B1 Transaction: Billing Request (Medicaid, CSHCN)
Transaction Header Segment
Mandatory in all cases
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
101-A1 | BIN Number | 610084 | M | |
102-A2 | Version/Release Number | D0 = Version D.0 | M | |
103-A3 | Transaction Code | B1 = Billing | M | Billing Request |
104-A4 | Processor Control Number | DRTXPROD | M | |
109-A9 | Transaction Count | 1 = One Occurrence 2 = Two Occurrences 3 = Three Occurrences 4 = Four Occurrences | M | Compounds must be transmitted as one transaction. |
202-B2 | Service Provider ID Qualifier | 01 = National Provider Identifier (NPI) | M | |
201-B1 | Service Provider ID | M | 10-digit NPI | |
401-D1 | Date of Service | M | Format = CCYYMMDD | |
110-AK | Software Vendor/Certification ID | M | Three-digit software identification number with space fill. |
Insurance Segment
Mandatory
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
111-AM | Segment Identification | 04 = Insurance Segment | M | |
302-C2 | Cardholder ID | M | 9-digit Medicaid and HTW cardholder ID numbers. 9-digit CSHCN cardholder ID numbers begin with 9. 16-digit DFPS ID cardholder numbers are 6-8 digits with leading zeroes. | |
301-C1 | Group ID | MEDICAID CHIP CSHCN | R | Enter the name of the payer program. For HTW and DFPS, enter 'MEDICAID'. Note: Transactions for CHIP will deny with error code "AF" ("Patient Enrolled Under Managed Care"). |
Patient Segment
Required
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
111-AM | Segment Identification | 01 = Patient Segment | M | |
304-C4 | Date of Birth | R | Format = CCYYMMDD | |
305-C5 | Patient Gender Code | 1 = Male 2 = Female | R | |
311-CB | Patient Last Name | R | Submit a comma as the second character if the last name has only 1 character |
Claim Segment
Mandatory
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
111-AM | Segment Identification | 07 = Claim Segment | M | |
455-EM | Prescription/Service Reference Number Qualifier | 1 = Rx Billing | M | |
402-D2 | Prescription/Service Reference Number | M | Twelve-digit prescription number | |
436-E1 | Product/Service ID Qualifier | 00 = Compound 03 = National Drug Code (NDC) | M | 00 = if Compound Code value is "2" |
407-D7 | Product/Service ID | M | NDC 0 = if Compound Code value is "2" | |
442-E7 | Quantity Dispensed | R | ||
403-D3 | Fill Number | R | 00 = indicates an original prescription 01-11 = indicates a refill prescription | |
405-D5 | Days Supply | R | May not exceed 185 for Medicaid and CSHCN | |
406-D6 | Compound Code | 1 = Not a Compound 2 = Compound | R | 2 = multi-ingredient compound claim |
408-D8 | Dispense As Written (DAW) / Product Selection Code | 0 = No Product Selection Indicated 1 = Substitution Not Allowed by Prescriber | R | 1 = MAC override when the physician writes "Brand Necessary" on the face of the prescription |
414-DE | Date Prescription Written | R | Format = CCYYMMDD | |
415-DF | Number of Refills Authorized | 0–11 = Non-schedule drugs 0–5 = Schedule 3, 4, or 5 drugs 0 = Schedule 2 drugs | R | 0 = for Schedule 2 drugs 5 = for Schedule 3, 4, or 5 drugs 5 = Home health supply products 11 = for non-schedule drugs |
419-DJ | Prescription Origin Code | 0 = Not Known 1 = Written 2 = Telephone 3 = Electronic 4 = Facsimile 5 = Pharmacy | R | |
354-NX | Submission Clarification Code Count | 1-3 | RW | |
420-DK | Submission Clarification Code | 1 = No Override 2 = Other override 6 = Starter Dose 7 = Medically Necessary 8 = Process Compound For Approved Ingredients 10 = Meets Plan Limitations 20& = 340B / Disproportionate Share Pricing/Public Health Service | RW ***R*** | Medicaid 2 = used when medically necessary for the prescribed quantity of a Home Health Supply product to exceed the maximum unit per filling Medicaid 7 = used for an medically necessary non-formulary drugs when approved Medicaid, CSHCN 8 = used for compound ingredient override Medicaid, CSHCN 20 = used for claims dispensed from 340B stock |
460-ET | Quantity Prescribed | RW | Required when Schedule II drug | |
308-C8 | Other Coverage Code | 0 = Not Specified By Patient 1 = No Other Coverage 2 = Other Coverage Exists – Payment Collected 3 = Other Coverage Billed – Claim Not Covered 4 = Other Coverage Exists – Payment Not Collected | RW | Required if the COB segment is transmitted |
600-28 | Unit of Measure | EA = Each GM = Grams ML = Milliliters | R | |
461-EU | Prior Authorization Type Code | Medicaid, DFPS ID, and CSHCN 8 = Payer Defined Exemption | RW | Required if Prior Authorization Number Submitted is transmitted |
462-EV | Prior Authorization Number Submitted | Medicaid 801 = 72-hour emergency override Medicaid and CSHCN 826 = Medically accepted indication for vitamins and minerals DFPS ID 1027 = Submission of DFPS ID All programs 901 = Override refill too soon edits for medication synchronization | RW | Required if Prior Authorization Type Code is transmitted |
343-HD | Dispensing Status | O | If submitted, the claim will reject | |
344-HF | Quantity Intended To Be Dispensed | O | If anything is submitted in this field, the claim will reject | |
345-HG | Days Supply Intended To Be Dispensed | O | If anything is submitted in this field, the claim will reject | |
995-E2 | Route of Administration | O | ||
996-G1 | Compound Type | 01 = Anti-Infective 02 = Ionotropic 03 = Chemotherapy 04 = Pain Management 05 = TPN/PPN 06 = Hydration 07 = Ophthalmic 99 = Other | RW | 2 = Required when compound code |
Prescriber Segment
Required
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
111-AM | Segment Identification | 03 = Prescriber Segment | M | |
466-EZ | Prescriber ID Qualifier | 01 = National Provider Identifier (NPI) | R | |
411-DB | Prescriber ID | R | 10-digit NPI | |
427-DR | Prescriber Last Name | O |
Coordination of Benefits/Other Payments Segment
Optional
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
111-AM | Segment Identification | 05 = COB/Other Payments Segment | M | |
337-4C | Coordination of Benefits/Other Payments Count | 1-9 | M | |
338-5C | Other Payer Coverage Type | Blank = Not Specified 01 = Primary 02 = Secondary 03 = Tertiary 04 = Quaternary 05 = Quinary 06 = Senary 07 = Septenary 08 = Octonary 09 = Nonary | M ***R*** | |
339-6C | Other Payer ID Qualifier | Medicaid with Private Insurance 03 = Bank Information Number (BIN) CSHCN with Private Insurance 99 = Other Medicaid with Medicare coverage 99 = Other | RW ***R*** | If the COB segment is transmitted. |
340-7C | Other Payer ID | RW ***R*** | Medicaid with Private Insurance If "Other Payer ID Qualifier" = 03, submit Other Payer's BIN. CSHCN with Private Insurance If “Other Payer ID Qualifier” = 99, submit “CSHCNTPL” Medicaid with Medicare Part B If "Other Payer ID Qualifier" = 99 and Other Payer is Medicare Part B, submit "MEDPARTB" | |
443-E8 | Other Payer Date | RW ***R*** | If the COB segment is transmitted. Format = CCYYMMDD | |
341-HB | Other Payer Amount Paid Count | 1-9 | RW | If "Reject Count" is not transmitted |
342-HC | Other Payer Amount Paid Qualifier | 01 = Delivery 02 = Shipping 03 = Postage 04 = Administrative 05 = Incentive 06 = Cognitive Service 07 = Drug Benefit 09 = Compound Prep Cost 10 = Sales Tax | RW ***R*** | If "Other Payer Amount Paid Count" is transmitted |
431-DV | Other Payer Amount Paid | RW ***R*** | If "Other Payer Amount Paid Qualifier" is transmitted | |
471-5E | Other Payer Reject Count | 1–5 | RW ***R*** | If "Other Payer Amount Paid Count" is not transmitted |
472-6E | Other Payer Reject Code | RW ***R*** | If "Other Payer Reject Count" is transmitted |
Drug Use Review/Professional Pharmacy Service Segment
Optional
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
111-AM | Segment Identification | 08 = DUR/PPS Segment | M | |
473-7E | DUR Code Counter | 1-9 | RW | If the DUR segment is transmitted. |
439-E4 | Reason for Service Code | DD = Drug-Drug Interaction HD = High Dose ID = Ingredient Duplication PH = Preventive Health Care PN = Prescriber Consultation PP = Plan Protocol RF = Health Provider Referral TD = Therapeutic | RW ***R*** | PH = use for pharmacist reimbursable injection or flu vaccine. PN = use for pharmacist reimbursable injections. RF = use for pharmacist reimbursable injections. PP = use for COVID-19 vaccines. |
440-E5 | Professional Service Code | 00 = No Intervention M0 = Prescriber consulted MA = Medication Administration P0 = Patient consulted R0 = Pharmacist consulted other source | RW ***R*** | MA = use for pharmacist reimbursable injections |
441-E6 | Result of Service Code | 1A = Filled As Is, False Positive 1B = Filled Prescription as is 1C = Filled, With Different Dose 1D = Filled, With Different Directions 1F = Filled, With Different Quantity 1G = Filled, With Prescriber Approval 3N = Medication Administration 4A = Prescribed with acknowledgment | RW ***R*** | 3N = Use for pharmacist reimbursable injections. |
Pricing Segment
Mandatory
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
111-AM | Segment Identification | 11 = Pricing Segment | M | |
409-D9 | Ingredient Cost Submitted | R | ||
426-DQ | Usual and Customary Charge | R | Call Help Desk for claims $10,000.00 or greater | |
430-DU | Gross Amount Due | R | Call Help Desk for claims $10,000.00 or greater | |
438-E3 | Incentive Amount Submitted | RW | Format=s$$$$$$cc Use for pharmacist reimbursable injections |
Compound Segment
Optional
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
111-AM | Segment Identification | 10 = Compound Segment | M | |
450-EF | Compound Dosage Form Description Code | 01 = Capsule 02 = Ointment 03 = Cream 04 = Suppository 05 = Powder 06 = Emulsion 07 = Liquid 10 = Tablet 11 = Solution 12 = Suspension 13 = Lotion 14 = Shampoo 15 = Elixir 16 = Syrup 17 = Lozenge 18 = Enema | M | |
451-EG | Compound Dispensing Unit Form Indicator | 1 = Each 2 = Grams 3 = Milliliters | M | |
447-EC | Compound Ingredient Component Count | 2–25 | M | |
488-RE | Compound Product ID Qualifier | 03 = National Drug Code | M ***R*** | |
489-TE | Compound Product ID | M ***R*** | 11-digit NDC, required by HHSC | |
448-ED | Compound Ingredient Quantity | M ***R*** | ||
449-EE | Compound Ingredient Drug Cost | RW ***R*** | Optional | |
490-UE | Compound Ingredient Basis of Cost Determination | 00 = Default 01 = AWP (Average Wholesale Price) 03 = Direct 08 = 340B / Disproportionate Share Pricing/Public Health Service 09 = Other | RW ***R*** | Optional “Blank” or “00” will default to “Direct”. |