Pharmacy Payer Sheets

Pharmacy providers and their contracted software companies should refer to the pharmacy payer sheets for specific claim processes. These documents define the required fields for processing a prescription claim and address specific claim-specific policies. While this information should be accessible through your pharmacy software system, pharmacy providers can refer to these payer sheets when questions arise.

Payer name

  • Texas Health and Human Services

Processor name

  • Conduent-Pharmacy
    • Since Jan. 1, 2017

NCPDP Standard version

  • National Council for Prescription Drug Programs (NCPDP) D.0
    • Since Feb. 1, 2012

Contact information

Claim Billing (B1) Transaction Payer Sheet

Program Name

  • Traditional Medicaid
  • Children with Special Health Care Needs (CSHCN) Services Program
  • Healthy Texas Women (HTW) Program
  • Kidney Health Care (KHC) Program

Transaction Code

  • National Council for Prescription Drug Programs (NCPDP) B1 - Claims Billing
  • Refer to the Claims Billing (B1) Transaction section of the Pharmacy Provider Procedure Manual for more information about the NCPDP transaction.

Notes

  • The processor edits all submitted data elements for valid format and values.
  • Provider software should support all data elements on the required segments.
  • In cases where multiple iterations of a field ("repeating fields") are allowed, the maximum number of iterations is indicated.

Field Usage Description

  • Mandatory (M):
    • Submitted following the NCPDP Telecommunication Implementation Guide Version D.0.
  • Required (R):
    • Always submitted.
  • Required When (RW):
    • Submitted under circumstances explained in the Comment column.
  • Optional (O):
    • Submitted at the discretion of the pharmacy provider.
  • Repeating (***R***):
    • Designates a repeating field.

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 begin with 1-6.

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

2 = used when the initial dose of the multi-dose COVID-19 vaccine

Medicaid

6 = used for final/ second dose of the multi-dose COVID-19 vaccine

Medicaid

7 = used for an additional dose of the multi-dose COVID-19 vaccine

Medicaid, CSHCN

8 = used for compound ingredient override

Medicaid

10 = used for a booster dose of the multi-dose COVID-19 vaccine

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 transmitted471-5E
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”.

B1 Transaction: Billing Request (KHC)

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 DRTXPRODKH 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 KHC cardholder ID numbers begin with 8.
301-C1 Group ID

KHC

 R

Enter the name of the payer program.

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 34 for KHC
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***

2 = used when medically necessary for the prescribed quantity of a Home Health Supply product to exceed the maximum unit per filling

8 = used for compound ingredient override

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

8 = Payer Defined Exemption

 RW Required if Prior Authorization Number Submitted is transmitted
462-EV Prior Authorization Number Submitted

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

KHC with Medicare coverage

99 = Other

 RW
***R***		 If the COB segment is transmitted.
340-7C Other Payer ID   RW
***R***

KHC with Medicare Part B

If “Other Payer ID Qualifier” = 99 and Other Payer is Medicare Part B, submit “MEDPARTB”

KHC with Medicare Part C or Part D

If “Other Payer ID Qualifier” = 99 and Other Payer is Medicare Part C or Part D, submit “MEDICARERX”
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
353-NR Other Payer-Patient Responsibility Amount Count 1-25 O Optional when Benefit Stage Count is submitted
351-NP Other Payer-Patient Responsibility Amount Qualifier   O
***R***		 Optional when Benefit Stage Count is submitted
352-NQ Other Payer-Patient Responsibility Amount   O
***R***		 Optional when Benefit Stage Count is submitted
392-MU Benefit Stage Count   RW Required if “Benefit Stage Qualifier” is submitted
393-MV Benefit Stage Qualifier

01=Deductible

02=Initial Benefit

03=Coverage Gap

04=Catastrophic Coverage

50=Not paid under Part D, paid under Part C benefit (for MA-PD plan)

60=Not paid under Part D, paid as or under supplemental benefit only

61=Part D drug not paid by Part D plan benefit, paid as or under a co-administered insured benefit only

62=Non-Part D/non-qualified drug not paid by Part D plan benefit. Paid as or under a co-administered benefit only

70=Part D drug not paid by Part D plan benefit, paid by beneficiary under plan-sponsored negotiated pricing

80=Non-Part D drug not paid by Part D plan benefit, paid by the beneficiary under plan-sponsored negotiated pricing

90=Enhance or OTC drug (PDE value of E/O) not applicable to the Part D drug spend, but is covered by the Part D plan

 RW
***R***		 Required if “Benefit Stage Count” is submitted
394-MW Benefit Stage Amount   RW
***R***		 Required if “Benefit Stage Count” is submitted

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

TD = Therapeutic Duplication

 RW
***R***		  
440-E5 Professional Service Code

00 = No Intervention

M0 =Prescriber consulted

P0 = Patient consulted

R0 = Pharmacist consulted other source

 RW
***R***		  
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

4A = Prescribed with acknowledgement

 RW
***R***		  

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

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”.

B1 Transaction: Accepted Response (Medicaid, CSHCN, KHC)

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 B1 = Billing M Billing 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 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 Message Segment

Mandatory

Field Number Field Name Value Usage Comment
111-AM Segment Identification 20 = Response Message Segment M  
504-F4 Message   RW Optional

Response Insurance Segment

Optional

Field Number Field Name Value Usage Comment
111-AM Segment Identification 25 = Response Insurance Segment M  
301-C1 Group ID

V

C

K

 RW

V = Medicaid/HTW

C = CSHCN

K = KHC
524-FO Plan ID

V

C

K

 RW

V = Medicaid/HTW

C = CSHCN

K = KHC

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

P=Paid

D=Duplicate of Paid

 M  
503-F3 Authorization Number   RW Returned when needed to identify the transaction.
130-UF Additional Message Information Count 1–25 RW  
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

Response Pricing Segment

Mandatory

Field Number Field Name Value Usage Comment
111-AM Segment Identification 23 = Response Pricing Segment M  
505-F5 Patient Pay Amount   R

Amount of Assessed Co-Pay

0 if no co-pay
506-F6 Ingredient Cost Paid   R

Ingredient Cost Calculated by the processor

Included in the 'Total Amount Paid' (509-F9)
507-F7 Dispensing Fee Paid   R

Sum of miscellaneous dispensing expenses

Included in the 'Total Amount Paid' (509-F9)
521-FL Incentive Amount Paid   RW Format=s$$$$$$cc
562-J1 Professional Service Fee Paid   RW Optional
566-J5 Other Payer Amount  Recognized   RW Sum of all Other Payer Amounts
509-F9 Total Amount Paid   R

Value equals = 

["Ingredient Cost Paid" (506-F6) plus
"Dispensing Fee Paid" (507-F7) plus
"Incentive Amount Paid" (521-FL)] minus
["Patient Pay Amount" (505-F5) plus "Other Payer Amount Recognized" (566-J5)]
522-FM Basis of Reimbursement Determination

0 = Not Specified

1 = Ingredient Cost Paid as Submitted

2 = Ingredient Cost Reduced to AWP Pricing

3 = Ingredient Cost Reduced to AWP Less X% Pricing

4 = Usual & Customary Paid as Submitted

5 = Paid Lower of Ingredient Cost Plus Fees Versus Usual & Customary

6 = MAC Pricing Ingredient Cost Paid

7 = MAC Pricing Ingredient Cost Reduced to MAC

8 = Contract Pricing

9 = Acquisition Pricing

12 = 340B / Disproportionate Share Pricing/Public Health Service

20 - National Average Drug Acquisition Cost (NADAC)

 R  

Response Drug Use Review/Professional Pharmacy Service Segment

Optional, returned if DUR alert generated

Field Number Field Name Value Usage Comment
111-AM Segment Identification 24 = Response DUR/PPS Segment M  
567-J6 DUR/PPS Response Code Counter 1–9 RW
***R***		  
439-E4 Reason for Service Code

DD = Drug-Drug Interaction

HD = High Dose

ID = Ingredient Duplication

TD = Therapeutic Duplication

 RW
***R***		  
528-FS Clinical Significance Code

Blank = Not Specified

1 = Major

2 = Moderate

3 = Minor

 RW
***R***		  
529-FT Other Pharmacy Indicator

0 = Not Specified

1 = Your Pharmacy

2 = Other Pharmacy in Same Chain

3 = Other Pharmacy

 RW
***R***		  
530-FU Previous Date of Fill   RW
***R***		  
531-FV Quantity of Previous Fill   RW
***R***		  
532-FW Database Indicator

Blank = Not Specified

1 = First Databank

 RW
***R***		  
533-FX Other Prescriber Indicator

0 = Not Specified

1 = Same Prescriber

2 = Other Prescriber

 RW
***R***		  
544-FY DUR Free Text Message   RW
***R***		 Required when text is needed for additional clarification.
570-NS DUR Additional Text   RW
***R***		  

B1 Transaction: Rejected Response (Medicaid, CSHCN, KHC)

Transaction Header Segment

Mandatory

Field Number Field Name Value Usage Comment
102-A2 Version/Release Number D0 = Version D.0 M  
103-A3 Transaction Code B1 = Billing M Billing 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 Message Segment

Mandatory

Field Number Field Name Value Usage Comment
111-AM Segment Identification 20 = Response Message Segment M  
504-F4 Message   RW Optional

Response Insurance Segment

Optional

Field Number Field Name Value Usage Comment
111-AM Segment Identification 25 = Response Insurance Segment M  
301-C1 Group ID

V

C

K

 RW

V = Medicaid/HTW

C = CSHCN

K = KHC
524-FO Plan ID

V

C

K

 RW

V = Medicaid/HTW

C = CSHCN

K = KHC

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
***R***		  
546-4F Reject Field Occurrence Indicator   R
***R***		 Optional
130-UF Additional Message Information Count 01–25 R  
132-UH Additional Message Information Qualifier 01–09 R
***R***		 The sequence number of message for each transaction
526-FQ Additional Message Information   R
***R***		 40 bytes
131-UG Additional Message Information Continuity + = Current text continues R
***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

Response Drug Use Review/Professional Pharmacy Service Segment

Optional, returned if DUR alert generated

Field Number Field Name Value Usage Comment
111-AM Segment Identification 24 = Response DUR/PPS Segment M  
567-J6 DUR/PPS Response Code Counter 1–9 RW
***R***		  
439-E4 Reason for Service Code

DD = Drug-Drug Interaction

HD = High Dose

ID = Ingredient Duplication

TD = Therapeutic Duplication

 RW
***R***		  
528-FS Clinical Significance Code

Blank = Not Specified

1 = Major

2 = Moderate

3 = Minor

 RW
***R***		  
529-FT Other Pharmacy Indicator

0 = Not Specified

1 = Your Pharmacy

2 = Other Pharmacy in Same Chain

3 = Other Pharmacy

 RW
***R***		  
530-FU Previous Date of Fill   RW
***R***		  
531-FV Quantity of Previous Fill   RW
***R***		  
532-FW Database Indicator

Blank = Not Specified

1 = First Databank

 RW
***R***		  
533-FX Other Prescriber Indicator

0 = Not Specified

1 = Same Prescriber

2 = Other Prescriber

 RW
***R***		  
544-FY DUR Free Text Message   RW
***R***		 Required when text is needed for additional clarification.
57Ø-NS DUR Additional Text   RW
***R***		  

B1 Revision History (Medicaid, CSHCN)

Status Date Description
Revision Sept. 22, 2021 Project: COVID-19 Vaccine Booster Doses
  • Billing transaction: claim segment (Submission Clarification Code)
Revision Sept. 28, 2021 Project: COVID-19 Vaccine Additional Doses
  • Billing transaction: claim segment (Submission Clarification Code)
Revision Dec. 28, 2020 Project: COVID-19 Vaccines
  • Billing transaction: claim segment (Submission Clarification Code) 
Revision Sept. 21, 2020 Project: Quantity Prescribed for Schedule II Drugs
  • Billing transaction: claim segment
Project: Pharmacist Reimbursable Injections
  • Billing transaction: DUR/PPS, pricing segments
Baseline Jan. 1, 2017 Initial publication

B1 Revision History (KHC)

Status Date Description
Revision April 1, 2021 Coordination of Benefits/Other Payments Segment:
  • Other Payer ID (34Ø-7C) values: added Part C
Revision Sept. 21, 2020 Project: Quantity Prescribed for Schedule II Drugs
  • Billing transaction: claim segment
Baseline Jan. 1, 2017 Initial publication

Claim Billing Reversal (B2) Transaction Payer Sheet

Program Name

  • Traditional Medicaid
  • Children with Special Health Care Needs (CSHCN) Services Program
  • Healthy Texas Women (HTW) Program
  • Kidney Health Care (KHC) Program

Transaction Code

  • National Council for Prescription Drug Programs (NCPDP) B2 - Reversal
  • Refer to the Claims Billing Reversal (B2) Transaction section of the Pharmacy Provider Procedure Manual for more information about the NCPDP transaction.

Notes

  • Reversals match on Provider Number, RX Number, Product/Service ID, and Date Of Service fields.
  • The processor edits all submitted data elements for valid format and values.
  • Provider software should support all data elements on the required segments.
  • In cases where multiple iterations of a field ("repeating fields") are allowed, the maximum number of iterations is indicated.

Field Usage Description

  • Mandatory (M):
    • Submitted following the NCPDP Telecommunication Implementation Guide Version D.0.
  • Required (R):
    • Always submitted.
  • Required When (RW):
    • Submitted under circumstances explained in the Comment column.
  • Optional (O):
    • Submitted at the discretion of the pharmacy provider.
  • Repeating (***R***):
    • Designates a repeating field.

B2 Transaction: Reversal Request

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 B2 = Reversal M Reversal Request
104-A4 Processor Control Number

DRTXPROD = Medicaid, CSHCN, and HTW

DRTXPRODKH = KHC

 M  
109-A9 Transaction Count

1 = One Occurrence

2 = Two Occurrences

3 = Three Occurrences

4 = Four Occurrences

 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
110-AK Software Vendor/Certification ID Three-digit software identification number with space fill M  

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 Value “00” if Compound Code = “2”
407-D7 Product/Service ID   M  

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 to 9 RW If segment transmitted
439-E4 Reason for Service Code DD = Drug-Drug Interaction
HD = High Dose
ID = Ingredient Duplication
TD = Therapeutic Duplication		 RW
***R***		  
440-E5 Professional Service Code 00 = No Intervention
M0 =Prescriber consulted
P0 = Patient consulted
R0 = Pharmacist consulted other source		 RW
***R***		  
441-E6 Result of Service Code 1C = Filled, With Different Dose
1D = Filled, With Different Directions
1E = Filled, With Different Drug
1F = Filled, With Different Quantity
2A = Prescription Not Filled
2B = Not Filled, Directions Clarified		 RW
***R***		  

B2 Transaction: Accepted 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 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

A = Approved

S = Duplicate of Approved

 M  
503-F3 Authorization Number   RW Returned when needed to identify the transaction.
130-UF Additional Message Information Count 1–25 RW  
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

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

Eligibility Verification (E1) Transaction Payer Sheet

Program Name

  • Traditional Medicaid
  • Children's Health Insurance Program (CHIP) *
  • Children with Special Health Care Needs (CSHCN) Services Program
  • Healthy Texas Women (HTW) Program
  • Kidney Health Care (KHC) Program

Transaction Code

  • National Council for Prescription Drug Programs (NCPDP) E1 - Eligibility Verification
  • Refer to the Eligibility Verification (E1) Transaction section of the Pharmacy Provider Procedure Manual for more information about the NCPDP transaction.

Notes

  • The processor edits all submitted data elements for valid format and values.
  • Provider software should support all data elements on the required segments.
  • In cases where multiple iterations of a field ("repeating fields") are allowed, the maximum number of iterations is indicated.
  • * E1 transactions submitted to HHSC for clients enrolled in CHIP will return a response identifying the name of the client's MCO. Pharmacies providers should contact the client's specific MCO for details.

Field Usage Description

  • Mandatory (M):
    • Submitted following the NCPDP Telecommunication Implementation Guide Version D.0
  • Required (R):
    • Always submitted
  • Required When (RW):
    • Submitted under circumstances explained in the Comment column
  • Optional (O):
    • Submitted at the discretion of the pharmacy provider
  • Repeating (***R***):
    • Designates a repeating field

E1 Transaction: Eligibility Request

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 E1 = Eligibility Verification M  
104-A4 Processor Control Number DRTXPROD M  
109-A9 Transaction Count 1 = One Occurrence 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
110-AK Software Vendor/Certification ID Three-digit software identification number with space fill M  

Insurance Segment

Mandatory

Field Number Field Name Value Usage Comment
111-AM Segment Identification 04 = Insurance Segment M  
302-C2 Cardholder ID   R

Recipient Program ID Number

  • Medicaid, CHIP, and HTW 
    • Nine-digit numbers begin with 1-6
  • CSHCN
    • Nine-digit numbers begin with 9.
  • KHC
    • Nine-digit numbers begin with 8.
  • Social Security Number
    • Nine-digit is proceeded with “S” (e.g., SSN 123456789 is entered as “S123456789”)
313-CD Cardholder Last Name   O Optional; must match if transmitted
301-C1 Group ID
  • MEDICAID
  • CHIP
  • CSHCN
  • KHC
 R For HTW cardholder IDs, enter ‘MEDICAID’

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  

E1 Transaction: Accepted 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 E1 = Eligibility Verification M Eligibility Verification Response
109-A9 Transaction Count 1 = One Occurrence M  
501-F1 Header Response Status A = Accepted 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 A=Approved    
130-UF Additional Message Information Count 1–25 RW  
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***
  • Cardholder ID is only returned when SSN is transmitted in field 302-C2. 
  • Refer to Field Response for an Accepted Eligibility Verification.
131-UG Additional Message Information Continuity + = Current text continues RW
***R***		  

Field Responses for an Accepted Eligibility Verification

Pharmacies must have an executed pharmacy provider agreement with HHSC for participation in other programs (CHIP, CSHCN, and KHC) before eligibility information is returned.

Medicaid, HTW program

Message Explanation
MEDmmddyy-mmddyy
  • The most current or the last effective Medicaid prescription eligibility period based on the date submitted in the "Date of Service" field (401-D1) is returned. This period could include an end date of eligibility if the person has been denied or will be denied for prescription coverage (e.g., MED010103-073104).
  • If the most current eligibility period reflects an actively-enrolled person with no denial of coverage, then only the start date is returned. Zeros are returned as an end date (e.g. MED010103-000000).
PACE ELIG
  • The person is enrolled in the Programs of All-Inclusive Care for the Elderly (PACE) and has no Medicaid drug benefit.
CONTACT (Plan name). CLIENT ENROLLED IN THIS PLAN
  • The person is enrolled in an MCO. The message will return the name of the MCO the person is enrolled in. Refer to the MCO resource information for MCO-specific BIN, PCN, and Group values.
MED NOT ELIGIBLE
  • Returned if the person’s number is found but no Medicaid drug eligibility exists.
UNLIM-RX-mm/yy
  • Designates whether the person qualifies for unlimited prescriptions. The response pertains only to the month of service of the date entered in the "Date of Service" field (401-D1).
3RX-LIMIT-mm/yy
  • Designates whether the person is limited to three prescriptions per month. The response pertains only to the month of service of the date entered in the "Date of Service" field (401-D1).
PRIOR ELIG EXIST
  • Returned only if prior occurrences exist to the HHSC eligibility period returned in the “MED” eligibility message.
POST ELIG EXIST
  • Returned only if post occurrences exist to the HHSC eligibility period returned in the “MED” eligibility message.
MCBmmddyy-mmddyy
  • Designates Medicare Part B eligibility and effective dates.
MCDmmddyy-mmddyy
  • Designates Medicare Part D eligibility and effective dates.
OTHER COV EXIST
  • For pharmacies enrolled in CSHCN:
    • OTHER COV EXIST CSHCN ID#nnnnnnnnn: If the Cardholder ID equals Medicaid and the person is dually-eligible for both Medicaid and CSHCN, then to obtain CSHCN eligibility information, submit an eligibility verification transaction using the CSHCN Cardholder ID number.
  • For pharmacies not enrolled in CSHCN:
    • OTHER COV EXIST: indicates coverage through another state program.

CSHCN Services Program

Message Explanation
CSHCNmmddyy-mmddyy
  • The most current or the last effective CSHCN prescription eligibility period based on the date submitted in the "Date of Service" field (401-D1) is returned. This period could include an end date of eligibility if the person has been denied or will be denied prescription coverage (e.g. CSHCN010103-073104).
  • If the most current eligibility period reflects an actively-enrolled person with no denial of coverage, only the start date is returned. Zeros are returned as an end date (e.g. CSHCN010103-000000).
ATmmddyy-mmddyy
  • Designates the person’s most current period of prior approval for aerosolized Tobramycin if applicable. This eligibility period is always returned, if it exists, regardless of the date entered in the "Date of Service" field (401-D1).
  • Prior approvals are granted for one-year periods and may not match the person’s prescription eligibility period shown under “CSHCN”. Should a person lose prescription eligibility within a prior approval period, the “one-year” prior approval period is returned but the person’s prescription eligibility will always take precedence.
OTHER COV EXIST
  • Returned if the person is dually eligible for CSHCN and Medicaid.
  • MED ID#nnnnnnnnn - Medicaid Cardholder ID. To obtain Medicaid eligibility information, submit an eligibility verification transaction using the Medicaid Cardholder ID number.

KHC Program

Message Explanation
KHCmmddyy-mmddyy
  • The most current or the last effective KHC prescription eligibility period based on the date submitted in the "Date of Service" field (401-D1) is returned. This period could include an end date of eligibility if the person has been denied or will be denied prescription coverage (e.g. KHC010103-073104).
  • If the most current eligibility period reflects an actively-enrolled person with no denial or coverage, only the start date is returned. Zeros are returned as an end date (e.g. KHC010103-000000).
COPAY $00 OR $00
  • The co-payment level of the person, for both brand and generic, is returned.
COPAY MAY NOT APPLY FOR CLIENTS WITH MEDICARE
  • Based on the date submitted in the "Date of Service" field (401-D1) for people with effective Medicare Part B and/or Medicare Part D coverage.
MCBmmddyy-mmddyy
  • Designates Medicare Part B eligibility and effective dates.
MCDmmddyy-mmddyy
  • Designates Medicare Part D eligibility and effective dates.

CHIP

Message Explanation
CONTACT (Plan name). CLIENT ENROLLED IN THIS PLAN
  • The person is enrolled in a CHIP MCO. The message returns the name of the MCO the person is enrolled in. Refer to the MCO resource information for MCO-specific BIN, PCN, and Group values.

E1 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 E1 = Eligibility Verification M Eligibility Verification Response
109-A9 Transaction Count 1 = One Occurrence M  
501-F1 Header Response Status 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    
510-FA Reject Count 1-5 R  
511-FB Reject Code   R Repeating
130-UF Additional Message Information Count 1–25 RW  
132-UH Additional Message Information Qualifier 1–9 RW
***R***		 The sequence number of message for each transaction
526-FQ Additional Message Information   RW
***R***

 
131-UG Additional Message Information Continuity + = Current text continues RW
***R***