Download D.0 Payer Sheet (Reversal Only)

Maryland Medical Assistance Program
ADAP
Request Claim Reversal Payer Sheet
** Start of Request Claim Reversal (B2) Payer Sheet Template**
GENERAL INFORMATION
Payer Name: Maryland Medical Assistance Program
Date: January 1, 2Ø12
Plan Name/Group Name: Maryland AIDS Drug Assistance Program BIN: 61ØØ84
(MADAP)
Plan Name/Group Name: Maryland AIDS Drug Assistance Program
(MADAP) (test)
Payer Usage
Column
MANDATORY
PCN: DRAPPROD = Production
PCN: DRAPPROD01 = Production
(For all Medicare Part D
beneficiaries)
PCN: DRAPACCP = Test
BIN: 61ØØ84
FIELD LEGEND FOR COLUMNS
Value
Explanation
M
The Field is mandatory for the Segment in the
designated Transaction.
REQUIRED
R
QUALIFIED REQUIREMENT
RW
The Field has been designated with the situation of
“Required” for the Segment in the designated
Transaction.
“Required when”. The situations designated have
qualifications for usage (“Required if x”, “Not
required if y”).
Question
What is your reversal window? (If transaction is billed today
what is the timeframe for reversal to be submitted?) Specify
timeframe
Payer Situation
Column
No
No
Yes
Answer
?
CLAIM REVERSAL TRANSACTION
The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard
Implementation Guide Version D.Ø.
Transaction Header Segment Questions
This Segment is always sent
Source of certification IDs required in Software
Vendor/Certification ID (11Ø-AK) is Not used
Field #
Transaction Header Segment
NCPDP Field Name
1Ø1-A1
1Ø2-A2
1Ø3-A3
1Ø4-A4
BIN NUMBER
VERSION/RELEASE NUMBER
TRANSACTION CODE
PROCESSOR CONTROL NUMBER
1Ø9-A9
2Ø2-B2
TRANSACTION COUNT
SERVICE PROVIDER ID QUALIFIER
2Ø1-B1
4Ø1-D1
11Ø-AK
SERVICE PROVIDER ID
DATE OF SERVICE
SOFTWAREVENDOR/CERTIFICATION ID
Check
Claim Reversal
If Situational, Payer Situation
X
X
Value
610084
DØ
B2
DRAPPROD = Production
DRAPPROD01 = Production
(For all Medicare Part D
beneficiaries)
DRAPACCP = Test.
1 = One Occurrence
Ø1 = National Provider
Identifier (NPI).
NPI Number
CCYYMMDD
This will be provided by the
provider's software vender
Payer
Usage
M
M
M
M
Claim Reversal
Payer Situation
M
M
M
M
M
If no number is supplied, populate with zeros
Insurance Segment Questions
Check
This Segment is always sent
Field #
3Ø2-C2
3Ø1-C1
X
Insurance Segment
Segment Identification (111-AM) = “Ø4”
NCPDP Field Name
Claim Reversal
Value
Recipient’s 11 digit MADAP ID
MADAP
CARDHOLDER ID
GROUP ID
Claim Segment Questions
Check
This Segment is always sent
X
Field #
Claim Reversal
If Situational, Payer Situation
Claim Segment
Segment Identification (111-AM) = “Ø7”
NCPDP Field Name
Payer
Usage
M
R
Payer Situation
Claim Reversal
If Situational, Payer Situation
Claim Reversal
Value
Payer
Usage
M
455-EM
PRESCRIPTION/SERVICE REFERENCE
NUMBER QUALIFIER
1 = RX Billing
4Ø2-D2
Number assigned by pharmacy
M
436-E1
4Ø7-D7
4Ø3-D3
PRESCRIPTION/SERVICE REFERENCE
NUMBER
PRODUCT/SERVICE ID QUALIFIER
PRODUCT/SERVICE ID
FILL NUMBER
Ø3 = NDC
NDC Number
Ø = Original Dispensing
1-99 = Number of refills
M
M
R
3Ø8-C8
OTHER COVERAGE CODE
Ø=Not Specified
1=No other Coverage Identified
2=Other coverage existspayment collected
3=Other coverage exists-this
claim not covered
4=Other coverage existspayment not collected
RW
Payer Situation
For Transaction Code of “B2”, in the Claim
Segment, the Prescription/Service
Reference Number Qualifier (455-EM) is “1”
(Rx Billing).
Imp Guide: Required if needed for reversals
when multiple fills of the same
Prescription/Service Reference Number (4Ø2D2) occur on the same day.
Imp Guide: Required if needed by receiver to
match the claim that is being reversed.
** End of Request Claim Reversal (B2) Payer Sheet Template**
RESPONSE CLAIM REVERSAL PAYER SHEET TEMPLATE
CLAIM REVERSAL ACCEPTED/APPROVED RESPONSE
** Start of Claim Reversal Response (B2) Payer Sheet Template**
GENERAL INFORMATION
Payer Name: Maryland Medical Assistance Program
Date: January 1, 2Ø12
Plan Name/Group Name: Maryland AIDS Drug Assistance Program BIN: 61ØØ84
(MADAP)
Plan Name/Group Name: Maryland AIDS Drug Assistance Program
(MADAP)
PCN: DRAPPROD = Production
PCN: DRAPPROD01 = Production
(For all Medicare Part D beneficiaries)
PCN: DRAPACCP = Test
BIN: 61ØØ84
CLAIM REVERSAL ACCEPTED/APPROVED RESPONSE
The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP
Telecommunication Standard Implementation Guide Version D.Ø.
Response Transaction Header Segment Questions
This Segment is always sent
Response Transaction Header Segment
Check
Claim Reversal – Accepted/Approved
If Situational, Payer Situation
X
Claim Reversal – Accepted/Approved
Field #
NCPDP Field Name
Value
1Ø2-A2
1Ø3-A3
1Ø9-A9
5Ø1-F1
2Ø2-B2
VERSION/RELEASE NUMBER
TRANSACTION CODE
TRANSACTION COUNT
HEADER RESPONSE STATUS
SERVICE PROVIDER ID QUALIFIER
2Ø1-B1
4Ø1-D1
SERVICE PROVIDER ID
DATE OF SERVICE
DØ
B2
1 = One Occurrence
A = Accepted
Ø1 = National Provider Identifier
(NPI).
NPI Number
CCYYMMDD
Response Status Segment Questions
Check
This Segment is always sent
Field #
112-AN
5Ø3-F3
13Ø-UF
132-UH
526-FQ
131-UG
Payer Situation
M
M
Claim Reversal – Accepted/Approved
If Situational, Payer Situation
X
Response Status Segment
Segment Identification (111-AM) = “21”
NCPDP Field Name
TRANSACTION RESPONSE STATUS
AUTHORIZATION NUMBER
ADDITIONAL MESSAGE INFORMATION
COUNT
ADDITIONAL MESSAGE INFORMATION
QUALIFIER
ADDITIONAL MESSAGE INFORMATION
Claim Reversal – Accepted/Approved
Value
A = Approved
17-digit MD TCN
Maximum count of 25.
RW
RW
Check
This Segment is always sent
Payer
Usage
M
R
RW
RW
ADDITIONAL MESSAGE INFORMATION
CONTINUITY
Response Claim Segment Questions
Field #
Payer
Usage
M
M
M
M
M
Payer Situation
Required if Additional Message Information
(526-FQ) is used.
Required if Additional Message Information
(526-FQ) is used.
Required when additional text is needed for
clarification or detail.
Required if and only if current repetition of
Additional Message Information (526-FQ) is
used, another populated repetition of Additional
Message Information (526-FQ) follows it, and
the text of the following message is a
continuation of the current.
Claim Reversal – Accepted/Approved
If Situational, Payer Situation
X
Response Claim Segment
Segment Identification (111-AM) = “22”
NCPDP Field Name
Claim Reversal – Accepted/Approved
Value
Payer
Usage
M
455-EM
PRESCRIPTION/SERVICE REFERENCE
NUMBER QUALIFIER
1 = RxBilling
4Ø2-D2
PRESCRIPTION/SERVICE REFERENCE
NUMBER
Number assigned by the
pharmacy
Payer Situation
For Transaction Code of “B2”, in the
Response Claim Segment, the
Prescription/Service Reference Number
Qualifier (455-EM) is “1” (Rx Billing).
M
CLAIM REVERSAL ACCEPTED/REJECTED RESPONSE
Response Transaction Header Segment Questions
This Segment is always sent
Field #
1Ø2-A2
1Ø3-A3
1Ø9-A9
5Ø1-F1
2Ø2-B2
Response Transaction Header Segment
NCPDP Field Name
VERSION/RELEASE NUMBER
TRANSACTION CODE
TRANSACTION COUNT
HEADER RESPONSE STATUS
SERVICE PROVIDER ID QUALIFIER
Check
Claim Reversal - Accepted/Rejected
If Situational, Payer Situation
X
Value
DØ
B2
1 = One Occurrence
A = Accepted
Ø1 = National Provider Identifier
(NPI).
Payer
Usage
M
M
M
M
M
Claim Reversal – Accepted/Rejected
Payer Situation
Field #
2Ø1-B1
4Ø1-D1
Response Transaction Header Segment
NCPDP Field Name
Value
SERVICE PROVIDER ID
DATE OF SERVICE
NPI Number
CCYYMMDD
Response Message Segment Questions
This Segment is situational
Field #
5Ø4-F4
Response Message Segment
Segment Identification (111-AM) = “2Ø”
NCPDP Field Name
This Segment is always sent
112-AN
5Ø3-F3
51Ø-FA
511-FB
546-4F
13Ø-UF
132-UH
526-FQ
131-UG
Response Status Segment
Segment Identification (111-AM) = “21”
NCPDP Field Name
TRANSACTION RESPONSE STATUS
AUTHORIZATION NUMBER
REJECT COUNT
REJECT CODE
REJECT FIELD OCCURRENCE
INDICATOR
ADDITIONAL MESSAGE INFORMATION
COUNT
ADDITIONAL MESSAGE INFORMATION
QUALIFIER
ADDITIONAL MESSAGE INFORMATION
Claim Reversal – Accepted/Approved
Value
Payer
Usage
RW
Check
This Segment is always sent
Response Claim Segment
Segment Identification (111-AM) = “22”
NCPDP Field Name
Payer Situation
Required if text is needed for clarification or
detail.
Claim Reversal – Accepted/Approved
If Situational, Payer Situation
X
Claim Reversal – Accepted/Rejected
Value
R = Reject
Maximum count of 5.
Maximum count of 25.
Payer
Usage
M
R
R
R
RW
RW
RW
RW
ADDITIONAL MESSAGE INFORMATION
CONTINUITY
Response Claim Segment Questions
Field #
X
Claim Reversal – Accepted/Rejected
Payer Situation
Claim Reversal - Accepted/Rejected
If Situational, Payer Situation
Segment sent if required for reject clarification
MESSAGE
Response Status Segment Questions
Field #
Check
Payer
Usage
M
M
Check
Payer Situation
Required if a repeating field is in error, to
identify repeating field occurrence.
Imp Guide: Required if Additional Message
Information (526-FQ) is used.
Required if Additional Message Information
(526-FQ) is used.
Required when additional text is needed for
clarification or detail.
Imp Guide: Required if and only if current
repetition of Additional Message Information
(526-FQ) is used, another populated repetition
of Additional Message Information (526-FQ)
follows it, and the text of the following
message is a continuation of the current.
Claim Reversal - Accepted/Rejected
If Situational, Payer Situation
X
Claim Reversal – Accepted/Rejected
Value
455-EM
PRESCRIPTION/SERVICE REFERENCE
NUMBER QUALIFIER
1 = RxBilling
4Ø2-D2
PRESCRIPTION/SERVICE REFERENCE
NUMBER
Number assigned by the
pharmacy
Payer
Usage
M
M
Payer Situation
For Transaction Code of “B2”, in the
Response Claim Segment, the
Prescription/Service Reference Number
Qualifier (455-EM) is “1” (Rx Billing).
CLAIM REVERSAL REJECTED/REJECTED RESPONSE
Response Transaction Header Segment Questions
Check
This Segment is always sent
Field #
X
Claim Reversal – Rejected/Rejected
Response Transaction Header
Segment
NCPDP Field Name
Value
1Ø2-A2
1Ø3-A3
1Ø9-A9
5Ø1-F1
2Ø2-B2
VERSION/RELEASE NUMBER
TRANSACTION CODE
TRANSACTION COUNT
HEADER RESPONSE STATUS
SERVICE PROVIDER ID QUALIFIER
2Ø1-B1
4Ø1-D1
SERVICE PROVIDER ID
DATE OF SERVICE
Response Message Segment Questions
5Ø4-F4
X
Response Message Segment
Segment Identification (111-AM) = “2Ø”
NCPDP Field Name
112-AN
5Ø3-F3
51Ø-FA
511-FB
546-4F
13Ø-UF
132-UH
526-FQ
131-UG
Payer Situation
M
M
Claim Reversal – Accepted/Approved
Value
Check
This Segment is always sent
Payer
Usage
M
M
M
M
M
Claim Reversal – Rejected/Rejected
If Situational, Payer Situation
Segment sent if required for reject clarification
Payer
Usage
RW
MESSAGE
Response Status Segment Questions
Field #
DØ
B2
1 = One Occurrence
R = Rejected
Ø1 = National Provider Identifier
(NPI).
NPI Number
CCYYMMDD
Check
This Segment is situational
Field #
Claim Reversal - Rejected/Rejected
If Situational, Payer Situation
Payer Situation
Required if text is needed for clarification or
detail.
Claim Reversal - Rejected/Rejected
If Situational, Payer Situation
X
Response Status Segment
Segment Identification (111-AM) = “21”
NCPDP Field Name
TRANSACTION RESPONSE STATUS
AUTHORIZATION NUMBER
REJECT COUNT
REJECT CODE
REJECT FIELD OCCURRENCE
INDICATOR
ADDITIONAL MESSAGE INFORMATION
COUNT
ADDITIONAL MESSAGE INFORMATION
QUALIFIER
ADDITIONAL MESSAGE INFORMATION
ADDITIONAL MESSAGE INFORMATION
CONTINUITY
Claim Reversal – Rejected/Rejected
Value
R = Reject
Maximum count of 5.
Maximum count of 25.
Payer
Usage
M
R
R
R
RW
RW
RW
RW
RW
Payer Situation
Required if a repeating field is in error, to
identify repeating field occurrence.
Required if Additional Message Information
(526-FQ) is used.
Required if Additional Message Information
(526-FQ) is used.
Imp Guide: Required when additional text is
needed for clarification or detail.
Imp Guide: Required if and only if current
repetition of Additional Message Information
(526-FQ) is used, another populated
repetition of Additional Message Information
(526-FQ) follows it, and the text of the
following message is a continuation of the
current.
Payer Requirement: (any unique payer
requirement(s))
** End of Claim Reversal (B2) Response Payer Sheet Template**