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

Medco100 Parsons Pond DriveFranklin Lakes, NJ 07417Response Coordination of Benefits/Other Payers Check Claim Billing Accepted/RejectedSegment QuestionsIf Situational, Payer SituationThis Segment is situational X When 4Rx or Medicare OHI data availableResponse Coordination ofBenefits/Other Payers SegmentSegment Identification (111-AM) =“28”Field # NCPDP Field Name Value PayerUsageClaim Billing/Accepted/RejectedPayer Situation355-NT OTHER PAYER ID COUNT Maximum count of 3. M338-5C OTHER PAYER COVERAGE TYPE M339-6C OTHER PAYER ID QUALIFIER 03 (BIN Number) RW Imp Guide: Required if Other Payer ID(34Ø-7C) is used.Payer Requirement: The 4Rx datasubmitted on the claim must beupdated this field maybe returned orwhen available Medicare D OHI Datamay be returned.34Ø-7C OTHER PAYER ID RW Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.991-MHOTHER PAYER PROCESSORCONTROL NUMBERRWPayer Requirement: The 4Rx datasubmitted on the claim must beupdated this field maybe returned orwhen available Medicare D OHI Datamay be returned.Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.Payer Requirement: The 4Rx datasubmitted on the claim must beupdated this field maybe returned orwhen available Medicare D OHI Datamay be returned.356-NU OTHER PAYER CARDHOLDER ID RW Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.Payer Requirement: The 4Rx datasubmitted on the claim must beupdated this field maybe returned orwhen available Medicare D OHI Datamay be returned.992-MJ OTHER PAYER GROUP ID RW Imp Guide: Required if other insuranceinformation is available for coordinationof benefits.Payer Requirement: The 4Rx datasubmitted on the claim must beupdated this field maybe returned orwhen available Medicare D OHI Datamay be returned.“Materials Reproduced With the Consent of©National Council for Prescription Drug Programs, Inc.2008 NCPDP”28