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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 4

Field 504 on a Reversal Response

Position Description Comments
1 - 3 EOB Will display an EOB number.
4 (Space) Format as a constant space.
5 - 10 REV SD Format as a constant.
11 (Space) Format as a constant space.
12 - 17 Reversed spenddown $ amount Will display the amount added back to the patient's spenddown.

Format: 9999v99

Note: This field will only be populated for SeniorCare claims.
18 (Space) Format as a constant space.
19 - 25 REV DED Format as a constant.
26 (Space) Format as a constant space.
27 - 31 Reversed deductible $ amount Will display the amount added back to the patient's deductible.

Format: 999v99

Note: This field will only be populated for SeniorCare claims.
32 (Space) Format as a constant space.
33 - 44 REMAINING SD Format as a constant.
45 (Space) Format as a constant space.
46 - 51 Remaining Spenddown $ Amount Will display the amount the participant has left to pay before his/her spenddown has been satisfied.

Format: 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.
52 (Space) Format as a constant space.
53 - 65 REMAINING DED Format as a constant.
66 (Space) Format as a constant space.
67 - 71 Remaining deductible $ amount Will display the amount the participant has left to pay before his/her deductible has been satisfied.

Format: 999v99

Note: This field will only be populated on SeniorCare claims.

Previous — Attachment 3

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