docaetna ncpdp commercial d0 claim billing b1
download 
Plainte Transcription
aetna ncpdp commercial d0 claim billing b1
Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet AETNA NCPDP D.Ø CLAIM BILLING (B1) COMMERCIAL PAYER SHEET IMPLEMENTATION GUIDE FOR VERSION D.Ø VERSION 2.Ø June 2Ø12 TABLE OF CONTENTS Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet 1. NCPDP VERSION D CLAIM BILLING COMMERCIAL ................................................................................................3 1.1 REQUEST CLAIM BILLING COMMERCIAL PAYER SHEET ..............................................................................................3 1.2 RESPONSE CLAIM BILLING COMMERCIAL PAYER SHEET............................................................................................9 1.2.1 Claim Billing Commercial Accepted/Paid (or Duplicate of Paid) Response .....................................................9 1.2.2 Claim Billing Commercial Accepted/Rejected Response ...............................................................................13 1.2.3 Claim Billing Commercial Rejected/Rejected Response ................................................................................15 2. 3. FREQUENTLY ASKED QUESTIONS ......................................................................................................................... 17 APPENDIX A. HISTORY OF IMPLEMENTATION GUIDE CHANGES .......................................................................18 3.1 3.2 VERSION 1.Ø ........................................................................................................................................................ 18 VERSION 2.Ø ........................................................................................................................................................ 18 Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet 1. NCPDP VERSION D CLAIM BILLING COMMERCIAL 1.1 REQUEST CLAIM BILLING COMMERCIAL PAYER SHEET ** Start of Request Claim Billing (B1) Payer Sheet ** Payer Name: Aetna Plan Name/Group Name: All Processor: Aetna Pharmacy Management Effective as of: Fall 2011 (Required 1/1/2Ø12) NCPDP Data Dictionary Version Date: October 2011 Contact/Information Source: [email protected] Provider Relations Help Desk Info: 8ØØ-238-6279 GENERAL INFORMATION Date: June 2012 BIN: 61Ø5Ø2 PCN: 00670000 NCPDP Telecommunication Standard Version/Release #: D.Ø NCPDP External Code List Version Date: October 2011 OTHER TRANSACTIONS SUPPORTED Transaction Code B2 Transaction Name Billing Reversal Payer Usage Column MANDATORY FIELD LEGEND FOR COLUMNS Value Explanation Payer Situation Column No M The Field is mandatory for the Segment in the designated Transaction. REQUIRED R QUALIFIED REQUIREMENT RW Yes NOT USED NA The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. “Required when”. The situations designated have qualifications for usage ("Required if x", "Not required if y"). The field is not used. Do not submit. OPTIONAL O The field is optional. Yes No No Fields that are defined as NOT USED in the D.Ø implementation guide should not be submitted. If a field that is defined as NOT USED is submitted, the transaction will be rejected. Fields that are defined as Optional in the D.Ø Implementation guide are not required for Aetna Processing however if they are submitted they must conform to NCPDP format. All Character fields will be checked for length limitations and the exceeding characters will be truncated. Example: A field can hold 2 Chars. If the value received for the field is ‘ABC’, the value will be truncated to 2 Chars and send ‘AB’. NOTE: Aetna only supports B1 and B2 Transactions. CLAIM BILLING TRANSACTION The following lists the segments and fields in a Claim Billing Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Transaction Header Segment Questions This Segment is always sent Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Payer Issued Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Switch/VAN issued Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Not used Check X X Claim Billing If Situational, Payer Situation Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet Field # 1Ø1-A1 1Ø2-A2 1Ø3-A3 1Ø4-A4 1Ø9-A9 2Ø2-B2 Transaction Header Segment NCPDP Field Name Value BIN NUMBER VERSION/RELEASE NUMBER TRANSACTION CODE PROCESSOR CONTROL NUMBER TRANSACTION COUNT 61Ø5Ø2 DØ B1 00670000 1-4 SERVICE PROVIDER ID QUALIFIER 1=One Occurrence 2=Two Occurrences 3=Three Occurrences 4=Four Occurrences Ø1 Payer Usage M M M M M Claim Billing Payer Situation If COMPOUND CODE (4Ø6-D6) = 2, TRANSACTION COUNT (1Ø9-A9) must = 1. M Ø1 = NPI 2Ø1-B1 4Ø1-D1 11Ø-AK SERVICE PROVIDER ID DATE OF SERVICE SOFTWARE VENDOR/CERTIFICATION ID Insurance Segment Questions This Segment is always sent Field # 3Ø2-C2 336-8C 3Ø1-C1 Insurance Segment Segment Identification (111-AM) = “Ø4” NCPDP Field Name NPI M M M Check Claim Billing If Situational, Payer Situation X Claim Billing Value CARDHOLDER ID FACILITY ID GROUP ID Payer Usage M NA R Payer Situation The Group number from the member's ID card must be entered exactly as written on the card, excluding dashes and spaces. 3Ø3-C3 PERSON CODE R 3Ø6-C6 PATIENT RELATIONSHIP CODE R Patient Segment Questions This Segment is always sent This Segment is situational Field 3Ø4-C4 3Ø5-C5 31Ø-CA 311-CB 334-1C Patient Segment Segment Identification (111-AM) = “Ø1” NCPDP Field Name DATE OF BIRTH PATIENT GENDER CODE PATIENT FIRST NAME PATIENT LAST NAME SMOKER/NON-SMOKER CODE Check Claim Billing If Situational, Payer Situation X Claim Billing Value Payer Usage R R R R NA Payer Situation Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet Claim Segment Questions Check This Segment is always sent This payer supports partial fills This payer does not support partial fills Field # 455-EM 4Ø2-D2 436-E1 Claim Segment Segment Identification (111-AM) = “Ø7” NCPDP Field Name PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUMBER PRODUCT/SERVICE ID QUALIFIER Claim Billing If Situational, Payer Situation X X Claim Billing Value 1 = Rx Billing Payer Usage M M ØØ, Ø3 M Use ØØ when Compound Code (4Ø6-D6) = 2 Use Ø3 when Compound Code (4Ø6-D6) = 1 M Use Ø when Compound Code (4Ø6-D6) = 2 R R Must be greater than zero ØØ-Not Specified Ø3-National Drug Code (NDC) 4Ø7-D7 PRODUCT/SERVICE ID 442-E7 4Ø3-D3 QUANTITY DISPENSED FILL NUMBER 4Ø5-D5 4Ø6-D6 DAYS SUPPLY COMPOUND CODE 4Ø8-D8 414-DE 419-DJ 354-NX 42Ø-DK Ø - Original dispensing 1 - 99 - Refill number 1, 2 1 = Not a Compound 2 = Compound DISPENSE AS WRITTEN (DAW)/PRODUCT Ø - No Product Selection SELECTION CODE Indicated 1 - Substitution Not Allowed by Prescriber 2 - Substitution Allowed-Patient Requested Product Dispensed 3 - Substitution AllowedPharmacist Selected Product Dispensed 4 - Substitution Allowed-Generic Drug Not in Stock 5 - Substitution Allowed-Brand Drug Dispensed as a Generic 6 - Override 7 - Substitution Not Allowed-Brand Drug Mandated by Law 8 - Substitution Allowed-Generic Drug Not Available in Marketplace 9 - Substitution Allowed By Prescriber but Plan Requests Brand DATE PRESCRIPTION WRITTEN PRESCRIPTION ORIGIN CODE Ø–4 SUBMISSION CLARIFICATION CODE COUNT SUBMISSION CLARIFICATION CODE Ø - Not Known 1 - Written 2 - Telephone 3 - Electronic 4 - Facsimile 1, 2 or 3. R R R QUANTITY PRESCRIBED OTHER COVERAGE CODE RW 8 418-DI LEVEL OF SERVICE Ø - Not Specified by patient 1 - No other coverage 3 - Emergency When claim is for a Multi-Source Brand the Dispense As Written cannot be Ø. If the DAW submitted is Ø the claim will reject. R R 8=Process Compound For Approved Ingredients 46Ø-ET 3Ø8-C8 Payer Situation NA R RW Required when Submission Clarification Code is used Required when pharmacist approves to process Compound for approved ingredients only. See COB Payer Sheet for COB values. Required when filling an emergency prescription. Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet Field # Claim Segment Segment Identification (111-AM) = “Ø7” NCPDP Field Name 88Ø-K5 TRANSACTION REFERENCE NUMBER 995-E2 ROUTE OF ADMINISTRATION 996-G1 COMPOUND TYPE 147-U7 PHARMACY SERVICE TYPE Pricing Segment Questions This Segment is always sent Field # 4Ø9-D9 412-DC 477-BE 478-H7 479-H8 Pricing Segment Segment Identification (111-AM) = “11” NCPDP Field Name INGREDIENT COST SUBMITTED DISPENSING FEE SUBMITTED PROFESSIONAL SERVICE FEE SUBMITTED OTHER AMOUNT CLAIMED SUBMITTED COUNT OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER Claim Billing Value Payer Usage NA O RW Required when Compound Code (4Ø6-D6) = 2 O Check Claim Billing If Situational, Payer Situation X Claim Billing Value Payer Usage R R NA Ø, 1 , 2, 3 RW Ø1 to Ø4, 99 RW Payer Situation Required if Other Amount Claimed Submitted Qualifier (479-H8) is used. Required when Other Amount Claimed Submitted Qualifier and Other Amount Claimed Submitted Amount are used. Required if Other Amount Claimed Submitted (48Ø-H9) is used. Required when Other Amount Claimed Submitted Count and Other Amount Claimed Submitted Amount are used. (Blank is not allowed) Ø1 - Delivery Cost Ø2 - Shipping Cost Ø3 - Postage Cost Ø4 - Administrative Cost 99 - Other 48Ø-H9 Payer Situation OTHER AMOUNT CLAIMED SUBMITTED RW 481-HA FLAT SALES TAX AMOUNT SUBMITTED RW 482-GE PERCENTAGE SALES TAX AMOUNT SUBMITTED RW Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. Required when Other Amount Claimed Submitted Count and Other Amount Claimed Submitted Qualifier are used. Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. Required if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. Required when Percentage Sales Tax Rate Submitted and Percentage Sales Tax Basis Submitted are used. Required when percentage sales tax applies to the claim. 483-HE PERCENTAGE SALES TAX RATE SUBMITTED 484-JE PERCENTAGE SALES TAX BASIS SUBMITTED RW Ø2, Ø3 Ø2 - Ingredient Cost Ø3 Ingredient Dispensing Fee RW Cost + Note: This currently applies to the following states: MN, IL, and LA Required if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Basis Submitted (484-JE) are used. Required if Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Rate Submitted (483-HE) are used. Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet Field # Pricing Segment Segment Identification (111-AM) = “11” NCPDP Field Name 426-DQ 43Ø-DU USUAL AND CUSTOMARY CHARGE GROSS AMOUNT DUE 423-DN BASIS OF COST DETERMINATION Claim Billing Value Payer Usage R R Ø1 - 13 Payer Situation Value in this field must balance with all submitted amount fields. R Ø1 - AWP (Average Wholesale Price) Ø2 - Local Wholesaler Ø3 - Direct Ø4 - EAC (Estimated Acquisition Cost) Ø5 - Acquisition Ø6 - MAC (Maximum Allowable Cost) Ø7 - Usual & Customary Ø8 - 34ØB / Disproportionate Share Pricing/Public Health Service Ø9 - Other 1Ø - ASP (Average Sales Price) 11 - AMP (Average Manufacturer Price) 12 - WAC (Wholesale Acquisition Cost) 13 - Special Patient Pricing – The cost calculated by the pharmacy for the drug for this special patient. Prescriber Segment Questions This Segment is always sent This Segment is situational Field # 466-EZ Prescriber Segment Segment Identification (111-AM) = “Ø3” NCPDP Field Name PRESCRIBER ID QUALIFIER Check Claim Billing If Situational, Payer Situation X Claim Billing Value Ø1, Ø8, 12 Payer Usage R Ø1=National Provider Identifier (NPI) Ø8=State License 12=Drug Enforcement Administration (DEA) 411-DB 367-2N 467-1E PRESCRIBER ID PRESCRIBER STATE/PROVINCE ADDRESS PRESCRIBER LOCATION CODE R NA Payer Situation Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet DUR/PPS Segment Questions This Segment is always sent This Segment is situational Field # DUR/PPS Segment Segment Identification (111-AM) = “Ø8” NCPDP Field Name Check Claim Billing If Situational, Payer Situation X Claim Billing Value Maximum of 9 occurrences. Payer Usage R RW 473-7E 439-E4 DUR/PPS CODE COUNTER REASON FOR SERVICE CODE 44Ø-E5 PROFESSIONAL SERVICE CODE RW 441-E6 RESULT OF SERVICE CODE RW 474-8E DUR/PPS LEVEL OF EFFORT Ø, 11 - 15 RW Payer Situation Required if DUR/PPS Segment is used. Required when used for DUR conflict resolution (drug/drug interactions or therapeutic duplication) Required when used for DUR conflict resolution Required when used for DUR conflict resolution Required when Compound Code (4Ø6-D6) = 2 Ø - Not Specified 11 - Level 1 (Lowest) 12 - Level 2 13 - Level 3 14 - Level 4 15 - Level 5 (Highest) Coupon Segment Questions This Segment is always sent This Segment is situational Field # 485-KE 486-ME Coupon Segment Segment Identification (111-AM) = “Ø9” NCPDP Field Name This Segment is always sent This Segment is situational 45Ø-EF 451-EG 447-EC 488-RE 489-TE 448-ED 449-EE 49Ø-UE Claim Billing If Situational, Payer Situation X Claim Billing Value Payer Usage M M COUPON TYPE COUPON NUMBER Compound Segment Questions Field # Check Compound Segment Segment Identification (111-AM) = “1Ø” NCPDP Field Name Check Payer Situation Claim Billing If Situational, Payer Situation X Claim Billing Value COMPOUND DOSAGE FORM DESCRIPTION CODE COMPOUND DISPENSING UNIT FORM INDICATOR COMPOUND INGREDIENT COMPONENT Maximum 25 ingredients COUNT COMPOUND PRODUCT ID QUALIFIER Ø3-National Drug Code (NDC) COMPOUND PRODUCT ID COMPOUND INGREDIENT QUANTITY Must be greater than zero. COMPOUND INGREDIENT DRUG COST Must be greater than zero. COMPOUND INGREDIENT BASIS OF COST 01 - 13 DETERMINATION Ø1 - AWP (Average Wholesale Price) Ø2 - Local Wholesaler Ø3 - Direct Ø4 - EAC (Estimated Acquisition Cost) Payer Usage M M M M M M R R Payer Situation Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet Field # Compound Segment Segment Identification (111-AM) = “1Ø” NCPDP Field Name Claim Billing Value Payer Usage Payer Situation Ø5 - Acquisition Ø6 - MAC (Maximum Allowable Cost) Ø7 - Usual & Customary Ø8 - 34ØB /Disproportionate Share Pricing/Public Health Service Ø9 - Other 1Ø - ASP (Average Sales Price) 11 - AMP (Average Manufacturer Price) 12 - WAC (Wholesale Acquisition Cost) 13 - Special Patient Pricing – The cost calculated by the pharmacy for the drug for this special patient. Clinical Segment Questions Check This Segment is always sent This Segment is situational Field # 491-VE 492-WE 424-DO 493-XE 494-ZE 495-H1 496-H2 497-H3 499-H4 Claim Billing If Situational, Payer Situation X Clinical Segment Segment Identification (111-AM) = “13” NCPDP Field Name Claim Billing Value DIAGNOSIS CODE COUNT DIAGNOSIS CODE QUALIFIER DIAGNOSIS CODE CLINICAL INFORMATION COUNTER MEASUREMENT DATE MEASUREMENT TIME MEASUREMENT DIMENSION MEASUREMENT UNIT MEASUREMENT VALUE Payer Usage R R O O O O O O O Payer Situation ** End of Request Claim Billing (B1) Payer Sheet ** 1.2 RESPONSE CLAIM BILLING COMMERCIAL PAYER SHEET 1.2.1 CLAIM BILLING COMMERCIAL ACCEPTED/PAID (OR DUPLICATE RESPONSE OF PAID) ** Start of Response Claim Billing (B1) Payer Sheet ** Payer Name: Aetna Plan Name/Group Name: All GENERAL INFORMATION Date: July 2Ø11 BIN: 61Ø5Ø2 PCN: 00670000 CLAIM BILLING PAID (OR DUPLICATE OF PAID) RESPONSE The following lists the segments and fields in a Claim Billing response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet Response Transaction Header Segment Questions Check This Segment is always sent Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation X Response Transaction Header Segment Field # 1Ø2-A2 1Ø3-A3 1Ø9-A9 5Ø1-F1 2Ø2-B2 2Ø1-B1 4Ø1-D1 NCPDP Field Name Value VERSION/RELEASE NUMBER TRANSACTION CODE TRANSACTION COUNT HEADER RESPONSE STATUS SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE DØ B1 Same value as in request A = Accepted Same value as in request Same value as in request Same value as in request Response Message Segment Questions Check This Segment is always sent This Segment is situational Field # 5Ø4-F4 Response Message Segment Segment Identification (111-AM) = “2Ø” NCPDP Field Name X 3Ø1-C1 524-FO 568-J7 569-J8 3Ø2-C2 Check Value GROUP ID PLAN ID PAYER ID QUALIFIER Ø3 PAYER ID CARDHOLDER ID This Segment is always sent This Segment is situational 31Ø-CA 311-CB 3Ø4-C4 Payer Usage O Response Patient Segment Segment Identification (111-AM) = “29” NCPDP Field Name PATIENT FIRST NAME PATIENT LAST NAME DATE OF BIRTH Claim Billing– Accepted/Paid (or Duplicate of Paid) Payer Situation Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation X Response Insurance Segment Segment Identification (111-AM) = “25” NCPDP Field Name Response Patient Segment Questions Field # If transmission level messaging applies. Value This Segment is always sent This Segment is situational Field # Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation MESSAGE Response Insurance Segment Questions Payer Usage M M M M M M M Claim Billing– Accepted/Paid (or Duplicate of Paid) Payer Situation Payer Usage R O R Ø3 = Bank Identification Number (BIN) 61Ø5Ø2 Check X Value R O Claim Billing– Accepted/Paid (or Duplicate of Paid) Payer Situation Will send back if available Will Send back the ID that is used in Adjudication, only if different than what was submitted on request. Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation When the submitted Patient First Name and/or Last Name are different than what is on the member record. Payer Usage R R R Claim Billing– Accepted/Paid (or Duplicate of Paid) Payer Situation Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet Response Status Segment Questions Check This Segment is always sent Field # Response Status Segment Segment Identification (111-AM) = “21” NCPDP Field Name 112-AN TRANSACTION RESPONSE STATUS 5Ø3-F3 AUTHORIZATION NUMBER 13Ø-UF ADDITIONAL MESSAGE INFORMATION COUNT 132-UH Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation X Value P=Paid D=Duplicate of Paid Payer Usage M Claim Billing– Accepted/Paid (or Duplicate of Paid) Payer Situation R RW Required if Additional Message Information (526-FQ) is used. ADDITIONAL MESSAGE INFORMATION QUALIFIER RW Required if Additional Message Information (526-FQ) is used. 526-FQ ADDITIONAL MESSAGE INFORMATION RW Required when additional text is needed for clarification or detail. 131-UG ADDITIONAL MESSAGE INFORMATION CONTINUITY RW Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current. 549-7F HELP DESK PHONE NUMBER QUALIFIER HELP DESK PHONE NUMBER 55Ø-8F Response Claim Segment Questions This Segment is always sent Field # Response Claim Segment Segment Identification (111-AM) = “22” NCPDP Field Name 455-EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER Response Pricing Segment Questions This Segment is always sent Field # 5Ø5-F5 5Ø6-F6 5Ø7-F7 558-AW Response Pricing Segment Segment Identification (111-AM) = “23” NCPDP Field Name PATIENT PAY AMOUNT INGREDIENT COST PAID DISPENSING FEE PAID FLAT SALES TAX AMOUNT PAID Maximum count of 9. Ø3 R 8ØØ2386279 R Check . Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation X Value 1 = RxBilling Payer Usage M Claim Billing– Accepted/Paid (or Duplicate of Paid) Payer Situation M Check Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation X Value Payer Usage R R R RW Claim Billing– Accepted/Paid (or Duplicate of Paid) Payer Situation Required if Flat Sales Tax Amount Submitted (481-HA) is greater than zero (Ø). Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet Field # 559-AX Response Pricing Segment Segment Identification (111-AM) = “23” NCPDP Field Name Value Payer Usage RW PERCENTAGE SALES TAX AMOUNT PAID Claim Billing– Accepted/Paid (or Duplicate of Paid) Payer Situation .Required if Percentage Sales Tax Amount Submitted (482-GE) is greater than zero (Ø). Required if Percentage Sales Tax Rate Paid (56Ø-AY) and Percentage Sales Tax Basis Paid (561-AZ) are used. 56Ø-AY PERCENTAGE SALES TAX RATE PAID RW Required if Percentage Sales Tax Amount Paid (559-AX) is greater than zero (Ø). 561-AZ PERCENTAGE SALES TAX BASIS PAID RW Required if Percentage Sales Tax Amount Paid (559-AX) is greater than zero (Ø). 521-FL INCENTIVE AMOUNT PAID RW Required if Incentive Amount Submitted (438-E3) is greater than zero (Ø). 563-J2 OTHER AMOUNT PAID COUNT RW Required if Other Amount Paid (565-J4) is used. 564-J3 OTHER AMOUNT PAID QUALIFIER RW Required if Other Amount Paid (565-J4) is used. 565-J4 OTHER AMOUNT PAID RW Required if Other Amount Claimed Submitted (48Ø-H9) is greater than zero (Ø). 5Ø9-F9 522-FM TOTAL AMOUNT PAID BASIS OF REIMBURSEMENT DETERMINATION ACCUMULATED DEDUCTIBLE AMOUNT REMAINING DEDUCTIBLE AMOUNT REMAINING BENEFIT AMOUNT AMOUNT APPLIED TO PERIODIC DEDUCTIBLE AMOUNT OF COPAY AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM AMOUNT OF COINSURANCE HEALTH PLAN-FUNDED ASSISTANCE AMOUNT AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG 512-FC 513-FD 514-FE 517-FH 518-FI 52Ø-FK 572-4U 129-UD 134-UK Response DUR/PPS Segment Questions This Segment is always sent This Segment is situational Field # Response DUR/PPS Segment Segment Identification (111-AM) = “24” NCPDP Field Name Maximum count of 3. R R Check X RW RW RW RW Returned if known or if applicable. Returned if known or if applicable. Returned if known or if applicable. Returned if known and impacts Patient Pay.. RW RW Returned if known and impacts Patient Pay. Returned if known and impacts Patient Pay. RW RW Returned if known and impacts Patient Pay. Returned if known and impacts Patient Pay.. RW Returned if known and impacts Patient Pay. Claim Billing Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation If DUR information applies. Value Maximum 9 occurrences supported. Payer Usage RW Claim Billing– Accepted/Paid (or Duplicate of Paid) Payer Situation 567-J6 DUR/PPS RESPONSE CODE COUNTER Required if Reason For Service Code (439-E4) is used. 439-E4 REASON FOR SERVICE CODE RW Required if utilization conflict is detected. 528-FS CLINICAL SIGNIFICANCE CODE RW Required if needed to supply additional information for the utilization conflict. 529-FT OTHER PHARMACY INDICATOR RW Required if needed to supply additional information for the utilization conflict. Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet Field # Response DUR/PPS Segment Segment Identification (111-AM) = “24” NCPDP Field Name Value Payer Usage RW Claim Billing– Accepted/Paid (or Duplicate of Paid) Payer Situation 53Ø-FU PREVIOUS DATE OF FILL Required if needed to supply additional information for the utilization conflict. 531-FV QUANTITY OF PREVIOUS FILL RW Imp Guide: Required if needed to supply additional information for the utilization conflict. 532-FW DATABASE INDICATOR RW Required if needed to supply additional information for the utilization conflict. 533-FX OTHER PRESCRIBER INDICATOR RW Required if needed to supply additional information for the utilization conflict. 544-FY DUR FREE TEXT MESSAGE RW Required if needed to supply additional information for the utilization conflict. 57Ø-NS DUR ADDITIONAL TEXT RW Required if needed to supply additional information for the utilization conflict. 1.2.2 CLAIM BILLING COMMERCIAL ACCEPTED/REJECTED RESPONSE CLAIM BILLING COMMERCIAL ACCEPTED/REJECTED RESPONSE Response Transaction Header Segment Questions Check Claim Billing Accepted/Rejected If Situational, Payer Situation This Segment is always sent X Field # 1Ø2-A2 1Ø3-A3 1Ø9-A9 5Ø1-F1 2Ø2-B2 2Ø1-B1 4Ø1-D1 Response Transaction Header Segment NCPDP Field Name Value VERSION/RELEASE NUMBER TRANSACTION CODE TRANSACTION COUNT HEADER RESPONSE STATUS SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE DØ B1 Same value as in request A = Accepted Same value as in request Same value as in request Same value as in request Response Message Segment Questions This Segment is always sent This Segment is situational Field # 5Ø4-F4 Response Message Segment Segment Identification (111-AM) = “2Ø” NCPDP Field Name This Segment is always sent This Segment is situational 3Ø1-C1 524-FO X Response Insurance Segment Segment Identification (111-AM) = “25” NCPDP Field Name GROUP ID PLAN ID Claim Billing Accepted/Rejected Payer Situation Claim Billing Accepted/Rejected If Situational, Payer Situation If transmission level messaging applies. Claim Billing Accepted/Rejected Value MESSAGE Response Insurance Segment Questions Field # Check Payer Usage M M M M M M M Check Payer Usage O Payer Situation Claim Billing Accepted/Rejected If Situational, Payer Situation X Claim Billing Accepted/Rejected Value Payer Usage R O Payer Situation Will send back if available Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet Field # 568-J7 569-J8 3Ø2-C2 Response Insurance Segment Segment Identification (111-AM) = “25” NCPDP Field Name Value PAYER ID QUALIFIER Ø3 PAYER ID CARDHOLDER ID Response Patient Segment Questions Claim Billing Accepted/Rejected Payer Usage R Ø3 = Bank Identification Number (BIN) 61Ø5Ø2 Check This Segment is always sent This Segment is situational X R O Payer Situation Will Send back the ID that is used in Adjudication, only if different than what was submitted on request. Claim Billing Accepted/Rejected If Situational, Payer Situation When the submitted Patient First Name and/or Last Name are different than Is on the member record. Field # Response Patient Segment Segment Identification (111-AM) = “29” NCPDP Field Name Claim Billing Accepted/Rejected 31Ø-CA PATIENT FIRST NAME Payer Usage R 311-CB 3Ø4-C4 PATIENT LAST NAME DATE OF BIRTH R R Response Status Segment Questions Value Check This Segment is always sent Field # Response Status Segment Segment Identification (111-AM) = “21” NCPDP Field Name Payer Situation Claim Billing Accepted/Rejected If Situational, Payer Situation X Claim Billing Accepted/Rejected Value 112-AN 5Ø3-F3 51Ø-FA 511-FB 546-4F TRANSACTION RESPONSE STATUS AUTHORIZATION NUMBER REJECT COUNT REJECT CODE REJECT FIELD OCCURRENCE INDICATOR R = Reject 13Ø-UF ADDITIONAL MESSAGE INFORMATION COUNT Maximum count of 9. 132-UH Maximum count of 5. Payer Usage M R M M RW Payer Situation Required if a repeating field is in error, to identify repeating field occurrence. RW Required if Additional Message Information (526-FQ) is used. ADDITIONAL MESSAGE INFORMATION QUALIFIER RW Required if Additional Message Information (526-FQ) is used. 526-FQ ADDITIONAL MESSAGE INFORMATION RW Required when additional text is needed for clarification or detail. 131-UG ADDITIONAL MESSAGE INFORMATION CONTINUITY RW Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current. 549-7F HELP DESK PHONE NUMBER QUALIFIER HELP DESK PHONE NUMBER 55Ø-8F Ø3 R 8ØØ2386279 R Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet Response Claim Segment Questions This Segment is always sent Field # 455-EM 4Ø2-D2 Response Claim Segment Segment Identification (111-AM) = “22” NCPDP Field Name PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUMBER Response DUR/PPS Segment Questions This Segment is always sent This Segment is situational Check Claim Billing Accepted/Rejected If Situational, Payer Situation X Claim Billing Accepted/Rejected Value Payer Usage M 1 = RxBilling Payer Situation M Check X Claim Billing Accepted/Rejected If Situational, Payer Situation If DUR information applies. Response DUR/PPS Segment Segment Identification (111-AM) = “24” NCPDP Field Name Value 567-J6 DUR/PPS RESPONSE CODE COUNTER Maximum 9 occurrences . 439-E4 REASON FOR SERVICE CODE RW Required if utilization conflict is detected. 528-FS CLINICAL SIGNIFICANCE CODE RW Required if needed to supply additional information for the utilization conflict. 529-FT OTHER PHARMACY INDICATOR RW Required if needed to supply additional information for the utilization conflict. 53Ø-FU PREVIOUS DATE OF FILL RW Required if needed to supply additional information for the utilization conflict. 531-FV QUANTITY OF PREVIOUS FILL RW Required if needed to supply additional information for the utilization conflict. 532-FW DATABASE INDICATOR RW Required if needed to supply additional information for the utilization conflict. 533-FX OTHER PRESCRIBER INDICATOR RW Required if needed to supply additional information for the utilization conflict. 544-FY DUR FREE TEXT MESSAGE RW Required if needed to supply additional information for the utilization conflict. 57Ø-NS DUR ADDITIONAL TEXT RW Required if needed to supply additional information for the utilization conflict. Field # Claim Billing Accepted/Rejected Payer Usage RW Payer Situation Required if Reason For Service Code (439E4) is used. 1.2.3 CLAIM BILLING COMMERCIAL REJECTED/REJECTED RESPONSE CLAIM BILLING COMMERCIAL REJECTED/REJECTED RESPONSE Response Transaction Header Segment Questions Check Claim Billing Rejected/Rejected If Situational, Payer Situation This Segment is always sent X Field # 1Ø2-A2 1Ø3-A3 1Ø9-A9 Response Transaction Header Segment NCPDP Field Name Value VERSION/RELEASE NUMBER TRANSACTION CODE TRANSACTION COUNT DØ B1 Same value as in request Payer Usage M M M Claim Billing Rejected/Rejected Payer Situation Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet Field # 5Ø1-F1 2Ø2-B2 2Ø1-B1 4Ø1-D1 Response Transaction Header Segment NCPDP Field Name Value HEADER RESPONSE STATUS SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE R = Rejected Same value as in request Same value as in request Same value as in request Response Message Segment Questions Check This Segment is always sent This Segment is situational Field # 5Ø4-F4 X Response Message Segment Segment Identification (111-AM) = “2Ø” NCPDP Field Name If transmission level messaging applies. Claim Billing Rejected/Rejected Value Check This Segment is always sent Field # Claim Billing Rejected/Rejected Payer Situation Claim Billing Rejected/Rejected If Situational, Payer Situation Payer Usage O MESSAGE Response Status Segment Questions Payer Usage M M M M Payer Situation Claim Billing Rejected/Rejected If Situational, Payer Situation X Response Status Segment Segment Identification (111-AM) = “21” NCPDP Field Name Claim Billing Rejected/Rejected Value 112-AN 5Ø3-F3 51Ø-FA 511-FB 546-4F TRANSACTION RESPONSE STATUS AUTHORIZATION NUMBER REJECT COUNT REJECT CODE REJECT FIELD OCCURRENCE INDICATOR R = Reject 13Ø-UF ADDITIONAL MESSAGE INFORMATION COUNT Maximum count of 9. 132-UH Maximum count of 5. Payer Usage M R M M RW Payer Situation Required if a repeating field is in error, to identify repeating field occurrence. RW Required if Additional Message Information (526-FQ) is used. ADDITIONAL MESSAGE INFORMATION QUALIFIER RW Required if Additional Message Information (526-FQ) is used. 526-FQ ADDITIONAL MESSAGE INFORMATION RW Required when additional text is needed for clarification or detail. 131-UG ADDITIONAL MESSAGE INFORMATION CONTINUITY RW Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current. 549-7F HELP DESK PHONE NUMBER QUALIFIER HELP DESK PHONE NUMBER 55Ø-8F Ø3 R 8ØØ2386279 R ** End of Response Claim Billing (B1) Payer Sheet ** Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet 2. FREQUENTLY ASKED QUESTIONS Aetna NCPDP D. Ø CLAIM BILLING (B1) COMMERCIAL Payer Sheet 3. APPENDIX A. HISTORY OF IMPLEMENTATION GUIDE CHANGES 3.1 VERSION 1.Ø July 2011 - Initial Creation of Aetna NCPDP D.Ø Claim Billing (B1) Commercial Payer Sheet. 3.2 VERSION 2.Ø June 2012 - Modified ECL version to October 2011 from March 2010. Modified NCPDP Data Dictionary Version Date to October 2011 from March 2010. Added 367-2N PRESCRIBER STATE/PROVINCE ADDRESS as a required field to the Prescriber Segment.
