Attachment 2 Medco Balance Inquiry Payer Sheet January 2010 To ...

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Billing Transaction (cont.):Prescriber Segment: MandatoryField # NCPDP Field Name NCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 03 M466-EZ Prescriber ID Qualifier Values 01 (NPI), 08 (State License),or M12(DEA)411-DB Prescriber ID NPI #, State License #, DEA # M427-DR Prescriber Last Name Required for State License NumberClaim Segment: MandatoryField # NCPDP Field Name NCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 07 M455-EM Prescription/Service Ref Number Qualifier 1 M4Ø2-D2 Prescription/Service Ref Number M436-E1 Product/Service ID Qualifier 03 M4Ø7-D7 Product/Service ID NDC M442-E7 Quantity Dispensed M4Ø3-D3 Fill Number M4Ø5-D5 Days Supply M4Ø6-D6 Compound Code M4Ø8-D8 DAW/Product Selection Code M414-DE Date Prescription Written M419-DJ Prescription Origin Code M42Ø-DK Submission Clarification Code M3Ø8-C8 Other Coverage Code Values 0-7 only M456-EN Associated Prescription/Service ReferencePartial FillNumber457-EP Associated Prescription/Service Date Partial Fill344-HF Quantity Intended to be Dispensed Partial Fill345-HG Days Supply Intended to be Dispensed Partial Fill343-HD Dispensing Status Partial Fill461-EU Prior Authorization Type Code Overrides462-EV Prior Authorization Number Submitted Overrides453-EJ Originally Prescribed Product/Service IDQualifier03 TherapeuticInterchange445-EA Originally Prescribed Product/Service Code NDC TherapeuticInterchange446-EB Originally Prescribed Quantity TherapeuticInterchangePage 4 of 9
Billing Transaction (cont.):Pricing Segment: MandatoryField # NCPDP Field Name NCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 11 M4Ø9-D9 Ingredient Cost Submitted M426-DQ Usual and Customary Charge M438-E3 Incentive Fee Submitted Mandatory when submitting a claim Mfor a vaccine drug and theadministrative fee481-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 Name NCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 08 M473-7E DUR/PPS Code Counter Up to 9 occurrences M439-E4 Reason for Service Code Mandatory when submittingDUR/PPS Segment and claim isnon-vaccine.ONot required when submitting aclaim for vaccine drug and theadministrative fee.44Ø-E5 Professional Service Code Mandatory when submittingDUR/PPS Segment and claim isnon-vaccine.Value = MA (MedicationAdministered),Mandatory when submitting a claimfor vaccine drug and theadministrative fee.441-E6 Result of Service Code Mandatory when submittingDUR/PPS Segment and claim isnon-vaccine.OONot required when submitting aclaim for a vaccine drug and theadministrative fee.Page 5 of 9
Page 1 and 2: Medco Health Solutions, Inc.100 Par
Page 6 and 7: Billing Transaction (cont.):COB/Oth
Page 8 and 9: Response Transaction (cont.):Respon

Attachment 2 Medco Balance Inquiry Payer Sheet January 2010 To ...

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