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

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

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