| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | bps claim(+) | 0;1 | POINTER | 9002313.02 | B | Identifier for BPS responses. |
| .02 | date response received | 0;2 | DATE-TIME | AE | Date that response was received on the system. | |
| 102 | version release number | 100;2 | FREE TEXT | NCPDP Version/Release Number. | ||
| 103 | transaction code | 100;3 | FREE TEXT | Code identifying the type of transaction. | ||
| 109 | transaction count | 100;9 | NUMERIC | Count of transactions in the transmission. | ||
| 115 | medicaid id indicator | 100;15 | FREE TEXT | This is used to store NCPDP field 115-N5 (Medicaid ID Number), which is defined as "A unique member identification number assigned by the Medicaid Agency." | ||
| 116 | medicaid agency number | 100;16 | FREE TEXT | This is used to store NCPDP field 116-N6 (Medicaid Agency Number), which is defined as "Number assigned by processor to identify the individual Medicaid Agency or representative." | ||
| 201 | service provider id | 200;1 | FREE TEXT | ID assigned to a pharmacy or provider. | ||
| 202 | service provider id qualifier | 200;2 | FREE TEXT | Code qualifying the 'Service Provider ID' (2Ø1) | ||
| 301 | group id | 300;1 | FREE TEXT | ID assigned to the cardholder group or employer group. | ||
| 302 | cardholder id | 300;2 | FREE TEXT | This is used to store NCPDP field 302-C2 (Cardholder ID), which is defined as "Insurance ID assigned to the cardholder or identification number used by the plan." | ||
| 304 | date of birth | 300;4 | FREE TEXT | This is used to store NCPDP field 304-C4 (Date Of Birth), which is defined as "Date of birth of patient." | ||
| 310 | patient first name | 300;10 | FREE TEXT | This is used to store NCPDP field 310-CA (Patient First Name), which is defined as "Individual first name." | ||
| 311 | patient last name | 310;1 | FREE TEXT | This is used to store NCPDP field 311-CB (Patient Last Name), which is defined as "Individual last name." | ||
| 401 | date of service | 400;1 | FREE TEXT | Identifies date the prescription was filled or professional service rendered. | ||
| 501 | response status | 500;1 | SET OF CODES | A:ACCEPTED R:REJECTED | A code indicating the status of this response. | |
| 504 | message | 504;1 | FREE TEXT | Free form message. | ||
| 524 | plan identification | 500;24 | FREE TEXT | Assigned by the processor to identify a set of parameters, benefit, or coverage criteria used to adjudicate a claim. | ||
| 545 | network reimbursement id | 540;5 | FREE TEXT | Field defined by the processor. It identifies the network, for the covered member, used to calculate the reimbursement to the pharmacy. | ||
| 568 | payer id qualifier | 560;8 | SET OF CODES | 01:Standard Unique Health Plan Identifier 02:HIN 03:BIN 04:NAIC 99:OTHER | Code indicating the type of payer ID. | |
| 569 | payer id | 560;9 | FREE TEXT | Payer identification - the payer this claim was submitted to. | ||
| 1000 | responses | 1000;0 | MULTIPLE | 9002313.0301 | This is the transaction response data returned by the third-party payer. | |
| 9999 | raw data received | M;0 | WORD-PROCESSING | This is to store the raw data received from the payer. |