2.5 Transaction Format (Rev. 09/03)

The transaction formats in this document are divided into two parts, Request and Response. Each part is displayed in table format. The tables consist of columns. The columns include the NCPDP assigned “Field Number,” “Field Identifier,” “Field Name,” “Format,” “Length” and “Position” and contain strictly NCPDP information. Additional information about these columns can be found in the NCPDP manual. The final two columns include the “Req” (required) and “Value/Comments” columns and are described in the following paragraphs.

For the data in the “Value/Comments” column, a definition of the Values shown in the formats can either be found in the NCPDP Data Dictionary or listed as a comment.

Note: In the POSITION Column, the word “variable” indicates the position of the field in the format can vary depending on the presence or absence of any preceding field.

The “Req” (required) column indicates if the field is required to successfully execute a transaction. The values found in the column include:

R = Completion (or inclusion) of this field is required to successfully complete the transaction. The requirement may be due to the NCPDP format or a MEVS Program (Utilization Threshold, Post & Clear, Electronic Claims Capture and Adjudication, etc.). The entered data in some of the required fields will not be used in the execution of the transactions. These fields are so indicated in the comments column.

O = This field is optional. It is not needed to successfully complete all transactions, but is needed for most transactions.

Request Format (Rev. 09/03)

The NCPDP input format allowed for MEVS/ProDUR/ECCA transactions will consist of the variable “5.1”.

The variable “5.1” format is made up of segments. The segments include the Transaction Header Segment, Patient Segment, Insurance Segment, Claim Segment, Prescriber Segment, COB/Other Payments Segment, DUR/PPS Segment, Pricing Segment, and Prior Authorization Segment. For multiple claims, all segments repeat for each claim up to a maximum of four claims except for the Transaction Header Segment, Patient Segment and Insurance Segment. EMedNY will not process the following segments if they are transmitted: Pharmacy Provider Segment, Workers’ Compensation Segment, Coupon Segment, Compound Segment, and the Clinical Segment. These segments will be ignored if sent.

Response Formats (Rev. 09/03)

Responses will be returned via the same method of input, immediately following the completion of the processing of the transaction. The variable “5.1” format will contain response status codes in the Response Header Segment and for each prescription in the Response Status Segment.

If the header status code indicates the header is acceptable (A), then no errors were detected in the header data. If the header status code indicates the header is unacceptable (R), all prescriptions (claims) submitted are also in error and the response status code for the prescription will be “R”. Reject codes applicable to the header will be present in the first claim reject code list in addition to any reject codes specific to the first claim.

If the header data is acceptable (A) and the prescription (claim) data has passed all edits and is accepted, a “C” will be returned in the prescription (claim) response status code. A “C” will also be returned for acceptable claims for which the Electronic Claims Capture and Adjudication option was selected. Each prescription segment submitted will receive an individual response status code. A single transaction with four (4) claim submissions could have a mixture of prescription (claim) response status codes. The first claim could be “R”, the second claim “C”, etc.

For each transaction, error codes will be returned, if applicable. NCPDP reject codes will be returned in Field 511-FB. MEVS Accepted and Denial Codes listed in Table 1 (page 8.0.1) and Table 2 (page 8.0.2), Rx Denial codes listed in Table 7 (page 8.0.5), UT/PC Codes listed in Table 8 (page 8.0.6), DVS codes listed in Table 9 (page 8.0.7), and the Pend Reason Codes listed in Table 10 (page 8.0.8) will be returned in Field 526-FQ, the additional message field. An NCPDP reject code will always be returned in Field 511-FB and may have a corresponding MEVS code placed in Field 526-FQ to clarify the error. Both Fields should always be reviewed. The valid MEVS and NCPDP codes can be found in Sections 8.0 (page 8.0.1) and 9.0 (page 9.0.1) of this document.

For ProDUR editing, denials will be returned via the rejected response format and can be found in the Response DUR/PPS Segment. DUR warnings will be returned via the approved claim response “C” format. Each submitted claim could have three (3) possible DUR responses. If a claim has three (3) denial responses and also has warnings, only the denials will be returned.

Dispensing Validation System Transactions (Rev. 02/05)

- Use NCPDP Field 103-A3, value B1. Although multiple line transactions (Transaction Count 2 – 4; Field 109-A9) can be submitted, only one DVS line item can be submitted per transaction and the DVS line must be the first line item within the transaction.

- Only items reimbursable under Category of Service 0288, 0161, and 0441 (RX) will be processed through ECCA. Items which are only reimbursable under Category of Service 0442 (DME) must be billed on HCFA 1500 Claim Form or 837 Professional ASC X12N. Be sure to put the DVS number on the claim form. For ECCA claims, the DVS number will remain with the claim for adjudication purposes. Pharmacies should record the DVS number that is returned in the response.

Note: There may be some non-drug items where you are specifically instructed by New York State to use the 11 digit National Drug Code. If this occurs, use field 407-D7 (Product/Service ID) to enter the NDC and field 436-E1 to enter the Qualifier of 03. Field 406-D6 value should then be 1. The New York State Department of Health has also designated certain prescription drugs as requiring a DVS number. Field 407-D7 is used to enter these drugs.

- No UT, Post and Clear or DUR processing will occur for DVS item/HCPCS transactions. Prescription Drugs requiring a DVS number will be processed through the UT, Post and Clear and DUR programs.

- Only Current Dates of Service will be accepted for DVS Transactions.

Reversal/Cancel Transactions (Rev. 02/05)

- Use NCPDP Field 103-A3 value B2.

- Reversals can be submitted for service dates up to two years old if the original transaction was submitted directly to the eMedNY contractor. This includes paper and electronic batch, as well as online claim submissions.

- If the reversal is negating a paid claim, the reversal will appear on your remittance statement.

- If the reversal is negating a paid claim, you must complete the Processor Control Number field.

- If the reversal is negating a non-ECCA transaction, the reversal will not appear on your remittance statement.

Rebill/Adjustment Transactions (Rev. 02/05)

- Use NCPDP Field 103-A3 value B3. Data field requirements are otherwise identical to Prescription Billing requirements (B1).

- Rebill transactions can be submitted for service dates up to two years old if the original transaction was submitted directly to the eMedNY contractor. This includes paper and electronic batch, as well as online claim submissions.

- If the rebill is adjusting a paid claim, the rebill will appear on your remittance statement.

- If the rebill is adjusting a paid claim, you must complete the Processor Control Number field.

- You cannot adjust a non-ECCA claim to become an ECCA claim. The adjustment will apply any updated information, but the adjustment claim will remain a non-ECCA claim.

- If the rebill is adjusting a non-ECCA transaction, the rebill will not appear on your remittance statement.

- Rebills will not affect previously established service authorization limits.

- Rebills will not be allowed for original claims that generated a DVS prior approval. If a change is needed to a paid DVS claim, then you can submit the adjustment on paper or electronic batch. You may also reverse the original claim and then submit another original transaction with the corrected information.

Duplicate Claim Transactions

When an online claim transaction is sent to the MEVS, it will be matched against previously captured (approved) claims. If the transaction is determined to be an exact duplicate of a previously approved claim, the MEVS will return a “C” in the Transaction Response Status (112-AN) field. The remaining response fields will contain the data that was returned in the original response. The following fields will be examined to determine if the original captured response will be issued:

· Service Provider Number (201-B1 positions 21-28 on Transaction Header Segment)

· Cardholder ID Number (302-C2 on Insurance Segment)

· Date of Service (401-D1 positions 39-46 on Transaction Header Segment)

· Prescription/Service Reference # (402-D2 on Claim Segment)

· Fill Number (403-D3 on Claim Segment)

· Prior Auth Number Submitted (462-EV on Claim Segment)

· Product/Service ID (4Ø7-D7 on Claim Segment)

If identical data exists only in certain subsets of the above fields, your claim will be rejected for NCPDP Reject Code 83 “Duplicate Paid/Captured Claim” unless prior approval was obtained for one of the two conflicting transactions (meaning Prior Auth Number Submitted (462-EV) would need to contain a PA Number on one claim, and no PA Number for the other claim.)

For example, a NCPDP Reject Code of 83 “Duplicate Paid/Captured Claim” is returned when a claim is submitted and the Service Provider Number, Cardholder ID, and Prior Approval Number fields match a previous paid claim and one of the following conditions also exists:

· Prescription Service Reference Number matches, but NDC/HCPCS is different.

· NDC/HCPCS matches, but Prescription Service Reference Number is different.

· Prescription Service Reference Number and Fill Number are the same, but the Date of Service is different.

If the original transaction was non-ECCA and the duplicate transaction is ECCA, the transaction response will be the original non-ECCA response. No adjudication process will occur.

2.10 Unique Treatment of Fields (Rev. 12/04)

General Edits

The following edits apply to all transactions:

1. The Date of Service (Date Filled) cannot be in the future.

2. The Date of Service (Date Filled) cannot be more than two years old. For an original ECCA transaction, if the date filled is over 90 days old, the transaction will be processed but will not be captured for adjudication. If all other editing is passed, “NO CLAIM TO FA” will be returned in the response. This 90-day rule does not apply to rebills or reversals.

3. The Date of Service cannot be prior to the Date Prescription Written or more than 60 calendar days from the Date Prescription Written.

4. DUR editing will not be performed for NDCs with a Date of Service more than 90 days old.

5. The Fill Number and the Number of Refills Authorized may not exceed five.

6. The Fill Number cannot be greater than the Number of Refills Authorized.

Processor Control Number – (Transaction Header Segment) Field 104-A4

(Rev. 02/05)

This is a ten (10) position field located in positions 11-20 on the Transaction Header segment. If a Pharmacy selects the Electronic Claims Capture and Adjudication option, this field must be completed and will be part of the claim record. It is required by New York State that the Certification Statement must be read prior to entering data in this field. The field entry consists of:

Position 1 Y or N. Y means the provider has read and attests to the facts in the Certification statement for this claim. N means the provider has not read and is not attesting to the statement. If you have been issued a 4 digit ETIN, you may leave off the “Y” or “N” (read certification statement) in the first position.

Positions 2-3 The pharmacist must enter their first and last initials.

Positions 4-7 The Pharmacy’s PIN must be entered here.

Positions 8-10 The Pharmacy’s ETIN must be entered here.

You must complete the Processor Control Number field in order for a reversal or rebill to appear on your remittance. Reversals and rebills will only appear on a remittance statement if the original transaction resulted in a paid claim. A reversal or rebill of a non-ECCA transaction (Processor Control Number not sent) will not appear on a remittance statement.

Service Provider ID Qualifier – (Transaction Header Segment) Field 202-B2

This is a two (2) position field located in positions 22-23 on the Transaction Header segment. This should always contain the value 05 to indicate Medicaid.

Service Provider ID – (Transaction Header Segment) Field 201-B1

This is a fifteen (15) position field located in positions 21-28 on the Transaction Header segments. The first eight positions of this field will always contain the eight digit MMIS assigned Provider Identification Number. The remaining seven positions will contain spaces.

Cardholder ID Number – (Insurance Segment) Field 302-C2

This is a twenty (20) position field. The only valid field entries are:

a. The eight (8) character ID number assigned by New York State which identifies each individual Medicaid Recipient. This number begins with two (2) alpha characters, followed by five (5) numeric digits and then one (1) alpha character. This is the Client Identification Number found on the recipient’s benefit card.

b. The thirteen (13) digit numeric access number found on the recipient’s benefit card under Access Number. The ISO # should not be entered in this field.

Person Code – (Insurance Segment) Field 303-C3

This field must contain the two (2) character field found on the recipient’s benefit card under SEQ #.

Other Coverage Code – (Claim Segment) Field 308-C8

This field will be used in conjunction with Field 431-DV, Other Payor Amount, to allow pharmacies to have their claims electronically captured and adjudicated when the recipient has other third party insurance. The field values are:

0= Not Specified

1= No Other coverage Identified

2= Other Coverage Exists – Payment Collected

3= Other Coverage Exists – This Claim Not Covered

4= Other Coverage Exists – Payment Not Collected (This value is only valid with non-ECCA transactions).

5= Managed Care Plan Denial (This functions the same as Coverage Code 3)

6= Other Coverage Denied – Not a participating provider (This functions the same as Coverage Code 3)

7= No Other coverage Identified (This functions the same as Coverage Code 1)

8= Other Coverage Exists – Payment Collected (This functions the same as Coverage Code 2)

There are several edits in place to ensure that logical entries are made in both field 308-C8 and 431-DV. The following two charts describe what the status of the claim will be based on the field entries. The edits on Chart 1 (page 2.10.4) will occur when the recipient has MEVS Insurance Coverage Codes H, K, M, O or ALL on file at the eMedNY contractor. Chart 2 (page 2.10.5) will occur when no MEVS Insurance Coverage Codes indicating Pharmacy coverage for the recipient are on file.

Chart 1 – Recipient with Coverage Codes H, K, M, O or ALL on file

Rev. (02/05)

Field 308-C8 Value	Field 431-DV Value	NCPDP Format Version	Field 104-A4 Value	Claim Status
0, 1, 2, 3, 4, 5, 6, 7, 8	431-DV is Not sent	51	Non-ECCA (Processor Control Number not sent) or ECCA (Processor Control Number sent)	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
0, 1, 4 or 7	Zeros or greater	51	ECCA or Non-ECCA	The transaction will be rejected. NCPDP Reject Code: 13 “M/I Other Coverage Code” and Response Code: 717 “Client Has Other Insurance” will be returned online.
2 or 8	Zeros	51	ECCA or Non-ECCA	The transaction will be rejected. NCPDP Reject Code 13 “M/I Other Coverage Code” and Response Code 715 ‘Other Payor Amount Must Be Greater Than 0’ will be returned.
2 or 8	Greater than Zero	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and spaces will be returned in (field 503-F3). Other payor amount will be subtracted from the claim’s payment amount.
2 or 8	Greater than Zero	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
3, 5 or 6	Zeros, blank or not sent	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and spaces will be returned in (field 503-F3).
3, 5 or 6	Zeros	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
3, 5 or 6	Greater than Zero	51	ECCA or Non-ECCA	The transaction will be rejected. NCPDP Reject Code “13 M/I Other Coverage Code” and Response Code “716 ‘ Other Payor Amount Must Be Equal to 0” will be returned.

Chart 2 – Recipient without Coverage Codes on file Rev. (02/05)

Field 308-C8 Value	Field 431-DV Value	NCPDP Format Version	Field 104-A4 Value	Claim Status
0, 1, 2, 3, 5, 6, 7 or 8	Not sent	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
0, 1 or 7	Not sent	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and spaces will be returned in (field 503-F3).
0, 1, 3, 5, 6 or 7	Zeros	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
0, 1or 7	Zeros	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and spaces will be returned in (field 503-F3).
3, 5 or 6	Zeros, blank or not sent	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and spaces will be returned in (field 503-F3).
0, 1, 3, 4, 5, 6 or 7	Greater than Zero	51	Non-ECCA or ECCA	The transaction will be rejected. NCPDP Reject Code “DV - M/I Other Payor Amount” and Response Code “510 – Other Insurance Information Inconsistent” will be returned.
2, 3, 5, 6, or 8	Not sent	51	Non-ECCA or ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
4	Not sent or zeros	51	Non-ECCA or ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
2 or 8	Greater than Zero	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
2 or 8	Greater than Zero	51	ECCA	If all other edits are passed, the transaction will be accepted for payment. (“C - capture” (field 112-AN) and spaces will be returned in (field 503-F3).
2 or 8	Zeros	51	Non-ECCA or ECCA	The claim will reject. NCPDP Reject Code “13 M/I Other Coverage Code” and Response Code “715 Other Payor Amount Must Be Greater Than 0” will be returned.

Eligibility Clarification Code – (Insurance Segment) Field 309-C9

This field is used to submit overrides for Excess Income/Spenddown or Nursing Home Resident denials.

This field will be used in conjunction with Field 433-DX, Patient Paid Amount (Pricing Segment), to allow pharmacies to have their claims electronically captured and adjudicated for Excess Income/Spenddown recipients. This field is used when the recipient’s eligibility has not yet been updated on file at the eMedNY contractor.

Only recognized entry is:

2 = Override (replaces SA Exception Code M – Temporary Medicaid Authorization/Excess Income - Spenddown) or Nursing Home Override

Note: The eMedNY will allow all NCPDP identified values (0 through 6). However, “2” is the only value utilized by the NYS Medicaid.

If field 309-C9 contains a value of “2” (to override Excess Income/ Spenddown) Field 433-DX must contain zeros or a dollar amount. Field 433-DX should only contain zeros when the recipient has already met their spenddown but eligibility has not yet been updated on the file at the eMedNY contractor. In all other cases, Field 433-DX should contain the dollar amount incurred or paid to the pharmacy by the recipient.

Excess Income claims will bypass eligibility editing but will be processed through the DUR edits. If the claim passes all edits, the recipient’s DUR drug profile will be updated and the entry in Field 433-DX will be included in the Other Insurance Paid field on your remittance statement.

Note: An approved Excess Income override claim will pend for thirty days waiting for the eligibility update to occur. The online response will be Table 10 response code 317 (Claim Pending: Excess Income/Spenddown). If the necessary update does not occur within the thirty-day period, your claim will be denied. More information on Table 10 Pend Response codes can be found under the Additional Message Field 526-FQ in this section.

The Eligibility Clarification Code (309-C9) field may also be used to report a Nursing Home Override in those instances where the Client’s file shows residency within an In-State Skilled Nursing Facility that covers pharmacy services. The override procedure may be used to resubmit a previously denied claim. If the Client has been discharged but the eMedNY Contractors’ file shows that the Client still resides in the Skilled Nursing Facility, you may submit an override. This will result in a pend status which will give the local districts time to update the Client’s file. If the update is not received within 30 days, the claim will deny.

Compound Code – (Claim Segment) Field 406-D6

This is a one (1) position field and will be used to alert the system as to the type of editing to perform. The allowable values are:

0 = Should be entered when dispensing any five (5) character alpha numeric Product Supply Code from sections 4.2 and 4.3 in the MMIS Pharmacy Provider Manual. Claim can be captured for adjudication and will be considered as one unit for UT and P & C. No DUR processing will occur. This value should also be used for DVS transactions.

1 = Should be entered when dispensing a prescription with an NDC code. Claim can be captured for adjudication and all processing will occur. May also be entered when dispensing a Product Supply Code as described above.

2 = Should be entered when dispensing a compound drug code. Claim will be considered as one unit for UT and P & C. No DUR processing will occur.

Prior Auth Type Code – (Claim Segment) Field 461-EU

This field is a two (2) position numeric field. There are three possible values for this field:

00 = Not specified

01 = Prior Authorization/Prior Approval. If this value is used, field 462-EV must contain the prior approval number.

04 = Exemption from co-pay. Use to indicate the recipient is exempt.

Prior Auth Number Submitted – (Claim Segment) Field 462-EV Rev. (02/05)

This field is an eleven (11) position numeric field. This field should be filled with an 11 digit prior approval number or an 8 digit prior approval number, followed by three zeros.

If a claim requires prior approval and the recipient is also exempt for co-pay, use a value of zero four (04) in Field 461-EU and the Prior Authorization Number in Field 462-EV. If submitting a DVS transaction and the recipient is also exempt from co-pay, use a value of zero four (04) in Field 461-EU and do not submit anything in Prior Authorization Number in Field 462-EV. All possible entry combinations are listed in the “Value/Comments” column of the formats.

Submission Clarification Code (Claim Segment) Field 420-DK

This is a two (2) position field and will be used to replace the SA (Service Authorization) Exception Code Field currently being used for UT overrides. This field must contain the same value for each claim submitted in the same transaction for the recipient. The recognized values are:

00 = Not Specified (NCPDP default value)

01 = No Override (No SA Exception Code)

02 = Other Override (use in place of SA Exception Code P – pending an override)

07 = Medically Necessary (use in place of SA Exception Codes J & L – Immediate Urgent Care & Emergency)

Reason for Service Code (DUR/PPS Segment) Field 439-E4

For a rejected transaction, the response may contain a DUR Conflict Code for a DUR edit that failed. If this is the case, an override may be submitted. To override a DUR reject, the DUR Conflict Code received in the response of the original transaction must be submitted with the transaction attempting the override. The DUR Conflict Code being sent in the override must match the DUR Conflict Code received in the response of the original transaction. A corresponding entry must also be entered in the DUR Outcome Code.

Result of Service Code – (DUR/PPS Segment) Field 441-E6

If a DUR override is being submitted, an entry in Field 441-E6, DUR Outcome Code, is required. The authorized values are detailed in each format and reflect the action taken by the pharmacist.

Authorization Number – (Response Status Segment) Field 503-F3

Rev. (02/05)

Spaces will be returned in this field if all edits are passed and the provider has elected to have the claim captured and adjudicated. If a claim will not be captured for adjudication by the system because it is too old or for other reasons, this field will contain “NO CLAIM TO FA”, meaning a claim has not been captured for adjudication. These claims need to be submitted to the eMedNY contractor via paper, or electronic batch.

Message – (Response Message Segment) Field 504-F4 & Additional Message – (Response Status Segment) Field 526-FQ Rev. (02/05)

Dependent on which NCPDP format was submitted, these fields will contain MEVS specific Eligibility, UT, Post & Clear, Co-pay, Denial responses, Pend responses, Drug Plan File price, DVS Number, Medicare, Restriction, Miscellaneous and other Insurance data. Refer to the formats for details concerning these fields.

Pend messages from Table 10 will be returned in Field 526-FQ, positions 1-3. These field positions normally contain the Eligibility Accepted Codes from Table 1. Table 1 codes will not be returned when a Table 10 response is necessary. Additionally, if a claim passes all other editing but requires pending for one of the reasons listed in Table 10, the:

· Header Response Status (Field 501-F1) will contain an ‘A’ (Accepted).

· Response Status (Field 112-AN) will contain a ‘C’ (Captured).

· Spaces will be returned in the Authorization Number (Field 503-F3).

Note: Once a pend is resolved, the results can be found on the provider’s remittance statement.

3.0 Variable “5.1” Transaction (Rev. 12/03)

3.1 Request Segment Usage Matrix (Rev. 12/03)

SEGMENT	ID	ELIG	Billing	Rev	Rebill	P/A Req & Billing	P/A Rev	P/A Req Only	Info Rptg	Info Rptg Rev	Info Rptg Rebill

Transaction Code	AM	E1	B1	B2	B3	P1	P2	P4	N1	N2	N3

Header	--	M	M	M	M	M	M	M	M	M	M
Patient	01	O	ONY	O	ONY	ONY	O	ONY	ONY	O	ONY
Insurance	04	M	M	O	M	M	O	M	M	O	M
Claim	07	N	M	M	M	M	M	M	M	M	M
Prescriber	03	N	ONY	N	ONY	ONY	O	ONY	ONY	N	ONY
COB/Other Payments	05	N	ONY	N	ONY	ONY	N	ONY	O	N	O
Pricing	11	N	M	O	M	M	O	O	O	O	O
Prior Authorization	12	N	O	N	O	M	O	M	N	N	N
DUR/PPS	08	N	O	O	O	O	O	O	O	O	O

M = mandatory

O = optional; conditional based on data content

ONY = optional; NYS data content required

1.0 INTRODUCTION (Rev. 09/03)

2.0 GENERAL INFORMATION (Rev. 09/03)

2.1 Access Methods (Rev. 11/02)

2.2 Communication Protocol (Rev. 11/02)

2.3 Card Swipe (Rev. 09/03)

2.4 Dispensing Validation System (Rev. 02/05)

2.5 Transaction Format (Rev. 09/03)

2.6 Electronic Claims Capture and Adjudication (Rev. 02/05)

2.7 Transaction Overrides (Rev. 09/03)

2.8 MEVS Program Information (Rev. 11/02)

2.9 NCPDP/MEVS Transaction Types (Rev. 02/04)

Eligibility Transactions

Service Authorizations – Prescription Billing Transactions (Rev. 02/05)

Dispensing Validation System Transactions (Rev. 02/05)

Reversal/Cancel Transactions (Rev. 02/05)

Rebill/Adjustment Transactions (Rev. 02/05)

Duplicate Claim Transactions

2.10 Unique Treatment of Fields (Rev. 12/04)

General Edits

Processor Control Number – (Transaction Header Segment) Field 104-A4

(Rev. 02/05)

Service Provider ID Qualifier – (Transaction Header Segment) Field 202-B2

Service Provider ID – (Transaction Header Segment) Field 201-B1

Cardholder ID Number – (Insurance Segment) Field 302-C2

Person Code – (Insurance Segment) Field 303-C3

Other Coverage Code – (Claim Segment) Field 308-C8

Chart 1 – Recipient with Coverage Codes H, K, M, O or ALL on file

Rev. (02/05)

Chart 2 – Recipient without Coverage Codes on file Rev. (02/05)

Eligibility Clarification Code – (Insurance Segment) Field 309-C9

Compound Code – (Claim Segment) Field 406-D6

Prior Auth Type Code – (Claim Segment) Field 461-EU

Prior Auth Number Submitted – (Claim Segment) Field 462-EV Rev. (02/05)

Submission Clarification Code (Claim Segment) Field 420-DK

Reason for Service Code (DUR/PPS Segment) Field 439-E4

Result of Service Code – (DUR/PPS Segment) Field 441-E6

Authorization Number – (Response Status Segment) Field 503-F3

Rev. (02/05)

Message – (Response Message Segment) Field 504-F4 & Additional Message – (Response Status Segment) Field 526-FQ Rev. (02/05)

3.0 Variable “5.1” Transaction (Rev. 12/03)

3.1 Request Segment Usage Matrix (Rev. 12/03)