|
|
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
B2 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 |
B2 |
M |
|
|
104-A4 |
Processor Control Number |
|
M |
Not used by Wisconsin Medicaid. |
|
109-A9 |
Transaction Count |
1 = 1 Occurrence |
M |
Note: Only one reversal transaction will be accepted
per transmission. |
|
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. |
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 |
|
M |
Not used by Wisconsin Medicaid. |
|
407-D7 |
Product/Service ID |
|
M |
Not used by Wisconsin Medicaid. |
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 = 1 set of data follows |
RW |
Enter when fields 439-E4, 440-E5, and 441-E6 are submitted.
This field indicates the number of repetitions that follow for the fields in
this grouping:
- Reason for service code (439-E4).
- Professional service code (440-E5).
- Result of service code (441-E6).
Note: Only the first set of DUR fields will be processed. If more
than one occurrence is submitted, the remaining occurrence(s) will be
ignored. |
|
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 dose form
SR = Suboptimal regimen
SX = Drug-gender
TD = Therapeutic
TN = Laboratory test needed |
RW |
Note: Only the first set of DUR fields will be
processed. If more than one occurrence is submitted, the remaining
occurrence(s) will be ignored. |
|
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 from other source
RT = Recommend laboratory test
SW = Literature search/review
TC = Payer/processor consulted
TH = Therapeutic product interchange |
RW |
Note: Only the first set of DUR fields will be
processed. If more than one occurrence is submitted, the remaining
occurrence(s) will be ignored. |
|
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 |
Note: Only the first set of DUR 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 — B2 Accepted Response
Previous — B1 Rejected Response
Back to the Table of Contents
Back to
Companion Documents
|
