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NOTE: A “Situational” data element means the NCPDP Standard does not require data on all claims, but the PLAN SPONSOR reserves the possibility of use in specific claim situations. The ‘Mandatory” and "Required" fields within a "Situational" segment are only mandatory IF the segment is being utilized.

Situtational segments can be transmitted, however, not all segments are supported. Please contact the information number for more information regarding the support of claim segments.

ELIGIBILITY VERIFICATION (E1) TRANSACTION DATA ELEMENTS

  • -

    This client does NOT SUPPORT eligibility verification transactions.

PRIOR AUTHORIZATION (P1, P2, P3) TRANSACTION DATA ELEMENTS

  • -

    This client does NOT SUPPORT prior authorization transactions.

  • -

    The use of the Prior Authorization Segment is NOT SUPPORTED.

INFORMATION (N1, N2, N3) TRANSACTION DATA ELEMENTS

  • -

    This client does NOT SUPPORT informational transactions

CONTROLLED SUBSTANCE REPORTING (C1, C2, C3) TRANSACTION DATA ELEMENTS

  • -

    This client does NOT SUPPORT controlled substance reporting transactions

PARTIAL FILL TRANSACTION REPORTING

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    USE OF PARTIAL FILE DATA ELEMENTS is NOT SUPPORTED

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    Reverse original partial claim and resubmit with final dispensed quantity.

COORDINATION OF BENEFITS REPORTING

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    USE OF COB SEGMENT DATA ELEMENTS is NOT FULLY SUPPORTED

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    Only the Other Coverage Code and Other Payer Amount Paid fields are currently supported.

COUPON REPORTING

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    USE OF THE COUPON SEGMENT DATA ELEMENTS is NOT FULLY SUPPORTED

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    Submit value of coupon in COB Segment’s Other Payer Amount field.

MULTIPLE-INGREDIENT COMPOUND CLAIMS SUBMISSION

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    USE OF COMPOUND SEGMENT DATA ELEMENTS is NOT SUPPORTED

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    Submit compound claims using value ‘2’ in the Compound Code field in the Claim Segment.

  • -

    Also submit the NDC of the most expensive ingredient in Claim Segment.

2.

GENERAL INFORMATION

Live Date: Maximum prescriptions per transaction: Plan specific information, customer service: Technical assistance, help desk: Vendor certification required: Pharmacy Registration with Payer Required: Switch Support:

4 ( ( Yes Yes NDC ) )

  • -

    SXC Health Solutions, Inc.

  • -

    SXC Health Solutions, Inc.

ENVOY

Other:

3.

OTHER INFORMATION

Prescriber ID - DEA# is the preferred entry for Prescriber ID. NOTE: The data elements listed in the SPECIFICATION SHEET are presented so as to encompass all Payer

Name subscriber plans. However, specific requirements may vary from plan to plan. The Payer Name Technical Help Number can be called for detailed information regarding specific plan requirements.

Payer Name provides on-line prospective DUR edits for all of their plans. Please contact the Help Desk for further information.

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