Appendix I_020926.pdf

Programmer Details

Routing Supplemental Transactions to the Transaction Facilitator

The Switches deliver the following claims to the Facilitator:

Claims with a BIN/PCN listed in the BIN_PCN_Switch_YYYY_MM_DD.txt file for the Date of Service on the claim.

NCPDP Telecommunication vD.0, B1, B2, and B3 transactions with a Response status in Field # 112-AN of:

• ‘A’ APPROVED,

• ‘C’ CAPTURED,

• ‘D’ DUPLICATE of PAID,

• ‘P’ PAID,

• ‘Q’ DUPLICATE OF CAPTURED, and

• ‘S’ DUPLICATE OF APPROVED.

Note: Duplicates are included to ensure that transaction that timeout are accounted for with the retransmission.

Claims are delivered in a composite format that contains a wrapper and claims detail.

Read more information on the wrapper specification.

RelayHealth Message Header Specifications (Wrapper for Switch Composite Transaction for Supplemental Claims):

• Message Header Specifications

• Reject Response Examples for Switch transactions

Multiple Switches

If multiple Switches are involved in routing a transaction from the pharmacy to a payer, only the Switch that receives the transaction from the pharmacy receives payment for sending the Request/Response.

Threading

The Facilitator supports multi-threading (up to 32 transactions at a time) and single threading of transactions. If the Switch sends more than 32 transactions at a time for https://medifacd.mckesson.com/siteassets/documents/switch-transaction-wrapper.pdf multithreaded applications, the Facilitator rejects the transactions after 32 and returns those transactions back to the Switch.

Supplemental Routing/Processing rules for Switches:

If BIN-PCN is on table based on date rules below and date is April 1, 2012 (or later if HIPAA compliance date is changed) only forward transactions (request and response) if response to request is accepted/paid and Claim is D.0.

• Date of Fill on Claim is not more than 3 years prior to receive date

• Claim DOS meets the date driven logic below:

1/1/2012 10 beneficiaries active in supplemental BIN-PCN in 2012

BIN PCN Effective date Termination date File update date

11111 SUPPD 1/1/2012 1/1/2012

1/7/2012 5 beneficiaries active in supplemental BIN-PCN in 2012

11111 SUPPD 1/1/2012 1/7/2012 1/7/2012

1/14/2012 10 beneficiaries active in supplemental BIN-PCN in 2012

11111 SUPPD 1/1/2012 1/7/2012 1/7/2012

11111 SUPPD 1/14/2012 1/14/2012

Date of Service Driven Logic:

• Claim received on 1-8-2012 for DOS of 1-2-2012 will be forwarded to TrOOP

• Claim received on 1-8-2012 for DOS of 1-8-2012 will NOT be sent to TrOOP

• Claim received on 1-15-2012 for DOS of 1-8-2012 will NOT be sent to TrOOP

• Claim received on 1-15-2012 for DOS of 1-15-2012 will be forwarded to TrOOP

• Claims received in the gap will not be retrospectively forwarded as this is consistent with current process. Retrospective pulls would require extra development work for all switches (extremely costly). Alternative options are that the plan can send an N batch for missing transactions or can request ad hoc pulls from all switches at their cost.

On 4-1-2012:

• All GHI only BIN-PCNs will have effective dates of 1-1-2006 and term dates of 3-31-

• Combined GHI/NDCHEALTH BINPCNs will have effective dates of 1-1-2006 and open-ended termination dates

• All NDCHEALTH only BIN-PCNs will have 1-1-2012 effective dates and open-ended termination dates.

• Claims will be processed using DOS to determine which date driven BIN- PCN should be applied.

RelayHealth Message Header Specifications (Wrapper for Switch Composite Transaction for Supplemental Claims)

Version 1.0 07/06/2005

The following wrapper must appear on each message submitted to RelayHealth and will appear on each message returned by RelayHealth.

Field Length Description STX 1 Start-of-Text, hex 02 Message Length 4 Total length of the message not including the STX and the 4 bytes used in the Message Length Field itself. Total length minus 5.

Header Length 3

Total number of characters in the Version field, Claim Length, Response Length, and Reference number fields. ASCII characters 0-9, right-justified, zero-filled. Current version only supports 32 bytes total for these 4 fields.

Version 2 Current value must be “01”.

Claim Length 4 Length of NCPDP formatted claim. Value should be right-justified and zero-filled.

Response Length 4 Length of NCPDP formatted response. Value should be right-justified and zero-filled.

Reference Number 0-22

Optional field for Switch to use.

May be a tracking number, system ID, etc.

Must be ASCII 0-9, A-Z.

RelayHealth will echo up to 22 bytes in the response message

Claim Varies NCPDP formatted Claim Response Varies NCPDP formatted Response ETX 1 End-of-Text (hex 03)

When RelayHealth processes the transaction, it returns a reply formatted the same as the request.

The reply includes the Reference Number field exactly as it was sent to RelayHealth. The Claim Length field is set to all zeros and the Reply Length field has the appropriate value for the reply.

Response Messages

Standard Captured Response

Response Header Segment Field Field Name Value

1Ø2-A2 VERSION/RELEASE NUMBER Same as Request 1Ø3-A3 TRANSACTION CODE Same as Request

1Ø9-A9 TRANSACTION COUNT 1

5Ø1-F1 HEADER RESPONSE STATUS C

2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Same as Request 2Ø1-B1 SERVICE PROVIDER ID Same as Request 4Ø1-D1 DATE OF SERVICE Same as Request

Reject - Too Many Threads

Response Header Segment Field Field Name Value

1Ø2-A2 VERSION/RELEASE NUMBER Same as Request 1Ø3-A3 TRANSACTION CODE Same as Request

1Ø9-A9 TRANSACTION COUNT 1

5Ø1-F1 HEADER RESPONSE STATUS R

2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Same as Request 2Ø1-B1 SERVICE PROVIDER ID Same as Request 4Ø1-D1 DATE OF SERVICE Same as Request

Response Status Segment Field Field Name Value 111-

AM

SEGMENT

IDENTIFICATION

112-

AN

TRANSACTION

RESPONSE STATUS R

51Ø-

FA REJECT COUNT 1

511-

FB REJECT CODE 85

526-

FQ

ADDITIONAL

MESSAGE

INFORMATION

Too Many Threads