J.5 N1 N2 and N3 Requirement.doc
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N1 N2 and N3 Requirements
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Attachment J.5
ATTACHMENT J.5- N1, N2, and n3 requirements Modified N1 Payer Sheet Part II – Field and Segment Requirements:
The following lists the segments available in a submission of an modified N1 Information Transaction. The Transaction Header Segment is mandatory, all other segments are identified as mandatory, situational (depending on the data required on the specific reporting event).
Transaction Header Segment: Mandatory in all cases
Real-Time Claims
For a real-time B1/B2/B3 transactions to be routed through the TrOOP Router a unique BIN/PCN combination must be assigned to identify the secondary/tertiary insurance. This will allow the router to determine the appropriate routing and the TrOOP Facilitator to create the modified N1/N2/N3 transaction for the PDP. The unique BIN/PCN will be sent to the PDP so they may identify the correct secondary/tertiary insurance.
If a unique BIN/PCN is not assigned by the secondary/tertiary or is not sent by the pharmacy then all real-time B1/B2/B3 transactions will not be routed through the TrOOP Router. It will be the responsibility of the secondary/tertiary insurance to correctly format and send the modified N1/N2/N3 transactions to the TrOOP Router. The secondary/tertiary insurance would have to create the modified N1/N2/N3 according to the following rules –
· If the secondary/tertiary is identified by a unique BIN/PCN and it is not sent by the pharmacy, the modified N1/N2/N3 must be formatted with the unique BIN/PCN and sent to the TrOOP Router
· If the secondary/tertiary does not have a unique BIN/PCN, it must be able to be uniquely identify by a combination of BIN/Group or BIN/PCN/Group. The modified N1/N2/N3 must be formatted with the unique combination and sent to the TrOOP Router.
Paper or Batch Claims
If the secondary/tertiary insurance receives a claim on paper or in a batch, then it is the responsibility of the secondary/tertiary to correctly format and send the modified N1/N2/N3 transactions to the TrOOP Router. The secondary/tertiary insurance would have to create the modified N1/N2/N3 according to the following rules –
· If the secondary/tertiary is identified by a unique BIN/PCN, the modified N1/N2/N3 must be formatted with the unique BIN/PCN and sent to the TrOOP Router.
· If the secondary/tertiary does not have a unique BIN/PCN, it must be able to be uniquely identify by a combination of BIN/Group or BIN/PCN/Group. The modified N1/N2/N3 must be formatted with the unique combination and sent to the TrOOP Router.
NOTE
Need to define details of field values of N1 from all entities Request Transaction:
Request Header Segment: Mandatory
| Field# |
| NCPDP Field Name |
| NCPDP Values Supported |
| Mandatory / Situational |
| 101-A1 |
| BIN Number |
| · When non-PDP sends - TrOOP Facilitator BIN |
· When TrOOP Facilitator sends - PDP BIN
(duplicate wording for other fields) M
| 102-A2 |
| Version/Release Number |
| 51 |
| M |
| 103-A3 |
| Transaction Code |
| N1 |
| M |
| 104-A4 |
| Processor Control Number |
| Assigned to Medicare D group |
| M |
| 109-A9 |
| Transaction Count |
| 1 |
| M |
| 202-B2 |
| Service Provider ID Qualifier |
M
| 201-B1 |
| Service Provider ID |
| · When routing from TrOOP Facilitator to PDP, filled with NCPDP Provider ID. |
· When routing from secondary/tertiary payer to TrOOP Facilitator filled with Secondary/Tertiary insurance’s Provider ID.
M
| 401-D1 |
| Date of Service |
M
| 110-AK |
| Software Vendor /Certification Id |
| Assigned when certified, transaction will reject if not valid for N1. Also used to identify source of transaction (i.e. TrOOP Facilitator, Secondary/Tertiary Payer) |
M
Insurance Segment: Mandatory
| Field# |
| NCPDP Field Name |
| NCPDP Values Supported |
| Mandatory / Situational |
| 111-AM |
| Segment Identification |
| 04 |
| M |
| 302-C2 |
| Cardholder ID |
| Primary Cardholder ID |
· When routing from TrOOP Facilitator to PDP, filled with PDP cardholder id.
· When routing from secondary/tertiary payer to TrOOP Facilitator filled with Secondary/Tertiary insurance’s cardholder id
Filled by TrOOP Facilitator M
| 301-C1 |
| Group ID |
| Primary Group ID |
Filled by TrOOP Facilitator S
Other Payer BIN
M
Other Payer PCN
M
Other Payer Cardholder ID
M
Other Payer Group ID
S
Claim Segment: Mandatory
| Field# |
| NCPDP Field Name |
| NCPDP Values Supported |
| Mandatory / Situational |
| 111-AM |
| Segment Identification |
| 07 |
| M |
| 455-EM |
| Prescription/ Service Ref Number Qualifier |
| 1 |
| M |
| 402-D2 |
| Prescription/ Service Ref Number |
M
| 436-E1 |
| Product/Service ID Qualifier |
| 01, 02, 03 |
M
| 407-D7 |
| Product/Service ID |
| UPC, HRI, NDC |
(see external code list) M
| 403-D3 |
| Fill Number |
M
| Transaction Sequence/Reference Number |
| Unique number to identify transaction. Number to be echoed back on response |
| S |
Pricing Segment: Mandatory
| Field# |
| NCPDP Field Name |
| NCPDP Values Supported |
| Mandatory / Situational |
| 111-AM |
| Segment Identification |
| 11 |
| M |
| 433-DX |
| Patient Paid Amount Submitted |
| Amount to be considered for TrOOP adjustment |
| M |
Response Transaction:
Response Header Segment: Mandatory
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
| Mandatory / Situational |
| 1Ø2-A2 |
| Version/Release Number |
| 51 |
| M |
| 1Ø3-A3 |
| Transaction Code |
| N1 |
| M |
| 1(9-A9 |
| Transaction Count |
| 1 |
| M |
| 5Ø1-F1 |
| Header Response Status |
M
| 2(2-B2 |
| Service Provider Id Qualifier |
M
| 2Ø1-B1 |
| Service Provider Id |
| · When routing between TrOOP Facilitator and PDP, filled with NCPDP Provider ID. |
· When routing between secondary/tertiary payer and TrOOP Facilitator filled with Secondary/Tertiary insurance’s Provider ID.
M
| 4Ø1-D1 |
| Date of Service |
M
Response Message Segment: Situational
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
| Mandatory / Situational |
| 111-AM |
| Segment Identification |
| 5Ø4-F4 |
| Message |
| Additional clarification |
Response Insurance Segment: Mandatory
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
| Mandatory / Situational |
| 111-AM |
| Segment Identification |
M
| 302-C2 |
| Cardholder ID |
| · When routing from TrOOP Facilitator to PDP, filled with PDP cardholder id. |
· When routing from secondary/tertiary payer to TrOOP Facilitator filled with Secondary/Tertiary insurance’s cardholder id.
M
| 301-C1 |
| Group ID |
| Primary Group ID |
| S |
Secondary/Tertiary BIN
M
Secondary/Tertiary PCN
M
Secondary/Tertiary Cardholder ID
M
Secondary/Tertiary Group ID
S
Response Status Segment: Mandatory
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
| Mandatory / Situational |
| 111-AM |
| Segment Identification |
| 21 |
| M |
| 112-AN |
| Transaction Response Status |
M
| 5Ø3-F3 |
| Authorization Number |
M
| 510-FA |
| Reject Count |
S
| 511-FB |
| Reject Code |
S
| Transaction Sequence/Reference Number |
| Unique number to identify transaction. Number to be echoed back from request. |
| 526-FQ |
| Additional Message Information |
S
| 549-7F |
| Help Desk Phone Number Qualifier |
S
| 55(-8F |
| Help Desk Phone Number |
S
Modified N2 Payer Sheet Part II – Field and Segment Requirements:
The following lists the segments available in a submission of an modified N2 Information Reversal or Adjustment Transaction. The Transaction Header Segment is mandatory, all other segments are identified as mandatory, situational (depending on the data required on the specific reporting event).
Transaction Header Segment: Mandatory in all cases
Real-Time Claims
For a real-time B1/B2/B3 transactions to be routed through the TrOOP Router a unique BIN/PCN combination must be assigned to identify the secondary/tertiary insurance. This will allow the router to determine the appropriate routing and the TrOOP Router to create the modified N1/N2/N3 transaction for the PDP. The unique BIN/PCN will be sent to the PDP so they may identify the correct secondary/tertiary insurance.
If a unique BIN/PCN is not assigned by the secondary/tertiary or is not sent by the pharmacy then all real-time B1/B2/B3 transactions will not be routed through the TrOOP Router. It will be the responsibility of the secondary/tertiary insurance to correctly format and send the modified N1/N2/N3 transactions to the TrOOP Router. The secondary/tertiary insurance would have to create the modified N1/N2/N3 according to the following rules –
· If the secondary/tertiary is identified by a unique BIN/PCN and it is not sent by the pharmacy, the modified N1/N2/N3 must be formatted with the unique BIN/PCN and sent to the TrOOP Router
· If the secondary/tertiary does not have a unique BIN/PCN, it must be able to be uniquely identify by a combination of BIN/Group or BIN/PCN/Group. The modified N1/N2/N3 must be formatted with the unique combination and sent to the TrOOP Router.
Paper or Batch Claims
If the secondary/tertiary insurance receives a claim on paper or in a batch, then it is the responsibility of the secondary/tertiary to correctly format and send the modified N1/N2/N3 transactions to the TrOOP Router. The secondary/tertiary insurance would have to create the modified N1/N2/N3 according to the following rules –
· If the secondary/tertiary is identified by a unique BIN/PCN, the modified N1/N2/N3 must be formatted with the unique BIN/PCN and sent to the TrOOP Router.
· If the secondary/tertiary does not have a unique BIN/PCN, it must be able to be uniquely identify by a combination of BIN/Group or BIN/PCN/Group. The modified N1/N2/N3 must be formatted with the unique combination and sent to the TrOOP Router.
Request Transaction:
Request Header Segment: Mandatory
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
Mandatory / Situational
| 101-A1 |
| BIN Number |
| · When non-PDP sends - TrOOP Facilitator BIN |
· When TrOOP Facilitator sends - PDP BIN
(duplicate wording for other fields) M
| 102-A2 |
| Version/Release Number |
M
| 103-A3 |
| Transaction Code |
| N2 |
| M |
| 104-A4 |
| Processor Control Number |
| Assigned to Medicare D group |
| M |
| 109-A9 |
| Transaction Count |
| 1 |
| M |
| 202-B2 |
| Service Provider ID Qualifier |
M
| 201-B1 |
| Service Provider ID |
| · When routing from TrOOP Router to PDP, filled with NCPDP Provider ID. |
· When routing from secondary/tertiary payer to TrOOP Router filled with Secondary/Tertiary insurance’s Provider ID.
M
| 401-D1 |
| Date of Service |
M
| 110-AK |
| Software Vendor /Certification Id |
| Assigned when certified, transaction will reject if not valid for N2. Also used to identify source of transaction (i.e. TrOOP Router, Secondary/Tertiary Payer) |
| M |
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
Mandatory / Situational
| 111-AM |
| Segment Identification |
| 04 |
| M |
| 302-C2 |
| Cardholder ID |
| · When routing from TrOOP Router to PDP, filled with PDP cardholder id. |
· When routing from secondary/tertiary payer to TrOOP Router filled with Secondary/Tertiary insurance’s cardholder id.
M
| 301-C1 |
| Group ID |
| · Primary Group ID |
· Filled by TrOOP Facilitator S
Other Payer BIN
S
Other Payer PCN
S
Other Payer Cardholder ID
M
Other Payer Group ID
S
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
Mandatory / Situational
| 111-AM |
| Segment Identification |
| 07 |
| M |
| 455-EM |
| Prescription/ Service Ref Number Qualifier |
| 1 |
| M |
| 402-D2 |
| Prescription/ Service Ref Number |
M
| 436-E1 |
| Product/Service ID Qualifier |
| 01, 02, 03 |
M
| 407-D7 |
| Product/Service ID |
| UPC, HRI, NDC |
(see external code list) M
| 403-D3 |
| Fill Number |
M
| Transaction Sequence/Reference Number |
| Unique number to identify transaction. Number to be echoed back on response |
| S |
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
| Mandatory / Situational |
| 1Ø2-A2 |
| Version/Release Number |
M
| 1Ø3-A3 |
| Transaction Code |
| N2 |
| M |
| 1(9-A9 |
| Transaction Count |
| 1 |
| M |
| 5Ø1-F1 |
| Header Response Status |
M
| 2(2-B2 |
| Service Provider Id Qualifier |
M
| 2Ø1-B1 |
| Service Provider Id |
| · When routing from TrOOP Router to PDP, filled with NCPDP Provider ID. |
· When routing from secondary/tertiary payer to TrOOP Router filled with Secondary/Tertiary insurance’s Provider ID.
M
| 4Ø1-D1 |
| Date of Service |
M
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
| Mandatory / Situational |
| 111-AM |
| Segment Identification |
| 5Ø4-F4 |
| Message |
| Additional clarification |
Response Insurance Segment: Mandatory
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
Mandatory / Situational
| 111-AM |
| Segment Identification |
M
| 302-C2 |
| Cardholder ID |
| · When routing from TrOOP Router to PDP, filled with PDP cardholder id. |
· When routing from secondary/tertiary payer to TrOOP Router filled with Secondary/Tertiary insurance’s cardholder id.
M
| 301-C1 |
| Group ID |
| · Primary Group ID |
· Filled by TrOOP Facilitator S
Other Payer BIN
M
Other Payer PCN
M
Other Payer Cardholder ID
M
Other Payer Group ID
S
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
| Mandatory / Situational |
| 111-AM |
| Segment Identification |
| 21 |
| M |
| 112-AN |
| Transaction Response Status |
M
| 5Ø3-F3 |
| Authorization Number |
M
| 510-FA |
| Reject Count |
S
| 511-FB |
| Reject Code |
S
| Transaction Sequence/Reference Number |
| Unique number to identify transaction. Number to be echoed back from request. |
| 526-FQ |
| Additional Message Information |
S
| 549-7F |
| Help Desk Phone Number Qualifier |
S
| 55(-8F |
| Help Desk Phone Number |
S
Modified N3 Payer Sheet Part II – Field and Segment Requirements:
The following lists the segments available in a submission of an N3 Information Transaction. The Transaction Header Segment is mandatory, all other segments are identified as mandatory, situational (depending on the data required on the specific reporting event).
Transaction Header Segment: Mandatory in all cases
Rule: The BIN/PCN/Group fields populated in the N3 must be the same fields submitted in the N1 to identify the secondary/tertiary insurance for the reversal portion of the transaction. To modify or correct the secondary/tertiary BIN/PCN/Group which was submitted on an N1, the reversal and resubmittal must be done by two separate transactions (i.e. N2 followed by an N1 with the correct secondary/tertiary BIN/PCN/Group information).
Real-Time Claims
For a real-time B1/B2/B3 transactions to be routed through the TrOOP Facilitator a unique BIN/PCN combination must be assigned to identify the secondary/tertiary insurance. This will allow the switch to determine the appropriate routing and the TrOOP Facilitator to create the N1/N2/N3 transaction for the PDP. The unique BIN/PCN will be sent to the PDP so they may identify the correct secondary/tertiary insurance.
If a unique BIN/PCN is not assigned by the secondary/tertiary or is not sent by the pharmacy then all real-time B1/B2/B3 transactions will not be routed through the TrOOP Facilitator. It will be the responsibility of the secondary/tertiary insurance to correctly format and send the N1/N2/N3 transactions to the TrOOP Facilitator. The secondary/tertiary insurance would have to create the N1/N2/N3 according to the following rules –
· If the secondary/tertiary is identified by a unique BIN/PCN and it is not sent by the pharmacy, the N1/N2/N3 must be formatted with the unique BIN/PCN and sent to the TrOOP Facilitator.
· If the secondary/tertiary is does not have a unique BIN/PCN, it must be able to be uniquely identified by a combination of BIN/Group or BIN/PCN/Group. The N1/N2/N3 must be formatted with the unique combination and sent to the TrOOP Facilitator.
Paper or Batch Claims
If the secondary/tertiary insurance receives a claim on paper or in a batch, then it is the responsibility of the secondary/tertiary to correctly format and send the N1/N2/N3 transactions to the TrOOP Facilitator. The secondary/tertiary insurance would have to create the N1/N2/N3 according to the following rules –
· If the secondary/tertiary is identified by a unique BIN/PCN, the N1/N2/N3 must be formatted with the unique BIN/PCN and sent to the TrOOP Facilitator.
· If the secondary/tertiary is does not have a unique BIN/PCN, it must be able to be uniquely identified by a combination of BIN/Group or BIN/PCN/Group. The N1/N2/N3 must be formatted with the unique combination and sent to the TrOOP Facilitator.
Request Transaction:
Request Header Segment: Mandatory
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
Mandatory / Situational
| 101-A1 |
| BIN Number |
| 610014 |
| M |
| 102-A2 |
| Version/Release Number |
| 51 |
| M |
| 103-A3 |
| Transaction Code |
| N3 |
| M |
| 104-A4 |
| Processor Control Number |
| Assigned to Medicare D group |
| M |
| 109-A9 |
| Transaction Count |
| 1 |
| M |
| 202-B2 |
| Service Provider ID Qualifier |
M
| 201-B1 |
| Service Provider ID |
| · When routing from TrOOP Facilitator to PDP, filled with NCPDP Provider ID. |
· When routing from secondary/tertiary payer to TrOOP Facilitator filled with Secondary/Tertiary insurance’s Provider ID.
M
| 401-D1 |
| Date of Service |
M
| 110-AK |
| Software Vendor /Certification Id |
| Assigned when certified, transaction will reject if not valid for N3. Also used to identify source of transaction (i.e. TrOOP Facilitator, Secondary/Tertiary Payer) |
M
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
Mandatory / Situational
| 111-AM |
| Segment Identification |
| 04 |
| M |
| 302-C2 |
| Cardholder ID |
| · When routing from TrOOP Facilitator to PDP, filled with PDP cardholder id. |
· When routing from secondary/tertiary payer to TrOOP Facilitator filled with Secondary/Tertiary insurance’s cardholder id.
M
| 301-C1 |
| Group ID |
| Secondary/Tertiary Group ID |
| S |
| New |
| Secondary/Tertiary BIN |
M
| New |
| Secondary/Tertiary PCN |
M
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
Mandatory / Situational
| 111-AM |
| Segment Identification |
| 07 |
| M |
| 455-EM |
| Prescription/ Service Ref Number Qualifier |
| 1 |
| M |
| 402-D2 |
| Prescription/ Service Ref Number |
M
| 436-E1 |
| Product/Service ID Qualifier |
| 03 |
M
| 407-D7 |
| Product/Service ID |
| NDC |
| M |
| 403-D3 |
| Fill Number |
M
| New |
| Transaction Sequence/Reference Number |
| Unique number to identify transaction. Number to be echoed back on response |
| M |
Pricing Segment: Mandatory
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
Mandatory / Situational
| 111-AM |
| Segment Identification |
| 11 |
| M |
| 433-DX |
| Patient Paid Amount Submitted |
M
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
| Mandatory / Situational |
| 1Ø2-A2 |
| Version/Release Number |
| 51 |
| M |
| 1Ø3-A3 |
| Transaction Code |
| N3 |
| M |
| 1(9-A9 |
| Transaction Count |
| 1 |
| M |
| 5Ø1-F1 |
| Header Response Status |
M
| 2(2-B2 |
| Service Provider Id Qualifier |
M
| 2Ø1-B1 |
| Service Provider Id |
| · When routing from TrOOP Facilitator to PDP, filled with NCPDP Provider ID. |
· When routing from secondary/tertiary payer to TrOOP Facilitator filled with Secondary/Tertiary insurance’s Provider ID.
M
| 4Ø1-D1 |
| Date of Service |
M
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
| Mandatory / Situational |
| 111-AM |
| Segment Identification |
M
| 5Ø4-F4 |
| Message |
| Additional clarification |
| S |
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
Mandatory / Situational
| 111-AM |
| Segment Identification |
| 04 |
| M |
| 302-C2 |
| Cardholder ID |
| · When routing from TrOOP Facilitator to PDP, filled with PDP cardholder id. |
· When routing from secondary/tertiary payer to TrOOP Facilitator filled with Secondary/Tertiary insurance’s cardholder id.
M
| 301-C1 |
| Group ID |
| Secondary/Tertiary Group ID |
| S |
| New |
| Secondary/Tertiary BIN |
M
| New |
| Secondary/Tertiary PCN |
M
| Field # |
| NCPDP Field Name |
| NCPDP Values Supported |
| Mandatory / Situational |
| 111-AM |
| Segment Identification |
| 21 |
| M |
| 112-AN |
| Transaction Response Status |
M
| 5Ø3-F3 |
| Authorization Number |
M
| 510-FA |
| Reject Count |
S
| 511-FB |
| Reject Code |
S
| New |
| Transaction Sequence/Reference Number |
| Unique number to identify transaction. Number to be echoed back from request. |
| M |
| 526-FQ |
| Additional Message Information |
S
| 549-7F |
| Help Desk Phone Number Qualifier |
S
| 55(-8F |
| Help Desk Phone Number |
S
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