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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

Attachment 1

Field 526 on a Paid or Duplicate of Paid Response When the AT DUR Alert Has Not Set

Position Description Comments
1 - 3 EOB #1 Will display the 1st Explanation of Benefit (EOB) number.
4 (Space) Format as a constant space.
5 - 7 EOB #2 Will display the 2nd EOB number.
8 (Space) Format as a constant space.
9 - 11 EOB #3 Will display the 3rd EOB number.
12 (Space) Format as a constant space.
13 - 15 EOB #4 Will display the 4th EOB number.
16 (Space) Format as a constant space.
17 - 19 EOB #5 Will display the 5th EOB number.
20 (Space) Format as a constant space.
21 - 23 EOB #6 Will display the 6th EOB number.
24 (Space) Format as a constant space.
25 - 26 RS Format as a constant.
27 - 32 Remaining spenddown $ amount Will display the amount the participant has left to pay before his/her spenddown is satisfied. 9999v99. If more than $9,999.99 of spenddown remains, the field will be filled with dollar signs.

Note: This field will only be populated on SeniorCare claims.
33 (Space) Format as a constant space.
34 - 35 RD Format as a constant.
36 - 40 Remaining deductible $ amount Will display the amount the participant has left to pay before his/her deductible is satisfied. 999v99.

Note: This field will only be populated on SeniorCare claims.
41 – 186 (Spaces) Format as constant spaces.

Field 526 on a Paid or Duplicate of Paid Response When the AT DUR Alert Has Set

Position Description Comments
1 - 3 EOB #1 Will display the 1st EOB number.
4 (Space) Format as a constant space.
5 - 7 EOB #2 Will display the 2nd EOB number.
8 (Space) Format as a constant space.
9 - 11 EOB #3 Will display the 3rd EOB number.
12 (Space) Format as a constant space.
13 - 15 EOB #4 Will display the 4th EOB number.
16 (Space) Format as a constant space.
17 - 19 EOB #5 Will display the 5th EOB number.
20 (Space) Format as a constant space.
21 - 23 EOB #6 Will display the 6th EOB number.
24 (Space) Format as a constant space.
25 - 26 RS Format as a constant.
27 - 32 Remaining spenddown $ amount Will display the amount the participant has left to pay before his/her spenddown is satisfied. 9999v99. If more than $9,999.99 of spenddown remains, the field will be filled with dollar signs.

Note: This field will only be populated on SeniorCare claims.
33 (Space) Format as a constant space.
34 - 35 RD Format as a constant.
36 - 40 Remaining deductible $ amount Will display the amount the participant has left to pay before his/her deductible is satisfied. 999v99.

Note: This field will only be populated on SeniorCare claims.
41 Space Format as a constant space.
42 - 67 Drug label name 1  
68 (Asterisk) Format as a constant asterisk.
69 - 94 Drug label name 2  
95 (Asterisk) Format as a constant asterisk.
96 - 121 Drug label name 3  
122 – 186 Spaces Format as constant spaces.

Next — Attachment 2
Previous — B2 Rejected Response

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