B2 Transaction: Rejected Response
Transaction Header Segment
Mandatory in all cases
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
102-A2 | Version/Release Number | D0 = Version D.0 | M | |
103-A3 | Transaction Code | B2 = Reversal | M | Reversal Response |
109-A9 | Transaction Count |
1 = One Occurrence 2 = Two Occurrences 3 = Three Occurrences 4 = Four Occurrences |
M | |
501-F1 | Header Response Status |
A = Accepted R = Rejected |
M | |
202-B2 | Service Provider ID Qualifier | 01 = National Provider Identifier (NPI) | M | |
201-B1 | Service Provider ID | 10-digit NPI | M | |
401-D1 | Date of Service | M | Fill Date, Format = CCYYMMDD |
Response Status Segment
Mandatory
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
111-AM | Segment Identification | 21 = Response Status Segment | M | |
112-AN | Transaction Response Status | R = Rejected | M | |
503-F3 | Authorization Number | RW | Returned when needed to identify the transaction. | |
510-FA | Reject Count | 1-5 | R | |
511-FB | Reject Code | R | ||
546-4F | Reject Field Occurrence Indicator | R ***R*** |
Optional | |
130-UF | Additional Message Information Count | 1–25 | R | |
132-UH | Additional Message Information Qualifier | 1–9 | RW ***R*** |
The sequence number of the message for each transaction |
526-FQ | Additional Message Information | RW ***R*** |
40 bytes |
|
131-UG | Additional Message Information Continuity | + = Current text continues | RW ***R*** |
Response Claim Segment
Mandatory
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
111-AM | Segment Identification | 22 = Response 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 |