Wisconsin Medicaid HIPAA Companion Document to HIPAA Implementation Guide: X12 NCPDP 5.1

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Wisconsin Medicaid Companion Document to HIPAA Implementation Guide — NCPDP 5.1

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

Attachment 2

Field 526 on a Rejected Response When the Claim Denies for a DUR Alert

Position	Descriptions	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 - 50	Drug label name 1
51	(Asterisk)	Format as a constant asterisk.
52 - 77	Drug label name 2
78	(Asterisk)	Format as a constant asterisk.
79 - 104	Drug label name 3
105	(Asterisk)	Format as a constant asterisk.
106 - 131	Drug label name 4
132	(Asterisk)	Format as a constant asterisk.
133 - 158	Drug label name 5
159	(Asterisk)	Format as a constant asterisk.
160 - 185	Drug label name 6
186	(Asterisk)	Format as a constant asterisk.

Field 526 on a Rejected Response When the Claim Does Not Deny for a DUR Alert

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 - 32	DUP ICN:	Format as a constant.
33 - 47	ICN	Will display the duplicate ICN when EOB 100 is displayed in one of the six EOB fields.
48	(Space)	Format as a constant space.
49 - 56	Date	Will display the paid pate of the duplicate ICN. Format: CCYYMMDD
57	(Space)	Format as a constant space.
58 - 61	MCP:	Format as a constant.
62 - 63	MCP code	Will display the managed care program (MCP) code when EOB 287 is displayed in one of the six EOB fields.
64	(Space)	Format as a constant space.
65 - 74	MCP phone number	Will display the MCP telephone number when EOB 287 is displayed in one of the six EOB fields.
75	(Space)	Format as a constant space.
76 - 78	MCP provider specialty	Will display the MCP provider specialty when EOB 287 is displayed in one of the six EOB fields.
79	(Space)	Format as a constant space.
80 - 83	TPL:	Format as a constant.
84	(Space)	Format as a constant space.
85 - 87	TPL carrier code	Will display the third-party liability (TPL – also known as private insurance or other insurance) carrier code when EOB 278 is displayed in one of the six EOB fields.
88	(Space)
89	TPL relationship code	Will display the TPL relationship code when EOB 278 is displayed in one of the six EOB fields.
90	(Space)
91 - 106	TPL policy number	Will display the TPL policy number when EOB 278 is displayed in one of the six EOB fields.
107	(Space)
108 - 123	TPL group number	Will display the TPL group number when EOB 278 is displayed in one of the six EOB fields.
124	(Space)
125 - 132	TPL policy start date	Will display the TPL policy start date when EOB 278 is displayed in one of the six EOB fields.
133	(Space)
134 - 141	TPL policy end date	Will display the TPL policy end date when EOB 278 is displayed in one of the six EOB fields.
142	(Space)
143 - 150	LOCK-IN:	Format as a constant.
151	(Space)
152 - 159	Lock-in period start date	Will display the lock-in period start date when EOB 631 is displayed in one of the six EOB fields.
160	(Space)
161 - 168	Lock-in period end date	Will display the lock-in period end date when EOB 631 is displayed in one of the six EOB fields.
169	(Space)
170	Lock-in coverage type	Will display the lock-in coverage type (1 = pharmacy; 8 = hospice) when EOB 631 is displayed in one of the six EOB fields.
171- 186	(Spaces)

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