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319-CJ 32Ø-CK 321-CL 327-CR 435-DZ

EMPLOYER ZIP/POSTAL ZONE EMPLOYER PHONE NUMBER EMPLOYER CONTACT NAME CARRIER ID CLAIM/REFERENCE ID

DUR/PPS Segment -- Situational

NCPDP Field

Field Name

111-AM

SEGMENT IDENTIFICATION

473-7E

DUR/PPS CODE COUNTER

439-E4 44Ø-E5 441-E6 474-8E 475-J9

REASON FOR SERVICE CODE PROFESSIONAL SERVICE CODE RESULT OF SERVICE CODE DUR/PPS LEVEL OF EFFORT DUR CO-AGENT ID QUALIFIER

476-H6

DUR CO-AGENT ID

Pricing Segment – Mandatory

NCPDP Field

Field Name

111-AM

SEGMENT IDENTIFICATION

4Ø9-D9 412-DC 477-BE 433-DX 438-E3 478-H7 479-H8 48Ø-H9 481-HA 482-GE 483-HE 484-JE 426-DQ 43Ø-DU 423-DN

INGREDIENT COST SUBMITTED DISPENSING FEE SUBMITTED PROFESSIONAL SERVICE FEE SUBMITTED PATIENT PAID AMOUNT SUBMITTED INCENTIVE AMOUNT SUBMITTED OTHER AMOUNT CLAIMED SUBMITTED COUNT OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER OTHER AMOUNT CLAIMED SUBMITTED FLAT SALES TAX AMOUNT SUBMITTED PERCENTAGE SALES TAX AMOUNT SUBMITTED PERCENTAGE SALES TAX RATE SUBMITTED PERCENTAGE SALES TAX BASIS SUBMITTED USUAL AND CUSTOMARY CHARGE GROSS AMOUNT DUE BASIS OF COST DETERMINATION

Coupon Segment – Situational

NCPDP Field

Field Name

111-AM

SEGMENT IDENTIFICATION

485-KE 486-ME 487-NE

COUPON TYPE COUPON NUMBER COUPON VALUE AMOUNT

4

S

Not Required.

S

Not Required.

S

Not Required.

S

Not Required.

S

Not Required.

Segment is Not Required. Use encouraged if applicable. Not required for B2 transaction.

Mandatory or Situational M

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

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

11

  • transmit ONLY if the segment is transmitted. Required. Required. Not Required. Not Required. Not Required. Required if 480-H9 submitted. Required if 480-H9 submitted. Not Required.

Required in applicable locations. Required in applicable locations. Required if 482-GE submitted. Required if 482-GE submitted. Required. Required. Not Required.

Required in B1 and B3 transactions ONLY if Coupons apply to the Claim. Not Required for B2 transaction.

Mandatory or Situational M

S***R***

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

S***R***

08

  • transmit ONLY if the segment is

transmitted. Required if segment used. One to 9 occurrences are supported. Required if segment used.

Required if segment used. Required if segment used. Required if segment used.

Required if 476-H6 used. Values 01, 02, 03, 20. Encouraged if code DC, DD, ID, MC, TD in 439-E4.

Mandatory or Situational l M

M M S

09

  • transmit ONLY if the segment is

transmitted. Required if Segment used.

Required if Segment used. Required if Segment used.

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