SeniorScript-NCPDP Version D0 Payer Sheet - Catamaran

Claim SegmentClaim BillingSegment Identification (111-AM) = “Ø7”Field # NCPDP Field Name Value Payer Usage Payer Situation4Ø5-D5 DAYS SUPPLY M4Ø6-D6 COMPOUND CODE 1 = NOT A COMPOUND2 = COMPOUNDMCompound Code = 2 requiredwhen submitting multi-ingredientcompound prescription4Ø8-D8 DISPENSE AS WRITTEN (DAW)/PRODUCTMSELECTION CODE414-DE DATE PRESCRIPTION WRITTEN M419-DJ PRESCRIPTION ORIGIN CODE 1 = Written2 = Telephone3 = Electronic4 = Facsimile5 = Pharmacy ← This valueindicates the pharmacy hascreated/generated a new R xnumber from an existing validprescription number.354-NX SUBMISSION CLARIFICATION CODE COUNT42Ø-DK SUBMISSION CLARIFICATION CODE 8 = Process Compound ForApproved IngredientsMRWPayer Requirement:Required value of 1,2,3,or 4If claim denies,will return NCPDP RejectCode „33‟ (M/I PrescriptionOrigin Code).Imp Guide: Required if clarification isneeded and value submitted is greater thanzero (Ø).Payer Requirement:. Initial compoundclaim may be submitted without 8 todetermine which drugs will be covered, butclaims must then be resubmitted withSCC8 to accept payment of covered drugs.3Ø8-C8 OTHER COVERAGE CODE 2 = Other coverage existspaymentcollected – Code used incoordination of benefitstransactions to convey that othercoverage is available, the payerhas been billed and paymentreceived.RWRequired for Coordination of Benefits.418-DILEVEL OF SERVICE996-G1 COMPOUND TYPEPrescriber Segment Questions Check Claim BillingIf Situational, Payer SituationThis Segment is always sentXPrescriber segment (111-AM)= “Ø3”Claim Billing/Claim Rebill466-EZ PRESCRIBER ID QUALIFIER Ø1 – NPI12 – DEAMNPI should be used DEA allowed if NPInot available411-DB PRESCRIBER ID M427-DR PRESCRIBER LAST NAME MPricing Segment Questions Check Claim BillingThis Segment is always sentXPricing SegmentClaim BillingSegment Identification (111-AM) = “11”Field # NCPDP Field Name Value Payer Usage Payer Situation4Ø9-D9 INGREDIENT COST SUBMITTED M412-DC DISPENSING FEE SUBMITTED RW Imp Guide: Required if its value has aneffect on the Gross Amount Due (43Ø-DU)

Coordination of Benefits/OtherPayments SegmentSegment Identification (111-AM) = “Ø5”Claim BillingField # NCPDP Field Name Value Payer Usage Payer Situation337-4C COORDINATION OF BENEFITS/OTHER Maximum count of 9.MPAYMENTS COUNT338-5C OTHER PAYER COVERAGE TYPE Blank = Not SpecifiedM01 = Primary – FirstØ2 = Secondary – SecondØ3 = Tertiary – ThirdØ4 = Quaternary – FourthØ5 = Quinary – FifthØ6 = Senary – SixthØ7 = Septenary – SeventhØ8 = Octonary – EighthØ9 = Nonary – NinthScenario 1 – Other Payer Amount PaidRepetitions Only339-6C OTHER PAYER ID QUALIFIER RW34Ø-7C OTHER PAYER ID RW443-E8 OTHER PAYER DATE RW Reporting other payer amount paid341-HB OTHER PAYER AMOUNT PAID COUNT Maximum count of 9. RW Reporting other payer amount paid342-HC OTHER PAYER AMOUNT PAID QUALIFIER RW Reporting other payer amount paid431-DV OTHER PAYER AMOUNT PAID RWNot used for patient financial responsibilityonly billing.Not used for non-governmental agencyprograms if Other Payer-PatientResponsibility Amount (352-NQ) issubmitted.Compound Segment Questions Check Claim BillingIf Situational, Payer SituationThis Segment is situational X Required to be sent if prescription is a compound.Compound SegmentClaim BillingSegment Identification (111-AM) = “1Ø”Field # NCPDP Field Name Value Payer Usage Payer Situation45Ø-EFCOMPOUND DOSAGE FORMDESCRIPTION CODEM451-EG COMPOUND DISPENSING UNIT FORM . M All Values acceptedINDICATOR447-EC COMPOUND INGREDIENT COMPONENT Maximum 25 ingredientsMCOUNT488-RE COMPOUND PRODUCT ID QUALIFIER 03 = NDC -National Drug Code M489-TE COMPOUND PRODUCT ID M448-ED COMPOUND INGREDIENT QUANTITY M49Ø-UE COMPOUND INGREDIENT BASIS OFCOST DETERMINATIONMAll values acceptedRequired for Compound claim