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

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