| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | transaction id(+) | 0;1 | NUMERIC | B | This is a numeric identifier that follows the same format as the IEN of the BPS TRANSACTION (#9002313.59) file. For billing requests and reversals, this is the Prescription IEN, followed by a decimal point, followed by the Fill Number left-padded with zeros up to four places and then followed by the COB indicator (1-Primary, 2-Secondary, 3-Tertiary). For a Eligibility Verification request, this is the Patient IEN, followed by a decimal point, followed by the Policy Number (with 9000 added to it) and then followed by 1. | |
| .02 | b1 payer sheet | 0;2 | POINTER | 9002313.92 | This is the payer sheet used to a submit billing request for this particular insurer. Billing request transmissions will be formatted per the specifications in this payer sheet. | |
| .03 | b2 payer sheet | 0;3 | POINTER | 9002313.92 | The Reversal payer sheet to be used to send reversals to the Insurer. | |
| .04 | b3 payer sheet | 0;4 | POINTER | 9002313.92 | This is the payer sheet to be used for a rebill request for this insurer. Rebill transmission will be formatted per the specifications in this payer sheet. | |
| .05 | certify mode | 0;5 | SET OF CODES | 0:CERTIFY MODE OFF 1:CERTFIY MODE ON | Certify mode is used for certifying software when required by switches and claims end processors. | |
| .06 | certification | 0;6 | POINTER | 9002313.31 | This field is used during certification testing, and points to the entry to use to pull certification data. | |
| .07 | insurance name | 0;7 | FREE TEXT | This is the free text name of the Insurance Company as determined by Integrated Billing insurance files. | ||
| .08 | plan id | 0;8 | POINTER | 355.3 | Group Insurance Plan used for the claim | |
| .09 | cob indicator | 0;9 | SET OF CODES | 1:PRIMARY 2:SECONDARY 3:TERTIARY | Coordination Of Benefits (COB) indicator for the payer. | |
| .1 | e1 payer sheet | 0;10 | POINTER | 9002313.92 | This is the payer sheet to be used for eligibility verification requests for this insurer. Eligibility verification transmissions will be formatted per the specifications in this payer sheet. | |
| .11 | policy number | 0;11 | NUMERIC | This is the policy number assigned for this particular patient and insurer. | ||
| 1.01 | bin | 1;1 | FREE TEXT | Card Issuer ID or Bank ID Number used for network routing. | ||
| 1.02 | pcn | 1;2 | FREE TEXT | The Processor Control Number for this claim. | ||
| 1.03 | group id | 1;3 | FREE TEXT | ID assigned to the cardholder group or employer group. | ||
| 1.04 | cardholder id | 1;4 | FREE TEXT | ID number assigned to Cardholder/Subscriber. | ||
| 1.05 | patient relationship code | 1;5 | SET OF CODES | 0:NOT SPECIFIED 1:CARDHOLDER (SELF) 2:SPOUSE 3:CHILD 4:OTHER | This stores the relationship of the patient to insurance subscriber and will be used to populate the NCPDP 306-C6 (PATIENT RELATIONSHIP CODE) field. | |
| 1.06 | cardholder first name | 1;6 | FREE TEXT | First name of the Cardholder/Subscriber. | ||
| 1.07 | cardholder last name | 1;7 | FREE TEXT | Last name of the Cardholder/Subscriber. | ||
| 1.08 | home plan state | 1;8 | FREE TEXT | Usually the state where the member lives or purchased their coverage. | ||
| 1.09 | person code | 1;9 | FREE TEXT | This is the Person Code that will be placed in NCPDP field 303-C3 (Person Code). This value is specified by the third-party payer and is found on the patient's insurance card. | ||
| 2.01 | dispensing fee submitted | 2;1 | FREE TEXT | Fee amount submitted for the cost associated with dispensing this prescription. | ||
| 2.02 | basis of cost determination | 2;2 | SET OF CODES | 01:AWP 05:Cost Calculations 07:Usual & Customary | Code indicating the method by which 'Ingredient Cost Submitted' was calculated. | |
| 2.03 | usual & customary charge | 2;3 | FREE TEXT | Amount charged cash customers for the prescription exclusive of sales tax or other amounts claimed. | ||
| 2.04 | gross amount due | 2;4 | FREE TEXT | Total price claimed from all sources. For prescription claim request, field represents a sum of 'Ingredient Cost Submitted' (4Ø9-D9), 'Dispensing Fee Submitted' (412-DC), 'Flat Sales Tax Amount Submitted'(481-HA), 'Percentage Sales Tax Amount Submitted' (482-GE), 'Incentive Amount Submitted' (438-E3), 'Other Amount Claimed' (48Ø-H9). For service claim request, field represents a sum of 'Professional Services Fee Submitted' (477-BE), 'Flat Sales Tax Amount Submitted'(481-HA), 'Percentage Sales Tax Amount Submitted'(482-GE), 'Other Amount Claimed' (48Ø-H9). | ||
| 2.05 | administrative fee | 2;5 | FREE TEXT | Fee charged for any costs related to preparing the prescription. | ||
| 2.06 | software vendor cert id | 2;6 | FREE TEXT | Certification number assigned by the payer for submission of claims. | ||
| 2.07 | maximum ncpdp transactions | 2;7 | NUMERIC | This is the maximum number of transactions that can be bundled in a transmission. It is specified by the NCPDP processor. | ||
| 2.08 | ingredient cost | 2;8 | NUMERIC | This is the INGREDIENT COST that will be placed in the NCPDP field 409-D9 (INGREDIENT COST SUBMITTED) field of the NCPDP submission. | ||
| 3.01 | group name | 3;1 | FREE TEXT | This is the group name from the Group Insurance File. | ||
| 3.02 | insurance co phone # | 3;2 | FREE TEXT | This is the Claim (RX) phone number from the Insurance Company file. | ||
| 3.03 | pharmacy plan id | 3;3 | FREE TEXT | This is the ID of the plan file. | ||
| 3.04 | eligibility | 3;4 | SET OF CODES | V:VETERAN T:TRICARE C:CHAMPVA | The insurance eligibility type of the claim. | |
| 3.05 | insurance company | 3;5 | POINTER | 36 | This is the INSURANCE COMPANY from file #36. | |
| 3.06 | plan cob | 3;6 | SET OF CODES | 1:PRIMARY 2:SECONDARY 3:TERTIARY | The Coordination of Benefits indicator of the patient's insurance plan. This field is a copy of the (#.2) COORDINATION OF BENEFITS field of the (#.3121) INSURANCE TYPE multiple of the PATIENT file (#2). | |
| 4.01 | b1 payer sheet name | 4;1 | FREE TEXT | This is the name of the Billing Request Payer Sheet, which comes from the RECORD FORMAT NAME (#.01) field of the BPS NCPDP FORMATS (#9002313.92) file. | ||
| 4.02 | b2 payer sheet name | 4;2 | FREE TEXT | B2 Payer sheet. The value of the field (#.01) Record Format Name of the file (#9002313.92) BPS NCPDP FORMATS ien Textual description of this record format. | ||
| 4.03 | b3 payer sheet name | 4;3 | FREE TEXT | This is the name of the Rebill Payer Sheet, which comes from the RECORD FORMAT NAME (#.01) field of the BPS NCPDP FORMATS (#9002313.92) file. | ||
| 4.04 | e1 payer sheet name | 4;4 | FREE TEXT | This is the name of the Eligibility Payer Sheet, which comes from the RECORD FORMAT NAME (#.01) field of the BPS NCPDP FORMATS (#9002313.92) file. | ||
| 5.01 | user | 5;1 | POINTER | 200 | ID (IEN of the NEW PERSON file) of the user name who entered this record. | |
| 5.02 | date and time was created | 5;2 | DATE-TIME | Date and time the record was created. |
Not Referenced