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Wisconsin Medicaid Companion Document to HIPAA
Implementation Guide — NCPDP 5.1
PHC 13052 (04/24/04)
PDF (197 KB)
B2 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 |
|
M |
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 |
|
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503-F3 |
Authorization Number |
|
R |
This field contains the Wisconsin
Medicaid-generated authorization number. |
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510-FA |
Reject Count |
1-10 |
R |
|
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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 field 112-AN = "R" and when the field in error is a
repeating field. |
M/R/RW = Mandatory/Required/Required When
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