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Wisconsin Medicaid Companion Document to HIPAA Implementation Guide — NCPDP 5.1

PHC 13052 (04/24/04)
PDF (197 KB)

Attachment 1

Field 526 on a Paid or Duplicate of Paid Response When the AT DUR Alert Has Not Set

Position

Description

Comments
1 - 3 EOB #1

Will display the 1st Explanation of Benefit (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 - 26 RS

Format as a constant.
27 - 32 Remaining spenddown $ amount

Will display the amount the participant has left to pay before his/her spenddown is satisfied. 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.
33 (Space)

Format as a constant space.
34 - 35 RD

Format as a constant.
36 - 40 Remaining deductible $ amount

Will display the amount the participant has left to pay before his/her deductible is satisfied. 999v99.

Note: This field will only be populated on SeniorCare claims.
41 – 186 (Spaces)

Format as constant spaces.

Field 526 on a Paid or Duplicate of Paid Response When the AT DUR Alert Has Set

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 - 26 RS

Format as a constant.
27 - 32 Remaining spenddown $ amount

Will display the amount the participant has left to pay before his/her spenddown is satisfied. 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.
33 (Space)

Format as a constant space.
34 - 35 RD

Format as a constant.
36 - 40 Remaining deductible $ amount

Will display the amount the participant has left to pay before his/her deductible is satisfied. 999v99.

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

Format as a constant space.
42 - 67 Drug label name 1  
68 (Asterisk)

Format as a constant asterisk.
69 - 94 Drug label name 2  
95 (Asterisk)

Format as a constant asterisk.
96 - 121 Drug label name 3  
122 – 186 Spaces

Format as constant spaces.

Next — Attachment 2
Previous — B2 Rejected Response
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