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 Billing/Accepted/RejectedPayer Situation142-UV OTHER PAYER PERSON CODE RW Imp Guide: Required if needed touniquely identify the family memberswithin the Cardholder ID, as assignedby the other payer.127-UBOTHER PAYER HELP DESKPHONE 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 needed toprovide a support telephone number ofthe other payer to the receiver.Payer Requirement: The 4Rx datasubmitted on the claim must beupdated this field maybe returned orwhen available Medicare D OHI Datamay be returned.CLAIM BILLING REJECTED/REJECTED RESPONSEResponse Transaction Header Segment Questions Check Claim BillingRejected/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 R M2Ø2-B2 SERVICE PROVIDER IDSame value as in request MQUALIFIER2Ø1-B1 SERVICE PROVIDER ID Same value as in request M4Ø1-D1 DATE OF SERVICE Same value as in request MClaim BillingRejected/RejectedPayer SituationResponse Message Segment Questions Check Claim BillingRejected/RejectedIf Situational, Payer SituationThis Segment is always sentThis Segment is situationalX“Materials Reproduced With the Consent of©National Council for Prescription Drug Programs, Inc.2008 NCPDP”29