Attachment 1 - Eligibility Primary Status Secondary Response Reversal and Reversal Response Formats updated 6-8-23.pdf

Attachment 1

Attachment 1 – Eligibility, Primary Status, Secondary Response, Reversal, and Reversal

Response Formats

Eligibility

PIECE FIELD

START

FIELD

END

HAC FIELD

DESCRIPTION

FIELD

NAME

LENGTH DATA OUTPUT GLOBAL EXAMPLE DATA

1 1 30 Bene CORR

ADDRESS 1

CHBADC1 30 ALPHA/NUMERIC $P(^AHCHVA(DFN,100,BFN,9),"^",1) (30 spaces - if blank entry)

2 31 60 Bene CORR

ADDRESS 2

CHBADC2 30 ALPHA/NUMERIC $P(^AHCHVA(DFN,100,BFN,9),"^",2) (30 spaces - if blank entry)

3 61 90 Bene CORR

ADDRESS 3

CHBADC3 30 ALPHA/NUMERIC $P(^AHCHVA(DFN,100,BFN,9),"^",3) (30 spaces - if blank entry)

4 91 120 Bene CORR

ADDRESS 4

CHBADC4 30 ALPHA/NUMERIC $P(^AHCHVA(DFN,100,BFN,9),"^",4) (30 spaces - if blank entry)

5 121 150 Bene REMIT

ADDRESS 1

CHBADR1 30 ALPHA/NUMERIC $P(^AHCHVA(DFN,100,BFN,1),"^",1) 123 TOM'S

ADDRESS + (13

spcs)

6 151 180 Bene REMIT

ADDRESS 2

CHBADR2 30 ALPHA/NUMERIC $P(^AHCHVA(DFN,100,BFN,1),"^",2) (30 spaces - if blank entry)

7 181 200 Bene CORR

CITY

CHCCTY 20 ALPHA/NUMERIC $P(^AHCHVA(DFN,100,BFN,9),"^",6) (20 spaces - if blank entry)

8 201 220 Bene REMIT

CITY

CHRCTY 20 ALPHA/NUMERIC $P(^AHCHVA(DFN,100,BFN,1),"^",3) DENVER + (14

spcs)

9 221 227 Bene

DEDUCTIBLE

CUM

CHBDED1 7 NUMERIC $P(^CHMDFN(I,100,J,1,K,0),"^",2) 0000000

10 228 230 Bene

DEDUCTIBLE

MET ($50)

CHBDED2 3 ALPHA (YES/NO) $P(^CHMDFN(I,100,J,1,K,0),"^",3) YES

11 231 238 Bene DOB CHBDOB 8 NUMERIC

(YYYYMMDD)

$P(^AHCHVA(DFN,100,BFN,0),"^",3) 19900119

12 239 246 Bene

CHAMPVA

ELIG STAT

DATE

CHBELDT1 8 NUMERIC

(YYYYMMDD)

$P(^AHCHVA(DFN,100,BFN,109,K,0)

,"^",1)

19980331

13 247 254 Bene

CHAMPVA

ELIG STAT

EXP DT

CHBELDT2 8 NUMERIC

(YYYYMMDD)

$P(^AHCHVA(DFN,100,BFN,109,K,0)

,"^",2)

20080118

14 255 257 Bene

CHAMPVA

ELIG STAT

CHBELSTA 3 ALPHA (YES/NO) $P(^AHCHVA(DFN,100,BFN,109,K,0)

,"^",1)

YES

15 258 277 Bene LAST

NAME

CHBLNAM 20 ALPHA $P(^AHCHVA(DFN,100,BFN,0),"^",1) BARD + (16

spcs)

16 278 292 Bene FIRST, MI

CHBFNAM 15 ALPHA $P(^AHCHVA(DFN,100,BFN,0),"^",1) DONALD J+ (7

spcs)

17 293 293 Bene SEX CHBSEX 1 ALPHA $P(^AHCHVA(DFN,100,BFN,0),"^",2) M (Defaults to F if blank)

18 294 301 Bene OHI

START DATE

CHBOSDT 8 NUMERIC

(YYYYMMDD)

$P(^CHMDFN(I,100,J,2,K,0),"^",1) 19800101

19 302 309 Bene OHI

END DATE

CHBOEDT 8 NUMERIC

(YYYYMMDD)

$P(^CHMDFN(I,100,J,2,K,0),"^",2) 19801230

20 310 334 Bene OHI

DESC

CHBODES 25 ALPHA $P(^CHMDFN(I,100,J,2,K,0),"^",3) Medicare A&B + (13 spcs)

21 335 337 SXC

Ineligible

CHBOPH 3 ALPHA (YES/NO) $P(^CHMDFN(I,100,J,2,K,0),"^",3) NO + (1 spcs)

PIECE FIELD

START

FIELD

END

HAC FIELD

DESCRIPTION

FIELD

NAME

LENGTH DATA OUTPUT GLOBAL EXAMPLE DATA

22 338 357 Bene CORR

PHONE

CHBCPH 20 NUMERIC $P(^AHCHVA(DFN,100,BFN,9),"^",1

0)

(20 zeros - if blank entry)

23 358 366 Bene

RELATIONSH

IP

CHBREL 9 ALPHA $P(^AHCHVA(DFN,100,BFN,0),"^",4) CHILD + (4

spcs)

24 367 386 Bene REMIT

PHONE

CHBRPH 20 NUMERIC $P(^AHCHVA(DFN,100,BFN,1),"^",6) 000000000030

31165999

25 387 395 Bene

MEMBER ID

CHBSSN 9 NUMERIC $P(^AHCHVA(DFN,100,BFN,0),"^",9) 309165999

26 396 397 Bene CORR

STATE

CHBCSTE 2 ALPHA $P(^AHCHVA(DFN,100,BFN,9),"^",7) (2 spaces - if blank entry)

27 398 407 Bene CORR

ZIP

CHBCZIP 10 NUMERIC $P(^AHCHVA(DFN,100,BFN,9),"^",8) (0 zeros padded on right)

28 408 409 Bene REMIT

STATE

CHBRSTE 2 ALPHA $P(^AHCHVA(DFN,100,BFN,1),"^",4) CO

29 410 419 Bene REMIT

ZIP

CHBRZIP 10 NUMERIC $P(^AHCHVA(DFN,100,BFN,1),"^",5) (0 zeros padded on right)

30 420 439 Sponsor

LAST NAME

**NOT

USED**

CHDLNAM 20 ALPHA $P(^AHCHVA(DFN,0),"^",1) BARD + (16

spcs)

31 440 454 Sponsor

FIRST, MI

**NOT

USED**

CHDFNAM 15 ALPHA $P(^AHCHVA(DFN,0),"^",1) JAMES L+ (8

spcs)

32 455 463 Sponsor SSN

**NOT

USED**

CHDFSSN 9 NUMERIC $P(^AHCHVA(DFN,0),"^",9) 987873452

33 464 470 Family CAT

CAP CUM

CHFCTCP1 7 NUMERIC $P(^CHMDFN(I,1,J,0),"^",4) 0193244

34 471 473 Family CAT

CAP MET

($3000)

CHFCTCP2 3 ALPHA(YES/NO) $P(^CHMDFN(I,1,J,0),"^",5) NO + (1 spcs)

35 474 480 Family

DEDUCTIBLE

CUM

CHFDED1 7 NUMERIC $P(^CHMDFN(I,1,J,0),"^",2) 0007680

36 481 483 Family

DEDUCTIBLE

MET ($100)

CHFDED2 3 ALPHA(YES/NO) $P(^CHMDFN(I,1,J,0),"^",3) YES

37 484 485 Bene OHI

CODE

CHBOHIC1 2 NUMERIC $P(^CHMDFN(I,100,J,2,K,0),"^",3) 8 + 1 spc

38 486 487 Bene OHI

LOGIC CODE

CHBOHIC2 2 NUMERIC $P(^CHMDIC(741002.76,I,0),"^",4) 6 + 1 spc

39 488 489 Flag

(CHVA="C"

SB="S"

Dual="CS")

CHCSFLAG 2 ALPHA $P(^AHCHVA(DFN,100,BFN,0),"^",1) C + 1 spc

40 490 496 Bene DED

CUM LAST

YEAR

CHBDEDA 7 NUMERIC $P(^CHMDFN(I,100,J,1,K,0),"^",2) 0000000

41 497 503 Family CAT

CAP CUM

LAST YEAR

CHFCTCPA 7 NUMERIC $P(^CHMDFN(I,1,J,0),"^",4) 0193244

PIECE FIELD

START

FIELD

END

HAC FIELD

DESCRIPTION

FIELD

NAME

LENGTH DATA OUTPUT GLOBAL EXAMPLE DATA

42 504 510 Family DED

CUM LAST

YEAR

CHFDEDA 7 NUMERIC $P(^CHMDFN(I,1,J,0),"^",2) 0007680

Primary Status

PRISTAT FIELD NAME TARGET VALUE LENGTH

JUSTIFY

FLAG

PAD

CHAR EXAMPLE DATA

1.ID PBM ID Number 6 L SPC 12111

2.BENE NAME Beneficiary Name 19 L SPC BROWN,JOE

3.SOCIAL

Social Security Number 10 L SPC 123456789

4.PHARMACY Pharmacy Number 10 L SPC 1255399952

5.PRESC.

NUMBER Prescription Number 13 L SPC 100018328900

6.DATE OF SVC Date of Service 7 L SPC 051712

7.BILL AMT Billed Amount 10 L SPC 12.18

8.CLM INVOICE # Claim#/Invoice# 17 L SPC CHVCFV3306/BROWN

9.STATE State 3 L SPC 1

10.CHECKNUM Check Number 12 L SPC

11.PAID Amount Paid 10 L SPC 0.00

12.VENDOR Vendor Paid 10 L SPC 0.00

13.BENE PD AMT Beneficiary Paid 10 L SPC 0.00

14.DD AMT Deductible Amount 10 L SPC 0.00

15.REJECTED Rejected Amount 10 L SPC 0.00

16.COST SHARE Cost Share 10 L SPC 0.00

17.ERJ Early Reject Code 4 L SPC 000

18.REJ Reject Code 4 L SPC 000

19.HICN HICN 12 1200000001

END OF RECORD

CITI PRIMARY

STATUS

PRISTAT1 FIELD NAME TARGET VALUE LENGTH

JUSTIFY

FLAG

PAD

CHAR

1.ID PBM ID Number 6 L SPC 12111

2.BENE NAME Beneficiary Name 19 L SPC BROWN,JOE

3.SOCIAL

Social Security Number 10 L SPC 123456789

4.PHARMACY Pharmacy Number 11 L SPC 12553999521

5.PRESC.

NUMBER Prescription Number 13 L SPC 100018328900

6.DATE OF SVC Date of Service 7 L SPC 051712

7.BILL AMT Billed Amount 10 L SPC 12.18

PRISTAT FIELD NAME TARGET VALUE LENGTH

JUSTIFY

FLAG

PAD

CHAR EXAMPLE DATA

8.CLM INVOICE # Claim#/Invoice# 17 L SPC CHVCFV3306/BROWN

9.STATE State 3 L SPC 1

10.CHECKNUM Check Number 12 L SPC

11.PAID Amount Paid 10 L SPC 0.00

12.VENDOR Vendor 10 L SPC 0.00

13.BENE PD AMT Beneficiary Paid 10 L SPC 0.00

14.DD AMT Deductible Amount 10 L SPC 0.00

15.REJECTED Rejected Amount 10 L SPC 0.00

16.COST SHARE Cost Share 10 L SPC 0.00

17.ERJ Early Reject Code 4 L SPC 000

18.REJ Reject Code 4 L SPC 000

19.HICN HICN 12 SPC 1200000001

END OF RECORD

Secondary Response File Format eTrans

NCPDP_B1_CLAIM_STATUS

NCPDP Response B1

Segment / Field Name

NCPDP Response B1

Field Number

BATCH_NUMBER BATCH NUMBER 806-5C

PATIENT_NAME FIRST AND LAST NAMES 310-CA;311-CB

PATIENT_SSN PATIENT ID 332-CY

PHARMACY_EIN

RESPONSE HEADER SEGMENT/

SERVICE PROVIDER ID 201-B1

RX_NUMBER

RESPONSE CLAIM SEGMENT/

PRESCRIPTION REFERENCE NUMBER 402-D2

DATE_OF_SERVICE

RESPONSE HEADER SEGMENT/

DATE OF SERVICE 401-D1

TOTAL_BILLED_AMT N/A 430-DU

HAC_CLAIM_NUM

RESPONSE STATUS SEGMENT/

AUTHORIZATION NUMBER 503-F3

CLAIM_STATUS

RESPONSE HEADER SEGMENT/

HEADER RESPONSE STATUS

RESPONSE STATUS SEGMENT/

TRANSACTION RESPONSE STATUS

501-F1

112-AN

eTrans

NCPDP_B1_CLAIM_STATUS

NCPDP Response B1

Segment / Field Name

NCPDP Response B1

Field Number

CHECK_NUM N/A Internal

TOTAL_PAID_AMT N/A 509-F9

AMT_PAID_VENDOR N/A 431-DV

AMT_PAID_PATIENT

PATIENT PAID AMMOUNT (SUBMITTED) 505-F5 OR 433-DX

DED_APPLIED_AMT N/A 517-FH

REJECTED_AMT SAME AS BILLED AMT 430-DU

PATIENT_COSTSHARE

555-AT

ERROR_REJ_CODE

RESPONSE STATUS SEGMENT/

REJECT CODE

(Also populate: RESPONSE STATUS SEGMENT/

REJECT COUNT)

511-FB

(510-FA)

REJ_CODE OTHER PAYER REJECT CODE 476-6E

RESPONSE MESSAGE SEGMENT/

MESSAGE

RESPONSE MESSAGE SEGMENT/

MESSAGE 504-F4

HIC_NUM THERE IS HICN IN PATIENT ID SEG. 332-CY

Reversal

NCPDP NCPDP Field Name Mandatory or Optional Field Name

Source Type

Target Type(ORACLE)

M FILE_NUMBER VARCHAR2(36)

M BATCH_KEY VARCHAR2(36)

701 M SEGMENT_ID VARCHAR2(2)

880-K6 M TRANSM_TYPE VARCHAR2(1)

880-K1 M SENDER_ID VARCHAR2(24)

806-5C M BATCH_NUMBER VARCHAR2(7)

880-K2 M CREATION_DATE VARCHAR2(8)

880-K3 M CREATION_TIME VARCHAR2(4)

702 M FILE_TYPE VARCHAR2(1)

102-A2 M VER_REL_NUMBER VARCHAR2(2)

880-K7 M RECEIVER_ID VARCHAR2(24)

O CREATED_BY VARCHAR2(20)

O DATE_CREATED DATE

O MODIFIED_BY VARCHAR2(20)

O DATE_MODIFIED DATE

M FILE_NUMBER VARCHAR2(36)

Mandatory or Optional Field Name

Source Type

Target Type(ORACLE)

M BATCH_KEY VARCHAR2(36)

M REAL_KEY VARCHAR2(36)

880-K5 M TRANSACTION_REF_NUM VARCHAR2(10)

1Ø1-A1 BIN NUMBER M BIN_NUMBER 9(6) VARCHAR2(6)

1Ø2-A2 VERSION/RELEASE NUMBER M VER_REL_NUM x(2) VARCHAR2(2)

1Ø3-A3 TRANSACTION CODE M TRANSACTION_CODE x(2) VARCHAR2(2)

1Ø4-A4 PROCESSOR CONTROL NUMBER M PRSER_CTL_NUM x(10) VARCHAR2(10)

1Ø9-A9 TRANSACTION COUNT M TRANSACTION_COUNT x(1) VARCHAR2(1)

2Ø2-B2 SERVICE PROVIDER ID QUALIFIER M SVC_PRV_QUAL x(2) VARCHAR2(2)

2Ø1-B1 SERVICE PROVIDER ID M SVC_PRV x(15) VARCHAR2(15)

4Ø1-D1 DATE OF SERVICE M DATE_OF_SERVICE 9(8) VARCHAR2(8)

11Ø-AK

SOFTWARE VENDOR/CERTIFICATION

ID M SW_VDR_CERT_ID x(10) VARCHAR2(10)

O CREATED_BY VARCHAR2(20)

O DATE_CREATED DATE

M REAL_KEY VARCHAR2(36)

M PATIENT_KEY VARCHAR2(36)

111-AM SEGMENT IDENTIFICATION M SEGMENT_ID x(2) VARCHAR2(2)

331-CX PATIENT ID QUALIFIER O PAT_ID_QUAL x(2) VARCHAR2(2)

332-CY PATIENT ID O PAT_ID x(20) VARCHAR2(20)

3Ø4-C4 DATE OF BIRTH O DATE_OF_BIRTH 9(8) VARCHAR2(8)

3Ø5-C5 PATIENT GENDER CODE O PAT_GENDER_CODE 9(1) VARCHAR2(1)

31Ø-CA PATIENT FIRST NAME O PAT_FIRST_NAME x(12) VARCHAR2(12)

311-CB PATIENT LAST NAME O PAT_ LAST_NAME x(15) VARCHAR2(15)

322-CM PATIENT STREET ADDRESS O PAT_STREET_ADDR x(30) VARCHAR2(30)

323-CN PATIENT CITY ADDRESS O PAT_CITY_ADDR x(20) VARCHAR2(20)

324-CO PATIENT STATE / PROVINCE ADDRESS O PAT_STATE_PROV_ADDR x(2) VARCHAR2(2)

Optional Field Name

Source Type

Target Type(ORACLE)

325-CP PATIENT ZIP/POSTAL ZONE O PAT_ZIP_PST_ZONE x(15) VARCHAR2(15)

326-CQ PATIENT PHONE NUMBER O PAT_PHONE_NUM 9(10) VARCHAR2(10)

3Ø7-C7 PATIENT LOCATION O PAT_LOCATION 9(2) VARCHAR2(2)

333-CZ EMPLOYER ID O EMPLOYER_ID x(15) VARCHAR2(15)

334-1C SMOKER / NON-SMOKER CODE O SMKR_NONSMKR_CD x(1) VARCHAR2(1)

335-2C PREGNANCY INDICATOR O PREGNANCY_IND x(1) VARCHAR2(1)

O CREATED_BY VARCHAR2(20)

O DATE_CREATED DATE

M REAL_KEY VARCHAR2(36)

M INSURANCE_KEY VARCHAR2(36)

111-AM SEGMENT IDENTIFICATION M SEGMENT_ID x(2) VARCHAR2(2)

3Ø2-C2 CARDHOLDER ID M CRDHLDR_ID x(20) VARCHAR2(20)

312-CC CARDHOLDER FIRST NAME O CRDHLDR_FIRST_NAME x(12) VARCHAR2(12)

313-CD CARDHOLDER LAST NAME O CRDHLDR_LAST_NAME x(15) VARCHAR2(15)

314-CE HOME PLAN O HOME_PLAN x(3) VARCHAR2(3)

524-FO PLAN ID O PLAN_ID x(8) VARCHAR2(8)

3Ø9-C9 ELIGIBILITY CLARIFICATION CODE O ELIG_CLARIFY_CD 9(1) VARCHAR2(1)

336-8C FACILITY ID O FACILITY_ID x(10) VARCHAR2(10)

3Ø1-C1 GROUP ID O GROUP_ID x(15) VARCHAR2(15)

3Ø3-C3 PERSON CODE O PERSON_CODE x(3) VARCHAR2(3)

3Ø6-C6 PATIENT RELATIONSHIP CODE O PAT_RELSHP_CD 9(1) VARCHAR2(1)

O CREATED_BY VARCHAR2(20)

O DATE_CREATED DATE

M BATCH_KEY VARCHAR2(36)

M REAL_KEY VARCHAR2(36)

M PATIENT_KEY VARCHAR2(36)

M CLAIM_KEY VARCHAR2(36)

111-AM SEGMENT IDENTIFICATION M SEGMENT_ID x(2) VARCHAR2(2)

Optional Field Name

Source Type

Target Type(ORACLE)

455-EM

PRESCRIPTION/SERVICE REFERENCE

NUMBER QUALIFIER M RX_SVC_REF_NUM_QUAL x(1) VARCHAR2(1)

4Ø2-D2

PRESCRIPTION/SERVICE REFERENCE

NUMBER M RX_SVC_REF_NUM 9(9) VARCHAR2(9)

436-E1 PRODUCT/SERVICE ID QUALIFIER M PRODUCT_SVC_ID_QUAL x(2) VARCHAR2(2)

4Ø7-D7 PRODUCT/SERVICE ID M PRODUCT_SVC_ID x(19) VARCHAR2(19)

456-EN

ASSOCIATED PRESCRIPTION/SERVICE

REFERENCE # O ASO_RX_SVC_REF_NUM 9(9) VARCHAR2(9)

457-EP

ASSOCIATED PRESCRIPTION/SERVICE

DATE O ASO_RX_SVC_DATE 9(8) VARCHAR2(8)

458-SE PROCEDURE MODIFIER CODE COUNT O PROC_MOD_CD_COUNT 9(1) VARCHAR2(1)

442-E7 QUANTITY DISPENSED O QUANTITY_DISPENSED 9(7)v999 NUMBER(10,3)

4Ø3-D3 FILL NUMBER O FILL_NUMBER 9(2) VARCHAR2(2)

4Ø5-D5 DAYS SUPPLY O DAYS_SUPPLY 9(3) VARCHAR2(3)

4Ø6-D6 COMPOUND CODE O COMPOUND_CODE 9(1) VARCHAR2(1)

4Ø8-D8

DISPENSE AS WRITTEN

(DAW)/PRODUCT SELECTION CODE O DAW_PRDT_SEL_CD x(1) VARCHAR2(1)

414-DE DATE PRESCRIPTION WRITTEN O DATE_RX_WRITTEN 9(8) VARCHAR2(8)

415-DF NUMBER OF REFILLS AUTHORIZED O NO_OF_REFILS_AUTH 9(2) VARCHAR2(2)

419-DJ PRESCRIPTION ORIGIN CODE O RX_ORIGIN_CD 9(1) VARCHAR2(1)

42Ø-DK SUBMISSION CLARIFICATION CODE O SUB_CLFTN_CD 9(2) VARCHAR2(2)

46Ø-ET QUANTITY PRESCRIBED O QTY_PRESCRIBED 9(7)v999 NUMBER(10,3)

3Ø8-C8 OTHER COVERAGE CODE O OT_CVG_CD 9(2) VARCHAR2(2)

429-DT UNIT DOSE INDICATOR O UNIT_DOSE_IND 9(1) VARCHAR2(1)

Optional Field Name

Source Type

Target Type(ORACLE)

453-EJ

ORIG PRESCRIBED PRODUCT/SERVICE

ID QUALIFIER O ORG_PRS_PRD_SVC_QL x(2) VARCHAR2(2)

445-EA

ORIGINALLY PRESCRIBED

PRODUCT/SERVICE CODE O ORG_PRS_PRD_SVC_CD x(19) VARCHAR2(19)

446-EB ORIGINALLY PRESCRIBED QUANTITY O ORG_PRS_QTY 9(7)v999 NUMBER(10,3)

33Ø- CW ALTERNATE ID O ALTERNATE_ID x(20) VARCHAR2(20)

454-EK

SCHEDULED PRESCRIPTION ID

NUMBER O SCH_RX_ID_NUM x(12) VARCHAR2(12)

6ØØ-28 UNIT OF MEASURE O UNIT_OF_MEASURE x(2) VARCHAR2(2)

418-DI LEVEL OF SERVICE O LEVEL_OF_SERVICE 9(2) VARCHAR2(2)

461-EU PRIOR AUTHORIZATION TYPE CODE O PRIOR_AUTH_TYPE_CD 9(2) VARCHAR2(2)

462-EV

PRIOR AUTHORIZATION NUMBER

SUBMITTED O PRIOR_AUTH_NUM_SUB 9(11) VARCHAR2(11)

463-EW

INTERMEDIARY AUTHORIZATION

TYPE ID O INTMDY_AUTH_TYPE_I 9(2) VARCHAR2(2)

464-EX INTERMEDIARY AUTHORIZATION ID O INTMDY_AUTH_ID x(11) VARCHAR2(11)

343-HD DISPENSING STATUS O DISPENSING_STATUS x(1) VARCHAR2(1)

344-HF

QUANTITY INTENDED TO BE

DISPENSED O QTY_INTD_TB_DISP 9(7)v999 NUMBER(10,3)

345-HG

DAYS SUPPLY INTENDED TO BE

DISPENSED O DAYS_SUP_INTD_DISP 9(3) VARCHAR2(3)

1Ø3-A3

TRANSACTION_HEADER.TRANSACTIO

N CODE M CLAIM_TYPE x(2) VARCHAR2(10)

M STATUS VARCHAR2(20)

O CREATED_BY VARCHAR2(20)

O DATE_CREATED DATE

M PROC_MOD_KEY VARCHAR2(36)

Optional Field Name

Source Type

Target Type(ORACLE)

459-ER PROCEDURE MODIFIER CODE O***R*** PROC_MOD_CD x(2) VARCHAR2(2)

M SEQUENCE_NUM VARCHAR2(3)

O CREATED_BY VARCHAR2(20)

O DATE_CREATED DATE

M DUR_PPS_KEY VARCHAR2(36)

111-AM SEGMENT IDENTIFICATION M SEGMENT_ID x(2) VARCHAR2(2)

473-7E DUR/PPS CODE COUNTER O***R*** DUR_PPS_CD_CTR 9(1) VARCHAR2(1)

439-E4 REASON FOR SERVICE CODE O***R*** REASON_FOR_SVC_CD x(2) VARCHAR2(2)

44Ø-E5 PROFESSIONAL SERVICE CODE O***R*** PRFSN_SVC_CD x(2) VARCHAR2(2)

441-E6 RESULT OF SERVICE CODE O***R*** RESULT_OF_SVC_CD x(2) VARCHAR2(2)

474-8E DUR/PPS LEVEL OF EFFORT O***R*** DUR_PPS_LVL_OF_EFT 9(2) VARCHAR2(2)

475-J9 DUR CO-AGENT ID QUALIFIER O***R*** DUR_COAGENT_ID_QUAL x(2) VARCHAR2(2)

476-H6 DUR CO-AGENT ID O***R*** DUR_COAGENT_ID x(19) VARCHAR2(19)

M SEQUENCE_NUM VARCHAR2(3)

O CREATED_BY VARCHAR2(20)

O DATE_CREATED DATE

M PRICING_KEY VARCHAR2(36)

111-AM SEGMENT IDENTIFICATION M SEGMENT_ID x(2) VARCHAR2(2)

4Ø9-D9 INGREDIENT COST SUBMITTED O INGDT_COST s9(6)v99 NUMBER(8,2)

412-DC DISPENSING FEE SUBMITTED O DISPENSING_FEE_SUB s9(6)v99 NUMBER(8,2)

477-BE

PROFESSIONAL SERVICE FEE

SUBMITTED O PRFSN_SVC_FEE_SUB s9(6)v99 NUMBER(8,2)

433-DX PATIENT PAID AMOUNT SUBMITTED O PAT_PAID_AMT s9(6)v99 NUMBER(8,2)

Optional Field Name

Source Type

Target Type(ORACLE)

438-E3 INCENTIVE AMOUNT SUBMITTED O INCENTIVE_AMT_SUB s9(6)v99 NUMBER(8,2)

478-H7

OTHER AMOUNT CLAIMED

SUBMITTED COUNT O OT_AMT_CLAIM_SUB_CNT 9(1) VARCHAR2(1)

481-HA

FLAT SALES TAX AMOUNT

SUBMITTED O FLAT_SALES_TAX_AMT s9(6)v99 NUMBER(8,2)

482-GE

PERCENTAGE SALES TAX AMOUNT

SUBMITTED O PCT_SLE_TAX_AMT_SUB s9(6)v99 NUMBER(8,2)

483-HE

PERCENTAGE SALES TAX RATE

SUBMITTED O PCT_SLE_TAX_RT_SUB s9(3)v4 NUMBER(7,4)

484-JE

PERCENTAGE SALES TAX BASIS

SUBMITTED O PCT_SLE_TAX_BS_SUB x(2) VARCHAR2(2)

426-DQ USUAL AND CUSTOMARY CHARGE O USUAL_AND_CST_CHG s9(6)v99 NUMBER(8,2)

43Ø-DU GROSS AMOUNT DUE O GROSS_AMT_DUE s9(6)v99 NUMBER(8,2)

423-DN BASIS OF COST DETERMINATION O BASIS_OF_COST_DETM x(2) VARCHAR2(2)

O CREATED_BY VARCHAR2(20)

O DATE_CREATED DATE

M PRICING_KEY VARCHAR2(36)

M OT_AMOUNT_KEY VARCHAR2(36)

479-H8

OTHER AMOUNT CLAIMED

SUBMITTED QUALIFIER O***R***

OT_AMT_CLAIM_SUB_QUA

L x(2) VARCHAR2(2)

48Ø-H9

OTHER AMOUNT CLAIMED

SUBMITTED O***R*** OT_AMT_CLAIM_SUB s9(6)v99 NUMBER(8,2)

M SEQUENCE_NUM VARCHAR2(3)

O CREATED_BY VARCHAR2(20)

O DATE_CREATED DATE

Reversal Response

Numbe r

FIELD

FIEL

D

MMX FIELD NAME

CPS“FAMILIA

R”

FL

D

DATA OUTPUT

FORMAT

“EXAMPLE” DATA

FORMAT

DATA

STAR

T

END FIELD NAME

LE

N

L / R

POS POS

JUSTIFIE

D

1 1 8 Date_Submitted

NA (MMI

Internal)

NUM(YYYYMMD

D) 19990301 Left

2 9 16 Date_Filled Date Of Service

NUM(YYYYMMD

D) 19990301 Left

3 17 28 RX_Number Prescription

Number 12 NUMERIC 6791540 Left

4 29 42 NDC NDC Code 14 NUMERIC 49884016501 Left space fill

5 43 47 Quantity Quantity 5 NUMERIC xxx99 Right

6 48 51 Days_Supply Days Supply 4 NUMERIC 30+(2 spaces) Left space fill

7 52 59 RX_Price (Billed Amt) Amount paid to vendor 8 NUMERIC xxxx9.69

Right space fill

8 60 67 Bene_Copayment Bene Payment 8 NUMERIC xxxx9.69 Right space fill

9 68 74 Pharmacy_NABP Pharmacy Number

7 NUMERIC 2005064 Left

10 75 83 Cardhold_Id (DFN SSN) Bene SSN 9 NUMERIC 528846500 Left

11 84 103 Patient_Last_Name Bene Last

Name 20 ALPHA ROBERTS+ (13 spaces)

Left space fill

12 104 128 Patient_First_Name Bene First

Name 15 ALPHA GAYLE V+ (8 spaces)

Left space fill

13 129 136 Date_Of_Birth Bene DOB 8

NUM(YYYYMMD

D) 19350306 Left

14 137 156 MMI_HAC_Clm

CHAMPVA

Claim Number

20 ALPHA/NUMERIC

C/CHVCJ99999/BNAM

E+ (2 spaces)

Left space fill

15 157 164 MMI_Payment

CHAMPVA

Amt Paid to Vendor

8 NUMERIC xxxx9.69 Right space fill

16 165 174 MMI_Reference_Num

NA (MMI

Internal)

10 NUMERIC 2005064 Left

17 175 181 HAC_Ret_Clm_Num

CHAMPVA

Claim Number 7 ALPHA/NUMERIC CE99999 Left

18 182 189 HAC_Ret_Clm_Date_Paid

CHAMPVA

Claim Date Paid (batch complete dte)

NUM(YYYYMMD

D) 19990305 Left

19 190 197 HAC_Ret_Clm_Paid_Amt

CHAMPVA

Amt Paid to Vendor

8 NUMERIC xxxx9.69 Right space fill

20 198 207 HAC_Ret_Clm_Paid_Check_Num ber

Vendor Treasury

Check Number 10 NUMERIC 99999999xx

Left space fill

21 208 208 Status Code Status 1 NUMERIC 99999999xx Left space fill