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

Medco100 Parsons Pond DriveFranklin Lakes, NJ 07417Response Pricing SegmentSegment Identification (111-AM)= “23”Field # NCPDP Field Name Value PayerUsage135-UM AMOUNT ATTRIBUTED TORWPRODUCT SELECTION/NON-PREFERRED FORMULARYSELECTIONClaim BillingAccepted/Paid (or Duplicate ofPaid)Payer SituationImp Guide: Required if Patient PayAmount (5Ø5-F5) includes anamount that is attributable to apatient’s selection of a non-preferredformulary product.136-UNAMOUNT ATTRIBUTED TOPRODUCT SELECTION/BRANDNON-PREFERRED FORMULARYSELECTIONRWImp Guide: Required if Patient PayAmount (5Ø5-F5) includes anamount that is attributable to apatient’s selection of a Brand nonpreferredformulary product.137-UPAMOUNT ATTRIBUTED TOCOVERAGE GAPRWImp Guide: Required when thepatient’s financial responsibility isdue to the coverage gap.566-J5 OTHER PAYER AMOUNTRECOGNIZEDImp Guide: Required if this value isused to arrive at the finalreimbursement.Required if Other Payer AmountPaid (431-DV) is greater than zero(Ø) and Coordination ofBenefits/Other Payments Segmentis supported.*Only available for use on claims with fill dates of 12/31/2012 and prior.**Benefit Stage Qualifier (393-MV) values 61 or 62 replace value of 6Ø. Available for use as of 1/1/13.*** Available for use as of 1/1/13.Check Claim BillingResponse DUR/PPS Segment QuestionsAccepted/Paid (or Duplicate of Paid)If Situational, Payer SituationThis Segment is always sentThis Segment is situational X When DUR Information to be providedResponse DUR/PPS SegmentSegment Identification (111-AM) =“24”Field # NCPDP Field Name Value PayerUsage567-J6 DUR/PPS RESPONSE CODECOUNTERMaximum 9 occurrencessupported.RWClaim BillingAccepted/Paid (or Duplicate ofPaid)Payer SituationImp Guide: Required if ReasonFor Service Code (439-E4) isused.439-E4 REASON FOR SERVICE CODE RW Imp Guide: Required if utilizationconflict is detected.“Materials Reproduced With the Consent of©National Council for Prescription Drug Programs, Inc.2008 NCPDP”20