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Sierra Health Services

PAYER SPECIFICATION SHEET

December 28, 2005 Bin #: States: Destination: Accepting: Format:

7382 National SXC (ComCoTec) / RxClaim Claim Adjudication, Reversals NCPDP Version 5.1

1.

Segment And Field Requirements By Transaction Type

BILLING (B1), REVERSAL (B2), and REBILLING (B3) TRANSACTION DATA ELEMENTS (M-Mandatory, S-Situational, ***R-Repeat Field)

Transaction Header Segment - Mandatory

NCPDP Field

Field Name

Mandatory or Situational

Segment is Required. COMMENTS/VALUES

1Ø1-A1 1Ø2-A2 1Ø3-A3 1Ø4-A4 1Ø9-A9

BIN NUMBER VERSION/RELEASE NUMBER TRANSACTION CODE PROCESSOR CONTROL NUMBER TRANSACTION COUNT

2Ø2-B2 2Ø1-B1

SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID

4Ø1-D1 11Ø-AK

DATE OF SERVICE SOFTWARE VENDOR/CERTIFICATION ID

M M M M M

M M

M M

007382 51 B1, B2 or B3 only SHS

01 – 04 (up to 4 transactions per B1 & B3 transmission) accepted; Only 01 for a B2 transaction 07 (NCPDP ID) or 13 (State Issued)

Value for the qualifier used in 202-B1 above CCYYMMDD

Use value for Switch’s requirements. If submitting claim without a Switch, populate with blanks.

Patient Segment – Situational

NCPDP Field

Field Name

111-AM

SEGMENT IDENTIFICATION

331-CX 332-CY 3Ø4-C4 3Ø5-C5 31Ø-CA 311-CB 322-CM 323-CN 324-CO 325-CP 326-CQ 3Ø7-C7 333-CZ 334-1C 335-2C

PATIENT ID QUALIFIER PATIENT ID DATE OF BIRTH PATIENT GENDER CODE PATIENT FIRST NAME PATIENT LAST NAME PATIENT STREET ADDRESS PATIENT CITY ADDRESS PATIENT STATE / PROVINCE ADDRESS PATIENT ZIP/POSTAL ZONE PATIENT PHONE NUMBER PATIENT LOCATION EMPLOYER ID SMOKER / NON-SMOKER CODE PREGNANCY INDICATOR

Client REQUIRES Segment for B1, B2, and B3 transactions to locate correct member.

Mandatory

or

Situational

M

01

– transmit ONLY if the segment is

transmitted.

S

Not Required.

S

Not Required.

S

Not Required.

S

Not Required.

S

Not Required for Twins/Triplets/etc

S

Not Required.

S

Not Required.

S

Not Required.

S

Not Required.

S

Not Required.

S

Not Required.

S

Not Required.

S

Not Required.

S

Not Required.

S

Not Required.

1

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