835 companion guide v4010 detail - november 2009

Medco X12N 835 Companion Guide (Detail) 835 (004010X091A1)

835 Companion Guide v4010 Detail - November 2009.doc of 45 September 1, 2009

MedcoX12N 835 Companion Guide (Detail)

DISCLAIMER:

This document is a tool designed to aid the provider/receiver in populating the ASC X12N 835 Health CareClaim Payment/Remittance Advice, version 004010X091A1, from the NCPDP 2.0 Payment standard. Theexample represented in the segments has ‘*’ as the element delimiter, ‘:’ as the sub-element delimiter and‘~’ as the segment terminator for illustration purpose only. See page 38 of this document for the actualdelimiters.

Medco makes the following assumptions:

A. Each 835 transaction set corresponds to one Check, unless the transaction amount is $0.00 inwhich case no check will be issued. Multiple claims can be referenced within one 835. Thetransaction limitation for a trading partner is extended by Medco to allow more than 10,000 Rxpayments for a given Check.

B. Balancing is substantially different between NCPDP and 835. The 835 starts with the GrossAmount Due then applies adjustments, resulting in an amount payable. There are 3 levels ofBalancing in 835.

1. SERVICE level, each service pertains to an Rx, the balancing within an Rx must be such thatthe Line Item Charge Amount (SVC02) minus the sum of all the Adjustment Amounts (co-pay,deductible, dispensing fee etc.) equals the Line Item Provider Payment Amount (SVC03) forthis prescription.

2. CLAIM level, the adjustments are handled in the Service level, so the claim level adjustmentis the same as the service level adjustments.

3. CHECK level, within the Check, the sum of all Rx payments minus the sum of all providerlevel adjustments (PLB) i.e., the non-claim adjustments like the transmission fee etc. equalsthe total payment amount on the Check.

C. Ingredient Cost is expanded to accommodate Rx's that are higher than $99,999.99.

D. NCPDP monetary amounts have signs imbedded as an ‘over punch’, while the 835 has aleading sign for negative numbers; positive numbers are unsigned.

E. NCPDP alphanumeric strings are fixed length, but are variable length for the 835 standard.

F. Pharmacy Total is no longer supported. Only Check totals will be supported.

G. Adjustments initiated by the Medco can be identified when field number CLP07, Payer ClaimControl Number contains the 12 digit Medco Batch Id that currently exists on the NCPDP 2.0format. Adjustments with Dates of Service prior to 9/28/02 will not have all of the fields indicated.

H. Non-claim adjustments i.e., Transmission Fee will be provided on the PLB segment in 835.

I. The Interchange Receiver ID (ISA08) and Application Receiver’s Code (GS03) default to Medco'sChain or Franchise ID. If you wish to use any other ID, please contact Medco at 1-800-922-1557.

Medco X12N 835 Pharmacy Remittance Payer Guide 835 (004010X091A1)


Heading:

Page Pos. Seg. Req. LoopNo. No. ID Name Des. Max.Use Repeat

3 010 ST Transaction Set Header M 14 020 BPR Financial Information M 17 040 TRN Reassociation Trace Number M 18 060 REF Receiver Identification S 19 070 DTM Production Date S 1

LOOP ID - 1000A PAYER IDENTIFICATION 110 080 N1 Payer Identification M 111 100 N3 Payer Address M 112 110 N4 Payer City, State, ZIP Code M 113 130 PER Payer Contact Information M 1

LOOP ID - 1000B PAYEE IDENTIFICATION 114 080 N1 Payee Identification M 115 100 N3 Payee Address S 116 110 N4 Payee City, State, ZIP Code S 117 120 REF Payee Additional Identification S 1

Detail:


LOOP ID – 2000 HEADER NUMBER >118 003 LX Header Number S 119 005 TS3 Provider Summary Information S 1

LOOP ID – 2100 CLAIM PAYMENT INFORMATION >120 010 CLP Claim Payment Information M 123 030 NM1 Patient Name M 124 030 NM1 Insured Name S 125 030 NM1 Service Provider Name S 1

LOOP ID – 2110 SERVICE PAYMENT INFORMATION 126 070 SVC Service Payment Information S 128 080 DTM Service Date S 133 110 AMT Service Supplemental Amount S 134 130 LQ Health Care Remark Codes S 5

Summary:


Note: For ICS Interchange Control Structures, see pages from 37 to 44 in this document.

35 010 PLB Provider Adjustment S >137 020 SE Transaction Set Trailer M 1



Segment: ST Transaction Set Header

Position: 010Loop:Level: Heading

Usage: MandatoryMax Use: 1Purpose: To indicate the start of a transaction set and to assign a control number

Syntax Notes:

Data Element Summary

Ref. DataUsage Des. Element Name Attributes

REQUIRED ST01 143 Transaction Set Identifier Code M ID 3/3Code uniquely identifying a Transaction Set

This data element will always be ‘835’ to represent the Pharmacy ClaimPayment/ Remittance Advice.

REQUIRED ST02 329 Transaction Set Control Number M AN 4/9Identifying control number that must be unique within the transaction setfunctional group assigned by the originator for a transaction set

The Transaction Set Control Numbers in ST02 and SE02 are identical andunique within a specific group and interchange, but it can be repeated inother groups and interchanges. This number aids in error resolutionresearch.

This field is Medco assigned number.



Segment: BPR Financial Information


Usage: MandatoryMax Use: 1Purpose: To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total

payment amount, or to enable related transfer of funds and/or information from payer topayee to occur. BPR segment addresses a single payment to a single payee.

Syntax Notes:Notes: Each 835 transaction set corresponds to one Check. Multiple claims can be

referenced within one 835. The transaction limitation for a trading partner isextended by Medco to allow more than 10,000 Rx payments for a givenCheck.

Example: BPR*I*150000*C*CHK************19960901~



REQUIRED BPR01 305 Transaction Handling Code M ID 1/2Code designating the action to be taken by all parties

I Remittance Information Only

Use this code to indicate to the payee that the remittance detail ismoving separately from the payment.

H Notification Only

Use this code to pass information only, without any reference topayment. Usually this code is used to pass predetermination ofbenefits information from a payer to a provider.

This field is populated with ‘H’, when BPR02 is equal to zero.

REQUIRED BPR02 782 Total Actual Provider Payment Amount M R 1/11

BPR02 is used to populate the Total Check Amount. The total paymentamount for this 835 will not exceed eleven characters, including decimals(99,999,999.99). The 835 will not be issued for less than zero dollars.

This field equals the sum of all CLP04 minus the sum of all PLB04.

REQUIRED BPR03 478 Credit or Debit Flag Code M ID 1/1Code indicating whether amount is a credit or debit

C Credit

Use this code to indicate a credit to the provider'saccount and a debit to the payer's account, initiated bythe payer.



This is the only value supported by Medco.

REQUIRED BPR04 591 Payment Method Code M ID 3/3Code identifying the method for the movement of payment instructions

CHK Check

Use this code to indicate that a check has been issuedfor payment.

NON Non-Payment Data

Use this code when the Transaction Handling Code(BPR01) is H, indicating that this is information only andno dollars are to be moved.

This field is populated with ‘NON’, when BPR01 is‘H’ and BPR02 equals to zero.

SITUATIONAL BPR05 812 Payment Format Code O ID 1/10Code identifying the payment format to be used

CCP Cash Concentration /Disbursement plus Addenda(CCD+) (ACH)

SITUATIONAL BPR06 506 Sender DFI ID Number Qualifier X ID 2/2Code identifying the type of identification number of Depository FinancialInstitution (DFI)

01 ABA Transit Routing Number Including Chjeck Digits (9digits)ABA is a unique number identifying every bank in theUnited States.

SITUATIONAL BPR07 507 Sender DFI Identifier X AN 3/12Code identifying the type of identification number of Depository FinancialInstitution (DFI)

SITUATIONAL BPR08 569 Account Number Qualifier O ID 1/3Code identifying the type of account

DA Demand Deposit

SITUATIONAL BPR09 508 Sender Bank Account Number X AN 1/35

SITUATIONAL BPR10 509 Payer Identifier O AN 10/10

Federal Tax ID Number preceeded by a “1”.

SITUATIONAL BPR11 510 Originating Company Supplemental Code O AN 9/9

SITUATIONAL BPR12 506 Receiver DFI ID Number Qualifier X ID 2/2

01 ABA Transit Routing Number including Check Digits (9



digits)ABA is a unique number identifying every bank in theUnited States.

SITUATIONAL BPR13 507 Receiver Bank ID Number X AN 3/12

This is the receiver or provider’s Federal Tax ID Number preceded by a “1”.

SITUATIONAL BPR14 569 (Receiver) Account Number Qualifier O ID 1/3Code identifying the type of account

DASG

Demand DepositSaving

SITUATIONAL BPR15 508 Receiver Bank Account Number X AN 1/35

REQUIRED BPR16 373 Check Issue Date O DT 8/8Date expressed as CCYYMMDD

This is the Check Issuance Date.



Segment: TRN Reassociation Trace Number


Usage: MandatoryMax Use: 1Purpose: To uniquely identify a transaction to an application

Syntax Notes:Notes: This segment's purpose is to uniquely identify this transaction set and to aid in

reassociating payments and remittances that have been separated.

Example: TRN*1*12345*1512345678~

Data Element SummaryRef. Data

Usage Des. Element Name AttributesREQUIRED TRN01 481 Trace Type Code M ID 1/2

Code identifying which transaction is being referenced

1 Current Transaction Trace Numbers

REQUIRED TRN02 127 Check Number M AN 1/30

REQUIRED TRN03 509 Payer Identifier O AN 10/10

This is the Medco's Tax ID preceded by '1’ i.e., 1223461740.



Segment: REF Receiver Identification


Usage: OptionalMax Use: 1Purpose: This segment is used only when the receiver of the transaction is other than the payee

(e.g., Clearing House or Franchise).Syntax Notes:

Notes:

This segment will always be populated by Medco.

Example: REF*EV*1235678~


Usage Des. Element Name AttributesREQUIRED REF01 128 Reference Identification Qualifier M ID 2/3

EV Receiver Identification NumberA unique number identifying the organization/sitelocation designated to receive the currenttransmitted transaction set

REQUIRED REF02 127 Receiver Identifier O AN 1/30

Default to Medco's Chain Identification # or FranchiseIdentification #. If you want to use any other number, pleasecontact Medco at 1-800-922-1557.



Segment: DTM Production Date


Usage: OptionalMax Use: 1Purpose: To specify pertinent dates and times.

Syntax Notes:Notes: The production date must be supplied when the cutoff date of the adjudication

system is different from the date of the 835.


Example: DTM*405*19960317~



REQUIRED DTM01 374 Date Time Qualifier M ID 3/3Code specifying type of date or time, or both date and time

405 ProductionUsed to identify dates and times that operations orprocesses were performed

REQUIRED DTM02 373 Production Date O DT 8/8Date expressed as CCYYMMDD

This is the cycle end date.



Segment: N1 Payer Identification

Position: 080Loop: 1000A MandatoryLevel: Heading

Usage: MandatoryMax Use: 1Purpose: To identify a party by type of organization, name, and code

Syntax Notes: 1 At least one of N102 or N103 is required.2 If either N103 or N104 is present, then the other is required.

Notes: This segment, used alone, provides the most efficient method of providingorganizational identification. To obtain this efficiency the ‘ID Code’ (N104) mustprovide a key to the table maintainable by the transaction processing party.

Example: N1*PR*INSURANCE COMPANY OF TIMBUCKTU*XV*88888888~



REQUIRED N101 98 Entity Identifier Code M ID 2/3Code identifying an organizational entity, a physical location, property oran individual

PR Payer

REQUIRED N102 93 Payer Name X AN 60/60

PAYER NAME is the Check Header name (from position 1 to 58) +CHECK STOCK ID (from position 59 to 60).

SITUATIONAL N103 66 Identification Code Qualifier X ID 1/2

This will be sent only when the National Plan ID is available.

XV Health Care Financing Administration NationalPayer Identification Number (PAYERID)

SITUATIONAL N104 67 Payer Identifier X AN 2/80

This will be sent only when the National Plan ID is available.



Segment: N3 Payer Address


Usage: MandatoryMax Use: 1Purpose: To specify the location of the Payer party

Syntax Notes:Notes: Example: N3*100 MAIN STREET~



REQUIRED N301 166 Payer Address Line M AN 1/55

Payer Address Line 1

SITUATIONAL N302 166 Payer Address Line O AN 1/55

Payer Address Line 2, if exists.



Segment: N4 Payer City, State, ZIP Code


Usage: MandatoryMax Use: 1Purpose: To specify the city, state and ZIP code of the payer party.

Syntax Notes:Notes: Example: N4*KANSAS CITY*MO*64108~



REQUIRED N401 19 Payer City Name O AN 2/30

REQUIRED N402 156 Payer State Code O ID 2/2

REQUIRED N403 116 Payer Postal Zone or ZIP Code O ID 3/15



Segment: PER Payer Contact Information

Position: 130Loop: 1000A OptionalLevel: Heading

Usage: OptionalMax Use: 1Purpose: To identify a person of office to whom adminstrative communications should be directed.

Notes: Example: PER*CX*JOHN WAYNE*TE*1-201-123-4567~



REQUIRED PER01 366 Contact Function Code M ID 2/2

CX - Payers Claim Office

REQUIRED PER03 365 Communication Number Qualifier X ID 2/2

TE - Telephone

REQUIRED PER04 364 Payer Contact Communication Number X AN 1/80

1-800-922-1557



Segment: N1 Payee Identification

Position: 080Loop: 1000B MandatoryLevel: Heading

Usage: MandatoryMax Use: 1Purpose: To identify a party by type of organization, name, and code

Syntax Notes: 1 At least one of N102 or N103 is required.2 If either N103 or N104 is present, then the other is required.

Notes: Use this N1 loop to provide the name/address information of the payee. Theidentifying reference number should be provided in N104.

Example: N1*PE*ABC PHARMACY*FI*12345678~



REQUIRED N101 98 Entity Identifier Code M ID 2/3Code identifying an organizational entity, a physical location, property oran individual

PE Payee

REQUIRED N102 93 Payee Name X AN 1/60

This field is the Chain Name or Pharmacy Name.

On NCPDP 2.0, the corresponding DD name is Destination Name,DD number is 818-5F and the position is from 116-130 for Chaintapes only. For Franchise tapes, there is no equivalent field onNCPDP 2.0.

REQUIRED N103 66 Identification Code Qualifier X ID 1/2

FIXX

Federal Taxpayer's Identification NumberNational Provider ID

(Note: Only ‘XX’ will be populated 5/23/07onwards.)

REQUIRED N104 67 Payee Identification Code X AN 2/80Payee's Federal Tax ID or National Provider ID.

For a Chain file, this is the Chain’s Tax ID or National Provider IDof one of the Chain Stores. For Franchise or IndependentPharmacy file, this is the Tax ID or National Provider ID of theDispensing Pharmacy. (Note: Only National Provider ID will bereturned 5/23/07 onwards.)



Segment: N3 Payee Address


Usage: OptionalMax Use: 1Purpose: To specify the location of the named party

Syntax Notes:Notes: Use of this segment is at the discretion of the payer for situations where the

sender needs to communicate the payee address to a transaction receiver (forexample, a VAB or a Clearinghouse).


Example: N3*Suite 200*1000 Main Street~



REQUIRED N301 166 Payee Address Line M AN 1/55

Payee Address Line 1

SITUATIONAL N302 166 Payee Address Line O AN 1/55

Required if a second address line exists.



Segment: N4 Payee City, State, ZIP Code


Usage: OptionalMax Use: 1Purpose: To specify the location of the named party.

Syntax Notes:Notes: Using this segment is at the discretion of the payer contingent on the business

needs of the payee (receiver).


Example: N4*Beverly Hills*CA*90210~



REQUIRED N401 19 Payee City Name O AN 2/30

REQUIRED N402 156 Payee State Code O ID 2/2

REQUIRED N403 116 Payee Postal Zone or ZIP Code O ID 3/15



Segment: REF Payee Additional Identification


Usage: OptionalMax Use: 1Purpose: To specify identifying information

Syntax Notes:

Notes: Use this REF segment only when more than one identification number is requiredto identify the payee. Always use the ID number available in the N1 segmentbefore using the REF segment.


Example: REF*PQ*12345678~



REQUIRED REF01 128 Reference Identification Qualifier M ID 2/3

If this segment is used, this field must be ‘PQ’.

PQ Payee Identification

REQUIRED REF02 127 Additional Payee Identifier O AN 1/30

Medco assigned Chain # or Medco Pharmacy ID.



Segment: LX Header Number

Position: 003Loop: 2000 OptionalLevel: Detail

Usage: OptionalMax Use: 1Purpose: To reference a line number in a transaction set

Syntax Notes:Notes: The LX segment is required whenever any information in the LX loop is included

in the transaction. In the event that claim/service information must be sorted, theLX segment must precede each series of claim level and service level segments.


Example: LX*1~

LX*961011~


Usage Des. Element Name AttributesREQUIRED LX01 554 Assigned Number M N0 1/6

Number assigned for differentiation within a transaction set

This field is Medco assigned Sequence Number.



Segment: TS3 Provider Summary Information


Usage: OptionalMax Use: 1Purpose: To supply provider-level control information

Syntax Notes:Notes: This segment will always be populated by Medco.

Example: TS3*123456*99*19961031*10*130957.66~



REQUIRED TS301 127 Provider Identifier M AN 1/30

This field will either be populated with NCPDP ID (previously calledNABP #) or National Provider ID. (Note: 5/23/07 onwards, only theNational Provider ID will be populated here.)

On NCPDP 2.0, the corresponding DD name is Pharmacy Number,DD number is 201-B1 and the position is from 17-28.

REQUIRED TS302 1331 Facility Type Code M AN 1/2Code identifying the type of facility were services were performed.

This field is not part of NCPDP 5.1. Will default to ‘99’.

99 Other

REQUIRED TS303 373 Fiscal Period Date M DT 8/8Date expressed as CCYYMMDD

Use December 31st of the current year.

REQUIRED TS304 380 Total Claim Count M R 1/15

Use this number for the total number of transactions includingpaid claims, adjustments and rejects.

REQUIRED TS305 782 Total Claim Charge Amount M R 1/11

Use this monetary amount for the total reported charges.

This field contains the Total of NCPDP Gross Amount Due (Total ofDollars Billed).

This is the sum of all CLP03 or the sum of all SVC02.



Segment: CLP Claim Payment Information

Position: 010Loop: 2100 MandatoryLevel: Detail

Usage: MandatoryMax Use: 1Purpose: To supply information common to all services of a claim.

Syntax Notes:Notes: Each CLP (Claim) corresponds to a SVC (Service Line) and all claim level

adjustments are handled in SVC level.

Example: CLP*7722337*1*211366.97*138018.4**13*119932404007801~



REQUIRED CLP01 1028 Patient Control Number M AN 1/38

This field will contain the Prescription number.

On NCPDP 2.0, the corresponding DD name is PrescriptionNumber, DD number is 402-D2 and the position is from 14-20.

On NCPDP 5.1, the corresponding DD name is Prescription/Service Reference Number, DD number is 402-D2.

REQUIRED CLP02 1029 Claim Status Code M ID 1/2Code identifying the status of an entire claim as assigned by the payer,claim review organization or repricing organization

Medco supported values are ‘1’, ‘2’, ‘4’, ‘22’ or ‘23’.

1 Processed as Primary

2 Processed as Secondary

4 Denied

22 Reversal of Previous Payment

23 Not Our Claim, Forwarded to Additional Payer(s)

REQUIRED CLP03 782 Total Claim Charge Amount M R 1/11

See 2.2.1, Balancing, in the X12N 835 Health Care ClaimPayment/Advice implementation guide for additional information.

Use this monetary amount for the submitted charges for this claim. Theamount can be zero or less, but the value in BPR02 may not benegative.



This field contains the NCPDP Gross Amount Due (Dollars Billed).

This field is the same as SVC02.

On NCPDP 2.0, the corresponding DD name is Amount Billed, DDnumber is 804-5B and the position is from 34-39.

On NCPDP 5.1, the corresponding DD name is Gross Amount Due,DD number is 430-DU.

REQUIRED CLP04 782 Claim Payment Amount M R 1/11

See 2.2.1, Balancing, in the X12N 835 Health Care ClaimPayment/Advice implementation guide for additional information.

Use this monetary amount for the amount paid for this claim. It can bezero or less, but the value in BPR02 may not be negative.

This field contains the NCPDP Total Amount Paid (Dollars Paid).

This field is the same as SVC03.

On NCPDP 2.0, the corresponding DD name is Amount Paid, DDnumber is 876-4B and the position is from 40-45.

On NCPDP 5.1, the corresponding DD name is Total Amount Paid,DD number is 509-F9.

REQUIRED CLP05 782 Patient Responsibility Amount O R 1/11

Amounts in CLP05 should have supporting adjustments reflected inCAS segment at the SVC loop level with a Claim Adjustment Group(CAS01) code of PR (Patient Responsibility).

Use this monetary amount for the payer's statement of the patientresponsibility amount for this claim, which can include such items asdeductible, non-covered services, co-pay, and co-insurance. Thisamount must be entered if it is greater than zero. See 2.2.1, Balancing,in the X12N 835 Health Care Claim Payment/Advice implementationguide for additional information.

This field contains the NCPDP Patient Pay Amount.

On NCPDP 2.0, the corresponding DD name is Co-pay Amount, DDnumber is 817-5E and the position is from 82-87.

On NCPDP 5.1, the corresponding DD name is Patient Pay Amount,DD number is 505-F5.

REQUIRED CLP06 1032 Claim Filing Indicator Code O ID 1/2Code identifying type of claim



Default to ‘13’.

13 Point of Service (POS)

REQUIRED CLP07 127 Payer Claim Control Number O AN 1/30Use this number for the payer's internal control number.

This field contains the 12 digit Medco Batch ID that currently existsin NCPDP 2.0 format in Payment Record (Record 5) positions 319-320 and positions 347-355. The Reason Code currently inpositions 347-348 (Record 5) will start in positions 4 of the PayerClaim Control Number.



Segment: NM1 Patient Name


Usage: MandatoryMax Use: 1Purpose: To supply the full name of an individual or organizational entity

Syntax Notes: 1 If either NM108 or NM109 is present, then the other is required.Notes: Provide the patient's identification number in NM109.

Example: NM1*QC*1*SHEPHARD*SAM****MI*666666666A~



REQUIRED NM101 98 Entity Identifier Code M ID 2/3Code identifying an organizational entity, a physical location, property oran individual

QC PatientIndividual receiving medical care

REQUIRED NM102 1065 Entity Type Qualifier M ID 1/1Code qualifying the type of entity

1 Person

REQUIRED NM103 1035 Patient Last Name O AN 1/35

On NCPDP 2.0, this field does not exist.On NCPDP 5.1, the corresponding DD name is Patient Last Name,DD number is 311-CB.

REQUIRED NM104 1036 Patient First Name O AN 1/25

On NCPDP 2.0, this field does not exist.On NCPDP 5.1, the corresponding DD name is Patient First Name,DD number is 310-CA.

REQUIRED NM108 66 Identification Code Qualifier M ID 1/2

MI Member Identification Number

REQUIRED NM109 67 Patient Identifier M AN 2/80

This field value is CardholderID and Person Code concatenated bya hyphen.

On NCPDP 2.0, this field does not exist.On NCPDP 5.1, the corresponding DD name is Cardholder ID +Person Code, DD number is 302-C2 + 303-C3.



Segment: NM1 Insured Name


Usage: OptionalMax Use: 1Purpose: To supply the full name of an individual or organizational entity

Syntax Notes: 1 If either NM108 or NM109 is present, then the other is required.Notes: Use this NM1 segment to identify the insured or subscriber whenever the insured

or subscriber is different from the patient. Any necessary identification numbershould be provided in NM109.

This segment will only be populated by Medco when the Patient is aDependent.

Example: NM1*IL*1*SHEPARD*JESSICA****MI*999887777A~


Usage Des. Element Name AttributesREQUIRED NM101 98 Entity Identifier Code M ID 2/3

Code identifying an organizational entity, a physical location, property oran individual

IL Insured or Subscriber


1 Person

REQUIRED NM103 1035 Subscriber Last Name M AN 1/35

On NCPDP 2.0, this field does not exist.On NCPDP 5.1, the corresponding DD name is Cardholder LastName, DD number is 313-CD.

REQUIRED NM104 1036 Subscriber First Name M AN 1/25

On NCPDP 2.0, this field does not exist.On NCPDP 5.1, the corresponding DD name is Cardholder FirstName, DD number is 312-CC.

REQUIRED NM108 66 Identification Code Qualifier X ID 1/2

MI Member Identification Number

REQUIRED NM109 67 Subscriber Identifier X AN 2/80

On NCPDP 2.0, this field does not exist.On NCPDP 5.1, the corresponding DD name is Cardholder ID, DDnumber is 302-C2.



Segment: NM1 Service Provider Name


Usage: OptionalMax Use: 1Purpose: To supply the full name of an individual or organizational entity

Syntax Notes: 1 If either NM108 or NM109 is present, then the other is required.Notes: Use this NM1 segment to provide information about the rendering provider. Any

reference number should be provided in NM109. This segment is required whenthe rendering provider is different from the Payee.

Example: NM1*82*2******PC*12345678~



REQUIRED NM101 98 Entity Identifier Code M ID 2/3Code identifying an organizational entity, a physical location, property oran individual

82 Rendering Provider


2 Non-Person Entity

SITUATIONAL NM103 1035 Rendering Provider Last or Organization Name O AN 1/35

Required when needed to confirm the identifier in NM109.

This field is the Pharmacy Name.

REQUIRED NM108 66 Identification Code Qualifier X ID 1/2

PC Provider Commercial NumberUnique number assigned to the provider forsubmitting claims to commercial insurance carriers

XX National Provider ID(Note: Only ‘XX’ will be populated 5/23/07onwards.)

REQUIRED NM109 67 Rendering Provider Identifier X AN 2/80

This field is the Medco's Internal Pharmacy ID when NM108/2100 =‘PC’; National Provider ID when NM108/2100 = ‘XX’ .

On NCPDP 2.0, the corresponding DD name is Pharmacy Number,DD number is 201-B1 and the position is from 2-13.



Segment: SVC Service Payment Information


Usage: OptionalMax Use: 1Purpose: To supply payment and control information to a provider for a particular service.

Syntax Notes:Notes: Each CLP corresponds to one SVC and only CAS within the SVC will be

utilized to reflect the differences between the submitted and paid amount.


Example: SVC*N4:99214*100*80~



REQUIRED SVC01 C003 Composite Medical Procedure Identifier MAdjudicated Medical Procedure Code. It is a composite data structure.

REQUIRED SVC01-1 235 Product or Service ID Qualifier M ID 2/2Code identifying the type/source of the descriptive number used inProduct/Service ID (234)

The value in SVC01-01 qualifies the values in SVC01-02.

N4 National Drug Code in 5-4-2 Format5-digit manufacturer ID, 4-digit product ID, 2-digittrade package size

REQUIRED SVC01-2 234 Product/Service ID M AN 1/48Identifying number for a product or service

This field contains value as submitted by the Pharmacy.

On NCPDP 5.1, the corresponding DD name is Product/Service ID,DD number is 407-D7.

REQUIRED SVC02 782 Line Item Charge Amount M R 1/11

Use this monetary amount for the submitted service charge amount.

This field is the same as CLP03.

This field contains the NCPDP Gross Amount Due.

On NCPDP 2.0, the corresponding DD name is Amount Billed, DDnumber is 840-5B and the position is from 34-39.

On NCPDP 5.1, the corresponding DD name is Gross Amount Due,



DD number is 430-DU.

REQUIRED SVC03 782 Line Item Provider Payment Amount O R 1/11

Use this number for the service amount paid. The value in SVC03should equal the value in SVC02 minus all monetary amounts in thesubsequent CAS segments of this loop. See 2.2.1, Balancing, in theX12N 835 Health Care Claim Payment/Advice implementation guide foradditional information.

This field is the same as CLP04.

This field contains the NCPDP Total Amount Paid.

On NCPDP 2.0, the corresponding DD name is Amount Paid, DDnumber is 876-4B and the position is from 40-45.

On NCPDP 5.1, the corresponding DD name is Total Amount Paid,DD number is 509-F9.

REQUIRED SVC05 380 Units of Service Paid Count O R 1/15

Use this number for the paid units of service. If not present, the value isassumed to be one.

This field contains the NCPDP Quantity Dispensed.

On NCPDP 2.0, the corresponding DD name is Quantity Dispensed,DD number is 442-E7 and the position is from 321-328.

On NCPDP 5.1, the corresponding DD name is Quantity Dispensed,DD number is 442-E7.

SITUATIONAL SVC07 380 Original Units of Service Count O R 1/15

This is REQUIRED when the paid units of service provided in SVC05 isdifferent from the submitted units of service from the original claim. Thisis NOT USED when the submitted units is the same as the value inSVC05.

This field contains Submitted Quantity prior to Cutback and notsent if same as SVC05.



Segment: DTM Service Date


Usage: OptionalMax Use: 1Purpose: To specify pertinent dates and times

Syntax Notes:Notes: Dates at the service line level apply only to the service line where they appear.

Service dates are required for every service line.


Example: DTM*472*19961031~


Usage Des. Element Name AttributesREQUIRED DTM01 374 Date Time Qualifier M ID 3/3

Code specifying type of date or time, or both date and time

472 ServiceDate the service being rendered

REQUIRED DTM02 373 Service Date O DT 8/8Date expressed as CCYYMMDD

On NCPDP 2.0, the corresponding DD name is Date Filled, DDnumber is 401-D1 and the position is from 21-28.

On NCPDP 5.1, the corresponding DD name is Date of Service, DDnumber is 401-D1.



Segment: CAS Service Adjustment


Usage: OptionalMax Use: 5Purpose: To supply adjustment reason codes and amounts as needed for an entire claim/service

being paid.Syntax Notes: 1 If CAS05 is present, then at least one of CAS06 or CAS07 is required.

2 If CAS06 is present, then CAS05 is required.3 If CAS07 is present, then CAS05 is required.4 If CAS08 is present, then at least one of CAS09 or CAS10 is required.5 If CAS09 is present, then CAS08 is required.6 If CAS10 is present, then CAS08 is required.7 If CAS11 is present, then at least one of CAS12 or CAS13 is required.8 If CAS12 is present, then CAS11 is required.9 If CAS13 is present, then CAS11 is required.10 If CAS14 is present, then at least one of CAS15 or CAS16 is required.11 If CAS15 is present, then CAS14 is required.12 If CAS16 is present, then CAS14 is required.13 If CAS17 is present, then at least one of CAS18 or CAS19 is required.14 If CAS18 is present, then CAS17 is required.15 If CAS19 is present, then CAS17 is required.

Notes: This CAS segment is optional and is intended to reflect reductions in paymentdue to adjustments particular to a claim/service. An example of this level of CASis the reduction for the part of the service charge that exceeds the usual andcustomary charge for the service. See 2.2.1, Balancing, and 2.2.4, ClaimAdjustment and Service Adjustment Segment Theory, in the X12N 835 HealthCare Claim Payment/Advice implementation guide for additional information.

A single CAS segment contains six repetitions of the ‘adjustment trio’ composedof adjustment reason code, adjustment amount, and adjustment quantity. Thesesix adjustment trios are used to report up to six adjustments related to aparticular Claim Adjustment Group Code (CAS01). The first adjustment isreported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07),and so on through the sixth adjustment trio (CAS17-CAS19).

This segment will be utilized to report the changes between the submittedand paid amount. Each service pertains to an Rx, the balancing within anRx must be such that the Line Item Charge Amount (SVC02) minus the sumof all the Adjustment Amounts (co-pay, deductible, dispensing fee etc.)equals the Line Item Provider Payment Amount (SVC03) for thisprescription.

Example: CAS*CO*23*20~


Usage Des. Element Name AttributesREQUIRED CAS01 1033 Claim Adjustment Group Code M ID 1/2

Code identifying the general category of payment adjustmentEvaluate the group codes in CAS01 based on the following order fortheir applicability to a set of one or more adjustments: PR, CO, PI, CR,OA. See 2.2.4, Claim Adjustment and Service Adjustment Segment



Theory, in the X12N 835 Health Care Claim Payment/Adviceimplementation guide for additional information. (Note: This does notmean that the adjustments must be reported in this order.)

CO Contractual ObligationsUse this code when a joint payer/payee agreementor a regulatory requirement has resulted in anadjustment.

CR Correction and ReversalsUse this code for corrections and reversals toPRIOR claims. Use when CLP02=22.

OA Other Adjustments

PI Payer Initiated ReductionsUse this code when, in the opinion of the payer, theadjustment is not the responsibility of the patient, butno supporting contract exists between the providerand the payer.

PR Patient Responsibility

REQUIRED CAS02 1034 Adjustment Reason Code M ID 1/5Code identifying the detailed reason the adjustment was made

For additional adjustment reason codes, refer to http://www.wpc-edi.com/codes/claimadjustment.

3 Co-Pay

16 Reject

23 Other Payer Paid Amount

90 Ingredient Cost

45 Other Paid Amount (i.e., Postage, Misc.)

91 Professional Fee

105 Sales Tax

125 Payer Initiated Adjustment

144 Incentive Amount

205 Discount Card Processing Fee(Effective on POS Cutoff Date 12/14/07, ‘205’ willreplace ‘A2’)

REQUIRED CAS03 782 Adjustment Amount M R 1/11

Use this monetary amount for the adjustment amount. A negativeamount increases the payment, and a positive amount decreases thepayment contained in SVC03 and CLP04.

SITUATIONAL CAS04 380 Adjustment Quantity O R 1/15



This element may be used only when the units of service are beingadjusted. A positive number decreases paid units, and a negative valueincreases paid units.

SITUATIONAL CAS05 1034 Adjustment Reason Code X ID 1/5Code identifying the detailed reason the adjustment was madeSee CAS02.

Used when additional adjustments apply within the group identified inCAS01.

SITUATIONAL CAS06 782 Adjustment Amount X R 1/11See CAS03.


SITUATIONAL CAS07 380 Adjustment Quantity X R 1/15See CAS04.


























SITUATIONAL CAS19 380 Adjustment Quantity X R 1/15

See CAS04.



Segment: AMT Service Supplemental Amount


Usage: OptionalMax Use: 12Purpose: To indicate the toal monetary amount

Notes: This segment is used to convey information only. It is not part of thefinancial balancing of the 835.

Example: AMT*T*425~


Usage Des. Element Name AttributesREQUIRED AMT01 522 Amount Qualifier Code O ID 1/3

Code to qualify amount

T Tax

REQUIRED AMT02 782 Service Supplemental Amount X R 1/18

On NCPDP 5.1, the corresponding DD name is Flat Sales TaxAmount Paid, DD number is 558-AW.



Segment: LQ Health Care Remark Codes


Usage: OptionalMax Use: 5Purpose: Code to transmit standard industry codes

Syntax Notes: 1 If LQ01 is present, then LQ02 is required.Notes: This segment will be populated only when CAS02 = ‘16’ meaning ‘Reject’.

For Reject Claims, CAS02, adjustment reason code, will be populated with'16' and will be sent along with the LQ segment which contains the NCPDPreject codes. There will be a maximum of only 5 occurrences of the LQsegment for a Rx.

Example: LQ*RX*12345~


Usage Des. Element Name AttributesREQUIRED LQ01 1270 Code List Qualifier Code O ID 1/3

Code identifying a specific industry code list

RX National Council for Prescription Drug ProgramsReject/Payment Codes

REQUIRED LQ02 1271 Remark Code X AN 1/30Code indicating a code from a specific industry code list

This field contains NCPDP Reject Code.

On NCPDP 5.1, the corresponding DD name is Reject Code, DDnumber is 511-FB.

Please refer to <http://www.medco.com/rph> for a list of NCPDP5.1 reject codes.

http://www.medco.com/rph



Segment: PLB Provider Adjustment

Position: 010Loop:Level: Summary

Usage: OptionalMax Use: >1Purpose: To convey provider level adjustment information.

Syntax Notes:Notes: Use the PLB segment to allow adjustments that are NOT specific to a particular

claim or service to the amount of the actual payment. These adjustments caneither decrease the payment (a positive number) or increase the payment (anegative number).

Example: PLB*123456*19960930*LS:9876514*-1.27~


Usage Des. Element Name AttributesREQUIRED PLB01 127 Provider Identifier M AN 1/30

Use this number for the provider identifier as assigned by the payer.

This field contains the NCPDP ID or National Provider ID and mustbe identical to TS301. (Note: This will be the National Provider ID5/23/07 onwards.)

REQUIRED PLB02 373 Fiscal Period Date M DT 8/8Date expressed as CCYYMMDD

Use this date for the last day of the provider's fiscal year. If the end ofthe provider's fiscal year is not known by the payer, use December 31stof the current year.

This field contains 12/31 of the year that the drug was dispensed.

REQUIRED PLB03 C042 Adjustment Identifier MTo provide the category and identifying reference information for anadjustment

This code is a composite data structure. The composite identifies thereason and identifying information for the adjustment dollar amount inPLB04.

REQUIRED PLB03-1 426 Adjustment Reason Code M ID 2/2Code indicating reason for debit or credit memo or adjustment toinvoice, debit or credit memo, or payment

LS

CS

Lump SumWhen Check Issue Date (BPR16) is prior to6/5/03.

Adjustment

AH Origination Fee



When Check Issue Date (BPR16) is 6/5/03onwards.

SITUATIONAL PLB03-2 127 Provider Adjustment Identifier O AN 1/30

Medco will populate '32T' to represent the Transmission Feecharged for this cycle. ‘32C’ to represent the Copay collected; ‘32I’to represent the Incentive Amount; and ‘32N’ to represent theStore Liability.

REQUIRED PLB04 782 Provider Adjustment Amount M R 1/11

Use this monetary amount for the adjustment amount for the precedingadjustment reason.

REQUIRED PLB05 C042 Adjustment Identifier MSee PLB03 for details.

REQUIRED PLB05-1 426 Adjustment Reason Code M ID 2/2


REQUIRED PLB06 782 Provider Adjustment Amount M R 1/11Use this monetary amount for the adjustment amount for the precedingadjustment reason.


REQUIRED PLB07-1 426 Adjustment Reason Code M ID 2/2Code indicating reason for debit or credit memo or adjustment toinvoice, debit or credit memo, or payment


REQUIRED PLB08 782 Provider Adjustment Amount M R 1/11Use this monetary amount for the adjustment amount for the precedingadjustment reason.


REQUIRED PLB09-1 426 Adjustment Reason Code M ID 2/2


REQUIRED PLB10 782 Provider Adjustment AmountUse this monetary amount for the adjustment amountfor the preceding adjustment reason.

M R 1/11



Segment: SE Transaction Set Trailer

Position: 020Loop:Level: Summary

Usage: MandatoryMax Use: 1Purpose: To indicate the end of the transaction set and provide the count of the transmitted

segments (including the beginning (ST) and ending (SE) segments)Syntax Notes:

Notes: Example: SE*45*1234~


Usage Des. Element Name AttributesREQUIRED SE01 96 Transaction Segment Count M N0 1/10

Total number of segments included in a transaction set including STand SE segments

Number of Included Segments

REQUIRED SE02 329 Transaction Set Control Number M AN 4/9Identifying control number that must be unique within the transaction setfunctional group assigned by the originator for a transaction set

The Transaction Set Control Numbers in ST02 and SE02 must beidentical. The originator assigns the Transaction Set Control Number,which must be unique within a functional group (GS-GE). This uniquenumber also aids in error resolution research.



ICS Interchange Control Structures

Introduction:

The purpose of the following segments (ISA, IEA, GS, GE) is to define the control structures for the electronicinterchange of one or more encoded business transactions including the EDI (Electronic Data Interchange)encoded transactions of Accredited Standards Committee X12.

Notes:

Please note: Medco uses, and recommends the use of, the following non-displayable delimiters;

DelimitersEBCDIC

ASCII

SegmentX'1D'X'1D'

ElementX'1C'X'1A'

Sub-elementX'1A'X'C8'


40 010 ISA Interchange Control Header M 143 020 GS Functional Group Header M 145 030 GE Functional Group Trailer M 146 040 IEA Interchange Control Trailer M 1

Segment: ISA Interchange Control HeaderPosition: 010



Loop:Level:

Usage: MandatoryMax Use: 1Purpose: To start and identify an interchange of zero or more functional groups and interchange-

related control segmentsSyntax Notes:

Semantic Notes:Comments:


Usage Des. Element Name AttributesREQUIRED ISA01 I01 Authorization Information Qualifier M ID 2/2

Code to identify the type of information in the Authorization Information00 No Authorization Information Present (No

Meaningful Information in I02)

REQUIRED ISA02 I02 Authorization Information M AN 10/10Information used for additional identification or authorization of theinterchange sender or the data in the interchange; the type ofinformation is set by the Authorization Information Qualifier (I01)

Always 10 spaces.

REQUIRED ISA03 I03 Security Information Qualifier M ID 2/2Code to identify the type of information in the Security Information

00 No Security Information Present (No MeaningfulInformation in I04)

REQUIRED ISA04 I04 Security Information M AN 10/10This is used for identifying the security information about theinterchange sender or the data in the interchange; the type ofinformation is set by the Security Information Qualifier (I03)

Always 10 spaces.

REQUIRED ISA05 I05 Interchange [Sender] ID Qualifier M ID 2/2Qualifier to designate the system/method of code structure used todesignate the sender or receiver ID element being qualified

30 U.S. Federal Tax Identification NumberMedco uses the Federal Tax ID.

REQUIRED ISA06 I06 Interchange Sender ID M AN 15/15Identification code published by the sender for other parties to use asthe receiver ID to route data to them; the sender always codes thisvalue in the sender ID element223461740

REQUIRED ISA07 I05 Interchange [Receiver] ID Qualifier M ID 2/2Qualifier to designate the system/method of code structure used todesignate the sender or receiver ID element being qualified

01 Duns (Dun & Bradstreet)



14 Duns Plus Suffix

20 Health Industry Number (HIN)

27 Carrier Identification Number as assigned by HealthCare Financing Administration (HCFA)

28 Fiscal Intermediary Identification Number asassigned by Health Care Financing Administration(HCFA)

29 Medicare Provider and Supplier IdentificationNumber as assigned by Health Care FinancingAdministration (HCFA)

30 U.S. Federal Tax Identification Number

33 National Association of Insurance CommissionersCompany Code (NAIC)

ZZ Mutually Defined

This qualifier reflects the Medco Chain/Franchise# which is used as the Interchange Receiver ID. Ifany other Interchange Receiver ID is used, thenthe qualifier can be chosen from the listindicated above.

REQUIRED ISA08 I07 Interchange Receiver ID M AN 15/15Identification code published by the receiver of the data; When sending,it is used by the sender as their sending ID, thus other parties sendingto them will use this as a receiving ID to route data to them

Defaults to Medco Chain or Franchise #. If you wish to use any otherID, please contact Medco at 1-800-922-1557.

REQUIRED ISA09 I08 Interchange Date M DT 6/6Creation Date

REQUIRED ISA10 I09 Interchange Time M TM 4/4Creation Time

REQUIRED ISA11 I10 Interchange Control Standards Identifier M ID 1/1Code to identify the agency responsible for the control standard used bythe message that is enclosed by the interchange header and trailer

U U.S. EDI Community of ASC X12, TDCC, and UCS

REQUIRED ISA12 I11 Interchange Control Version Number M ID 5/5This version number covers the interchange control segments

00401 Draft Standards for Trial Use Approved forPublication by ASC X12 Procedures ReviewBoard through October 1997

REQUIRED ISA13 I12 Interchange Control Number M N0 9/9



A control number assigned by the interchange sender

Control # assigned by Medco. The Interchange Control Numbers inISA13 and IEA02 must be identical.

REQUIRED ISA14 I13 Acknowledgment Requested M ID 1/1Code sent by the sender to request an interchange acknowledgment(TA1)

0 No Acknowledgment Requested

REQUIRED ISA15 I14 Usage Indicator M ID 1/1Code to indicate whether data enclosed by this interchange envelope istest, production or information

P Production Data

REQUIRED ISA16 I15 Component Element Separator M AN 1/1Type is not applicable; the component element separator is a delimiterand not a data element; this field provides the delimiter used toseparate component data elements within a composite data structure;this value must be different than the data element separator and thesegment terminator

Always X'1A' for EBCDIC and X'C8' for ASCII.



Segment: GS Functional Group Header

Position: 020Loop:Level:

Usage: MandatoryMax Use: 1Purpose: To indicate the beginning of a functional group and to provide control information

Syntax Notes:Semantic Notes: 1 GS04 is the group date.

2 GS05 is the group time.3 The data interchange control number GS06 in this header must be identical to the

same data element in the associated functional group trailer, GE02.Comments: 1 A functional group of related transaction sets, within the scope of X12 standards,

consists of a collection of similar transaction sets enclosed by a functional groupheader and a functional group trailer.


Usage Des. Element Name AttributesREQUIRED GS01 479 Functional Identifier Code M ID 2/2

Code identifying a group of application related transaction sets

HP Health Care Claim Payment/Advice (835)

REQUIRED GS02 142 Application Sender's Code M AN 2/15Code identifying party sending transmission; codes agreed to by tradingpartners

This is the Medco’s Tax ID.

223461740.

REQUIRED GS03 124 Application Receiver's Code M AN 2/15Code identifying party receiving transmission; codes agreed to bytrading partners

Defaults to ISA08. If you wish to use any other ID, please contactMedco at 1-800-922-1557.

REQUIRED GS04 373 Date M DT 8/8Creation Date

REQUIRED GS05 337 Time M TM 4/8Creation Time

REQUIRED GS06 28 Group Control Number M N0 1/9Assigned number originated and maintained by the sender

Medco assigned number. This must be identical to GE02.

REQUIRED GS07 455 Responsible Agency Code M ID 1/2Code used in conjunction with Data Element 480 to identify the issuer of



the standardX Accredited Standards Committee X12

REQUIRED GS08 480 Version / Release / Industry Identifier Code M AN 1/12

004010X091 - when Check Issue Date (BPR16) is prior to 6/5/03.

004010X091A1 - when Check Issue Date (BPR16) is 6/5/03onwards.



Segment: GE Functional Group Trailer


Usage: MandatoryMax Use: 1Purpose: To indicate the end of a functional group and to provide control information

Syntax Notes:Semantic Notes: 1 The data interchange control number GE02 in this trailer must be identical to the same

data element in the associated functional group header, GS06.Comments: 1 The use of identical data interchange control numbers in the associated functional

group header and trailer is designed to maximize functional group integrity. The controlnumber is the same as that used in the corresponding header.


Usage Des. Element Name AttributesREQUIRED GE01 97 Number of Transaction Sets Included M N0 1/6

Total number of transaction sets included in the functional group orinterchange (transmission) group terminated by the trailer containingthis data element.

REQUIRED GE02 28 Group Control Number M N0 1/9Assigned number originated and maintained by the sender.

This is the same as GS06.



Segment: IEA Interchange Control Trailer


Usage: MandatoryMax Use: 1Purpose: To define the end of an interchange of zero or more functional groups and interchange-

related control segmentsSyntax Notes:

Semantic Notes:Comments:


Usage Des. Element Name AttributesREQUIRED IEA01 I16 Number of Included Functional Groups M N0 1/5

A count of the number of functional groups included in an interchange.

REQUIRED IEA02 I12 Interchange Control Number M N0 9/9A control number assigned by the interchange sender

This is the same as ISA13.

835 companion guide v4010 detail - november 2009

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