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

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Response Transaction (cont.):Response Pricing Segment: OptionalField # NCPDP Field Name NCPDP Values Supported by Medco Mandatory /Optional111-AM Segment Identification 23 M5Ø5-F5 Patient Pay Amount M5Ø6-F6 Ingredient Cost Paid M5Ø7-F7 Dispensing Fee Paid M558-AW Flat Sales Tax Amount Paid559-AX Percentage Sales Tax Amount Paid56-AY Percentage Sales Tax Rate Paid561-AZ Percentage Sales Tax Basis Paid521-FL Incentive Fee Amount Paid5Ø9-F9 Total Amount Paid M522-FM Basis of Reimbursement Determination M523-FN Amount Attributed to Sales Tax512-FC Accumulated Deductible Amount513-FD Remaining Deductible Amount514-FE Remaining Benefit Amount517-FH Amount Applied to Periodic Deductible518-FI Amount of Copay/Coinsurance519-FJ Amount Attributed to Product Selection52Ø-FK Amount Exceeding Periodic Benefit Maximum566-J5 Other Amount Paid Recognized COB only346-HH Basis of Calculation – Dispensing Fee Partial Fill347-HJ Basis of Calculation – Copay Partial Fill348-HK Basis of Calculation – Flat Sales Tax Partial Fill349-HM Basis of Calculation – Percentage Sales Tax Partial FillResponse DUR/PPS Segment: OptionalField # NCPDP Field Name NCPDP Values Supported by Medco Mandatory /Optional111-AM Segment Identification 08 M567-J6 DUR/PPS Response Code Counter Up to 9 occurrences439-E4 Reason for Service Code528-FS Clinical Significance Code529-FT Other Pharmacy Indicator53Ø-FU Previous Date of Fill531-FV Quantity of Previous Fill532-FW Database Indicator544-FY DUR Free Text MessagePage 8 of 9
Reversal Transaction:Transaction Header Segment: Mandatory in all casesField # NCPDP Field Name NCPDP Values Supportedby MedcoMandatory /Optional1Ø1-A1 BIN Number 610056 M1Ø2-A2 Version/Release Number 51 M1Ø3-A3 Transaction Code B2 M1Ø4-A4 Processor Control Number Anything but zeros M1Ø9-A9 Transaction Count 1 M2Ø2-B2 Service Provider ID Qualifier Values 01 (NPI), 07 (NCPDP),Mor 99 (Medco)2Ø1-B1 Service Provider ID NPI #, NCPDP #, MEDCO # M4Ø1-D1 Date of Service M11Ø-AK Software Vendor/Certification ID Assigned when certified, claim willreject if not valid for 51MClaim 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 M4Ø3-D3 Fill Number M3Ø8-C8 Other Coverage Code When reversing a secondary claim Requiredwhen COBReversalPage 9 of 9
Page 1 and 2: Medco Health Solutions, Inc.100 Par
Page 4 and 5: Billing Transaction (cont.):Prescri
Page 6 and 7: Billing Transaction (cont.):COB/Oth

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

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