| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | transaction order | 0;1 | NUMERIC | B | This sequential value indicates the number of this transaction within the transaction set. | |
| 112 | transaction response status | 110;2 | SET OF CODES | A:APPROVED C:CAPTURED D:DUPLICATE OF PAID F:PA DEFERRED P:PAID Q:DUPLICATE OF CAPTURED R:REJECTED S:DUPLICATE OF APPROVED | Code indicating the status of the transaction. | |
| 114 | medicaid subrogation icn/tcn | 100;14 | FREE TEXT | This is used to store NCPDP field 114-N4 (Medicaid Subrogation Internal Control Number/Transaction Control Number (ICN/TCN), which is defined as "Claim number assigned by the Medicaid Agency." | ||
| 128 | spending account amt remaining | 120;8 | FREE TEXT | This is used to store NCPDP field 128-UC (Spending Account Amount Remaining), which is defined as "The balance from the patient's spending account after this transaction was applied." | ||
| 129 | health plan-funded asstnce amt | 120;9 | FREE TEXT | This is used to store NCPDP field 129-UD (Health Plan-funded Assistance Amount), which is defined as "The amount from the health plan-funded assistance account for the patient that was applied to reduce Patient Pay Amount (505-F5). This amount is used in Healthcare Reimbursement Account (HRA) benefits only. This field is always a negative amount or zero." | ||
| 130 | additional message info count | 120;10 | FREE TEXT | This is used to store NCPDP field 130-UF (Additional Message Information Count), which is defined as "Count of the 'Additional Message Information' (526-FQ) occurrences that follow." | ||
| 130.01 | additional message mltpl | 130.01;0 | MULTIPLE | 9002313.13001 | This sub-file contains Additional Message information. | |
| 133 | amt attrib to prvdr ntwrk sel | 130;3 | FREE TEXT | This is used to store NCPDP field 133-UJ (Amount Attributed to Provider Network Selection), which is defined as "Amount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patient's provider network selection." | ||
| 134 | amt attr prod sel brand drug | 130;4 | FREE TEXT | This is used to store NCPDP field 134-UK (Amount Attributed to Product Selection/Brand Drug), which is defined as "Amount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patient's selection of a Brand product." | ||
| 135 | amt attr prd non-pref frmlry | 130;5 | FREE TEXT | This is used to store NCPDP field 135-UM (Amount Attributed to Product Selection/Non-Preferred Formulary Selection), which is defined as "Amount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patient's selection of a Non-Preferred Formulary product." | ||
| 136 | amt attr brand non-pref frmlry | 130;6 | FREE TEXT | This is used to store NCPDP field 136-UN (Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection), which is defined as "Amount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patient's selection of a Brand Non-Preferred Formulary product." | ||
| 137 | amount attrib to coverage gap | 130;7 | FREE TEXT | This is used to store NCPDP field 137-UP (Amount Attributed to Coverage Gap), which is defined as "Amount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patient being in the coverage gap (for example Medicare Part D Coverage Gap (donut hole)). A coverage gap is defined as the period or amount during which the previous coverage ends and before an additional coverage begins." | ||
| 138 | cms lics level | 130;8 | FREE TEXT | This is used to store NCPDP field 138-UQ (CMS Low Income Cost Sharing (LICS) Level), which is defined as "Free form text that provides the low-income subsidy copay level for a Part D patient." | ||
| 139 | medicare part d coverage code | 130;9 | FREE TEXT | This is used to store NCPDP field 139-UR (Medicare Part D Coverage Code), which is defined as "Code indicating the position of Medicare Part D in the billing order." | ||
| 140 | next medicare part d effctv dt | 130;10 | FREE TEXT | This is used to store NCPDP field 140-US (Next Medicare Part D Effective Date), which is defined as "Future date Part D coverage begins for the patient." | ||
| 141 | next medicare part d term date | 140;1 | FREE TEXT | This is used to store NCPDP field 141-UT (Next Medicare Part D Termination Date), which is defined as "Future date Part D coverage ends for the patient." | ||
| 148 | ingred cost cntrctd reimb amt | 140;8 | FREE TEXT | This is used to store NCPDP field 148-U8 (Ingredient Cost Contracted/Reimbursable Amount), which is defined as "Informational field used when Other Payer-Patient Responsibility Amount (352-NQ) or Patient Pay Amount (505-F5) is used for reimbursement. Amount is equal to contracted or reimbursable amount for product being dispensed." | ||
| 149 | disp fee cntrctd reimb amount | 140;9 | FREE TEXT | This is used to store NCPDP field 149-U9 (Dispensing Fee Contracted/Reimbursable Amount), which is defined as "Informational field used when Other Payer-Patient Responsibility Amount (352-NQ) or Patient Pay Amount (505-F5) is used for reimbursement. Amount is equal to contracted or reimbursable dispensing fee for product being dispensed." | ||
| 240 | contract number | 230;10 | FREE TEXT | This is used to store NCPDP field 240-U1 (Contract Number), which is defined as "Account Number assigned during installation for segments of business." | ||
| 346 | basis of calc-dispensing fee | 340;6 | SET OF CODES | 00:NOT SPECIFIED 01:QUANTITY DISPENSED 02:QUANTITY INTENDED TO BE DISP 03:USUAL & CUSTOMARY/PRORATED 04:WAIVED DUE TO PARTIAL FILL 99:OTHER | This is used to store NCPDP field 346-HH (Basis Of Calculation-Dispensing Fee), which is defined as "Code indicating how the reimbursement amount was calculated for Dispensing Fee Paid (507-F7)." | |
| 347 | basis for copay | 340;7 | SET OF CODES | 00:NOT SPECIFIED 01:QUANTITY DISPENSED 02:QUANTITY INTENDED TO BE DISPENSED 03:USUAL & CUSTOMARY/PRORATED 04:WAIVED DO TO PARTIAL FILL 99:OTHER | Code indicating how the reimbursement amount was calculated for 'Patient Pay Amount'(5Ø5). | |
| 348 | basis of calc-flat sales tax | 340;8 | SET OF CODES | 00:NOT SPECIFIED 01:QUANTITY DISPENSED 02:QUANTITY INTENDED TO BE DISPENSED | This is used to store NCPDP field 348-HK (Basis Of Calculation-Flat Sales Tax), which is defined as "Code indicating how the reimbursement amount was calculated for Flat Sales Tax Amount Paid (558-AW)." | |
| 349 | basis for percentage tax | 340;9 | SET OF CODES | 00:NOT SPECIFIED 01:QUANTITY DISPENSED 02:QUANTITY INTENDED TO BE DISPENSED | Code indicating how the reimbursement amount was calculated for 'Percentage Sales Tax Amount Paid' (559). | |
| 355 | other payer id count | 350;5 | FREE TEXT | This is used to store NCPDP field 355-NT (Other Payer ID Count), which is defined as "Count of other payers with payment responsibility." | ||
| 355.01 | other payer id mltpl | 355.01;0 | MULTIPLE | 9002313.035501 | This sub-file contains OTHER PAYER ID values. | |
| 392 | benefit stage count | 390;2 | FREE TEXT | This is used to store NCPDP field 392-MU (Benefit Stage Count), which is defined as "Count of 'Benefit Stage Amount' (394-MW) occurrences." | ||
| 392.01 | benefit stage info | 392.01;0 | MULTIPLE | 9002313.039201 | This sub-file contains Benefit Stage values. | |
| 402 | prescription reference number | 400;2 | FREE TEXT | This is used to store NCPDP field 402-D2 (Prescription/Service Reference Number), which is defined as "Reference number assigned by the provider for the dispensed drug/product and/or service provided." | ||
| 455 | rx reference number qualifier | 450;5 | SET OF CODES | 1:RX BILLING 2:SERVICE BILLING | Indicates the type of billing submitted. | |
| 498.14 | prior auth number-assigned | 498;6 | FREE TEXT | This is used to store NCPDP field 498-PY (Prior Authorization Number-Assigned), which is defined as "Unique number identifying the prior authorization assigned by the processor." | ||
| 498.51 | date of prior authorization | 498;1 | FREE TEXT | Date the prior authorization request was processed. | ||
| 498.52 | prior authorization start | 498;2 | FREE TEXT | Date the prior authorization became effective. | ||
| 498.53 | prior authorization end | 498;3 | FREE TEXT | Date the prior authorization expires. | ||
| 498.54 | prior auth no refills authrzd | 498;4 | NUMERIC | This is used to store NCPDP field 498-PW (Prior Authorization Number Of Refills Authorized), which is defined as "Number of refills authorized by the prior authorization." | ||
| 498.55 | prior auth qty accumulated | 498;5 | FREE TEXT | This is used to store NCPDP field 498-PX (Prior Authorization Quantity Accumulated), which is defined as "Accumulated authorized amount expressed in metric decimal units." | ||
| 498.57 | prior authorization quantity | 498;7 | FREE TEXT | This is used to store NCPDP field 498-RA (Prior Authorization Quantity), which is defined as "Amount authorized expressed in metric decimal units." | ||
| 498.58 | prior authorization amount | 498;8 | FREE TEXT | Amount authorized in the prior authorization. | ||
| 501 | header response status | 500;1 | SET OF CODES | A:ACCEPTED R:REJECTED CLAIM P:CLAIM PAYABLE C:CLAIM CAPTURED D:DUPLICATE CLAIM DP:DUPLICATE OF PAYABLE CLAIM DC:DUPLICATE OF CAPTURED CLAIM | AC | This is used to store NCPDP field 501-F1 (Header Response Status). |
| 503 | authorization number | 500;3 | FREE TEXT | Number assigned by the processor to identify an authorized transaction. | ||
| 504 | message | 504;1 | FREE TEXT | Free text message from payer. | ||
| 505 | patient pay amount | 500;5 | FREE TEXT | Amount that is calculated by the processor and returned to the pharmacy as the TOTAL amount to be paid by the patient to the pharmacy; the patient's total cost share, including co-payments, amounts applied to deductible, over maximum amounts, penalties, etc. | ||
| 506 | ingredient cost paid | 500;6 | FREE TEXT | Drug ingredient cost paid included in the 'Total Amount Paid' (5Ø9). | ||
| 507 | dispensing fee paid | 500;7 | FREE TEXT | Dispensing fee paid included in the 'Total Amount Paid' (5Ø9). | ||
| 509 | total amount paid | 500;9 | FREE TEXT | Total amount to be paid by the claims processor (i.e. pharmacy receivable). Represents a sum of 'Ingredient Cost Paid' (5Ø6), 'Dispensing Fee Paid' (5Ø7), 'Flat Sales Tax Amount Paid' (558), 'Percentage Sales Tax Amount Paid' (559), 'Incentive Amount Paid' (521), 'Professional Service Fee Paid' (562), 'Other Amount Paid' (565), less 'Patient Pay Amount' (5Ø5) and 'Other Payer Amount Recognized' (566). | ||
| 510 | reject count | 500;10 | FREE TEXT | Count of 'Reject Code' (511) occurrences. | ||
| 511 | reject code | 511;0 | MULTIPLE | 9002313.03511 | Multiple rejection codes. | |
| 512 | accumulated deductible amount | 500;12 | FREE TEXT | Amount in dollars met by the patient/family in a deductible plan. | ||
| 513 | remaining deductible amount | 500;13 | FREE TEXT | Amount not met by the patient/family in the deductible plan. | ||
| 514 | remaining benefit amount | 500;14 | FREE TEXT | Amount remaining in a patient/family plan with a periodic maximum benefit. | ||
| 517 | amt appld periodic deductible | 500;17 | FREE TEXT | This is used to store NCPDP field 517-FH (Amount Applied To Periodic Deductible), which is defined as "Amount to be collected from a patient that is included in 'Patient Pay Amount' (505-F5) that is applied to a periodic deductible." | ||
| 518 | amount of copay | 500;18 | FREE TEXT | This is used to store NCPDP field 518-FI (Amount Of Copay), which is defined as "Amount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to a per prescription copay." | ||
| 519 | amt attrib to prod selection | 500;19 | FREE TEXT | This is used to store NCPDP field 519-FJ (Amount Attributed To Product Selection), which is defined as "Amount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patients selection of drug product." | ||
| 520 | amt exceeding period bnft max | 500;20 | FREE TEXT | This is used to store NCPDP field 520-FK (Amount Exceeding Periodic Benefit Maximum), which is defined as "Amount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patient exceeding a periodic benefit maximum." | ||
| 521 | incentive amount paid | 500;21 | FREE TEXT | Amount represents the contractually agreed upon incentive fee paid for specific services rendered. Amount is included in the 'Total Amount Paid' (5Ø9). | ||
| 522 | basis of reimb determination | 500;22 | FREE TEXT | This is used to store NCPDP field 522-FM (Basis Of Reimbursement Determination), which is defined as "Code identifying how the reimbursement amount was calculated for Ingredient Cost Paid (506-F6)." | ||
| 523 | amount attributed to sales tax | 500;23 | FREE TEXT | Amount to be collected from the patient that is included in 'Patient Pay Amount' (5Ø5) that is due to sales tax paid. | ||
| 525 | dur response data | 525;1 | FREE TEXT | Text that provides additional detail regarding a DUR conflict. | ||
| 526 | *additional message informatio | 526;1 | FREE TEXT | * This field is no longer used in NCPDP vD.0. * | ||
| 547 | approved message code count | 540;7 | FREE TEXT | Count of the 'Approved Message Code' (548-6F) occurrences. | ||
| 548 | approved message code | 548;0 | MULTIPLE | 9002313.301548 | ||
| 549 | help desk phone qualifier | 540;9 | FREE TEXT | Code qualifying the phone number in the 'Help Desk Phone Number' (55Ø). | ||
| 550 | help desk phone number | 540;10 | FREE TEXT | Ten digit phone number of the help desk. | ||
| 551 | preferred product count | 550;1 | NUMERIC | Count of preferred product occurrences. | ||
| 551.01 | preferred product repeating | 551.01;0 | MULTIPLE | 9002313.1301 | ||
| 557 | tax exempt indicator | 550;7 | SET OF CODES | 1:PAYER/PLAN IS TAX EXEMPT 2:NOT TAX EXEMPT 3:PATIENT IS TAX EXEMPT 4:PAYER/PLAN AND PATIENT TAX EXEMPT | Code indicating the payer and/or patient is exempt from taxes. | |
| 558 | flat sales tax paid | 550;8 | FREE TEXT | Flat sales tax paid which is included in the 'Total Amount Paid' (5Ø9). | ||
| 559 | percentage sales tax paid | 550;9 | FREE TEXT | Amount of percentage sales tax paid which is included in the 'Total Amount Paid' (5Ø9). | ||
| 560 | percentage sales tax rate paid | 550;10 | FREE TEXT | Percentage sales tax rate used to calculate 'Percentage Sales Tax Amount Paid' (559). | ||
| 561 | percentage sales tax basis pd | 560;1 | SET OF CODES | 01:GROSS AMOUNT DUE 02:INGREDIENT COST 03:INGREDIENT COST + DISPENSING FEE | This is used to store NCPDP field 561-AZ (Percentage Sales Tax Basis Paid), which is defined as "Code indicating the percentage sales tax paid basis." | |
| 562 | professional service fee paid | 560;2 | FREE TEXT | Amount submitted by the provider for professional services rendered. | ||
| 563 | other amount paid count | 560;3 | FREE TEXT | Count of the other amount paid occurrences. | ||
| 563.01 | other amounts paid | 563.01;0 | MULTIPLE | 9002313.1401 | ||
| 566 | other payer amount recognized | 560;6 | FREE TEXT | Total dollar amount of any payment from another source including coupons. | ||
| 567.01 | dur pps | 567.01;0 | MULTIPLE | 9002313.1101 | ||
| 571 | amount attributed to proc fee | 570;1 | FREE TEXT | This is used to store NCPDP field 571-NZ (Amount Attributed to Processor Fee), which is defined as "Amount to be collected from the patient that is included in Patient Pay Amount (505-F5) that is due to the processing fee imposed by the processor." | ||
| 572 | amount of coinsurance | 570;2 | FREE TEXT | This is used to store NCPDP field 572-4U (Amount of Coinsurance), which is defined as "Amount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to a per prescription coinsurance." | ||
| 573 | basis of calc-coinsurance | 570;3 | FREE TEXT | This is used to store NCPDP field 573-4V (Basis of Calculation-Coinsurance), which is defined as "Code indicating how the Coinsurance reimbursement amount was calculated for 'Patient Pay Amount' (505-F5)." | ||
| 574 | plan sales tax amount | 570;4 | FREE TEXT | This is used to store NCPDP field 574-2Y (Plan Sales Tax Amount), which is defined as "Plan sales tax responsibility. This field is not a component of the Patient Pay Amount (505-F5) formula." | ||
| 575 | patient sales tax | 570;5 | FREE TEXT | This is used to store NCPDP field 575-EQ (Patient Sales Tax Amount), which is defined as "Patient sales tax responsibility. This field is not a component of the Patient Pay Amount (505-F5) formula." | ||
| 577 | estimated generic savings | 570;7 | FREE TEXT | This is used to store NCPDP field 577-G3 (Estimated Generic Savings), which is defined as "The amount, not included in the Total Amount Paid (509-F9), that the patient would have saved if they had chosen the generic drug instead of the brand drug." | ||
| 757 | benefit id | 750;7 | FREE TEXT | This is used to store NCPDP field 757-U6 (Benefit ID), which is defined as "Assigned by processor to identify a set of parameters, benefits, or coverage criteria used to adjudicate a claim." | ||
| 880 | transaction reference number | 870;10 | FREE TEXT | This is used to store NCPDP field 880-K5 (Transaction Reference Number). | ||
| 926 | formulary id | 920;6 | FREE TEXT | This is used to store NCPDP field 926-FF (Formulary ID), which is defined as "ID for the formulary list." | ||
| 987 | url | 987;1 | FREE TEXT | This is used to store NCPDP field 987-MA (URL), which is defined as "The web page address." | ||
| 993 | internal control number | 990;3 | FREE TEXT | This is used to store NCPDP field 993-A7 (Internal Control Number), which is defined as "Number assigned by the processor to identify an adjudicated claim when supplied in payer-to-payer coordination of benefits only." | ||
| 1000 | duplicate response data | 1000;1 | FREE TEXT | Response text to indicate duplicated data. | ||
| 1028 | adjudicated payment type | A20;8 | FREE TEXT | This is used to store NCPDP field A28-ZR (Adjudicated Payment Type) | ||
| 2004 | next avail fill date | B00;4 | FREE TEXT | This is used to store NCPDP field B04-BT (Next Available Fill Date) |
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