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Nevada MedicaidNational Council for Prescription DrugProgram (NCPDP) Encounter ClaimsCompanion GuideThe information in this Companion Guide is valid to use for thecertification/testing to transition to the modernized MMIS and uponimplementation of the MMIS Modernization ProjectJuly 1, 2022Medicaid Management Information System (MMIS)Department of Health and Human Services (DHHS)Division of Health Care Financing and Policy (DHCFP)
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter ClaimsDisclosure StatementThe information contained in this companion guide is subject to change. Managed Care Organizations(MCOs) are advised to check the Nevada Medicaid EDI webpage athttps://www.medicaid.nv.gov/providers/edi.aspx regularly for the latest updates.Gainwell Technologies is the fiscal agent for Nevada Medicaid and is referred to as Nevada Medicaidthroughout this document.About DHCFPThe Nevada Department of Health and Human Services’ Division of Health Care Financing and Policy(DHCFP) works in partnership with the Centers for Medicare & Medicaid Services (CMS) to assist inproviding quality medical care for eligible individuals and families with low incomes and limitedresources. The medical programs are known as Medicaid and Nevada Check Up.DHCFP website: Medicaid Services Manual, rates, policy updates, public notices: http://dhcfp.nv.gov.Effective 07/01/2022i
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter ClaimsTable of Contents1Introduction .41.1NCPDP Batch Transaction Standard Version 1.2 and Telecommunication Standard Version D.042 Getting Started .52.1Trading Partner Enrollment .52.2Certification and Testing Overview .63 Testing with Nevada Medicaid .73.1Testing Process .73.2File Naming Standard .73.3Duplicate Pharmacy Logic .84 Connectivity with Nevada Medicaid/ Communications .94.1Process Flows .94.2Encounter Response Files . 104.3Transmission Administrative Procedures . 104.4System Availability . 104.5Transmission File Size . 104.6Re-transmission Procedure . 114.7Communication Protocol Specifications . 114.8Passwords . 114.9NCPDP Batch Transaction Standard Version 1.2 . 114.10 Separator Characters . 125 NCPDP Batch Transaction Standard Version 1.2 File Information and Telecommunication StandardVersion D.0 Transaction Set Specifications . 135.1Transmission Header (Required/1 per file) . 136 NCPDP Version 1.2 . 146.1Transaction Detail (Required/1 per transaction) . 146.2NCPDP D.0 Billing Request (Required) . 146.3Insurance Segment (Required) . 156.4Patient Segment (Situational) . 156.5Claim Segment (Required) . 166.6Pricing Segment (Required) . 186.7Provider Segment (Required) . 186.8Prescriber Segment (Required) . 196.9COB/Other Payments Segment (Situational). 196.10 DUR/PPS Segment (Situational). 196.11 Compound Segment (Situational) . 206.12 Clinical Segment (Required for Encounter) . 206.13 Transmission Trailer (1 per file required) . 217 The NCPDP Encounter Response File . 227.1File layout of the NCPDP Encounter Response File . 228 Encounter Claim Duplicate File . 239 Contact Information . 249.1EDI Customer Service. 24Effective 07/01/2022ii
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter Claims9.2EDI Technical Assistance . 249.3Applicable Websites/Email . 24Appendix A: Dispense as Written (DAW) Product Selection Code . 27Appendix B: Other Coverage Code . 28Appendix C: Other Payer Amount Paid Qualifier . 29Appendix D: Reason for Service Code . 30Appendix E: Professional Service Code . 34Appendix F: Result of Service Code . 36Appendix G: Compound Dosage Form Description Code . 37Appendix H: Basis of Cost Determination . 38Appendix I: Frequently Asked Questions . 39Appendix J: Change Summary . 41Effective 07/01/2022iii
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter Claims1 Introduction1.1NCPDP Batch Transaction Standard Version 1.2 andTelecommunication Standard Version D.0These supplemental instructions are issued to help contractors submit pharmacy encounter data toNevada Medicaid.Every effort has been made to prevent errors in this document. However, if there is a discrepancybetween this document and the National Council for Prescription Drug Programs (NCPDP)Telecommunication Standard Implementation Guide Version D.0 and the Telecomm ImplementationGuide Version 1.2, the Implementation Guides are the final authority.Nevada Medicaid supports the B1 Billing NCPDP transaction for Pharmacy Encounters:These specifications cover the required fields per the NCPDP Batch Transaction StandardImplementation Guide Version 1.2 and NCPDP Telecommunication Standard Implementation GuideVersion D.0, as well as the required fields needed for encounter claims processing by Nevada Medicaid.When additional segments and/or fields that are allowed within the supported NCPDP versions areprovided, Nevada Medicaid will accept the transaction, but only those segments and fields pertinent toencounter claims processing will be utilized.Any NCPDP transaction that is not supported by Nevada Medicaid will be rejected.Effective 07/01/20224
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter Claims2 Getting StartedThis section describes how to interact with Nevada Medicaid’s Help Desk.The Nevada Medicaid EDI Help Desk can be contacted at (877) 638-3472 options 2, 0, and then 3,Monday through Friday, 8:00 a.m. to 5:00 p.m. Pacific Time, with the exception of Nevada Stateholidays. You can also send an email to ing Partner EnrollmentThis section describes how to enroll as an Encounter Trading Partner with Nevada Medicaid.In order to submit and/or receive transactions with Nevada Medicaid, Trading Partners must complete aTrading Partner Profile (TPP) agreement, establish connectivity and certify transactions. A Trading Partner is any entity (provider, billing service, clearinghouse, software vendor, etc.)that transmits electronic data to and receives electronic data from another entity. NevadaMedicaid requires all Trading Partners to complete a TPP agreement regardless of the TradingPartner type listed below. Vendor is an entity that provides hardware, software and/or ongoing technical support forcovered entities. In EDI, a vendor can be classified as a software vendor, billing or networkservice vendor or clearinghouse.oSoftware vendor is an entity that creates software used by billing services,clearinghouses and providers/suppliers to conduct the exchange of electronictransactions.oBilling service is a third party that prepares and/or submits claims for a provider.oClearinghouse is a third party that submits and/or exchanges electronic transactions onbehalf of a provider.Establishing a Trading Partner Profile (TPP) agreement is a simple process which the Trading Partnercompletes using the Nevada Medicaid Provider Web Portal. The Provider Web Portal is located g Partners must agree to the Nevada Medicaid Trading Partner Agreement at the end of theTrading Partner Profile enrollment process. Once the TPP application is completed, an 8-digit TradingPartner ID will be assigned.After the TPP Agreement has been completed, the Trading Partner must submit a Secure Shell (SSH)public key file to Nevada Medicaid to complete their enrollment. Once the SSH key is received, you willbe contacted to initiate the process to exchange the directory structure and authorization access on theNevada Medicaid external SFTP servers.Failure to provide the SSH key file to Nevada Medicaid will result in your TPP application request beingrejected and you will be unable to submit transactions electronically to Nevada Medicaid. Please submityour SSH public key via email within five business days of completing the TPP application. Should yourequire additional assistance with information on SSH keys, please contact the Nevada EDI Help Desk at(877) 638-3472 options 2, 0, and then 3.Effective 07/01/20225
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter Claims2.2Certification and Testing OverviewThis section provides a general overview of what to expect during certification and testing phases.All Trading Partners who submit electronic transactions with Nevada Medicaid will be certified throughthe completion of Trading Partner testing. This includes Clearinghouses, Software Vendors, ProviderGroups and Managed Care Organizations (MCOs).Providers who use a billing agent, clearinghouse or software vendor will not need to test for thoseelectronic transactions that their entity submits on their behalf.Effective 07/01/20226
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter Claims3 Testing with Nevada MedicaidThis section contains a detailed description of the testing phase.Testing data such as provider IDs and recipient IDs will not be provided. Users should submit recipientinformation and provider information as done for production as the test environment is continuallyupdated with production information.There is no limit to the number of files that may be submitted. Results of the system’s processing of yourtransactions are reviewed and communicated back via email. Once the test file(s) passes validationedits, a production URL and Production Authorization letter will be sent confirming certification.The following Encounter transactions are available for testing:3.1 837D Encounter Dental Claim 837P Encounter Professional (CMS-1500) Claim 837P NET Encounter Professional (CMS-1500) Claim 837I Encounter Institutional (UB-04) Claim NCPDP Batch Transaction Standard Version 1.2 and Telecommunication Standard VersionD.0Testing ProcessThe following points are actions that a Trading Partner will need to take before submitting productionfiles to Nevada Medicaid: Enroll by using the Trading Partner Enrollment Application on the Nevada Medicaid ProviderWeb Portal to obtain a new Trading Partner ID Register on the Nevada Medicaid Provider Web Portal (optional unless submitting files via theWeb Portal) Receive EDI Trading Partner Welcome Letter indicating Trading Partner Profile (TPP) has beenapproved for testing Submit test files using SFTP until transaction sets pass compliance testing Receive Production Authorization letter containing the list of approved transactions that couldbe submitted to the production environment along with the connection information Upon completion of the testing process, you may begin submitting production files for allapproved transactions via the Nevada Medicaid Provider Web Portal or SFTPTo begin the testing process, please review the Nevada Medicaid Trading Partner User Guide located 3.2File Naming StandardUse the following naming standards when submitting encounter files to Nevada Medicaid. Trading Partner ID Encounters filetype Environment DateTime.dat or .txtExamples are as follows:Effective 07/01/20227
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter Claims 01234567 ENCOUNTERS NCPDP PROD 201808301140512.dat 01234567 ENCOUNTERS NCPDP PROD 201808301140512.txtThe preferred extension is .dat; however, .txt is also allowed. Zip files (.zip) may also be submitted, buteach zip file can contain only one encounter file, either .dat or .txt. Both the zip file and the encounterfile it contains must meet the file naming standards.If the file does not meet the file naming standard, the file will not be processed. In this instance, theNevada Medicaid EDI Help Desk will notify the submitter of the issue and request correction andresubmittal. You will need to correct the file name and resubmit the file in order for it to process.3.3Duplicate Pharmacy LogicPharmacy LogicLogic will consider each Detail on the incoming claim.Logic will consider history claims.If a detail is Denied, do not check it for duplicate.Since we do not reject pharmacy claims for lacking a NDC code, check if we do not have one. If wedon’t, do not check the detail for duplicate claims.Since we do not reject claims for a provider that is not enrolled with NV Medicaid, check if we do nothave a valid enrolled one. If we don’t, do not check for duplicate claims.Considering the ‘dispense date’ as the Date of first service.Check current pharm detail against history claim details.If an Encounter claim detail is found on history where, compared to current claim detail:-recipients are equalproviders are equalDOS (dates dispensed) are equal,NDC’s are equal, andTrading partners are equalThen set ENC DUP PHARMNote: When referring to the ‘history claims’ used in the duplicate logic against the current incomingclaims:-If a claim is denied at the Header level, it does not get added to the audit history tableIf a Paid claim at the Header level has details that were denied, those denied details do not getadded to the history tableThus, only paid details will be found on the audit history table for comparisonEffective 07/01/20228
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter Claims4 Connectivity with Nevada Medicaid/ CommunicationsThis section describes the process to submit NCPDP Encounter transactions, along with submissionmethods, security requirements, and exception handling procedures.Nevada Medicaid supports multiple methods for exchanging electronic healthcare transactionsdepending on the Trading Partner’s needs. For NCPDP Batch Encounter transactions, the following canbe used: Secure File Transfer Protocol (SFTP) (this only applies to batch transactions) The Nevada Medicaid Provider Web Portal (not recommended for Encounter claims due to thesize limitations)4.1Process FlowsThis section contains a process flow diagram and appropriate text.Effective 07/01/20229
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter Claims4.2Encounter Response Files1. The Trading Partner submits a batch of encounter claims to the Nevada Medicaid SFTP server.2. EDI processes the batch.Note: With an NCPDP transaction, the TA1 and 999 responses are not available. If an error isdetected with a batch/file, the Trading Partner will be contacted via email from the EDI HelpDesk. The email will contain the reason why the file rejected.3. When the batch successfully processes through EDI, the encounter claims are transformed intoXML records and submitted to the interChange Encounter Claim engine for further validationand processing. At this stage, individual encounter claims are inspected and if necessaryrejected and sent back to the submitter for correction. (When resubmitting a rejectedencounter claim, the same MCO ICN/TCN must be used on the corrected encounter claim). Thesubmitter can expect two different response files as follows: 4.3The proprietary encounter NCPDP response report will be generated daily once thetranslated file has processed. This report will contain the status of each encounter claimwithin the transaction. The Encounter Engine contains informational and threshold edits.Both types of edits are reported on the response file; however, only threshold edits willreject a claim. A claim with no edits or informational edits will be accepted. Claims can haveboth threshold and informational edits, but only the information pertaining to the thresholdedit will need to be corrected and resubmitted for the claim to be accepted. If a claim withinthe batch is rejected due to duplicate, then an Encounter Claim Duplicate file will also begenerated. This file provides information on the current claim that is being rejected and therelated claim in the Encounter Claim Engine.Transmission Administrative ProceduresThis section provides Nevada Medicaid’s specific transmission administrative procedures.For details about available Nevada Medicaid Access Methods, refer to the Communication ProtocolSpecifications section below.Nevada Medicaid is only available to authorized users. The submitter/receiver must be a NevadaMedicaid Trading Partner. Each submitter/receiver is authenticated using the Username and private SSHkey provided by the Trading Partner as part of the enrollment process.4.4System AvailabilityThe system is typically available 24X7 with the exception of scheduled maintenance windows as notedon the Nevada Medicaid website at https://www.medicaid.nv.gov/.4.5Transmission File SizeTransactionsSubmission MethodFile Size LimitNCPDPSFTP200 MB per batchNCPDPWeb Portal4 MBEffective 07/01/2022Other Conditions10
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter Claims4.6Re-transmission ProcedureNevada Medicaid does not require any identification of a previous transmission of a file with the Noteexception listed below. All files sent should be marked as original transmissions.Nevada Medicaid does identify duplicate files based on content of the file before it reaches the MMISsystem. The duplicate check algorithm only checks for file content. It does not check for filename or filesize.The submitter must correct and resubmit a disputed encounter file or claim within sixty (60) calendardays of receipt of rejection.Note: If the same file was resubmitted using SFTP and the data content is the same content ofanother file, this file will be detected as a duplicate file. The EDI Help Desk will contact the EDIcontact listed on file to see if the file was meant to be reprocessed.4.7Communication Protocol SpecificationsThis section describes Nevada Medicaid's communication protocol(s). Secure File Transfer Protocol (SFTP): Nevada Medicaid allows Trading Partners to connect to theNevada Medicaid SFTP server using the SSH private key and assigned user name. There is nopassword for the connection. Nevada Medicaid Provider Web Portal: Nevada Medicaid allows Trading Partners to connect tothe Nevada Medicaid Provider Web Portal. Refer to the Trading Partner User Guide forinstructions.4.8PasswordsTrading Partners must adhere to Nevada Medicaid’s use of passwords. Trading Partners are responsiblefor managing their own data. Each Trading Partner must take all necessary precautions to ensure thatthey are safeguarding their information and sharing their data (e.g., granting access) only with users andentities who meet the required privacy standards. It is equally important that Trading Partners knowwho on their staff is linked to other providers or entities, in order to notify those entities whenever theyremove access for that person in your organization(s).4.9NCPDP Batch Transaction Standard Version 1.2The batch specifications contained in this document include the header, data and trailer. Batch filesshould contain one header record, one trailer record, and a maximum of 5,000 transaction details. Header (1 per file) Transaction Detail (can include 1 transaction) Trailer (1 per file)Values in the header and trailer will be edited to verify that they contain appropriate values. Carriagereturns/line feeds are not allowed within the batch file. If a file is received with carriage returns/linefeeds, the file will be rejected.Effective 07/01/202211
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter Claims4.10 Separator CharactersSegment Separator (hex character 1E, decimal 3Ø) delineates each segment within the transaction.A Group Separator (hex character 1D, decimal 29) denotes the start of each transaction in thetransmission.A Field Separator (hex character 1C, decimal 28) separates each field in a transaction’s segments.Each field has a unique identifier code that, when used in conjunction with the Field Separator, showsthe start of a new field in the record (for example, FB refers to Field 511-FB, Reject Code).Effective 07/01/202212
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter Claims5 NCPDP Batch Transaction Standard Version 1.2 FileInformation and Telecommunication Standard VersionD.0 Transaction Set SpecificationsFollowing is a list of the field, use, field name and values/comments for Nevada Medicaid using thebatch NCPDP Batch Transaction Standard Version v1.2 and Telecommunication Standard Version vD.0.The following definitions are given to ensure consistency of interpretation: Field: The NCPDP Batch Transaction Standard v1.2 or NCPDP Telecommunication Standard vD.0data element identifier for a given transaction. Field Name: The short definition, name, or literal constant of the data located within thetransaction at the positions indicated. Format: Defines the field as alpha/numeric or numeric. Length: Defines the length the Nevada Medicaid allows. Values/Comments: If a particular value is expected, that value is given within single quotes.NCPCP Telecommunication Standard vD.0 is a variable length format. Therefore, with theexception of the header fields (which are always required), a transaction will contain only thoseelements that are necessary.5.1 Transmission Header (Required/1 per file)FieldUseField NameFormatLengthValues/Comments880-K4MText IndicatorA/N1Start of Text (STX) X’02’701MSegmentIdentifierA/N200 File Control Header880-K6MTransmissionTypeA/N1T Transaction880-K1MSender IDA/N24Trading Partner ID assigned by NevadaMedicaid.806-5CMBatch NumberN7Assigned by the sender and must matchthe Transaction Trailer Batch Numberfield.880-K2MCreation DateN8Create Date CCYYMMDD880-K3MCreation TimeN4Create Time HHMM702MFile TypeA/N1P ProductionT Test102-A2MVersion/ ReleaseNumberA/N212 Version 1.2880-K7MReceiver IDA/N24NVMED880-K4MText IndicatorA/N1End of Text (ETX) X’03’Effective 07/01/202213
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter Claims6 NCPDP Version 1.26.1Transaction Detail (Required/1 per transaction)FieldUseField NameFormatLengthValues/Comments880-K4MText IndicatorA/N1Start of Text (STX) X’02’701MSegmentIdentifierA/N2G1 Detail data record880-K5MMCOTransactionControlNumber (MCOTCN)A/N10A reference number assigned by the providerto each of the data records in the batch.6.2WHEN RE-SUBMITTING A REJECTEDENCOUNTER CLAIM, THIS FIELD NEEDS TOCONTAIN THE SAME TCN AS ON THE ORIGINALENCOUNTER CLAIMNCPDP D.0 Billing Request (Required)FieldField NameFormatLengthValues/Comments101-A1BIN NumberN6Use “999999”102-A2Version/ReleaseNumberA/N2D0 Version D.0103-A3Transaction CodeA/N2B1 Billing104-A4Processor ControlNumberA/N10Audit Number assigned at point of adjudication.Number assigned by processor. Suggestion:Populate unique characters in the first ninebytes to prevent processing numberduplication.MCO Internal Control Number109-A9Transaction CountX11 One occurrence202-B2Service Provider IDQualifierA/N201 NPI/API05 MedicaidNote: 05 is only valid for “Atypical” Providers all other providers must submit their NPI (Value 01), File will be rejected if value other than 01or 05 is submitted.201-B1Service Provider IDA/N15Billing Provider NPI401-D1Date of ServiceN8Date Format CCYYMMDD110-AKSoftware Vendor/Certification IDA/N10The 8-digit Trading Partner ID assigned byNevada Medicaid left justified and space filled.Effective 07/01/202214
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter Claims6.3Insurance Segment (Required)FieldField NameFormatLengthValues/Comments111-AMSegment IdentificationN204 Insurance302-C2Cardholder IDA/N20Nevada Medicaid Member or Recipient ID301-C1GROUP IDA/N15CMO Medicaid ID Number and Record IDXXXXXXXXXXXBX CMO Regional Medicaid IDB Record ID 0 Denied Claim 1 Original Claim 2 Voided Claim1st- 10th Byte will be equal to the CMO MedicaidID, 11th byte will be equal to the Record ID toillustrate a voided, original or denied claim.115-N56.4MEDICAID ID NUMBERA/N15Nevada Medicaid Member or Recipient IDPatient Segment (Situational)FieldField NameFormatLengthValues/Comments111-AMSegment IdentificationN201 Patient304-C4Date of BirthN8Format: CCYYMMDD305-C5Patient Gender CodeN10 Not Specified1 Male2 Female310-CAPatient First NameA/N12311-CBPatient Last NameA/N15326-CQPatient PhoneN10Effective 07/01/202215
Nevada Medicaid Electronic Transaction Companion Guide:NCPDP Encounter ClaimsFieldField NameFormatLengthValues/Comments307-C7Place of ServiceN200 Not Specified01 Home02 Inter-Care03 Nursing Home04 Long Term/Extended Care05 Rest Home06 Boarding Home07 Skilled Care Facility08 Sub-Acute Care Facility09 Acute Care Facility10 Outpatient11 Hospice6.5Claim Segment (Required)FieldField NameFormatLengthValues/Comments111-AMSegment IdentificationN207 Claim455-EMPrescription/ ServiceReference NumberQualifierN11 Rx BillingNotes: “1” is the only value accepted. All othervalues will reject the file.Prescription/ ServiceReference NumberN436-E1Product/Service IDQualifierA/N203 NDC407-D7Product/Service IDA/N11NDC402-D212Prescription NumberNote: When prescription number is less than therequired length, leading zeroes are not required,may use spaces to make ma
Nevada Medicaid Electronic Transaction Companion Guide: NCPDP Encounter Claims Effective 07/01/2022 5 2 Getting Started This section describes how to interact with Nevada Medicaids Help Desk. The Nevada Medicaid EDI Help Desk can be contacted at (877) 638-3472 options 2, 0, and then 3,
