay in eligibility determination 9 = Original claims rejected or denied due to a reason unrelated to the billing limitation rules 10 = Administration delay in the prior approval process 11 = Other 12 = Received late with no exceptions 13 = Substantial damage by fire, etc to provider records 14 = Theft, sabotage/other willful acts by employee	RW	Required when needed to specify the reason that submission of the transaction has been delayed.
995-E2	ROUTE OF ADMINISTRATION	SNOMED	RW	Required when specified in trading partner agreement Payer Requirement: (any unique payer requirement(s))
996-G1	COMPOUND TYPE	01 = Anti-infective 02 = Ionotropic 03 = Chemotherapy 04 = Pain management 05 = TPN/PPN (Hepatic, Renal, Pediatric) Total Parenteral Nutrition/ Peripheral Parenteral Nutrition 06 = Hydration 07 = Ophthalmic 99 = Other	RW	Required when submitting new compound. Payer Requirement: Same as implementation guide: Same as Imp Guide.

Pricing Segment (111-AM="11") - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
409-D9	INGREDIENT COST SUBMITTED	Mandatory	M	Mandatory
412-DC	DISPENSING FEE SUBMITTED	Mandatory	M	Mandatory
478-H7	OTHER AMOUNT CLAIMED SUBMITTED COUNT	Maximum count of 3.	RW***	Required when Other Amount Claimed Submitted Qualifier (479-H8) is used.
479-H8	OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER	Blank 01 = Delivery Cost 02 = Shipping Cost 03 = Postage Cost 04 = Administrative Cost 09 = Compound Preparation Cost Submitted	RW***	Required when Other Amount Claimed Submitted (480-H9) is used.
480-H9	OTHER AMOUNT CLAIMED SUBMITTED	Required when its value has an effect on the Gross Amount Due (430-DU) calculation.	RW***	Required when its value has an effect on the Gross Amount Due (430-DU) calculation.
426-DQ	USUAL AND CUSTOMARY CHARGE	Required when needed per trading partner agreement.	RW	Required when needed per trading partner agreement.
430-DU	GROSS AMOUNT DUE	Mandatory	M	Mandatory

Prescriber Segment (111-AM = "03") - Segment Required for B1 and B3 transactions.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
466-EZ	PRESCRIBER ID QUALIFIER	01 = National Provider Identifier (NPI) 08 = State License Number 12 = Drug Enforcement Administration (DEA) Number	M	Mandatory
411-DB	PRESCRIBER ID	NPI State License DEA Number	M	Format: NPI = NNNNNNNNN State License = NNNNNNN DEA Number = AANNNNNNN

COB/Other Payments Segment (111-AM = "05") - Segment is situational. Required only for secondary, tertiary, etc., claims. Required for B1 and B3 transactions when there is other payer information. Scenario 2 - Other Payer-Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
337-4C	COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT	Maximum count of 9.	M	Mandatory
338-5C	OTHER PAYER COVERAGE TYPE	Blank = Not Specified 01 = Primary — First 02 = Secondary — Second 03 = Tertiary — Third	M***	Mandatory
339-6C	OTHER PAYER ID QUALIFIER	03 = Bank Information Number (BIN) Card Issuer ID	RW	Required when Other Payer ID (340-7C) is used.
340-7C	OTHER PAYER ID	Other Payer Bank Information Number (BIN)	R	Required for this program.
443-E8	OTHER PAYER DATE	Required for this program.	R	Required for this program.
471-5E	OTHER PAYER REJECT COUNT	Maximum count of 5.	RW	Required when the Other Payer Reject Code (472-6E) is used.
472-6E	OTHER PAYER REJECT CODE	NCPDP Reject Code (511-FB) values	RW	Required for this program when the Other Coverage Code (308-C8) of "3" is used.
353-NR	OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT	Maximum count of 25.	RW	Required when Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used.
351-NP	OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER	Blank = Not Specified 01 = Amount Applied to Periodic Deductible (517-FH) as reported by previous payer 02 = Amount attributed to Product Selection/Brand Drug (134-UK) as reported by previous payer 03 = Amount Attributed to Sales Tax (5123-FN) as reported by previous payer 04 = Amount Exceeding Periodic Benefit Maximum (520-FK) as reported by previous payer 05 = Amount of Co-pay (518-FI) as reported by previous payer 07 = Amount of Coinsurance (572-4U) as reported by previous payer 08 = Amount Attributed to Product Selection/Non-Preferred Formulary Selection (135-UM) as reported by previous payer 09 = Amount Attributed to Health Plan Assistance Amount (129-UD) as reported by previous payer 10 = Amount Attributed to Provider Network Selection (133-UJ) as reported to previous payer 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) as reported by previous payer 12 = Amount Attributed to Coverage Gap (137-UP) that was collected from the patient due to a coverage gap 13 = Amount Attributed to Processor Fee (571-NZ) as reported by previous payer	RW	Required when Other Payer-Patient Responsibility Amount (352-NQ) is used.These values will be the only ones accepted by EPIC. Any other values will deny.
352-NQ	OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT	Required when necessary for patient financial responsibility only billing. Not used when Other Payer Amount Paid (431-DV) is submitted.	RW	Required when necessary for patient financial responsibility only billing. Not used when Other Payer Amount Paid (431-DV) is submitted.
392-MU	BENEFIT STAGE COUNT	Maximum count of 4.	RW	Required when Benefit Stage Amount (394-MW) is used.
393-MV	BENEFIT STAGE QUALIFIER	01 = Deductible 02 = Initial Benefit 03 = Coverage Gap 04 = Catastrophic Coverage	RW	Required when Benefit Stage Amount (394-MW) is used.
394-MW	BENEFIT STAGE AMOUNT	Required when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. This field is required when the plan is a participant in a Medicare Part D program that requires reporting of benefit stage specific financial amounts.	RW	Required when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. This field is required when the plan is a participant in a Medicare Part D program that requires reporting of benefit stage specific financial amounts.

DUR/PPS Segment (111-AM = "08") - Segment Mandatory for B1 and B3 transactions when there is DUR information.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
473-7E	DUR/PPS CODE COUNTER	Maximum of 9 occurrences.	RW***	Required when DUR/PPS Segment is used.
439-E4	REASON FOR SERVICE CODE	Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required when this field affects payment for or documentation of professional pharmacy service.	RW***	Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required when this field affects payment for or documentation of professional pharmacy service.
440-E5	PROFESSIONAL SERVICE CODE	Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required when this field affects payment for or documentation of professional pharmacy service.	RW***	Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required when this field affects payment for or documentation of professional pharmacy service.
441-E6	RESULT OF SERVICE CODE	00 = Not Specified 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 1H = Brand-to-Generic Change 1J = Rx-to-OTC Change 1K = Filled with Different Dosage Form 2A = Prescription Not Filled 2B = Not Filled, Directions Clarified 3A = Recommendation Accepted 3B = Recommendation Not Accepted 3C = Discontinued Drug 3D = Regimen Changed 3E = Therapy Changed 3F = Therapy Changed 3G = Drug Therapy Unchanged 3H = Follow-Up/Report 3J = Patient Referral 3K = Instructions Understood 3M = Compliance Aid Provided 3N = Medication Administered 4A = Prescribed with acknowledgements	RW***	Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required when this field affects payment for or documentation of professional pharmacy service.

Compound Segment - Segment Mandatory for these transactions: B1 and B3 when there is Compound information.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
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	Mandatory
451-EG	COMPOUND DISPENSING UNIT FORM INDICATOR	1 = Each 2 = Grams 3 = Milliliters	M	Mandatory
447-EC	COMPOUND INGREDIENT COMPONENT COUNT	Maximum of 25 ingredients.	M	Mandatory
488-RE	COMPOUND PRODUCT ID QUALIFIER	03	M	03 = National Drug Code (NDC) - Formatted 11 digits (N)
489-TE	COMPOUND PRODUCT ID	Mandatory	M	Mandatory
448-ED	COMPOUND INGREDIENT QUANTITY	Amount expressed in metric decimal units of the product included in the compound.	M	Mandatory
449-EE	COMPOUND INGREDIENT DRUG COST	Enter the ingredient drug cost for each product used in making the compound.	RW	Required when needed for receiver claim determination when multiple products are billed.
490-UE	COMPOUND INGREDIENT BASIS OF COST DETERMINATION	00 = Default 01 = AWP 02 = Local Wholesaler 03 = Direct 04 = EAC (Estimated Acquisition Cost) 05 = Acquisition 06 = MAC (Maximum Allowable Cost) 07 = Usual & Customary 08 = 340B/Disproportionate Share Pricing 09 = Other 10 = ASP (Average Sales Price) 11 = AMP (Average Manufacturer Price) 12 = WAC (Wholesale Acquisition Cost) 13 = Special Patient Pricing	M	Mandatory
362-2G	COMPOUND INGREDIENT MODIFIER CODE COUNT	Maximum count of 10.	RW	Required when Compound Ingredient Modifier Code (363-2H) is sent.
363-2H	COMPOUND INGREDIENT MODIFIER CODE	HCPCS	R	Required for this program.

Clinical Segment - Segment is situational; Segment may be required at a future date for B1 and B3 transactions when Designated Clinical Information is needed for drug coverage consideration; fields intentionally not listed.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
intentionally not listed	intentionally not listed	intentionally not listed	intentionally not listed	intentionally not listed

End of Request Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template

Start of Response Claim Billing/Claim Re-bill Accepted/Paid (or Duplicate of Paid)(B1/B3) Payer Sheet Template

General Information Column	Information
Payer Name:	New York EPIC
Date:	10/16/2014
Plan Name/Group Name:	New York EPIC
BIN:	012345
PCN:	P024012345
Processor:	Processor/Fiscal Intermediary
Effective as of:	10/18/2014
NCPDP Telecommunication Standard Version/Release #:	D.0
NCPDP Data Dictionary Version Date:	June 2010
NCPDP External Code List Version Date:	June 2010
Contact/Information Source:	Magellan Health Services — Albany, NY
Certification Testing Window:	TBD (to be determined)
Certification Contact Information:	804-217-7900
Provider Relations Help Desk Information:	866-254-1669
Other versions supported:	NCPDP Telecommunication version 5.1 until TBD

Claim Billing/Claim Re-bill Paid (or Duplicate of Paid) Response

The following lists the segments and fields in a Claim Billing or Claim Re-bill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0.

Response Transaction Header Segment - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
102-A2	VERSION/RELEASE NUMBER	D0	M	Mandatory
103-A3	TRANSACTION CODE	B1 B3	M	Mandatory
109-A9	TRANSACTION COUNT	Same value as in request	M	Mandatory
501-F1	HEADER RESPONSE STATUS	A = Accepted	M	Mandatory
202-B2	SERVICE PROVIDER ID QUALIFIER	Same value as in request	M	Mandatory
201-B1	SERVICE PROVIDER ID	Same value as in request	M	Mandatory
401-D1	DATE OF SERVICE	Same value as in request	M	Mandatory

Response Message Segment (111-AM = "20")- This segment is Situational. Provide general information when used for transmission-level messaging.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
504-F4	MESSAGE	Required when text is needed for clarification or detail.	RW	Required when text is needed for clarification or detail.

Response Insurance Segment (111-AM = "25") - This segment is situational.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
301-C1	GROUP ID	Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.	RW	Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.
524-FO	PLAN ID	Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.	RW	Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.
545-2F	NETWORK REIMBURSEMENT ID	Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.	RW	Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.
568-J7	PAYER ID QUALIFIER	Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.	RW	Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.
569-J8	PAYER ID	Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.	RW	Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.
302-C2	CARDHOLDER ID	Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.	RW	Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available.

Patient Segment (111-AM="29") - This segment is situational.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
310-CA	PATIENT FIRST NAME	Required when known.	RW	Required when known.
311-CB	PATIENT LAST NAME	Required when known.	RW	Required when known.
304-C4	DATE OF BIRTH	Format = CCYYMMDD	RW	Required when known.

Response Status Segment (111-AM = "21") - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
112-AN	TRANSACTION RESPONSE STATUS	P = Paid D = Duplicate	M	Mandatory
503-F3	AUTHORIZATION NUMBER	Required when needed to identify the transaction.	RW	Required when needed to identify the transaction.
547-5F	APPROVED MESSAGE CODE COUNT	Maximum count of 5.	RW	Required when Approved Message Code (548-6F) is used.
548-6F	APPROVED MESSAGE CODE	Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity.	RW	Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity.
130-UF	ADDITIONAL MESSAGE INFORMATION COUNT	Maximum count of 25.	RW	Required when Additional Message Information (526-FQ) is used.
132-UH	ADDITIONAL MESSAGE INFORMATION QUALIFIER	Required when Additional Message Information (526-FQ) is used.	RW	Required when Additional Message Information (526-FQ) is used.
526-FQ	ADDITIONAL MESSAGE INFORMATION	Required when additional text is needed for clarification or detail.	RW	Required when additional text is needed for clarification or detail.
131-UG	ADDITIONAL MESSAGE INFORMATION CONTINUITY	Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQW) follows it, and the text of the following message is a continuation of the current.	RW	Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQW) follows it, and the text of the following message is a continuation of the current.
549-7F	HELP DESK PHONE NUMBER QUALIFIER	Required when Help Desk Phone Number (550-8F) is used.	RW	Required when Help Desk Phone Number (550-8F) is used.
550-8F	HELP DESK PHONE NUMBER	Required when needed to provide a support telephone number.	RW	Required when needed to provide a support telephone number.

Response Claim Segment (111-AM = "22") - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
455-EM	PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER	1 = Rx billing	M	Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing)
402-D2	PRESCRIPTION/ SERVICE REFERNCE NUMBER	Mandatory	M	Mandatory
551-9F	PREFERRED PRODUCT COUNT	Maximum count of 6.	RW	Required when Preferred Product ID (553-AR) is used.
552-AP	PREFERRED PRODUCT ID QUALIFIER	Required when Preferred Product ID (553-AR) is used.	RW	Required when Preferred Product ID (553-AR) is used.
553-AR	PREFERRED PRODUCT ID	Required when a product preference exists that needs to be communicated to the receiver via an ID.	RW	Required when a product preference exists that needs to be communicated to the receiver via an ID.
554-AS	PREFERRED PRODUCT INCENTIVE	Required when there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU).	RW	Required when there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU).
555-AT	PREFERRED PRODUCT COST SHARE INCENTIVE	Required when there is a known patient financial responsibility incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU).	RW	Required when there is a known patient financial responsibility incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU).
556-AU	PREFERRED PRODUCT DESCRIPTION	Required when a product preference exists that either cannot be communicated by the Preferred Product ID (553-AR) or to clarify the Preferred Product ID (553-AR).	RW	Required when a product preference exists that either cannot be communicated by the Preferred Product ID (553-AR) or to clarify the Preferred Product ID (553-AR).

Response Pricing Segment (111-AM = "23") - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
505-F5	PATIENT PAY AMOUNT	Required for this program.	R	Required for this program.
506-F6	INGREDIENT COST PAID	Required for this program.	R	Required for this program.
507-F7	DISPENSING FEE PAID	Required when this value is used to arrive at the final reimbursement.	RW	Required when this value is used to arrive at the final reimbursement.
557-AV	TAX EXEMPT INDICATOR	Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing.	RW	Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing.
558-AW	FLAT SALES TAX AMOUNT PAID	Required when Flat Sales Tax Amount Submitted (481-HA) is greater than zero (0) or when Flat Sales Tax Amount Paid (558-AW) is used to arrive at the final reimbursement.	RW	Required when Flat Sales Tax Amount Submitted (481-HA) is greater than zero (0) or when Flat Sales Tax Amount Paid (558-AW) is used to arrive at the final reimbursement.
559-AX	PERCENTAGE SALES TAX AMOUNT PAID	Required when this value is used to arrive at the final reimbursement. Required when Percentage Sales Tax Amount Submitted (482-GE) is greater than zero (0). Required when Percentage Sales Tax Rate Paid (560-AY) and Percentage Sales Tax Basis Paid (561-AZ) are used.	RW	Required when this value is used to arrive at the final reimbursement. Required when Percentage Sales Tax Amount Submitted (482-GE) is greater than zero (0). Required when Percentage Sales Tax Rate Paid (560-AY) and Percentage Sales Tax Basis Paid (561-AZ) are used.
560-AY	PERCENTAGE SALES TAX RATE PAID	Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0).	RW	Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0).
561-AZ	PERCENTAGE SALES TAX BASIS PAID	Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0).	RW	Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0).
521-FL	INCENTIVE AMOUNT PAID	Required when this value is used to arrive at the final reimbursement. Required when Incentive Amount Submitted (438-E3) is greater than zero (0).	RW	Required when this value is used to arrive at the final reimbursement. Required when Incentive Amount Submitted (438-E3) is greater than zero (0).
563-J2	OTHER AMOUNT PAID COUNT	Maximum count of 3.	RW	Required when Other Amount Paid (565-J4) is used.
564-J3	OTHER AMOUNT PAID QUALIFIER	Required when Other Amount Paid (565-J4) is used.	RW	Required when Other Amount Paid (565-J4) is used.
565-J4	OTHER AMOUNT PAID	Required when this value is used to arrive at the final reimbursement. Required when Other Amount Claimed Submitted (480-H9) is greater than zero (0).	RW	Required when this value is used to arrive at the final reimbursement. Required when Other Amount Claimed Submitted (480-H9) is greater than zero (0).
566-J5	OTHER PAYER AMOUNT RECOGNIZED	Required when this value is used to arrive at the final reimbursement. Required when Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported.	RW	Required when this value is used to arrive at the final reimbursement. Required when Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported.
509-F9	TOTAL AMOUNT PAID	Required for this program.	R	Required for this program.
522-FM	BASIS OF REIMBURSEMENT DETERMINATION	Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required when Basis of Cost Determination (432-DN) is submitted on billing.	RW	Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required when Basis of Cost Determination (432-DN) is submitted on billing.
523-FN	AMOUNT ATTRIBUTED TO SALES TAX	Required when Patient Pay Amount (505-F5) includes sales tax that is the financial responsibility of the member but is not also included in any of the other fields that add up to Patient Pay Amount.	RW	Required when Patient Pay Amount (505-F5) includes sales tax that is the financial responsibility of the member but is not also included in any of the other fields that add up to Patient Pay Amount.
512-FC	ACCUMULATED DEDUCTIBLE AMOUNT	Provided for informational purposes only.	RW	Provided for informational purposes only.
513-FD	REMAINING DEDUCTIBLE AMOUNT	Provided for informational purposes only.	RW	Provided for informational purposes only.
514-FE	REMAINING BENEFIT AMOUNT	Provided for informational purposes only.	RW	Provided for informational purposes only.
517-FH	AMOUNT APPLIED TO PERIODIC DEDUCTIBLE	Required when Patient Pay Amount (505-F5) includes deductible.	RW	Required when Patient Pay Amount (505-F5) includes deductible.
518-FI	AMOUNT OF COPAY/CO-INSURANCE	Required when Patient Pay Amount (5o5-F5) includes co-pay as patient financial responsibility.	RW	Required when Patient Pay Amount (5o5-F5) includes co-pay as patient financial responsibility.
520-FK	AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM	Required when Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum.	RW	Required when Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum.
346-HH	BASIS OF CALCULATION - DISPENSING FEE	Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill).	RW	Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill).
347-HJ	BASIS OF CALCULATION - COPAY	Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill).	RW	Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill).
348-HK	BASIS OF CALCULATION - FLAT SALES TAX	Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Flat Sales Tax Amount Paid (558-AW) is greater than zero (0).	RW	Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Flat Sales Tax Amount Paid (558-AW) is greater than zero (0).
349-HM	BASIS OF CALCULATION - PERCENTAGE SALES TAX	Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0).	RW	Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0).
571-NZ	AMOUNT ATTRIBUTED TO PROCESSOR FEE	Required when the customer is responsible for 100 percent of the prescription payment and when the provider net sale is less than the amount the customer is expected to pay.	RW	Required when the customer is responsible for 100 percent of the prescription payment and when the provider net sale is less than the amount the customer is expected to pay.
575-EQ	PATIENT SALES TAX AMOUNT	Required when necessary to identify the Patient's portion of the Sales Tax.	RW	Required when necessary to identify the Patient's portion of the Sales Tax.
574-2Y	PLAN SALES TAX AMOUNT	Required when necessary to identify the Plan's portion of the Sales Tax.	RW	Required when necessary to identify the Plan's portion of the Sales Tax.
572-4U	AMOUNT OF COINSURANCE	Required when Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility.	RW	Required when Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility.
573-4V	BASIS OF CALCULATION-COINSURANCE	Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill).	RW	Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill).
392-MU	BENEFIT STAGE COUNT	Maximum count of 4.	RW	Required when Benefit Stage Amount (394-MW) is used.
393-MV	BENEFIT STAGE QUALIFIER	Required when Benefit Stage Amount (394-MW) is used.	RW	Required when Benefit Stage Amount (394-MW) is used.
394-MW	BENEFIT STAGE AMOUNT	Required when a Medicare Part D payer applies financial amounts to Medicare Part D beneficiary benefit stages. This field is required when the plan is a participant in a Medicare Part D program that requires reporting of benefit stage specific financial amounts. Required when necessary for state/federal/regulatory agency programs.	RW	Required when a Medicare Part D payer applies financial amounts to Medicare Part D beneficiary benefit stages. This field is required when the plan is a participant in a Medicare Part D program that requires reporting of benefit stage specific financial amounts. Required when necessary for state/federal/regulatory agency programs.
577-G3	ESTIMATED GENERIC SAVINGS	Required when a patient selected the brand drug and a generic form of the drug was available. It will contain an estimate of the difference between the cost of the brand drug and the generic drug, when the brand drug is more expensive than the generic.	RW	Required when a patient selected the brand drug and a generic form of the drug was available. It will contain an estimate of the difference between the cost of the brand drug and the generic drug, when the brand drug is more expensive than the generic.
128-UC	SPENDING ACCOUNT AMOUNT REMAINING	This dollar amount will be provided, when known, to the receiver when the transaction had spending account dollars reported as part of the patient pay amount.	RW	This dollar amount will be provided, when known, to the receiver when the transaction had spending account dollars reported as part of the patient pay amount.
129-UD	HEALTH PLAN-FUNDED ASSISTANCE AMOUNT	Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero.	RW	Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero.
133-UJ	AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION	Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a cost share differential due to the selection of one pharmacy over another.	RW	Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a cost share differential due to the selection of one pharmacy over another.
134-UK	AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG	Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug.	RW	Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug.
135-UM	AMOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORMULARY SELECTION	Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a non-preferred formulary product.	RW	Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a non-preferred formulary product.
136-UN	AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NON-PREFERRED FORMULARY SELECTION	Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand non-preferred formulary product.	RW	Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand non-preferred formulary product.
137-UP	AMOUNT ATTRIBUTED TO COVERAGE GAP	Required when the patient's financial responsibility is due to the coverage gap.	RW	Required when the patient's financial responsibility is due to the coverage gap.
148-U8	INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT	Required when Basis of Reimbursement Determination (522-FM) is "14" (Patient Responsibility Amount) or "15" (Patient Pay Amount) unless prohibited by state/federal/regulatory agency.	RW	Required when Basis of Reimbursement Determination (522-FM) is "14" (Patient Responsibility Amount) or "15" (Patient Pay Amount) unless prohibited by state/federal/regulatory agency.
149-U9	DISPENSING FEE CONTRACTED/REIMBURSABLE AMOUNT	Required when Basis of Reimbursement Determination (522-FM) is "14" (Patient Responsibility Amount) or "15" (Patient Pay Amount) unless prohibited by state/federal/regulatory agency.	RW	Required when Basis of Reimbursement Determination (522-FM) is "14" (Patient Responsibility Amount) or "15" (Patient Pay Amount) unless prohibited by state/federal/regulatory agency.

Response DUR / PPS Segment (111-AM = "24") - This segment is situational.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
567-J6	DUR/ PPS RESPONSE CODE COUNTER	Maximum of 9 occurrences.	RW	Required when Reason For Service Code (439-E4) is used.
439-E4	REASON FOR SERVICE CODE	Required when utilization conflict is detected.	RW	Required when utilization conflict is detected.
528-FS	CLINICAL SIGNIFICANCE CODE	Required when needed to supply additional information for the utilization conflict.	RW	Required when needed to supply additional information for the utilization conflict.
529-FT	OTHER PHARMACY INDICATOR	Required when needed to supply additional information for the utilization conflict.	RW	Required when needed to supply additional information for the utilization conflict.
530-FU	PREVIOUS DATE OF FILL	Required when Quantity of Previous Fill (531-FV) is used.	RW	Required when Quantity of Previous Fill (531-FV) is used.
531-FV	QUANTITY OF PREVIOUS FILL	Required when Previous Date Of Fill (530-FU) is used.	RW	Required when Previous Date Of Fill (530-FU) is used.
532-FW	DATABASE INDICATOR	Required when needed to supply additional information for the utilization conflict.	RW	Required when needed to supply additional information for the utilization conflict.
533-FX	OTHER PRESCRIBER INDICATOR	Required when needed to supply additional information for the utilization conflict.	RW	Required when needed to supply additional information for the utilization conflict.
544-FY	DUR FREE TEXT MESSAGE	Required when needed to supply additional information for the utilization conflict.	RW	Required when needed to supply additional information for the utilization conflict.
570-NS	DUR ADDITIONAL TEXT	Required when needed to supply additional information for the utilization conflict.	RW	Required when needed to supply additional information for the utilization conflict.

Response COB / Other Payers Segment (111-AM = "28") - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
355-NT	OTHER PAYER ID COUNT	Maximum count of 3.	M	Mandatory
338-5C	OTHER PAYER COVERAGE TYPE	Mandatory	M	Mandatory
339-6C	OTHER PAYER ID QUALIFIER	Required when Other Payer ID (340-7C) is used.	RW	Required when Other Payer ID (340-7C) is used.
340-7C	OTHER PAYER ID	Required when other insurance information is available for coordination of benefits.	RW	Required when other insurance information is available for coordination of benefits.
991-MH	OTHER PAYER PROCESSOR CONTROL NUMBER	Required when other insurance information is available for coordination of benefits.	RW	Required when other insurance information is available for coordination of benefits.
356-NU	OTHER PAYER CARDHOLDER ID	Required when other insurance information is available for coordination of benefits.	RW	Required when other insurance information is available for coordination of benefits.
992-MJ	OTHER PAYER GROUP ID	Required when other insurance information is available for coordination of benefits.	RW	Required when other insurance information is available for coordination of benefits.
142-UV	OTHER PAYER PERSON CODE	Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer.	RW	Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer.
127-UB	OTHER PAYER HELP DESK PHONE NUMBER	Required when needed to provide a support telephone number of the other payer to the receiver.	RW	Required when needed to provide a support telephone number of the other payer to the receiver.
143-UW	OTHER PAYER PATIENT RELATIONSHIP CODE	Required when needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer.	RW	Required when needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer.
144-UX	OTHER PAYER BENEFIT EFFECTIVE DATE	Required when other coverage is known, which is after the Date of Service submitted.	RW	Required when other coverage is known, which is after the Date of Service submitted.
145-UY	OTHER PAYER BENEFIT TERMINATION DATE	Required when other coverage is known, which is after the Date of Service submitted.	RW	Required when other coverage is known, which is after the Date of Service submitted.

End of Response Claim Billing/Claim Re-bill Accepted/Paid (or Duplicate of Paid)(B1/B3) Payer Sheet Template

Start of Request Claim Reversal (B2) Payer Sheet Template

General Information Column	Information
Payer Name:	New York EPIC
Date:	10/16/2014
Plan Name/Group Name:	New York EPIC
BIN:	012345
PCN:	P024012345
Processor:	Processor/Fiscal Intermediary
Effective as of:	10/18/2014
NCPDP Telecommunication Standard Version/Release #:	D.0
Contact/Information Source:	Magellan Health Services — Albany, NY
Certification Contact Information:	804-217-7900
Provider Relations Help Desk Information:	866-254-1669
Reversal Window (If transaction is billed today, what is the timeframe for reversal to be submitted?):	365 days

Claim Reversal Transaction

The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0.

Transaction Header Segment - This segment is always sent. Source of certification IDs required in Software Vendor/Certification ID (110-AK) is Payer Issued.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
101-A1	BIN NUMBER	012345	M	012345 — New York EPIC
102-A2	VERSION/RELEASE NUMBER	D.0	M	Mandatory
103-A3	TRANSACTION CODE	B2 Reversal	M	Mandatory
104-A4	PROCESSOR CONTROL NUMBER	P024012345	M	Mandatory
109-A9	TRANSACTION COUNT	Mandatory	M	Mandatory
202-B2	SERVICE PROVIDER ID QUALIFIER	01 = National Provider Identifier (NPI)	M	Mandatory
201-B1	SERVICE PROVIDER ID	National Provider Identifier (NPI)	M	Mandatory
401-D1	DATE OF SERVICE	Format = CCYYMMDD	M	Mandatory
110-AK	SOFTWARE VENDOR/CERTIFICATION ID	Assigned by Magellan Health Services.	M	Assigned by Magellan Health Services.

Insurance Segment (111-AM="04") - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
302-C2	CARDHOLDER ID	EPIC Cardholder ID	M	NY EPIC Number <patient specific> Format = EPNNNNNNN
301-C1	GROUP ID	NY EPIC	RW	Required when needed to match the reversal to the original billing transaction

Claim Segment (111-AM = "07") - This segment is always sent and the Payer supports partial fills.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
455-EM	PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER	1 = Rx billing	M	For Transaction Code of "B2", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing).
402-D2	PRESCRIPTION/SERVICE REFERENCE NUMBER	Mandatory	M	Mandatory
436-E1	PRODUCT/SERVICE ID QUALIFIER	00 = Compound 03 = National Drug Code (NDC)	M	If reversal is for multi-ingredient prescription, the value must be 00.
407-D7	PRODUCT/SERVICE ID	NDC - for non-compound claims '0' - for compound claims	M	Mandatory

Pricing Segment (111-AM = "11") - This segment is always sent; intentionally not listed.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
intentionally not listed	intentionally not listed	intentionally not listed	intentionally not listed	intentionally not listed

Coordination of Benefits/Other Payments Segment (111-AM = "05") - This segment is situational; intentionally not listed.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
intentionally not listed	intentionally not listed	intentionally not listed	intentionally not listed	intentionally not listed

DUR/PPS Segment (111-AM = "08") - This segment is situational; intentionally not listed.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
intentionally not listed	intentionally not listed	intentionally not listed	intentionally not listed	intentionally not listed

End of Request Claim Reversal (B2) Payer Sheet Template

Start of Response Claim Reversal (B2) Accepted/Approved Payer Sheet Template

Claim Reversal Accepted/Approved Response

The following lists the segments and fields in a Claim Reversal Response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0.

Transaction Header Segment - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
102-A2	VERSION/RELEASE NUMBER	D.0	M	Mandatory
103-A3	TRANSACTION CODE	B2 Reversal	M	Mandatory
109-A9	TRANSACTION COUNT	Same value as in request	M	Mandatory
501-F1	HEADER RESPONSE STATUS	A = Accepted	M	Mandatory
202-B2	SERVICE PROVIDER ID QUALIFIER	Same value as in request	M	Mandatory
201-B1	SERVICE PROVIDER ID	Same value as in request	M	Mandatory
401-D1	DATE OF SERVICE	Same value as in request Format = CCYYMMDD	M	Mandatory

Response Message Segment (111-AM = "20")- This segment is Situational. Provide general information when used for transmission-level messaging.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
504-F4	MESSAGE	Required when text is needed for clarification or detail.	RW	Required when text is needed for clarification or detail.

Response Status Segment (111-AM = "21") - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
112-AN	TRANSACTION RESPONSE STATUS	A = Approved	M	Mandatory
503-F3	AUTHORIZATION NUMBER	Required when needed to identify the transaction.	RW	Required when needed to identify the transaction.
547-5F	APPROVED MESSAGE CODE COUNT	Maximum count of 5.	RW***	Required when Approved Message Code (548-6F) is used.
548-6F	APPROVED MESSAGE CODE	Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity.	RW***	Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity.
130-UF	ADDITIONAL MESSAGE INFORMATION COUNT	Maximum count of 25.	RW***	Required when Additional Message Information (526-FQ) is used.
132-UH	ADDITIONAL MESSAGE INFORMATION QUALIFIER	Required when Additional Message Information (526-FQ) is used.	RW***	Required when Additional Message Information (526-FQ) is used.
526-FQ	ADDITIONAL MESSAGE INFORMATION	Required when additional text is needed for clarification or detail.	RW***	Required when additional text is needed for clarification or detail.
131-UG	ADDITIONAL MESSAGE INFORMATION CONTINUITY	Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.	RW***	Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
549-7F	HELP DESK PHONE NUMBER QUALIFIER	Required when Help Desk Phone Number (550-8F) is used.	RW	Required when Help Desk Phone Number (550-8F) is used.
550-8F	HELP DESK PHONE NUMBER	Required when needed to provide a support telephone number.	RW	Required when needed to provide a support telephone number.

Response Claim Segment (111-AM = "22") - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
455-EM	PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER	1 = Rx billing	M	Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing)
402-D2	PRESCRIPTION/ SERVICE REFERNCE NUMBER	Mandatory	M	Mandatory

Response Pricing Segment (111-AM = "23") - This segment is situational.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
509-F9	TOTAL AMOUNT PAID	Required when any other payment fields sent by the sender.	RW	Required when any other payment fields sent by the sender.

End of Response Claim Reversal (B2) Accepted/Approved Payer Sheet Template

Start of Response Claim Reversal (B2) Accepted/Rejected Payer Sheet Template

Claim Reversal Accepted/Rejected Response

Transaction Header Segment - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
102-A2	VERSION/RELEASE NUMBER	D.0	M	Mandatory
103-A3	TRANSACTION CODE	B2 = Reversal	M	Mandatory
109-A9	TRANSACTION COUNT	Same value as in request	M	Mandatory
501-F1	HEADER RESPONSE STATUS	A = Accepted	M	Mandatory
202-B2	SERVICE PROVIDER ID QUALIFIER	01 = National Provider Identifier	M	Mandatory
201-B1	SERVICE PROVIDER ID	Same value as in request	M	Mandatory
401-D1	DATE OF SERVICE	Same value as in request Format = CCYYMMDD	M	Mandatory

Response Message Segment (111-AM = "20")- This segment is Situational.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
504-F4	MESSAGE	Required when text is needed for clarification or detail.	RW	Required when text is needed for clarification or detail.

Response Status Segment (111-AM = "21") - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
112-AN	TRANSACTION RESPONSE STATUS	R = Rejected	M	Mandatory
503-F3	AUTHORIZATION NUMBER	Required for this program.	R	Required for this program.
510-FA	REJECT COUNT	Maximum count of 5.	R	Required for this program.
511-FB	REJECT CODE	Required for this program.	R	Required for this program.
546-4F	REJECT FIELD OCCURRENCE INDICATOR	Required when a repeating field is in error, to identify repeating field occurrence.	RW***	Required when a repeating field is in error, to identify repeating field occurrence.
130-UF	ADDITIONAL MESSAGE INFORMATION COUNT	Maximum count of 25.	RW***	Required when Additional Message Information (526-FQ) is used.
132-UH	ADDITIONAL MESSAGE INFORMATION QUALIFIER	Required when Additional Message Information (526-FQ) is used.	RW***	Required when Additional Message Information (526-FQ) is used.
526-FQ	ADDITIONAL MESSAGE INFORMATION	Required when additional text is needed for clarification or detail.	RW***	Required when additional text is needed for clarification or detail.
131-UG	ADDITIONAL MESSAGE INFORMATION CONTINUITY	Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.	RW***	Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
549-7F	HELP DESK PHONE NUMBER QUALIFIER	Required when Help Desk Phone Number (550-8F) is used.	RW	Required when Help Desk Phone Number (550-8F) is used.
550-8F	HELP DESK PHONE NUMBER	Required when needed to provide a support telephone number.	RW	Required when needed to provide a support telephone number.

Response Claim Segment (111-AM = "22") - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
455-EM	PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER	1 = Rx billing	M	Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing)
402-D2	PRESCRIPTION/ SERVICE REFERNCE NUMBER	Mandatory	M	Mandatory

End of Response Claim Reversal (B2) Accepted/Rejected Payer Sheet Template

Start of Response Claim Reversal (B2) Rejected/Rejected Payer Sheet Template

Claim Reversal Rejected/Rejected Response

Transaction Header Segment - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
102-A2	VERSION/RELEASE NUMBER	D.0	M	Mandatory
103-A3	TRANSACTION CODE	B2 = Reversal	M	Mandatory
109-A9	TRANSACTION COUNT	Same value as in request	M	Mandatory
501-F1	HEADER RESPONSE STATUS	A = Accepted	M	Mandatory
202-B2	SERVICE PROVIDER ID QUALIFIER	01 = National Provider Identifier	M	Mandatory
201-B1	SERVICE PROVIDER ID	Same value as in request	M	Mandatory
401-D1	DATE OF SERVICE	Same value as in request Format = CCYYMMDD	M	Mandatory

Response Message Segment (111-AM = "20")- This segment is Situational.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
504-F4	MESSAGE	Required when text is needed for clarification or detail.	RW	Required when text is needed for clarification or detail.

Response Status Segment (111-AM = "21") - This segment is always sent.

Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
112-AN	TRANSACTION RESPONSE STATUS	R = Rejected	M	Mandatory
503-F3	AUTHORIZATION NUMBER	Required for this program.	R	Required for this program.
510-FA	REJECT COUNT	Maximum count of 5.	R	Required for this program.
511-FB	REJECT CODE	Required for this program.	R	Required for this program.
546-4F	REJECT FIELD OCCURRENCE INDICATOR	Required when a repeating field is in error, to identify repeating field occurrence.	RW***	Required when a repeating field is in error, to identify repeating field occurrence.
130-UF	ADDITIONAL MESSAGE INFORMATION COUNT	Maximum count of 25.	RW***	Required when Additional Message Information (526-FQ) is used.
132-UH	ADDITIONAL MESSAGE INFORMATION QUALIFIER	Required when Additional Message Information (526-FQ) is used.	RW***	Required when Additional Message Information (526-FQ) is used.
526-FQ	ADDITIONAL MESSAGE INFORMATION	Required when additional text is needed for clarification or detail.	RW***	Required when additional text is needed for clarification or detail.
131-UG	ADDITIONAL MESSAGE INFORMATION CONTINUITY	Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.	RW***	Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
549-7F	HELP DESK PHONE NUMBER QUALIFIER	Required when Help Desk Phone Number (550-8F) is used.	RW	Required when Help Desk Phone Number (550-8F) is used.
550-8F	HELP DESK PHONE NUMBER	Required when needed to provide a support telephone number.	RW	Required when needed to provide a support telephone number.

End of Response Claim Reversal (B2) Rejected/Rejected Payer Sheet Template