Appendix E_020226.pdf

Effective 10/16/2023 1

NCPDP Version D.0 E1 Specifications for Medicare Part D Effective Date: 10/16/2023

Includes MA and QMB values. Last updated 10.16.23

Note: If a "Value" contains quotation marks around it, then the value is a literal character that must be included in the transaction. If a "Value" is listed but does not contain quotation marks, then the value is an example.

M= Mandatory | O = Optional | R= Required vD.0 E1 Request for Medicare Part D Transaction Header Segment: Mandatory

Field Field Name Value Comments

101-A1 BIN NUMBER “011727” M – Facilitator BIN

102-A2 VERSION/RELEASE

NUMBER

"D0" M – D.0 Transaction Format

103-A3 TRANSACTION CODE "E1" M – Eligibility Verification

104-A4 PROCESSOR CONTROL

NUMBER

“2222222222” M – Must be as indicated for E1

109-A9 TRANSACTION COUNT "1" M – One occurrence

202-B2 SERVICE PROVIDER ID

QUALIFIER

“01” M –NPI Number of Requesting

Pharmacy

201-B1 SERVICE PROVIDER ID 1234567890bbbbb M – Left justified, space filled

401-D1 DATE OF SERVICE 20060101 M – Must be within 9 months prior to the current date or within 4 months after the current date

110-AK SOFTWARE

VENDOR /

CERTIFICATION ID

bbbbbbbbbb M - Field must be submitted but is not validated

Patient Segment: Required for Proper Matching

111-AM SEGMENT IDENTIFICATION “01” M – Patient Segment

304-C4 DATE OF BIRTH 19400615 R – Field must be populated

305-C5 PATIENT GENDER CODE 1 O – 1 = Male, 2 = Female

310-CA PATIENT FIRST NAME JOHN R - Must submit at least first digit of patient first name

311-CB PATIENT LAST NAME DOE R - Must submit complete patient last name

325-CP PATIENT ZIP/POSTAL ZONE 34567 O – inclusion of the zip code fields increases the chances for a match

Effective 10/16/2023 2

Insurance Segment: Mandatory

111-AM SEGMENT IDENTIFICATION “04” M – INSURANCE SEGMENT

302-C2 CARDHOLDER ID 998877665 M – Must include one of the following:

– Full SSN

– Last 4 digits of the SSN

– Full MBI

Note: Effective 1/1/2020, HICN and RRB will no longer be allowed on the request vD.0 E1: Accepted Response for Medicare Part D

The Facilitator sends this response when the data provided in the E1 Request enables the Facilitator to find exactly one matching patient who has Part D coverage that is active on the requested Date of Service. The MBI that will be returned is the MBI that is effective as of the receipt date of the E1 transaction. There may be instances where a pharmacy has submitted a MBI that is no longer active for the patient. In that instance the facilitator will crosswalk to the current MBI and will return the current MBI (based on receipt date) in the formatted Message field (504-F4) on the response.

Response Header Segment: Mandatory

102-A2 VERSION/RELEA

SE NUMBER

"D0"

M – D.0 Transaction Standard

103-A3 TRANSACTION CODE "E1" M – Eligibility Verification

109-A9 TRANSACTION COUNT "1" M – One occurrence

501-F1

HEADER

RESPONSE

STATUS

"A" M – Accepted

202-B2 SERVICE PROVIDER

ID QUALIFIER

“01” M –NPI Number of Requesting Pharmacy

201-B1 SERVICE PROVIDER ID 1234567890bbbbb Pharmacy provided in the Request

401-D1 DATE OF SERVICE ccyymmdd M – Contains the same value provided in the Request

Effective 10/16/2023 3

Response Message Segment: Mandatory

111-AM SEGMENT

IDENTIFICATION

“20” M – Response Message Segment

504-F4 MESSAGE Structured messaging

See Structure Message information below.

This field will contain data elements that will always be present as well as values that will be populated based on the existence of data in the CMS Eligibility

File.

Below is an example of how the structured response will be provided in the Messaging Field, 504-F4.

Field Name Field ID Data

Start

Max

Bytes/Max

Data

Length

Values

LICS Level LISLVL: 8 1 1 digit numeric (e.g. 0, 1, 2, 3,4, 5) blank (none)

Terminator ; 9 1

LICS Effective Date LISEFF: 17 8

CCYYMMDD

Terminator ; 25 1

LICS Termination

Date

LISTERM: 34 8

CCYYMMDD

Terminator ; 42 1

Plan Type PLAN: 48 4 MAPD, LINT, etc

Note: “MA “ (MA followed by two blank spaces) will be used for MA plans

Terminator ; 52 1

Active MBI MBI: 57 11 Patient’s Current / Active MBI

Terminator ; 68 1

Active MBI Effective Date

ED: 72 8 CCYYMMDD:20170101

Terminator ; 80 1

Effective 10/16/2023 4

QMB QMB: 85 1 Y (yes) or N (no)

Terminator ; 86 1

QMB Effective date QED: 91 8 CCYYMMDD (blank if QMB is N (no))

Terminator ; 99 1

QMB Term date QTERM: 106 8 CCYYMMDD (blank if QMB is N (no))

Terminator ; 114 1

Structured Messaging Field 504-F4 Examples:

1. MAPD Example with terminated LIS, no QMB

LISLVL:3;LISEFF:20120701;LISTERM:20120831;PLAN:MAPD;MBI:1EG4TE5MK73;ED:20170101;

QMB:N;QED: ;QTERM: ;

2. LINET Example with no LIS level, no QMB

LISLVL: ;LISEFF: ;LISTERM: ;PLAN:LINT; MBI:1EG4TE5MK73;ED: 20170101;QMB:N

;QED: ;QTERM: ;

3. PDP example with active LIS, no QMB

LISLVL:1;LISEFF:20120601;LISTERM: ;PLAN:PDP ; MBI:1EG4TE5MK73;ED: 20170101;

;QMB:N;QED: ;QTERM: ;

4. MA plan Example with no LIS, no QMB

LISLVL: ;LISEFF: ;LISTERM: ;PLAN:MA ; MBI:1EG4TE5MK73;ED: 20170101;

QMB:N;QED: ;QTERM: ;

5. MAPD Example with active LIS, with active QMB

LISLVL:1;LISEFF:20120601;LISTERM: ;PLAN:MAPD;MBI:1EG4TE5MK73;ED:

20170101;QMB:Y;QED:20210101;QTERM:20211231;

Effective 10/16/2023 5

Response Insurance: Always Returned by the Facilitator

IDENTIFICATION

“27” M – Response Insurance Segment

139-UR MEDICARE PART D

COVERAGE CODE

1 R – Indicates the position of Medicare Part D in the billing order

138-UQ CMS LOW

INCOMECOST

SHARING (LICS)

LEVEL

N R – Y for Yes or N for No

240-U1 CONTRACT NUMBER TESTZ R – Contract Number of Coverage

757-U6 BENEFIT ID 001 R – PBP Number of the coverage

140-US NEXT MEDICARE PART D

EFFECTIVE DATE

ccyymmdd This field will not be returned if beneficiary does not have a future Part D plan relative to the submitted Date of Service.

141-UT NEXT MEDICARE

PART D

TERMINATION

DATE

ccyymmdd This field will not be returned if beneficiary does not have a future Part D plan relative to the submitted Date of Service. If the beneficiary has a future plan and the termination date is blank in the CMS database, this field will not be returned

Response Patient Segment: Always Returned by the Facilitator

IDENTIFICATION

“29” M – Response Patient Segment

310-CA PATIENT FIRST NAME JOHN R – Will contain the first name of the patient the eligibility query matched on in the TrOOP Database

311-CB PATIENT LAST NAME DOE R - Will contain the last name of the patient the eligibility query matched on in the TrOOP Database

304-C4 DATE OF BIRTH 19650615 R - Will contain the Date of Birth of the patient the eligibility query matched on in the TrOOP Database

Effective 10/16/2023 6

Response Status Segment: Always Returned by the Facilitator

IDENTIFICATION

“21” M – Response Status Segment

112-AN TRANSACTION

RESPONSE STATUS

"A" M – Approved

Response Coordination of Benefits Segment: Always Returned by the Facilitator

IDENTIFICATION

“28” M – Response Coordination of Benefits

Segment

355-NT OTHER PAYER ID COUNT 1 R – Will contain the count of the number of occurrences of Other Payer Information.

338-5C OTHER PAYER

COVERAGE TYPE

01 R – Indicates whether Coverage is Primary, secondary, tertiary, etc.

339-6C OTHER PAYER ID

QUALIFIER

“03”

Or

“10”

O – 03 (BIN) for plan types other than MA plans or

10 (Payer Name) for MA plans

340-7C OTHER PAYER ID 123456

Or

Payer Name

O – BIN Number for plan types other than

MA plans or

The first 10 bytes of the Payer Name for

MA Plans

991-MH OTHER PAYER

PROCESSOR CONTROL

NUMBER

TESTBENEPD O – PCN of Other payer; N/A for MA plans

356-NU OTHER PAYER

CARDHOLDER ID

TEST00001

Or

“NOTAVAILABLE”

O – Cardholder ID for plan types other than MA plans

Or

“NOTAVAILABLE” is the default for MA

Plans

992-MJ OTHER PAYER GROUP ID TEST00001 O – Group Number of Other payer; N/A for

MA plans

142-UV OTHER PAYER

PERSON CODE

01 O –Patient Person Code for coverage.

Provided if on file

143-UW OTHER PAYER PATIENT

RELATIONSHIP CODE

1 O– Patient Relationship Code for

Coverage, Provided if on file

Effective 10/16/2023 7

127-UB OTHER PAYER HELP

DESK NUMBER

O – Payer Helpdesk for coverage.

Provided if on file

144-UX OTHER PAYER BENEFIT

EFFECTIVE DATE

20110101 R – Effective Date of Coverage

145-UY OTHER PAYER

BENEFIT

TERMINATION DATE

20111231 O – Termination Date of Coverage.

Provided if on file

338-5C OTHER PAYER

COVERAGE TYPE

02 R – Indicates whether Coverage is

Primary, secondary, tertiary, etc.

339-6C OTHER PAYER ID

QUALIFIER

“03” R – Always 03 for BIN

340-7C OTHER PAYER ID 456789 R – BIN Number for Coverage

991-MH OTHER PAYER

PROCESSOR CONTROL

NUMBER

TESTBENEP2 R – Processor Control Number for

Coverage

356-NU OTHER PAYER

CARDHOLDER ID

TEST00002 R – Cardholder ID

992-MJ OTHER PAYER GROUP ID TEST00002 R – Group Number

142-UV OTHER PAYER PESON

CODE

O –Patient Person Code for Coverage, Provided if on file

143-UW OTHER PAYER PATIENT

RELATIONSHIP CODE

1 O– Patient Relationship Code for

Coverage, Provided if on file

127-UB OTHER PAYER

HELP DESK

NUMBER

O – Payer Helpdesk for coverage-provided if on file

144-UX OTHER PAYER

BENEFIT

EFFECTIVE DATE

20110101 R – Effective Date of Coverage

145-UY OTHER PAYER BENEFIT

TERMINATION DATE.

20111231 O – Termination Date of Coverage-provided if on file

338-5C OTHER PAYER

COVERAGE TYPE

03 R – Indicates whether Coverage is Primary, secondary, tertiary, etc.

339-6C OTHER PAYER ID

QUALIFIER

“03” R – Always 03 for BIN

340-7C OTHER PAYER ID 789123 R – BIN Number

991-MH OTHER PAYER

PROCESSOR CONTROL

NUMBER

TESTBENEP3 R – PCN

356-NU OTHER PAYER

CARDHOLDER ID

TEST00003 R – Cardholder ID

992-MJ OTHER PAYER GROUP ID TEST00003 R – Group Number

Effective 10/16/2023 8

142-UV OTHER PAYER PESON

CODE

010 O –Patient Person Code for coverage.

Provided if on file

143-UW OTHER PAYER PATIENT

RELATIONSHIP CODE

1 O– Patient Relationship Code for

Coverage, Provided if on file

127-UB OTHER PAYER HELP

DESK NUMBER

O – Payer Helpdesk for coverage.

Provided if on file

144-UX OTHER PAYER BENEFIT

EFFECTIVE DATE

20110101 R – Effective Date of Coverage

145-UY OTHER PAYER

BENEFIT

TERMINATION DATE

20111231 O – Termination Date of Coverage.

Provided if on file.

Response Coordination of Benefits Segment for MA Plans NOTE: 4Rx information is not available for MA Plans. Only one loop of Response Coordination of

Benefit segment data is returned and only the following fields will be populated in that segment for

MA plan beneficiaries:

Field Field Name Value Comments

355-NT OTHER PAYER ID COUNT 1 R – Will contain the count of the number of occurrences of Other Payer Information

338-5C OTHER PAYER

COVERAGE TYPE

01 R – Indicates whether Coverage is Primary, secondary, tertiary, etc.

339-6C OTHER PAYER ID

QUALIFIER

10 10 (Payer Name) for MA plans

340-7C OTHER PAYER ID Payer Name Will include the first 10 bytes of the

Plan/Payer Name for MA Plans

356-NU OTHER PAYER

CARDHOLDER ID

“NOTAVAILBLE” Will return “NOTAVAILABLE” as a default for MA Plans

127-UB OTHER PAYER HELP

DESK NUMBER

O – Payer Helpdesk for coverage.

Provided if on file

144-UX OTHER PAYER BENEFIT

EFFECTIVE DATE

20110101 R – Effective Date of Coverage

145-UY OTHER PAYER BENEFIT

TERMINATION DATE

20111231 O – Termination Date of Coverage.

Provided if on file

Effective 10/16/2023 9 vD.0 E1: Rejected Response for Medicare Part D

The Facilitator sends this response when the data provided in the E1 Request does not enable the Facilitator to find one unique patient.

M= Mandatory | O = Optional | R= Required

Response Header Segment: Mandatory

102-A2 VERSION/RELEASE

NUMBER

"D0" M – D.0 Transaction Standard

103-A3

TRANSACTION

"E1"

M – Eligibility Verification

109-A9

TRANSACTION

COUNT

"1"

M – One occurrence

501-F1 HEADER RESPONSE

STATUS

"A" M – Accepted

202-B2 SERVICE

PROVIDER ID

QUALIFIER

“01” M –NPI Number of Requesting Pharmacy

201-B1 SERVICE PROVIDER ID 1234567890bbbbb Pharmacy Request

401-D1 DATE OF SERVICE ccyymmdd M – Contains the same value provided in the Request

Response Message Segment: Always Returned by the Facilitator

IDENTIFICATION

“20” M – Response Status Segment

504-F4 MESSAGE See below Structured manner as outlined below.

Response Status Segment: Always Returned by the Facilitator

IDENTIFICATION

“21” M – Response Status Segment

112-AN TRANSACTION

RESPONSE STATUS

R M – Rejected

510-FA REJECT COUNT 1 R

511-FB REJECT CODE See “Non-Matched Reject Codes and Messages” section

R – Varies; three different codes depending on reject reason. See “Reject Codes and Messages” topic for details

Effective 10/16/2023 10

130-UF ADDITIONAL

MESSAGE

INFORMATION

COUNT

R– If 526-FQ is returned

132-UH ADDITIONAL MESSAGE

INFORMATION

QUALIFIER

R – If 526-FQ is returned

526-FQ ADDL MESSAGE

INFORMATION

O – Used for overflow from 504-F4, if needed

(need for overflow not expected)

Note: Other optional fields not shown in these segments are not used.

For accessibility please note that cells in the headers are intentionally left blank as prescribed in the NCPDP Payer Sheet Template Version 1.5

Reject Codes and Messages

Reject Message General Structure

A Reject (Non-Matched) Eligibility Response complies with the following general rules:

The Reject Code field (511-FB) will contain an appropriate reject code based on the cause of the reject (see table below).

The Message field (504-F4) will contain appropriate descriptive rejection information; this will be a free text message that does not contain parsable information (see table below).

If needed, overflow rejection information can be placed in Additional Message Information

(526- FQ). However, such an overflow is highly unlikely.

E1 Reject Conditions and associated Codes and Messages

The Facilitator system will return the following reject codes and messages for each condition listed:

Condition Reject Code Reject Description Comments/Message (526-FQ)

Service Provider ID

Qualifier is not a National

Provider Identifier (NPI)

7B Service Provider ID

Qualifier Value Not

Supported for

Processor/Payer

QUALIFIER MUST BE AN NPI

Not all the required information is provided, even if the submitted

Cardholder ID information is correct.

07 M/I Cardholder ID MCARE ELIG;MISSING

REQUIRED FIELD

Effective 10/16/2023 11

Full Cardholder ID matches exactly but first 4 characters of Last Name do not match

62 Patient/Card Holder ID

Name Mismatch

MCARE ELIG;PATIENT NOT

FOUND: CARDHOLDER ID

MATCHED BUT LAST NAME DID

NOT

Patient not found 52 Non-Matched

Cardholder ID

MCARE ELIG;NO PATIENT

MATCH FOUND

Patient found but Part D coverage is not active during the submitted Date of Service

15 M/I Date of Service MCARE ELIG;PATIENT FOUND

BUT PART D COVERAGE

OUTSIDE SUBMITTED DATE OF

SERVICE

OS on the E1 exceeds the allowable “look back or look forward” timeframe

VD Eligibility Search Time

Frame Exceeded

MCARE ELIG;DATE OF SERVICE

OUT OF RANGE or LASTKNOWN

MM/YY TOO OLD

Note: this reject code and

LASTKNOWN MM/YY TOO OLD

MSG will be used temporarily until

9-31-2020 for Last Known 4Rx MM and YY combination is outside of

CMS allowed timeframe

Pharmacy not Contracted with Transaction

Facilitator

50 Non-matched pharmacy number

MCARE ELIG;SUBMITTER IS NOT

CONTRACTED FOR E1

NPI does not appear to be valid

05 M/I Service Provider

Number

MCARE ELIG;INVALID NPI

Provider is on the OIG sanction list

559 ID Submitted is associated with a excluded Pharmacy

MCARE ELIG;PROVIDER ON

SANCTION LIST

Provider is not active on the NPPES file

877 Service Provider ID

Terminated on NPPES

File

MCARE ELIG;PROVIDER

TERMINATED ON NPPES FILE

Provider is not enrolled with CMS

878 Service Provider ID Not

Found On NPPES File

MCARE ELIG;PROVIDER NOT ON

NPPES

Pharmacy is on the CMS precluded list

930 ID Submitted Is

Associated To A

Precluded Pharmacy

MCARE ELIG;PHARMACY IS

ON CMS PRECLUDED LIST

NPI is does not have an NPPES taxonomy code = pharmacy

879 Service Provider ID

Excluded From

Receiving CMS

Enrollment Data

MCARE ELIG;NPI IS NOT A

PHARMACY

CMS does not allow this provider to receive eligibility data

879 Service Provider ID

Excluded From

Receiving CMS

Enrollment Data

PROVIDER QUESTIONS-

CONTACT

PARTD_COB@CMS.HHS.GOV

mailto:PartD_COB@cms.hhs.gov

Effective 10/16/2023 12

The combination of

B60-3J YEAR OF

LAST PAID CLAIM

and B61-3K MONTH

OF LAST PAID

CLAIM exceeds the timeframe allowed by

CMS

946 Last Known Rx Claim

Date Submitted Too Old

Note: Available for use 10-1-2019.

Prior to 10-1-2019 reject code VD will be used.

LASTKNOWN is sent in Cardholder ID however Last Known 4Rx Segment is not sent

M/I Last Known 4Rx

Segment

This reject code has not been approved at NCPDP yet, until it is available we will use reject code 85-

Claim not paid and will return: M/I

Last Known Segment in 504-F4

Rejected Response Message Text Field Examples

Key: b=blank

Example 1: Eligibility Rejected Response resulting from Cardholder ID matching but Name not matching

Reject Code (511-FB) will be “62 “(Patient/Cardholder ID Name Mismatch)

Message (504-F4)

MCARE ELIG;PATIENT NOT FOUND: CARDHOLDER ID MATCHED BUT LAST NAME DID NOT

Example 2: Eligibility Rejected Response resulting from inability to match the supplied request data to the database

Reject Code (511-FB) will be “52 “(Non-matched Cardholder ID)

MCARE ELIG;NO PATIENT MATCH FOUND

Example 3: Eligibility Rejected Response resulting from a found patient not having active Part D coverage on the Date of Service submitted but subsequent coverage exists

Reject Code (511-FB) will be “15” (M/I Date of Service)

MCARE ELIG;PATIENT FOUND BUT PART D COVERAGE OUTSIDE SUBMITTED DATE OF

SERVICE

Example 4: Eligibility Rejected Response resulting from a found patient not having active Part D coverage on the Date Of Service submitted and no subsequent coverage exists

Reject Code (511-FB) will be “52” “(Non-matched Cardholder ID)

MCARE ELIG;NO PATIENT MATCH FOUND

D0 CMS Real-Time N Request and Response Transaction Specifications (4).docx 1

Real-Time D.0 Nx Transaction Request (N1, N2, N3)

REQUEST HEADER SEGMENT: MANDATORY FOR N1, N2, AND N3

Field Field Name Type Length Start End Value

1Ø1-A1 BIN NUMBER N 6 1 6 Part D plan BIN

1Ø2-A2 VERSION/RELEASE

A/N

2 7 8

D0

1Ø3-A3 TRANSACTION

CODE

A/N 2 9 10 N1, N2, or N3

1Ø4-A4 PROCESSOR

CONTROL

NUMBER

A/N 10 11 20 Part D PCN

1Ø9-A9 TRANSACTION

COUNT

A/N 1 21 21 1

2Ø2-B2 SERVICE

PROVIDER ID

QUALIFIER

A/N 2 22 23 This should be an Ø1-NPI however Ø7=NCPDP Provider ID will also be used, but the N may not be accepted by the Part D Plan

2Ø1-B1 SERVICE

PROVIDER ID

A/N 15 24 38 Actual NPI or NCPDP ID must be padded on the right to 15 spaces if significant values are less than 15. Note: If your NPI/NCPDP ID starts with leading zero(s) they are significant and must be sent

4Ø1-D1 DATE OF

SERVICE

N 8 39 46 Format=CCYYMMDD, CC=Century, YY=Year, MM=Month, DD=Day

11Ø-AK SOFTWARE

VENDOR/

A/N 10 47 56 TROOP or TROOPBATCH

INSURANCE SEGMENT: MANDATORY FOR N1, N2 AND N3

Field Field Name Type Maximum

Bytes M/O Required Value

111-AM

SEGMENT

IDENTIFICATION

A/N 2 M Ø4=Insurance

3Ø2-C2 CARDHOLDER ID A/N 20 M Part D Cardholder ID

312-CC CARDHOLDER

FIRST NAME

A/N 12 O Cardholder First name of the beneficiary from the Supplemental transaction. N1 and N3 only.

313-CD CARDHOLDER

LAST NAME

A/N 15 O Cardholder Last name of the beneficiary from the Supplemental transaction. N1 and N3 only.

301-C1 GROUP ID A/N 15 O PartD Group ID. Field not sent if blank.

99Ø-MG OTHER PAYER

BIN

N 6 M Supplemental payer BIN from the supplemental transaction.

991-MH OTHER PAYER

PCN

A/N 10 O Supplemental payer PCN from the supplemental transaction. Field not send if blank.

356-NU OTHER PAYER

CARDHOLDER ID

A/N 20 M Supplemental payer Cardholder ID from the supplemental transaction.

992-MJ OTHER PAYER

GROUP ID

A/N 15 O Supplemental payer Group from the supplemental transaction. Field not sent if blank.

D0 CMS Real-Time N Request and Response Transaction Specifications (4).docx 2

CLAIM SEGMENT: MANDATORY FOR N1, N2 AND N3

Field

Field Name

Type

Maximum

M/R/O

Comments

IDENTIFICATION

A/N 2 M Ø7=Claim

455-EM PRESCRIPTION/

SERVICE REF

NUMBER

QUALIFIER

A/N 1 M From the supplemental transaction

4Ø2-D2 PRESCRIPTION/

SERVICE REF

NUMBER

N 12 M From the supplemental transaction

436-E1 PRODUCT/

SERVI CE ID

QUALIFIER

A/N 2 M From the supplemental transaction

407-D7 PRODUCT/

SERVICE ID

A/N 19 M From the supplemental transaction

442-E7 QUANTITY

DISPENSED

9(7)v999 10 O From the supplemental transaction. N1 and N3 only.

403-D3 FILL NUMBER N 2 O From the supplemental transaction

405-D5 DAYS SUPPLY N 3 O From the supplemental transaction. N1 and N3 l 88Ø-K5 TRANSACTION

REFERENCE

NUMBER

A/N 10 R This number is generated by the Transaction Facilitator. If this is an N2, it will match the N1 or N3 transaction.

CLAIM SEGMENT: PRICING SEGMENT MANDATORY FOR N1 AND N3 ONLY

M/O Comments

111-AM SEGMENT

IDENTIFICATION

A/N 2 M 11=Pricing

433-DX PATIENT PAID

AMOUNT

SUBMITTED

N 8 O Format=s$$$$$$cc. The values in this field are provided by the supplemental payer and represent the amount that the patient paid after the supplemental adjudicated the claim. (This amount is subtracted from the Part D patient liability to determine the amount considered as payment by the supplemental payer and applied to Other TrOOP or PLRO.) N1 and N3 only.

Pricing segment is not sent if 433- DX is not sent.

D0 CMS Real-Time N Request and Response Transaction Specifications (4).docx 3

Real-Time D.0 N Transaction Response (N1, N2, N3)

RESPONSE HEADER SEGMENT: MANDATORY

Field Field Name Type Length Start End Value

1Ø2-A2 VERSION/ RELEASE

NUMBER

A/N 2 1 2 D0

1Ø3-A3 TRANSACTION

CODE

A/N 2 3 4 N1, N2, or N3

1Ø9-A9 TRANSACTION

COUNT

N 1 5 5 1

5Ø1-F1 HEADER

RESPONSE

STATUS

A/N 1 6 6 A/R

2Ø2-B2 SERVICE

PROVIDER ID

QUALIFIER

A/N 2 7 8 Qualifier provided on the N Request Transaction

2Ø1-B1 SERVICE

PROVIDER ID

A/N 15 9 23 ID provided on the N Request Transaction

4Ø1-D1 DATE OF SERVICE N 8 24 31 DOS provided on the N Request Transaction

RESPONSE STATUS SEGMENT: MANDATORY

M/O Comments

111-AM SEGMENT

IDENTIFICATION

A/N 2 M 21=Response Status

112-AN TRANSACTION

RESPONSE

STATUS

A/N 1 M A= Accepted, C=Captured (passed required fields), or R=Rejected

503-F3 AUTHORIZATION

NUMBER

A/N 20 O N/A

51Ø-FA REJECT COUNT N 2 O N/A

511-FB REJECT CODE A/N 3 O See NCPDP D.0 Reject Code list (if required field is missing or syntax error if response status is R, otherwise field is not sent. If 510- FA >1 then this field repeats)

88Ø-K5 TRANSACTION

REFERENCE

NUMBER

A/N 10 M Same information as provided N Request Transaction

RESPONSE CLAIM SEGMENT: MANDATORY

M/O Comments

111-AM SEGMENT

IDENTIFICATION

A/N 2 M 22=Response Claim Segment

455-EM PRESCRIPTION/

SERVICE

REFERENCE

NUMBER

QUALIFIER

A/N 1 M Same information as provided on the N request from supplemental payer

4Ø2-D2 PRESCRIPTION/

SERVICE

REFERENCE

NUMBER

N 12 M Same information as provided on the N request file from supplemental payer

NCPDP Batch Standard

To implement the Batch Standard for HIPAA, the Batch Standard Implementation Guide Version 1.2 is used. Since the Batch Standard uses the data elements, parsing routine and many of the rules of the Telecommunication Standard, the following are used:

Telecommunication Standard Implementation Guide (for transactions, segments, fields, rules) Data Dictionary (for field definitions and formats) External Code List (for field values)

These documents are available to NCPDP members at the Standards Download page http://www.ncpdp.org/members/members_download.aspx. Information on becoming an NCPDP member which includes all documents published is available at http://www.ncpdp.org/signup.aspx.

Many of the pharmacy transactions today are processed online, real-time; hence the NCPDP Telecommunication Standard is used. There was a business need to support the same functionality as the Telecommunication Standard, except in a batch environment.

The NCPDP Batch Standard was created to use the functionality of the Telecommunication Standard. The Batch Standard uses the same syntax, formatting, data set, and rules as the Telecommunication Standard. The Batch Standard “wraps” the Telecommunication Standard around a detail record; then adds a batch header and trailer.

This allows implementers to “code once”. It was intended that once a NCPDP Data Record (containing the Telecommunication Standard transaction) was built, it could then be “wrapped” with the Detail Data Record.

Then the Transmission Header Record and the Transmission Trailer Record are created. The Batch consisting of Header, Detail Data Records, and Trailer are formed into a batch file. The creation of the Detail Data Record could be processed in the same manner as the online, real-time transaction, since they both began as the Telecommunication Standard transaction.

Detailed information of the transactions, segments, fields, rules, syntax is found in the Telecommunication Standard Implementation Guide. While there is much more information for a developer contained in the guide, for purposes of this information, note that the Transaction Header Segment in the request, and the Response Header Segment in the response are fixed length segments containing fixed length fields. The rest of the segments in the request or response (such as Patient Segment, Insurance Segment, Claim Segment, Response Status Segment, Response Claim Segment, etc) are variable segments with variable fields (where applicable) and variable field lengths.

Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc.

2Ø12 NCPDP

1 of 8 NCPDP Batch Overview 2-4-2015

Batch N Transaction Request File Format

88Ø-K4 TEXT INDICATOR A/N 1 1 1 Start of Text (STX) = x'02' (NOTE: this is the hex 02 NOT ASCII).

7Ø1 SEGMENT

IDENTIFIER

A/N 2 2 3 00=File Control (header)

88Ø-K6 TRANSMISSION

TYPE

A/N 1 4 4 T=Transaction

88Ø-K1 SENDER ID A/N 24 5 28 Recommend that this value be a concatenation of the Supplemental payers BIN and PCN

8Ø6-5C BATCH NUMBER N 7 29 35 Assigned by Sender. Must match Trailer 88Ø-K2 CREATION DATE N 8 36 43 Format=CCYYMMDD

88Ø-K3 CREATION TIME N 4 44 47 Format=HHMM 7Ø2 FILE TYPE A/N 1 48 48 P=Production, T=Test

1Ø2-A2 VERSION/RELEASE

NUMBER

A/N 2 49 50 Must = 12 (v1.2)

88Ø-K7 RECEIVER ID A/N 24 51 74 TROOPBATCH

88Ø-K4 TEXT INDICATOR A/N 1 75 75 End of Text (ETX) = X'03'. (NOTE: this is the hex 03 NOT ASCII)

Field Field Name Type Length Start End Value C o

88Ø-K4 TEXT INDICATOR A/N 1 1 1 Start of Text (STX) = x'02' (NOTE: this is the hex 02 NOT ASCII)

7Ø1 SEGMENT

IDENTIFIER

A/N 2 2 3 G1=Detail Data Record

88Ø-K5 TRANSACTION

REFERENCE

NUMBER

A/N 10 4 13 Supplemental payer defined number that allows the payer to match the Transaction Facilitator's response. Ideally this should be the same value as 88Ø-K5 in the claim segment

Header

The naming convention for the request file is 10000120120125180432S where 100001 represents the supplemental payer (sender's) BIN, 20120125180432 is the current timestamp, at time of file creation, in CCYYMMDDHHMMSS format, and S is a constant. An optional filename suffix is allowed, such as 10000120120125180432S.txt or 10000120120125180432S_xyz however one is not required.

DETAIL HEADER: MANDATORY FOR N1, N2, AND N3

Note: The request batch file is allowed to have line feeds between records, however the Transaction Facilitator batch response file will not contain line feeds between records.

2 of 8 Batch N Request Specifications for Payments Supplemental to Part D 2-4-2015

1Ø1-A1 BIN NUMBER N 6 1 6 Must be Ø11735- Transaction Facilitator BIN

1Ø2-A2 VERSION/RELEASE

NUMBER

A/N 2 7 8 D0

1Ø3-A3 TRANSACTION

CODE

A/N 2 9 10 N1, N2, or N3

1Ø4-A4 PROCESSOR

CONTROL NUMBER

A/N 10 11 20 Enter 1Ø spaces

1Ø9-A9 TRANSACTION

COUNT

A/N 1 21 21 1

2Ø2-B2 SERVICE

PROVIDER ID

QUALIFIER

A/N 2 22 23 This should be an Ø1-NPI however Ø7=NCPDP Provider ID will also be used, but the N may not be accepted by the Part D Plan

2Ø1-B1 SERVICE

PROVIDER ID

A/N 15 24 38 Actual NPI or NCPDP ID must be padded on the right to 15 spaces if significant values are less than 15. Note: If your NPI/NCPDP ID starts with leading zero(s) they are significant and must be sent

4Ø1-D1 DATE OF SERVICE N 8 39 46 Format=CCYYMMDD, CC=Century, YY=Year, MM=Month, DD=Day

11Ø-AK SOFTWARE

VENDOR/

A/N 10 47 56 Enter 1Ø spaces

Field Field Name Type Maximum Bytes

M/O

111-AM SEGMENT

IDENTIFICATION

A/N 2 M

3Ø2-C2 CARDHOLDER ID A/N 20 M

312-CC CARDHOLDER

FIRST NAME

A/N 12 R

313-CD CARDHOLDER

LAST NAME

A/N 15 R

This field is ignored by the Transaction Facilitator, however due to some system limitations, it may need to be sent. If sent, it must contain 20 or less characters and ideally should match the Other Payer Cardholder ID. This field is not passed on in the N transaction

First name of the beneficiary from the Supplemental plans eligibility database. Sending this may help the Part D Plan with matching

Note the fields listed in the following segments are required for batch N transactions. While the length for these fields is variable, If a field length in the batch file exceeds the standard field length, the record will be rejected and the appropriate reject code will be provided.

INSURANCE SEGMENT: MANDATORY FOR N1, N2 AND N3

Required Value

Ø4=Insurance

Last name of the beneficiary from the Supplemental plans eligibility database. Sending this may help the Part D plan with matching

Additionally, the transmission must be in NCPDP format. For example the Insurance Segment must start with "<SS><FS>AM04" where <SS> (segment separator) is hex 1E , <FS> (field separator) is hex 1C, and "04" is the insurance segment indicator. Also each field must have a <FS> followed by the field code. For example: "<FS>C2CardId" for 302-C2. In addition there must be a group separator (hex 1D) between the Patient and Claim segments, but not between the other segments.

REQUEST HEADER SEGMENT: MANDATORY FOR N1, N2, AND N3

3 of 8 Batch N Request Specifications for Payments Supplemental to Part D 2-4-2015

Field Field Name Type Maximum

Bytes M/O

99Ø-MG OTHER PAYER BIN N 6 M

991-MH OTHER PAYER

PCN

A/N 10 M

356-NU OTHER PAYER

CARDHOLDER ID

A/N 20 M

992-MJ OTHER PAYER

GROUP ID

A/N 15 O

Field Field Name Type Maximum

Bytes M/O

111-AM SEGMENT

IDENTIFICATION

A/N 2 M

304-C4 DATE OF BIRTH N 8 M

Field Field Name Type Maximum Bytes

M/O

111-AM SEGMENT

IDENTIFICATION

A/N 2 M

455-EM PRESCRIPTION/SE

RVICE REF

NUMBER

QUALIFIER

A/N 1 M

4Ø2-D2 PRESCRIPTION/SE

RVICE REF

NUMBER

N 12 M

436-E1 PRODUCT/SERVIC

E ID QUALIFIER

A/N 2 M

407-D7 PRODUCT

/SERVICE ID

A/N 19 M

442-E7 QUANTITY

DISPENSED

9(7)v999 10 O

403-D3 FILL NUMBER N 2 O

405-D5 DAYS SUPPLY N 3 O

88Ø-K5

TRANSACTION

REFERENCE

NUMBER A/N 10 O

Supp Payer PCN- must match what is submitted on CMS eligibility file sent to COBC. If field is not sent, it is treated as blank/spaces

INSURANCE SEGMENT: MANDATORY FOR N1, N2 AND N3

Required Value Supp Payer BIN- must match what is submitted on CMS eligibility file sent to COBC. Required for N1, N2, N3

Supp Payer Cardholder ID- must match what is submitted on CMS eligibility file sent to COBC This field is ignored (but passed through) by the Transaction Facilitator. However it may be used to match by the Part D Plan. Therefore Supp Payer Group ID must match what is submitted on CMS eligibility file sent to

COBC

CLAIM SEGMENT: MANDATORY FOR N1, N2 AND N3

Comments

Blank=Not Specified, 1=Rx Billing, 2=Service Billing

Use field as defined by NCPDP This number should be the same as in the detail header.

This is used to populate the response file so that submitted can match response to original batch submission

PATIENT SEGMENT: MANDATORY

Comments

Format=CCYYMMDD, CC=Century, YY=Year, MM=Month, DD=Day. This is used for tiebreakers if a cardholder ID is not unique to an individual. For example: the same cardholder ID is used for a family and person code distinguishes the individual. The COBC file does not contain person code and DOB is needed to ensure that the claim is associated with the correct OHI record. If two people in the same family have the same cardholder ID and DOB, an N transaction cannot be generated

Ø1=Patient

Use field as defined by NCPDP

Ø7=Claim

Use field as defined by NCPDP

Use field as defined by NCPDP

Use field as defined by NCPDP

Ø=Original dispensing, 1 to 99 = Refill number. Required for N1/N3. Highly recommended that this field be included.

N2 (reversal) needs to match the original N1

4 of 8 Batch N Request Specifications for Payments Supplemental to Part D 2-4-2015 o

Field Field Name Type Maximum

Bytes M/O

IDENTIFICATION A/N 2 M

433-DX PATIENT PAID

AMOUNT

SUBMITTED

N 8 O

88Ø-K4 TEXT INDICATOR Varies 1 Varies

Field Field Name Type Length Start End Value 88Ø-K4 TEXT INDICATOR A/N 1 1 1 Start of Text (STX) = x'02' (NOTE: this is the hex 02 NOT ASCII)

7Ø1 SEGMENT

IDENTIFIER

A/N 2 2 3 99=File Trailer

8Ø6-5C BATCH NUMBER N 7 4 10 Assigned by Sender. Matches Header 751 RECORD COUNT N 10 11 20 This count includes the total number of records including the Header and Trailer record

5Ø4-F4 MESSAGE A/N 35 21 55

88Ø-K4 TEXT INDICATOR A/N 1 56 56 End of Text (ETX) = X'03' (NOTE: this is the hex 03 NOT ASCII)

TRAILER

Format=s$$$$$$cc. This field represents the amount that the patient paid after the supplemental adjudicated the claim. Even though the field is signed, the sign is not indicated at the beginning. The last character indicates the sign using overpunch characters as described in the NCPDP spec. For example "10A" represents $1.01 and "10J" represents -$1.01. should not put decimal points, positive, or negative signs should not be used in this field.

(This amount is subtracted from the Part D patient liability to determine the amount considered as payment by the supplemental payer and applied to Other TrOOP or PLRO.) This field is not validated by the Transaction Facilitator, please make sure that it contains the correct values/format ( ) y this. (NOTE: this is the hex 03 NOT ASCII)

Comments 11=Pricing

PRICING SEGMENT: MANDATORY for N1 AND N3 only

5 of 8 Batch N Request Specifications for Payments Supplemental to Part D 2-4-2015

Batch N Transaction Response File Format

88Ø-K4 TEXT INDICATOR A/N 1 1 1 Start of Text (STX) = x'02' (NOTE: this is the hex 02 NOT ASCII)

7Ø1 SEGMENT

IDENTIFIER

A/N 2 2 3 00=File Control (header)

88Ø-K6 TRANSMISSION

TYPE

A/N 1 4 4 R=Response, E=Error

88Ø-K1 SENDER ID A/N 24 5 28 TROOPBATCH

8Ø6-5C BATCH NUMBER N 7 29 35 Batch number from the request files is used in this field.

88Ø-K2 CREATION DATE N 8 36 43 Format=CCYYMMDD

88Ø-K3 CREATION TIME N 4 44 47 Format=HHMM 7Ø2 FILE TYPE A/N 1 48 48 P=Production, T=Test

1Ø2-A2 VERSION/RELEA

SE NUMBER

A/N 2 49 50 Must = 12 (v1.2)

88Ø-K7 RECEIVER ID A/N 24 51 74 Recommend that this value be a concatenation of the Supplemental payers BIN and PCN, however whatever is sent on the supplemental batch file is what the Transaction Facilitator returns

88Ø-K4 TEXT INDICATOR A/N 1 75 75 End of Text (ETX) = X'03' (NOTE: this is the hex 03 NOT ASCII)

Field Field Name Type Length Start End Value C o

88Ø-K4 TEXT INDICATOR A/N 1 1 1

Start of Text (STX) = x'02' (NOTE: this is the hex 02 NOT ASCII)

7Ø1

SEGMENT

IDENTIFIER A/N 2 2 3 G1=Detail Data Record

88Ø-K5

TRANSACTION

REFERENCE

NUMBER A/N 10 4 13

This matches the transaction number sent by the sender

Field Field Name Type Length Start End Value

1Ø2-A2 VERSION/RELEA

SE NUMBER

A/N 2 1 2 D0

1Ø3-A3 TRANSACTION

CODE

A/N 2 3 4 N1, N2, or N3

1Ø9-A9 TRANSACTION

COUNT

N 1 5 5 1

Header

RESPONSE HEADER SEGMENT: MANDATORY

DETAIL HEADER: MANDATORY FOR N1, N2, AND N3

RESPONSE HEADER SEGMENT: MANDATORY

Any request filename that contains an optional filename suffix such as 10000120120125180432S.txt or 10000120120125180432S_xyz, will have the S (following the current date-timestamp)changed to an R and any suffix after the S is retained in the response file name.For request file names without an optional suffix, the response filename will be the same as the request except that “.TrOOP.response” will be appended to the end.

Note: The Transaction Facilitator batch response file will not contain line feeds between records even if the request batch file contained line feeds.

6 of 8 Batch N Response Specifications for Payments Supplemental to Part D 2-4-2015

5Ø1-F1 HEADER

RESPONSE

A/N 1 6 6 A

2Ø2-B2 SERVICE

PROVIDER ID

QUALIFIER

A/N 2 7 8 Qualifier provided on the N Request Transaction

2Ø1-B1 SERVICE

PROVIDER ID

A/N 15 9 23 ID provided on the N Request Transaction

4Ø1-D1 DATE OF

SERVICE

N 8 24 31 DOS provided on the N Request Transaction

Field Field Name Type Maximum

Bytes M/O

111-AM SEGMENT

IDENTIFICATION

A/N 2 M

112-AN TRANSACTION

RESPONSE

STATUS

A/N 1 M

51Ø-FA REJECT COUNT N 2 O

511-FB REJECT CODE A/N 3 O

88Ø-K5 TRANSACTION

REFERENCE

NUMBER

A/N 10 O

Field Field Name Type Maximum Bytes

M/O

111-AM SEGMENT

IDENTIFICATION

A/N 2 M

455-EM PRESCRIPTION/S

ERVICE

REFERENCE

NUMBER

QUALIFIER

A/N 1 M

4Ø2-D2 PRESCRIPTION/S

ERVICE

REFERENCE

N 12 M

88Ø-K4 TEXT INDICATOR Varies 1 Varies

Note the fields listed in the following segments are required for batch N transaction Response File. The length of these fields are variable and will not exceed the maximum length.

The Response Status Segment will start with "<SS><FS>AM21" where <SS> (segment separator) is hex 1E , <FS> (field separator) is hex 1C, and "21" is the Response Status segment indicator. Also each field will have a <FS> followed by the field code. For example: "<FS>ANC" for 112-AN. In addition there must be a group separator (hex 1D) between the Response Status and Claim segments.

21=Response Status

C=Captured (passed required fields), R=Rejected

Comments

22=Response Claim Segment

Same information as provided on batch N file from supplemental payer

Same information as provided on batch N file from supplemental payer

Same information as provided on batch N file from supplemental payer

Use field as defined by NCPDP. Only sent if 112-AN = R See NCPDP D.0 Reject Code list (if required field is missing or syntax error if response status is R, otherwise field is not sent. If 510-FA >1 then this field repeats

End of Text (ETX) = X'03'. Every detail records ends with thi (NOTE thi i th h 03 NOT ASCII)

RESPONSE CLAIM SEGMENT: MANDATORY

RESPONSE STATUS SEGMENT: MANDATORY

7 of 8 Batch N Response Specifications for Payments Supplemental to Part D 2-4-2015

88Ø-K4 TEXT INDICATOR A/N 1 1 1 Start of Text (STX) = x'02' (NOTE: this is the hex 02 NOT ASCII)

7Ø1 SEGMENT

IDENTIFIER

A/N 2 2 3 99=File Trailer

8Ø6-5C BATCH NUMBER N 7 4 10 Batch number from the request files is used in this field and should match the request file header

751 RECORD COUNT N 10 11 20 This count includes the total number of records including the Header and Trailer record

5Ø4-F4 MESSAGE A/N 35 21 55 If 880-K6 = E this field will contain a reject message, otherwise it will contain spaces

88Ø-K4 TEXT INDICATOR A/N 1 56 56 End of Text (ETX) = X'03' (NOTE: this is the hex 03 NOT ASCII)

TRAILER

8 of 8 Batch N Response Specifications for Payments Supplemental to Part D 2-4-2015

D.0 Hospice Nx Payer Sheet 5.13.24 Page 1 of 6

D.0 Hospice Election Status Nx Transaction Request (N1, N2, N3) Modified 5/13/24 to update Date/Timestamp format sent in Patient Phone Number field.

Modified 4/15/24 to include additional four Patient Segment fields, added Use column.

Use column indicates whether the field is M (Mandatory), R (Required), or O (Optional)

D.0 Hospice Election Status NX Transaction Request (N1, N2, N3)

REQUEST HEADER SEGMENT: MANDATORY

Field Field Name Use Value Comments

101-A1 BIN NUMBER M Part D plan BIN from CMS eligibility file

102-A2 VERSION/RELEASE

NUMBER

M D0

103-A3 TRANSACTION CODE M N1, N2, N3

104-A4 PROCESSOR

CONTROL NUMBER

M Part D plan PCN from CMS eligibility file

109-A9 TRANSACTION

COUNT

M 1 1

202-B2 SERVICE PROVIDER

ID QUALIFIER

M 01 01 = NPI

201-B1 SERVICE PROVIDER

ID

M Hospice NPI

401-D1 DATE OF SERVICE M The date the transaction facilitator received 837i or CMS transaction, or the effective date for a record being cancelled, or the incorrect effective date being removed.

110-AK SOFTWARE VENDOR

/CERTIFICATION ID

M HOSPICE Hospice related N transactions

D.0 Hospice Nx Payer Sheet 5.13.24 Page 2 of 6

INSURANCE SEGMENT: MANDATORY

Field Field Name Use Value Comments

111-AM SEGMENT ID M 04 04 = Insurance

302-C2 CARDHOLDER ID M Part D Plan Cardholder ID

312-CC CARDHOLDER

FIRST NAME

R Cardholder First name of the beneficiary from CMS eligibility database. N1 and N3 only.

313-CD CARDHOLDER

LAST NAME

R Cardholder Last name of the beneficiary from the CMS eligibility database. N1 and N3 only.

301-C1 GROUP ID O Field is not sent if Group ID is unknown.

PATIENT SEGMENT: MANDATORY

Field Field Name Use Value Comments

111-AM SEGMENT ID M 01 01 = Patient Segment

311-CX PATIENT ID

QUALIFIER

R 09 09 = MBI

332-CY PATIENT ID R Patient MBI

304-C4 DATE OF BIRTH R

305-C5 PATIENT GENDER

CODE

R

326-CQ PATIENT PHONE

NUMBER*

R Date/Timestamp of when 837I or CMS Hospice transaction was received at RelayHealth. Format: YYMMDDHHMM

333-CZ EMPLOYER ID R Part D Plan Contract ID

* Note: The Patient Phone Number has been repurposed for the Hospice Election Status Nx transactions, where it represents the Date/Timestamp the corresponding NOE was received by RelayHealth.

D.0 Hospice Nx Payer Sheet 5.13.24 Page 3 of 6

CLAIM SEGMENT: MANDATORY

Field Field Name Use Value Comments

111-AM SEGMENT ID M 07 07 = Claim

455-EM PRESCRIPTION/

SERVICE REF

NUMBER QUALIFIER

M 2 2 = Service Billing

402-D2 PRESCRIPTION/

SERVICE

REFERENCE

NUMBER

M 999999999999 or 3

-If N2 and = 999999999999 remove entire record for the NPI in the Service

Provider ID field as the only action to be completed

-If N2 and = 3 - multiple actions: remove entire record for NPI in the Service

Provider ID and reinstate (remove termination date) of prior NPI

436-E1 PRODUCT/SERVICE

ID QUALIFIER

M 99 99 = Other

407-D7 PRODUCT/SERVICE

ID

M HOSPICE837 (originated from hospice provider) or HOSPICECWF (originated from CMS)

880-K5 TRANSACTION

REFERENCE

NUMBER

R This number is generated by the

Transaction Facilitator.

CLINICAL SEGMENT: (N1 or N3 ONLY)

IDENTIFICATION

M 13 13 = Clinical

493-XE CLINICAL

INFORMATION

COUNTER

R 1

494-ZE MEASUREMENT

DATE

R The date associated with the clinical count being reported. If the counter is not applicable to the transaction the date will contain 99999999

493-XE CLINICAL COUNTER R 2

494-ZE MEASUREMENT

DATE

R The date associated with the clinical count being reported. If the counter is not applicable to the transaction the date will contain 99999999

493-XE CLINICAL COUNTER R 3

D.0 Hospice Nx Payer Sheet 5.13.24 Page 4 of 6

494-ZE MEASUREMENT

DATE

R The date associated with the clinical count being reported. If the counter is not applicable to the transaction the date will contain 99999999

493-XE CLINICAL COUNTER R 4

Note: Clinical Information Counter number represents:

1 = Hospice Effective Date of Election – (NOE)

2 = Live Discharge – (NOT and NOTR) 3 = Hospice Transfer Date – (NOC) 4 = This represents the date that needs to be replaced or updated for a previously sent record, used with clinical counters 1, 2 or 3. It is the effective date, termination date or transfer date that needs to be replaced or updated.

Note: The Clinical Segment has been repurposed for the Hospice Election Status Nx transactions. The Clinical Information Counter value, along with the Measurement Date, indicate appropriate application of the transaction by the plan.

D.0 Hospice Nx Payer Sheet 5.13.24 Page 5 of 6

D.0 Hospice Election Status NX Transaction Response (N1, N2, N3)

RESPONSE HEADER SEGMENT: MANDATORY

Field Field Name Use Value Comment

102-A2 VERSION/ RELEASE

NUMBER

M D0 Current Version

103-A3 TRANSACTION CODE M N1, N2, or N3

109-A9 TRANSACTION

COUNT

M 1 1

501-F1 HEADER RESPONSE

STATUS

M A (Accepted) or R (Rejected)

202-B2 SERVICE PROVIDER

ID QUALIFIER

M 01 01 = NPI

201-B1 SERVICE PROVIDER

ID

M Return the hospice provider NPI from the

N request

401-D1 DATE OF SERVICE M Return the date provided on the N

Request

111-AM SEGMENT ID M 21 21=Response Status

112-AN TRANSACTION

M A= Approved (Accepted) or R=Rejected

C

CcC

510-FA REJECT COUNT R Required when Hospice Nx is rejected.

Not sent for Accepted response.

511-FB REJECT CODE R Required when Hospice Nx is rejected.

Not sent for Accepted response.

880-K5 TRANSACTION

REFERENCE

NUMBER

R Return the same information as provided

N Request Transaction.

D.0 Hospice Nx Payer Sheet 5.13.24 Page 6 of 6

111-AM SEGMENT

IDENTIFICATION

M 22 22=Response Claim Segment

455-EM PRESCRIPTION/

SERVICE

REFERENCE

NUMBER QUALIFIER

M Return the same information as provided on the N request

402-D2 PRESCRIPTION/

SERVICE

REFERENCE

NUMBER

M Return the same information as provided on the N request

F6 Hospice Nx Payer Sheet 5.13.24.docx 1 of 6

F6 Hospice Election Status Nx Transaction Request (N1, N2, N3) Use column indicates whether the field is M (Mandatory), R (Required) or O (Optional)

F6 Hospice Election Status NX Transaction Request (N1, N2, N3)

REQUEST HEADER SEGMENT: MANDATORY

102-A2 VERSION/RELEASE

NUMBER

M F6 Current version

103-A3 TRANSACTION CODE M N1, N2, N3

101-A1 IIN NUMBER M Part D Plan IIN from CMS Eligibility File

104-A4 PROCESSOR

CONTROL NUMBER

M Part D PCN from CMS Eligibility File

109-A9 TRANSACTION

COUNT

M 1 1

202-B2 SERVICE PROVIDER

ID QUALIFIER

M 01 01 = NPI

201-B1 SERVICE PROVIDER

ID

M Hospice NPI

401-D1 DATE OF SERVICE M The date the transaction facilitator received 837i or CMS transaction, or the effective date for a record being cancelled, or the incorrect effective date being removed.

110-AK SOFTWARE VENDOR/

CERTIFICATION ID

M HOSPICE Hospice related N transactions

F6 Hospice Nx Payer Sheet 5.13.24.docx 2 of 6

INSURANCE SEGMENT: MANDATORY

Field Field Name Use Value Comments

111-AM SEGMENT

IDENTIFICATION

M 04 04 = Insurance

302-C2 CARDHOLDER ID M Part D Plan Cardholder ID

312-CC CARDHOLDER

FIRST NAME

R Cardholder First name of the beneficiary from CMS eligibility database. N1 and N3 only

313-CD CARDHOLDER

LAST NAME

R Cardholder Last name of the beneficiary from the CMS eligibility database. N1 and N3 only

301-C1 GROUP ID O Field is not sent if Group ID is unknown

PATIENT SEGMENT: MANDATORY

111-AM SEGMENT ID M 01 01 = Patient Segment

311-CX PATIENT ID

QUALIFIER

R 09 09 = MBI

332-CY PATIENT ID R Patient MBI

304-C4 DATE OF BIRTH R

305-C5 PATIENT GENDER

CODE

R

326-CQ PATIENT

TELEPHONE

NUMBER*

R Date/Timestamp of when 837I or CMS Hospice transaction was received at RelayHealth. Format: YYMMDDHHMM

333-CZ EMPLOYER ID R Part D Plan Contract ID

* Note: The Patient Phone Number has been repurposed for the Hospice Election Status Nx transactions, where it represents 10 digits of the Date/Timestamp that the corresponding NOE was received by RelayHealth.

F6 Hospice Nx Payer Sheet 5.13.24.docx 3 of 6

CLAIM SEGMENT: MANDATORY

Field Field Name Use Value Comments

111-AM SEGMENT

IDENTIFICATION

M 07 07 = Claim

455-EM PRESCRIPTION/

SERVICE REF

NUMBER QUALIFIER

M 2 2 = Service Billing

402-D2 PRESCRIPTION/

SERVICE

REFERENCE

NUMBER

M 999999999999 or 3

-If N2 and = 999999999999 remove entire record for NPI in the Service

Provider ID field as the only action to be completed

- If N2 and = 3 - multiple actions:

remove entire record for NPI in the Service Provider ID and reinstate (remove termination date) of prior NPI

436-E1 PRODUCT/SERVICE

ID QUALIFIER

M 99 99 = Other

407-D7 PRODUCT/SERVICE M HOSPICE837 (from hospice provider) or HOSPICECWF (from CMS)

B98-34 RECONCILIATION ID R N2 and N3 only. On the N2 and N3 the field will contain the RelayHealth

Transaction Reference Number.

F6 Hospice Nx Payer Sheet 5.13.24.docx 4 of 6

CLINICAL SEGMENT: MANDATORY - N1 or N3 Only

Field Field Name Use Value Comments

111-AM SEGMENT ID M 13 13 = Clinical

493-XE CLINICAL

INFORMATION

COUNTER

R 1

494-ZE MEASUREMENT DATE R The date associated with the clinical count being reported. If the counter is not applicable to the transaction the date will contain 99999999

493-XE CLINICAL

INFORMATION

COUNTER

R 2

494-ZE MEAUREMENT DATE R The date associated with the clinical count being reported. If the counter is not applicable to the transaction the date will contain 99999999

493-XE CLINICAL

INFORMATION

COUNTER

R 3

494-ZE MEASUREMENT DATE R The date associated with the clinical count being reported. If the counter is not applicable to the transaction the date will contain 99999999

493-XE CLINICAL

INFORMATION

COUNTER

R 4

494-ZE MEASUREMENT DATE R The date associated with the clinical count being reported. If the counter is not applicable to the transaction the date will contain 99999999

Note: Clinical Information Counter number represents:

1 = Hospice Effective Date of Election – (NOE)

2 = Live Discharge – (NOT and NOTR) 3 = Hospice Transfer Date – (NOC) 4 = This represents the date that needs to be replaced or updated for a previously sent record, used with clinical counters 1, 2 or 3. It is the effective date, termination date or transfer date that needs to be replaced or updated.

Note: The Clinical Segment has been repurposed for the Hospice Election Status Nx transactions. The Clinical Information Counter value, along with the Measurement Date, indicate appropriate application of the transaction by the plan.

F6 Hospice Nx Payer Sheet 5.13.24.docx 5 of 6

F6 Hospice Election Status Nx Transaction Response (N1, N2, N3)

RESPONSE HEADER SEGMENT: MANDATORY

Field Field Name Use Value Comment

102-A2 VERSION/RELEASE

NUMBER

M F6 Current Version

103-A3 VERSION/RELEASE

NUMBER

M N1, N2, or N3

109-A9 TRANSACTION

COUNT

M 1 1

501-F1 HEADER

RESPONSE

M A (Accepted) or R

(Rejected)

202-B2 SERVICE

PROVIDER ID

QUALIFIER

M 01 01 = NPI

201-B1 SERVICE

PROVIDER ID

M Return the hospice provider NPI from the N request

401-D1 DATE OF SERVICE M Return the date provided on the N request

111-AM SEGMENT

IDENTIFICATION

M 21 21=Response Status

112-AN TRANSACTION

M A= Approved (Accepted) or R=Rejected

C

CcC

B98-34 RECONCILIATION ID R Accepted Response only. This field will contain the RelayHealth Transaction

Reference Number.

510-FA REJECT COUNT R Required for Transaction Response

Status = R (Rejected). Otherwise, field is not sent.

511-FB REJECT CODE R Required for Transaction Response

Status = R (Rejected). Otherwise, field is not sent.

C72-BH HELP DESK M

F6 Hospice Nx Payer Sheet 5.13.24.docx 6 of 6

SUPPORT TYPE

COUNT

C71-BG HELP DESK

SUPPORT TYPE

M 4 4 = Other Payer – N1 Reporting

C67-BB HELP DESK

BUSINESS UNIT

TYPE COUNT

R

C66-BA HELP DESK

BUSINESS UNIT

TYPE

R 1 1 = Pharmacy Help Desk

C70-BF HELP DESK

CONTACT

INFORMATION

QUALIFIER

R 1 1 = Telephone Number

C68-BC HELP DESK

CONTACT

INFORMATION

R

880-K5 TRANSACTION

REFERENCE

NUMBER

R Return the same information as provided on the N request

111-AM SEGMENT

IDENTIFICATION

M 22 22=Response Claim Segment

455-EM PRESCRIPTION/

SERVICE REF

NUMBER QUALIFIER

M Return the same information as provided on the N request

402-D2 PRESCRIPTION/

SERVICE

REFERENCE

NUMBER

M Return the same information as provided on the N request

F6 Supplemental Payer Real-Time Nx Payer Sheet v3 3.12.24.docx 1 of 5

F6 Supplemental Payer Real-Time TrOOP Nx Transaction Request

3.12.24: Updated to include Request Patient Segment, add four additional Help Desk related fields and minor corrections.

Note: The Use column includes the following values: M (Mandatory), R (Required) and O (Optional, submitted when available).

REQUEST HEADER SEGMENT: MANDATORY (N1, N2, N3)

102-A2 VERSION/RELEASE

M F6

103-A3 TRANSACTION CODE M

N1, N2, N3

101-A1 IIN NUMBER M Part D Plan IIN

104-A4 PROCESSOR CONTROL

NUMBER

M Part D Plan PCN

109-A9 TRANSACTION COUNT M 1

202-B2 SERVICE PROVIDER ID

QUALIFIER

M 01 01=NPI

201-B1 SERVICE PROVIDER ID M From the supplemental transaction.

401-D1 DATE OF SERVICE M…