Medco Version 5.1 Payer Sheet January 2006 Use when submitting ...

Medco Health Solutions, Inc.100 Parsons Pond DriveFranklin Lakes, NJ 07417www.medco.com/rph1 800-922-1557Medco Version 5.1 Payer Sheet January 2006Use when submitting non-primary claims for Medicare patients whengroups require the COB SegmentPart I: General InformationPayer Name: Medco (formerly known as Medco Health Solutions)Processor: Medicare non-primary participants using the COBsegment as opposed to copay only billingEffective as of: January 2006Pharmacy Services Help Desk Number: 1-800-922-1557Vendor Certification Help Number: 1-201-703-7499Date:Switch: These claims route via the switch to the Troopfacilitator even if there is a direct connection to Medco.Information Source:Version 5.1: Transactions supported/not supportedSupportedNot SupportedB1 Billing Transaction B3 Rebill TransactionB2 Billing Reversal C1,C2,C3 Controlled Substance ReportingN1,N2,N3P1,P2,P3,P4E1Information ReportingPrior Authorization RequestEligibility VerificationVersion 5.1: Billing Transaction Segments Mandatory/Optional/Not SupportedMandatory/OptionalNot SupportedTransaction Header & ResponseInsurance & ResponsePatientClaim & ResponsePrescriberPharmacy ProviderWorker’s CompensationPrior AuthorizationCouponCompoundDUR/PPS & ResponsePricing & ResponseClinicalResponse Message & StatusCoordination of Benefits/Other PayerVersion 5.1: High level summary of changesFunctionality ChangesPartial Fills will not be supportedSales Tax will be paid using the new sales tax fields1

Medco Health Solutions, Inc.100 Parsons Pond DriveFranklin Lakes, NJ 07417www.medco.com/rph1 800-922-1557Compounds will be processed using highest price ingredientClaims and Reversals may be submitted with only 1 transaction count, meaning multi-scripts will be rejected.Duplicate and reversal logic include fill numberThe software/certification ID will control whether 5.1 claims will be accepted by the production systemPaper claims (UCFs) will not be accepted for pharmacies that are able to submit claims online.Billing for services will be rejected.Version 5.1 (cont.): High level summary of changesFunctionality ChangesCompound segments will not be rejected; however, they are not used for claim processing and reimbursement.Coordination of Benefits for Medicare non-primary eligibles will be supported via the COB segment and copay only billing and thebin/pcn combination will identify which format is required. This payer sheet is to be used when submitting claims when the COBsegment is required by the Medicare group.Product Service ID qualifier supported is NDC. Claims submitted with any other qualifier will be rejected for missing/invalidqualifier.Patient location is required when the patient is residing in a skilled nursing facility, or is at home in a home infusion settingService provider id and qualifier must be submitted with NCPDP valuesNon secondary claims sent to this bin number will rejectReversals must include this bin/pcn combinationAll transactions with this bin must route through the CMS Troop Facilitator – NO DIRECT BILLINGPart II: Field and Segment RequirementsThe following lists the segments available in a Billing Transaction and Reversal. The document also lists Summary Dataas defined under Version 5.1. The Transaction Header Segment is mandatory, all other segments are identified asmandatory, optional (depending on the data required on the specific claim), not supported at this time. The SegmentSummaries included below list the mandatory data fields as defined by NCPDP as well as any additional fields that we defineas mandatory, the accepted code values, and the situations that drive the need for a given field. Shaded fields indicate thatfurther instructions are provided within the Pharmacy Services Manual.Billing Transaction: Transaction Header Segment: Mandatory in all casesNCPDP Values SupportedField #NCPDP Field Nameby MedcoMandatory /Optional101-A1 BIN Number 610031 M102-A2 Version/Release Number 51 M103-A3 Transaction Code B1 M104-A4 Processor Control Number Meddcobseg M109-A9 Transaction Count 1 M202-B2 Service Provider ID Qualifier Values 07 M201-B1 Service Provider ID NCPDP M401-D1 Date of Service M110-AK Software Vendor /Certification Id Assigned when certified, M2

Medco Health Solutions, Inc.100 Parsons Pond DriveFranklin Lakes, NJ 07417www.medco.com/rph1 800-922-1557Patient Segment: MandatoryField #NCPDP Field NameNCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 01 M304-C4 Date of Birth M305-C5 Patient Gender Code M310-CA Patient First Name M307-C7 Patient Location Values 1, 7 OBilling Transaction (cont.): Insurance Segment: MandatoryField #NCPDP Field NameNCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 04 M302-C2 Cardholder ID M303-C3 Person Code M306-C6 Patient Relationship Code M309-C9 Eligibility Clarification Code M301-C1 Group ID MPrescriber Segment: OptionalField #NCPDP Field NameNCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 03 M466-EZ Prescriber ID Qualifier Values 08, 12, M411-DB Prescriber ID State License, DEA M427-DR Prescriber Last Name Required for state license numberClaim Segment: MandatoryField #NCPDP Field NameNCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 07 M455-EM Prescription/ Service Ref Number Qualifier 1 M402-D2 Prescription/ Service Ref Number M436-E1 Product/Service ID Qualifier407-D7 Product/Service ID NDC M442-E7 Quantity Dispensed M403-D3 Fill Number M405-D5 Days Supply M03M3

Medco Health Solutions, Inc.100 Parsons Pond DriveFranklin Lakes, NJ 07417www.medco.com/rph1 800-922-1557406-D6 Compound Code M408-D8 DAW/Product Selection Code M414-DE Date Prescription Written M420-DK Submission Clarification Code M308-C8 Other Coverage Code Values 2-7 only M456-EN Associated Prescription / Service Reference Number Not supported Partial Fill457-EP Associated Prescription / Service Date Not supported Partial Fill344-HF Quantity Intended to be Dispensed Not supported Partial Fill345-HG Days Supply intended to be Dispensed Not supported Partial Fill343-HD Dispensing Status Not supported Partial Fill461-EU Prior Authorization Type Code Overrides462-EV Prior Authorization Number Submitted OverridesClaim Segment (cont.): MandatoryField #NCPDP Field NameNCPDP Values SupportedMandatory /by MedcoOptional453-EJ Originally Prescribed Product/Service ID Qualifier03 therapeuticinterchange445-EA Originally Prescribed Product/Service Code NDCtherapeuticinterchange446-EB Originally Prescribed QuantitytherapeuticinterchangePricing Segment: MandatoryField #NCPDP Field NameNCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 11 M409-D9 Ingredient Cost Submitted M426-DQ Usual and Customary Charge M481-HA Flat Sales Tax Amount Submitted M482-GE Percentage Sales Tax Amount Submitted M483-HE Percentage Sales Tax Rate Submitted When percentage tax submitted M484-JE Percentage Sales Tax Basis Submitted When percentage tax submitted M43Ø-DU Gross Amount Due Will reject if out of balance M423-DN Basis of Cost Determination MDUR/PPS Segment: OptionalField #NCPDP Field NameNCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 08 M473-7E DUR/PPS Code Counter Up to 9 occurrences M4

Medco Health Solutions, Inc.100 Parsons Pond DriveFranklin Lakes, NJ 07417www.medco.com/rph1 800-922-1557439-E4 Reason for Service Code M440-E5 Professional Service Code M441-E6 Result of Service Code MCOB/Other Payments Segment: RequiredField #NCPDP Field NameNCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 05 M337-4C Coordination of Benefits / Other Payments Count Up to 3 occurrences M338-5C Other Payer Coverage Type 01, 02, 03 M339-6C Other Payer Id Qualifier 03 M340-7C Other Payer Id M443-E8 Other Payer Date If paid471-5E Other Payer Reject Count If rejected472-6E Other Payer Reject Code If rejected341-HB Other Payer Amount Paid Count If paid342-HC Other Payer Amount Paid Qualifier 07 If paid431-DV Other Payer Amount Paid If paidClinical Segment: OptionalField #NCPDP Field NameNCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 13 M491-VE Diagnosis Code Count Up to 5 occurrences M492-WE Diagnosis Code Qualifier Value 01 only M424-DO Diagnosis Code ICD-9 M493-XE Clinical Information Counter Up to 5 occurrencesResponse Transaction: Response Header Segment: MandatoryField # NCPDP Field Name NCPDP Values Supported by MedcoMandatory /Optional1Ø2-A2 Version/Release Number 51 M1Ø3-A3 Transaction Code B1, B2 M1∅9-A9 Transaction Count 1 only M5Ø1-F1 Header Response Status M2∅2-B2 Service Provider Id Qualifier M2Ø1-B1 Service Provider Id M4Ø1-D1 Date of Service M5

Medco Health Solutions, Inc.100 Parsons Pond DriveFranklin Lakes, NJ 07417www.medco.com/rph1 800-922-1557Response Message Segment: OptionalField # NCPDP Field Name NCPDP Values Supported by MedcoMandatory /Optional111-AM Segment Identification 20 M5Ø4-F4MessageResponse Insurance Segment: OptionalAdditional coverage information when claimrejects for 41Field # NCPDP Field Name NCPDP Values Supported by MedcoMandatory /Optional111-AM Segment Identification 25 M3Ø1-C1Group Id524-FO Plan ID Medicare545-2F Network Reimbursement IDResponse Status Segment: MandatoryField # NCPDP Field Name NCPDP Values Supported by MedcoMandatory /Optional111-AM Segment Identification 21 M112-AN Transaction Response Status P, R, D M5Ø3-F3 Authorization Number Paid claim only510-FA Reject Count Rejected claims only511-FB Reject Code Rejected claims only546-4F Reject Field Occurrence Indicator Rejected claims only547-5F Approved Message Code Count548-6F Approved Message Code526-FQAdditional Message Informationbrand/generic price estimates,Other coverage information when availableon both payable and rejected claims549-7F Help Desk Phone Number Qualifier 03, 9955∅-8F Help Desk Phone Number Processor, OtherResponse Claim Segment: MandatoryField # NCPDP Field Name NCPDP Values Supported by MedcoMandatory /Optional111-AM Segment Identification 22 M455-EM Prescription/Service Reference Number Qualifier 1 M4Ø2-D2 Prescription/Service Reference Number M551-9F Preferred Product Count Up to 5 Occurrences552-AP Preferred Product ID Qualifier 03553-AR Preferred Product ID NDC6

Medco Health Solutions, Inc.100 Parsons Pond DriveFranklin Lakes, NJ 07417www.medco.com/rph1 800-922-1557556-AUPreferred Product DescriptionResponse Pricing Segment: OptionalField # NCPDP Field Name NCPDP Values Supported by MedcoMandatory /Optional111-AM Segment Identification 23 M5Ø5-F5 Patient Pay Amount M5Ø6-F6 Ingredient Cost Paid M5Ø7-F7 Dispensing Fee Paid M558-AW559-AX56∅-AY561-AZ521-FLFlat Sales Tax Amount PaidPercentage Sales Tax Amount PaidPercentage Sales Tax Rate PaidPercentage Sales Tax Basis PaidIncentive Fee Amount Paid5Ø9-F9 Total Amount Paid M566-J5 Other Payer amount paid recognized522-FM Basis of Reimbursement Determination M523-FN512-FC513-FD514-FE517-FH518-FI519-FJ52Ø-FKAmount Attributed to Sales TaxAccumulated Deductible AmountRemaining Deductible AmountRemaining Benefit AmountAmount Applied to Periodic DeductibleAmount of Copay/CoinsuranceAmount Attributed to Product SelectionAmount Exceeding Periodic Benefit Maximum346-HH Basis of Calculation – Dispensing Fee Not supported Partial Fill347-HJ Basis of Calculation – Copay Not supported Partial Fill348-HK Basis of Calculation – Flat Sales Tax Not supported Partial Fill349-HM Basis of Calculation – Percentage Sales Tax Not supported Partial FillResponse Transaction (cont): Response DUR/PPS Segment: OptionalField # NCPDP Field Name NCPDP Values Supported by MedcoMandatory /Optional111-AM Segment Identification 08 M567-J6 DUR/PPS Response Code Counter Up to 9 occurrences439-E4 Reason for Service Code528-FSClinical Significance Code7

Medco Health Solutions, Inc.100 Parsons Pond DriveFranklin Lakes, NJ 07417www.medco.com/rph1 800-922-1557529-FT530-FU531-FV532-FW544-FYOther Pharmacy IndicatorPrevious Date of FillQuantity of Previous FillDatabase IndicatorDUR Free Text MessageReversal Transaction: Transaction Header Segment: Mandatory in all casesNCPDP Values SupportedField #NCPDP Field Nameby MedcoMandatory /Optional101-A1 BIN Number 610031 M102-A2 Version/Release Number 51 M103-A3 Transaction Code B2 M104-A4 Processor Control Number Meddcobseg M109-A9 Transaction Count 1 M202-B2 Service Provider ID Qualifier Values 07 M201-B1 Service Provider ID NCPDP M401-D1 Date of Service M110-AKSoftware Vendor /Certification IdClaim Segment: MandatoryField #NCPDP Field NameAssigned when certified, claim will reject ifnot valid for 51NCPDP Values Supportedby MedcoMMandatory /Optional111-AM Segment Identification 07 M455-EM Prescription/ Service Ref Number Qualifier 1 M402-D2 Prescription/ Service Ref Number M436-E1 Product/Service ID Qualifier 03 M407-D7 Product/Service ID NDC M403-D3 Fill Number M308-C8 Other Coverage Code When reversing a secondary claim COB8