Telecommunication_Guide_D.0.pdf

PDF 6 MB Posted Oct 27, 2025

Attached to: DDS RFI 25-70008 Medicare Part D Claims Services
Solicitation number: 0000037087
Issued by: California

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Written by GovTribe AI · Nov 19, 2025

Summary

This is an NCPDP Telecommunication Standard Implementation Guide (Version D.0) technical specification document published by the National Council for Prescription Drug Programs, with application to the California Department of Developmental Services (DDS) Request for Information (RFI 25-70008) concerning Medicare Part D Claims Services. The document provides comprehensive guidelines for implementing standardized electronic formats for pharmacy transaction processing, including claim billing, eligibility verification, prior authorization, service billing, reversals, rebills, and information reporting. The specification addresses transactions between healthcare providers (pharmacies, clinics, hospitals) and adjudicators (insurers, third-party administrators, governmental programs), supporting both provider-to-payer and payer-to-payer communications. The standard defines mandatory, situational, and optional data segments and fields for multiple transaction types, with specific requirements for segment structure, field definitions, character sets, and transmission protocols. Implementation guidance includes business rules for Medicare Part D eligibility transactions, DUR (Drug Utilization Review) processing, coordination of benefits scenarios, and handling of duplicate transactions.

The standard establishes detailed transmission structure requirements including response status codes (Approved, Rejected, Captured, Paid, Deferred, Benefit), pricing formulas, patient financial responsibility calculations, and processing guidelines for complex scenarios such as partial fills, compound prescriptions, and multi-payer coordination of benefits. The document encompasses technical conventions for data formatting, decimal point handling, date formats, repeating field elements, and error reporting with reject codes. Notably, the specification addresses Medicare Part D-specific requirements including True Out-Of-Pocket (TrOOP) facilitation, benefit stage reporting, coverage gap identification, and payer-to-payer communication through a designated Facilitator entity. The guide includes numerous transaction examples, frequently asked questions, and appendices covering ORDUR (Online Real-Time Drug Utilization Review) processing, historical version changes, and data dictionary field deletions, making it a comprehensive technical resource for organizations implementing pharmacy claims processing systems consistent with NCPDP standards.

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DDS_RFI_25-70008_Medicare_Part_D_Claims_Addendum_01.docx	DOCX document	Oct 27, 2025
CRS_Drug_Billing_Extract_Layout.txt	TXT text file	Oct 27, 2025
DDS_RFI_25-70008_Medicare_Part_D_Claims_Services_Final.docx	DOCX document	Oct 27, 2025
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TELECOMMUNICATION STANDARD

IMPLEMENTATION GUIDE

VERSION D.Ø

This document provides guidelines for implementing the NCPDP Telecommunication Standard Format to ensure a consistent implementation of the standard.

Approval Date for ANS: August 7, 2ØØ7

August 2Ø1Ø

National Council for Prescription Drug Programs 924Ø East Raintree Drive Scottsdale, AZ 8526Ø

Phone: (48Ø) 477-1ØØØ Fax: (48Ø) 767-1Ø42 E-mail: ncpdp@ncpdp.org http: www.ncpdp.org

Version D.Ø August 2Ø1Ø

**OFFICIAL RELEASE***

National Council for Prescription Drug Programs, Inc.

Copyrighted Materials - See Copyright Statement for Allowed Use

- 2 -

Telecommunication Standard Implementation Guide Version D.Ø

2ØØ9

This work is owned by National Council for Prescription Drug Programs, Inc., 924Ø E. Raintree Drive, Scottsdale, AZ 8526Ø, (48Ø) 477-1ØØØ, ncpdp@ncpdp.org, and protected by the copyright laws of the United States. 17 U.S.C. §1Ø1,

et. seq. Permission is given to Council members to copy and use the work or any part thereof in connection with the business purposes of the Council members.

The work may not be changed or altered. The work may not be sold, used or exploited for commercial purposes. This permission may be revoked by National Council for Prescription Drug Programs, Inc., at any time. The National Council for Prescription Drugs Programs, Inc. is not responsible for any errors or damage as a result of the use of the work.

NCPDP recognizes the confidentiality of certain information exchanged electronically through the use of its standards.

Users should be familiar with the federal, state, and local laws, regulations and codes requiring confidentiality of this information and should utilize the standards accordingly.

NOTICE: In addition, this NCPDP Standard contains certain data fields and elements that may be completed by users with the proprietary information of third parties. The use and distribution of third parties' proprietary information without such third parties' consent, or the execution of a license or other agreement with such third party, could subject the user to numerous legal claims. All users are encouraged to contact such third parties to determine whether such information is proprietary and if necessary, to consult with legal counsel to make arrangements for the use and distribution of such proprietary information.

Published by:

National Council for Prescription Drug Programs

Publication History:

Version 1.Ø September 1, 1988 Version 2.Ø December 1, 1989 Version 3.1 February 5, 1991

Version 3.2 February 11, 1992 Version 5.Ø June 1999

Version 5.1, September 1999 Version 5.2, May 2ØØØ Version 5.3, June 2ØØØ

Version 5.4, September 2ØØØ Version 5.5, November 2ØØØ

Version 5.6, August 2ØØ1 Version 6.Ø January, 2ØØ2 Version 7.Ø January, 2ØØ2

Version 7.1, June, 2ØØ2 Version 8.Ø February, 2ØØ3 Vers ion 8 .1 August, 2ØØ3 Vers ion 8 .2 October, 2ØØ3 Vers ion 8 .3 October, 2ØØ3

Vers ion 9 .Ø May, 2ØØ4 Version A.Ø August, 2ØØ4 Version A.1 October, 2ØØ4

Version B.Ø May, 2ØØ5 Version C.Ø July, 2ØØ5

Version C.1 October, 2ØØ5 Version C.2 June 2ØØ6

Version C.3 September 2ØØ6 Version C.4 January 2ØØ7

Version D.Ø July, 2ØØ7, August 2ØØ7, November 2ØØ7, July 2ØØ9, August 2Ø1Ø

Telecommunication Standard Implementation Guide Version D.Ø

Version D.Ø Augsut 2Ø1Ø

***OFFICIAL RELEASE***

National Council for Prescription Drug Programs, Inc.

Copyrighted Materials - See Copyright Statement for Allowed Use

- 3 -

TABLE OF CONTENTS

1. INTRODUCTION

1.1 DOCUMENT SCOPE

2. BACKGROUND

3. BUSINESS ENVIRONMENT

3.1 OBJECTIVES

3.2 PARTICIPANTS

3.2.1 Between Providers and Adjudicators

3.2.2 Between Adjudicators (Payer-to-Payer)

4. BUSINESS FUNCTIONS

4.1 INTRODUCTION

4.2 MEDICAID SUBROGATION

5. TERMINOLOGY USED THROUGHOUT

5.1 TABLE DESIGNATION – LEGEND

5.2 TABLE DESIGNATION

5.3 TRANSMISSION DISCUSSION

6. ELIGIBILITY VERIFICATION INFORMATION

6.1 ELIGIBILITY VERIFICATION

6.1.1 Medicare Part D Eligibility

6.1.1.1 Business Rules for Medicare Part D Eligibility Transactions between the Pharmacy and the Facilitator

6.2 ELIGIBILITY VERIFICATION REQUEST DIAGRAMS

6.2.1 Diagram For Transmission Of Eligibility Verification Transaction

6.3 ELIGIBILITY VERIFICATION REQUEST SEGMENTS

6.3.1 Transaction Header Segment (Eligibility Verification)

6.3.2 Insurance Segment (Eligibility Verification)

6.3.3 Patient Segment (Eligibility Verification)

6.3.4 Pharmacy Provider Segment (Eligibility Verification)

6.3.5 Prescriber Segment (Eligibility Verification)

6.3.6 Additional Documentation Segment (Eligibility Verification)

6.4 ELIGIBILITY VERIFICATION RESPONSE DIAGRAMS AND SEGMENTS

6.4.1 Transmission Accepted/Transaction Approved

6.4.1.1 Diagram For Transmission Of Eligibility Verification Response (Transmission Accepted/Transaction Approved)

6.4.1.2 Eligibility Verification Response Segments (Transmission Accepted/Transaction Approved)

6.4.1.2.1 Response Header Segment (Eligibility Verification) (Transmission Accepted/Transaction Approved)

6.4.1.2.2 Response Message Segment (Eligibility Verification) (Transmission Accepted/Transaction Approved)

6.4.1.2.3 Response Insurance Segment (Eligibility Verification) (Transmission Accepted/Transaction Approved)

6.4.1.2.4 Response Insurance Additional Information Segment (Eligibility Verification) (Transmission Accepted/Transaction Approved) 49

6.4.1.2.5 Response Patient Segment (Eligibility Verification) (Transmission Accepted/Transaction Approved)

6.4.1.2.6 Response Status Segment (Eligibility Verification) (Transmission Accepted/Transaction Approved)

6.4.1.2.7 Response Coordination of Benefits/Other Payers Segment (Eligibility Verification) (Transmission Accepted/Transaction Approved) 51

6.4.2 Transmission Accepted/Transaction Rejected

6.4.2.1 Diagram For Transmission Of Eligibility Verification Response (Transmission Accepted/Transaction Rejected)

6.4.2.2 Eligibility Verification Response Segments (Transmission Accepted/Transaction Rejected)

6.4.2.2.1 Response Header Segment (Eligibility Verification) (Transmission Accepted/Transaction Rejected)

6.4.2.2.2 Response Message Segment (Eligibility Verification) (Transmission Accepted/Transaction Rejected)

6.4.2.2.3 Response Insurance Additional Information Segment (Eligibility Verification) (Transmission Accepted/Transaction Rejected) 54

6.4.2.2.4 Response Patient Segment (Eligibility Verification) (Transmission Accepted/Transaction Rejected)

6.4.2.2.5 Response Status Segment (Eligibility Verification) (Transmission Accepted/Transaction Rejected)

6.4.2.2.6 Response Coordination of Benefits/Other Payers Segment (Eligibility Verification) (Transmission Accepted/Transaction Rejected) 56

6.4.3 Transmission Rejected/Transaction Rejected

6.4.3.1 Diagram For Transmission Of Eligibility Verification Response (Transmission Rejected/Transaction Rejected)

6.4.3.2 Eligibility Verification Response Segments (Transmission Rejected/Transaction Rejected)

6.4.3.2.1 Response Header Segment (Eligibility Verification) (Transmission Rejected/Transaction Rejected)

6.4.3.2.2 Response Message Segment (Eligibility Verification) (Transmission Rejected/Transaction Rejected)

6.4.3.2.3 Response Status Segment (Eligibility Verification) (Transmission Rejected/Transaction Rejected)

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7. CLAIM BILLING OR ENCOUNTER INFORMATION

7.1 CLAIM BILLING

7.2 ENCOUNTER

7.2.1 Encounter Diagrams

7.2.1.1 Diagram For Transmission Of One, Two, Three, or Four Encounter Transactions

7.2.1.2 Diagram For Transmission Of One, Two, Three, or Four Encounter Response Transactions

7.3 CLAIM BILLING OR ENCOUNTER REQUEST DIAGRAMS

7.3.1 Diagram For Transmission Of One Claim Billing or Encounter Transaction

7.3.2 Diagram For Transmission of Two Claim Billing or Encounter Transactions

7.3.3 Diagram For Transmission of Three Claim Billing or Encounter Transactions

7.3.4 Diagram For Transmission of Four Claim Billing or Encounter Transactions

7.4 CLAIM BILLING OR ENCOUNTER REQUEST SEGMENTS

7.4.1 Transaction Header Segment (Claim Billing or Encounter)

7.4.2 Insurance Segment (Claim Billing or Encounter)

7.4.2.1 Insurance Segment (Medicaid Subrogation Claim Billing or Encounter)

7.4.3 Patient Segment (Claim Billing or Encounter)

7.4.3.1 Patient Segment (Medicaid Subrogation Claim Billing or Encounter)

7.4.4 Claim Segment (Claim Billing or Encounter)

7.4.4.1 Claim Segment (Medicaid Subrogation Claim Billing or Encounter)

7.4.5 Pricing Segment (Claim Billing or Encounter)

7.4.5.1 Pricing Segment (Medicaid Subrogation Claim Billing or Encounter)

7.4.6 Pharmacy Provider Segment (Claim Billing or Encounter)

7.4.7 Prescriber Segment (Claim Billing or Encounter)

7.4.8 Coordination of Benefits/Other Payments Segment (Claim Billing or Encounter)

7.4.9 Workers’ Compensation Segment (Claim Billing or Encounter)

7.4.10 DUR/PPS Segment (Claim Billing or Encounter)

7.4.11 Coupon Segment (Claim Billing or Encounter)

7.4.12 Compound Segment (Claim Billing or Encounter)

7.4.13 Clinical Segment (Claim Billing or Encounter)

7.4.14 Additional Documentation Segment (Claim Billing or Encounter)

7.4.15 Facility Segment (Claim Billing or Encounter)

7.4.16 Narrative Segment (Claim Billing or Encounter)

7.5 CLAIM BILLING OR ENCOUNTER RESPONSE DIAGRAMS AND SEGMENTS

7.5.1 Transmission Accepted/Transaction Paid

7.5.1.1 Diagram For Transmission of One Claim Billing or Encounter Response (Transmission Accepted/Transaction Paid)

7.5.1.2 Diagram For Transmission of Two Claim Billing Or Encounter Responses (Transmission Accepted/Transaction Paid)

7.5.1.3 Diagram For Transmission of Three Claim Billing Or Encounter Responses (Transmission Accepted/Transaction Paid) ... 83

7.5.1.4 Diagram For Transmission of Four Claim Billing Or Encounter Responses (Transmission Accepted/Transaction Paid)

7.5.1.5 Claim Billing Or Encounter Response Segments (Transmission Accepted/Transaction Paid)

7.5.1.5.1 Response Header Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Paid)

7.5.1.5.2 Response Message Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Paid)

7.5.1.5.3 Response Insurance Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Paid)

7.5.1.5.3.1 Response Insurance Segment (Medicaid Subrogation Claim Billing or Encounter) (Transmission Accepted/Transaction Paid)

7.5.1.5.4 Response Patient Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Paid)

7.5.1.5.5 Response Status Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Paid)

7.5.1.5.6 Response Claim Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Paid)

7.5.1.5.6.1 Response Claim Segment (Medicaid Subrogation Claim Billing or Encounter) (Transmission Accepted/Transaction Paid) 89

7.5.1.5.7 Response Pricing Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Paid)

7.5.1.5.8 Response DUR/PPS Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Paid)

7.5.1.5.9 Response Coordination of Benefits/Other Payers Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Paid)

7.5.2 Transmission Accepted/Transaction Captured

7.5.2.1 Diagram For Transmission of One Claim Billing Or Encounter Response (Transmission Accepted/Transaction Captured) 94

7.5.2.2 Diagram For Transmission of Two Claim Billing or Encounter Responses (Transmission Accepted/Transaction Captured)

7.5.2.3 Diagram For Transmission of Three Claim Billing or Encounter Responses (Transmission Accepted/Transaction Captured)

7.5.2.4 Diagram For Transmission of Four Claim Billing or Encounter Responses (Transmission Accepted/Transaction Captured)

7.5.2.5 Claim Billing or Encounter Response Segments (Transmission Accepted/Transaction Captured)

7.5.2.5.1 Response Header Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Captured)

7.5.2.5.2 Response Message Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Captured)

7.5.2.5.3 Response Insurance Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Captured)

7.5.2.5.3.1 Response Insurance Segment (Medicaid Subrogation Claim Billing or Encounter) (Transmission Accepted/Transaction Captured)

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7.5.2.5.4 Response Patient Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Captured)

7.5.2.5.5 Response Status Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Captured)

7.5.2.5.6 Response Claim Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Captured)

7.5.2.5.7 Response Pricing Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Captured)

7.5.2.5.8 Response DUR/PPS Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Captured)

7.5.3 Transmission Accepted/Transaction Rejected

7.5.3.1 Diagram For Transmission Of One Claim Billing or Encounter Response (Transmission Accepted/Transaction Rejected)

7.5.3.2 Diagram For Transmission Of Two Claim Billing or Encounter Responses (Transmission Accepted/Transaction Rejected)

7.5.3.3 Diagram For Transmission Of Three Claim Billing or Encounter Responses (Transmission Accepted/Transaction Rejected)

7.5.3.4 Diagram For Transmission Of Four Claim Billing or Encounter Responses (Transmission Accepted/Transaction Rejected)

7.5.3.5 Claim Billing or Encounter Response Segments (Transmission Accepted/Transaction Rejected)

7.5.3.5.1 Response Header Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Rejected)

7.5.3.5.2 Response Message Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Rejected)

7.5.3.5.3 Response Insurance Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Rejected)

7.5.3.5.3.1 Response Insurance Segment (Medicaid Subrogation Claim Billing or Encounter) (Transmission Accepted/Transaction Rejected)

7.5.3.5.4 Response Patient Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Rejected)

7.5.3.5.5 Response Status Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Rejected)

7.5.3.5.6 Response Claim Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Rejected)

7.5.3.5.6.1 Response Claim Segment (Medicaid Subrogation Claim Billing or Encounter) (Transmission Accepted/Transaction Rejected) 111

7.5.3.5.7 Response DUR/PPS Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Rejected)

7.5.3.5.8 Response Prior Authorization Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Rejected) . 112

7.5.3.5.9 Response Coordination of Benefits/Other Payers Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Rejected)

7.5.4 Transmission Rejected/Transaction Rejected

7.5.4.1 Diagram For Transmission Of One Claim Billing or Encounter Response (Transmission Rejected/Transaction Rejected)114

7.5.4.2 Diagram For Transmission Of Two Claim Billing or Encounter Responses (Transmission Rejected/Transaction Rejected)

7.5.4.3 Diagram For Transmission Of Three Claim Billing or Encounter Responses (Transmission Rejected/Transaction Rejected)

7.5.4.4 Diagram For Transmission Of Four Claim Billing or Encounter Responses (Transmission Rejected/Transaction Rejected)

7.5.4.5 Claim Billing or Encounter Response Segments (Transmission Rejected/Transaction Rejected)

7.5.4.5.1 Response Header Segment (Claim Billing or Encounter) (Transmission Rejected/Transaction Rejected)

7.5.4.5.2 Response Message Segment (Claim Billing or Encounter) (Transmission Rejected/Transaction Rejected)

7.5.4.5.3 Response Status Segment (Claim Billing or Encounter) (Transmission Rejected/Transaction Rejected)

8. PREDETERMINATION OF BENEFITS INFORMATION

8.1 PREDETERMINATION OF BENEFITS REQUEST DIAGRAMS

8.1.1 Diagram For Transmission Of One Predetermination of Benefits Transaction

8.1.2 Diagram For Transmission Of Two Predetermination of Benefits Transactions

8.1.3 Diagram For Transmission Of Three Or Four Predetermination of Benefits Transactions

8.2 PREDETERMINATION OF BENEFITS REQUEST SEGMENTS

8.2.1 Pricing Segment (Predetermination Of Benefits)

8.3 PREDETERMINATION OF BENEFITS RESPONSE DIAGRAMS AND SEGMENTS

8.3.1 Transmission Accepted/Transaction Benefit

8.3.1.1 Diagram For Transmission of One Predetermination Of Benefit Response (Transmission Accepted/Transaction Benefit)121

8.3.1.2 Diagram For Transmission of Two Predetermination Of Benefit Responses (Transmission Accepted/Transaction Benefit)

8.3.1.3 Diagram For Transmission of Three Or Four Predetermination Of Benefit Responses (Transmission Accepted/Transaction Benefit) 122

8.3.1.4 Predetermination Of Benefits Response Segments (Transmission Accepted/Transaction Benefit)

8.3.1.4.1 Response Pricing Segment (Predetermination Of Benefits) (Transmission Accepted/Transaction Benefit)

8.3.2 Transmission Accepted/Transaction Rejected

8.3.2.1 Diagram For Transmission Of One Predetermination Of Benefits Response (Transmission Accepted/Transaction Rejected)

8.3.2.2 Diagram For Transmission Of Two Predetermination Of Benefits Responses (Transmission Accepted/Transaction Rejected) 124

8.3.2.3 Diagram For Transmission Of Three Or Four Predetermination Of Benefit Responses (Transmission Accepted/Transaction Rejected) 125

8.3.2.4 Predetermination Of Benefits Response Segments (Transmission Accepted/Transaction Rejected)

8.3.3 Transmission Rejected/Transaction Rejected

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8.3.3.1 Diagram For Transmission Of One Predetermination Of Benefits Response (Transmission Rejected/Transaction Rejected)

8.3.3.2 Diagram For Transmission Of Two Predetermination Of Benefits Responses (Transmission Rejected/Transaction Rejected) 125

8.3.3.3 Diagram For Transmission Of Three Or Four Predetermination Of Benefits Responses (Transmission Rejected/Transaction Rejected)

8.3.3.4 Predetermination Of Benefits Response Segments (Transmission Rejected/Transaction Rejected)

9. SERVICE BILLING (PROFESSIONAL PHARMACY SERVICE) INFORMATION

9.1 SERVICE BILLING

9.2 SERVICE BILLING REQUEST DIAGRAMS

9.2.1 Diagram For Transmission Of One Service Billing Transaction

9.2.2 Diagram For Transmission Of Two Service Billing Transactions

9.2.3 Diagram For Transmission Of Three Service Billing Transactions

9.2.4 Diagram For Transmission Of Four Service Billing Transactions

9.3 SERVICE BILLING REQUEST SEGMENTS

9.3.1 Transaction Header Segment (Service Billing)

9.3.2 Insurance Segment (Service Billing)

9.3.3 Patient Segment (Service Billing)

9.3.4 Claim Segment (Service Billing)

9.3.5 Pricing Segment (Service Billing)

9.3.6 Pharmacy Provider Segment (Service Billing)

9.3.7 Prescriber Segment (Service Billing)

9.3.8 Coordination of Benefits /Other Payments Segment (Service Billing)

9.3.9 Workers’ Compensation Segment (Service Billing)

9.3.10 DUR/PPS Segment (Service Billing)

9.3.11 Clinical Segment (Service Billing)

9.3.12 Additional Documentation Segment (Service Billing)

9.3.13 Facility Segment (Service Billing)

9.3.14 Narrative Segment (Service Billing)

9.4 SERVICE BILLING RESPONSE DIAGRAMS AND SEGMENTS

9.4.1 Transmission Accepted/Transaction Paid

9.4.1.1 Diagram For Transmission Of One Service Billing Response (Transmission Accepted/Transaction Paid)

9.4.1.2 Diagram For Transmission Of Two Service Billing Responses (Transmission Accepted/Transaction Paid)

9.4.1.3 Diagram For Transmission Of Three Service Billing Responses (Transmission Accepted/Transaction Paid)

9.4.1.4 Diagram For Transmission Of Four Service Billing Responses (Transmission Accepted/Transaction Paid)

9.4.1.5 Service Billing Response Segments (Transmission Accepted/Transaction Paid)

9.4.1.5.1 Response Header Segment (Service Billing) (Transmission Accepted/Transaction Paid)

9.4.1.5.2 Response Message Segment (Service Billing) (Transmission Accepted/Transaction Paid)

9.4.1.5.3 Response Insurance Segment (Service Billing) (Transmission Accepted/Transaction Paid)

9.4.1.5.4 Response Patient Segment (Service Billing) (Transmission Accepted/Transaction Paid)

9.4.1.5.5 Response Status Segment (Service Billing) (Transmission Accepted/Transaction Paid)

9.4.1.5.6 Response Claim Segment (Service Billing) (Transmission Accepted/Transaction Paid)

9.4.1.5.7 Response Pricing Segment (Service Billing) (Transmission Accepted/Transaction Paid)

9.4.1.5.8 Response DUR/PPS Segment (Service Billing) (Transmission Accepted/Transaction Paid)

9.4.1.5.9 Response Coordination of Benefits/Other Payers Segment (Service Billing) (Transmission Accepted/Transaction Paid)

9.4.2 Transmission Accepted/Transaction Captured

9.4.2.1 Diagram For Transmission Of One Service Billing Response (Transmission Accepted/Transaction Captured)

9.4.2.2 Diagram For Transmission Of Two Service Billing Responses (Transmission Accepted/Transaction Captured)

9.4.2.3 Diagram For Transmission Of Three Service Billing Responses (Transmission Accepted/Transaction Captured)

9.4.2.4 Diagram For Transmission Of Four Service Billing Responses (Transmission Accepted/Transaction Captured)

9.4.2.5 Service Billing Response Segments (Transmission Accepted/Transaction Captured)

9.4.2.5.1 Response Header Segment (Service Billing) (Transmission Accepted/Transaction Captured)

9.4.2.5.2 Response Message Segment (Service Billing) (Transmission Accepted/Transaction Captured)

9.4.2.5.3 Response Insurance Segment (Service Billing) (Transmission Accepted/Transaction Captured)

9.4.2.5.4 Response Patient Segment (Service Billing) (Transmission Accepted/Transaction Captured)

9.4.2.5.5 Response Status Segment (Service Billing) (Transmission Accepted/Transaction Captured)

9.4.2.5.6 Response Claim Segment (Service Billing) (Transmission Accepted/Transaction Captured)

9.4.2.5.7 Response Pricing Segment (Service Billing) (Transmission Accepted/Transaction Captured)

9.4.3 Transmission Accepted/Transaction Rejected

9.4.3.1 Diagram for Transmission Of One Service Billing Response (Transmission Accepted/Transaction Rejected)

9.4.3.2 Diagram for Transmission Of Two Service Billing Responses (Transmission Accepted/Transaction Rejected)

9.4.3.3 Diagram for Transmission Of Three Service Billing Responses (Transmission Accepted/Transaction Rejected)

9.4.3.4 Diagram for Transmission Of Four Service Billing Responses (Transmission Accepted/Transaction Rejected)

9.4.3.5 Service Billing Response Segments (Transmission Accepted/Transaction Rejected)

9.4.3.5.1 Response Header Segment (Service Billing) (Transmission Accepted/Transaction Rejected)

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9.4.3.5.2 Response Message Segment (Service Billing) (Transmission Accepted/Transaction Rejected)

9.4.3.5.3 Response Insurance Segment (Service Billing) (Transmission Accepted/Transaction Rejected)

9.4.3.5.4 Response Patient Segment (Service Billing) (Transmission Accepted/Transaction Rejected)

9.4.3.5.5 Response Status Segment (Service Billing) (Transmission Accepted/Transaction Rejected)

9.4.3.5.6 Response Claim Segment (Service Billing) (Transmission Accepted/Transaction Rejected)

9.4.3.5.7 Response Prior Authorization Segment (Service Billing) (Transmission Accepted/Transaction Rejected)

9.4.3.5.8 Response Coordination of Benefits/Other Payers Segment (Service Billing) (Transmission Accepted/Transaction Rejected) 171

9.4.4 Transmission Rejected/Transaction Rejected

9.4.4.1 Diagram For Transmission Of One Service Billing Response (Transmission Rejected/Transaction Rejected)

9.4.4.2 Diagram For Transmission Of Two Service Billing Responses (Transmission Rejected/Transaction Rejected)

9.4.4.3 Diagram For Transmission Of Three Service Billing Responses (Transmission Rejected/Transaction Rejected)

9.4.4.4 Diagram For Transmission Of Four Service Billing Responses (Transmission Rejected/Transaction Rejected)

9.4.4.5 Service Billing Response Segments (Transmission Rejected/Transaction Rejected)

9.4.4.5.1 Response Header Segment (Service Billing) (Transmission Rejected/Transaction Rejected)

9.4.4.5.2 Response Message Segment (Service Billing) (Transmission Rejected/Transaction Rejected)

9.4.4.5.3 Response Status Segment (Service Billing) (Transmission Rejected/Transaction Rejected)

10. REVERSAL INFORMATION

10.1 CLAIM OR SERVICE REVERSAL

10.2 CLAIM REVERSAL REQUEST DIAGRAMS

10.2.1 Diagram For Transmission Of One Claim Reversal Transaction

10.2.2 Diagram For Transmission Of Two Claim Reversal Transactions

10.2.3 Diagram For Transmission Of Three Claim Reversal Transactions

10.2.4 Diagram For Transmission Of Four Claim Reversal Transactions

10.3 CLAIM REVERSAL REQUEST SEGMENTS

10.3.1 Transaction Header Segment (Claim Reversal)

10.3.2 Insurance Segment (Claim Reversal)

10.3.2.1 Insurance Segment (Medicaid Subrogation Claim Reversal)

10.3.3 Claim Segment (Claim Reversal)

10.3.4 DUR/PPS Segment (Claim Reversal)

10.3.5 Pricing Segment (Claim Reversal)

10.3.5.1 Example 1: Reporting a DUR event on a Claim Reversal without any incentive submitted

10.3.5.2 Example 2: No Incentive Amount Submitted (438-E3) for a Claim Reversal. Incentive Paid

10.3.5.3 Example 3: Incentive Amount Submitted (438-E3) for a Claim Reversal

10.3.5.4 Example 4: Incentive Amount Submitted (438-E3) for a Claim Reversal

10.3.6 Coordination of Benefits/Other Payments Segment (Claim Reversal)

10.3.6.1 Coordination of Benefits/Other Payments Segment Usage in Claim Reversal

10.3.6.1.1 Excerpt Example 1

10.3.6.1.2 Excerpt Example 2

10.4 CLAIM REVERSAL RESPONSE DIAGRAMS AND SEGMENTS

10.4.1 Transmission Accepted/Transaction Approved

10.4.1.1 Diagram For Transmission Of One Claim Reversal Response (Transmission Accepted/Transaction Approved)

10.4.1.2 Diagram For Transmission Of Two Claim Reversal Responses (Transmission Accepted/Transaction Approved)

10.4.1.3 Diagram For Transmission Of Three Claim Reversal Responses (Transmission Accepted/Transaction Approved)

10.4.1.4 Diagram For Transmission Of Four Claim Reversal Responses (Transmission Accepted/Transaction Approved)

10.4.1.5 Claim Reversal Response Segments (Transmission Accepted/Transaction Approved)

10.4.1.5.1 Response Header Segment (Claim Reversal) (Transmission Accepted/Transaction Approved)

10.4.1.5.2 Response Message Segment (Claim Reversal) (Transmission Accepted/Transaction Approved)

10.4.1.5.3 Response Status Segment (Claim Reversal) (Transmission Accepted/Transaction Approved)

10.4.1.5.4 Response Claim Segment (Claim Reversal) (Transmission Accepted/Transaction Approved)

10.4.1.5.4.1 Response Claim Segment (Medicaid Subrogation Claim Reversal) (Transmission Accepted/Transaction Approved) 191

10.4.1.5.5 Response Pricing Segment (Claim Reversal) (Transmission Accepted/Transaction Approved)

10.4.2 Transmission Accepted/Transaction Captured

10.4.2.1 Diagram For Transmission Of One Claim Reversal Response (Transmission Accepted/Transaction Captured)

10.4.2.2 Diagram For Transmission Of Two Claim Reversal Responses (Transmission Accepted/Transaction Captured)

10.4.2.3 Diagram For Transmission Of Three Claim Reversal Responses (Transmission Accepted/Transaction Captured)

10.4.2.4 Diagram For Transmission Of Four Claim Reversal Responses (Transmission Accepted/Transaction Captured)

10.4.2.5 Claim Reversal Response Segments (Transmission Accepted/Transaction Captured)

10.4.2.5.1 Response Header Segment (Claim Reversal) (Transmission Accepted/Transaction Captured)

10.4.2.5.2 Response Message Segment (Claim Reversal) (Transmission Accepted/Transaction Captured)

10.4.2.5.3 Response Status Segment (Claim Reversal) (Transmission Accepted/Transaction Captured)

10.4.2.5.4 Response Claim Segment (Claim Reversal) (Transmission Accepted/Transaction Captured)

10.4.3 Transmission Accepted/Transaction Rejected

10.4.3.1 Diagram For Transmission Of One Claim Reversal Response (Transmission Accepted/Transaction Rejected)

10.4.3.2 Diagram For Transmission Of Two Claim Reversal Responses (Transmission Accepted/Transaction Rejected)

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10.4.3.3 Diagram For Transmission Of Three Claim Reversal Responses (Transmission Accepted/Transaction Rejected)

10.4.3.4 Diagram For Transmission Of Four Claim Reversal Responses (Transmission Accepted/Transaction Rejected)

10.4.3.5 Claim Reversal Response Segments (Transmission Accepted/Transaction Rejected)

10.4.3.5.1 Response Header Segment (Claim Reversal) (Transmission Accepted/Transaction Rejected)

10.4.3.5.2 Response Message Segment (Claim Reversal) (Transmission Accepted/Transaction Rejected)

10.4.3.5.3 Response Status Segment (Claim Reversal) (Transmission Accepted/Transaction Rejected)

10.4.3.5.4 Response Claim Segment (Claim Reversal) (Transmission Accepted/Transaction Rejected)

10.4.4 Transmission Rejected/Transaction Rejected

10.4.4.1 Diagram For Transmission Of One Claim Reversal Response (Transmission Rejected/Transaction Rejected)

10.4.4.2 Diagram For Transmission Of Two Claim Reversal Responses (Transmission Rejected/Transaction Rejected)

10.4.4.3 Diagram For Transmission Of Three Claim Reversal Responses (Transmission Rejected/Transaction Rejected)

10.4.4.4 Diagram For Transmission Of Four Claim Reversal Responses (Transmission Rejected/Transaction Rejected)

10.4.4.5 Claim Reversal Response Segments (Transmission Rejected/Transaction Rejected)

10.4.4.5.1 Response Header Segment (Claim Reversal) (Transmission Rejected/Transaction Rejected)

10.4.4.5.2 Response Message Segment (Claim Reversal) (Transmission Rejected/Transaction Rejected)

10.4.4.5.3 Response Status Segment (Claim Reversal) (Transmission Rejected/Transaction Rejected)

10.5 SERVICE REVERSAL REQUEST DIAGRAMS

10.5.1 Diagram For Transmission Of One Service Reversal Transaction

10.5.2 Diagram For Transmission Of Two Service Reversal Transactions

10.5.3 Diagram For Transmission Of Three Service Reversal Transactions

10.5.4 Diagram For Transmission Of Four Service Reversal Transactions

10.6 SERVICE REVERSAL REQUEST SEGMENTS

10.6.1 Transaction Header Segment (Service Reversal)

10.6.2 Insurance Segment (Service Reversal)

10.6.3 Claim Segment (Service Reversal)

10.6.4 Coordination of Benefits/Other Payments Segment (Service Reversal)

10.6.4.1 Coordination of Benefits/Other Payments Segment Usage in Service Reversal

10.6.4.1.1 Excerpt Example 1

10.6.4.1.2 Excerpt Example 2

10.7 SERVICE REVERSAL RESPONSE DIAGRAMS AND SEGMENTS

10.7.1 Transmission Accepted/Transaction Approved

10.7.1.1 Diagram For Transmission Of One Service Reversal Response (Transmission Accepted/Transaction Approved)

10.7.1.2 Diagram For Transmission Of Two Service Reversal Responses (Transmission Accepted/Transaction Approved)

10.7.1.3 Diagram For Transmission Of Three Service Reversal Responses (Transmission Accepted/Transaction Approved)

10.7.1.4 Diagram For Transmission Of Four Service Reversal Responses (Transmission Accepted/Transaction Approved)

10.7.1.5 Service Reversal Response Segments (Transmission Accepted/Transaction Approved)

10.7.1.5.1 Response Header Segment (Service Reversal) (Transmission Accepted/Transaction Approved)

10.7.1.5.2 Response Message Segment (Service Reversal) (Transmission Accepted/Transaction Approved)

10.7.1.5.3 Response Status Segment (Service Reversal) (Transmission Accepted/Transaction Approved)

10.7.1.5.4 Response Claim Segment (Service Reversal) (Transmission Accepted/Transaction Approved)

10.7.2 Transmission Accepted/Transaction Captured

10.7.2.1 Diagram For Transmission Of One Service Reversal Response (Transmission Accepted/Transaction Captured)

10.7.2.2 Diagram For Transmission Of Two Service Reversal Responses (Transmission Accepted/Transaction Captured)

10.7.2.3 Diagram For Transmission Of Three Service Reversal Responses (Transmission Accepted/Transaction Captured)

10.7.2.4 Diagram For Transmission Of Four Service Reversal Responses (Transmission Accepted/Transaction Captured)

10.7.2.5 Service Reversal Response Segments (Transmission Accepted/Transaction Captured)

10.7.2.5.1 Response Header Segment (Service Reversal) (Transmission Accepted/Transaction Captured)

10.7.2.5.2 Response Message Segment (Service Reversal) (Transmission Accepted/Transaction Captured)

10.7.2.5.3 Response Status Segment (Service Reversal) (Transmission Accepted/Transaction Captured)

10.7.2.5.4 Response Claim Segment (Service Reversal) (Transmission Accepted/Transaction Captured)

10.7.3 Transmission Accepted/Transaction Rejected

10.7.3.1 Diagram For Transmission Of One Service Reversal Response (Transmission Accepted/Transaction Rejected)

10.7.3.2 Diagram For Transmission Of Two Service Reversal Responses (Transmission Accepted/Transaction Rejected)

10.7.3.3 Diagram For Transmission Of Three Service Reversal Responses (Transmission Accepted/Transaction Rejected)

10.7.3.4 Diagram For Transmission Of Four Service Reversal Responses (Transmission Accepted/Transaction Rejected)

10.7.3.5 Service Reversal Response Segments (Transmission Accepted/Transaction Rejected)

10.7.3.5.1 Response Header Segment (Service Reversal) (Transmission Accepted/Transaction Rejected)

10.7.3.5.2 Response Message Segment (Service Reversal) (Transmission Accepted/Transaction Rejected)

10.7.3.5.3 Response Status Segment (Service Reversal) (Transmission Accepted/Transaction Rejected)

10.7.3.5.4 Response Claim Segment (Service Reversal) (Transmission Accepted/Transaction Rejected)

10.7.4 Transmission Rejected/Transaction Rejected

10.7.4.1 Diagram For Transmission Of One Service Reversal Response (Transmission Rejected/Transaction Rejected)

10.7.4.2 Diagram For Transmission Of Two Service Reversal Responses (Transmission Rejected/Transaction Rejected)

10.7.4.3 Diagram For Transmission Of Three Service Reversal Responses (Transmission Rejected/Transaction Rejected)

10.7.4.4 Diagram For Transmission Of Four Service Reversal Responses (Transmission Rejected/Transaction Rejected)

10.7.4.5 Service Reversal Response Segments (Transmission Rejected/Transaction Rejected)

10.7.4.5.1 Response Header Segment (Service Reversal) (Transmission Rejected/Transaction Rejected)

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10.7.4.5.2 Response Message Segment (Service Reversal) (Transmission Rejected/Transaction Rejected)

10.7.4.5.3 Response Status Segment (Service Reversal) (Transmission Rejected/Transaction Rejected)

11. REBILL INFORMATION

11.1 CLAIM OR SERVICE REBILL

11.2 CLAIM REBILL REQUEST DIAGRAMS

11.2.1 Diagram For Transmission Of One Claim Rebill Transaction

11.2.2 Diagram For Transmission Of Two Claim Rebill Transactions

11.2.3 Diagram For Transmission Of Three Claim Rebill Transactions

11.2.4 Diagram For Transmission Of Four Claim Rebill Transactions

11.3 CLAIM REBILL REQUEST SEGMENTS

11.3.1 Transaction Header Segment (Claim Rebill)

11.3.2 Insurance Segment (Claim Rebill)

11.3.2.1 Insurance Segment (Medicaid Subrogation Claim Rebill)

11.3.3 Patient Segment (Claim Rebill)

11.3.3.1 Patient Segment (Medicaid Subrogation Claim Rebill)

11.3.4 Claim Segment (Claim Rebill)

11.3.4.1 Claim Segment (Medicaid Subrogation Claim Rebill)

11.3.5 Pricing Segment (Claim Rebill)

11.3.5.1 Pricing Segment (Medicaid Subrogation Claim Rebill)

11.3.6 Pharmacy Provider Segment (Claim Rebill)

11.3.7 Prescriber Segment (Claim Rebill)

11.3.8 Coordination of Benefits/Other Payments Segment (Claim Rebill)

11.3.9 Workers’ Compensation Segment (Claim Rebill)

11.3.10 DUR/PPS Segment (Claim Rebill)

11.3.11 Coupon Segment (Claim Rebill)

11.3.12 Compound Segment (Claim Rebill)

11.3.13 Clinical Segment (Claim Rebill)

11.3.14 Additional Documentation Segment (Claim Rebill)

11.3.15 Facility Segment (Claim Rebill)

11.3.16 Narrative Segment (Claim Rebill)

11.4 CLAIM REBILL RESPONSE DIAGRAMS AND SEGMENTS

11.4.1 Transmission Accepted/Transaction Paid

11.4.1.1 Diagram For Transmission of One Claim Rebill Response (Transmission Accepted/Transaction Paid)

11.4.1.2 Diagram For Transmission of Two Claim Rebill Responses (Transmission Accepted/Transaction Paid)

11.4.1.3 Diagram For Transmission of Three Claim Rebill Responses (Transmission Accepted/Transaction Paid)

11.4.1.4 Diagram For Transmission of Four Claim Rebill Responses (Transmission Accepted/Transaction Paid)

11.4.2 Claim Rebill Response Segments (Transmission Accepted/Transaction Paid)

11.4.2.1.1 Response Header Segment (Claim Rebill) (Transmission Accepted/Transaction Paid)

11.4.2.1.2 Response Message Segment (Claim Rebill) (Transmission Accepted/Transaction Paid)

11.4.2.1.3 Response Insurance Segment (Claim Rebill) (Transmission Accepted/Transaction Paid)

11.4.2.1.3.1 Response Insurance Segment (Medicaid Subrogation Claim Rebill) (Transmission Accepted/Transaction Paid)253

11.4.2.1.4 Response Patient Segment (Claim Rebill) (Transmission Accepted/Transaction Paid)

11.4.2.1.5 Response Status Segment (Claim Rebill) (Transmission Accepted/Transaction Paid)

11.4.2.1.6 Response Claim Segment (Claim Rebill) (Transmission Accepted/Transaction Paid)

11.4.2.1.6.1 Response Claim Segment (Medicaid Subrogation Claim Rebill) (Transmission Accepted/Transaction Paid)

11.4.2.1.7 Response Pricing Segment (Claim Rebill) (Transmission Accepted/Transaction Paid)

11.4.2.1.8 Response DUR/PPS Segment (Claim Rebill) (Transmission Accepted/Transaction Paid)

11.4.2.1.9 Response Coordination of Benefits/Other Payers Segment (Claim Rebill) (Transmission Accepted/Transaction Paid)

11.4.3 Transmission Accepted/Transaction Captured

11.4.3.1 Diagram For Transmission of One Claim Rebill Response (Transmission Accepted/Transaction Captured)

11.4.3.2 Diagram For Transmission of Two Claim Rebill Responses (Transmission Accepted/Transaction Captured)

11.4.3.3 Diagram For Transmission of Three Claim Rebill Responses (Transmission Accepted/Transaction Captured)

11.4.3.4 Diagram For Transmission of Four Claim Rebill Responses (Transmission Accepted/Transaction Captured)

11.4.3.5 Claim Rebill Response Segments (Transmission Accepted/Transaction Captured)

11.4.3.5.1 Response Header Segment (Claim Rebill) (Transmission Accepted/Transaction Captured)

11.4.3.5.2 Response Message Segment (Claim Rebill) (Transmission Accepted/Transaction Captured)

11.4.3.5.3 Response Insurance Segment (Claim Rebill) (Transmission Accepted/Transaction Captured)

11.4.3.5.3.1 Response Insurance Segment (Medicaid Subrogation Claim Rebill) (Transmission Accepted/Transaction Captured) 264

11.4.3.5.4 Response Patient Segment (Claim Rebill) (Transmission Accepted/Transaction Captured)

11.4.3.5.5 Response Status Segment (Claim Rebill) (Transmission Accepted/Transaction Captured)

11.4.3.5.6 Response Claim Segment (Claim Rebill) (Transmission Accepted/Transaction Captured)

11.4.3.5.7 Response Pricing Segment (Claim Rebill) (Transmission Accepted/Transaction Captured)

11.4.3.5.8 Response DUR/PPS Segment (Claim Rebill) (Transmission Accepted/Transaction Captured)

11.4.4 Transmission Accepted/Transaction Rejected

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11.4.4.1 Diagram For Transmission Of One Claim Rebill Response (Transmission Accepted/Transaction Rejected)

11.4.4.2 Diagram For Transmission Of Two Claim Rebill Responses (Transmission Accepted/Transaction Rejected)

11.4.4.3 Diagram For Transmission Of Three Claim Rebill Responses (Transmission Accepted/Transaction Rejected)

11.4.4.4 Diagram For Transmission Of Four Claim Rebill Responses (Transmission Accepted/Transaction Rejected)

11.4.4.5 Claim Rebill Response Segments (Transmission Accepted/Transaction Rejected)

11.4.4.5.1 Response Header Segment (Claim Rebill) (Transmission Accepted/Transaction Rejected)

11.4.4.5.2 Response Message Segment (Claim Rebill) (Transmission Accepted/Transaction Rejected)

11.4.4.5.3 Response Insurance Segment (Claim Rebill) (Transmission Accepted/Transaction Rejected)

11.4.4.5.3.1 Response Insurance Segment (Medicaid Subrogation Claim Rebill) (Transmission Accepted/Transaction Rejected) 275

11.4.4.5.4 Response Patient Segment (Claim Rebill) (Transmission Accepted/Transaction Rejected)

11.4.4.5.5 Response Status Segment (Claim Rebill) (Transmission Accepted/Transaction Rejected)

11.4.4.5.6 Response Claim Segment (Claim Rebill) (Transmission Accepted/Transaction Rejected)

11.4.4.5.7 Response DUR/PPS Segment (Claim Rebill) (Transmission Accepted/Transaction Rejected)

11.4.4.5.8 Response Prior Authorization Segment (Claim Rebill) (Transmission Accepted/Transaction Rejected)

11.4.4.5.9 Response Coordination of Benefits/Other Payers Segment (Claim Rebill) (Transmission Accepted/Transaction Rejected) 278

11.4.5 Transmission Rejected/Transaction Rejected

11.4.5.1 Diagram For Transmission Of One Claim Rebill Response (Transmission Rejected/Transaction Rejected)

11.4.5.2 Diagram For Transmission Of Two Claim Rebill Responses (Transmission Rejected/Transaction Rejected)

11.4.5.3 Diagram For Transmission Of Three Claim Rebill Responses (Transmission Rejected/Transaction Rejected)

11.4.5.4 Diagram For Transmission Of Four Claim Rebill Responses (Transmission Rejected/Transaction Rejected)

11.4.5.5 Claim Rebill Response Segments (Transmission Rejected/Transaction Rejected)

11.4.5.5.1 Response Header Segment (Claim Rebill) (Transmission Rejected/Transaction Rejected)

11.4.5.5.2 Response Message Segment (Claim Rebill) (Transmission Rejected/Transaction Rejected)

11.4.5.5.3 Response Status Segment (Claim Rebill) (Transmission Rejected/Transaction Rejected)

11.5 SERVICE REBILL REQUEST DIAGRAMS

11.5.1.1 Diagram For Transmission Of One Service Rebill Transaction

11.5.1.2 Diagram For Transmission Of Two Service Rebill Transactions

11.5.1.3 Diagram For Transmission Of Three Service Rebill Transactions

11.5.1.4 Diagram For Transmission Of Four Service Rebill Transactions

11.6 SERVICE REBILL REQUEST SEGMENTS

11.6.1 Transaction Header Segment (Service Rebill)

11.6.2 Insurance Segment (Service Rebill)

11.6.3 Patient Segment (Service Rebill)

11.6.4 Claim Segment (Service Rebill)

11.6.5 Pricing Segment (Service Rebill)

11.6.6 Pharmacy Provider Segment (Service Rebill)

11.6.7 Prescriber Segment (Service Rebill)

11.6.8 Coordination of Benefits/Other Payments Segment (Service Rebill)

11.6.9 Workers’ Compensation Segment (Service Rebill)

11.6.10 DUR/PPS Segment (Service Rebill)

11.6.11 Clinical Segment (Service Rebill)

11.6.12 Additional Documentation Segment (Service Rebill)

11.6.13 Facility Segment (Service Rebill)

11.6.14 Narrative Segment (Service Rebill)

11.7 SERVICE REBILL RESPONSE DIAGRAMS AND SEGMENTS

11.7.1 Transmission Accepted/Transaction Paid

11.7.1.1 Diagram For Transmission Of One Service Rebill Response (Transmission Accepted/Transaction Paid)

11.7.1.2 Diagram For Transmission Of Two Service Rebill Responses (Transmission Accepted/Transaction Paid)

11.7.1.3 Diagram For Transmission Of Three Service Rebill Responses (Transmission Accepted/Transaction Paid)

11.7.1.4 Diagram For Transmission Of Four Service Rebill Responses (Transmission Accepted/Transaction Paid)

11.7.1.5 Service Rebill Response Segments (Transmission Accepted/Transaction Paid)

11.7.1.5.1 Response Header Segment (Service Rebill) (Transmission Accepted/Transaction Paid)

11.7.1.5.2 Response Message Segment (Service Rebill) (Transmission Accepted/Transaction Paid)

11.7.1.5.3 Response Insurance Segment (Service Rebill) (Transmission Accepted/Transaction Paid)

11.7.1.5.4 Response Patient Segment (Service Rebill) (Transmission Accepted/Transaction Paid)

11.7.1.5.5 Response Status Segment (Service Rebill) (Transmission Accepted/Transaction Paid)

11.7.1.5.6 Response Claim Segment (Service Rebill) (Transmission Accepted/Transaction Paid)

11.7.1.5.7 Response Pricing Segment (Service Rebill) (Transmission Accepted/Transaction Paid)

11.7.1.5.8 Response DUR/PPS Segment (Service Rebill) (Transmission Accepted/Transaction Paid)

11.7.1.5.9 Response Coordination of Benefits/Other Payers Segment (Service Rebill) (Transmission Accepted/Transaction Paid)

11.7.2 Transmission Accepted/Transaction Captured

11.7.2.1 Diagram For Transmission Of One Service Rebill Response (Transmission Accepted/Transaction Captured)

11.7.2.2 Diagram For Transmission Of Two Service Rebill Responses (Transmission Accepted/Transaction Captured)

11.7.2.3 Diagram For Transmission Of Three Service Rebill Responses (Transmission Accepted/Transaction Captured)

11.7.2.4 Diagram For Transmission Of Four Service Rebill Responses (Transmission Accepted/Transaction Captured)

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11.7.2.5 Service Rebill Response Segments (Transmission Accepted/Transaction Captured)

11.7.2.5.1 Response Header Segment (Service Rebill) (Transmission Accepted/Transaction Captured)

11.7.2.5.2 Response Message Segment (Service Rebill) (Transmission Accepted/Transaction Captured)

11.7.2.5.3 Response Insurance Segment (Service Rebill) (Transmission Accepted/Transaction Captured)

11.7.2.5.4 Response Patient Segment (Service Rebill) (Transmission Accepted/Transaction Captured)

11.7.2.5.5 Response Status Segment (Service Rebill) (Transmission Accepted/Transaction Captured)

11.7.2.5.6 Response Claim Segment (Service Rebill) (Transmission Accepted/Transaction Captured)

11.7.2.5.7 Response Pricing Segment (Service Rebill) (Transmission Accepted/Transaction Captured)

11.7.3 Transmission Accepted/Transaction Rejected

11.7.3.1 Diagram for Transmission Of One Service Rebill Response (Transmission Accepted/Transaction Rejected)

11.7.3.2 Diagram for Transmission Of Two Service Rebill Responses (Transmission Accepted/Transaction Rejected)

11.7.3.3 Diagram for Transmission Of Three Service Rebill Responses (Transmission Accepted/Transaction Rejected)

11.7.3.4 Diagram for Transmission Of Four Service Rebill Responses (Transmission Accepted/Transaction Rejected)

11.7.3.5 Service Rebill Response Segments (Transmission Accepted/Transaction Rejected)

11.7.3.5.1 Response Header Segment (Service Rebill) (Transmission Accepted/Transaction Rejected)

11.7.3.5.2 Response Message Segment (Service Rebill) (Transmission Accepted/Transaction Rejected)

11.7.3.5.3 Response Insurance Segment (Service Rebill) (Transmission Accepted/Transaction Rejected)

11.7.3.5.4 Response Patient Segment (Service Rebill) (Transmission Accepted/Transaction Rejected)

11.7.3.5.5 Response Status Segment (Service Rebill) (Transmission Accepted/Transaction Rejected)

11.7.3.5.6 Response Claim Segment (Service Rebill) (Transmission Accepted/Transaction Rejected)

11.7.3.5.7 Response Prior Authorization Segment (Service Rebill) (Transmission Accepted/Transaction Rejected)

11.7.3.5.8 Response Coordination of Benefits/Other Payers Segment (Service Rebill) (Transmission Accepted/Transaction Rejected) 325

11.7.4 Transmission Rejected/Transaction Rejected

11.7.4.1 Diagram For Transmission Of One Service Rebill Response (Transmission Rejected/Transaction Rejected)

11.7.4.2 Diagram For Transmission Of Two Service Rebill Responses (Transmission Rejected/Transaction Rejected)

11.7.4.3 Diagram For Transmission Of Three Service Rebill Responses (Transmission Rejected/Transaction Rejected)

11.7.4.4 Diagram For Transmission Of Four Service Rebill Responses (Transmission Rejected/Transaction Rejected)

11.7.4.5 Service Rebill Response Segments (Transmission Rejected/Transaction Rejected)

11.7.4.5.1 Response Header Segment (Service Rebill) (Transmission Rejected/Transaction Rejected)

11.7.4.5.2 Response Message Segment (Service Rebill) (Transmission Rejected/Transaction Rejected)

11.7.4.5.3 Response Status Segment (Service Rebill) (Transmission Rejected/Transaction Rejected)

12. PRIOR AUTHORIZATION INFORMATION

13. PRIOR AUTHORIZATION REQUEST AND BILLING INFORMATION

13.1 PRIOR AUTHORIZATION REQUEST AND BILLING REQUEST DIAGRAMS

13.1.1 Diagram For Transmission Of One Prior Authorization Request And Billing Transaction

13.2 PRIOR AUTHORIZATION REQUEST AND BILLING REQUEST SEGMENTS

13.2.1 Transaction Header Segment (Prior Authorization Request And Billing)

13.2.2 Insurance Segment (Prior Authorization Request And Billing)

13.2.3 Patient Segment (Prior Authorization Request And Billing)

13.2.4 Claim Segment (Prior Authorization Request And Billing)

13.2.5 Pricing Segment (Prior Authorization Request And Billing)

13.2.6 Prior Authorization Segment (Prior Authorization Request And Billing)

13.2.7 Pharmacy Provider Segment (Prior Authorization Request And Billing)

13.2.8 Prescriber Segment (Prior Authorization Request And Billing)

13.2.9 Coordination of Benefits/Other Payments Segment (Prior Authorization Request And Billing)

13.2.10 Workers’ Compensation Segment (Prior Authorization Request And Billing)

13.2.11 DUR/PPS Segment (Prior Authorization Request And Billing)

13.2.12 Compound Segment (Prior Authorization Request And Billing)

13.2.13 Clinical Segment (Prior Authorization Request And Billing)

13.2.14 Additional Documentation Segment (Prior Authorization Request And Billing)

13.2.15 Facility Segment (Prior Authorization Request And Billing)

13.2.16 Narrative Segment (Prior Authorization Request And Billing)

13.3 PRIOR AUTHORIZATION REQUEST AND BILLING RESPONSE DIAGRAMS AND SEGMENTS

13.3.1 Transmission Accepted/Transaction Paid

13.3.1.1 Diagram For Transmission Of One Prior Authorization Request And Billing Response (Transmission Accepted/Transaction Paid) 350

13.3.1.2 Prior Authorization Request And Billing Response Segments (Transmission Accepted/Transaction Paid)

13.3.1.2.1 Response Header Segment (Prior Authorization Request And Billing) (Transmission Accepted/Transaction Paid)

13.3.1.2.2 Response Message Segment (Prior Authorization Request And Billing) (Transmission Accepted/Transaction Paid) . 351

13.3.1.2.3 Response Insurance Segment (Prior Authorization Request And Billing) (Transmission Accepted/Transaction Paid) 351

13.3.1.2.4 Response Patient Segment (Prior Authorization Request And Billing) (Transmission Accepted/Transaction Paid)

13.3.1.2.5 Response Status Segment (Prior Authorization Request And Billing) (Transmission Accepted/Transaction Paid)

13.3.1.2.6 Response Claim Segment (Prior Authorization Request And Billing) (Transmission Accepted/Transaction Paid)

13.3.1.2.7 Response Pricing Segment (Prior Authorization Request And Billing) (Transmission Accepted/Transaction Paid)

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