WIXLIB

415-DFNUMBER OF REFILLS AUTHORIZEDRWImp Guide: Required if necessary for planbenefit administration.Payer Requirement: Refer to on-line responsefor additional detailClaim SegmentSegment Identification (111-AM) “Ø7”419-DJ354-NXPRESCRIPTION ORIGIN CODEClaim Billing/Claim Rebill1 Written – Prescriptionobtained via paper.2 Telephone – Prescriptionobtained via oral instructions orinteractive voice response using aphone.3 Electronic – Prescriptionobtained via SCRIPT or HL7Standard transactions4 Facsimile – Prescriptionobtained via transmission using afax machine.MPayer Requirement: Refer to on-lineresponse for additional detailRWSUBMISSION CLARIFICATION CODECOUNTImp Guide: Required if necessary for planbenefit administration.Imp Guide: Required if SubmissionClarification Code (42Ø-DK) is used.Payer Requirement: Required whenSubmission Clarification Code value is used.42Ø-DKSUBMISSION CLARIFICATION CODE8 Process Compound ForApproved IngredientsRWImp Guide: Required if clarification is neededand value submitted is greater than zero (Ø).If the Date of Service (4Ø1-D1) contains thesubsequent payer coverage date, theSubmission Clarification Code (42Ø-DK) isrequired with value of ―19‖ (Split Billing –indicates the quantity dispensed is theremainder billed to a subsequent payer whenMedicare Part A expires. Used only in longterm care settings) for individual unit of usemedications.Payer Requirement: Refer to on-lineresponse for additional detail46Ø-ETQUANTITY PRESCRIBEDRWImp Guide: Required for all Medicare Part Dclaims for drugs dispensed as Schedule II. Maybe used by trading partner agreement forclaims for drugs dispensed as Schedule II only.Payer Requirement: Refer to on-line responsefor additional detail3Ø8-C8OTHER COVERAGE CODE1 No other Coverage2 Other coverage existspayment collected – Code used incoordination of benefitstransactions to convey that othercoverage is available, the payerhas been billed and paymentreceived3 Exists-Claim not Covered4 Exists-Payment not Collected8 Claim Billing for PatientFinancial Responsibility Only.-7-RWImp Guide: Required if needed by receiver, tocommunicate a summation of other coverageinformation that has been collected from otherpayers.Required for Coordination of Benefits.Payer Requirement: Required Only forCoordination of Benefits claim processing.

429-DTUNIT DOSE INDICATORRWImp Guide: Required if this field could result indifferent coverage, pricing, or patient financialresponsibility.Payer Requirement: Refer to on-line responsefor additional detailClaim SegmentSegment Identification (111-AM) “Ø7”453-EJClaim Billing/Claim RebillORIG PRESCRIBED PRODUCT/SERVICE IDQUALIFIERRWImp Guide: Required if Originally PrescribedProduct/Service Code (455-EA) is used.Payer Requirement: Refer to on-line responsefor additional detail445-EA446-EB6ØØ-28ORIGINIALLY PRESCRIBEDPRODUCT/SERVICE CODERWORIGINALLY PRESCRIBED QUANTITYRWUNIT OF MEASURERWImp Guide: Required if the receiver requestsassociation to a therapeutic, or a preferredproduct substitution, or when a DUR alert hasbeen resolved by changing medications, or analternative service than what was originallyprescribed.Payer Requirement: Refer to on-line responsefor additional detailImp Guide: Required if the receiver requestsreporting for quantity changes due to atherapeutic substitution that has occurred or apreferred product/service substitution that hasoccurred, or when a DUR alert has beenresolved by changing quantities.Payer Requirement: Refer to on-line responsefor additional detailImp Guide: Required if necessary forstate/federal/regulatory agency programs.Required if this field could result in differentcoverage, pricing, or patient financialresponsibility.Payer Requirement: Refer to on-line responsefor additional detail418-DILEVEL OF SERVICERWI Imp Guide: Required if this field could result indifferent coverage, pricing, or patient financialresponsibility.Payer Requirement: Refer to on-line responsefor additional detail461-EUPRIOR AUTHORIZATION TYPE CODERW.-8-Imp Guide: Required if this field could result indifferent coverage, pricing, or patient financialresponsibility.Required if this field could result in differentcoverage, pricing, or patient financialPayer Requirement: Refer to on-line responseresponsibility.for additional detail

462-EVSUBMIT PRIOR AUTHORIZATION NUMBERRWImp Guide: Required if this field could result indifferent coverage, pricing, or patient financialresponsibility.Payer Requirement: Refer to on-line responsefor additional detail463-EWINTERMEDIARY AUTHORIZATION TYPE IDRWClaim SegmentSegment Identification (111-AM) “Ø7”464-EXINTERMEDIARY AUTHORIZATION IDRWImp Guide: Required for overriding anauthorized intermediary system edit when thepharmacy participates with an intermediary.Payer Requirement: Refer to on-line responsefor additional detailClaim Billing/Claim RebillRequired if Intermediary Authorization ID (464EX)used.Required for overriding anImp isGuide:authorized intermediary system edit when thepharmacy participates with an intermediary.343-HDDISPENSING STATUSP Partial FillC Completion of Partial FillRWPayer Requirement: Refer to on-line responsefor additional detailImp Guide: Required for the partial fill or thecompletion fill of a prescription.Payer Requirement: Refer to on-line responsefor additional detail344-HFQUANTITY INTENDED TO BE DISPENSEDRWImp Guide: Required for the partial fill or thecompletion fill of a prescription.Payer Requirement: Payer Requirement: Referto on-line response for additional detail345-HGRWDAYS SUPPLY INTENDED TO BEDISPENSEDImp Guide: Required for the partial fill or thecompletion fill of a prescription.Payer Requirement: Refer to on-line responsefor additional detail357-NV391-MTRWDELAY REASON CODERWPATIENT ASSIGNMENT INDICATOR(DIRECT MEMBER REIMBURSEMENTINDICATOR)Imp Guide: Required when needed to specifythe reason that submission of the transactionhas been delayed.Payer Requirement: Refer to on-lineresponse for additional detailImp Guide: Required when the claimsadjudicator does not assume the patientassigned his/her benefits to the provider orwhen the claims adjudicator supports apatient determination of whether he/shewants to assign or retain his/her benefits.Payer Requirement: Refer to on-lineresponse for additional detail995-E2RWROUTE OF ADMINISTRATIONImp Guide: Required if specified in tradingpartner agreement.Payer Requirement: Refer to on-lineresponse for additional detail.-9-

996-G1147-U7RWCOMPOUND TYPERWPHARMACY SERVICE TYPEImp Guide: Required if specified in tradingpartner agreement.Payer Requirement: Refer to on-line responsefor additional detailImp Guide: Required when the submitter mustclarify the type of services being performed as acondition for proper reimbursement by thepayer.Payer Requirement: Refer to on-lineresponse for additional detailPricing SegmentThis Segment is always sentField #4Ø9-D9412-DC477-BE433-DXPricing SegmentSegment Identification (111-AM) “11”NCPDP Field NameCheckClaim Billing/Claim RebillXClaim Billing/Claim RebillValuePayerUsageMRWINGREDIENT COST SUBMITTEDDISPENSING FEE SUBMITTEDPROFESSIONAL SERVICE FEE SUBMITTEDPATIENT PAID AMOUNT SUBMITTEDPayer SituationImp Guide: Required if its value has an effecton the Gross Amount Due (43Ø-DU)calculation.RWPayer Requirement: Refer to on-line responsefor additional detailImp Guide: Required if its value has an effecton the Gross Amount Due (43Ø-DU)calculation.RWPayer Requirement: For Vaccine BillingclaimsImp Guide: Required if this field could result indifferent coverage, pricing, or patient financialresponsibility.Payer Requirement: Refer to on-lineresponse for additional detail438-E3INCENTIVE AMOUNT SUBMITTEDRWImp Guide: Required if its value has an effecton the Gross Amount Due (43Ø-DU)calculation.Payer Requirement: For Vaccine Billing claims478-H7479-H8OTHER AMOUNT CLAIMED SUBMITTEDCOUNTRWOTHER AMOUNT CLAIMED SUBMITTEDQUALIFIERRWImp Guide: Required if Other Amount ClaimedSubmitted Qualifier (479-H8) is used.Payer Requirement: Refer to on-lineresponse for additional detailImp Guide: Required if Other Amount ClaimedSubmitted (48Ø-H9) is used.Payer Requirement: Refer to on-lineresponse for additional detail.- 10-

48Ø-H9OTHER AMOUNT CLAIMED SUBMITTEDRWImp Guide: Required if its value has an effecton the Gross Amount Due (43Ø-DU)calculation.Payer Requirement: Refer to on-line responsefor additional detail481-HAFLAT SALES TAX AMOUNT SUBMITTEDRWImp Guide: Required if its value has an effecton the Gross Amount Due (43Ø-DU)calculation.Payer Requirement: Refer to on-line responsefor additional detail482-GERWPERCENTAGE SALES TAX AMOUNTSUBMITTEDImp Guide: Required if its value has an effecton the Gross Amount Due (43Ø-DU)calculation.Payer Requirement: Refer to on-line responsefor additional detail483-HEPricing SegmentSegment Identification (111-AM) “11”PERCENTAGE SALES TAX RATESUBMITTEDClaim Billing/Claim RebillRWImp Guide: Required if Percentage Sales TaxAmount Submitted (482-GE) and PercentageSales Tax Basis Submitted (484-JE) are used.Required if this field could result in differentpricing.Required if needed to calculate PercentageSales Tax Amount Paid (559-AX).Payer Requirement: Refer to on-line responsefor additional detail484-JEPERCENTAGE SALES TAX BASISSUBMITTEDRWImp Guide: Required if Percentage Sales TaxAmount Submitted (482-GE) and PercentageSales Tax Rate Submitted (483-HE) are used.Required if this field could result in differentpricing.Required if needed to calculate PercentageSales Tax Amount Paid (559-AX).426-DQUSUAL AND CUSTOMARY CHARGER43Ø-DUGROSS AMOUNT DUER423-DNBASIS OF COST DETERMINATIONRImp Guide: Required if needed for receiverclaim/encounter adjudication.Payer Requirement: Refer to on-line responsefor additional detailPharmacy Provider SegmentThis Segment is situationalCheckXClaim Billing/Claim RebillThis segment may be required as determined by benefit design.Pharmacy Provider SegmentSegment Identification (111-AM) “Ø2”Claim Billing/Claim Rebill.- 11-

465-EYRProvider ID QualifierImp Guide: Required if Provider ID (444-E9) isused.Payer Requirement: Refer to on-line responsefor additional detail444-E9Provider IDRImp Guide: Required if necessary forstate/federal/regulatory agency programs.Required if necessary to identify the individualresponsible for dispensing of the prescription.Required if needed for reconciliation ofencounter-reported data or encounter reporting.Prescriber SegmentThis Segment is situationalField #466-EZPrescriber SegmentSegment Identification (111-AM) “Ø3”NCPDP Field NameCheckXClaim Billing/Claim RebillThis segment may be required as determined by benefit design.Claim Billing/Claim RebillValuePayerUsageMPRESCRIBER ID QUALIFIERPayer SituationImp Guide: Required if Prescriber ID (411-DB)is used.Payer Requirement: Refer to on-line responsefor additional detail411-DBPRESCRIBER IDMImp Guide: Required if this field could result indifferent coverage or patient financialresponsibility.Required if necessary forstate/federal/regulatory agency programs.Payer Requirement: Refer to on-line responsefor additional detail427-DRPRESCRIBER LAST NAMEMImp Guide: Required when the Prescriber ID(411-DB) is not known.Required if needed for Prescriber ID (411-DB)validation/clarification.Payer Requirement: Refer to on-line responsefor additional detail.- 12-

498-PMPRESCRIBER PHONE NUMBERRWImp Guide: Required if needed for Workers‘Compensation.Required if needed to assist in identifying theprescriber.Required if needed for Prior Authorizationprocess.Payer Requirement: Refer to on-lineresponse for additional detail468-2EPRIMARY CARE PROVIDER ID QUALIFIERRWImp Guide: Required if Primary Care ProviderID (421-DL) is used.Payer Requirement: Refer to on-lineresponse for additional detail421-DLPRIMARY CARE PROVIDER IDRWImp Guide: Required if needed for receiverclaim/encounter determination, if known andavailable.Required if this field could result in differentcoverage or patient financial responsibility.Required if necessary forstate/federal/regulatory agency programs.Payer Requirement: Refer to on-lineresponse for additional detailPrescriber SegmentSegment Identification (111-AM) “Ø3”47Ø-4EClaim Billing/Claim RebillPRIMARY CARE PROVIDER LAST NAMERWImp Guide: Required if this field is used as analternative for Primary Care Provider ID (421DL) when ID is not known.Required if needed for Primary Care ProviderID (421-DL) validation/clarification.Payer Requirement: Refer to on-lineresponse for additional detail364-2JPRESCRIBER FIRST NAMERWImp Guide: Required if needed to assist inidentifying the prescriber.Required if necessary forstate/federal/regulatory agency programs.365-2KPRESCRIBER STREET ADDRESSRWPayer Requirement: Refer to on-lineresponse for additional detailImp Guide: Required if needed to assist inidentifying the prescriber.Required if necessary forstate/federal/regulatory agency programs.Payer Requirement: Refer to on-lineresponse for additional detail.- 13-

366-2MPRESCRIBER CITY ADDRESSRWImp Guide: Required if needed to assist inidentifying the prescriber.Required if necessary forstate/federal/regulatory agency programs.367-2NPRESCRIBER STATE/PROVINCEADDRESSRWPayer Requirement: Refer to on-lineresponse for additional detailImp Guide: Required if needed to assist inidentifying the prescriber.Required if necessary forstate/federal/regulatory agency programs.368-2PPRESCRIBER ZIP/POSTAL ZONERWPayer Requirement: Refer to on-lineresponse for additional detailImp Guide: Required if needed to assist inidentifying the prescriber.Required if necessary forstate/federal/regulatory agency programs.Payer Requirement: Refer to on-lineresponse for additional detail.- 14-

Coordination of Benefits/Other Payments SegmentCheckThis Segment is situationalXClaim BillingRequired only for secondary, tertiary, etc claims.Rather than provide separate payer sheets that are very repetitive, we have opted to indicate here the 2 types of COB methods for billing that aresupported by the plans in the General Information section.Scenario 1 - Other Payer Amount Paid Repetitions OnlyXScenario 2 - Other Payer-Patient Responsibility AmountRepetitions and Benefit Stage Repetitions OnlyXScenario 1 - Other Payer Amount Paid Repetitions OnlyCoordination of Benefits/OtherPayments SegmentSegment Identification (111-AM) “Ø5”Field #337-4C338-5CNCPDP Field NameCOORDINATION OF BENEFITS/OTHERPAYMENTS COUNTOTHER PAYER COVERAGE TYPEClaim Billing/Claim RebillValueMaximum count of 9.PayerUsageMBlank Not SpecifiedMScenario 1 - Other Payer Amount PaidRepetitions OnlyPayer SituationØ1 Primary – FirstØ2 Secondary – SecondØ3 Tertiary – ThirdØ4 Quaternary – FourthØ5 Quinary – FifthØ6 Senary – SixthØ7 Septenary – SeventhØ8 Octonary – EighthØ9 Nonary – Ninth339-6C34Ø-7COTHER PAYER ID QUALIFIERRWOTHER PAYER IDRWImp Guide: Required if Other Payer ID (34Ø7C) is used.Payer Requirement: Refer to on-line responsefor additional detailImp Guide: Required if identification of theOther Payer is necessary for claim/encounteradjudication.Payer Requirement: Refer to on-line responsefor additional detail443-E8341-HB342-HCOTHER PAYER DATEOTHER PAYER AMOUNT PAID COUNTRWMaximum count of 9.OTHER PAYER AMOUNT PAID QUALIFIERRWRWImp Guide: Required if identification of theOther Payer Date is necessary forclaim/encounter adjudication.Payer Requirement: Refer to on-lineresponse for additional detailImp Guide: Required if Other Payer AmountPaid Qualifier (342-HC) is used.Payer Requirement: Refer to on-line responsefor additional detailImp Guide: Required if Other Payer AmountPaid (431-DV) is used.Payer Requirement: Refer to on-line responsefor additional detail.- 14 -

Coordination of Benefits/OtherPayments SegmentSegment Identification (111-AM) “Ø5”431-DVClaim Billing/Claim RebillScenario 1 - Other Payer Amount PaidRepetitions OnlyOTHER PAYER AMOUNT PAIDRWImp Guide: Required if other payer hasapproved payment for some/all of the billing.Not used for patient financial responsibility onlybilling.Not used for non-governmental agencyprograms if Other Payer-Patient ResponsibilityAmount (352-NQ) is submitted.471-5EOTHER PAYER REJECT COUNTRWPayer Requirement: Refer to on-line responsefor additional detailImp Guide: Required if Other Payer RejectCode (472-6E) is used.Payer Requirement: Refer to on-lineresponse for additional detail472-6EOTHER PAYER REJECT CODERWImp Guide: Required when the other payer hasdenied the payment for the billing.Payer Requirement: Refer to on-lineresponse for additional detailScenario 2 - Other Payer-Patient Responsibility Amount Repetitions and Benefit Stage Repetitions OnlyCoordination of Benefits/OtherPayments SegmentSegment Identification (111-AM) “Ø5”Field #337-4C338-5CNCPDP Field NameCOORDINATION OF BENEFITS/OTHERPAYMENTS COUNTOTHER PAYER COVERAGE TYPEClaim Billing/Claim RebillScenario 2 - Other Payer – PatientResponsibility Amount Repetitions andBenefit Stage Repetitions OnlyValueMaximum count of 9.PayerUsageMBlank Not SpecifiedMPayer SituationØ1 Primary – FirstØ2 Secondary – SecondØ3 Tertiary – ThirdØ4 Quaternary – FourthØ5 Quinary – FifthØ6 Senary – SixthØ7 Septenary – SeventhØ8 Octonary – EighthØ9 Nonary – Ninth339-6COTHER PAYER ID QUALIFIERRWImp Guide: Required if Other Payer ID (34Ø7C) is used.Payer Requirement: Refer to on-line responsefor additional detail34Ø-7COTHER PAYER IDRWImp Guide: Required if identification of theOther Payer is necessary for claim/encounteradjudication.Payer Requirement: Refer to on-line responsefor additional detail.- 15 -

Coordination of Benefits/OtherPayments SegmentSegment Identification (111-AM) “Ø5”443-E8Claim Billing/Claim RebillScenario 2 - Other Payer – PatientResponsibility Amount Repetitions andBenefit Stage Repetitions OnlyOTHER PAYER DATERWImp Guide: Required if identification of theOther Payer Date is necessary forclaim/encounter adjudication.Payer

For Catamaran Medicare Part D- Please see the Catamaran Med D specific payer sheet for processing . Customer Care/Pharmacy Help Desk: 1-8ØØ-244-6224 Prior Authorization: TBD Certification Testing Window: No Certification Required . 326-CQ PATIENT PHONE NUMBER RW Imp Guide: Optional. Payer Requirement: Refer to on-line response for .