| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | prescription(+) | 0;1 | FREE TEXT | B | ||
| .02 | patient | 0;2 | POINTER | 2 | ||
| .03 | card holder ssn | 0;3 | FREE TEXT | |||
| .04 | ndc | 0;4 | FREE TEXT | |||
| .05 | amount transmitted | 0;5 | NUMERIC | |||
| .06 | quantity | 0;6 | NUMERIC | |||
| .07 | transaction date | 0;7 | DATE-TIME | |||
| .08 | copayment charge | 0;8 | POINTER | 350 | ACC | This field points to the copayment charge in the INTEGRATED BILLING ACTION (#350) file which was actually billed to the patient. |
| .09 | fiscal intermediary claim | 0;9 | POINTER | 399 | ACL | This field points to the claim in the BILL/CLAIMS (#399) file which was created after the response from the FI was received. Creation of this claim also establishes a receivable in the ACCOUNTS RECEIVABLE (#430) file against which the FI payment will be posted. |
| .1 | product selection reason | 0;10 | POINTER | 351.53 | This field will store the Product Selection Reason for billing acceptance. | |
| 2.01 | copay | 2;1 | NUMERIC | |||
| 2.02 | ingredient cost paid | 2;2 | NUMERIC | |||
| 2.03 | contract fee paid | 2;3 | NUMERIC | |||
| 2.04 | sales tax paid | 2;4 | NUMERIC | |||
| 2.05 | total amount paid | 2;5 | NUMERIC | |||
| 2.06 | authorization number | 2;6 | FREE TEXT | AUTH | ||
| 2.07 | message | 2;7 | FREE TEXT | |||
| 3.01 | accumulated deductible amount | 3;1 | NUMERIC | |||
| 3.02 | remaining deductable amount | 3;2 | NUMERIC | |||
| 3.03 | remaining benefit amount | 3;3 | NUMERIC | |||
| 3.04 | atm appl to per deductible | 3;4 | NUMERIC | |||
| 3.05 | amt copay/coinsurance | 3;5 | NUMERIC | |||
| 3.06 | amt attrib to prod sel | 3;6 | NUMERIC | |||
| 3.07 | amt exceeding periodic max ben | 3;7 | NUMERIC | |||
| 3.08 | incentive fee paid | 3;8 | NUMERIC | |||
| 3.09 | basis of reimb determination | 3;9 | SET OF CODES | 0:NOT SPECIFIED 1:PAID AS SUBMITTED 2:REDUCED TO AWP 3:AWP-X% PRICING 4:USUAL AND CUSTOMARY 5:LOWER IF ING. COST PLUS FEES VS U&C 6:MAC PRICING 7:MAC REDUCED TO MAC 8:CONTRACT PRICING | ||
| 3.1 | amount attrib to sales tax | 3;10 | NUMERIC | |||
| 5.01 | error codes | 5;1 | FREE TEXT | |||
| 6.01 | reversal auth number | 6;1 | FREE TEXT | |||
| 6.02 | reversed by | 6;2 | POINTER | 200 | ||
| 6.03 | reversal error codes | 6;3 | FREE TEXT | |||
| 7.01 | dur response data | 7;1 | FREE TEXT | |||
| 8.01 | additional message information | 8;1 | FREE TEXT |