Effective as of: 01/01/2021 NCPDP Telecommunication Standard Version/Release #: D.0 NCPDP Data Dictionary Version Date: October 2019 NCPDP External Code List Version Date: October 2019 Contact/Information Source: https://medi-calrx.dhcs.ca.gov/home/ The Pharmacy Provider Manual can be found on this link with additional helpful information.
California Department of Health Care Services (Medi-Cal Rx) NCPDP Standard Payer Sheet
Version 1.0
October 22, 2020
Instructions Related to Transactions Based on NCPDP Version D.0
(B1) Claim Billing (B2) Claim Reversal (B3) Claim Rebill (P2) Prior Authorization Reversal (P3) Prior Authorization Inquiry (P4) Prior Authorization Request
Note: (E1) Eligibility Verification and (B1) SB393 Drug Price Inquiry to be incorporated in an upcoming revision of this document.
Proprietary & Confidential © 2020 California Department of Health Care Services. All rights reserved.
Revision History
Document Version 1.0
Date 10/22/2020
Comments Initial Version
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Table of Contents
General Information ................................................................................................................................... 5 Transactions Supported ....................................................................................................................... 6 Field Legend for Columns ................................................................................................................... 6 BIN/PCN Information ............................................................................................................................ 7
1.0 NCPDP Version D.0 Claim Billing/Claim Re-Bill Template ................................................. 8 1.1 B1/B3 Claim Billing/Claim Re-Bill Request....................................................................... 8 1.2 B1/B3 Claim Billing/Claim Re-Bill Response.................................................................. 20 1.2.1 Accepted/PAID or Duplicate of PAID.......................................................................... 20 1.2.2 Accepted/Rejected ............................................................................................................ 28 1.2.3 Rejected/Rejected .............................................................................................................. 35
2.0 NCPDP Version D.0 Claim Reversal Template ...................................................................... 37 2.1 B2 Claim Reversal Request ............................................................................................... 37 2.2 B2 Claim Reversal Response ............................................................................................... 40 2.2.1 Accepted/Approved .......................................................................................................... 40 2.2.2 Accepted/Rejected ............................................................................................................ 44 2.2.3 Rejected/Rejected .............................................................................................................. 47
3.0 NCPDP Version D.0 Prior Authorization Reversal Template ........................................... 49 3.1 P2 Prior Authorization Reversal Request........................................................................ 49 3.2 P2 Prior Authorization Reversal Response..................................................................... 51 3.2.1 Accepted/Approved or Captured................................................................................. 51 3.2.2 Accepted/Rejected ............................................................................................................ 53 3.2.3 Rejected/Rejected .............................................................................................................. 55
4.0 NCPDP Version D.0 Prior Authorization Inquiry Template .............................................. 57 4.1 P3 Prior Authorization Inquiry Request .......................................................................... 57 4.2 P3 Prior Authorization Inquiry Response ....................................................................... 59 4.2.1 Accepted/Captured ........................................................................................................... 59 4.2.2 Accepted/Approved .......................................................................................................... 61 4.2.3 Accepted/Deferred ............................................................................................................ 64 4.2.4 Accepted/Rejected ............................................................................................................ 67 4.2.5 Rejected/Rejected .............................................................................................................. 69
5.0 NCPDP Version D.0 Prior Authorization Request Only Template ................................. 72 5.1 P4 Prior Authorization Request Only Request ............................................................. 72
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
5.2 P4 Prior Authorization Request Only Response........................................................... 80 5.2.1 Accepted/Captured ........................................................................................................... 80 5.2.2 Accepted/Rejected ............................................................................................................ 82 5.2.3 Rejected/Rejected .............................................................................................................. 85
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
General Information
The information within this section is NEW! and applies to all transactions in the document.
Refer to the information in the chart below for successful transmission of transactions as well as contact and support numbers that have changed with the transition.
Payer Name: Magellan Medicaid Administration
Date: 01/01/2021
Plan Name/Group Name: Medi-Cal Rx NEW! BIN*: 022659 NEW! PCN*: 6334225
Processor: Magellan Medicaid Administration
Effective as of: 01/01/2021
NCPDP Telecommunication Standard Version/Release #: D.0
NCPDP Data Dictionary Version Date: NCPDP External Code List Version Date:
October 2019
October 2019
Contact/Information Source: https://medi-calrx.dhcs.ca.gov/home/ The Pharmacy Provider Manual can be found on this link with additional helpful information.
Pharmacy Help Desk Information: 1-800-424-3310
Certification Contact Information: MRxPharmacyTesting@magellanhealth.com
Provider Relations Department: 1-800-441-6001
Other versions supported: No
*Refer to the BIN/PCN Information table below for the full list of transactions and associated BIN/PCNs.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Transactions Supported
Payer: List each transaction supported with the segments, fields, and pertinent information on each transaction. NEW! Note that B3 Claim Rebill is now a valid Transaction for submission.
Transaction Code B1 B2 B3 E1 P2 P3 P4
Claim Billing
Transaction Name
Claim Reversal
Claim Re-Bill
Eligibility Verification
Prior Authorization Reversal
Prior Authorization Inquiry
Prior Authorization Request
Field Legend for Columns
Fields that are not used in the transactions and those that do not have qualified requirements (i.e., not used) for this payer are excluded from the templates as specified in each respective section in this document.
Payer Usage Column
Value
MANDATORY M
REQUIRED
R
QUALIFIED
RW
REQUIREMENT
Explanation
Payer Situation Column
The Field is mandatory for the Segment in No the designated Transaction.
The Field has been designated with the No situation of "Required" for the Segment in the designated Transaction.
"Required when". The situations
Yes
designated have qualifications for usage
("Required if x", "Not required if y").
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
BIN/PCN Information
Transaction Type
Transaction Code 1Ø3-A3
Claim Billing Request
B1
Claim Billing Reversal Request
B2
Claim Rebill
B3
Eligibility Verification Request
E1
Prior Authorization Reversal
P2
Prior Authorization Inquiry
P3
Prior Authorization Request Only
P4
SB393 Drug Inquiry Pricing Request
B1
BIN 1Ø1-A1
022659
022667
PCN 1Ø4-A4
6334225
393
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
1.0 NCPDP Version D.0 Claim Billing/Claim Re-Bill Template
1.1 B1/B3 Claim Billing/Claim Re-Bill Request
**Start of Request Claim Billing/Claim Re-Bill (B1/B3) Payer Sheet Template**
Refer to the General Information tables at the beginning of this document for contact and processing information.
The following lists the segments and fields in a Claim Billing or Claim Re-Bill Transaction for the National Council for Prescription Drug Programs (NCPDP) Telecommunication Standard Implementation Guide Version D.0.
Transaction Header Segment Questions
This Segment is always sent.
X
Source of certification IDs required in X Software Vendor/Certification ID (110-AK) is Payer Issued.
Check
Claim Billing/Claim Re-Bill If Situational, Payer Situation
Transaction Header Segment
Claim Billing/Claim Re-Bill
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
101-A1 BIN Number
022659
M
NEW!
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
B1, B3
M
104-A4 Processor Control Number 6334225
M
NEW!
109-A9 Transaction Count
M
One transaction for compound
claim; Four allowed for B1 or B3.
202-B2
Service Provider ID Qualifier
01 = National Provider M Identifier (NPI)
201-B1 Service Provider ID
M
401-D1 Date of Service
M
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Transaction Header Segment
Field #
NCPDP Field Name
110-AK Software Vendor/Certification ID
Claim Billing/Claim Re-Bill
Value
This will be provided by the provider's software vendor.
Payer Usage
Payer Situation
M
Required when vendor is
certified with Magellan
otherwise submit all zeroes.
Insurance Segment Questions
This Segment is always sent.
Check X
Claim Billing/Claim Re-Bill If Situational, Payer Situation
Insurance Segment Segment Identification
(111-AM) = "04"
Claim Billing/Claim Re-Bill
Field # NCPDP Field Name
Value
Payer Usage
Payer Situation
302-C2 Cardholder ID
M
Submit Cardholder
Identification Number (CIN),
Health Access Programs (HAP),
or Benefits Identification Card
(BIC).
301-C1 Group ID
MediCalRx
R
NEW!
306-C6
Patient Relationship Code 1 = Cardholder 3 = Child 4 = Other (use for Transplant Donor)
RW NEW! Required to submit "3" when submitting newborn claims using Mom's Medi-Cal Cardholder ID. Required to submit "4" when submitting claims for a transplant donor, when using transplant recipient's Medi-Cal Cardholder ID.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Patient Segment Questions
This Segment is always sent.
Check X
Claim Billing/Claim Re-Bill If Situational, Payer Situation
Patient Segment Segment Identification
(111-AM) = "01"
Field
NCPDP Field Name
304-C4 305-C5 310-CA 311-CB 307-C7
Date of Birth Patient Gender Code Patient First Name Patient Last Name Place of Service
335-2C Pregnancy Indicator 384-4X Patient Residence
Claim Billing/Claim Re-Bill
Value
Payer Usage
Payer Situation
R
R
R
R
RW
Required if this field could
result in different coverage, or
pricing, or patient financial
responsibility.
The use of "31," "32," or "54" in this field as an identifier for beneficiaries residing in Long
Term Care will sunset on
02/28/2021.
Blank = Not Specified RW 1 = Not Pregnant 2 = Pregnant
NEW! Required if the patient is known to be pregnant.
3 = Nursing Facility
RW
9 = Intermediate Care
Facility/Individuals with
Intellectual Disabilities
NEW! Required if this field could result in different coverage, pricing, or patient financial responsibility. Required for Long Term Care.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Claim Segment Questions
This Segment is always sent.
X
This plan does not support partial X fills.
Check
Claim Billing/Claim Re-Bill If Situational, Payer Situation
Claim Segment Segment Identification
(111-AM) = "07"
Claim Billing/Claim Re-Bill
Field # NCPDP Field Name
Value
Payer Usage
Payer Situation
455-EM Prescription/Service
1= Rx Billing
M
Reference Number
Qualifier
402-D2 Prescription/Service
M
Reference Number
436-E1
Product/Service ID Qualifier
00 = Not specified
M
03 = National Drug
Code (NDC)
00 = Compound 03 = NDC, Medical Supplies and Enteral Nutrition
407-D7 Product/Service ID
M
NDC for non-compound claims
"0" for compound claims.
442-E7 Quantity Dispensed
R
460-ET Quantity Prescribed
RW
Required when a transmission
is for a Scheduled II drug as
defined in 21 CFR 1308.12 and
per CMS-0055-F (Compliance
Date 09/21/2020. Refer to the
Version D.0 Editorial
Document).
403-D3 Fill Number
R
405-D5 Days' Supply
R
406-D6 Compound Code
R
408-D8 Dispense as Written
R
(DAW)/Product Selection
Code
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Claim Segment Segment Identification
(111-AM) = "07"
Claim Billing/Claim Re-Bill
Field # NCPDP Field Name
Value
Payer Usage
Payer Situation
414-DE Date Prescription Written
R
415-DF Number of Refills Authorized
0 = No refills authorized R 199 = Authorized Refill number
NEW!
419-DJ Prescription Origin Code 1 = Written
R
2 = Telephone
3 = Electronic
4 = Facsimile
5 = Pharmacy
354-NX Submission Clarification Maximum count of 3. RW Code Count
420-DK Submission Clarification
RW
Code
308-C8 Other Coverage Code
RW
NEW!
7 = Medically Necessary (indicates that Code 1 Restrictions have been met) 8 = Process Compound for Approved Ingredients 13 = Payer-Recognized Emergency/Disaster Assistance (providers will be notified when activated for use). 20 = 340B pharmacy has determined the product being billed is purchased pursuant to rights available under Section 340B of the Public Health Act of 1992.
Required for Coordination of Benefits.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Claim Segment Segment Identification
(111-AM) = "07"
Claim Billing/Claim Re-Bill
Field # NCPDP Field Name
Value
Payer Usage
Payer Situation
600-28 Unit of Measure
Values: EA = Each GM = Grams ML = Milliliters
R
NEW!
418-DI Level of Service
3 = Emergency
RW
NEW!
Required when self-certifying
the Emergency Statement is
met for a 72 hours emergency
supply on POS claims.
461-EU
Prior Authorization Type 1 = Prior Authorization RW
Code
(PA) (used for Medi-Cal
pricing)
8 = Newborn Claims
NEW! Required if this field could result in different coverage, pricing, or patient financial responsibility. Submit "1" when PA is approved to override Medi-Cal pricing. Submit "8" for newborn claims.
462-EV
Prior Authorization Number Submitted
RW
Required if this field could
result in different coverage,
pricing, or patient financial
responsibility.
Not required to submit
historical PA numbers.
995-E2 Route of Administration SNOMED
RW
Required when submitting
compound claims.
996-G1 Compound Type
RW
NEW!
Required when needed to clarify the type of compound.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Pricing Segment Questions
This Segment is always sent.
Check X
Claim Billing/Claim Re-Bill If Situational, Payer Situation
Pricing Segment Segment Identification
(111-AM)="11"
Claim Billing/Claim Re-Bill
Field # NCPDP Field Name
409-D9 Ingredient Cost Submitted
Value
Payer Usage R
Payer Situation
412-DC Dispensing Fee Submitted
RW Required if its value has an effect on the Gross Amount Due (430-DU) calculation.
433-DX Patient Paid Amount Submitted
RW NEW! NOT REQUIRED; DO NOT SEND
438-E3
Incentive Amount Submitted
RW Required if its value has an effect on the Gross Amount Due (430-DU) calculation. Used to indicate Compound Sterilization Fee.
478-H7 Other Amount Claimed Maximum count of 3. RW Required if Other Amount Claimed
Submitted Count
Submitted Qualifier (479-H8) is used.
479-H
Other Amount Claimed 09 = Compound
Submitted Qualifier
Prep Cost
RW Required if Other Amount Claimed Submitted (480-H9) is used. Used to indicate Compounding Fee.
480-H9 Other Amount Claimed Submitted
RW Required if its value has an effect on the Gross Amount Due (430-DU) calculation. Used to indicate Compounding Fee.
426-DQ Usual and Customary
R
Charge
430-DU Gross Amount Due
R
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Pricing Segment Segment Identification
(111-AM)="11"
Field # NCPDP Field Name
423-DN Basis of Cost Determination
Claim Billing/Claim Re-Bill
Value
Payer Usage
Payer Situation
RW Required if needed for receiver claim/encounter adjudication.
Submit "08" - 340B/Disproportionate Share Pricing/Public Health Service.
Provider Segment Questions
This Segment is not sent. This Segment is always sent.
Check X X
Claim Billing/Claim Re-Bill If Situational, Payer Situation
Prescriber Segment Segment Identification
(111-AM) = "03"
Field # NCPDP Field Name
Value
466-EZ 411-DB 427-DR 364-2J
Prescriber ID Qualifier 01 = NPI Prescriber ID Prescriber Last Name Prescriber First Name
Claim Billing/Claim Re-Bill
Payer Usage
Payer Situation
R
R Must submit valid individual NPI.
RW Required if known.
RW Required if known.
Coordination of Benefits/ Other Payments Segment Questions
Check
This Segment is situational.
X
Scenario 1 - Other Payer Amount Paid X Repetitions Only.
Claim Billing If Situational, Payer Situation Required only for secondary, tertiary, etc. claims.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Coordination of Benefits/ Other Payments Segment
Segment Identification (111-AM) = "05"
Scenario 1 - Other Payer Amount Paid Repetitions Only
Field # NCPDP Field Name
Value
Payer Usage
Payer Situation
337-4C Coordination of Benefits/ Maximum count of 9. M Other Payments Count
NEW! Up to maximum of 9 allowed for submission.
338-5C Other Payer Coverage Type
M
339-6C Other Payer ID Qualifier
RW Required if Other Payer ID (340-7C) is used.
340-7C Other Payer ID
RW Required if identification of the Other Payer is necessary for claim/encounter adjudication.
443-E8 Other Payer Date
RW Required if identification of the Other Payer Date is necessary for claim/encounter adjudication.
341-HB Other Payer Amount Paid Maximum count of 9. Count
Required if Other Payer Amount Paid Qualifier (342-HC) is used. Required on all Coordination of Benefits (COB) claims with Other Coverage Code of "2" or "4."
342-HC Other Payer Amount Paid Qualifier
Required if Other Payer Amount Paid (431-DV) is used.
431-DV Other Payer Amount Paid
Required if other payer has approved payment for some/all of the billing. Required on all COB claims with Other Coverage Code of "2" or "4."
471-5E Other Payer Reject Count Maximum count of 5. RW
NEW! Required if Other Payer Reject Code (472-6E) is used.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Coordination of Benefits/ Other Payments Segment
Segment Identification (111-AM) = "05"
Field # NCPDP Field Name
472-6E Other Payer Reject Code
Scenario 1 - Other Payer Amount Paid Repetitions Only
Value
Payer Usage
Payer Situation
RW NEW!
Required when the other payer has denied the payment for the billing, designated with Other Coverage Code (308-C8) = "3" (Other Coverage Billed claim not covered).
DUR/PPS Segment Questions This Segment is situational.
Check X
Claim Billing/Claim Re-Bill If Situational, Payer Situation
Submitted if required to affect outcome of claim related to DUR intervention.
DUR/PPS Segment Segment Identification
(111-AM) = "08"
Field # NCPDP Field Name
Value
473-7E
DUR/PPS Code Counter Maximum of 9 occurrences.
439-E4 Reason for Service Code
440-E5 441-E6
Professional Service Code
Result of Service Code
474-8E DUR/PPS Level of Effort
Claim Billing/Claim Re-Bill
Payer Usage
Payer Situation
RW Required if Drug Use Review/Professional Pharmacy Service (DUR/PPS) Segment is used.
RW Required when needed to communicate DUR information.
RW Required when needed to communicate DUR information.
RW Required when needed to communicate DUR information.
RW Required when needed to communicate DUR information.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Compound Segment Questions
This Segment is situational.
Check X
Claim Billing/Claim Re-Bill If Situational, Payer Situation
It is used for multi-ingredient prescriptions when each ingredient is reported.
Compound Segment Segment Identification
(111-AM) = "10"
Claim Billing/Claim Re-bill
Field # NCPDP Field Name
Value
Payer Usage
Payer Situation
450-EF Compound Dosage Form
M
Description Code
451-EG Compound Dispensing
M
Unit Form Indicator
447-EC
Compound Ingredient Component Count
Maximum 25 ingredients. M
Medi-Cal supports up to 24 compound product IDs and 1 for the container count (25 Product IDs if a container count is included).
488-RE
Compound Product ID Qualifier
03 = NDC
M
99 = Other (Container
Count)
99 = Other (Container Count) Must be accompanied with 99999999997 in field 489-TE.
489-TE Compound Product ID
M When specifying the number of containers as an ingredient the NDC should be equal to 99999999997.
448-ED Compound Ingredient
M
Quantity
449-EE Compound Ingredient
M
Drug Cost
490-UE
Compound Ingredient Basis of Cost Determination
R
Required if needed for receiver
claim/encounter adjudication.
Submit "08" -
340B/Disproportionate Share
Pricing/Public Health Service.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Clinical Segment Questions
This Segment is situational.
Check X
Claim Billing/Claim Re-Bill If Situational, Payer Situation Submitted if the clinical detail will affect the outcome of claims processing.
Clinical Segment Segment Identification
(111-AM)="13"
Claim Billing/Claim Re-bill
Field # NCPDP Field Name
Value
Payer Usage
Payer Situation
491-VE Diagnosis Code Count Maximum count of 5. RW
Required if Diagnosis Code Qualifier (492-WE) and Diagnosis Code (424-DO) are used.
492-WE
Diagnosis Code Qualifier
02= International
RW
Classification of
Diseases (ICD-10 CM)
Required if Diagnosis Code (424DO) is used.
424-DO Diagnosis Code
RW Required if this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome.
Required if this information can be used in place of prior authorization. Required if necessary, for state/federal/regulatory agency programs.
**End of Request Claim Billing/Claim Re-Bill (B1/B3) Payer Sheet Template **
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
1.2 B1/B3 Claim Billing/Claim Re-Bill Response
1.2.1 Accepted/PAID or Duplicate of PAID
**Start of Response Claim Billing/Claim Re-Bill (B1/B3) Payer Sheet Template**
Refer to the General Information tables at the beginning of this document for contact and processing information.
The following lists the segments and fields in a Claim Billing or Claim Re-Bill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0.
Response Transaction Header Segment Questions
This Segment is always sent.
X
Check
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
Response Transaction Header Segment
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
B1, B3
M
109-A9 Transaction Count
Same value as in request. M
501-F1 Header Response Status A = Accepted
M
202-B2 Service Provider ID Qualifier Same value as in request. M
201-B1 Service Provider ID
Same value as in request. M
401-D1 Date of Service
Same value as in request. M
Response Message Segment Questions
This Segment is situational.
Check X
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
Sent if additional information is available from the payer/processor.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Message Segment Segment Identification (111-AM) = "20"
Field # NCPDP Field Name
504-F4 Message
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
Value
Payer Usage
Payer Situation
R
Required if text is needed for
clarification or detail.
Response Insurance Segment Questions
This Segment is situational.
Check X
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
Response Insurance Segment Segment Identification (111-AM)="25"
Field # NCPDP Field Name
524-FO 301-C1 302-C2
Plan ID Group ID Cardholder ID
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
Value
Payer Usage RW RW
RW
Payer Situation
Response Patient Segment Questions
This Segment is situational.
Check X
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Patient Segment Segment Identification (111-AM)="29"
Field # NCPDP Field Name
310-CA 311-CB 304-C4
Patient First Name Patient Last Name Date of Birth
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
Value
Payer Usage
Payer Situation
RW
Required if known.
RW
Required if known.
RW
Required if known.
Response Status Segment Questions
This Segment is always sent.
Check X
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
Response Status Segment Segment Identification (111-AM)="21"
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
Field # NCPDP Field Name
Value
Payer Usage
Payer Situation
112-AN
Transaction Response Status
P = Paid
M
D = Duplicate of Paid
503-F3 Authorization Number
RW
Required if needed to identify
the transaction.
547-5F
Approved Message Code Count
Maximum count of 5. RW
Required if Approved Message Code (548-6F) is used.
548-6F
Approved Message Code
RW
Required if Approved Message
Code Count (547-5F) is used.
130-UF
Additional Message Information Count
Maximum count of 25. RW
Required if Additional Message Information (526-FQ) is used.
132-UH
Additional Message Information Qualifier
RW
Required if Additional Message
Information (526-FQ) is used.
526-FQ
Additional Message Information
RW
Required when additional text is
needed for clarification or detail.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Segment Identification (111-AM)="21"
Field # NCPDP Field Name
131-UG
Additional Message Information Continuity
549-7F 550-8F
Help Desk Phone Number Qualifier
Help Desk Phone Number
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
Value
Payer Usage
Payer Situation
RW
Required if and only if current
repetition of Additional
Message Information (526-FQ)
is used.
RW
Required if Help Desk Phone
Number (550-8F) is used.
RW
Required if needed to provide a
support telephone number to
the receiver.
Response Claim Segment Questions
This Segment is always sent.
Check X
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
Response Claim Segment Segment Identification (111-AM) = "22"
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
455-EM Prescription/Service
1 = Rx Billing
M
Reference Number Qualifier
402-D2 Prescription/Service
M
Reference Number
Response Pricing Segment Questions
This Segment is always sent.
Check X
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Pricing Segment Segment Identification (111-AM)="23"
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
Field # NCPDP Field Name
Value
Payer Usage
Payer Situation
505-F5 Patient Pay Amount
R
506-F6 Ingredient Cost Paid
R
507-F7 Dispensing Fee Paid
RW
Required if this value is used to
arrive at the final
reimbursement.
521-FL Incentive Amount Paid
RW
Required if Incentive Amount
Submitted (438-E3) is greater
than zero (0).
563-J2
Other Amount Paid Count
Maximum count of 3. RW
Required if Other Amount Paid (565-J4) is used.
564-J3
Other Amount Paid Qualifier
RW
Required if Other Amount Paid
(565-J4) is used.
565-J4 Other Amount Paid
RW
Required if Other Amount
Claimed Submitted (480-H9) is
greater than zero (0).
566-J5
Other Payer Amount Recognized
RW
Required if Other Payer Amount
Paid (431-DV) is greater than
zero (0) and Coordination of
Benefits/Other Payments
Segment is supported.
509-F9 Total Amount Paid
R
522-FM
Basis of Reimbursement Determination
RW
Required if Ingredient Cost Paid
(506-F6) is greater than zero (0).
Required if Basis of Cost
Determination (432-DN) is
submitted on billing.
346-HH Basis of Calculation-
RW
Dispensing Fee
347-HJ Basis of Calculation-
RW
Copay
572-4U Amount of Coinsurance
RW
Page 24
Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Pricing Segment Segment Identification (111-AM)="23"
Field # NCPDP Field Name
573-4V
Basis of CalculationCoinsurance
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
Value
Payer Usage
RW
Payer Situation
Response DUR/PPS Segment Questions
This Segment is situational.
Check X
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
Sent when DUR intervention is encountered during claim processing.
Response DUR/PPS Segment Segment Identification (111-AM)="24"
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
Field # NCPDP Field Name
Value
Payer Usage
Payer Situation
567-J6
DUR/PPS Response Code Counter
Maximum 9
RW
occurrences supported.
Required if Reason for Service Code (439-E4) is used.
439-E4
Reason for Service Code
RW Required if utilization conflict is detected.
528-FS
Clinical Significance Code
RW Required if needed to supply additional information for the utilization conflict.
529-FT
Other Pharmacy Indicator
RW Required if needed to supply additional information for the utilization conflict.
530-FU
Previous Date of Fill
RW Required if Quantity of Previous Fill (531-FV) is used.
531-FV
Quantity of Previous Fill
RW Required if Previous Date of Fill (530-FU) is used.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response DUR/PPS Segment Segment Identification (111-AM)="24"
Field # NCPDP Field Name
532-FW Database Indicator
533-FX
Other Prescriber Indicator
544-FY
DUR Free Text Message
570-NS DUR Additional Text
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
Value
Payer Usage
Payer Situation
RW Required if needed to supply additional information for the utilization conflict.
RW Required if needed to supply additional information for the utilization conflict.
RW Required if needed to supply additional information for the utilization conflict.
RW Required if needed to supply additional information for the utilization conflict.
Response Coordination of Benefits/ Other Payers Segment Questions
This Segment is situational.
Check X
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
Sent when Other Health Insurance (OHI) is encountered during claims processing.
Response Coordination of Benefits/ Other Payers Segment Segment Identification (111-AM) = "28"
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
355-NT Other Payer ID Count
Maximum count of 3. M
338-5C
Other Payer Coverage Type
M
339-6C
Other Payer ID Qualifier
RW Required if Other Payer ID (340-7C) is used.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Coordination of Benefits/ Other Payers Segment Segment Identification (111-AM) = "28"
Field #
NCPDP Field Name
340-7C
Other Payer ID
991-MH
Other Payer Processor Control Number
356-NU Other Payer Cardholder ID
992-MJ
Other Payer Group ID
142-UV Other Payer Person Code
127-UB
Other Payer Help Desk Phone Number
143-UW
Other Payer Patient Relationship Code
144-UX
Other Payer Benefit Effective Date
145-UY
Other Payer Benefit Termination Date
Claim Billing/Claim Re-Bill Accepted/Paid (or Duplicate of Paid)
Value
Payer Usage
Payer Situation
RW Required if other insurance information is available for coordination of benefits.
RW Required if other insurance information is available for coordination of benefits.
RW Required if other insurance information is available for coordination of benefits.
RW Required if other insurance information is available for coordination of benefits.
RW Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer.
RW Required if needed to provide a support telephone number of the other payer to the receiver.
RW Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer.
RW Required when other coverage is known which is after the Date of Service submitted.
RW Required when other coverage is known which is after the Date of Service submitted.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
1.2.2 Accepted/Rejected
Response Transaction Header Segment Questions
Check
This Segment is always sent.
X
Claim Billing/Claim Re-Bill Accepted/Rejected
If Situational, Payer Situation
Response Transaction Header Segment
Claim Billing/Claim Re-Bill Accepted/Rejected
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2
Version/Release Number D0
M
103-A3
Transaction Code
B1, B3
M
109-A9
Transaction Count
Same value as in request. M
501-F1
Header Response Status A = Accepted
M
202-B2
Service Provider ID Qualifier
Same value as in request. M
201-B1
Service Provider ID
Same value as in request. M
401-D1
Date of Service
Same value as in request. M
Response Message Segment Questions
This Segment is situational.
Check X
Claim Billing/Claim Re-Bill Accepted/Rejected
If Situational, Payer Situation
Response Message Segment Segment Identification (111-AM) = "20"
Field # NCPDP Field Name
504-F4
Message
Claim Billing/Claim Re-Bill Accepted/Rejected
Value
Payer Usage
Payer Situation
RW Required if text is needed for clarification or detail.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Insurance Segment Questions
This Segment is always sent.
Check X
Claim Billing/Claim Re-Bill Accepted/Rejected
If Situational, Payer Situation
Response Insurance Segment Segment Identification (111-AM) = "25"
Field #
NCPDP Field Name
301-C1 524-FO 302-C2
Group ID Plan ID Cardholder ID
Value
Claim Billing/Claim Re-Bill Accepted/Rejected
Payer Usage R RW
RW
Payer Situation
Response Patient Segment Questions
This Segment is always sent. This Segment is situational.
Check X
Claim Billing/Claim Re-Bill Accepted/Rejected
If Situational, Payer Situation
Sent when known by plan.
Response Patient Segment Segment Identification (111-AM) = "29"
Field #
NCPDP Field Name
310-CA 311-CB 304-C4
Patient First Name Patient Last Name Date of Birth
Claim Billing/Claim Re-Bill Accepted/Rejected
Value
Payer Usage
Payer Situation
RW
Required if known.
RW
Required if known.
RW
Required if known.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Questions
This Segment is always sent.
Check X
Claim Billing/Claim Re-Bill Accepted/Rejected
If Situational, Payer Situation
Response Status Segment Segment Identification (111-AM)="21"
Claim Billing/Claim Re-Bill Accepted/Rejected
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
112-AN Transaction Response R = Reject
M
Status
503-F3
Authorization Number
RW Required if needed to identify the transaction.
510-FA
Reject Count
Maximum count 5. R
511-FB
Reject Code
R
546-4F
Reject Field Occurrence Indicator
RW Required if a repeating field is in error, to identify repeating field occurrence.
130-UF
Additional Message Information Count
Maximum count 25. RW
Required if Additional Message Information (526-FQ) is used.
132-UH
Additional Message Information Qualifier
RW Required if Additional Message Information (526-FQ) is used.
526-FQ
Additional Message Information
RW Required when additional text is needed for clarification or detail.
131-UG
Additional Message Information Continuity
RW Required if and only if current repetition of Additional Message Information (526-FQ) is used.
549-7F
Help Desk Phone Number Qualifier
RW Required if Help Desk Phone Number (550-8F) is used.
550-8F
Help Desk Phone Number
RW Required if needed to provide a support telephone number to the receiver.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Segment Identification (111-AM)="21"
Field #
NCPDP Field Name
987-MA URL
Claim Billing/Claim Re-Bill Accepted/Rejected
Value
Payer Usage
Payer Situation
RW Provided for informational purposes only to relay health care communications via the Internet.
Response Claim Segment Questions
This Segment is always sent.
Check X
Claim Billing/Claim Re-Bill Accepted/Rejected
If Situational, Payer Situation
Response Claim Segment Segment Identification (111-AM) = "22"
Field #
NCPDP Field Name
455-EM 402-D2
Prescription/ Service Reference Number Qualifier
Prescription/ Service Reference Number
Value 1 = Rx Billing
Claim Billing/Claim Re-Bill Accepted/Rejected
Payer Usage
M
Payer Situation
M
Response DUR/PPS Segment Questions
This Segment is situational.
Check X
Claim Billing/Claim Re-Bill Accepted/Rejected
If Situational, Payer Situation
Sent when DUR intervention is encountered during claim adjudication.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response DUR/PPS Segment Segment Identification (111-AM)="24"
Claim Billing/Claim Re-Bill Accepted/Rejected
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
567-J6
DUR/PPS Response Code Maximum 9
RW Required if Reason for Service
Counter
occurrences supported.
Code (439-E4) is used.
439-E4 Reason for Service Code
RW Required if utilization conflict is detected.
528-FS Clinical Significance Code
RW Required if needed to supply additional information for the utilization conflict.
529-FT Other Pharmacy Indicator
RW Required if needed to supply additional information for the utilization conflict.
530-FU Previous Date of Fill
RW Required if Quantity of Previous Fill (531-FV) is used.
531-FV Quantity of Previous Fill
RW Required if Previous Date of Fill (530-FU) is used.
532-FW Database Indicator
RW Required if needed to supply additional information for the utilization conflict.
533-FX Other Prescriber Indicator
RW Required if needed to supply additional information for the utilization conflict.
544-FY DUR Free Text Message
RW Required if needed to supply additional information for the utilization conflict.
570-NS DUR Additional Text
RW Required if needed to supply additional information for the utilization conflict.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Coordination of Benefits/Other Payers Segment Questions
This Segment is situational.
Check X
Claim Billing/Claim Re-Bill Accepted/Rejected
If Situational, Payer Situation
Sent when Other Health Insurance (OHI) is encountered during claim processing.
Response Coordination of Benefits/Other Payers Segment
Segment Identification (111-AM) = "28"
Claim Billing/Claim Re-Bill Accepted/Rejected
Field # NCPDP Field Name
Value
Payer Usage
Payer Situation
355-NT Other Payer ID Count
Maximum count of 3. M
338-5C Other Payer Coverage Type
M
339-6C Other Payer ID Qualifier
RW Required if Other Payer ID (340-7C) is used.
340-7C Other Payer ID
RW Required if other insurance information is available for coordination of benefits.
991-MH Other Payer Processor Control Number
RW Required if other insurance information is available for coordination of benefits.
356-NU Other Payer Cardholder ID
RW Required if other insurance information is available for coordination of benefits.
992-MJ Other Payer Group ID
RW Required if other insurance information is available for coordination of benefits.
142-UV Other Payer Person Code
RW Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer.
127-UB Other Payer Help Desk Phone Number
RW Required if needed to provide a support telephone number of the other payer to the receiver.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Coordination of Benefits/Other Payers Segment
Segment Identification (111-AM) = "28"
Field # NCPDP Field Name 143-UW Other Payer Patient
Relationship Code
144-UX Other Payer Benefit Effective Date
145-UY Other Payer Benefit Termination Date
Claim Billing/Claim Re-Bill Accepted/Rejected
Value
Payer Usage
Payer Situation
RW Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer.
RW Required when other coverage is known which is after the Date of Service submitted.
RW Required when other coverage is known which is after the Date of Service submitted.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
1.2.3 Rejected/Rejected
Response Transaction Header Segment Questions
Check
This Segment is always sent.
X
Claim Billing/Claim Re-Bill Rejected/Rejected
If Situational, Payer Situation
Response Transaction Header Segment
Claim Billing/Claim Re-Bill Rejected/Rejected
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
B1, B3
M
109-A9 Transaction Count
Same value as in request. M
501-F1 Header Response Status R = Rejected
M
202-B2 Service Provider ID Qualifier Same value as in request. M
201-B1 Service Provider ID
Same value as in request. M
401-D1 Date of Service
Same value as in request. M
Response Message Segment Questions
This Segment is situational.
Check X
Claim Billing/Claim Re-Bill Rejected/Rejected
If Situational, Payer Situation
Response Message Segment Segment Identification (111-AM) = "20"
Field #
NCPDP Field Name
504-F4 Message
Claim Billing/Claim Re-Bill Rejected/Rejected
Value
Payer Usage
Payer Situation
RW Required if text is needed for clarification or detail.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Questions
This Segment is always sent.
Check X
Claim Billing/Claim Re-Bill Rejected/Rejected
If Situational, Payer Situation
Response Status Segment Segment Identification (111-AM) = "21"
Claim Billing/Claim Re-Bill Rejected/Rejected
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
112-AN Transaction Response Status R = Reject
M
503-F3 Authorization Number
RW Required if needed to identify the transaction.
510-FA Reject Count
Maximum count 5. R
511-FB Reject Code
R
546-4F
Reject Field Occurrence Indicator
RW Required if a repeating field is in error, to identify repeating field occurrence.
130-UF Additional Message Information Count
Maximum count of RW 25.
Required if Additional Message Information (526-FQ) is used.
132-UH Additional Message Information Qualifier
RW Required if Additional Message Information (526-FQ) is used.
526-FQ Additional Message Information
RW Required when additional text is needed for clarification or detail.
131-UG Additional Message Information Continuity
RW Required if and only if current repetition of Additional Message Information (526-FQ) is used.
549-7F
Help Desk Phone Number Qualifier
RW Required if Help Desk Phone Number (550-8F) is used.
550-8F Help Desk Phone Number
RW Required if needed to provide a support telephone number to the receiver.
**End of Response Claim Billing/Claim Re-Bill (B1/B3) Payer Sheet Template **
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
2.0 NCPDP Version D.0 Claim Reversal Template
2.1 B2 Claim Reversal Request
**Start of Request Claim Reversal (B2) Payer Sheet Template**
Refer to the General Information tables at the beginning of this document for contact and processing information.
The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0.
Transaction Header Segment Questions
This Segment is always sent.
X
Source of certification IDs required in
X
Software Vendor/Certification ID (110-AK)
is Payer Issued.
Check
Claim Reversal If Situational, Payer Situation
Transaction Header Segment
Field #
NCPDP Field Name
Value
101-A1 102-A2 103-A3 104-A4
BIN NUMBER
022659
Version/Release Number D0
Transaction Code
B2
Processor Control Number 6334225
Claim Reversal
Payer Usage
Payer Situation
M
NEW!
M
M
M
NEW!
109-A9 Transaction Count
M
202-B2 Service Provider ID Qualifier 01 = NPI
M
201-B1 Service Provider ID
M
401-D1 Date of Service
M
110-AK Software Vendor/Certification ID
This will be provided M by the provider's software vendor.
Required when vendor is certified with Magellan otherwise submit all zeroes.
Page 37
Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Insurance Segment Questions
This Segment is always sent.
Check X
Claim Reversal If Situational, Payer Situation
Insurance Segment Segment Identification
(111-AM) = "04"
Field #
NCPDP Field Name
302-C2 Cardholder ID
Value
Claim Reversal
Payer Usage
Payer Situation
M
Submit CIN, HAP, or BIC.
Claim Segment Questions
This Segment is always sent.
Check X
Claim Reversal If Situational, Payer Situation
Claim Segment Segment Identification
(111-AM) = "07"
Field #
NCPDP Field Name
Value
455-EM
402-D2
436-E1 407-D7 403-D3
Prescription/Service Reference Number Qualifier
Prescription/Service Reference Number
Product/Service ID Qualifier
Product/Service ID
Fill Number
0 = Original Dispensing 199 = Number of refills
308-C8 Other Coverage Code
Claim Reversal
Payer Usage
M
Payer Situation
M
M
M
RW Required if needed for reversals when multiple fills of the same Prescription/ Service Reference Number (402-D2) occur on the same day.
RW NEW! Required if needed by receiver to match the claim that is being reversed.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Pricing Segment Questions
This Segment is not sent.
Check X
Claim Reversal If Situational, Payer Situation
Coordination of Benefits/ Other Payments Segment
Segment Identification (111-AM) = "05"
Claim Reversal
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
337-4C
Coordination of Benefits/Other Payments Count
Maximum count of 9. M
NEW!
338-5C
Other Payer Coverage Type
M
NEW!
**End of Request Claim Reversal (B2) Payer Sheet Template**
Page 39
Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
2.2 B2 Claim Reversal Response
** Start of Claim Reversal Response (B2) Payer Sheet Template**
Refer to the General Information tables at the beginning of this document for contact and processing information.
2.2.1 Accepted/Approved
The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0.
Response Transaction Header Segment Questions
This Segment is always sent.
Check X
Claim Reversal Accepted/Approved If Situational, Payer Situation
Response Transaction Header Segment
Claim Reversal Accepted/Approved
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
B2
M
109-A9 Transaction Count
Same value as in request. M
501-F1 Header Response Status A = Accepted
M
202-B2 Service Provider ID Qualifier 01= NPI
M
201-B1 Service Provider ID
M
401-D1 Date of Service
M
Response Message Segment Questions
This Segment is situational.
Check X
Claim Reversal Accepted/Approved If Situational, Payer Situation
Provide general information when used for transmission-level messaging.
Page 40
Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Message Segment Segment Identification (111-AM) = "20"
Field #
NCPDP Field Name
504-F4 Message
Value
Claim Reversal Accepted/Approved
Payer Usage
Payer Situation
RW Required if text is needed for clarification or detail.
Response Status Segment Questions
This Segment is always sent.
Check X
Claim Reversal Accepted/Approved If Situational, Payer Situation
Response Status Segment Segment Identification (111-AM) ="21"
Claim Reversal Accepted/Approved
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
112-AN Transaction Response Status A = Approved
M
503-F3 Authorization Number
RW Required if needed to identify the transaction.
547-5F
Approved Message Code Count
Maximum count of 5. RW Required if Approved Message Code (548-6F) is used.
548-6F Approved Message Code
RW Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity.
130-UF Additional Message Information Count
Maximum count of 25.
RW Required if Additional Message Information (526-FQ) is used.
132-UH Additional Message Information Qualifier
RW Required if Additional Message Information (526-FQ) is used.
526-FQ Additional Message Information
RW Required when additional text is needed for clarification or detail.
Page 41
Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Segment Identification (111-AM) ="21"
Field #
NCPDP Field Name
131-UG Additional Message Information Continuity
549-7F 550-8F
Help Desk Phone Number Qualifier
Help Desk Phone Number
Value
Claim Reversal Accepted/Approved
Payer Usage
Payer Situation
RW Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
RW Required if Help Desk Phone Number (550-8F) is used.
RW Required if needed to provide a support telephone number to the receiver.
Response Claim Segment Questions
This Segment is always sent.
Check X
Claim Reversal Accepted/Approved If Situational, Payer Situation
Response Claim Segment Segment Identification (111-AM) = "22"
Field #
NCPDP Field Name
Value
455-EM 402-D2
Prescription/Service
1 = Rx Billing
Reference Number Qualifier
Prescription/Service Reference Number
Claim Reversal Accepted/Approved
Payer Usage
M
Payer Situation
M
Page 42
Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Pricing Segment Questions
This Segment is always sent. This Segment is situational.
Check X
Claim Reversal Accepted/Approved If Situational, Payer Situation
Sent if reversal results in generation of pricing detail.
Response Pricing Segment Segment Identification (111-AM) = "23"
Field #
NCPDP Field Name
521-FL Incentive Amount Paid
509-F9 Total Amount Paid
Value
Claim Reversal Accepted/Approved
Payer Usage
Payer Situation
RW Required if this field is reporting a contractually agreed upon payment. Represents compound sterilization fee.
RW Required if any other payment fields sent by the sender.
Page 43
Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
2.2.2 Accepted/Rejected
Response Transaction Header Segment Questions
This Segment is always sent.
X
Check
Claim Reversal Accepted/Rejected If Situational, Payer Situation
Response Transaction Header Segment
Claim Reversal Accepted/Rejected
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
B2
M
109-A9 Transaction Count
Same value as in request. M
501-F1 Header Response Status A = Accepted
M
202-B2 Service Provider ID Qualifier 01 = NPI
M
201-B1 Service Provider ID
M
401-D1 Date of Service
M
Response Message Segment Questions This Segment is situational.
Check X
Claim Reversal Accepted/Rejected If Situational, Payer Situation
Response Message Segment Segment Identification (111-AM) = "20"
Field #
NCPDP Field Name
504-F4 Message
Value
Claim Reversal Accepted/Rejected
Payer Usage
Payer Situation
RW
Required if text is needed for
clarification or detail.
Response Status Segment Questions This Segment is always sent.
Check X
Claim Reversal Accepted/Rejected If Situational, Payer Situation
Page 44
Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Segment Identification (111-AM)="21"
Field #
NCPDP Field Name
Value
112-AN 503-F3 510-FA 511-FB 546-4F
Transaction Response Status R = Reject Authorization Number Reject Count Reject Code Reject Field Occurrence Indicator
130-UF 132-UH 526-FQ 131-UG
Additional Message Information Count
Additional Message Information Qualifier
Additional Message Information
Additional Message Information Continuity
549-7F 550-8F
Help Desk Phone Number Qualifier
Help Desk Phone Number
Claim Reversal Accepted/Rejected
Payer Usage
Payer Situation
M
R
R
R
RW Required if a repeating field is in error, to identify repeating field occurrence.
RW Required if Additional Message Information (526-FQ) is used.
RW Required if Additional Message Information (526-FQ) is used.
RW Required when additional text is needed for clarification or detail.
RW Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
RW Required if Help Desk Phone Number (550-8F) is used.
RW Required if needed to provide a support telephone number to the receiver.
Response Claim Segment Questions This Segment is always sent.
Check X
Claim Reversal Accepted/Rejected If Situational, Payer Situation
Page 45
Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Claim Segment Segment Identification (111-AM) = "22"
Field #
NCPDP Field Name
Value
455-EM 402-D2
Prescription/Service Reference 1 = Rx Billing Number Qualifier
Prescription/Service Reference Number
Claim Reversal Accepted/Rejected
Payer Usage
M
Payer Situation
M
Coordination of Benefits/Other Payments Segment Questions
This Segment is situational.
X
Check
Claim Reversal If Situational, Payer Situation
Coordination of Benefits/ Other Payments Segment
Segment Identification (111-AM) = "05"
Field #
NCPDP Field Name
337-4C 338-5C
Coordination of Benefits/Other Payments Count
Other Payer Coverage Type
Claims Reversal
Value
Payer Usage M
M
Payer Situation
Page 46
Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
2.2.3 Rejected/Rejected
Response Transaction Header Segment Questions
This Segment is always sent.
X
Check
Claim Reversal Rejected/Rejected If Situational, Payer Situation
Response Transaction Header Segment
Claim Reversal Rejected/Rejected
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
B2
M
109-A9 Transaction Count
1 = One Occurrence M
501-F1 Header Response Status R = Rejected
M
202-B2 Service Provider ID Qualifier 01 = NPI
M
201-B1 Service Provider ID
M
401-D1 Date of Service
M
Response Message Segment Questions This Segment is situational.
Check X
Claim Reversal Rejected/Rejected If Situational, Payer Situation
Response Message Segment Segment Identification (111-AM) = "20"
Field #
NCPDP Field Name
504-F4 Message
Value
Claim Reversal Rejected/Rejected
Payer Usage
RW
Payer Situation
Required if text is needed for clarification or detail.
Response Status Segment Questions This Segment is always sent.
Check X
Claim Reversal Rejected/Rejected If Situational, Payer Situation
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Segment Identification (111-AM) ="21"
Field #
NCPDP Field Name
Value
112-AN Transaction Response Status R = Reject 503-F3 Authorization Number 510-FA Reject Count 511-FB Reject Code 546-4F Reject Field Occurrence
Indicator
130-UF Additional Message Information Count
132-UH Additional Message Information Qualifier
526-FQ Additional Message Information
131-UG Additional Message Information Continuity
549-7F Help Desk Phone Number Qualifier
550-8F Help Desk Phone Number
Claim Reversal Rejected/Rejected
Payer Usage
Payer Situation
M
R
R
R
RW Required if a repeating field is in error, to identify repeating field occurrence.
RW Required if Additional Message Information (526-FQ) is used.
RW Required if Additional Message Information (526-FQ) is used.
RW Required when additional text is needed for clarification or detail.
RW Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
RW Required if Help Desk Phone Number (550-8F) is used.
RW Required if needed to provide a support telephone number to the receiver.
**End of Claim Reversal (B2) Response Payer Sheet Template**
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
3.0 NCPDP Version D.0 Prior Authorization Reversal Template
3.1 P2 Prior Authorization Reversal Request
***Start of Request Prior Authorization Reversal (P2) Payer Sheet Template***
Refer to the General Information tables at the beginning of this document for contact and processing information.
The following lists the segments and fields in a Prior Authorization Reversal Request Transaction for NCPDP Telecommunication Standard Implementation Guide Version D.0.
Transaction Header Segment Question
This segment is always sent.
X
Source of certification IDs required in X Software Vendor/Certification ID is Payer issued.
Check
Prior Authorization Reversal
Transaction Header Segment
Prior Authorization Reversal
Field #
NCPDP Field Name
101-A1 BIN Number
Value 022659
Payer Usage
Payer Situation
M
NEW!
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
P2
M
104-A4 Processor Control Number 6334225
M
NEW!
109-A9 Transaction Count
1
M
202-B2 Service Provider ID Qualifier 01 = NPI
M
201-B1 Service Provider ID
M
401-D1 Date of Service
M
110-AK
Software Vendor/ Certification ID
This will be provided M by the provider's software vendor.
Required when vendor is certified with Magellan otherwise submit all zeroes.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Prior Authorization Segment Segment Identification (111-AM) = "12"
Field #
NCPDP Field Name
498-PA 498-PB 498-PC 498-PD 498-PY
Request Type Request Period Date Begin Request Period Date End Basis of Request Prior Authorization Number Assigned
503-F3 Authorization Number
Value
Prior Authorization Reversal
Payer Usage
Payer Situation
M
M
M
M
RW Required if known to sender; otherwise send Authorization Number (503-F3). Payer Requirement: Not Used.
RW Required if PA NumberAssigned (498-PY) is not known.
***End of Request Prior Authorization Reversal (P2) Payer Sheet Template***
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
3.2 P2 Prior Authorization Reversal Response
3.2.1 Accepted/Approved or Captured
***Start of Response Prior Authorization Reversal (P2) Payer Sheet Template***
Refer to the General Information tables at the beginning of this document for contact and processing information.
Response Transaction Header Question
This Segment is always sent.
Check X
Prior Authorization Reversal Accepted/Captured
Response Transaction Header Segment
Prior Authorization Reversal Accepted/Captured
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
P2
M
109-A9 Transaction Count
Same value as in request. M
501-F1 Header Response Status A = Accepted
M
202-B2 Service Provider ID Qualifier Same value as in request. M
201-B1 401-D1
Service Provider ID Date of Service
Same value as in request. M Same value as in request. M
Response Message Segment Question This segment is always sent. This segment is situational.
Check X
Prior Authorization Reversal Accepted/Captured
Provide general information when used for transmission-level messaging.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Message Segment Segment Identification (111-AM) = "20"
Field # NCPDP Field Name
504-F4 Message
Prior Authorization Reversal Accepted/Captured
Value
Payer Usage
Payer Situation
RW Required if text is needed for clarification or detail.
Response Status Segment Question This segment is always sent.
Check X
Prior Authorization Reversal Accepted/Captured
Response Status Segment Segment Identification (111-AM) = "21"
Field # NCPDP Field Name
112-AN 503-F3
Transaction Response Status
Authorization Number
130-UF 132-UH 526-FQ 131-UG
Additional Message Information Count
Additional Message Information Qualifier
Additional Message Information
Additional Message Information Continuity
549-7F 550-8F
Help Desk Phone Number Qualifier
Help Desk Phone Number
Prior Authorization Reversal Accepted/Captured
Values
A = Accepted C = Captured
Payer Usage
M
Payer Situation
RW Required if needed to identify the transaction.
RW Required if Additional Message Information (526-FQ) is used.
RW Required if Additional Message Information (526-FQ) is used.
RW Required when additional text is needed for clarification or detail.
RW Required only if current repetition of Additional Message Information (526-FQ) is used.
RW Required if Help Desk Phone Number (550-8F) is used.
RW Required if needed to provide a support telephone number to the receiver.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
3.2.2 Accepted/Rejected
Response Transaction Header Question
This segment is always sent.
X
Check
Prior Authorization Reversal Accepted/Rejected
Response Transaction Header Segment
Prior Authorization Reversal Accepted/Rejected
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
P2
M
109-A9 Transaction Count
Same value as in request. M
501-F1 Header Response Status A = Accepted
M
202-B2 Service Provider ID Qualifier Same value as in request. M
201-B1 Service Provider ID
Same value as in request. M
401-D1 Date of Service
Same value as in request. M
Response Message Segment Question This segment is always sent. This segment is situational.
Check X
Prior Authorization Reversal Accepted/Rejected
Provide general information when used for transmission-level messaging.
Response Message Segment Segment Identification (111-AM) = "20"
Field # NCPDP Field Name
504-F4 Message
Value
Prior Authorization Reversal Accepted/Rejected
Payer Usage
Payer Situation
RW Required if text is needed for clarification or detail.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Question This segment is always sent.
Check X
Prior Authorization Reversal Accepted/Rejected
Response Status Segment Segment Identification (111-AM) = "21"
Field #
NCPDP Field Name
Values
112-AN Transaction Response Status R = Rejected 503-F3 Authorization Number
510-FA Reject Count 511-FB Reject Code 546-4F Reject Field Occurrence
Indicator
130-UF Additional Message Information Count
132-UH Additional Message Information Qualifier
526-FQ Additional Message Information
131-UG Additional Message Information Continuity
549-7F Help Desk Phone Number Qualifier
550-8F Help Desk Phone Number
Prior Authorization Reversal Accepted/Rejected
Payer Usage
Payer Situation
M
RW Required if needed to identify the transaction.
R
R
RW Required if a repeating field is in error, to identify repeating field occurrence.
RW Required if Additional Message Information (526-FQ) is used.
RW
Required if Additional Message
Information (526-FQ) is used.
RW
Required when additional text is
needed for clarification or detail.
RW
Required if current repetition of
Additional Message Information
(526-FQ) is used.
RW
Required if Help Desk Phone
Number (550-8F) is used.
RW
Required if needed to provide a
support telephone number to
the receiver.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
3.2.3 Rejected/Rejected
Response Transaction Header Question
This segment is always sent.
X
Check
Prior Authorization Reversal Rejected/Rejected
Response Transaction Header Segment
Prior Authorization Reversal Rejected/Rejected
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
P2
M
109-A9 Transaction Count
Same value as in request. M
501-F1 Header Response Status R = Rejected
M
202-B2 Service Provider ID Qualifier Same value as in request. M
201-B1 Service Provider ID
Same value as in request. M
401-D1 Date of Service
Same value as in request. M
Response Message Segment Question This segment is always sent. This segment is situational.
Check X
Prior Authorization Reversal Rejected/Rejected
Provide general information when used for transmission-level messaging.
Response Message Segment Segment Identification (111-AM) = "20"
Field #
NCPDP Field Name
504-F4 Message
Prior Authorization Reversal Rejected/Rejected
Value
Payer Usage
Payer Situation
RW Required if text is needed for clarification or detail.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Question This segment is always sent.
Check X
Prior Authorization Reversal Rejected/Rejected
Response Status Segment Segment Identification (111-AM) = "21"
Prior Authorization Reversal Rejected/Rejected
Field # NCPDP Field Name
Values
112-AN
Transaction Response Status
R = Rejected
Payer Usage
M
Payer Situation
503-F3 Authorization Number
RW Required if needed to identify the transaction.
510-FA Reject Count
R
511-FB Reject Code
R
546-4F
Reject Field Occurrence Indicator
RW Required if a repeating field is in error, to identify repeating field occurrence.
130-UF
Additional Message Information Count
RW Required if Additional Message Information (526-FQ) is used.
132-UH
Additional Message Information Qualifier
RW Required if Additional Message Information (526-FQ) is used.
526-FQ
Additional Message Information
RW Required when additional text is needed for clarification or detail.
131-UG
Additional Message Information Continuity
RW Required only if current repetition of Additional Message Information (526-FQ) is used.
549-7F
Help Desk Phone Number Qualifier
RW Required if Help Desk Phone Number (550-8F) is used.
550-8F
Help Desk Phone Number
RW Required if needed to provide a support telephone number to the receiver.
***End of Response Prior Authorization Reversal (P2) Payer Sheet Template***
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
4.0 NCPDP Version D.0 Prior Authorization Inquiry Template
4.1 P3 Prior Authorization Inquiry Request
***Start of Request Prior Authorization Inquiry (P3) Payer Sheet Template***
Refer to the General Information tables at the beginning of this document for contact and processing information.
The following lists the segments and fields in a Request Prior Authorization Reversal Transaction for NCPDP Telecommunication Standard Implementation Guide Version D.0.
Transaction Header Segment Question
This segment is always sent.
X
Source of certification IDs required in X Software Vendor/Certification ID is Payer issued.
Check
Prior Authorization Inquiry
Transaction Header Segment
Prior Authorization Inquiry
Field #
NCPDP Field Name
Value
101-A1 102-A2 103-A3 104-A4 109-A9 202-B2
BIN Number
022659
Version/Release Number D0
Transaction Code
P3
Processor Control Number 6334225
Transaction Count
1
Service Provider ID Qualifier 01 = NPI
Payer Usage
Payer Situation
M NEW!
M
M
M NEW!
M
M
201-B1 401-D1 110-AK
Service Provider ID Date of Service Software Vendor/ Certification ID
M
M
This will be provided M by the provider's software vendor.
Required when vendor is certified with Magellan otherwise submit all zeroes.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Insurance Segment Question This segment is always sent.
Check X
Prior Authorization Inquiry
Insurance Segment Segment Identification
(111-AM) = "004"
Field # NCPDP Field Name
302-C2
Cardholder ID
Prior Authorization Inquiry
Value
Payer Usage
Payer Situation
M
Submit CIN, HAP, or BIC.
Prior Authorization Segment Question This Segment is always sent.
Check X
Prior Authorization Inquiry
Prior Authorization Segment Segment Identification (111-AM) = "12"
Field #
NCPDP Field Name
498-PA 498-PB 498-PC 498-PD 498-PY
Request Type Request Period Date Begin Request Period Date End Basis of Request Prior Authorization Number Assigned
503-F3
Authorization Number
Prior Authorization Inquiry
Value
Payer Usage
Payer Situation
M
M
M
M
RW
Required if known to sender;
otherwise send Authorization
Number (503-F3).
RW
Required if Prior Authorization
Number-Assigned (498-PY) is
not known.
Payer Requirement: This field is required to process the
transaction.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
4.2 P3 Prior Authorization Inquiry Response
4.2.1 Accepted/Captured
***Start of Response Prior Authorization Inquiry (P3) Payer Sheet Template***
Refer to the General Information tables at the beginning of this document for contact and processing information.
Response Transaction Header Question
This Segment is always sent.
Check X
Prior Authorization Inquiry Accepted/Captured
Response Transaction Header Segment
Prior Authorization Inquiry Accepted/Captured
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2
Version/Release Number D0
M
103-A3
Transaction Code
P3
M
109-A9
Transaction Count
Same value as in request. M
501-F1
Header Response Status A = Accepted
M
202-B2
Service Provider ID Qualifier Same value as in request. M
201-B1
Service Provider ID
Same value as in request. M
401-D1
Date of Service
Same value as in request. M
Response Message Segment Question This Segment is always sent. This Segment is situational.
Check X
Prior Authorization Inquiry Accepted/Captured
Provide general information when used for transmission-level messaging.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Message Segment Segment Identification (111-AM) ="20"
Field # NCPDP Field Name
504-F4
Message
Prior Authorization Inquiry Accepted/Captured
Value
Payer Usage
Payer Situation
RW
Required if text is needed for
clarification or detail.
Response Status Segment Question This Segment is always sent.
Check X
Prior Authorization Inquiry Accepted/Captured
Response Status Segment Segment Identification (111-AM) = "21"
Prior Authorization Inquiry Accepted/Captured
Field #
NCPDP Field Name
Values
Payer Usage
Payer situation
112-AN Transaction Response Status C = Captured M
503-F3
Authorization Number
RW Required if needed to identify the transaction.
130-UF
Additional Message Information Count
RW Required if Additional Message Information (526-FQ) is used.
132-UH
Additional Message Information Qualifier
RW Required if Additional Message Information (526-FQ) is used.
526-FQ
Additional Message Information
RW Required when additional text is needed for clarification or detail.
131-UG
Additional Message Information Continuity
RW Required only if current repetition of Additional Message Information (526-FQ) is used.
549-7F
Help Desk Phone Number Qualifier
RW Required if Help Desk Phone Number (550-8F) is used.
550-8F
Help Desk Phone Number
RW Required if needed to provide a support telephone number to the receiver.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
4.2.2 Accepted/Approved
Response Transaction Header Question
This Segment is always sent.
X
Check
Prior Authorization Inquiry Accepted/Approved
Response Transaction Header Segment
Prior Authorization Inquiry Accepted/Approved
Field #
NCPDP Field Name
Value
Payer Usage
Payer situation
102-A2
Version/Release Number D0
M
103-A3
Transaction Code
P3
M
109-A9
Transaction Count
Same value as in request. M
501-F1
Header Response Status A = Accepted
M
202-B2
Service Provider ID Qualifier Same value as in request. M
401-D1
Date of Service
Same value as in request. M
Response Message Segment Question This Segment is always sent. This Segment is situational.
Check X
Prior Authorization Inquiry Accepted/Approved
Provide general information when used for transmission-level messaging.
Response Message Segment Segment Identification (111-AM) = "20"
Field #
NCPDP Field Name
504-F4
Message
Prior Authorization Inquiry Accepted/ Approved
Value
Payer Usage
Payer situation
RW Required if text is needed for clarification or detail.
Response Status Segment Question This Segment is always sent.
Check X
Prior Authorization Inquiry Accepted/Approved
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Segment Identification (111-AM) = "21"
Prior Authorization Inquiry Accepted/Approved
Field # NCPDP Field Name
Values
Payer Usage
Payer Situation
112-AN Transaction Response A = Approved
M
Status
130-UF
Additional Message Information Count
RW Required if Additional Message Information (526-FQ) is used.
132-UH
Additional Message Information Qualifier
RW Required if Additional Message Information (526-FQ) is used.
526-FQ
Additional Message Information
RW Required when additional text is needed for clarification or detail.
131-UG
Additional Message Information Continuity
RW Required only if current repetition of Additional Message Information (526-FQ) is used.
Response Claim Segment Question This Segment is always sent.
Check X
Prior Authorization Inquiry Accepted/Approved
Response Claim Segment Segment Identification (111-AM) = "22"
Field #
NCPDP Field Name
Value
455-EM Prescription/ Service
1 = Rx Billing
Reference Number Qualifier
402-D2 Prescription/ Service Reference Number
Prior Authorization Inquiry Accepted/Approved
Payer Usage
M
Payer Situation
M
Response Prior Authorization Segment Question
This Segment is always sent.
X
Check
Prior Authorization Inquiry Accepted/Approved
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Prior Authorization Segment Segment Identification
(111-AM) = "26"
Field # NCPDP Field Name
498-PR Prior Authorization Processed Date
498-PS
Prior Authorization Effective Date
498-PT
Prior Authorization Expiration Date
498-RA Prior Authorization Quantity
498-RB Prior Authorization Dollars Authorized
498-PW
Prior Authorization Number of Refills Authorized
498-PY
Prior Authorization Number Assigned
Prior Authorization Inquiry Accepted/Approved
Value
Payer Usage
R
Payer Situation
RW Required if the PA has an effective date.
RW Required if the PA has an expiration date.
RW Required if the total quantity authorized is greater than zero.
RW Required if the total dollars authorized is greater than zero.
RW Required if a specific number of refills is authorized.
RW Required if the receiver's system assigns this number.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
4.2.3 Accepted/Deferred
Response Transaction Header Question
This Segment is always sent.
X
Check
Prior Authorization Inquiry Accepted/Deferred
Response Transaction Header Segment
Prior Authorization Inquiry Accepted/Deferred
Field #
NCPDP Field Name
102-A2 Version/Release Number D0
Value
Payer Usage
M
Payer Situation
103-A3 Transaction Code
P3
M
109-A9 Transaction Count
Same value as in request. M
501-F1 Header Response Status A = Accepted
M
202-B2 Service Provider ID Qualifier Same value as in request. M
201-B1 Service Provider ID
Same value as in request. M
401-D1 Date of Service
Same value as in request. M
Response Message Segment Question This Segment is always sent. This Segment is situational.
Check X
Prior Authorization Inquiry Accepted/Deferred
Provide general information when used for transmission-level messaging.
Response Message Segment Segment Identification (111-AM) = "20"
Field #
NCPDP Field Name
504-F4 Message
Value
Prior Authorization Inquiry Accepted/Deferred
Payer Usage
RW
Payer Situation
Required if text is needed for clarification or detail.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Question This Segment is always sent.
Check X
Prior Authorization Inquiry Accepted/Deferred
Response Status Segment Segment Identification (111-AM) = "21"
Field # NCPDP Field Name
112-AN 503-F3
Transaction Response Status
Authorization Number
Values F = Deferred
130-UF Additional Message Information Count
132-UH Additional Message Information Qualifier
526-FQ Additional Message Information
131-UG Additional Message Information Continuity
549-7F 550-8F
Help Desk Phone Number Qualifier
Help Desk Phone Number
Prior Authorization Inquiry Accepted/Deferred
Payer Usage
M
Payer Situation
RW Required if needed to identify the transaction.
RW Required if Additional Message Information (526-FQ) is used.
RW Required if Additional Message Information (526-FQ) is used.
RW Required when additional text is needed for clarification or detail.
RW Required only if current repetition of Additional Message Information (526-FQ) is used.
RW Required if Help Desk Phone Number (550-8F) is used.
RW Required if needed to provide a support telephone number to the receiver.
Response Claim Segment Question This Segment is always sent.
Check X
Prior Authorization Inquiry Accepted/Deferred
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Claim Segment Segment Identification (111-AM) = "22"
Field #
NCPDP Field Name
Value
455-EM 402-D2
Prescription/ Service
1 = Rx Billing
Reference Number Qualifier
Prescription/ Service Reference Number
Prior Authorization Inquiry Accepted/Deferred
Payer Usage
M
Payer Situation
M
Response Prior Authorization Segment Question
This Segment is situational.
X
Check
Prior Authorization Inquiry Accepted/Deferred
Response Prior Authorization Segment
Segment Identification (111-AM) = "26"
Field # NCPDP Field Name
498-PR
Prior Authorization Processed Date
Prior Authorization Inquiry Accepted/Deferred
Value
Payer Usage
R
Payer Situation
Page 66
Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
4.2.4 Accepted/Rejected
Response Transaction Header Question
This Segment is always sent.
X
Check
Prior Authorization Inquiry Accepted/Rejected
Response Transaction Header Segment
Prior Authorization Inquiry Accepted/Rejected
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
P3
M
109-A9 Transaction Count
Same value as in request. M
51-F1 Header Response Status
A = Accepted
M
202-B2 Service Provider ID Qualifier Same value as in request. M
201-B1 Service Provider ID
Same value as in request. M
401-D1 Date of Service
Same value as in request. M
Response Message Segment Question This Segment is always sent. This Segment is situational.
Check X
Prior Authorization Inquiry Accepted/Rejected
Provide general information when used for transmission-level messaging.
Response Message Segment Segment Identification (111-AM) = "20"
Field #
NCPDP Field Name
504-F4 Message
Prior Authorization Inquiry Accepted/Rejected
Value
Payer Usage
RW
Payer Situation
Required if text is needed for clarification or detail.
Response Status Segment Question This Segment is always sent.
Check X
Prior Authorization Inquiry Accepted/Rejected
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Segment Identification (111-AM) = "21"
Prior Authorization Inquiry Accepted/Rejected
Field #
NCPDP Field Name
Values
112-AN Transaction Response Status R = Rejected
Payer Usage
M
Payer Situation
503-F3 Authorization Number
RW Required if needed to identify the transaction.
510-FA Reject Count
R
511-FB Reject Code
R
546-4F Reject Field Occurrence
R
Indicator
130-UF Additional Message Information Count
RW Required if Additional Message Information (526-FQ) is used.
132-UH Additional Message Information Qualifier
RW Required if Additional Message Information (526-FQ) is used.
526-FQ Additional Message Information
RW Required when additional text is needed for clarification or detail.
131-UG Additional Message Information Continuity
RW Required if current repetition of Additional Message Information (526-FQ) is used.
549-7F
Help Desk Phone Number Qualifier
RW Required if Help Desk Phone Number (550-8F) is used.
550-8F Help Desk Phone Number
RW Required if needed to provide a support telephone number to the receiver.
Response Claim Segment Question This Segment is always sent.
Check X
Prior Authorization Inquiry Accepted/Rejected
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Claim Segment Segment Identification (111-AM) = "22"
Field #
NCPDP Field Name
Value
455-EM 402-D2
Prescription/ Service
1 = Rx Billing
Reference Number Qualifier
Prescription/ Service Reference Number
Prior Authorization Inquiry Accepted/Rejected
Payer Usage
M
Payer Situation
M
4.2.5 Rejected/Rejected
Response Transaction Header Question
This Segment is always sent.
X
Check
Prior Authorization Inquiry Rejected/Rejected
Response Transaction Header Segment
Prior Authorization Inquiry Rejected/Rejected
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
P3
M
109-A9 Transaction Count
Same value as in request. M
501-F1 Header Response Status R = Rejected
M
202-B2 Service Provider ID Qualifier Same value as in request. M
201-B1 Service Provider ID
Same value as in request. M
401-D1 Date of Service
Same value as in request. M
Response Message Segment Question This Segment is always sent. This Segment is situational.
Check X
Prior Authorization Inquiry Rejected/Rejected
Provide general information when used for transmission-level messaging.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Message Segment Segment Identification (111-AM) = "20"
Field #
NCPDP Field Name
504-F4 Message
Prior Authorization Inquiry Rejected/Rejected
Value
Payer Usage
Payer Situation
RW
Required if text is needed for
clarification or detail.
Response Status Segment Question This Segment is always sent.
Check X
Prior Authorization Inquiry Rejected/Rejected
Response Status Segment Segment Identification (111-AM) = "21"
Prior Authorization Inquiry Rejected/Rejected
Field #
NCPDP Field Name
Values
Payer Usage
Payer Situation
112-AN Transaction Response Status R = Rejected
M
503-F3 Authorization Number
RW Required if needed to identify the transaction.
510-FA Reject Count
R
511-FB Reject Code
R
546-4F Reject Field Occurrence
R
Indicator
130-UF
Additional Message Information Count
RW Required if Additional Message Information (526-FQ) is used.
132-UH Additional Message Information Qualifier
RW Required if Additional Message Information (526-FQ) is used.
526-FQ
Additional Message Information
RW Required when additional text is needed for clarification or detail.
131-UG Additional Message Information Continuity
RW Required only if current repetition of Additional Message Information (526-FQ) is used.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Segment Identification (111-AM) = "21"
Field #
NCPDP Field Name
549-7F 550-8F
Help Desk Phone Number Qualifier
Help Desk Phone Number
Prior Authorization Inquiry Rejected/Rejected
Values
Payer Usage
Payer Situation
RW Required if Help Desk Phone Number (550-8F) is used.
RW Required if needed to provide a support telephone number to the receiver.
***End of Response Prior Authorization Inquiry (P3) Payer Sheet Template***
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
5.0 NCPDP Version D.0 Prior Authorization Request Only Template
5.1 P4 Prior Authorization Request Only Request
***Start of Request Prior Authorization Request Only (P4) Payer Sheet Template***
Refer to the General Information tables at the beginning of this document for contact and processing information.
The following lists the segments and fields in a Request Prior Authorization Request Only transaction for NCPDP Telecommunication Standard Implementation Guide Version D.0.
Transaction Header Segment Question
This Segment is always sent.
X
Source of certification IDs required in X Software Vendor/ Certification ID is Payer issued.
Check
Prior Authorization Request Only
Transaction Header Segment
Prior Authorization Request Only
Field #
NCPDP Field Name
101-A1 BIN Number
Value 022659
Payer Usage
Payer Situation
M NEW!
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
P4
M
104-A4 Processor Control Number 6334225
M NEW!
109-A9 Transaction Count
1
M
202-B2 Service Provider ID Qualifier 01 = NPI
M
201-B1 Service Provider ID
M
401-D1 Date of Service
M
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Transaction Header Segment
Field #
NCPDP Field Name
110-AK
Software Vendor/ Certification ID
Prior Authorization Request Only
Value
Payer Usage
Payer Situation
This will be provided by M Required when vendor is
the provider's software
certified with Magellan
vendor.
otherwise submit all zeroes.
Insurance Segment Question
Check
This Segment is always sent.
X
Prior Authorization Request Only
Insurance Segment Segment Identification
(111-AM) = "04"
Field #
NCPDP Field Name
302-C2 306-C6
Cardholder ID Patient Relationship Code
Value
1 = Cardholder 3 = Child 4 = Other (use for Transplant Donor)
Prior Authorization Request Only
Payer Usage
Payer Situation
M
Submit CIN, HAP, or BIC.
RW
NEW!
Required to submit "3" when
submitting newborn claims
using Mom's Medi-Cal
Cardholder ID.
Required to submit "4" when submitting claims for a transplant donor, when using transplant recipient's Medi-Cal Cardholder ID.
Patient Segment Question
This Segment is always sent.
X
This Segment is Situational.
Check
Prior Authorization Request Only
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Patient Segment Segment Identification
(111-AM) = "01"
Field # NCPDP Field Name
304-C4 Date of Birth
Value
Prior Authorization Request Only
Payer Usage
R
Payer Situation
305-C5 Patient Gender Code
RW Required if additional verification of the submitted eligibility information is needed.
310-CA Patient First Name
R
311-CB Patient Last Name
R
307-C7 Place of Service
RW Required if this field could result in different coverage, pricing, or patient financial responsibility. The use of code "31," "32," or "54" in this field as an identifier for beneficiaries residing in Long Term Care will sunset on 02/28/2021
384-4X
Patient Residence
3 = Nursing Facility
RW
9 = Intermediate Care
Facility/Individuals with
Intellectual Disabilities
NEW! Required if this field could result in different coverage, pricing, or patient financial responsibility. Required for Long Term Care.
Claim Segment Question
This Segment is always sent.
Check X
Prior Authorization Request Only
Claim Segment Segment Identification
(111-AM) = "07"
Field # NCPDP Field Name
Value
455-EM
Prescription/ Service Reference Number Qualifier
1 = Rx Billing
Prior Authorization Request Only
Payer Usage
M
Payer Situation
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Claim Segment Segment Identification
(111-AM) = "07"
Prior Authorization Request Only
Field # NCPDP Field Name
Value
Payer Usage
Payer Situation
402-D2 Prescription/ Service
M
Reference Number
436-EI
Product/Service ID Qualifier
03 = NDC
M
00 = Compound drug
407-D7 Product/Service ID
M
442-E7 Quantity Dispensed
R
460-ET Quantity Prescribed
RW Required when a transmission is for a Scheduled II drug as defined in 21 CFR 1308.12 and per CMS-0055-F (Compliance Date 09/21/2020. Refer to the Version D.0 Editorial Document).
405-D5 Days Supply
R
406-D6 Compound Code
1 = Not Compound 2 = Compound
RW Required if requesting a prior authorization for a compound (Compound Code (406-D6) = 2).
408-D8
Dispense as Written (DAW)/Product Selection Code
RW Required if this field results in different coverage.
415-DF Number of Refills
R
Authorized
995-E2 Route of Administration
RW Required for multi-ingredient compounds.
Prior Authorization Segment Question This Segment is always sent.
Check X
Prior Authorization Request Only
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Prior Authorization Segment Segment Identification (111-AM) = "12"
Field #
NCPDP Field Name
498-PA 498-PB 498-PC 498-PD 498-PE
498-PF
498-PG
498-PH
498-PJ
498-PK
498-PY
Request Type Request Period Date Begin Request Period Date End Basis of Request Authorized Representative First Name Authorized Representative Last Name Authorized Representative Street Address Authorized Representative City Address Authorized Representative State/Province Address Authorized Representative Zip/Postal Zone Prior Authorization Number Assigned
498-PP
Prior Authorization Supporting Documentation
Value
Prior Authorization Request Only
Payer Usage
Payer Situation
M
M
M
M
RW
Required if needed for prior
authorization determination.
RW
Required if needed for prior
authorization determination.
RW
Required if needed for prior
authorization determination.
RW
Required if needed for prior
authorization determination.
RW
Required if needed for prior
authorization determination.
RW
Required if needed for prior
authorization determination.
RW
Required if known to sender.
Payer Requirement: Required
on a reauthorization.
RW
Required if additional
information is needed for
prior authorization
determination.
Prescriber Segment Question
This Segment is situational.
Check X
Prior Authorization Request Only
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Prescriber Segment Segment Identification
(111-AM) =" 03"
Field #
NCPDP Field Name
466-EZ Prescriber ID Qualifier
Value 01= NPI
411-DB Prescriber ID
427-DR 498-PM
Prescriber Last Name Prescriber Phone Number
Prior Authorization Request Only
Payer Usage
Payer Situation
RW Required if Prescriber ID (411DB) is used.
RW Required if this field could result in different coverage or patient financial responsibility.
RW Required if known.
RW Required if known.
Compound Segment Question This Segment is always sent. This Segment is situational.
Check X
Prior Authorization Request Only Required for submitting compound drug.
Compound Segment Segment Identification
(111-AM) = "10"
Prior Authorization Request Only
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
450-EF Compound Dosage Form
M
Description Code
451-EG Compound Dispensing Unit
M
Form Indicator
447-EC
Compound Ingredient Component Count
Maximum count M of 25 ingredients.
Medi-Cal supports up to 24 compound product IDs and 1 for the container count (25 Product IDs if a container count is included).
488-RE Compound Product ID Qualifier
M
99 = Other (Container Count)
Must be accompanied with
99999999997 in field 489-TE.
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Compound Segment Segment Identification
(111-AM) = "10"
Field #
NCPDP Field Name
489-TE Compound Product ID
448-ED Compound Ingredient Quantity
Value
Prior Authorization Request Only
Payer Usage
Payer Situation
M
When specifying the number
of containers as an ingredient,
the NDC should be equal to
99999999997.
M
Clinical Segment Question This Segment is always sent. This Segment is situational.
Check
Prior Authorization Request Only
X
Please see Pharmacy Provider Manual for
diagnosis code submission requirements.
Clinical Segment Segment Identification
(111-AM) = "13"
Field #
NCPDP Field Name
491-VE Diagnosis Code Count
492-WE Diagnosis Code Qualifier
424-DO 493-XE
Diagnosis Code
Clinical Information Counter
Prior Authorization Request Only
Value
Payer Usage
Payer Situation
Maximum count of 5. RW
Required if Diagnosis Code Qualifier (492-WE) and Diagnosis Code (424-DO) are used.
02= International
RW
Classification of
Diseases (ICD-10 CM)
Required if Diagnosis Code (424DO) is used.
R Required to be submitted.
RW Maximum of 5 occurrences supported.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Clinical Segment Segment Identification
(111-AM) = "13"
Field #
NCPDP Field Name
Value
496-H2
Measurement Dimension 14 = Height 16 = Weight
497-H3 Measurement Unit
01 = Inches 03 = Pounds
499-H4 Measurement Value
Prior Authorization Request Only
Payer Usage
Payer Situation
RW Required if Measurement Unit (497-H3) and Measurement Value (499-H4) is used. Required if necessary when this field could result in different coverage and/or drug utilization review outcome and is a requirement for authorization.
Payer Requirement: Must be present with counter value found in field 493-XE.
RW Required if Measurement Dimension (496-H2) and Measurement Value (499-H4) are used. Required if necessary when this field could result in different coverage and/or drug utilization review outcome and is a requirement for authorization.
Payer Requirement: Must be present with counter value found in field 493-XE.
RW Required if Measurement Dimension (496-H2) and Measurement Unit (497-H3) are used. Required if necessary when this field could result in different coverage and/or drug utilization review outcome and is a requirement for authorization.
***End of Request Prior Authorization Request Only (P4) Payer Sheet Template***
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
5.2 P4 Prior Authorization Request Only Response
5.2.1 Accepted/Captured
***Start of Response Prior Authorization Request Only (P4) Payer Sheet Template***
Refer to the General Information tables at the beginning of this document for contact and processing information.
Response Transaction Header Question
This Segment is always sent.
Check X
Prior Authorization Request Only
Accepted/Captured
Response Transaction Header Segment
Prior Authorization Request Only Accepted/Captured
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
P4
M
109-A9 Transaction Count
Same value as in request. M
501-F1 Header Response Status A = Accepted
M
202-B2 Service Provider ID Qualifier Same value as in request. M
201-B1 Service Provider ID
Same value as in request. M
401-D1 Date of Service
Same value as in request. M
Response Message Segment Question This Segment is always sent. This Segment is situational.
Check X
Prior Authorization Request Only Accepted/Captured
Provide general information when used for transmission-level messaging.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Message Segment Segment Identification (111-AM) = "20"
Field #
NCPDP Field Name
504-F4 Message
Prior Authorization Request Only Accepted/Captured
Value
Payer Usage
Payer Situation
RW Required if text is needed for clarification or detail.
Response Status Segment Question This Segment is always sent.
Check X
Prior Authorization Request Only Accepted/Captured
Response Status Segment Segment Identification (111-AM) = "21"
Prior Authorization Request Only Accepted/Captured
Field #
NCPDP Field Name
Values
Payer Usage
Payer Situation
112-AN Transaction Response Status C = Captured
M
503-F3 Authorization Number
RW Required if needed to identify the transaction.
130-UF
Additional Message Information Count
RW Required if Additional Message Information (526-FQ) is used.
132-UH
Additional Message Information Qualifier
RW Required if Additional Message Information (526-FQ) is used.
526-FQ
Additional Message Information
RW Required when additional text is needed for clarification or detail.
131-UG
Additional Message Information Continuity
RW Required only if current repetition of Additional Message Information (526-FQ) is used.
549-7F
Help Desk Phone Number Qualifier
RW Required if Help Desk Phone Number (550-8F) is used.
550-8F Help Desk Phone Number
RW Required if needed to provide a support telephone number to the receiver.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Claim Segment Question This Segment is always sent.
Check X
Prior Authorization Request Only Accepted/Captured
Response Claim Segment Segment Identification (111-AM) = "22"
Prior Authorization Request Only Accepted/Captured
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
455-EM Prescription/ Service
1 = Rx Billing
M
Reference Number Qualifier
402-D2 Prescription/ Service
M
Reference Number
5.2.2 Accepted/Rejected
Response Transaction Header Question
This Segment is always sent.
X
Check
Prior Authorization Request Only Accepted/Rejected
Response Transaction Header Segment
Prior Authorization Request Only Accepted/Rejected
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2 Version/Release Number
D0
M
103-A3 Transaction Code
P4
M
109-A9 Transaction Count
Same value as in request. M
501-F1 Header Response Status
A = Accepted
M
202-B2 Service Provider ID Qualifier Same value as in request. M
201-B1 Service Provider ID
Same value as in request. M
401-D1 Date of Service
Same value as in request. M
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Message Segment Question This Segment is always sent. This Segment is situational.
Check X
Prior Authorization Request Only Accepted/Rejected
Provide general information when used for transmission-level messaging.
Response Message Segment Segment Identification (111-AM) ="20"
Field #
NCPDP Field Name
504-F4 Message
Prior Authorization Request Only Accepted/Rejected
Value
Payer Usage
Payer Situation
RW Required if text is needed for clarification or detail.
Response Status Segment Question This Segment is always sent.
Check X
Prior Authorization Request Only Accepted/Rejected
Response Status Segment Segment Identification (111-AM) = "21"
Prior Authorization Request Only Accepted/Rejected
Field #
NCPDP Field Name
Values
Payer Usage
Payer Situation
112-AN Transaction Response Status R = Rejected
M
503-F3 Authorization Number
RW Required if needed to identify the transaction.
510-FA Reject Count
R
511-FB Reject Code
R
546-4F Reject Field Occurrence
R
Indicator
130-UF
Additional Message Information Count
RW Required if Additional Message Information (526-FQ) is used.
132-UH
Additional Message Information Qualifier
RW Required if Additional Message Information (526-FQ) is used.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Segment Identification (111-AM) = "21"
Field #
NCPDP Field Name
526-FQ 131-UG
Additional Message Information
Additional Message Information Continuity
549-7F 550-8F
Help Desk Phone Number Qualifier
Help Desk Phone Number
Prior Authorization Request Only Accepted/Rejected
Values
Payer Usage
Payer Situation
RW Required when additional text is needed for clarification or detail.
RW Required only if current repetition of Additional Message Information (526-FQ) is used.
RW Required if Help Desk Phone Number (550-8F) is used.
RW Required if needed to provide a support telephone number to the receiver.
Response Claim Segment Question This Segment is always sent.
Check X
Prior Authorization Request Only Accepted/Rejected
Response Claim Segment Segment Identification (111-AM) = "22"
Prior Authorization Request Only Accepted/Rejected
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
455-EM Prescription/ Service
1 = Rx Billing
M
Reference Number Qualifier
402-D2 Prescription/ Service
M
Reference Number
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
5.2.3 Rejected/Rejected
Response Transaction Header Question
This Segment is always sent.
X
Check
Prior Authorization Request Only Rejected/Rejected
Response Transaction Header Segment
Prior Authorization Request Only Rejected/Rejected
Field #
NCPDP Field Name
Value
Payer Usage
Payer Situation
102-A2 Version/Release Number D0
M
103-A3 Transaction Code
P4
M
109-A9 Transaction Count
Same value as in request. M
501-F1 Header Response Status R = Rejected
M
202-B2 Service Provider ID Qualifier Same value as in request. M
201-B1 Service Provider ID
Same value as in request. M
401-D1 Date of Service
Same value as in request. M
Response Message Segment Question This Segment is always sent. This Segment is situational.
Check X
Prior Authorization Request Only Rejected/Rejected
Provide general information when used for transmission-level messaging.
Response Message Segment Segment Identification (111-AM) = "20"
Field #
NCPDP Field Name
504-F4 Message
Prior Authorization Request Only Rejected/Rejected
Value
Payer Usage
Payer Situation
RW Required if text is needed for clarification or detail.
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Response Status Segment Question This Segment is always sent.
Check X
Prior Authorization Request Only Rejected/Rejected
Response Status Segment Segment Identification (111-AM) = "21"
Prior Authorization Request Only Rejected/Rejected
Field #
NCPDP Field Name
Values
112-AN Transaction Response Status R = Rejected
Payer Usage
M
Payer Situation
503-F3 Authorization Number
RW Required if needed to identify the transaction.
510-FA Reject Count
R
511-FB Reject Code
R
546-4F Reject Field Occurrence
R
Indicator
130-UF
Additional Message Information Count
RW Required if Additional Message Information (526-FQ) is used.
132-UH
Additional Message Information Qualifier
RW Required if Additional Message Information (526-FQ) is used.
526-FQ
Additional Message Information
RW Required when additional text is needed for clarification or detail.
131-UG
Additional Message Information Continuity
RW Required only if current repetition of Additional Message Information (526-FQ) is used.
549-7F
Help Desk Phone Number Qualifier
RW Required if Help Desk Phone Number (550-8F) is used.
550-8F Help Desk Phone Number
RW Required if needed to provide a support telephone number to the receiver.
***End of Response Prior Authorization Request Only (P4) Payer Sheet Template***
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Medi-Cal Rx Payer Specification Sheet Proprietary & Confidential
Microsoft Word for Microsoft 365