| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | rx #(+) | 0;1 | FREE TEXT | B | The prescription number for the refill. | |
| .02 | bill number(+) | 0;2 | POINTER | 399 | C | The bill this rx refill is associated with. |
| .03 | date | 0;3 | DATE-TIME | The date of the refill that is being billed. | ||
| .04 | drug(+) | 0;4 | POINTER | 50 | The drug prescribed. | |
| .05 | record | 0;5 | POINTER | 52 | Enter the Prescription record for this refill. | |
| .06 | days supply | 0;6 | NUMERIC | This should be the number of days supplied of the drug dispensed in this refill. | ||
| .07 | qty | 0;7 | NUMERIC | This should be the quantity (# of tablets, pills, items, etc.) of the drug dispensed in this refill. | ||
| .08 | ndc # | 0;8 | FREE TEXT | Enter the NDC number for this drug, if it should be printed on the bill. | ||
| .09 | format of ndc# | 0;9 | SET OF CODES | 1:4-4-2 FORMAT 2:5-3-2 FORMAT 3:5-4-1 FORMAT 4:5-4-2 FORMAT | This is the NATIONAL DRUG CODE format in which the NDC# for the drug has been entered. | |
| .1 | fill number | 0;10 | NUMERIC | This is the Fill Number for the prescription. Where 0 = original fill and 1 = 1st refill, etc. | ||
| .11 | order date | 0;11 | DATE-TIME | This field will be stuffed with the ISSUE DATE (#1) field of the Rx from the PRESCRIPTION (#52) file, if a corresponding entry exists in that file. Otherwise, it will be blank. |
Not Referenced