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Wisconsin Medicaid Companion Document to HIPAA Implementation Guide — NCPDP 5.1

Effective on and after 12/14/04

NCPDP 5.1 V4
PHC 13052 (9/15/04)
PDF (113 KB)
Revision Log

B1 Billing Request

Transaction Header Segment

Field Number

Field Name

Value

M/R/
RW

Comment

101-A1

 BIN Number 610499

M

  

102-A2

 Version/Release Number 51

M

  

103-A3

 Transaction Code B1

M

  

104-A4

 Processor Control Number  

M

 Not used by Wisconsin Medicaid.

109-A9

 Transaction Count 1 = 1 Occurrence
2 = 2 Occurrences
3 = 3 Occurrences
4 = 4 Occurrences

M

  

202-B2

 Service Provider ID Qualifier 05 = Medicaid

M

  

201-B1

 Service Provider ID  

M

 Enter the 8-digit Wisconsin Medicaid provider ID.

Note: Pad with spaces on the right.

401-D1

 Date of Service  

M

 Enter the date the prescription was filled.

110-AK

 Software Vendor/Certification ID  

M

 Enter the Medicaid assigned vendor code.

Note: For testing, use "TESTMODO."

Pad with spaces on the right.

Insurance Segment

Field Number

Field Name

Value

M/R/
RW

Comment

111-AM

 Segment Identification 04 = Insurance

M

  

302-C2

 Cardholder ID  

M

 Enter the patient's 10-digit Medicaid identification number.

Patient Segment

Field Number

Field Name

Value

M/R/
RW

Comment

111-AM

 Segment Identification 01 = Patient

M

  

310-CA

 Patient First Name  

R

 Enter the patient's first name.

311-CB

 Patient Last Name  

R

 Enter the patient's last name.

307-C7

 Patient Location 0 = Not specified
1 = Home
4 = Extended care facility
7 = Skilled care facility
10 = Outpatient

R

  

Claim Segment

Field Number

Field Name

Value

M/R/
RW

Comment

111-AM

 Segment Identification 07 = Claim

M

  

455-EM

 Prescription/Service Reference Number Qualifier 1 = Rx billing

M

  

402-D2

 Prescription/Service Reference Number  

M

 Enter the 7-digit prescription number.

436-E1

 Product/Service ID Qualifier 03 = National Drug Code
(NDC)

M

  

407-D7

 Product/Service ID  

M

 Enter the 11-digit NDC identifying the drug dispensed.

442-E7

 Quantity Dispensed  

R

 Note: The maximum length allowed is 8 significant bytes. If more than 8 significant bytes are submitted, the transaction will be rejected. Leading zeros will not cause a rejection.

Format: s9999999v999

403-D3

 Fill Number 0 = Original dispensing
1 - 99 = Refill number

R

  

405-D5

 Days Supply  

R

 Enter the estimated number of days prescription will last.

406-D6

 Compound Code 1 = Not a compound
2 = Compound

R

  

408-D8

 Dispense As Written (DAW)/Product Selection Code 0 = No product selection indicated
1 = Substitution not allowed by prescriber
8 = Substitution allowed - generic drug not in marketplace

R

  

414-DE

 Date Prescription Written  

R

 Enter the date the prescription was written by the prescriber.

420-DK

 Submission Clarification Code 0 = Not specified
2 = Other override
8 = Process compound for approved ingredients

RW

 Enter "2" to indicate repackaging.

Enter "8" on a compound claim to indicate acceptance of payment for only those ingredients covered.

Note: An "8" must be submitted on all compound claims.

308-C8

 Other Coverage Code 0 = Not specified
1 = No other coverage identified
2 = Other coverage exists - payments collected
3 = Other coverage exists - this claim not covered
4 = Other coverage exists - payment not collected
5 = Managed care plan denial
6 = Other coverage denied - not a participating provider
7 = Other coverage exists - not in effect at time of service

R

  

429-DT

 Unit Dose Indicator 0 = Not specified
1 = Not unit dose
2 = Manufacturer unit dose
3 = Pharmacy unit dose

RW

 Enter one of the accepted values when billing for unit dose.

461-EU

 Prior Authorization Type Code 1=Prior Authorization
4=Exemption from copay
8=Payer defined exemption (copay exemption + prior authorization number)

RW

 Enter to indicate a prior authorization number or to indicate a copay exemption.

Note: When a "1" or "8" is entered, field 462-EV must be submitted. "4" and "8" will not exempt SeniorCare participants from copay requirements.

462-EV

 Prior Authorization Number Submitted  

RW

 Enter the 7-digit prior authorization (PA) number if one has been obtained.

Note: When submitted, field 461-E4 must also be submitted.

Pricing Segment

Field Number

Field Name

Value

M/R/
RW

Comment

111-AM

 Segment Identification 11 = Pricing

M

  

433-DX

 Patient Paid Amount Submitted  

RW

 SeniorCare — Enter the amount of out-of-pocket expenses to be paid by the patient towards the prescription due to other coverage.

SeniorCare and Medicaid — Do not use this field to indicate expected copay.

Note: Negative dollar amounts will not be accepted.

426-DQ

 Usual and Customary Charge  

R

 Enter the amount charged cash customers exclusive of sales tax and other amounts claimed.

Note: Negative dollar amounts will not be accepted.

430-DU

 Gross Amount Due  

R

 Enter the total price claimed from all sources.

Note: Negative dollar amounts will not be accepted.

Prescriber Segment

Field Number

Field Name

Value

M/R/
RW

Comment

111-AM

 Segment Identification 03 = Prescriber

M

  

466-EZ

 Prescriber ID Qualifier 12 = Drug Enforcement Administration (DEA)

R

  

411-DB

 Prescriber ID  

R

 Enter the 9-digit DEA number of the prescriber.

Coordination of Benefits/Other Payments Segment

Field Number

Field Name

Value

M/R/
RW

Comment

111-AM

 Segment Identification 5 = Coordination of Benefits/Other Payments

M

  

337-4C

 Coordination of Benefits/Other Payments Count 1 = 1 set of data follows

M

 Indicates the number of repetitions that follow for the fields in this grouping:
  • Other payer coverage type.
  • Other payer amount paid count.
    • Other payer amount paid qualifier.
    • Other payer amount paid.
Note: Only 1 set of COB fields will be accepted. If more than one occurrence is submitted, the transaction will be rejected.

338-5C

 Other Payer Coverage Type 99 = Composite

M

  

341-HB

 Other Payer Amount Paid Count 1 = 1 set of data follows

RW

 Enter when fields 342-HC and 431-DV are submitted.

Maximum of 1 occurrence supported. If more than 1 occurrence is sent, the transaction will be rejected.

Indicates the number of repetitions that follow for the fields in this grouping:
  • Other payer amount paid qualifier.
  • Other payer amount paid.

342-HC

 Other Payer Amount Paid Qualifier 08 = Sum of all reimbursement

RW

 Enter when field 431-DV is submitted.

431-DV

 Other Payer Amount Paid  

RW

 Enter the sum of all reimbursement from all other payers.

Note: Negative dollar amounts will not be accepted.

DUR/PPS Segment

Field Number

Field Name

Value

M/R/
RW

Comment

111-AM

 Segment Identification 08 = DUR/PPS

M

  

473-7E

 DUR/PPS Code Counter

1 = First occurrence of DUR fields
2 = Second occurrence of DUR fields

RW

 Enter when fields 439-E4, 440-E5, 441-E6, or 474-8E are submitted.

Indicates the occurrence number for each set of the following repeatable fields:
  • Reason for service code (439-E4).
  • Professional service code (440-E5).
  • Result of service code (441-E6).
  • DUR/PPS level of effort (474-8E).
Note: Only the first two sets of DUR fields will be processed for non-compound submissions, and only the first set of DUR fields will be processed for compound submissions and reversals. Any additional sets of DUR fields will be ignored if submitted.

439-E4

 Reason for Service Code AD = Additional drug needed
AN = Prescription authentication
AR = Adverse drug reaction
AT = Additive toxicity
CD = Chronic disease management
CS = Patient complaint/symptom
DA = Drug-allergy
DC = Drug-disease (inferred)
DD = Drug-drug interaction
DF = Drug-food interaction
DI = Drug incompatibility
DL = Drug-lab conflict
DM = Apparent drug misuse
DS = Tobacco Use
ER = Overuse
EX = Excessive quantity
HD = High dose
IC = Iatrogenic Condition
ID = Ingredient duplication
LD = Low dose
LK = Lock-in recipient
LR = Underuse
MC = Drug-disease (reported)
MN = Insufficient duration
MX = Excessive duration
ND = New disease/diagnosis
NN = Unnecessary drug
NP = New patient processing
NR = Lactation/nursing interaction
NS = Insufficient quantity
OH = Alcohol conflict
PA = Drug-age
PG = Drug-pregnancy
PR = Prior Adverse Reaction
PS = Product selection opportunity
RE = Suspected environmental risk
SC = Suboptimal compliance
SE = Side effect
SF = Suboptimal dosage form
SR = Suboptimal regimen
SX = Drug-gender
TD = Therapeutic
TN = Laboratory test needed

RW

 Enter when billing Pharmaceutical Care services or overriding DUR alerts.

 Note: Only the first two sets of DUR fields will be processed for non-compound submissions, and only the first set of DUR fields will be processed for compound submissions and reversals. Any additional sets of DUR fields will be ignored if submitted.

It is recommended that Pharmaceutical Care be separate from DUR alert pre-override/override. If the values are the same for both, they may be submitted as one set of fields.

440-E5

 Professional Service Code AS = Patient assessment
CC = Coordination of care
M0 = Prescriber consulted
MR = Medication review
P0 = Patient consulted
PE = Patient education/instruction
PH = Patient medication history
R0 = Pharmacist consulted other source
RT = Recommend laboratory test
SW = Literature search/review
TC = Payer/processor consulted
TH = Therapeutic product interchange

RW

 Enter when billing Pharmaceutical Care services or overriding DUR alerts.

 Note: Only the first two sets of DUR fields will be processed for non-compound submissions, and only the first set of DUR fields will be processed for compound submissions and reversals. Any additional sets of DUR fields will be ignored if submitted.

It is recommended that Pharmaceutical Care be separate from DUR alert pre-override/override. If the values are the same for both, they may be submitted as one set of fields.

441-E6

 Result of Service Code 1A = Filled as is, false positive
1C = Filled, with different dose
1D = Filled, with different directions
1E = Filled, with different drug
1F = Filled, with different quantity
1G = Filled, with prescriber approval
1K = Filled, with different dosage form
2A = Prescription not filled
2B = Not filled, directions clarified
3G = Drug therapy unchanged
3H = Follow-up/report
3K = Instructions understood
3M = Compliance aid provided

RW

 Enter when billing Pharmaceutical Care services or overriding DUR alerts.

Note: Only the first two sets of DUR fields will be processed for non-compound submissions, and only the first set of DUR fields will be processed for compound submissions and reversals. Any additional sets of DUR fields will be ignored if submitted.

It is recommended that Pharmaceutical Care be separate from DUR alert pre-override/override. If the values are the same for both, they may be submitted as one set of fields.

474-8E

 DUR/PPS Level of Effort 11 = 0 - 5 minutes
12 = 6 - 15 minutes
13 = 16 - 30 minutes
14 = 31 - 60 minutes
15 = More than 60 minutes

RW

 Enter when billing Pharmaceutical Care services or when the compound segment is present.

 Note: Only the first two sets of DUR fields will be processed for non-compound submissions, and only the first set of DUR fields will be processed for compound submissions and reversals. Any additional sets of DUR fields will be ignored if submitted.

It is recommended that Pharmaceutical Care be separate from DUR alert pre-override/override. If the values are the same for both, they may be submitted as one set of fields.

Compound Segment

Field Number

Field Name

Value

M/R/
RW

Comment

111-AM

 Segment Identification 10 = Compound

M

  

450-EF

 Compound Dosage Form Description Code  

M

 Not used by Wisconsin Medicaid.

451-EG

 Compound Dispensing Unit Form Indicator  

M

 Not used by Wisconsin Medicaid.

452-EH

 Compound Route of Administration  

M

 Not used by Wisconsin Medicaid.

447-EC

 Compound Ingredient Component Count 1 - 25

M

 Indicates the number of repetitions that follow for the fields in this grouping:
  • Compound product ID qualifier (488-RE).
  • Compound product ID (489-TE).
  • Compound ingredient quantity (448-ED).
  • Compound ingredient drug cost (449-EE).
Note: Up to 25 compound ingredients will be processed.

488-RE

 Compound Product ID Qualifier 03 = National Drug Code (NDC)

M

  

489-TE

 Compound Product ID  

M

 Enter the 11-digit NDC identifying the compound ingredient.

448-ED

 Compound Ingredient Quantity  

M

 Note: The maximum length allowed is 8 significant bytes. If more than 8 significant bytes are submitted, the transaction will be rejected. Leading zeros will not cause a rejection.

Format: s9999999v999

449-EE

 Compound Ingredient Drug Cost  

R

 Enter the ingredient cost for the compound ingredient.

Clinical Segment

Field Number

Field Name

Value

M/R/
RW

Comment

111-AM

 Segment Identification 13 = Clinical

M

  

491-VE

 Diagnosis Code Count 1 = 1 set of data follows

RW

 Enter when fields 492-WE and 424-DO are submitted.

Indicates the number of repetitions that follow of the fields in this grouping:
  • Diagnosis code qualifier (492-WE).
  • Diagnosis code (424-DO).
Note: Only one set of diagnosis code fields will be processed. If more than one occurrence is submitted, the remaining occurrence(s) will be ignored.

492-WE

 Diagnosis Code Qualifier 01 = International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM)

RW

 Enter when field 424-DO is submitted.

Note: Only one set of diagnosis code fields will be processed. If more than one occurrence is submitted, the remaining occurrence(s) will be ignored.

424-DO

 Diagnosis Code  

RW

 Enter the ICD-9-CM diagnosis code when the billed drug requires a diagnosis or when billing for Pharmaceutical Care (PC) services.

Note: Only one set of diagnosis code fields will be processed. If more than one occurrence is submitted, the remaining occurrence(s) will be ignored.

M/R/RW = Mandatory/Required/Required When

Next — B1 Accepted Response
Previous — Table of Contents and Revision Logs

Back to the Companion Documents

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