| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | name(+) | 0;1 | FREE TEXT | B | Name of the certification - typically whichever Processor the certification is being done for. | |
| .03 | claim | 0;3 | POINTER | 9002313.02 | This is the last BPS CLAIMS (#9002313.02) record that was created. | |
| .04 | billing payer sheet | 0;4 | POINTER | 9002313.92 | This is the payer sheet to be used for Certification Testing when the test claim is a billing request. | |
| .05 | reversal payer sheet | 0;5 | POINTER | 9002313.92 | This is the payer sheet that will be used for certification testing when the test is a reversal. | |
| .06 | max claims per transmission | 0;6 | NUMERIC | This is the maximum number of claims that can be bundled in a transmission. If not entered, the certification code will set this to 1. | ||
| .07 | cob indicator | 0;7 | SET OF CODES | 1:PRIMARY 2:SECONDARY 3:TERTIARY | This field is used to indicate the order of the payer (first-primary, second-secondary, third-tertiary). | |
| .08 | eligibility payer sheet | 0;8 | POINTER | 9002313.92 | This is the payer sheet to be used for Certification Testing when the test claim is an eligibility verification claim. | |
| 1 | ncpdp field # | 1;0 | MULTIPLE | 9002313.311 | Contains field information for any NCPDP fields which need to be defaulted. | |
| 2 | rx in position # | 2;0 | MULTIPLE | 9002313.312 | The prescription order when submitting multiple claims in one transmission. | |
| 903 | patient ien | 4;2 | POINTER | 2 | Pointer to the patient file to link the patient being used for certification to the certification being performed. |