Download Payer Specification Sheet

Payer Specification Sheet
for Prime Therapeutics’ Medicare Part D Clients
General information
Prime Therapeutics LLC
Plan Name
December 7, 2015
Arkansas Blue Cross Blue Shield Medi-Pak Rx (PDP)
Arkansas Blue Cross Blue Shield Medi-Pak Advantage MA-PD (PFFS)
Arkansas Blue Cross Blue Shield Medi-Pak Advantage (PPO)
Arkansas Blue Cross Blue Shield Medi-Pak Advantage (HMO)
Arkansas Blue Cross Blue Shield Medi-Pak Rx Group (PDP)
BCBS of Alabama Blue Advantage (MA-PD)
BCBS of Alabama BlueRx (PDP) Employer Group
BCBS of Alabama BlueRx (PDP)
UTIC Insurance Company
BCBS of Florida
Florida Blue BlueMedicare Preferred HMO
Florida Healthcare Plans BlueMedicare Preferred HMO
BCBS of Florida Employer Groups
BCBS of North Carolina Blue Medicare HMO (MA-PD)
BCBS of North Carolina Blue Medicare PPO (MA-PD)
BCBS of North Carolina Blue Medicare Rx (PDP)
BCBS of North Carolina Blue Medicare HMO Enhanced Employer Group (MA-PD)
BCBS of North Carolina Blue Medicare PPO Enhanced Freedom Employer Group (MA-PD)
BCBS of North Carolina Blue Medicare Rx (PDP) Enhanced Employer Group
BCBS of South Carolina MedBlue Rx and MedBlue Rx +Plus (PDP)
BCBS of South Carolina Blue Retiree Rx and Blue Retiree Rx +Plus (PDP)
HISC BCBS of Illinois Blue Cross Medicare Advantage (HMO)
HISC BCBS of Illinois Blue Cross Medicare Advantage (PPO)
HISC BCBS of Illinois Blue Cross Medicare Advantage (HMO)
HISC BCBS of Illinois Blue Cross Medicare Advantage Employer Group (PPO)
HISC BCBS of Illinois Blue Cross MedicareRx Employer Groups (PDP)
HISC BCBS of Illinois Blue Cross MedicareRx (PDP)
HISC BCBS of Illinois Blue Cross Community MMAI (Medicare-Medicaid Plan)
HISC BCBS of Montana Blue Cross Medicare Advantage (PPO)
HISC BCBS of Montana Blue Cross Medicare Advantage Employer Group (PPO)
HISC BCBS of New Mexico Blue Cross Medicare Advantage (HMO)
HISC BCBS of New Mexico Blue Cross Medicare Advantage Employer Groups
HISC BCBS of New MexicoBlue Cross MedicareRx Employer Groups (PDP)
HISC BCBS of New Mexico Blue Cross MedicareRx (PDP)
HISC BCBS of New Mexico Blue Cross Medicare Advantage Choice (PPO)
HISC BCBS of New Mexico Blue Cross Medicare Advantage (PPO)
HISC BCBS of New Mexico Blue Cross Medicare Advantage (HMO)
HISC BCBS of New Mexico Blue Cross Medicare Advantage Dual Care (HMO SNP)
HISC BCBS of Oklahoma Blue Cross Medicare Advantage Basic or Premier Plus (HMO)
HISC BCBS of Oklahoma Blue Cross Medicare Advantage Choice (PPO)
HISC BCBS of Oklahoma Blue Cross Medicare Advantage (HMO)
HISC BCBS of Oklahoma Blue Cross Medicare Advantage (PPO)
HISC BCBS of Texas Blue Cross Medicare Advantage (PPO)
HISC BCBS of Texas Blue Cross Medicare Advantage (HMO)
HISC BCBS of Texas Blue Cross Medicare Advantage Employer Groups (PPO)
HISC BCBS of Texas Blue Cross Medicare Advantage Employer Group (PPO)
HISC BCBS of Texas Blue Cross Medicare Advantage Employer Groups
BIN
Ø16895
Ø14897
PCN
PDPAR
PFFSAR
PPOAR
HMOAR
PDPARG
MBG
RPDG
RPD
Ø12833
Ø159Ø5
Ø16862
Ø11552
MEDDPRIME
MEDDPRIMEG
HMONC
PPONC
PDPNC
HMONCG
PPONCG
PDPNCG
PDPSC
PDPSCG
MAPDIL
MAPDIL1
MAPDILG
MAPDILG1
PDGIL
PDPIL
ILDEMD
MAPDMT
MAPDMTG
MAPDNM
MPGNM
PDGNM
PDPNM
NMPARTD1
NMPARTDG
MAPDNMG
NMSNP
MAPDOK
MAPDOK1
MAPDOKG
OKMAPDG
MAPDTX
MAPDTX1
MAPDTXG
MAPDTXG2
MPGTX
Page 1 of 14
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Medicare Part D Clients © Prime Therapeutics LLC 07/11
Payer Specification Sheet
for Prime Therapeutics’ Medicare Part D Clients
HISC BCBS of Texas Blue Cross MedicareRx Employer Groups (PDP)
HISC BCBS of Texas Blue Cross MedicareRx (PDP)
HISC BCBS of Texas Blue Cross Medicare Advantage Dual Care (HMO SNP)
Horizon BCBS of New Jersey Medicare Blue Value w/Rx Standard (HMO)
Horizon BSBS of New Jersey Medicare BlueRx Standard and Enhanced (PDP)
Horizon BCBS of New Jersey Medicare Blue PPO (MA-PD)
Horizon BCBS of New Jersey Medicare Blue Access Group w/ Rx (HMO-POS)
Horizon BCBS of New Jersey Medicare Blue Group w/ Rx (Group PDP)
Horizon BCBS of New Jersey Medicare Advantage Group PPO w/ Rx
BCBS of Minnesota (Secure Blue (MSHO))BCBS of Minnesota (Secure Blue (MSHO))
BCBS of Minnesota Platinum Blue with Rx (Cost)
Blue Plus Medicare Advantage BCBS of Oklahoma (Employer Groups PDP Region 23)
Blue Plus Medicare Advantage BCBS of Oklahoma PDP Region 23
Capital Health Plan Medicare Advantage Plus (HMO) and Preferred Advantage (HMO)
Capital Health Plan Medicare Retiree Advantage (HMO)
Alignment Health Plan
Ø16499
61Ø455
PDGTX
PDPTX
TXSNP
HMOPOSNJ
PDPNJ
PPONJ
HMOPOSNJG
PDPNJG
PPONJG
MPDBP
MPDPB
PDGOK
PDPOK
MEDDADV
MEDDADVG
AHPPARTD
Page 2 of 14
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Medicare Part D Clients © Prime Therapeutics LLC 07/11
Payer Specification Sheet
for Prime Therapeutics’ Medicare Part D Clients
Processor
Effective as of: Ø9/Ø1/2Ø11
NCPDP Telecommunication Standard
Version/Release #: D.Ø
NCPDP Data Dictionary Version Date: July 2ØØ7
NCPDP External Code List Version Date:
October 2Ø14
Contact/Information Source: Prime Contact Center Phone number 8ØØ.821.4795. Other reference
materials are available on Prime’s web site.
http://www.primetherapeutics.com/pharmacistsindex.html
Other versions supported: Will continue to accept NCPDP Telecommunication version 5.1 based upon
the CMS statement of “Discretionary Enforcement” until Ø3/3Ø/2Ø12
OTHER TRANSACTIONS SUPPORTED
Transaction Code
B2
FIELD LEGEND FOR COLUMNS
Payer Usage
Value
Column
MANDATORY
M
Transaction Name
Reversals
Explanation
Payer Situation
Column
No
The Field is mandatory for the
Segment in the designated
Transaction.
REQUIRED
R
The Field has been designated
No
with the situation of "Required"
for the Segment in the
designated Transaction.
QUALIFIED REQUIREMENT
RW
“Required when”. The situations
Yes
designated have qualifications for
usage ("Required if x", "Not
required if y").
Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have
qualified requirements (i.e. not used) are excluded from the template.
CLAIM BILLING/CLAIM REBILL TRANSACTION
The following lists the segments and fields in a Claim Billing or Claim Rebill Transaction for the NCPDP
Telecommunication Standard Implementation Guide Version D.Ø.
Page 3 of 14
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Medicare Part D Clients © Prime Therapeutics LLC 07/11
Payer Specification Sheet
for Prime Therapeutics’ Medicare Part D Clients
Transaction Header Segment
Questions
This Segment is always sent
Source of certification IDs
required in Software
Vendor/Certification ID (11ØAK) is Not used
Claim Billing/Claim Rebill
If Situational, Payer Situation
Check
X
X
Transaction Header Segment
Field #
1Ø1-A1
NCPDP Field Name
BIN NUMBER
Value
Multiple
Payer Usage
M
1Ø2-A2
1Ø3-A3
1Ø4-A4
VERSION/RELEASE NUMBER
TRANSACTION CODE
PROCESSOR CONTROL NUMBER
DØ
B1
Multiple
M
M
M
1Ø9-A9
TRANSACTION COUNT
Ø1-Ø4
M
2Ø2-B2
2Ø1-B1
4Ø1-D1
11Ø-AK
SERVICE PROVIDER ID QUALIFIER
SERVICE PROVIDER ID
DATE OF SERVICE
SOFTWARE VENDOR/CERTIFICATION
ID
Ø1-NPI
M
M
M
M
Insurance Segment Questions
Field #
3Ø2-C2
Insurance Segment
Segment Identification
(111-AM) = “Ø4”
NCPDP Field Name
PCN’s listed in
General
Information
Section
Up to 4
transactions per
B1 transmissions
accepted
CCYYMMDD
Use value for
Switch’s
requirements
Claim Billing/Claim Rebill
If Situational, Payer Situation
Check
This Segment is always sent
Claim
Billing/Claim
Rebill
Payer Situation
BIN’s listed in
General
Information
Section
X
Value
Payer Usage
CARDHOLDER ID
Claim
Billing/Claim
Rebill
Payer Situation
M
Page 4 of 14
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Medicare Part D Clients © Prime Therapeutics LLC 07/11
Payer Specification Sheet
for Prime Therapeutics’ Medicare Part D Clients
Insurance Segment
Segment Identification
(111-AM) = “Ø4”
3Ø1-C1
GROUP ID
RW
Claim
Billing/Claim
Rebill
Payer Requirement:
Required for:
BIN: Ø11552 PCN:
ILDEMD,
MAPDIL, MAPDIL1,
MAPDILG,
MAPDILG1,
MAPDMT,
MAPDMTG,
MAPDNM,
MAPDNMG,
MAPDOK,
MAPDOK1,
MAPDOKG,
MAPDTX,
MAPDTX1,
MAPDTXG,
MAPDTXG2,
MPGNM, MPGTX ,
NMPARTD1,
NMPARTDG,
NMSNP, OKMAPDG,
PDPIL, PDGIL,
PDPNM,PDGNM, ,
PDPTX, PDGTX,
TXSNP
BIN: Ø12833 PCN:
MEDDPRIME and
MEDDPRIMEG
Ø14897 PCN:
MBG, RPD and
RPDG
BIN:
BIN: Ø159Ø5 PCN:
Page 5 of 14
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Medicare Part D Clients © Prime Therapeutics LLC 07/11
Payer Specification Sheet
for Prime Therapeutics’ Medicare Part D Clients
Insurance Segment
Segment Identification
(111-AM) = “Ø4”
Claim
Billing/Claim
Rebill
HMONC, PPONC,
PDPNC, HMONCG,
PPONCG AND
PDPNCG
BIN: Ø16499 PCN:
HMOPOSNJ, PDPNJ,
PPONJ,
HMOPOSNJG,
PDPNJG, PPONJG
BIN: Ø16862 PCN:
PDPSC, PDPSCG
BIN: Ø16895 PCN:
PDPAR, PFFSAR,
PPOAR, HMOAR,
PDPARG
BIN: 61Ø455 PCN:
MEDDADV,
MEDDADVG,
MPDBP, MPDPB,
PDPOK, PDGOK,
AHPPARTD
997-G2
CMS PART D DEFINED QUALIFIED
FACILITY
Y-CMS
Qualified
Facility
N-Not a CMS
Qualified
Facility
RW
Payer Requirement:
Required for: Long
Term Care
Pharmacy claim
submission
Page 6 of 14
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Medicare Part D Clients © Prime Therapeutics LLC 07/11
Payer Specification Sheet
for Prime Therapeutics’ Medicare Part D Clients
Patient Segment Questions
This Segment is always sent
Field#
3Ø4-C4
3Ø5-C5
311-CB
3Ø7-C7
Claim Billing/Claim Rebill
If Situational, Payer Situation
Check
X
Patient Segment
Segment Identification
(111-AM) = “Ø1”
NCPDP Field Name
Value
DATE OF BIRTH
PATIENT GENDER CODE
PATIENT LAST NAME
PLACE OF SERVICE
Payer
Usage
R
R
R
01-Pharmacy
RW
384-4X
PATIENT RESIDENCE
Claim Segment Questions
ØØ-Not Specified
Ø1-Home
Ø3-Nursing
Facility
Ø4-Assisted
Living Facility
Ø6-Group Home
Ø9- Intermediate
Care Facility
/Mentally
Retarded
11-Hospice
Field #
R
X
X
Claim Segment
Segment Identification
(111-AM) = “Ø7”
NCPDP Field Name
455-EM
PRESCRIPTION/SERVICE REFERENCE
NUMBER QUALIFIER
4Ø2-D2
PRESCRIPTION/SERVICE REFERENCE
NUMBER
PRODUCT/SERVICE ID QUALIFIER
436-E1
Payer
Requirement:
Required for Long
Term Care, Asst
Living or Home
Infusion claim
processing
Claim Billing/Claim Rebill
If Situational, Payer Situation
Check
This Segment is always sent
This payer does not support partial
fills
Claim
Billing/Claim
Rebill
Payer Situation
Value
1-Rx Billing
Payer
Usage
M
Claim
Billing/Claim
Rebill
Payer Situation
M
Ø1-Universal
Product Code
(UPC)
Ø2-Health
Related Item
M
If billing for a
Multi-Ingredient
Compound , value
is “ØØ”-Not
Page 7 of 14
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Medicare Part D Clients © Prime Therapeutics LLC 07/11
Payer Specification Sheet
for Prime Therapeutics’ Medicare Part D Clients
Field #
Claim Segment
Segment Identification
(111-AM) = “Ø7”
NCPDP Field Name
Value
Payer
Usage
(HRI)
Ø3-National Drug
Code (NDC)
4Ø7-D7
PRODUCT/SERVICE ID
Claim
Billing/Claim
Rebill
Payer Situation
Specified
M
NDC Number
If billing for a
Multi-Ingredient
Compound , value
is “Ø”
442-E7
4Ø3-D3
4Ø5-D5
4Ø6-D6
QUANTITY DISPENSED
FILL NUMBER
DAYS SUPPLY
COMPOUND CODE
4Ø8-D8
DISPENSE AS WRITTEN
(DAW)/PRODUCT SELECTION CODE
DATE PRESCRIPTION WRITTEN
PRESCRIPTION ORIGIN CODE
414-DE
419-DJ
354-NX
SUBMISSION CLARIFICATION CODE
COUNT
1-Not a
Compound
2-Compound
R
R
R
R
See Compound
Segment for
support of multiingredient
compounds
R
1-Written
2-Telephone
3-Electronic
4-Facsimile
5-Pharmacy
Maximum count
of 3
R
R
RW
Payer
Requirement:
Required if
Submission
Clarification Code
(42Ø-DK) is used
Page 8 of 14
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Medicare Part D Clients © Prime Therapeutics LLC 07/11
Payer Specification Sheet
for Prime Therapeutics’ Medicare Part D Clients
Field #
42Ø-DK
Claim Segment
Segment Identification
(111-AM) = “Ø7”
NCPDP Field Name
SUBMISSION CLARIFICATION CODE
Value
8-Process
Compound for
Approved
Ingredients
16- Long Term Care
Emergency box (kit)
or automated
dispensing machine
19-Split Billing
21- LTC dispensing:
14 days or less not
applicable
22- LTC dispensing:
7 days
23- LTC dispensing:
4 days
24- LTC dispensing:
3 days
25- LTC dispensing:
2 days
26- LTC dispensing:
1 day
27- LTC dispensing:
4-3 days
28- LTC dispensing:
2-2-3 days
29- LTC dispensing:
daily and 3-day
weekend
3Ø- LTC dispensing:
Per shift dispensing
31- LTC dispensing:
Per med pass
dispensing
32- LTC dispensing:
PRN on demand
33- LTC dispensing:
7 day or less cycle
not otherwise
represented
34- LTC dispensing:
14 days dispensing
35- LTC dispensing:
8-14 day dispensing
method not listed
above
36- LTC dispensing:
dispensed outside
Payer
Usage
RW
Claim
Billing/Claim
Rebill
Payer Situation
Payer
Requirement:
Applies for Multi –
Ingredient
Compound when
determined by
client, or when
submitting for LTC
Short Cycle
Dispensing or
when split billing
from a LTC or for
Prescriber ID
clarification
Page 9 of 14
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Medicare Part D Clients © Prime Therapeutics LLC 07/11
Payer Specification Sheet
for Prime Therapeutics’ Medicare Part D Clients
3Ø8-C8
OTHER COVERAGE CODE
short cycle
42-Prescriber ID
Submitted is valid
and prescribing
requirements have
been validated
43-Prescriber's DEA
is active with DEA
Authorized
Prescriptive Right
45-Prescriber’s DEA
is a valid Hospital
DEA with Suffix and
has prescriptive
authority for this
drug DEA Schedule
46-Prescriber's DEA
has prescriptive
authority for this
drug DEA Schedule
47-Shortened Days
Supply Fill - only
used to request an
override to plan
limitations when a
shortened days
supply is being
Dispensed
48-Fill Subsequent
to a Shortened Days
Supply Fill - only
used to request an
override to plan
limitations when a
fill subsequent to a
shortened days
supply is being
dispensed.
Ø-Not specified by
patient
1-No other
coverage
2-Other coverage
exists/billedpayment collected
3-Other coverage
billed-claim not
covered
4-Other coverage
exists/billedpayment not
collected
RW
Payer
Requirement:
Required for
Coordination of
Benefits
Page 10 of 14
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Medicare Part D Clients © Prime Therapeutics LLC 07/11
Payer Specification Sheet
for Prime Therapeutics’ Medicare Part D Clients
429-DT
SPECIAL PACKAGING INDICATOR
RW
461-EU
PRIOR AUTHORIZATION TYPE CODE
RW
462-EV
PRIOR AUTHORIZATION NUMBER
SUBMITTED
RW
Payer
Requirement:
Applies for Multi –
Ingredient
Compound
Payer
Requirement:
Submit a value of
‘1’ when a PA
number is
submitted in field
462-EV
Payer
Requirement:
Situation determined
by client
995-E2
ROUTE OF ADMINISTRATION
147-U7
PHARMACY SERVICE TYPE
Pricing Segment Questions
RW
1- Community/Retail
Pharmacy Services
3- Home Infusion
Therapy Provider
Services
5- Long Term Care
Pharmacy Services
6- Mail Order
Pharmacy Services
8- Specialty Care
Pharmacy Services
X
Field #
4Ø9-D9
438-E3
Pricing Segment
Segment Identification
(111-AM) = “11”
NCPDP Field Name
INGREDIENT COST SUBMITTED
INCENTIVE AMOUNT SUBMITTED
426-DQ
43Ø-DU
USUAL AND CUSTOMARY CHARGE
GROSS AMOUNT DUE
Prescriber Segment Questions
R
Claim Billing/Claim Rebill
If Situational, Payer Situation
Check
This Segment is always sent
Payer
Requirement:
Applies for Multi –
Ingredient
Compound when
determined by
client
Check
Value
Payer Usage
R
RW
Claim
Billing/Claim
Rebill
Payer Situation
Payer Requirement:
Required when field
44Ø-E5 is used
R
R
Claim Billing/Claim Rebill
If Situational, Payer Situation
Page 11 of 14
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Medicare Part D Clients © Prime Therapeutics LLC 07/11
Payer Specification Sheet
for Prime Therapeutics’ Medicare Part D Clients
This Segment is always sent
X
Field #
466-EZ
Prescriber Segment
Segment Identification (111-AM)
= “Ø3”
NCPDP Field Name
PRESCRIBER ID QUALIFIER
411-DB
PRESCRIBER ID
Coordination of Benefits/Other
Payments Segment Questions
This Segment is situational
Scenario 1 - Other Payer Amount Paid
Repetitions Only
Value
Ø1-NPI
Payer Usage
R
R
Check
X
X
Field #
NCPDP Field Name
Value
337-4C
338-5C
COORDINATION OF BENEFITS/OTHER
PAYMENTS COUNT
OTHER PAYER COVERAGE TYPE
339-6C
OTHER PAYER ID QUALIFIER
Maximum
count of 9
Ø1-PrimaryFirst
Ø2-SecondarySecond
Ø3-TertiaryThird
Ø3-Bank
Identification
Number (BIN)
34Ø-7C
443-E8
341-HB
OTHER PAYER ID
OTHER PAYER DATE
OTHER PAYER AMOUNT PAID COUNT
342-HC
OTHER PAYER AMOUNT PAID
QUALIFIER
431-DV
OTHER PAYER AMOUNT PAID
This Segment is situational
Payer
Requirement:
Applicable value
for the qualifier
used in 466-EZ
Claim Billing/Claim Rebill
If Situational, Payer Situation
Required only for secondary, tertiary, etc claims.
Coordination of Benefits/Other
Payments Segment
Segment Identification
(111-AM) = “Ø5”
DUR/PPS Segment Questions
Claim
Billing/Claim
Rebill
Payer Situation
NPI Required
Maximum count
of 9
Ø7-Drug Benefit
Payer
Usage
M
Claim
Billing/Claim
Rebill
Scenario 1 Other Payer
Amount Paid
Repetitions Only
Payer Situation
M
RW
RW
RW
RW
RW
RW
Check
Claim Billing/Claim Rebill
If Situational, Payer Situation
X
Page 12 of 14
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Medicare Part D Clients © Prime Therapeutics LLC 07/11
Payer Specification Sheet
for Prime Therapeutics’ Medicare Part D Clients
Field #
DUR/PPS Segment
Segment Identification (111-AM)
= “Ø8”
NCPDP Field Name
473-7E
DUR/PPS CODE COUNTER
Maximum of 9
occurrences
439-E4
REASON FOR SERVICE CODE
DC-DrugDisease(Inferred)
DD-Drug-Drug
Interaction
RW
44Ø-E5
PROFESSIONAL SERVICE CODE
MØ-Prescriber
Consulted
MA-Medication
Administration
MR-Medication
Review
PH-Patient
Medication History
PO-Patient
Consulted
RW
441-E6
RESULT OF SERVICE CODE
Value
Payer
Usage
RW
RW
Claim
Billing/Claim
Rebill
Payer Situation
Payer
Requirement:
Required if
DUR/PPS Segment
is used
Payer
Requirement:
Required if
DUR/PPS Segment
is used
Payer
Requirement:
Required if
DUR/PPS Segment
is used
Payer
Requirement:
Required if
DUR/PPS Segment
is used
475-J9
DUR CO-AGENT ID QUALIFIER
476-H6
DUR CO-AGENT ID
Compound Segment Questions
This Segment is situational
Ø1-Universal
Product Code
(UPC)
Ø2-Health Related
Item (HRI)
Ø3-National Drug
Code (NDC)
2Ø-International
Classification of
Diseases (ICD1Ø)
Check
X
RW
Payer
Requirement:
Required if 476-H6
is used
RW
Payer
Requirement:
Required if 439-E4
is used
Claim Billing/Claim Rebill
If Situational, Payer Situation
Required when Compound Code is =2
Page 13 of 14
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Medicare Part D Clients © Prime Therapeutics LLC 07/11
Payer Specification Sheet
for Prime Therapeutics’ Medicare Part D Clients
Field #
45Ø-EF
Compound Segment
Segment Identification
(111-AM) = “1Ø”
NCPDP Field Name
Value
Payer
Usage
M
488-RE
COMPOUND DOSAGE FORM
DESCRIPTION CODE
COMPOUND DISPENSING UNIT FORM
INDICATOR
COMPOUND INGREDIENT COMPONENT
COUNT
COMPOUND PRODUCT ID QUALIFIER
489-TE
448-ED
449-EE
COMPOUND PRODUCT ID
COMPOUND INGREDIENT QUANTITY
COMPOUND INGREDIENT DRUG COST
M
M
R
49Ø–UE
COMPOUND INGREDIENT BASIS OF
COST DETERMINATION
R
451-EG
447-EC
Clinical Segment Questions
Check
This Segment is situational
Field #
491-VE
Clinical Segment
Segment Identification
(111-AM) = “13”
NCPDP Field Name
DIAGNOSIS CODE COUNT
492-WE
DIAGNOSIS CODE QUALIFIER
424-DO
DIAGNOSIS CODE
Claim
Billing/Claim
Rebill
Payer Situation
M
Maximum 25
ingredients
Ø1-Universal
Product Code
(UPC)
Ø3-National
Drug Code
(NDC)
M
M
Payer Requirement:
Required for each
ingredient
Payer Requirement:
Required for each
ingredient
Claim Billing/Claim Rebill
If Situational, Payer Situation
X
Value
Maximum
count of 5
Ø2International
Classification
of Diseases
(ICD1Ø)
Claim
Billing/Claim
Rebill
Payer Usage Payer Situation
RW
Payer Requirement:
Required When
instructed by POS
Messaging
RW
Payer Requirement:
Required When
instructed by POS
Messaging
RW
Payer Requirement
Required When
instructed by POS
Messaging
Page 14 of 14
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Medicare Part D Clients © Prime Therapeutics LLC 07/11