101-A1

M

102-A2

M

103-A3

M

104-A4

M

Not used by Wisconsin Medicaid.

109-A9

1 = 1 Occurrence

2 = 2 Occurrences

3 = 3 Occurrences

4 = 4 Occurrences

M

202-B2

M

201-B1

M

Enter the 8-digit Wisconsin Medicaid provider ID.

Note: Pad with spaces on the right.

401-D1

M

Enter the date the prescription was filled.

110-AK

M

Enter the Medicaid assigned vendor code.

Note: For testing, use "TESTMODO."

Pad with spaces on the right.

111-AM

04 = Insurance

M

302-C2

M

Enter the patient's 10-digit Medicaid identification number.

111-AM

M

455-EM

M

402-D2

M

Enter the 7-digit prescription number.

436-E1

M

407-D7

M

Enter the 11-digit NDC identifying the drug dispensed.

442-E7

R

Note: The maximum length allowed is 8 significant bytes. If more than 8 significant bytes are submitted, the transaction will be rejected. Leading zeros will not cause a rejection.

Format: s9999999v999

403-D3

0 = Original dispensing

1 - 99 = Refill number

R

405-D5

R

Enter the estimated number of days prescription will last.

406-D6

1 = Not a compound

2 = Compound

R

408-D8

0 = No product selection indicated

1 = Substitution not allowed by prescriber

8 = Substitution allowed - generic drug not in marketplace

R

414-DE

R

Enter the date the prescription was written by the prescriber.

420-DK

0 = Not specified

2 = Other override

8 = Process compound for approved ingredients

RW

Enter "2" to indicate repackaging.

Enter "8" on a compound claim to indicate acceptance of payment for only those ingredients covered.

Note: An "8" must be submitted on all compound claims.

308-C8

0 = Not specified

1 = No other coverage identified

2 = Other coverage exists - payments collected

3 = Other coverage exists - this claim not covered

4 = Other coverage exists - payment not collected

5 = Managed care plan denial

6 = Other coverage denied - not a participating provider

7 = Other coverage exists - not in effect at time of service

R

429-DT

0 = Not specified

1 = Not unit dose

2 = Manufacturer unit dose

3 = Pharmacy unit dose

RW

Enter one of the accepted values when billing for unit dose.

461-EU

1=Prior Authorization

4=Exemption from copay

8=Payer defined exemption (copay exemption + prior authorization number)

RW

Enter to indicate a prior authorization number or to indicate a copay exemption.

Note: When a "1" or "8" is entered, field 462-EV must be submitted. "4" and "8" will not exempt SeniorCare participants from copay requirements.

462-EV

RW

Enter the 7-digit prior authorization (PA) number if one has been obtained.

Note: When submitted, field 461-E4 must also be submitted.

111-AM

11 = Pricing

M

433-DX

RW

SeniorCare - Enter the amount of out-of-pocket expenses to be paid by the patient towards the prescription due to other coverage.

SeniorCare and Medicaid - Do not use this field to indicate expected copay.

Note: Negative dollar amounts will not be accepted.

426-DQ

R

Enter the amount charged cash customers exclusive of sales tax and other amounts claimed.

Note: Negative dollar amounts will not be accepted.

430-DU

R

Enter the total price claimed from all sources.

Note: Negative dollar amounts will not be accepted.

111-AM

03 = Prescriber

M

466-EZ

12 = Drug Enforcement Administration (DEA)

R

411-DB

R

Enter the 9-digit DEA number of the prescriber.

111-AM

5 = Coordination of Benefits/Other Payments

M

337-4C

1 = 1 set of data follows

M

Indicates the number of repetitions that follow for the fields in this grouping:

• Other payer coverage type.
• Other payer amount paid count.
  • Other payer amount paid qualifier.
  • Other payer amount paid.

Note: Only 1 set of COB fields will be accepted. If more than one occurrence is submitted, the transaction will be rejected.

338-5C

99 = Composite

M

341-HB

1 = 1 set of data follows

RW

Enter when fields 342-HC and 431-DV are submitted.

Maximum of 1 occurrence supported. If more than 1 occurrence is sent, the transaction will be rejected.

Indicates the number of repetitions that follow for the fields in this grouping:

• Other payer amount paid qualifier.
• Other payer amount paid.

342-HC

08 = Sum of all reimbursement

RW

Enter when field 431-DV is submitted.

431-DV

RW

Enter the sum of all reimbursement from all other payers

Note: Negative dollar amounts will not be accepted.

111-AM

08 = DUR/PPS

M

473-7E

1 = 1 set of data follows

RW

Enter when fields 439-E4, 440-E5 and 441-E6 are submitted.

Indicates the number of repetitions that follow of the fields in this grouping:

• Reason for service code (439-E4).
• Professional service code (440-E5).
• Result of service code (441-E6).
• DUR/PPS level of effort (474-8E).

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

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 dosage form

SR = Suboptimal regimen

SX = Drug-gender

TD = Therapeutic

TN = Laboratory test needed

RW

Enter when billing Pharmaceutical Care (PC) services or overriding DUR alerts.

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

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 other source

RT = Recommend laboratory test

SW = Literature search/review

TC = Payer/processor consulted

TH = Therapeutic product interchange

RW

Enter when billing Pharmaceutical Care (PC) services or overriding DUR alerts.

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

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

Enter when billing Pharmaceutical Care (PC) services or overriding DUR alerts.

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.

474-8E

11 = 0 - 5 minutes

12 = 6 - 15 minutes

13 = 16 - 30 minutes

14 = 31 - 60 minutes

15 = More than 60 minutes

RW

Enter when billing Pharmaceutical Care (PC) services or when the compound segment is present.

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.

111-AM

10 = Compound

M

450-EF

M

Not used by Wisconsin Medicaid.

451-EG

M

Not used by Wisconsin Medicaid.

452-EH

M

Not used by Wisconsin Medicaid.

447-EC

1 - 25

M

Indicates the number of repetitions that follow for the fields in this grouping:

• Compound product ID qualifier (488-RE).
• Compound product ID (489-TE).
• Compound ingredient quantity (448-ED).
• Compound ingredient drug cost (449-EE).

Note: Up to 25 compound ingredients will be processed.

488-RE

03 = National Drug Code (NDC)

M

489-TE

M

Enter the 11-digit NDC identifying the compound ingredient.

448-ED

M

Note: The maximum length allowed is 8 significant bytes. If more than 8 significant bytes are submitted, the transaction will be rejected. Leading zeros will not cause a rejection.

Format: s9999999v999

449-EE

R

Enter the ingredient cost for the compound ingredient.

111-AM

13 = Clinical

M

491-VE

1 = 1 set of data follows

RW

Enter when fields 492-WE and 424-DO are submitted.

Indicates the number of repetitions that follow of the fields in this grouping:

• Diagnosis code qualifier (492-WE).
• Diagnosis code (424-DO).

Note: Only one set of diagnosis code fields will be processed. If more than one occurrence is submitted, the remaining occurrence(s) will be ignored.

492-WE

01 = International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM)

RW

Enter when field 424-DO is submitted.

Note: Only one set of diagnosis code fields will be processed. If more than one occurrence is submitted, the remaining occurrence(s) will be ignored.

424-DO

RW

Enter the ICD-9-CM diagnosis code when the billed drug requires a diagnosis or when billing for Pharmaceutical Care (PC) services.

Note: Only one set of diagnosis code fields will be processed. If more than one occurrence is submitted, the remaining occurrence(s) will be ignored.