Download Payer Sheet - Primary - Envolve Pharmacy Solutions

Envolve Pharmacy Solutions NCPDP D.0 Claim Billing EPS-CNC Primary Payer Sheet
NCPDP VERSION D.0 CLAIM BILLING MEDICAID/COMMERCIAL
REQUEST CLAIM BILLING PRIMARY PAYER SHEET
GENERAL INFORMATION
Payer Name: Envolve Pharmacy Solutions
Date: 03/20/2015
Plan Name/Group Name: Medicaid/Commercial/Non Medicare D Plans
BIN: ØØ8Ø19
PCN:
Plan Name/Group Name: Magnolia Health Plan
BIN: ØØ8Ø19
PCN:
Plan Name/Group Name: Magnolia Health Plan - CHIP
BIN: ØØ8Ø19
PCN: MSCHIP
Plan Name/Group Name: Centene Corp.
BIN: Ø16788
PCN:
Processor: Envolve Pharmacy Solutions
Effective as of: 4/1/2015
NCPDP Telecommunication Standard Version/Release #: D.0
NCPDP Data Dictionary Version Date: July 2007
NCPDP External Code List Version Date: October 2013
Contact/Information Source: ITS Service Desk (800) 460-8988
Certification Testing Window:
Certification Contact Information:
Provider Relations Help Desk Info: (800) 460-8988
OTHER TRANSACTIONS SUPPORTED
Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.
Transaction Code
Transaction Name
B1
Billing
B2
Reversal
FIELD LEGEND FOR COLUMNS
Explanation
Payer Usage
Column
Value
Payer Situation
Column
MANDATORY
M
The Field is mandatory for the Segment in the designated
Transaction.
No
REQUIRED
R
The Field has been designated with the situation of
"Required" for the Segment in the designated Transaction.
No
QUALIFIED REQUIREMENT
RW
“Required when”. The situations designated have
qualifications for usage ("Required if x", "Not required if y").
Yes
Fields that are not used in the Claim Billing transactions and those that do not have qualified requirements (i.e. not used)
for this payer are excluded from the template.
CLAIM BILLING TRANSACTION
Transaction Header Segment Questions
This Segment is always sent
Source of certification IDs required in Software
Vendor/Certification ID (11Ø-AK) is Payer Issued
Source of certification IDs required in Software
Vendor/Certification ID (11Ø-AK) is Switch/VAN issued
Source of certification IDs required in Software
Vendor/Certification ID (11Ø-AK) is Not used
Field #
1Ø1-A1
1Ø2-A2
1Ø3-A3
1Ø4-A4
1Ø9-A9
2Ø2-B2
Transaction Header Segment
NCPDP Field Name
BIN NUMBER
VERSION/RELEASE NUMBER
TRANSACTION CODE
PROCESSOR CONTROL NUMBER
TRANSACTION COUNT
SERVICE PROVIDER ID QUALIFIER
2Ø1-B1
4Ø1-D1
SERVICE PROVIDER ID
DATE OF SERVICE
Check
X
Claim Billing
X
Value
DØ
B1
1-4
Ø1=NPI
Ø7=NCPDP#
Payer Usage
M
M
M
M
M
M
Claim Billing Comment
Payer Situation
BIN listed in General Information
See General Information
M
M
“Materials Reproduced With the Consent of
©National Council for Prescription Drug Programs, Inc.
2Ø1Ø NCPDP”
03/20/2015
Page: 1
Envolve Pharmacy Solutions NCPDP D.0 Claim Billing EPS-CNC Primary Payer Sheet
Field #
11Ø-AK
Transaction Header Segment
NCPDP Field Name
SOFTWARE
VENDOR/CERTIFICATION ID
Value
M
Insurance Segment Questions
This Segment is always sent
Check
X
Insurance Segment
Segment Identification (111-AM) = “Ø4”
Field #
NCPDP Field Name
3Ø2-C2 CARDHOLDER ID
312-CC CARDHOLDER FIRST NAME
313-CD
CARDHOLDER LAST NAME
524-FO
3Ø1-C1
3Ø3-C3
3Ø6-C6
PLAN ID
GROUP ID
PERSON CODE
PATIENT RELATIONSHIP CODE
Payer Usage
Claim Billing
Claim Billing Comment
Value
Payer Usage
M
RW
RW
RW
RW
RW
Check
This Segment is always sent
Claim Billing Comment
Value
31Ø-CA PATIENT FIRST NAME
335-2C
PREGNANCY INDICATOR
384-4X
PATIENT RESIDENCE
Ø1=HOME Ø2=SKILLED NURSING
FACILITY Ø3=NURSING FACILITY
Ø4=ASSISTED LIVING FACILITY
Ø5=CUSTODIAL CARE FACILITY
Ø6=GROUP HOME Ø7=INPATIENT
PSYCHIATRIC FACILITY
Ø9=INTERMEDIATE CARE
FACILITY/MENTALLY RETARDED
11=HOSPICE 12=PSYCHIATRIC
RESIDENTIAL TREATMENT FACILITY
13=COMPREHENSIVE INPATIENT
REHABILITATION FACILITY
Claim Segment Questions
This Segment is always sent
This payer supports partial fills
This payer does not support partial fills
Field #
Needed for Worker’s Comp and POS Eligibility
Needed to identify specific multi-birth dependent.
Claim Billing
If Situational, Payer Situation
R3Ø4-C4 DATE OF BIRTH
3Ø5-C5 PATIENT GENDER CODE
PATIENT LAST NAME
POS Eligibility is allowed by the group; Otherwise
will not cause failure if not submitted
POS Eligibility is allowed by the group; Otherwise
will not cause failure if not submitted
X
Patient Segment
Segment Identification (111-AM) = “Ø1”
NCPDP Field Name
311-CB
Payer Situation
R
Patient Segment Questions
Field
Claim Billing Comment
Payer Situation
Software Vendor ID; Will not cause failure
Check
X
Payer
Payer Situation
Usage
Patient’s Date of Birth
R
POS Eligibility is allowed by the group;
RW
Otherwise will not cause failure if not
submitted
POS Eligibility is allowed by the group;
RW
Otherwise will not cause failure if not
submitted
POS Eligibility is allowed by the group;
RW
Otherwise will not cause failure if not
submitted
Group/plan dependent; otherwise will not
RW
cause failure if not submitted
Required for MHS-IN only
R
Claim Billing
X
Claim Segment
Segment Identification (111-AM) = “Ø7”
NCPDP Field Name
Claim Billing Comment
Value
Payer
Usage
Payer Situation
“Materials Reproduced With the Consent of
©National Council for Prescription Drug Programs, Inc.
2Ø1Ø NCPDP”
03/20/2015
Page: 2
Envolve Pharmacy Solutions NCPDP D.0 Claim Billing EPS-CNC Primary Payer Sheet
Field #
455-EM
4Ø2-D2
436-E1
Claim Segment
Segment Identification (111-AM) = “Ø7”
NCPDP Field Name
PRODUCT/SERVICE ID
QUANTITY DISPENSED
FILL NUMBER
4Ø5-D5
4Ø6-D6
DAYS SUPPLY
COMPOUND CODE
4Ø8-D8
DISPENSE AS WRITTEN (DAW)/PRODUCT
SELECTION CODE
DATE PRESCRIPTION WRITTEN
NUMBER OF REFILLS AUTHORIZED
PRESCRIPTION ORIGIN CODE
354-NX
Payer
Usage
1 = Rx Billing
Payer Situation
M
M
Ø1=UPC
Ø2=HRI
Ø3=NDC
M
M
R
R
R
42Ø-DK
SUBMISSION CLARIFICATION CODE
COUNT
SUBMISSION CLARIFICATION CODE
3Ø8-C8
OTHER COVERAGE CODE
1 = Not a Compound
2 = Compound
0,1,2,3,4,5,6,7,8,9
R
R
R
R
0,1,2,3,4,5
RW
Maximum count of 3.
RW
RW
0 = Unspecified
1 = No other coverage
3 = Other Coverage Billedclaim not covered
0 = Unspecified
3= Emergency
418-DI
LEVEL OF SERVICE
461-EU
PRIOR AUTHORIZATION TYPE CODE
462-EV
995-E2
PRIOR AUTHORIZATION NUMBER
SUBMITTED
ROUTE OF ADMINISTRATION
996-G1
COMPOUND TYPE
Pricing Segment Questions
This Segment is always sent
Field #
Value
PRESCRIPTION/SERVICE REFERENCE
NUMBER QUALIFIER
PRESCRIPTION/SERVICE REFERENCE
NUMBER
PRODUCT/SERVICE ID QUALIFIER
4Ø7-D7
442-E7
4Ø3-D3
414-DE
415-DF
419-DJ
Claim Billing Comment
Pricing Segment
Segment Identification (111-AM) = “11”
NCPDP Field Name
PATIENT PAID AMOUNT SUBMITTED
438-E3
INCENTIVE AMOUNT SUBMITTED
481-HA
FLAT SALES TAX AMOUNT SUBMITTED
482-GE
PERCENTAGE SALES TAX AMOUNT
SUBMITTED
RW
Group/plan dependent; otherwise will not cause
failure if not submitted
Group/plan dependent; otherwise will not cause
failure if not submitted
Group/plan dependent; otherwise will not cause
failure if not submitted
Informational; will not cause failure if not submitted
RW
Informational; will not cause failure if not submitted
RW
RW
Claim Billing
Claim Billing Comment
Value
Payer
Payer Situation
Usage
R
RW
Imp Guide: Required if its value has an effect on the
Gross Amount Due (43Ø-DU) calculation.
Imp Guide: Required if this field could result in
RW
different coverage, pricing, or patient financial
responsibility.
Imp Guide: Required if its value has an effect on the
RW
Gross Amount Due (43Ø-DU) calculation.
4Ø9-D9 INGREDIENT COST SUBMITTED
412-DC DISPENSING FEE SUBMITTED
433-DX
R
RW
Check
X
Group/plan dependent; otherwise will not cause
failure if not submitted
Payer Requirement: Required if Submission
Clarification Code is sent.
Group/plan dependent; otherwise will not cause
failure if not submitted
RW
RW
Imp Guide: Required if its value has an effect on the
Gross Amount Due (43Ø-DU) calculation.
Imp Guide: Required if its value has an effect on the
Gross Amount Due (43Ø-DU) calculation.
“Materials Reproduced With the Consent of
©National Council for Prescription Drug Programs, Inc.
2Ø1Ø NCPDP”
03/20/2015
Page: 3
Envolve Pharmacy Solutions NCPDP D.0 Claim Billing EPS-CNC Primary Payer Sheet
Field #
483-HE
Pricing Segment
Segment Identification (111-AM) = “11”
NCPDP Field Name
Claim Billing Comment
Value
Payer
Usage
PERCENTAGE SALES TAX RATE
SUBMITTED
Imp Guide: Required if Percentage Sales Tax
Amount Submitted (482-GE) and Percentage Sales
Tax Basis Submitted (484-JE) are used.
RW
484-JE
Payer Situation
Required if this field could result in different pricing.
Required if needed to calculate Percentage Sales
Tax Amount Paid (559-AX).
Imp Guide: Required if Percentage Sales Tax
Amount Submitted (482-GE) and Percentage Sales
Tax Rate Submitted (483-HE) are used.
PERCENTAGE SALES TAX BASIS
SUBMITTED
RW
Required if this field could result in different pricing.
Required if needed to calculate Percentage Sales
Tax Amount Paid (559-AX).
426-DQ USUAL AND CUSTOMARY CHARGE
43Ø-DU GROSS AMOUNT DUE
R
R
423-DN
BASIS OF COST DETERMINATION
Prescriber Segment Questions
R
Check
This Segment is always sent
Field #
466-EZ
411-DB
Claim Billing
If Situational, Payer Situation
X
Prescriber Segment
Segment Identification (111-AM) = “Ø3”
NCPDP Field Name
PRESCRIBER ID QUALIFIER
Claim Billing Comment
Value
Payer
Usage
01 = NPI, 12 = DEA, 05 =
Medicaid, 08 = State Lic., 14 =
Plan specific, 99 = Other
PRESCRIBER ID
R
R
427-DR PRESCRIBER LAST NAME
498-PM PRESCRIBER PHONE NUMBER
R
RW
364-2J
PRESCRIBER FIRST NAME
367-2N
PRESCRIBER STATE/PROVINCE
ADDRESS
PRIMARY CARE PROVIDER ID QUALIFIER
468-2E
Payer Situation
RW
421-DL
PRIMARY CARE PROVIDER ID
47Ø-4E
PRIMARY CARE PROVIDER LAST NAME
RW
01 = NPI, 12 = DEA, 05 =
Medicaid, 08 = State Lic, 14 =
Plan Specific, 99 = Other
RW
RW
RW
Required if needed for Prescriber ID clarification.
Required if needed for Prescriber ID clarification.
Required if needed for Prescriber ID clarification.
Group/plan dependent; otherwise will not cause
failure if not submitted
Group/plan dependent; otherwise will not cause
failure if not submitted
Group/plan dependent; otherwise will not cause
failure if not submitted
“Materials Reproduced With the Consent of
©National Council for Prescription Drug Programs, Inc.
2Ø1Ø NCPDP”
03/20/2015
Page: 4
Envolve Pharmacy Solutions NCPDP D.0 Claim Billing EPS-CNC Primary Payer Sheet
Compound Segment Questions
Check
This Segment is situational
Field #
Claim Billing
If Situational, Payer Situation
Only required if at least one ingredient sent and compound type in claim
segment exists
X
Compound Segment
Segment Identification (111-AM) = “1Ø”
NCPDP Field Name
45Ø-EF COMPOUND DOSAGE FORM
DESCRIPTION CODE
451-EG COMPOUND DISPENSING UNIT FORM
INDICATOR
447-EC COMPOUND INGREDIENT COMPONENT
COUNT
488-RE COMPOUND PRODUCT ID QUALIFIER
Claim Billing Comment
Value
Payer
Usage
M
M
Maximum 25 ingredients
Ø1=UPC
Ø2=HRI
Ø3=NDC
M
M
489-TE COMPOUND PRODUCT ID
448-ED COMPOUND INGREDIENT QUANTITY
449-EE COMPOUND INGREDIENT DRUG COST
M
M
RW
49Ø-UE COMPOUND INGREDIENT BASIS OF COST
DETERMINATION
362-2G COMPOUND INGREDIENT MODIFIER
Maximum count of 1Ø.
CODE COUNT
363-2H COMPOUND INGREDIENT MODIFIER
CODE
RW
Clinical Segment Questions
Check
This Segment is situational
Field #
X
Clinical Segment
Segment Identification (111-AM) = “13”
NCPDP Field Name
491-VE DIAGNOSIS CODE COUNT
492-WE DIAGNOSIS CODE QUALIFIER
Payer Situation
RW
RW
Group/plan dependent; otherwise will not cause
failure if not submitted
Group/plan dependent; otherwise will not cause
failure if not submitted
Required when Compound Ingredient Modifier Code
(363-2H) is sent.
Group/plan dependent; otherwise will not cause
failure if not submitted
Claim Billing
If Situational, Payer Situation
This segment may be required as determined by benefit design.
Claim Billing Comment
Value
Maximum count of 5.
Ø1=ICD9
424-DO DIAGNOSIS CODE
Payer
Usage
R
R
Payer Situation
R
“Materials Reproduced With the Consent of
©National Council for Prescription Drug Programs, Inc.
2Ø1Ø NCPDP”
03/20/2015
Page: 5