Wisconsin Medicaid HIPAA Companion Document to HIPAA Implementation Guide: X12 NCPDP 5.1

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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 Accepted Response

Response Header Segment

Field Number	Field Name	Value	M/R/ RW	Comment
102-A2	Version/Release Number		M	This field contains the same value as submitted on the request.
103-A3	Transaction Code		M	This field contains the same value as submitted on the request.
109-A9	Transaction Count		M	This field contains the same value as submitted on the request.
501-F1	Header Response Status	A = Accepted	M
202-B2	Service Provider ID Qualifier		M	This field contains the same value as submitted on the request.
201-B1	Service Provider ID		M	This field contains the same value as submitted on the request.
401-D1	Date of Service		M	This field contains the same value as submitted on the request.

Response Status Segment

Field Number	Field Name	Value	M/R/ RW	Comment
111-AM	Segment Identification	21 = Response status	M
112-AN	Transaction Response Status	D = Duplicate of paid P = Paid R = Rejected	M
503-F3	Authorization Number		R	This field contains an authorization number on duplicate and rejected responses; Internal Control Number (ICN) on paid responses.
510-FA	Reject Count	1 - 10	RW	Note: This field will only display when field 112-AN = "R."
511-FB	Reject Code		RW	This field contains an NCPDP reject code; reference NCPDP September 1999 Data Dictionary, Appendix F, for a list of valid values. Note: This field will only display when field 112-AN = "R."
546-4F	Reject Field Occurrence Indicator		RW	This field contains the counter number or occurrence of the field that is being rejected. Note: This field will only display when the field in error is a repeating field and field 112-AN = "R."
526-FQ	Additional Message Information		R	See Attachment 1 for Paid or Duplicate of Paid Response. See Attachment 2 for Rejected Response.

Response Claim Segment

Field Number	Field Name	Value	M/R/ RW	Comment
111-AM	Segment Identification	22 = Response claim	M
455-EM	Prescription/Service Reference Number Qualifier		M	This field contains the same value as submitted on the request.
402-D2	Prescription/Service Reference Number		M	This field contains the same value as submitted on the request.

Response Pricing Segment

Field Number	Field Name	Value	M/R/ RW	Comment
111-AM	Segment Identification	23 = Response pricing	M
505-F5	Patient Pay Amount		R	This field contains the total amount to be collected from the patient for the prescription. Note: Amount applied to periodic deductible (517-FH) + amount of copay/co- insurance (518-FI) ---------------------------------- = patient pay amount (505- F5)
506-F6	Ingredient Cost Paid		R	This field contains the amount paid for the drug based on the total amount paid pricing formula. Note: Included in the total amount paid (509-F9).
507-F7	Dispensing Fee Paid		R	This field contains the amount paid for the dispensing fee based on the total amount paid pricing formula. Note: Included in the total amount paid (509-F9).
557-AV	Tax Exempt Indicator	1 = Tax exempt	R
566-J5	Other Payer Amount Recognized		R	This field contains the amount recognized as being paid by another payer. Note: Included in the total amount paid (509-F9).
509-F9	Total Amount Paid		R	This field contains the total amount to be paid by Wisconsin Medicaid for the prescription. Note: Ingredient cost paid (506-F6) + dispensing fee paid (507- F7) - patient pay amount (505-F5) - other payer amount recognized (566-J5) ------------------------- = total amount paid (509-F9)
513-FD	Remaining Deductible Amount		R	This field contains the total amount the patient has yet to pay before satisfying his/her annual spenddown and/or deductible.
517-FH	Amount Applied to Periodic Deductible		R	This field contains the total amount applied to the patient's annual spenddown and/or deductible. Note: Included in the patient pay amount (505-F5).
518-FI	Amount of Copay/Co-Insurance		R	This field contains the total amount of copay for which the patient is responsible. Note: Included in the patient pay amount (505-F5).

Response DUR/PPS Segment

Field Number	Field Name	Value	M/R/ RW	Comment
111-AM	Segment Identification	24 = Response DUR/PPS	M
567-J6	DUR/PPS Response Code Counter	1 - 5	RW	This field indicates the number of repetitions that follow for the fields in this grouping: Reason for service code (439-E4). Clinical significance code (528-FS). Other pharmacy indicator (529-FT). Previous date of fill (530-FU). Quantity of previous fill (531-FV). Database indicator (532-FW). Other prescriber indicator (533-FY). DUR free text message (544-FY).
439-E4	Reason for Service Code	AT = Additive toxicity DC = Drug-disease (inferred) DD = Drug-drug interaction ER = Overuse LR = Underuse MC = Drug-disease (reported) PA = Drug-age PG = Drug-pregnancy TD = Therapeutic	RW	This field contains the DUR alert code when a DUR alert sets.
528-FS	Clinical Significance Code	1 = Major 2 = Moderate 3 = Minor	RW	This field contains additional DUR alert information.
529-FT	Other Pharmacy Indicator	1 = Your pharmacy 3 = Other pharmacy	RW	This field contains additional DUR alert information.
530-FU	Previous Date of Fill		RW	This field contains additional DUR alert information. Note: CCYYMMDD = This field contains the date of service from the claim causing the alert to set. If the alert is set based on data from the current claim only, the field will be omitted from the response.
531-FV	Quantity of Previous Fill		RW	This field contains additional DUR alert information. Note: 99999v999 = This field contains the quantity from the claim causing the alert to set. If the alert is set based on data from the current claim only, the field will be omitted from the response.
532-FW	Database Indicator	1 = First Databank 4 = Processor developed	RW	This field contains additional DUR alert information.
533-FX	Other Prescriber Indicator	1 = Same prescriber 2 = Other prescriber	RW	This field contains additional DUR alert information.
544-FY	DUR Free Text Message		RW	This field contains additional DUR alert information. Note: See Attachment 3 of this document for the messages that will appear in this field.

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

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