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

Response Coordination ofBenefits/Other Payers SegmentSegment Identification (111-AM) =“28”Field # NCPDP Field Name Value PayerUsageMedco100 Parsons Pond DriveFranklin Lakes, NJ 07417Claim BillingAccepted/Paid (or Duplicate of Paid)Payer Situation339-6C OTHER PAYER ID QUALIFIER RW Imp Guide: Required if Other Payer ID(34Ø-7C) is used.Payer Requirement: When availableand required, 4Rx (Primary) orMedicare D OHI Data may be returnedon a claim response.34Ø-7C OTHER PAYER ID RW Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.991-MHOTHER PAYER PROCESSORCONTROL NUMBERRWPayer Requirement: When availableand required, 4Rx (Primary) orMedicare D OHI Data may be returnedon a claim response.Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.Payer Requirement: When availableand required, 4Rx (Primary) orMedicare D OHI Data may be returnedon a claim response.356-NU OTHER PAYER CARDHOLDER ID RW Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.Payer Requirement: When availableand required, 4Rx (Primary) orMedicare D OHI Data may be returnedon a claim response.992-MJ OTHER PAYER GROUP ID RW Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.Payer Requirement: When availableand required, 4Rx (Primary) orMedicare D OHI Data may be returnedon a claim response.142-UV OTHER PAYER PERSON CODE RW Imp Guide: Required if needed touniquely identify the family memberswithin the Cardholder ID, as assignedby the other payer.Payer Requirement: When availableand required, 4Rx (Primary) orMedicare D OHI Data may be returnedon a claim response.“Materials Reproduced With the Consent of©National Council for Prescription Drug Programs, Inc.2008 NCPDP”22