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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 2

Field 526 on a Rejected Response When the Claim Denies for a DUR Alert

Position Descriptions 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 - 50 Drug label name 1  
51 (Asterisk) Format as a constant asterisk.
52 - 77 Drug label name 2  
78 (Asterisk) Format as a constant asterisk.
79 - 104 Drug label name 3  
105 (Asterisk) Format as a constant asterisk.
106 - 131 Drug label name 4  
132 (Asterisk) Format as a constant asterisk.
133 - 158 Drug label name 5  
159 (Asterisk) Format as a constant asterisk.
160 - 185 Drug label name 6  
186 (Asterisk) Format as a constant asterisk.

Field 526 on a Rejected Response When the Claim Does Not Deny for a DUR Alert

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 - 32 DUP ICN: Format as a constant.
33 - 47 ICN Will display the duplicate ICN when EOB 100 is displayed in one of the six EOB fields.
48 (Space) Format as a constant space.
49 - 56 Date Will display the paid pate of the duplicate ICN. Format: CCYYMMDD
57 (Space) Format as a constant space.
58 - 61 MCP: Format as a constant.
62 - 63 MCP code Will display the managed care program (MCP) code when EOB 287 is displayed in one of the six EOB fields.
64 (Space) Format as a constant space.
65 - 74 MCP phone number Will display the MCP telephone number when EOB 287 is displayed in one of the six EOB fields.
75 (Space) Format as a constant space.
76 - 78 MCP provider specialty Will display the MCP provider specialty when EOB 287 is displayed in one of the six EOB fields.
79 (Space) Format as a constant space.
80 - 83 TPL: Format as a constant.
84 (Space) Format as a constant space.
85 - 87 TPL carrier code Will display the third-party liability (TPL – also known as private insurance or other insurance) carrier code when EOB 278 is displayed in one of the six EOB fields.
88 (Space)  
89 TPL relationship code Will display the TPL relationship code when EOB 278 is displayed in one of the six EOB fields.
90 (Space)  
91 - 106 TPL policy number Will display the TPL policy number when EOB 278 is displayed in one of the six EOB fields.
107 (Space)  
108 - 123 TPL group number Will display the TPL group number when EOB 278 is displayed in one of the six EOB fields.
124 (Space)  
125 - 132 TPL policy start date Will display the TPL policy start date when EOB 278 is displayed in one of the six EOB fields.
133 (Space)  
134 - 141 TPL policy end date Will display the TPL policy end date when EOB 278 is displayed in one of the six EOB fields.
142 (Space)  
143 - 150 LOCK-IN: Format as a constant.
151 (Space)  
152 - 159 Lock-in period start date Will display the lock-in period start date when EOB 631 is displayed in one of the six EOB fields.
160 (Space)  
161 - 168 Lock-in period end date Will display the lock-in period end date when EOB 631 is displayed in one of the six EOB fields.
169 (Space)  
170 Lock-in coverage type Will display the lock-in coverage type (1 = pharmacy; 8 = hospice) when EOB 631 is displayed in one of the six EOB fields.
171- 186 (Spaces)  

Next — Attachment 3
Previous — Attachment 1

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