X hits on this document

18 views

0 shares

0 downloads

0 comments

3 / 7

344-HF 345-HG

QUANTITY INTENDED TO BE DISPENSED DAYS SUPPLY INTENDED TO BE DISPENSED

Pharmacy Provider Segment – Situational

NCPDP Field

Field Name

111-AM

SEGMENT IDENTIFICATION

465-EY

PROVIDER ID QUALIFIER

444-E9

PROVIDER ID (NCPDP #)

Prescriber Segment – Situational

NCPDP Field

Field Name

111-AM

SEGMENT IDENTIFICATION

466-EZ

PRESCRIBER ID QUALIFIER

411-DB

PRESCRIBER ID

467-1E

PRESCRIBER LOCATION CODE

427-DR

PRESCRIBER LAST NAME

498-PM

PRESCRIBER PHONE NUMBER

468-2E

PRIMARY CARE PROVIDER ID QUALIFIER

421-DL

PRIMARY CARE PROVIDER ID

469-H5

PRIMARY CARE PROVIDER LOCATION CODE

47Ø-4E

PRIMARY CARE PROVIDER LAST NAME

COB/Other Payments Segment – Situational

NCPDP Field

Field Name

111-AM

SEGMENT IDENTIFICATION

338-5C

OTHER PAYER COVERAGE TYPE

339-6C

OTHER PAYER ID QUALIFIER

34Ø-7C

OTHER PAYER ID

443-E8

OTHER PAYER DATE

341-HB

OTHER PAYER AMOUNT PAID COUNT

342-HC

OTHER PAYER AMOUNT PAID QUALIFIER

431-DV

OTHER PAYER AMOUNT PAID

471-5E

OTHER PAYER REJECT COUNT

472-6E

OTHER PAYER REJECT CODE

337-4C

COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT

Workers’ Compensation Segment – Situational

NCPDP Field

Field Name

111-AM

SEGMENT IDENTIFICATION

434-DY 315-CF 316-CG 317-CH 318-CI

DATE OF INJURY EMPLOYER NAME EMPLOYER STREET ADDRESS EMPLOYER CITY ADDRESS EMPLOYER STATE/PROVINCE ADDRESS

3

S S

Mandatory or Situational M

S S

Mandatory or Situational M

S S S S S S S S S

Mandatory or Situational M

M

M***R*** S***R*** S***R*** S***R*** S S***R*** S***R*** S S***R***

Mandatory or Situational M

M S S S S

Not Required. Partial Fills not supported. Not Required. Partial Fills not supported.

Segment is Not Required.

02

  • transmit ONLY if the segment is transmitted. Not Required. Not Required.

Segment is Required for B1 and B3 transaction.

03

  • transmit ONLY if the segment is

transmitted. Required. Prefer Use of 12, 13, 14.

Required. Not Required. Not Required. Not Required. Not Required. Not Required. Not Required. Not Required.

Segment is Required ONLY if COB or Coupons apply to the Claim. Not Required for B2 transaction.

05

  • transmit ONLY if the segment is

transmitted. Required if Segment is Used. 3. Required if Segment is

Required if Segment is Required if Segment is Required if Segment is Required if Segment is Required if Segment is Required if Segment is

Maximum =

Used. Used. Used. Used. Used. Used. Used.

Not Required. Not Required.

Segment is Not Required. Not Required for B2 transaction.

06

  • transmit ONLY if the segment is transmitted. Not Required. Not Required. Not Required. Not Required. Not Required.

Document info
Document views18
Page views18
Page last viewedMon Dec 05 17:22:19 UTC 2016
Pages7
Paragraphs455
Words2666

Comments