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Insurance Segment – Situational

NCPDP Field

Field Name

111-AM

SEGMENT IDENTIFICATION

3Ø2-C2 312-CC 313-CD 314-CE 524-FO 3Ø9-C9

CARDHOLDER ID CARDHOLDER FIRST NAME CARDHOLDER LAST NAME HOME PLAN PLAN ID ELIGIBILITY CLARIFICATION CODE

336-8C 3Ø1-C1 3Ø3-C3 3Ø6-C6

FACILITY ID GROUP ID PERSON CODE PATIENT RELATIONSHIP CODE

Claim Segment – Mandatory

NCPDP Field

Field Name

111-AM

SEGMENT IDENTIFICATION

455-EM 4Ø2-D2 436-E1 4Ø7-D7 456-EN 457-EP 458-SE

PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUMBER PRODUCT/SERVICE ID QUALIFIER PRODUCT/SERVICE ID ASSOCIATED PRESCRIPTION/SERVICE REFERENCE # ASSOCIATED PRESCRIPTION/SERVICE DATE PROCEDURE MODIFIER CODE COUNT

459-ER 442-E7 4Ø3-D3 4Ø5-D5 4Ø6-D6

PROCEDURE MODIFIER CODE QUANTITY DISPENSED FILL NUMBER DAYS SUPPLY COMPOUND CODE

4Ø8-D8 414-DE 415-DF 419-DJ 42Ø-DK

DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE DATE PRESCRIPTION WRITTEN NUMBER OF REFILLS AUTHORIZED PRESCRIPTION ORIGIN CODE SUBMISSION CLARIFICATION CODE

46Ø-ET 3Ø8-C8 429-DT 453-EJ 445-EA 446-EB 33Ø-CW 454-EK 6ØØ-28 418-DI 461-EU 462-EV 463-EW 464-EX 343-HD

QUANTITY PRESCRIBED OTHER COVERAGE CODE UNIT DOSE INDICATOR ORIG PRESCRIBED PRODUCT/SERVICE ID QUALIFIER ORIGINALLY PRESCRIBED PRODUCT/SERVICE CODE ORIGINALLY PRESCRIBED QUANTITY ALTERNATE ID SCHEDULED PRESCRIPTION ID NUMBER UNIT OF MEASURE LEVEL OF SERVICE PRIOR AUTHORIZATION TYPE CODE PRIOR AUTHORIZATION NUMBER SUBMITTED INTERMEDIARY AUTHORIZATION TYPE ID INTERMEDIARY AUTHORIZATION ID DISPENSING STATUS

2

Mandatory or Situational M

M S S S S S

S S S S

Mandatory or Situational M

M M M M S S S

S***R*** S S S S

S S S S S

S S S S S S S S S S S S S S S

Segment is Required for B1 and B3 transactions. Not Required for B2 transaction.

04

  • transmit ONLY if the segment is transmitted. Required. From ID Card Required. Required. Not Required. Not Required.

As needed to override a Reject (3 for Full time Student) Not Required.

Not Required. From ID Card Required. From ID Card Required. From ID Card

Segment is Required for B1, B2, B3 transactions.

07

  • transmit ONLY if the segment is

transmitted. Required. Only value '1' is accepted.

Required. Only supports 7 digit Rx #. 03 NDC number Not Required. Not Required.

Required ONLY if Procedure Modifier Code Submitted. Submit ONLY if instructed by Help Desk.

Required for B1 & B3 claims. Required for B1 & B3 claims. Required for B1 & B3 claims.

Required for B1 & B3 claims. Use '2' if product is a compound. Required for B1 & B3 claims.

Required for B1 & B3 claims. Not Required. Not Required.

As needed to override a Reject (3 for Vacation Supply) Not Required. Partial Fills not supported.

Only Required if 01 - 08 applies. Not Required. Not Required. Partial Fills not supported. Not Required. Partial Fills not supported. Not Required. Partial Fills not supported. Not Required. Not Required. Not Required. Not Required. Not Required. Not Required. Not Required. Not Required. Not Required. Partial Fills not supported.

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