# | Name | Location | Type | Details | Index | Description |
---|---|---|---|---|---|---|
.01 | key1(+) | 0;1 | NUMERIC | B | For claim requests and reversals, this is the prescription IEN that will be processed. For Eligibility Verification requests, this is the Patient IEN that will be processed. | |
.02 | key2(+) | 0;2 | NUMERIC | For billing requests and reversals, this is the fill number where 0 is the original fill and 1-999 are refills. For eligibility verification requests, this is the policy number plus 9000. So, for policy number 4, this would be 9004. | ||
.03 | acting cob | 0;3 | SET OF CODES | 1:PRIMARY 2:SECONDARY 3:TERTIARY | This field indicates for which insurer (in terms of coordination of benefits) this particular request was created. For example, if the patient has three insurances then three separate requests can be created for the same prescription/refill in order to bill patient's Primary, Secondary and Tertiary insurers. This field indicates for which insurer this request is for. | |
.04 | process flag(+) | 0;4 | SET OF CODES | 0:SCHEDULED 1:ACTIVATED 2:IN PROCESS 3:COMPLETED 4:CANCELLED 5:INACTIVE | State of the request. SCHEDULED - scheduled for the future (for example : the secondary claim is scheduled to be processed after the primary is completed) ACTIVATED - ready to be processed IN PROCESS - currently in process COMPLETED - has been completed CANCELLED - cancelled INACTIVE - the system marks the records with "bad" data as inactive instead of removing them - to keep them for repair or for investigation | |
.05 | next request | 0;5 | POINTER | 9002313.77 | To store the pointer to the next request which should be processed. | |
.06 | ecme transaction record | 0;6 | POINTER | 9002313.59 | C | This is the BPS Transaction. It is not initially populated but is populated after the request is activated and the BPS Transaction record is created. |
.07 | waiting resolution? | 0;7 | BOOLEAN | 0:NO 1:YES | Flag to mark requests with problems. | |
.08 | dont process until | 0;8 | DATE-TIME | The request cannot be processed until the date and time specified in this field. If null then it can be processed at any time (immediately). | ||
1.01 | rx action | 1;1 | FREE TEXT | This is the action that is being performed on this request. It is either the BWHERE parameter passed into BPSNCPDP or 'ELIG' for an eligibility verification request. The list of BWHERE values are documented at the top of routine BPSNCPD3. | ||
1.02 | outpatient site | 1;2 | POINTER | 59 | This is the outpatient site that will be used to generate the NPI number for the Service Provider ID (201-B1) field of a NCPDP request. | |
1.04 | transaction type | 1;4 | SET OF CODES | C:CLAIM E:ELIGIBILITY U:UNCLAIM | This is the type of transaction that is being processed: CLAIM - An NCPDP billing request. UNCLAIM - An NCPDP reversal request. ELIGIBILITY - An eligibility verification request. | |
1.05 | billing determination | 1;5 | SET OF CODES | 0:NOT BILLABLE 1:BILLABLE | Billing determination result | |
1.06 | eligibility | 1;6 | SET OF CODES | V:VETERAN T:TRICARE C:CHAMPVA | The insurance eligibility type of the claim. | |
1.07 | claim status | 1;7 | FREE TEXT | The status of the transaction as a percentage of completion. The text
value can be obtained by running $$STATI^BPSOSU( | ||
1.08 | rate type | 1;8 | POINTER | 399.3 | The Rate Type selected by the user for billing. | |
1.09 | primary payer bill | 1;9 | POINTER | 399 | Primary bill which should be used to create the secondary bill. This field is used for secondary billing only. | |
1.1 | prior payment | 1;10 | NUMERIC | Dollar amount paid by the Primary insurer. This field is used for secondary billing only. | ||
1.11 | cob other payments count | 1;11 | NUMERIC | NCPDP field 337-4C - Coordination of Benefits/Other Payments Count This value corresponds to the number of multiple entries in the #8 multiple field - COB OTHER PAYERS. | ||
1.12 | other coverage code | 1;12 | SET OF CODES | 00:NOT SPECIFIED 01:NO OTH COVERAGE 02:PYMT COLLECT/OTH PAYER 03:CLAIM NOT COVER/OTH PAYER 04:PYMT NOT COLLECT/OTH PAYER 05:PLAN DENIAL 06:NONPARTICIPAT PROV/OTH PAYER 07:OTH COVER NOT EFFECT ON DOS 08:COPAY BILLING | NCPDP field 308-C8 - code indicating whether or not the patient has other insurance coverage. | |
1.13 | rx number | 1;13 | POINTER | 52 | For billing requests and reversal, this is the prescription that will be processed for the request. If an eligibility verification request is initiated from the ECME User Screen, this field will also be populated and will be used to get the Prescriber information from the prescription. | |
1.14 | fill no | 1;14 | NUMERIC | For billing requests and reversals, this is the fill number to be processed, where 0 is the original fill and 1-99 are refills. If an eligibility verification request is initiated from the ECME User Screen, this field will also be populated and will be used to get the Prescriber information from the prescription. | ||
1.15 | patient | 1;15 | POINTER | 2 | For billing requests and reversals, this is the patient associated with the prescription. For eligibility verification requests, this is the patient for which the insurance is being verified. | |
1.16 | policy number | 1;16 | NUMERIC | This is the policy number of the patient that is being verified in an eligibility verification request. | ||
2.01 | date of service | 2;1 | DATE-TIME | This is the date of service that will be used to populate the 401-D1 field of the NCPDP request. It is generally the fill/refill date of the prescription but may also be the release date. | ||
2.02 | reversal reason | 2;2 | FREE TEXT | Reversal Reason as a free text. Examples: ECME RESUBMIT, RX EDITED, RX DISCONTINUED | ||
2.03 | durrec | 2;3 | FREE TEXT | Drug Utilization Review (DUR) information passed by Outpatient Pharmacy to ECME. | ||
2.04 | override code | 2;4 | POINTER | 9002313.511 | This is used to store overrides entered by the user via the Resubmit with Edits (RED) option in the ECME User Screen to change certain data elements sent to the payer during resubmission of the claim. | |
2.05 | clarification code | 2;5 | FREE TEXT | The Submission Clarification Code is entered by the pharmacist and passed by Outpatient Pharmacy to ECME to put into the claim to support/justify the claim request when the payer rejects it. Valid clarification codes are selected from BPS NCPDP CLARIFICATION CODES file (#9002313.25). These codes justify an earlier fill date to the payer. For example if a patient needed an early refill due to being on vacation when the prescription would normally be filled, a VACATION SUPPLY clarification code can be used as justification to the payer for filling the prescription thereby mitigating any claims rejections. | ||
2.06 | bill ndc | 2;6 | FREE TEXT | Valid NDC# used in the prescription/refill and which is passed to ECME to be used for billing. | ||
2.07 | pre auth type code | 2;7 | FREE TEXT | PRIOR AUTHORIZATION TYPE CODE - the first piece of the BPSAUTH parameter passed to ECME engine. | ||
2.08 | pre auth num sub | 2;8 | FREE TEXT | PRIOR AUTHORIZATION NUM SUB - the second piece of the BPSAUTH parameter passed to ECME engine. | ||
2.09 | sc and ei override flag | 2;9 | BOOLEAN | 0:NO 1:YES | Service Connected and Environmental Indicators override flag. 0 - the system should use the existing answers to SC and EI questions, if there is no answer then SC/EI determination needed and the RX/refill cannot be billed. 1 - the user chose to override all SC and EI related answers with "NO", which means the RX/refill should be billed. | |
2.1 | delay reason code | 2;10 | POINTER | 9002313.29 | This is the Delay Reason Code that is entered by the user from the IB Back Billing Option of Claims Tracking and passed to ECME. It will be be put into field 357-NV of the billing request that is created for third-party billing. | |
3 | dur | 3;0 | MULTIPLE | 9002313.771 | DUR multiple | |
4.01 | quantity | 4;1 | NUMERIC | NCPDP quantity (Billing Quantity) - the amount of medication that was dispensed (stored in PRESCRIPTION file (#52)) multiplied by the NCPDP QUANTITY MULTIPLIER (stored in DRUG file (#50)). The negative value -1 indicates an invalid drug. | ||
4.02 | unit price | 4;2 | NUMERIC | Price per unit of prescription. | ||
4.03 | ndc | 4;3 | FREE TEXT | The NDC number of the drug involved in this transaction. | ||
4.04 | refill | 4;4 | NUMERIC | Refill number. 0-original | ||
4.05 | certify mode | 4;5 | SET OF CODES | 0:OFF 1:ON | Certify mode is used for certifying software when required by switches and claims end processors. | |
4.06 | certification ien | 4;6 | POINTER | 9002313.31 | This field is used during certification testing, and points to the entry to use to pull certification data. | |
4.07 | unit of measure | 4;7 | FREE TEXT | Enter the Unit of Measure for the drug. This is usually GR (grams), ML (milliliters), or EA (Each). | ||
4.08 | billing quantity | 4;8 | NUMERIC | This is the quantity from the prescription and is used to calculate the ingredient cost. It may be different than the quantity used in the actual NCPDP submission. | ||
4.09 | billing unit | 4;9 | FREE TEXT | This is the billing units associated with the billing quantity. | ||
5 | insurer data | 5;0 | MULTIPLE | 9002313.772 | Contains set of IB determination data for all billable payers - primary, secondary and tertiary. Should contain at least one entry - usually for the primary payer. | |
6.01 | request date and time | 6;1 | DATE-TIME | The Date and Time when the request record was created. | ||
6.02 | user who made the request | 6;2 | POINTER | 200 | The user who created the request | |
6.03 | activated date time | 6;3 | DATE-TIME | The date and time when the request was activated | ||
6.04 | user who activated request | 6;4 | POINTER | 200 | The user who activated the request. | |
6.05 | date and time updated | 6;5 | DATE-TIME | E | The date and time when the request was updated. | |
6.06 | user who updated the request | 6;6 | POINTER | 200 | The user who updated the request. | |
7.01 | close aft rev | 7;1 | BOOLEAN | 0:NO 1:YES | This field indicates whether the claim should be closed after successful reversal. The ECME engine checks this field when it receives a response from the payer. If the field is set to YES and the reversal was accepted by the payer then the claim will be closed automatically. | |
7.02 | close aft rev reason | 7;2 | POINTER | 356.8 | The NON-BILLABLE REASON selected by the user to be used in IB CLAIM TRACKING system. | |
7.03 | close aft rev comment | 7;3 | FREE TEXT | Comment for CLOSE action | ||
8 | cob other payers | 8;0 | MULTIPLE | 9002313.778 | This multiple structure stores information about each of the other payers involved in the payment or rejection of the claim. NCPDP has a maximum of 9 occurrences here with a recommendation of less than or equal to 3 occurrences. However, VA only stores data for at most 3 insurance policies for any given claim. So at most there will only be 2 occurrences of this other payer multiple. | |
9.01 | inactivation reason | 9;1 | FREE TEXT | When a request is inactivated, the reason that it was inactivated will be stored here so that the cause of the inactivation can be investigated. |