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

Billing Transaction (cont.):COB/Other Payments Segment: OptionalField # NCPDP Field Name NCPDP 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 Values 01, 02, 03 only M339-6C Other Payer ID Qualifier 03–BIN or 99-Other M34Ø-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–Drug Benefit If paid431-DV Other Payer Amount Paid If paidClinical Segment: OptionalField # NCPDP Field Name NCPDP 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 Medco Mandatory /Optional1Ø2-A2 Version/Release Number 51 M1Ø3-A3 Transaction Code B1, B2 M19-A9 Transaction Count 1 M5Ø1-F1 Header Response Status M22-B2 Service Provider ID Qualifier M2Ø1-B1 Service Provider ID M4Ø1-D1 Date of Service MResponse Message Segment: OptionalField # NCPDP Field Name NCPDP Values Supported by Medco Mandatory /Optional111-AM Segment Identification 20 M5Ø4-F4 Message Additional clarificationPage 6 of 9