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 800-922-1557406-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
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