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Wisconsin Medicaid Companion Document to HIPAA
Implementation Guide — NCPDP 5.1
PHC 13052 (4/24/04)
PDF (143 KB)
B1 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 |
|
|
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 a 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 the field in error is a repeating
field. |
|
526-FQ |
Additional Message Information |
|
R |
See Attachment 2. |
M/R/RW = Mandatory/Required/Required When
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