Medco Version D.0 Medicare Part D Payer Sheet - Express Scripts
Medco Version D.0 Medicare Part D Payer Sheet - Express Scripts
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 <strong>Payer</strong>Usage132-UH526-FQ131-UGADDITIONAL MESSAGEINFORMATION QUALIFIERADDITIONAL MESSAGEINFORMATIONADDITIONAL MESSAGEINFORMATION CONTINUITY549-7F HELP DESK PHONE NUMBERQUALIFIERØ1- Ø9 = Free-Form Text1Ø = Next Available FillDate (CCYYMMDD)RWRWRWRW<strong>Medco</strong>100 Parsons Pond DriveFranklin Lakes, NJ 07417Claim Billing Accepted/Rejected<strong>Payer</strong> SituationImp Guide: Required if AdditionalMessage Information (526-FQ) isused.Imp Guide: Required whenadditional text is needed forclarification or detail.Imp Guide: Required if and only ifcurrent repetition of AdditionalMessage Information (526-FQ) isused, another populated repetitionof Additional Message Information(526-FQ) follows it, and the text ofthe following message is acontinuation of the current.Imp 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 telephonenumber.987-MA URL RW Imp Guide: Provided forinformational purposes only to relayhealthcare communications via theInternet.<strong>Payer</strong> Requirement: Will returnhttp://www.expressscripts.com/services/pharmacistsResponse Claim Segment Questions Check Claim Billing Accepted/RejectedIf Situational, <strong>Payer</strong> SituationThis Segment is always sentXResponse Claim SegmentSegment Identification (111-AM) =“22”Field # NCPDP Field Name Value <strong>Payer</strong>Usage455-EMPRESCRIPTION/SERVICEREFERENCE NUMBER QUALIFIERClaim BillingAccepted/Paid (or Duplicate ofPaid)<strong>Payer</strong> Situation1 M Imp Guide: For Transaction Codeof “B1”, in the Response ClaimSegment, the Prescription/ServiceReference Number Qualifier (455-EM) is “1” (Rx Billing).M4Ø2-D2 PRESCRIPTION/SERVICEREFERENCE NUMBER551-9F PREFERRED PRODUCT COUNT Maximum count of 6. RW Imp Guide: Required if PreferredProduct ID (553-AR) is used.552-APPREFERRED PRODUCT IDQUALIFIERRWImp Guide: Required if PreferredProduct ID (553-AR) is used.“Materials Reproduced With the Consent of©National Council for Prescription Drug Programs, Inc.2008 NCPDP”25
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