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

Response Insurance SegmentSegment Identification (111-AM) =“25”Field # NCPDP Field Name Value PayerUsageMedco100 Parsons Pond DriveFranklin Lakes, NJ 07417Claim BillingAccepted/RejectedPayer Situation3Ø1-C1 GROUP ID RW Imp Guide: Required if needed toidentify the actual cardholder oremployer group, to identifyappropriate group number, whenavailable.Required to identify the actual groupthat was used when multiple groupcoverage exist.545-2F NETWORK REIMBURSEMENT ID RW Imp Guide: Required if needed toidentify the network for the coveredmember.Required if needed to identify theactual Network Reimbursement ID,when applicable and/or available.Required to identify the actualNetwork Reimbursement ID thatwas used when multiple NetworkReimbursement IDs exist.3Ø2-C2 CARDHOLDER ID RW Imp Guide: Required if theidentification to be used in futuretransactions is different than whatwas submitted on the request.Response Status Segment Questions Check Claim BillingAccepted/RejectedIf Situational, Payer SituationThis Segment is always sentXResponse Status SegmentSegment Identification (111-AM) =“21”Field # NCPDP Field Name Value PayerUsage112-AN TRANSACTION RESPONSER = RejectMSTATUS51Ø-FA REJECT COUNT Maximum count of 5 R511-FB REJECT CODE R546-4F REJECT FIELD OCCURRENCERWINDICATOR13Ø-UFADDITIONAL MESSAGEINFORMATION COUNTClaim Billing Accepted/RejectedPayer SituationImp Guide: Required if a repeatingfield is in error, to identify repeatingfield occurrenceMaximum count of 9 RW Imp Guide: Required if AdditionalMessage Information (526-FQ) isused.“Materials Reproduced With the Consent of©National Council for Prescription Drug Programs, Inc.2008 NCPDP”24