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

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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
Medco100 Parsons Pond DriveFranklin Lakes, NJ 07417Response Coordination ofBenefits/Other Payers SegmentSegment Identification (111-AM) =“28”Field # NCPDP Field Name Value PayerUsage127-UB OTHER PAYER HELP DESKRWPHONE NUMBERClaim BillingAccepted/Paid (or Duplicate of Paid)Payer SituationImp Guide: Required if needed toprovide a support telephone number ofthe other payer to the receiver.Payer Requirement: When availableand required, 4Rx (Primary) orMedicare D OHI Data may be returnedon a claim response.CLAIM BILLING/ACCEPTED/REJECTED RESPONSEResponse Transaction Header Segment Questions Check Claim Billing/Claim Rebill Accepted/RejectedIf Situational, Payer SituationThis Segment is always sentXResponse Transaction HeaderSegmentField # NCPDP Field Name Value PayerUsage1Ø2-A2 VERSION/RELEASE NUMBER DØ M1Ø3-A3 TRANSACTION CODE B1 M1Ø9-A9 TRANSACTION COUNT Same value as in request M5Ø1-F1 HEADER RESPONSE STATUS A M2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Same value as in request M2Ø1-B1 SERVICE PROVIDER ID Same value as in request M4Ø1-D1 DATE OF SERVICE Same value as in request MClaim BillingAccepted/RejectedPayer SituationResponse Message Segment Questions Check Claim Billing/Claim Rebill Accepted/RejectedIf Situational, Payer SituationThis Segment is always sentThis Segment is situational X Provided when additional message textResponse Message SegmentSegment Identification (111-AM) =“2Ø”Field # NCPDP Field Name Value PayerUsageClaim BillingAccepted/RejectedPayer Situation5Ø4-F4 MESSAGE Imp Guide: Required if text isneeded for clarification or detail.Response Insurance Segment Questions Check Claim Billing Accepted/RejectedIf Situational, Payer SituationThis Segment is always sentXThis Segment is situational“Materials Reproduced With the Consent of©National Council for Prescription Drug Programs, Inc.2008 NCPDP”23
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Medco Version D.0 Medicare Part D Payer Sheet - Express Scripts

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