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Compound Segment – Situational

COMPOUND COMPOUND COMPOUND COMPOUND COMPOUND

DOSAGE FORM DESCRIPTION CODE DISPENSING UNIT FORM INDICATOR ROUTE OF ADMINISTRATION INGREDIENT COMPONENT COUNT PRODUCT ID QUALIFIER

COMPOUND COMPOUND

PRODUCT ID INGREDIENT QUANTITY

COMPOUND COMPOUND

INGREDIENT DRUG COST INGREDIENT BASIS OF COST DETERMINATION

NCPDP Field

111-AM

45Ø-EF 451-EG 452-EH 447-EC 488-RE

489-TE 448-ED

449-EE 49Ø-UE

Field Name

SEGMENT IDENTIFICATION

Prior Authorization Segment – Situational

NCPDP Field

Field Name

111-AM

SEGMENT IDENTIFICATION

498-PA 498-PB 498-PC 498-PD 498-PE 498-PF 498-PG 498-PH 498-PJ 498-PK 498-PY 5Ø3-F3 498-PP

REQUEST TYPE REQUEST PERIOD DATE-BEGIN REQUEST PERIOD DATE-END BASIS OF REQUEST AUTHORIZED REPRESENTATIVE FIRST NAME AUTHORIZED REPRESENTATIVE LAST NAME AUTHORIZED REPRESENTATIVE STREET ADDRESS AUTHORIZED REPRESENTATIVE CITY ADDRESS AUTHORIZED REPRESENTATIVE STATE/PROVINCE ADDRESS AUTHORIZED REPRESENTATIVE ZIP/POSTAL ZONE PRIOR AUTHORIZATION NUMBER--ASSIGNED AUTHORIZATION NUMBER PRIOR AUTHORIZATION SUPPORTING DOCUMENTATION

Clinical Segment – Situational

491-VE

DIAGNOSIS CODE COUNT

492-WE

DIAGNOSIS CODE QUALIFIER

424-DO

DIAGNOSIS CODE

493-XE

CLINICAL INFORMATION COUNTER

494-ZE

MEASUREMENT DATE

495-H1

MEASUREMENT TIME

496-H2

MEASUREMENT DIMENSION

497-H3

MEASUREMENT UNIT

499-H4

MEASUREMENT VALUE

NCPDP Field

Field Name

111-AM

SEGMENT IDENTIFICATION

5

Not Required. Segment is NOT

SUPPORTED.

Mandatory

or

Situational

M

10

– transmit ONLY if the segment is

transmitted.

M

Not Required.

M

Not Required.

M

Not Required.

M

Not Required.

M***R***

Not Required.

M***R***

Not Required.

M***R***

Not Required.

S***R***

Not Required.

S***R***

Not Required.

Submit segment for B1 and B3 transaction upon Help Desk request. Not Required for B2 transaction.

Mandatory or Situational M

M M M M S S S S S S S S S

12

  • transmit ONLY if the segment is

transmitted. Values 1, 2, 3 accepted.

Not used. Format must be correct, though. Not used. Format must be correct, though. Values ME, PR, PL accepted. Not Required. Not Required. Not Required. Not Required. Not Required. Not Required. Not Required. Not Required. Not Required.

Not Required. Submit segment for B1 or B3 transaction ONLY if one or more specific fields are required for a specific claim

Mandatory or Situational M

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

13

  • transmit ONLY if the segment is

transmitted. Required if 424-DO populated.

Required if 424-DO populated. Required for certain plan limitations.

Not Required.

Not Supported.

Not Required.

Not Supported.

Not Required.

Not Supported.

Not Required.

Not Supported.

Not Required.

Not Supported.

Not Required.

Not Supported.

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