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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
B2 Rejected 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 |
R = Rejected |
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 |
R =
Rejected |
M |
|
|
503-F3 |
Authorization Number |
|
R |
This field contains the Wisconsin Medicaid-generated authorization number. |
|
510-FA |
Reject Count |
1-10 |
R |
|
|
511-FB |
Reject Code |
|
R |
This field contains an NCPDP reject code; reference NCPDP September 1999
Data Dictionary, Appendix F, for a list of valid values. |
|
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 field 112-AN =
"R" and when the field in error is a repeating field. |
M/R/RW = Mandatory/Required/Required When
Next — Attachment 1
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