The formats for sending claims. As derived from NDC Payer Sheets and Envoy Plan Sheets. Never modify locally, except in cooperation with development. Per VHA Directive 2004-038, this file definition should not be modified.
.01record format name(+)0;1FREE TEXTBTextual description of this record format.
1.02version1;2SET OF CODES51:Version 5.1
D0:Version D.0
This is the NCPDP Version Number. The request that is created will follow the specification of this NCPDP Version.
1.06production status1;6SET OF CODES0:DISABLED
To be used as a screen when attaching a format to an insurer. Don't allow non-production formats. Those will have to be entered directly with Fileman.
1.1total exclusive patient amount1;10BOOLEAN1:Y
This refers to the interpretation of the fields in the response packets, as copied to 9002313.03, Response(s) multiple, fields 509 Total Amount Paid and 505 Patient Paid Amount. For most formats and insurers 509 Total Amount Paid means Total, Patient plus Insurer. Other insurers don't do it that way - for them, 509 contains only the amount paid by insurance. $$NETPAID1 needs to know whether to do the subtraction. If $$NETPAID1 encounters a case where (#509)<(#505), it will set the flag in the format, locally.
1.11asleep prober1;11POINTER9002313.59The BPS Transaction used as the test prober to test when the insurer is 'awake'.
1.12asleep retry time1;12DATE-TIMEThe time to wait before re-trying to see if the insurer is 'awake'.
1.14payer sheet version(+)1;14NUMERICWhich version of the NCPDP standard this payer sheet is for.
100transaction header segment100;0MULTIPLE9002313.9205
110patient segment110;0MULTIPLE9002313.9206
120insurance segment120;0MULTIPLE9002313.9207
130claim segment130;0MULTIPLE9002313.9208
140pharmacy provider segment140;0MULTIPLE9002313.9209
150prescriber segment150;0MULTIPLE9002313.921
160cob other payments segment160;0MULTIPLE9002313.9213
170workers comp segment170;0MULTIPLE9002313.9214
180dur pps segment180;0MULTIPLE9002313.9215
190pricing segment190;0MULTIPLE9002313.9216
200coupon segment200;0MULTIPLE9002313.9217
210compound segment210;0MULTIPLE9002313.9218
220prior auth segment220;0MULTIPLE9002313.9219
230clinical segment230;0MULTIPLE9002313.922
240addl doc segment240;0MULTIPLE9002313.9223This subfile holds the fields and processing rules for the Additional Documentation Segment.
250facility segment250;0MULTIPLE9002313.9224This subfile holds the fields and processing rules for the Facility segment.
260narrative segment260;0MULTIPLE9002313.9225This subfile holds the fields and processing rules for the Narrative segment.
270purchaser segment270;0MULTIPLE9002313.9227This subfile holds the fields and processing rules for the Purchaser segment.
280service provider segment280;0MULTIPLE9002313.9228This subfile holds the fields and processing rules for the Service Provider segment.
1901development remarksDEVELOPER'S REMARKS;0WORD-PROCESSINGGeneral remarks for the payer sheet, anything that will help describe the function of the sheet, etc.

Referenced by 4 types

  1. PLAN (366.03) -- billing payer sheet name, reversal payer sheet name, rebill payer sheet name, test billing payer sheet, test reversal payer sheet name, test rebill payer sheet name, test eligibility sheet name, eligibility payer sheet name
  2. BPS CLAIMS (9002313.02) -- electronic payer
  3. BPS CERTIFICATION (9002313.31) -- billing payer sheet, reversal payer sheet, eligibility payer sheet
  4. BPS INSURER DATA (9002313.78) -- b1 payer sheet, b2 payer sheet, b3 payer sheet, e1 payer sheet