Medco Version D.0 Medicare Part D Payer Sheet - Express Scripts

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Response Status SegmentSegment Identification (111-AM) =“21”Field # NCPDP Field Name Value PayerUsageMedco100 Parsons Pond DriveFranklin Lakes, NJ 07417Claim BillingAccepted/Paid (or Duplicate ofPaid)Payer Situation548-6F APPROVED MESSAGE CODE RW Imp Guide: Required if ApprovedMessage Code Count (547-5F) isused and the sender needs tocommunicate additional follow up fora potential opportunity.13Ø-UFADDITIONAL MESSAGEINFORMATION COUNTMaximum count of 9. RW Imp Guide: Required if AdditionalMessage Information (526-FQ) isused.132-UHADDITIONAL MESSAGEINFORMATION QUALIFIERØ1-Ø9 = Free Form Text1Ø = Next Available FillDate (CCYYMMDDRWImp Guide: Required if AdditionalMessage Information (526-FQ) isused.526-FQADDITIONAL MESSAGEINFORMATIONRWImp Guide: Required when additionaltext is needed for clarification ordetail.131-UGADDITIONAL MESSAGEINFORMATION CONTINUITYRWImp Guide: Required if and only ifcurrent repetition of AdditionalMessage Information (526-FQ) isused, another populated repetition ofAdditional Message Information (526-FQ) follows it, and the text of thefollowing message is a continuation ofthe current.549-7F HELP DESK PHONE NUMBERQUALIFIERRWImp Guide: Required if Help DeskPhone Number (55Ø-8F) is used.55Ø-8F HELP DESK PHONE NUMBER RW Imp Guide: Required if needed toprovide a support telephone numberto the receiver.Response Claim Segment Questions Check Claim BillingAccepted/Paid (or Duplicate of Paid)If Situational, Payer SituationThis Segment is always sentXResponse Claim SegmentSegment Identification (111-AM) =“22”Field # NCPDP Field Name Value PayerUsage455-EM PRESCRIPTION/SERVICEMREFERENCE NUMBER QUALIFIER4Ø2-D2PRESCRIPTION/SERVICEREFERENCE NUMBERM“Materials Reproduced With the Consent of©National Council for Prescription Drug Programs, Inc.2008 NCPDP”Claim BillingAccepted/Paid (or Duplicate ofPaid)Payer SituationImp Guide: For Transaction Code of“B1”, in the Response ClaimSegment, the Prescription/ServiceReference Number Qualifier (455-EM)is “1” (Rx Billing).14
Response Claim SegmentSegment Identification (111-AM) =“22”Field # NCPDP Field Name Value PayerUsageMedco100 Parsons Pond DriveFranklin Lakes, NJ 07417Claim BillingAccepted/Paid (or Duplicate ofPaid)Payer Situation551-9F PREFERRED PRODUCT COUNT Maximum count of 6. RW Imp Guide: Required if PreferredProduct ID (553-AR) is used.Payer Requirement: Based on benefitand when preferred alternative areavailable for the submitted productservice ID.552-APPREFERRED PRODUCT IDQUALIFIERRWImp Guide: Required if PreferredProduct ID (553-AR) is used.553-AR PREFERRED PRODUCT ID RW Imp Guide: Required if a productpreference exists that needs to becommunicated to the receiver via anID.556-AUPREFERRED PRODUCTDESCRIPTIONRWImp Guide: Required if a productpreference exists that either cannotbe communicated by the PreferredProduct ID (553-AR) or to clarify thePreferred Product ID (553-AR).Response Pricing Segment Questions Check Claim BillingAccepted/Paid (or Duplicate of Paid)If Situational, Payer SituationThis Segment is always sentXResponse Pricing SegmentSegment Identification (111-AM)= “23”Field # NCPDP Field Name Value PayerUsageClaim BillingAccepted/Paid (or Duplicate ofPaid)Payer Situation5Ø5-F5 PATIENT PAY AMOUNT R5Ø6-F6 INGREDIENT COST PAID R5Ø7-F7 DISPENSING FEE PAID R Imp Guide: Required if this value isused to arrive at the finalreimbursement.557-AV TAX EXEMPT INDICATOR R Imp Guide: Required if the sender(health plan) and/or patient is taxexempt and exemption applies tothis billing.558-AW FLAT SALES TAX AMOUNT PAID RW Imp Guide: Required if Flat SalesTax Amount Submitted (481-HA) isgreater than zero (Ø) or if Flat SalesTax Amount Paid (558-AW) is usedto arrive at the final reimbursement.“Materials Reproduced With the Consent of©National Council for Prescription Drug Programs, Inc.2008 NCPDP”15
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Medco Version D.0 Medicare Part D Payer Sheet - Express Scripts

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