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					                                                                  Batch Header Record

                                                                                                                                    VMS Claim/CMN field
NCPDP Data Dictionary     Field                                            Batch 1.1   Batch 1.2                                       that is currently
                                       NCPDP Definition of Field                                   Valid values per the Standard
       Name              Number                                             Format     Format                                        populated from this
                                                                                                                                         information

Segment Identification   111-AM   Identifies the segment in the request    X(02)       SAME        00 = File Control (header)      N/A
                                  record.
Transmission Type        880-K6   Defines the Type of transmission         X(01)       SAME        T = Transaction                 N/A
                                  being sent.                                                      R = Response
*Part of External Code                                                                             E = Error
List under D.0
Sender ID                880-K1   Identification number assigned to the    X(24)       SAME        To be defined by                Submitter ID
                                  sender of the data by the processor                              processor/switch.
                                  of the data.
Batch Number             806-5C   Number assigned by processor.            9(07)       SAME        Matches Trailer                 N/A
                                  Matches Trailer record.
Creation Date            880-K2   Date the file was created.               9(08)       SAME        Format = CCYYMMDD               Submitter Creation Date
Creation Time            880-K3   Time the file was created.               9(04)       SAME        Format = HHMM                   N/A
File Type                702-MC   Identifies that the data to be applied   X(01)       SAME        P = production                  N/A
                                  is a test or production file.                                    T = test
*Part of External Code
List under D.0
Version/Release Number   102-A2   Code identifying the release syntax      X(02)       SAME        11=Version 1.1                  N/A
                                  and corresponding Data Dictionary.                               12=Version 1.2
Receiver ID              880-K7   Identification number assigned to the    X(24)       SAME        To be defined by                N/A
                                  receiver of the data by the processor                            processor/switch.
                                  of the data.




              1
                                                          Transmission Header Segment

                                                                                                                           VMS Claim/CMN field
                                                                      Version   Version
NCPDP Data Dictionary    Field                                                                                                that is currently
                                     NCPDP Definition of Field          5.1     D.0       Valid values per the Standard
       Name             Number                                                                                              populated from this
                                                                      Format    Format
                                                                                                                                information

BIN Number              101-A1   Card Issuer or Bank ID used for     9(06)      SAME      N/A                             N/A
                                 network routing.




         2
                                                            Transmission Header Segment

                                                                                                                              VMS Claim/CMN field
                                                                         Version   Version
NCPDP Data Dictionary     Field                                                                                                  that is currently
                                       NCPDP Definition of Field           5.1     D.0       Valid values per the Standard
       Name              Number                                                                                                populated from this
                                                                         Format    Format
                                                                                                                                   information

Version/Release Number   102-A2   Code identifying the release syntax   X(02)      SAME      01=Version 1.0
                                  and corresponding Data Dictionary.                         02=Version 2.0                  N/A
*Part of External Code                                                                       03=Version 3.0
                                                                                             31=Version 3.1                  *Currently, VMS only
List under D.0
                                                                                             32=Version 3.2                  processes Version 5.1
                                                                                             3A=Standard Claim/Reversal
                                                                                             3B=Workers Compensation
                                                                                             3C=Medicaid Claim/Reversal
                                                                                             33=Version 3.3
                                                                                             34=Version 3.4
                                                                                             35=Version 3.5
                                                                                             40=Version 4.0
                                                                                             41=Version 4.1
                                                                                             42=Version 4.2
                                                                                             50=Version 5.0
                                                                                             51=Version 5.1
                                                                                             52=Version 5.2
                                                                                             53=Version 5.3
                                                                                             54=Version 5.4
                                                                                             55=Version 5.5
                                                                                             56=Version 5.6
                                                                                             60=Version 6.0
                                                                                             70=Version 7.0
                                                                                             71=Version 7.1
                                                                                             80=Version 8.0
                                                                                             81=Version 8.1
                                                                                             82=Version 8.2
                                                                                             83=Version 8.3
                                                                                             90=Version 9.0
                                                                                             A0=Version A.0
                                                                                             A1=Version A.1
                                                                                             B0=Version B.0
                                                                                             C0=Version C.0
                                                                                             C1=Version C.1
                                                                                             C2=Version C.2
                                                                                             C3=Version C.3
                                                                                             C4=Version C.4
                                                                                             D0=Version D.0




           3
                                                              Transmission Header Segment

                                                                                                                                 VMS Claim/CMN field
                                                                          Version   Version
NCPDP Data Dictionary     Field                                                                                                     that is currently
                                       NCPDP Definition of Field            5.1     D.0       Valid values per the Standard
       Name              Number                                                                                                   populated from this
                                                                          Format    Format
                                                                                                                                      information

Transaction Code         103-A3   Identifies type of transaction         X(02)      SAME      B1=Billing                        N/A
                                                                                              B2=Reversal
*Part of External Code                                                                        B3=Rebill                         *Currently, VMS only
List under D.0                                                                                C1=Controlled Substance           processes the Billing
                                                                                              Reporting                         (B1) transaction
                                                                                              C2=Controlled Substance
                                                                                              Reporting
                                                                                              Reversal
                                                                                              C3=Controlled Substance
                                                                                              Reporting Rebill
                                                                                              *D1=Determination of Benefits
                                                                                              E1=Eligibility Verification
                                                                                              N1=Information Reporting
                                                                                              N2=Information Reporting
                                                                                              Reversal
                                                                                              N3=Information Reporting Rebill
                                                                                              P1=P.A. Request & Billing
                                                                                              P2=P.A. Reversal
                                                                                              P3=P.A. Inquiry
                                                                                              P4=P.A. Request Only
                                                                                              *S1=Service Billing
                                                                                              *S2=Service Reversal
                                                                                              *S3=Service Rebill

                                                                                              *New value under D.0
Processor Control        104-A4   Number assigned by processor.          X(10)      SAME      N/A                               Patient Account Number
Number
Transaction Count        109-A9   Number of transactions in the          X(01)      SAME      Blank=Not Specified               Claim Line Count
                                  transmission.                                               1=One Occurrence
*Part of External Code                                                                        2=Two Occurrences
List under D.0                                                                                3=Three Occurrences
                                                                                              4=Four Occurrences




           4
                                                              Transmission Header Segment

                                                                                                                                     VMS Claim/CMN field
                                                                              Version   Version
NCPDP Data Dictionary     Field                                                                                                         that is currently
                                        NCPDP Definition of Field               5.1     D.0       Valid values per the Standard
       Name              Number                                                                                                       populated from this
                                                                              Format    Format
                                                                                                                                          information

Service Provider ID      202-B2    Code qualifying the Service Provider      X(02)      SAME      Blank=Not Specified               N/A
Qualifier                          ID                                                             01=National Provider Identifier
                                                                                                  (NPI)                             *Value 01 (NPI) should
*Part of External Code                                                                            02=Blue Cross                     be only valid value for
List under D.0                                                                                    03=Blue Shield                    Medicare once NPI is
                                                                                                  04=Medicare                       fully implemented
                                                                                                  05=Medicaid
                                                                                                  06=UPIN
                                                                                                  07=NCPDP Provider ID
                                                                                                  08=State License
                                                                                                  09=Champus
                                                                                                  10=Health Industry Number
                                                                                                  (HIN)
                                                                                                  11=Federal Tax ID
                                                                                                  12=Drug Enforcement
                                                                                                  Administration (DEA)
                                                                                                  13=State Issued
                                                                                                  14=Plan Specific
                                                                                                  *15=HCID (HC IDea)
                                                                                                  99=Other

                                                                                                  *New value under D.0
Service Provider ID      201-B1    ID assigned to pharmacy or provider.      X(15)      SAME      N/A                               Supplier/Rendering
                                                                                                                                    Provider
Date of Service           401-D1   Identifies date the prescription was      9(08)      SAME      Format=CCYYMMDD                   From/To Dates of
                                   filled or professional service rendered                                                          Service
                                   or subsequent payer began coverage
                                   following Part A expiration in a long-
                                   term care setting only.
Software Vendor/         110-AK    ID assigned by the switch or              X(10)      SAME      N/A                               N/A
Certification ID                   processor to identify the software
                                   source.




           5
                                                            Transmission Patient Segment

                                                                                                                                 VMS Claim/CMN field
                                                                           Version   Version
NCPDP Data Dictionary     Field                                                                                                     that is currently
                                       NCPDP Definition of Field             5.1     D.0       Valid values per the Standard
       Name              Number                                                                                                   populated from this
                                                                           Format    Format
                                                                                                                                      information

Segment Identification   111-AM   Identifies the segment in the request   X(02)      SAME      Blank=Not Specified              N/A
                                  record.                                                      01=Patient
*Part of External Code                                                                         02=Pharmacy Provider
List under D.0                                                                                 03=Prescriber
                                                                                               04=Insurance
                                                                                               05=Coordination of
                                                                                               Benefits/Other
                                                                                               Payments
                                                                                               06=Worker’s Compensation
                                                                                               07=Claim
                                                                                               08=DUR/PPS
                                                                                               09=Coupon
                                                                                               10=Compound
                                                                                               11=Pricing
                                                                                               12=Prior Authorization
                                                                                               13=Clinical
                                                                                               *14=Additional Documentation
                                                                                               *15=Facility
                                                                                               *16=Narrative
                                                                                               20=Response Message
                                                                                               21=Response Status
                                                                                               22=Response Claim
                                                                                               23=Response Pricing
                                                                                               24=Response DUR/PPS
                                                                                               25=Response Insurance
                                                                                               26=Response Prior
                                                                                               Authorization
                                                                                               *27=Response Insurance
                                                                                               Additional Information Segment
                                                                                               *28=Response Coordination of
                                                                                               Benefits/Other Payers

                                                                                               *New value under D.0




           6
                                                                Transmission Patient Segment

                                                                                                                                  VMS Claim/CMN field
                                                                            Version    Version
NCPDP Data Dictionary     Field                                                                                                      that is currently
                                       NCPDP Definition of Field              5.1      D.0       Valid values per the Standard
       Name              Number                                                                                                    populated from this
                                                                            Format     Format
                                                                                                                                       information

Patient ID Qualifier     331-CX   Code qualifying the Patient ID           X(02)       SAME      Blank=Not Specified             N/A
                                                                                                 01=Social Security Number
*Part of External Code                                                                           02=Driver’s License Number
List under D.0                                                                                   03=U.S. Military ID
                                                                                                 *04=SSN-based ID assigned by
                                                                                                 plan
                                                                                                 *05= Non-SSN-based ID
                                                                                                 assigned by plan
                                                                                                 *06=Medicaid ID
                                                                                                 99=Other

                                                                                                 *New value under D.0
Patient ID               332-CY   ID assigned to the patient.              X(20)       SAME      N/A                             Beneficiary HICN
Date of Birth            304-C4   Date of birth of patient.                9(08)       SAME      Format=CCYYMMDD                 Beneficiary Birth Date

Patient Gender Code      305-C5   Code indicating the gender of the        9(01)       SAME      0=Not Specified                 Beneficiary Sex
                                  patient.                                                       1=Male
*Part of External Code                                                                           2=Female
List under D.0
Patient First Name       310-CA   Patient's first name.                    X(12)       SAME      N/A                             Beneficiary First Name
Patient Last Name        311-CB   Patient's last name.                     X(15)       SAME      N/A                             Beneficiary Last Name
Patient Street Address   322-CM   Free form text for address               X(30)       SAME      N/A                             Beneficiary Address
                                  information.
Patient City Address     323-CN   Free form text for city name.            X(20)       SAME      N/A                             Beneficiary City
Patient State/           324-CO   Standard state/province code as          X(02)       SAME      Standard United States and      Beneficiary State
Province Address                  defined by appropriate government                              Canadian province two-letter    Beneficiary Pricing State
                                  agency.                                                        postal service abbreviations
*Part of External Code                                                                           should be used.
List under D.0




            7
                                                              Transmission Patient Segment

                                                                                                                                      VMS Claim/CMN field
                                                                             Version   Version
NCPDP Data Dictionary      Field                                                                                                         that is currently
                                        NCPDP Definition of Field              5.1     D.0          Valid values per the Standard
       Name               Number                                                                                                       populated from this
                                                                             Format    Format
                                                                                                                                           information

Patient ZIP/              325-CP   Code defining international postal       X(15)      SAME         N/A                              Beneficiary Zip Code
Postal Zone                        zone excluding punctuation and
                                   blanks (zip code for US).
Patient Phone Number      326-CQ   Patient's 10-digit phone number          9(10)      SAME         Format=AAAEEENNNN                N/A

Patient Location          307-C7   Code identifying the location of the     9(02)      SAME         5.1 Values                       Place of Service
*Field name changed to             patient when receiving pharmacy
Place of Service as of             services                                                         0=Not specified
version B.0                                                                                         1=Home
                                                                                                    2=Inter-Care
**Part of External Code                                                                             3=Nursing Home
List under D.0                                                                                      4=Long Term/Extended Care
                                                                                                    5=Rest Home
                                                                                                    6=Boarding Home
                                                                                                    7=Skilled Care Facility
                                                                                                    8=Sub-Acute Care Facility
                                                                                                    9=Acute Care Facility
                                                                                                    10=Outpatient
                                                                                                    11=Hospice

                                                                                                    *As of version B.0, this field
                                                                                                    uses the standard CMS Place of
                                                                                                    Service values
Employer ID               333-CZ   ID assigned to the employer.             X(15)      SAME         N/A                              N/A
Smoker/                   334-1C   Code indicating whether the patient is   X(01)      Not Used     Blank=Not Specified              N/A
Non-Smoker Code                    a smoker or not.                                    in Billing   1=Non-Smoker
                                                                                       Trans.       2=Smoker
*Part of External Code
List under D.0
Pregnancy Indicator       335-2C   Code indicating whether the patient is   X(01)      SAME         Blank=Not Specified              N/A
                                   pregnant or not.                                                 1=Not pregnant
*Part of External Code                                                                              2=Pregnant
List under D.0




               8
                                                             Transmission Patient Segment

                                                                                                                                    VMS Claim/CMN field
                                                                            Version   Version
NCPDP Data Dictionary     Field                                                                                                        that is currently
                                       NCPDP Definition of Field              5.1     D.0       Valid values per the Standard
       Name              Number                                                                                                      populated from this
                                                                            Format    Format
                                                                                                                                         information

Patient E-mail Address   350-HN   The E-Mail address of the patient         N/A       X(80)     N/A                                N/A
                                  (member).
Patient Residence        384-4X   Code identifying the patient’s place of   N/A       9(02)     0=Not Specified                    N/A
                                  residence.                                                    1=Home
*Part of External Code                                                                          2=Skilled Nursing Facility
List under D.0                                                                                  3=Nursing Facility
                                                                                                4=Assisted Living Facility
                                                                                                5=Custodial Care Facility
                                                                                                6=Group Home
                                                                                                7=Inpatient Psychiatric Facility
                                                                                                8=Psychiatric Facility – Partial
                                                                                                Hospitalization
                                                                                                9=Intermediate Care
                                                                                                Facility/Mentally Retarded
                                                                                                10=Residential Substance
                                                                                                Abuse Treatment Facility
                                                                                                11=Hospice
                                                                                                12=Psychiatric Residential
                                                                                                Treatment Facility
                                                                                                13=Comprehensive Inpatient
                                                                                                Rehabilitation Facility
                                                                                                14=Homeless Shelter
                                                                                                15=Correctional Institution




           9
                                                                 Transaction Pharmacy Segment
         *This segment is not currently edited beyond the Implementation Guide level in VMS and is not used to populate any VMS claim or CMN fields.

                                                                                                                                        VMS Claim/CMN field
                                                                                Version   Version
NCPDP Data Dictionary       Field                                                                                                          that is currently
                                            NCPDP Definition of Field             5.1     D.0        Valid values per the Standard
       Name                Number                                                                                                        populated from this
                                                                                Format    Format
                                                                                                                                             information

Segment Identification     111-AM      Identifies the segment in the request   X(02)      SAME       See Listing in the Transmission   N/A
                                       record.                                                       Patient Segment
Provider ID Qualifier      465-EY      Code qualifying the Provider ID         X(02)      SAME       Blank=Not Specified               N/A
                                                                                                     01=Drug Enforcement
*Part of External Code                                                                               Administration                    *Value 05 (NPI) should
List under D.0                                                                                       (DEA)                             be only valid value for
                                                                                                     02=State License                  Medicare once NPI is
                                                                                                     03=Social Security Number         fully implemented
                                                                                                     (SSN)
                                                                                                     04=Name
                                                                                                     05=National Provider Identifier
                                                                                                     (NPI)
                                                                                                     06=Health Industry Number
                                                                                                     (HIN)
                                                                                                     07=State Issued
                                                                                                     99=Other
Provider ID                444-E9      ID assigned to the person               X(15)      SAME       N/A                               N/A
                                       responsible for the dispensing of the
                                       prescription.




              10
                                                              Transaction Prescriber Segment

                                                                                                                                     VMS Claim/CMN field
                                                                             Version   Version
NCPDP Data Dictionary       Field                                                                                                       that is currently
                                         NCPDP Definition of Field             5.1     D.0        Valid values per the Standard
       Name                Number                                                                                                     populated from this
                                                                             Format    Format
                                                                                                                                          information

Segment Identification     111-AM   Identifies the segment in the request   X(02)      SAME       See Listing in the Transmission   N/A
                                    record.                                                       Patient Segment
Prescriber ID Qualifier    466-EZ   Code qualifying the Prescriber ID       X(02)      SAME       Blank=Not Specified               N/A
                                                                                                  01=National Provider Identifier
*Part of External Code                                                                            (NPI)                             *Value 01(NPI) should be
List under D.0                                                                                    02=Blue Cross                     only valid value for
                                                                                                  03=Blue Shield                    Medicare once NPI is
                                                                                                  04=Medicare                       fully implemented
                                                                                                  05=Medicaid
                                                                                                  06=UPIN
                                                                                                  07=NCPDP Provider ID
                                                                                                  08=State License
                                                                                                  09=Champus
                                                                                                  10=Health Industry Number
                                                                                                  (HIN)
                                                                                                  11=Federal Tax ID
                                                                                                  12=Drug Enforcement
                                                                                                  Administration
                                                                                                  (DEA)
                                                                                                  13=State Issued
                                                                                                  14=Plan Specific
                                                                                                  *15=HC IDea
                                                                                                  99=Other
                                                                                                  *New value under D.0
Prescriber ID              411-DB   ID assigned to the prescriber.          X(15)      SAME       N/A                               Referring Provider
                                                                                                                                    Number
Prescriber Location Code   467-1E   Location address code assigned to       X(03)      Deleted    N/A                               N/A
                                    the prescriber as identified in the                from
                                    National Provider System (NPS).                    Telecom.
                                                                                       Std.
Prescriber Last Name       427-DR   Individual last name.                   X(15)      SAME       N/A                               Referring Physician Last
                                                                                                                                    Name




            11
                                                            Transaction Prescriber Segment

                                                                                                                                  VMS Claim/CMN field
                                                                         Version    Version
NCPDP Data Dictionary       Field                                                                                                    that is currently
                                        NCPDP Definition of Field          5.1      D.0        Valid values per the Standard
       Name                Number                                                                                                  populated from this
                                                                         Format     Format
                                                                                                                                       information

Prescriber Phone Number    498-PM   Prescribers 10-digit phone number   9(10)       SAME       N/A                               CMN Referring Physician
                                                                                                                                 Phone
Primary Care Provider ID   468-2E   Code qualifying the Primary Care    X(02)       SAME       Blank=Not Specified               N/A
Qualifier                           Provider ID                                                01=National Provider Identifier
                                                                                               (NPI)                             *Value 01(NPI) should be
*Part of External Code                                                                         02=Blue Cross                     only valid value for
List under D.0                                                                                 03=Blue Shield                    Medicare once NPI is
                                                                                               04=Medicare                       fully implemented
                                                                                               05=Medicaid
                                                                                               06=UPIN
                                                                                               **07=NCPDP Provider ID
                                                                                               08=State License
                                                                                               09=Champus
                                                                                               10=Health Industry Number
                                                                                               (HIN)
                                                                                               11=Federal Tax ID
                                                                                               12=Drug Enforcement
                                                                                               Administration
                                                                                               (DEA)
                                                                                               13=State Issued
                                                                                               14=Plan Specific
                                                                                               *15= HC IDea
                                                                                               99=Other

                                                                                               *New value under D.0

                                                                                               **Not valid for D.0
Primary Care Provider ID   421-DL   Assigned to the primary care        X(15)       SAME       N/A                               N/A
                                    provider.
Primary Care Provider      469-H5   Location address code assigned to   X(03)       Deleted    N/A                               N/A
Location Code                       the provider as identified in the               from
                                    National Provider System (NPS).                 Telecom.
                                                                                    Std.




           12
                                                               Transaction Prescriber Segment

                                                                                                                                    VMS Claim/CMN field
                                                                               Version   Version
NCPDP Data Dictionary         Field                                                                                                    that is currently
                                           NCPDP Definition of Field             5.1     D.0       Valid values per the Standard
       Name                  Number                                                                                                  populated from this
                                                                               Format    Format
                                                                                                                                         information

Primary Care Provider        470-4E   Providers last name.                    X(15)      SAME      N/A                             N/A
Last Name
Prescriber First Name        364-2J   Individual first name                   N/A        X(12)     N/A                             N/A

*This replaces the
Ordering Physician First
Name that is currently
defined as a subset of the
Prior Authorization
Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use
by Medicare under 5.1
Prescriber Street Address    365-2K   Free Form text for prescriber address   N/A        X(30)     N/A                             N/A
                                      information.
*This replaces the
Ordering Physician
Address that is currently
defined as a subset of the
Prior Authorization
Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use
by Medicare under 5.1




            13
                                                                   Transaction Prescriber Segment

                                                                                                                                      VMS Claim/CMN field
                                                                                Version    Version
NCPDP Data Dictionary           Field                                                                                                    that is currently
                                             NCPDP Definition of Field            5.1      D.0       Valid values per the Standard
       Name                    Number                                                                                                  populated from this
                                                                                Format     Format
                                                                                                                                           information

Prescriber City Address        366-2M   Free form text for prescriber city     N/A         X(20)     N/A                             N/A
                                        name.
*This replaces the
Ordering Physician City
that is currently defined as
a subset of the Prior
Authorization Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use
by Medicare under 5.1
Prescriber State/Province      367-2N   Standard state/province code as        N/A         X(02)     Standard United States and      N/A
Address                                 defined by appropriate government                            Canadian province two-letter
                                        agency.                                                      postal service abbreviations
*This replaces the                                                                                   should be used.
Ordering Physician State
that is currently defined as
a subset of the Prior
Authorization Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use
by Medicare under 5.1




            14
                                                                  Transaction Prescriber Segment

                                                                                                                                     VMS Claim/CMN field
                                                                               Version    Version
NCPDP Data Dictionary           Field                                                                                                   that is currently
                                             NCPDP Definition of Field           5.1      D.0       Valid values per the Standard
       Name                    Number                                                                                                 populated from this
                                                                               Format     Format
                                                                                                                                          information

Prescriber Zip/Postal          368-2P   Code defining international postal    N/A         X(15)     N/A                             N/A
Zone                                    zone excluding punctuation and
                                        blanks (zip code for US).
*This replaces the
Ordering Physician Zip
that is currently defined as
a subset of the Prior
Authorization Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use
by Medicare under 5.1




            15
                                                                 Transmission Insurance Segment

                                                                                                                                            VMS Claim/CMN field
                                                                                   Version   Version
NCPDP Data Dictionary         Field                                                                                                            that is currently
                                           NCPDP Definition of Field                 5.1     D.0         Valid values per the Standard
       Name                  Number                                                                                                          populated from this
                                                                                   Format    Format
                                                                                                                                                 information

Segment Identification       111-AM   Identifies the segment in the request       X(02)      SAME        See Listing in the Transmission   N/A
                                      record.                                                            Patient Segment
Cardholder ID                302-C2   Insurance ID assigned to the                X(20)      SAME        N/A                               Beneficiary HICN
                                      cardholder.
Cardholder First Name        312-CC   Individual first name.                      X(12)      SAME        N/A                               N/A
Cardholder Last Name         313-CD   Individual last name.                       X(15)      SAME        N/A                               N/A
Home Plan                    314-CE   Blue Cross/Blue Shield plan ID              X(03)      SAME        N/A                               N/A
Plan ID                      524-FO   Assigned by the processor to identify       X(08)      SAME        N/A                               N/A
                                      coverage criteria used to adjudicate a
                                      claim.
Eligibility Clarification    309-C9   Code indicating that the pharmacy is        9(01)      SAME        0=Not Specified                   N/A
Code                                  clarifying eligibility based on receiving                          1=No Override
                                      a denial.                                                          2=Override
*Part of External Code                                                                                   3=Full Time Student
List under D.0                                                                                           4=Disabled Dependent
                                                                                                         5=Dependent Parent
                                                                                                         6=Significant Other
Facility ID                  336-8C   ID assigned to the patients clinic/host     X(10)      No longer   N/A                               Facility Number
*Moved to new Facility                party.                                                 used in
Segment in D.0                                                                               this
                                                                                             segment
Group ID                     301-C1   ID assigned to the cardholders or           X(15)      SAME        N/A                               Other Carrier Name and
                                      employers group.                                                                                     Address Key - Used to
*This functionally will be                                                                                                                 identify claim-based
addressed by the new                                                                                                                       Medicaid crossover
Medicaid Indicator (360-                                                                                                                   claims
2B) in the Insurance
Segment under D.0
Person Code                  303-C3   Code assigned to a specific person          X(03)      SAME        N/A                               N/A
                                      within a family.




              16
                                                              Transmission Insurance Segment

                                                                                                                                       VMS Claim/CMN field
                                                                               Version   Version
NCPDP Data Dictionary        Field                                                                                                        that is currently
                                          NCPDP Definition of Field              5.1     D.0          Valid values per the Standard
       Name                 Number                                                                                                      populated from this
                                                                               Format    Format
                                                                                                                                            information

Patient Relationship Code   306-C6   Code identifying relationship of         9(01)      SAME         0=Not Specified                 N/A
                                     patient to cardholder.                                           1=Cardholder
*Part of External Code                                                                                2=Spouse
List under D.0                                                                                        3=Child
                                                                                                      4=Other
Other Payer BIN Number      990-MG   Card Issuer or Bank ID used for          N/A        Not Used     N/A                             N/A
                                     network routing.                                    in Billing
                                                                                         Trans.
Other Payer Processor       991-MH   A number that uniquely identifies the    N/A        Not Used     N/A                             N/A
Control Number                       secondary, tertiary, etc. payer to the              in Billing
                                     processor.                                          Trans.
Other Payer Cardholder      356-NU   Cardholder ID for this member            N/A        Not Used     N/A                             N/A
ID                                   that is associated with the                         in Billing
                                     Payer noted.                                        Trans.
Other Payer Group ID        992-MJ   ID assigned to the cardholder group      N/A        Not Used     N/A                             N/A
                                     or employer group by the secondary,                 in Billing
                                     tertiary, etc. payer.                               Trans.
Medigap ID                  359-2A   Patient’s ID assigned by the             N/A        X(20)        N/A                             N/A
                                     Medigap Insurer
*This field will address
functionality that is
currently addressed by
the Alternate ID (330-CW)
in the Claim Segment
under 5.1




             17
                                                               Transmission Insurance Segment

                                                                                                                                       VMS Claim/CMN field
                                                                               Version   Version
NCPDP Data Dictionary       Field                                                                                                         that is currently
                                         NCPDP Definition of Field               5.1     D.0          Valid values per the Standard
       Name                Number                                                                                                       populated from this
                                                                               Format    Format
                                                                                                                                            information

Medicaid Indicator         360-2B   Two character State Postal Code            N/A       X(02)        Standard United States and      N/A
                                    indicating the state where Medicaid                               Canadian province two-letter
*This field will address            coverage exists.                                                  postal service abbreviations
functionality that is                                                                                 should be used.
currently addressed by
the Group ID (301-C1) in
the Insurance Segment
under 5.1

**Part of External Code
List under D.0
Provider Accept            361-2D   Code indicating whether the provider       N/A       X(01)        Y=Assigned                      N/A
Assignment Indicator                accepts assignment.                                               N=Non-assigned                  *Currently, VMS
                                                                                                                                      processes all NCPDP
*Part of External Code                                                                                                                claims as Assigned
List under D.0                                                                                                                        claims, based on CMS’
                                                                                                                                      Mandatory Assignment
                                                                                                                                      Policy for Drugs and
                                                                                                                                      Biologicals
CMS Part D Defined         997-G2   Indicates that the patient resides in a    N/A       X(01)        Y=Yes                           N/A
Qualified Facility                  facility that qualifies for the CMS Part                          N=No
                                    D benefit.
*Part of External Code
List under D.0
Medicaid ID Number         115-N5   A unique member identification             N/A       X(20)        N/A                             N/A
                                    number assigned by the Medicaid
                                    Agency.
Medicaid Agency Number     116-N6   Number assigned by processor to            N/A       Not used     N/A                             N/A
                                    identify the individual Medicaid                     in Billing
                                    Agency or representative.                            Trans.




           18
                                                              Transaction Other COB Segment

                                                                                                                                     VMS Claim/CMN field
                                                                              Version   Version
NCPDP Data Dictionary        Field                                                                                                      that is currently
                                          NCPDP Definition of Field             5.1     D.0       Valid values per the Standard
       Name                 Number                                                                                                    populated from this
                                                                              Format    Format
                                                                                                                                          information

Segment Identification      111-AM   Identifies the segment in the request   X(02)      SAME      See Listing in the Transmission   N/A
                                     record.                                                      Patient Segment
Coordination of Benefits/   337-4C   Count of other payment occurrences.     9(02)      SAME      Maximum count of 9                N/A
Other Payments Count
Other Payer Coverage        338-5C   Code identifying the type of Other      X(02)      SAME      Blank=Not Specified               Other Primary Insurance
Type                                 Payer ID.                                                    01=Primary                        Indicator
                                                                                                  02=Secondary
*Part of External Code                                                                            03=Tertiary
List under D.0                                                                                    *04=Quaternary
                                                                                                  *05=Quinary
                                                                                                  *06=Senary
                                                                                                  *07=Septenary
                                                                                                  *08=Octonary
                                                                                                  *09=Nonary
                                                                                                  **98=Coupon
                                                                                                  **99=Composite
                                                                                                  *New value under D.0

                                                                                                  **Not valid for D.0




            19
                                                             Transaction Other COB Segment

                                                                                                                                 VMS Claim/CMN field
                                                                            Version   Version
NCPDP Data Dictionary        Field                                                                                                  that is currently
                                         NCPDP Definition of Field            5.1     D.0       Valid values per the Standard
       Name                 Number                                                                                                populated from this
                                                                            Format    Format
                                                                                                                                      information

Other Payer ID Qualifier    339-6C   Code qualifying the Other Payer ID.   X(02)      SAME      Blank=Not Specified             N/A
                                                                                                01=National Payer ID
*Part of External Code                                                                          02=Health Industry Number
List under D.0                                                                                  (HIN)
                                                                                                03=Bank Information Number
                                                                                                (BIN)
                                                                                                04=National Association of
                                                                                                Insurance
                                                                                                Commissioners (NAIC)
                                                                                                *05=Medicare Carrier Number
                                                                                                **09=Coupon
                                                                                                99=Other
                                                                                                *New value under D.0

                                                                                                **Not valid for D.0
Other Payer ID              340-7C   ID assigned to the payer.             X(10)      SAME      N/A                             N/A
Other Payer Date            443-E8   Payment or denial date of the claim   9(08)      SAME      N/A                             N/A
                                     submitted to the other payer.
Internal Control Number     993-A7   Number assigned by the processor to   N/A        X(30)     N/A                             N/A
                                     identify an adjudicated claim when
*This field will address             supplied in payer-to-payer
functionality that is                coordination of benefits only.
currently addressed by
the Alternate ID (330-CW)
in the Claim Segment
under 5.1
Other Payer Amount Paid     341-HB   Count of the Other Payer Amount       9(02)      SAME      Maximum count of 9              N/A
Count                                Paid occurrences.




            20
                                                            Transaction Other COB Segment

                                                                                                                               VMS Claim/CMN field
                                                                         Version   Version
NCPDP Data Dictionary       Field                                                                                                 that is currently
                                        NCPDP Definition of Field          5.1     D.0        Valid values per the Standard
       Name                Number                                                                                               populated from this
                                                                         Format    Format
                                                                                                                                    information

Other Payer Amount Paid    342-HC   Code qualifying the Other Payer     X(02)      SAME       Blank=Not Specified             N/A
Qualifier                           Amount Paid.                                              01=Delivery
                                                                                              02=Shipping
*Part of External Code                                                                        03=Postage
List under D.0                                                                                04=Administrative
                                                                                              05=Incentive
                                                                                              06=Cognitive Service
                                                                                              07=Drug Benefit
                                                                                              **08=Sum of All Reimbursement
                                                                                              **98=Coupon
                                                                                              **99=Other
                                                                                              **Not valid for D.0
Other Payer Amount Paid    431-DV   Amount of any payment known by      s9(6)v99   SAME       N/A                             MSP Primary Paid Amt.
                                    the pharmacy from other sources                                                           MSP OTA Amount
                                    (including coupons).                                                                      MSP Primary Allowed
                                                                                                                              Amt.

Other Payer Reject Count   471-5E   Count of the Other Payer Reject     9(02)      SAME       Maximum count of 5              N/A
                                    Code occurrences.
Other Payer Reject Code    472-6E   The error encountered by the        X(03)      SAME       See current NCPDP Reject        N/A
                                    previous Other Payer.                                     Code list
Other Payer-Patient        353-NR   The patient’s cost share from a     N/A        s9(8)v99   Maximum count of 25             N/A
Responsibility Amount               previous payer.
Count




           21
                                                            Transaction Other COB Segment

                                                                                                                                 VMS Claim/CMN field
                                                                         Version   Version
NCPDP Data Dictionary      Field                                                                                                    that is currently
                                        NCPDP Definition of Field          5.1     D.0        Valid values per the Standard
       Name               Number                                                                                                  populated from this
                                                                         Format    Format
                                                                                                                                      information

Other Payer-Patient       351-NP   Code qualifying the “Other Payer-     N/A       X(02)      00=Blank Not Specified            N/A
Responsibility Amount              Patient Responsibility Amount (352-                        01=Amount Applied to Periodic
Qualifier                          NQ)”.                                                      Deductible (517-FH).
                                                                                              02=Amount Attributed to
                                                                                              Product Selection/Brand Drug
                                                                                              (134-UK).
                                                                                              03=Amount Attributed to Sales
                                                                                              Tax (523-FN).
                                                                                              04=Amount Exceeding Periodic
                                                                                              Benefit Maximum (520-FK).
                                                                                              05=
                                                                                              Amount of Copay (518-FI).
                                                                                              06=Patient Pay Amount (505-
                                                                                              F5).
                                                                                              07=Amount of Coinsurance
                                                                                              (572-4U).
                                                                                              08=Amount Attributed to
                                                                                              Product Selection/Non-Preferred
                                                                                              Formulary
                                                                                              Selection (135-UM).
                                                                                              09=Amount Attributed to Health
                                                                                              Plan Assistance Amount (129-
                                                                                              UD).
Other Payer-Patient       352-NQ   The patient’s cost share from a       N/A       s9(8)v99   N/A                               N/A
Responsibility Amount              previous payer
Benefit Stage Count       392-MU   Count of ‘Benefit Stage Amount’       N/A       9(02)      Maximum count of 4                N/A
                                   (394-MW) occurrences.
Benefit Stage Qualifier   393-MV   Code qualifying the ’Benefit Stage    N/A       X(02)      01=Deductible                     N/A
                                   Amount’ (394-MW).                                          02=Initial Benefit
                                                                                              03=Coverage Gap (donut hole)
                                                                                              04=Catastrophic Coverage




            22
                                                          Transaction Other COB Segment

                                                                                                                              VMS Claim/CMN field
                                                                        Version   Version
NCPDP Data Dictionary    Field                                                                                                   that is currently
                                      NCPDP Definition of Field           5.1     D.0        Valid values per the Standard
       Name             Number                                                                                                 populated from this
                                                                        Format    Format
                                                                                                                                   information

Benefit Stage Amount    394-MW   The amount of claim allocated to the   N/A       s9(6)v99   N/A                             N/A
                                 Medicare stage identified by the
                                 ‘Benefit Stage Qualifier’ (393-MV).




           23
                                                               Transaction Workers Comp Segment
          *This segment is not currently edited beyond the Implementation Guide level in VMS and is not used to populate any VMS claim or CMN fields.

                                                                                 Version   Version                                      VMS Claim/CMN field
NCPDP Data Dictionary        Field
                                             NCPDP Definition of Field             5.1     D.0       Valid values per the Standard     that is populated from
       Name                 Number
                                                                                 Format    Format                                         this information

Segment Identification      111-AM      Identifies the segment in the request   X(02)      SAME      See Listing in the Transmission   N/A
                                        record.                                                      Patient Segment
Date of Injury              434-DY      Date on which the injury occurred.      9(08)      SAME      N/A                               N/A
Employer Name               315-CF      Complete name of employer.              X(30)      SAME      N/A                               N/A
Employer Street Address     316-CG      Free-form text for address              X(30)      SAME      N/A                               N/A
                                        information.
Employer City Address       317-CH      Free-form text for city name.           X(20)      SAME      N/A                               N/A
Employer State/Province     318-CI      Standard state/province code as         X(02)      SAME      Standard United States and        N/A
Address                                 defined by appropriate government                            Canadian province two-letter
                                        agency.                                                      postal service abbreviations
*Part of External Code                                                                               should be used.
List under D.0


Employer ZIP/Postal         319-CJ      Code defining international postal      X(15)      SAME      N/A                               N/A
Code                                    zone excluding punctuation and
                                        blanks (zip code for US).
Employer Phone Number       320-CK      Ten-digit phone number of employer.     9(10)      SAME      N/A                               N/A
Employer Contact Name       321-CL      Employer primary contact.               X(30)      SAME      N/A                               N/A
Carrier ID                  327-CR      Carrier code assigned in Worker's       X(10)      SAME      N/A                               N/A
                                        Compensation program
Claim/Reference ID          435-DZ      Identifies the claim number assigned    X(30)      SAME      N/A                               N/A
                                        by the Worker's Compensation
                                        program.
Billing Entity Type         117-TR      A code that identifies the entity       N/A        9(02)     00=Provider Submitted-Pay to      N/A
Indicator                               submitting the billing transaction.                          Provider
                                                                                                     01=Provider Submitted-Pay to
*Part of External Code                                                                               Another Party
List under D.0                                                                                       02=Agent Submitted-Pay to
                                                                                                     Agent
                                                                                                     03=Agent Submitted-Pay to
                                                                                                     Another Party




            24
                                                               Transaction Workers Comp Segment
         *This segment is not currently edited beyond the Implementation Guide level in VMS and is not used to populate any VMS claim or CMN fields.

                                                                                 Version   Version                                     VMS Claim/CMN field
NCPDP Data Dictionary       Field
                                            NCPDP Definition of Field              5.1     D.0       Valid values per the Standard    that is populated from
       Name                Number
                                                                                 Format    Format                                        this information

Pay To Qualifier           118-TS      Code qualifying the ‘Pay To ID’           N/A       X(02)     00=Not Specified                N/A
                                       (119-TT).                                                     01=NPI
*Part of External Code                                                                               11= Federal Tax ID
List under D.0
Pay To ID                  119-TT      Identifying number of the entity to       N/A       X(15)     N/A                             N/A
                                       receive payment for claim.
Pay To Name                120-TU      Name of the entity to receive             N/A       X(20)     N/A                             N/A
                                       payment for claim.
Pay To Street Address      121-TV      Street address of the entity to receive   N/A       X(30)     N/A                             N/A
                                       payment for claim.
Pay To City Address        122-TW      City of the entity to receive payment     N/A       X(20)     N/A                             N/A
                                       for claim.
Pay To State/Province      123-TX      Standard state/province code as           N/A       X(02)     Standard United States and      N/A
Address                                defined by appropriate government                             Canadian province two-letter
                                       agency.                                                       postal service abbreviations
                                                                                                     should be used.

Pay To Zip/Postal Zone     124-TY      Code defining international postal        N/A       X(15)     N/A                             N/A
                                       zone excluding punctuation and
                                       blanks (zip code for US).
Generic Equivalent         125-TZ      Code qualifying the ‘Generic              N/A       X(02)     See Listing for the             N/A
Product ID Qualifier                   Equivalent Product ID’ (126-UA).                              Product/Service ID Qualifier
*Part of External Code                                                                               (436-E1) in the Claim Segment
List under D.0
Generic Equivalent         126-UA      Identifies the generic equivalent of      N/A       X(19)     N/A                             N/A
Product ID                             the brand product dispensed.




           25
                                                                Transaction Claim Segment

NCPDP Data Dictionary    Field    NCPDP Definition of Field                  Version   Version   Valid values per the Standard     VMS Claim/CMN field
Name                     Number                                              5.1       D.0                                         that is currently
                                                                             Format    Format                                      populated from this
                                                                                                                                   information

Segment Identification   111-AM   Identifies the segment in the request      X(02)     SAME      See Listing in the Transmission   N/A
                                  record.                                                        Patient Segment
Prescription/Service     455-EM   Indicates the type of billing submitted.   X(01)     SAME      Blank=Not Specified               N/A
Reference Number                                                                                 1=Rx Billing
Qualifier                                                                                        2=Service Billing

*Part of External Code
List under D.0
Prescription/Service     402-D2   Reference number assigned by the           9(07)     9(12)     N/A                               Line Control Number
Reference Number                  provider for the dispensed
                                  drug/product and/or service provided.




            26
                                                              Transaction Claim Segment

NCPDP Data Dictionary    Field    NCPDP Definition of Field             Version    Version   Valid values per the Standard    VMS Claim/CMN field
Name                     Number                                         5.1        D.0                                        that is currently
                                                                        Format     Format                                     populated from this
                                                                                                                              information

Product/Service ID       436-E1   Code qualifying the Product/Service   X(02)      SAME      00=Not Specified                 N/A
Qualifier                         ID                                                         01=UPC
                                                                                             02=HRI                           *Currently, only value 3
*Part of External Code                                                                       03=NDC                           (NDC) is accepted in
List under D.0                                                                               04=UPN (5.1)/HIBCC (D.0)         VMS
                                                                                             **05=DOD
                                                                                             06= DUR/PPS
                                                                                             07=CPT4
                                                                                             08=CPT5
                                                                                             09=HCPCS
                                                                                             10=PPAC
                                                                                             11=NAPPI
                                                                                             12=EAN (5.1)/GTIN (D.0)
                                                                                             **13=DIN
                                                                                             *15=GCN
                                                                                             *28= FDB Med Name ID
                                                                                             *29= FDB Routed Name ID
                                                                                             *30= FDB Rtd. Dos. Form Med ID
                                                                                             *31= FDBMedID
                                                                                             *32=GCN_SEQ_NO
                                                                                             *33= HICL_SEQ_NO
                                                                                             *34=UPN
                                                                                             99=Other

                                                                                             *New value under D.0

                                                                                             **Not valid for D.0
Product/Service ID       407-D7   ID of the product dispensed or        X(19)      SAME      N/A                              Procedure Code (The
                                  service provided.                                                                           submitted NDC is
                                                                                                                              crosswalked to a HCPCS
                                                                                                                              code for processing).




           27
                                                                     Transaction Claim Segment

NCPDP Data Dictionary      Field    NCPDP Definition of Field                  Version    Version   Valid values per the Standard   VMS Claim/CMN field
Name                       Number                                              5.1        D.0                                       that is currently
                                                                               Format     Format                                    populated from this
                                                                                                                                    information

Associated Prescription/   456-EN   Related Prescription/Service               9(07)      9(12)     N/A                             N/A
Service Reference                   Reference Number to which the
Number                              service is associated.
Associated Prescription/   457-EP   Date of the Associated                     9(08)      SAME      Format=CCYYMMDD                 N/A
Service Date                        Prescription/Service Reference
                                    Number.
Procedure Modifier Code    458-SE   Count of the Procedure Modifier            9(02)      SAME      Maximum count is 10             *VMS is currently limited
Count                               Code                                                                                            to 4 modifiers per
                                                                                                                                    Procedure Code
Procedure Modifier Code    459-ER   Identifies special circumstances           X(02)      SAME      CMS code set of HCPCS           Procedure Code Modifier
                                    related to the performance of the                               modifiers
                                    service.
Quantity Dispensed         442-E7   Quantity dispensed expressed in            9(7)v999   SAME      N/A                             Metric Decimal Quantity,
                                    metric decimal units.                                                                           which is converted to
                                                                                                                                    Number Of Services for
                                                                                                                                    processing
Fill Number                403-D3   The code indicating whether the            9(02)      SAME      0=Original dispensing           N/A
                                    prescription is an original or a refill.                        1-99=Refill number
*Part of External Code
List under D.0
Days Supply                405-D5   Estimated number of days that the          9(03)      SAME      N/A                             N/A
                                    prescription will last.
Compound Code              406-D6   Code indicating whether or not the         9(01)      SAME      0=Not Specified                 N/A
                                    prescription is a compound.                                     1= Not a Compound
*Part of External Code                                                                              2=Compound                      *Determines whether
List under D.0                                                                                                                      Compound Segment is
                                                                                                                                    processed or not




              28
                                                                  Transaction Claim Segment

NCPDP Data Dictionary       Field    NCPDP Definition of Field                Version   Version   Valid values per the Standard       VMS Claim/CMN field
Name                        Number                                            5.1       D.0                                           that is currently
                                                                              Format    Format                                        populated from this
                                                                                                                                      information

Dispense As Written         408-D8   Code indicating whether or not the       X(01)     SAME      0=No Product Selection Indicated    N/A
(DAW)/Product Selection              prescriber's instructions regarding                          1=Substitution Not Allowed by
Code                                 generic substitution were followed.                          Prescriber
                                                                                                  2=Substitution Allowed-Patient
*Part of External Code                                                                            Requested Product Dispensed
List under D.0                                                                                    3=Substitution Allowed-
                                                                                                  Pharmacist Selected Product
                                                                                                  Dispensed
                                                                                                  4=Substitution Allowed-Generic
                                                                                                  Drug Not in Stock
                                                                                                  5=Substitution Allowed-Brand
                                                                                                  Drug Dispensed as a Generic
                                                                                                  6=Override
                                                                                                  7=Substitution Not Allowed-Brand
                                                                                                  Drug Mandated by Law
                                                                                                  8=Substitution Allowed-Generic
                                                                                                  Drug Not Available in Marketplace
                                                                                                  9= Other (5.1)/Substitution
                                                                                                  Allowed By Prescriber but Plan
                                                                                                  Requests Brand - Patient's Plan
                                                                                                  Requested Brand
                                                                                                  Product To Be Dispensed (D.0)
Date Prescription Written   414-DE   Date prescription was written.           9(08)     SAME      Format=CCYYMMDD                     N/A
Number of Refills           415-DF   Number of refills authorized by the      9(02)     SAME      0=Original dispensing               N/A
Authorized                           prescriber.                                                  1-99=Refill number
Prescription Origin Code    419-DJ   Code indicating the origin of the        9(01)     SAME      0=Not Known                         N/A
                                     prescription.                                                1=Written
*Part of External Code                                                                            2=Telephone
List under D.0                                                                                    3=Electronic
                                                                                                  4=Facsimile
Submission Clarification    354-NX   Count of the ‘Submission Clarification   N/A       9(02)     Maximum Count is 3.                 N/A
Code Count                           Code’ (420-DK) occurrences.




            29
                                                                    Transaction Claim Segment

NCPDP Data Dictionary         Field    NCPDP Definition of Field                Version   Version   Valid values per the Standard       VMS Claim/CMN field
Name                          Number                                            5.1       D.0                                           that is currently
                                                                                Format    Format                                        populated from this
                                                                                                                                        information

Submission Clarification      420-DK   Code indicating that the pharmacist is   9(02)     SAME      0=Not Specified                     N/A
Code                                   clarifying the submission.                                   1=No Override
                                                                                                    2=Other Override
*New value 11 addresses                                                                             3=Vacation Supply
by the functionality that                                                                           4=Lost Prescription
was addressed by the                                                                                5=Therapy Change
Certificate on File                                                                                 6=Starter Dose
Indicator that is currently                                                                         7=Medically Necessary
defined as a subset of the                                                                          8=Process Compound For
Prior Authorization                                                                                 Approved Ingredients
Supporting                                                                                          9=Encounters
Documentation (498-PP)                                                                              *10=Meets Plan Limitations
on the Prior Authorization                                                                          *11=Certification on File
segment, defined for use                                                                            *12=DME Replacement Indicator
by Medicare under 5.1                                                                               *13=Payer-Recognized
                                                                                                    Emergency/Disaster Assistance
**New value 12 will be                                                                              Request
utilized if VMS’ NCPDP                                                                              *14=Long Term Care Leave of
processing is expanded to                                                                           Absence
include Durable Medical                                                                             *15=Long Term Care
Equipment.                                                                                          Replacement Medication
                                                                                                    *16=Long Term Care Emergency
***Part of External Code                                                                            box (kit) or automated dispensing
List under D.0                                                                                      machine
                                                                                                    *17=Long Term Care Emergency
                                                                                                    supply remainder
                                                                                                    *18=Long Term Care Patient
                                                                                                    Admit/Readmit Indicator
                                                                                                    *19=Split Billing
                                                                                                    99=Other

                                                                                                    *New value under D.0




            30
                                                                    Transaction Claim Segment

NCPDP Data Dictionary         Field    NCPDP Definition of Field               Version    Version      Valid values per the Standard      VMS Claim/CMN field
Name                          Number                                           5.1        D.0                                             that is currently
                                                                               Format     Format                                          populated from this
                                                                                                                                          information

Quantity Prescribed           460-ET   Amount expressed in metric decimal      9(7)v999   Not Used     N/A                                N/A
                                       units.                                             in Billing
                                                                                          Trans.
Other Coverage Code           308-C8   Code indicating whether or not the      9(02)      SAME         0=Not Specified by patient         N/A
                                       patient has other insurance                                     1=No other coverage.
*Part of External Code                 coverage.                                                       2=Other coverage exists-payment
List under D.0                                                                                         collected.
                                                                                                       3=Other Coverage Billed – claim
                                                                                                       not covered.
                                                                                                       4=Other coverage exists-payment
                                                                                                       not collected.
                                                                                                       **5=Managed care plan denial
                                                                                                       **6=Other coverage denied-not a
                                                                                                       participating provider
                                                                                                       **7=Other coverage exists-not in
                                                                                                       effect at time of service
                                                                                                       8=Claim is billing for patient
                                                                                                       financial responsibility only.

                                                                                                       **Not valid for D.0
Unit Dose Indicator           429-DT   Code indicating the type of unit dose   9(01)      SAME         0=Not Specified                    N/A
                                       dispensing.                                                     1=Not Unit Dose.
*Field name changed to                                                                                 2=Manufacturer Unit Dose.
Special Packaging                                                                                      3=Pharmacy Unit Dose.
Indicator as of version C.4                                                                            *4=Custom Packaging.
                                                                                                       *5=Multi-drug compliance
**Part of External Code                                                                                packaging.
List under D.0
                                                                                                       *New value under D.0




            31
                                                                  Transaction Claim Segment

NCPDP Data Dictionary       Field    NCPDP Definition of Field               Version    Version      Valid values per the Standard        VMS Claim/CMN field
Name                        Number                                           5.1        D.0                                               that is currently
                                                                             Format     Format                                            populated from this
                                                                                                                                          information

Originally Prescribed       453-EJ   Code qualifying the value in            X(02)      SAME         See Listing for the                  N/A
Product/Service ID                   Originally Prescribed Product/Service                           Product/Service ID Qualifier (436-
Qualifier                            Code.                                                           E1) in the Claim Segment

*Part of External Code
List under D.0
Originally Prescribed       445-EA   Code of the initially prescribed        X(19)      SAME         N/A                                  N/A
Product/Service Code                 product or service.
Originally Prescribed       446-EB   Product initially prescribed amount     9(7)v999   SAME         N/A                                  N/A
Quantity                             expressed in metric decimal units.
Alternate ID                330-CW   Person identifier to be used for        X(20)      Not Used     N/A                                  Medigap ID (Inbound)
                                     controlled product reporting. ID may               in Billing
*The current inbound                 be that of person picking up the                   Trans.                                            Claim Control Number
functionally will be                 prescription.                                                                                        (Outbound)
addressed by the new
Medigap ID (359-2A) in
the Insurance Segment
under D.0

**The current outbound
functionally will be
addressed by the new
Internal Control Number
(993-A7) in the
COB/Other Payments
Segment under D.0
Scheduled Prescription ID   454-EK   The serial number of the prescription   X(12)      Not Used     N/A                                  N/A
Number                               blank/form.                                        in Billing
                                                                                        Trans.
Unit of Measure             600-28   NCPDP standard product billing          X(02)      SAME         EA=Each.                             N/A
                                     codes                                                           GM=Grams.
*Part of External Code                                                                               ML=Milliliters.
List under D.0




            32
                                                                      Transaction Claim Segment

NCPDP Data Dictionary        Field    NCPDP Definition of Field                Version     Version   Valid values per the Standard      VMS Claim/CMN field
Name                         Number                                            5.1         D.0                                          that is currently
                                                                               Format      Format                                       populated from this
                                                                                                                                        information

Level of Service             418-DI   Coding indicating the type of service    9(02)       SAME      0=Not Specified                    N/A
                                      the provider rendered.                                         1=Patient consultation
*Part of External Code                                                                               2=Home delivery
List under D.0                                                                                       3=Emergency
                                                                                                     4=24 hour service
                                                                                                     5=Patient consultation regarding
                                                                                                     generic product selection
                                                                                                     6=In-Home Service
Prior Authorization Type     461-EU   Code clarifying the Prior                9(02)       SAME      0=Not Specified                    N/A
Code                                  Authorization Number                                           1=Prior Authorization.
                                                                                                     2=Medical Certification.
*Part of External Code                                                                               3=EPSDT (Early Periodic
List under D.0                                                                                       Screening Diagnosis Treatment.
                                                                                                     4=Exemption from Copay and/or.
                                                                                                     5=Exemption from RX.
                                                                                                     6=Family Planning Indicator.
                                                                                                     7=AFDC (5.1)/ TANF (D.0).
                                                                                                     8=Payer Defined Exemption.
                                                                                                     *9=Emergency Preparedness

                                                                                                     *New value under D.0
Prior Authorization          462-EV   Number submitted by the provider to      9(11)       SAME      N/A                                N/A
Number Submitted                      identify the prior authorization.
Intermediary Authorization   463-EW   Value indicating that authorization      9(02)       SAME      0=Not Specified                    N/A
Type ID                               occurred for intermediary processing.                          1=Intermediary Authorization.
                                                                                                     99=Other Override
*Part of External Code
List under D.0
Intermediary Authorization   464-EX   Value indicating intermediary            X(11)       SAME      N/A                                N/A
ID                                    authorization occurred.




            33
                                                                   Transaction Claim Segment

NCPDP Data Dictionary     Field    NCPDP Definition of Field                    Version    Version   Valid values per the Standard          VMS Claim/CMN field
Name                      Number                                                5.1        D.0                                              that is currently
                                                                                Format     Format                                           populated from this
                                                                                                                                            information

Dispensing Status         343-HD   Code indicating the quantity is a            X(01)      SAME      **Blank=Not Specified.                 N/A
                                   partial fill or the completion of a                               P= Partial Fill.
*Part of External Code             partial fill.                                                     C=Completion of Partial Fill.
List under D.0
                                                                                                     **Not valid for D.0
Quantity Intended To Be   344-HF   Metric decimal quantity of medication        9(7)v999   SAME      N/A                                    N/A
Dispensed                          that would be dispensed on original
                                   filling if inventory were available.
Days Supply Intended To   345-HG   Days supply for metric decimal               9(03)      SAME      N/A                                    N/A
Be Dispensed                       quantity that would be dispensed on
                                   original fill if inventory were available.
Delay Reason Code         357-NV   Code to specify the reason that              N/A        9(02)     1=Proof of eligibility unknown or      N/A
                                   submission of the transactions has                                unavailable
*Part of External Code             been delayed.                                                     2=Litigation
List under D.0                                                                                       3=Authorization delays
                                                                                                     4=Delay in certifying provider
                                                                                                     5=Delay in supplying billing forms
                                                                                                     6=Delay in delivery of custom-
                                                                                                     made appliances
                                                                                                     7=Third party processing delay
                                                                                                     8=Delay in eligibility determination
                                                                                                     9=Original claims rejected or
                                                                                                     denied due to a reason unrelated
                                                                                                     to the billing limitation rules
                                                                                                     10=Administration delay in the
                                                                                                     prior approval process
                                                                                                     11=Other
                                                                                                     12=Received late with no
                                                                                                     exceptions
                                                                                                     13=Substantial damage by fire,
                                                                                                     etc to provider records
                                                                                                     14=Theft, sabotage/other willful
                                                                                                     acts by employee




           34
                                                                  Transaction Claim Segment

NCPDP Data Dictionary      Field    NCPDP Definition of Field                 Version   Version      Valid values per the Standard        VMS Claim/CMN field
Name                       Number                                             5.1       D.0                                               that is currently
                                                                              Format    Format                                            populated from this
                                                                                                                                          information

Transaction Reference      880-K5   A reference number assigned by the        N/A       Not Used     N/A                                  N/A
Number                              provider to each of the data records                in Billing
                                    in the batch or real-time transactions.             Trans.
                                    The purpose of this number is to
                                    facilitate the process of matching the
                                    transaction response to the
                                    transaction. The transaction
                                    reference number assigned should
                                    be returned in the response.
Patient assignment         391-MT   Code to indicate a patient’s choice on    N/A       X(01)        Y=Patient assigns benefits           N/A
Indicator (Direct Member            assignment of benefits.                                          N=Patient does not assign
Reimbursement Indicator)                                                                             benefits
*Part of External Code
List under D.0
Route of Administration    995-E2   This is an override to the “default”      N/A       X(11)        Systematized Nomenclature of         N/A
                                    route referenced for the product. For                            Medicine Clinical Terms®
*This replaces Compound             a multi-ingredient compound, it is the                           (SNOMED CT) SNOMED CT®
Route of Administration             route of the complete compound                                   terminology which is available
(452-EH) on the                     mixture.                                                         from the College of American
Compound Segment                                                                                     Pathologists, Northfield, Illinois
                                                                                                     http://www.snomed.org/
Compound Type              996-G1   Clarifies the type of compound            N/A       X(02)        01=Anti-infective                    N/A
                                                                                                     02=Ionotropic
*Part of External Code                                                                               03=Chemotherapy
List under D.0                                                                                       04=Pain management
                                                                                                     05=TPN/PPN (Hepatic, Renal,
                                                                                                     Pediatric)
                                                                                                     06=Hydration
                                                                                                     07=Ophthalmic
                                                                                                     99=Other




           35
                                                              Transaction Claim Segment

NCPDP Data Dictionary    Field    NCPDP Definition of Field             Version    Version      Valid values per the Standard       VMS Claim/CMN field
Name                     Number                                         5.1        D.0                                              that is currently
                                                                        Format     Format                                           populated from this
                                                                                                                                    information

Medicaid Subrogation     114-N4   Claim number assigned by the          N/A        Not Used     N/A                                 N/A
Internal Control                  Medicaid Agency.                                 in Billing
Number/Transaction                                                                 Trans.
Control Number
(ICN/TCN)
Pharmacy Service Type    147-U7   The type of service being performed   N/A        9(02)        1=Community/Retail Pharmacy         N/A
                                  by a pharmacy when different                                  Services
*Part of External Code            contractual terms exist between a                             2=Compounding Pharmacy
List under D.0                    payer and the pharmacy, or when                               Services
                                  benefits are based upon the type of                           3=Home Infusion Therapy
                                  service performed.                                            Provider Services
                                                                                                4=Institutional Pharmacy Services
                                                                                                5=Long Term Care Pharmacy
                                                                                                Services
                                                                                                6=Mail Order Pharmacy Services
                                                                                                7=Managed Care Organization
                                                                                                Pharmacy Services
                                                                                                8=Specialty Care Pharmacy
                                                                                                Services
                                                                                                99=Other




           36
                                                                   Transaction DUR-PPS Segment
         *This segment is not currently edited beyond the Implementation Guide level in VMS and is not used to populate any VMS claim or CMN fields.

                                                                                                                                          VMS Claim/CMN field
                                                                                   Version   Version
NCPDP Data Dictionary       Field                                                                                                            that is currently
                                            NCPDP Definition of Field                5.1     D.0       Valid values per the Standard
       Name                Number                                                                                                          populated from this
                                                                                   Format    Format
                                                                                                                                               information

Segment Identification     111-AM      Identifies the segment in the request      X(02)      SAME      See Listing in the Transmission   N/A
                                       record.                                                         Patient Segment
DUR/PPS Code Counter       473-7E      Counter number for each DUR/PPS            9(02)      SAME      Maximum count of 9.               N/A
                                       set/logical grouping.
Reason For Service Code    439-E4      Code identifying the type of utilization   X(02)      SAME      See NCPDP External Code List.     N/A
                                       conflict detected or the reason for the
*Part of External Code                 pharmacist's professional service.
List under D.0
Professional Service       440-E5      Code identifying pharmacist                X(02)      SAME      See NCPDP External Code List      N/A
Code                                   intervention when a conflict code has
                                       been identified or service has been
*Part of External Code                 rendered.
List under D.0
Result Of Service Code     441-E6      Action taken by pharmacist in              X(02)      SAME      See NCPDP External Code List      N/A
                                       response to a conflict or the result of
*Part of External Code                 a pharmacist's professional service.
List under D.0
DUR/PPS Level Of Effort    474-8E      Code indicating the level of effort as     9(02)      SAME      0=Not Specified                   N/A
                                       determined by the complexity of                                 11=Level 1 (Lowest)
*Part of External Code                 decision making or resources utilized                           12=Level 2
List under D.0                         by a pharmacist to perform a                                    13=Level 3
                                       professional service.                                           14=Level 4
                                                                                                       15=Level 5 (Highest)
DUR Co-agent ID            476-H6      Code qualifying the value in DUR Co-       X(02)      SAME      See Listing for the               N/A
Qualifier                              agent ID.                                                       Product/Service ID Qualifier
                                                                                                       (436-E1) in the Claim Segment
*Part of External Code
List under D.0
DUR Co-agent ID            458-SE      Identifies the co-existing agent           X(19)      SAME      N/A                               N/A
                                       contributing to the DUR event.




           37
                                                                  Transaction Coupon Segment
         *This segment is not currently edited beyond the Implementation Guide level in VMS and is not used to populate any VMS claim or CMN fields.

                                                                                                                                        VMS Claim/CMN field
                                                                                Version   Version
NCPDP Data Dictionary       Field                                                                                                          that is currently
                                            NCPDP Definition of Field             5.1     D.0        Valid values per the Standard
       Name                Number                                                                                                        populated from this
                                                                                Format    Format
                                                                                                                                             information

Segment Identification     111-AM      Identifies the segment in the request   X(02)      SAME       See Listing in the Transmission   N/A
                                       record.                                                       Patient Segment
Coupon Type                485-KE      Code indicating the type of coupon      X(02)      SAME       01=Price Discount                 N/A
                                       being used.                                                   02=Free Product
*Part of External Code                                                                               99=Other
List under D.0
Coupon Number              486-ME      Unique serial number assigned to the    X(15)      SAME       N/A                               N/A
                                       prescription coupons.
Coupon Value Amount        487-NE      Value of the coupon.                    s9(6)v99   SAME       N/A                               N/A




           38
                                                           Transaction Compound Segment

                                                                                                                                  VMS Claim/CMN field
                                                                           Version   Version
NCPDP Data Dictionary     Field                                                                                                      that is currently
                                       NCPDP Definition of Field             5.1     D.0       Valid values per the Standard
       Name              Number                                                                                                    populated from this
                                                                           Format    Format
                                                                                                                                       information

Segment Identification   111-AM   Identifies the segment in the request   X(02)      SAME      See Listing in the Transmission   N/A
                                  record.                                                      Patient Segment
Compound Dosage Form     450-EF   Dosage form of the complete             X(02)      SAME      Blank=Not Specified               N/A
Description Code                  compound mixture.                                            01=Capsule
                                                                                               02=Ointment
*Part of External Code                                                                         03=Cream
List under D.0                                                                                 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
Compound Dispensing      451-EG   NCPDP standard product billing          9(01)      SAME      1=Each.                           N/A
Unit Form Indicator               codes.                                                       2=Grams.
                                                                                               3=Milliliters.
*Part of External Code
List under D.0




           39
                                                             Transaction Compound Segment

                                                                                                                                   VMS Claim/CMN field
                                                                              Version   Version
NCPDP Data Dictionary      Field                                                                                                      that is currently
                                        NCPDP Definition of Field               5.1     D.0       Valid values per the Standard
       Name               Number                                                                                                    populated from this
                                                                              Format    Format
                                                                                                                                        information

Compound Route of         452-EH   Code for the route of administration      9(02)      N/A       0=Not Specified                 N/A
Administration                     of the complete compound mixture.                              1=Buccal
                                                                                                  2=Dental
*This is replaced by                                                                              3=Inhalation
Route of Administration                                                                           4=Injection
(995-E2) on the Claim                                                                             5=Intraperitoneal
Segment                                                                                           6=Irrigation
                                                                                                  7=Mouth/Throat
                                                                                                  8=Mucous Membrane
                                                                                                  9=Nasal
                                                                                                  10=Ophthalmic
                                                                                                  11=Oral
                                                                                                  12=Other/Miscellaneous
                                                                                                  13=Otic
                                                                                                  14=Perfusion
                                                                                                  15=Rectal
                                                                                                  16=Sublingual
                                                                                                  17=Topical
                                                                                                  18=Transdermal
                                                                                                  19=Translingual
                                                                                                  20=Urethral
                                                                                                  21=Vaginal
                                                                                                  22=Enteral
Compound Ingredient       447-EC   Count of compound product IDs in          9(02)      SAME      Maximum count remains at 25.    Claim Line Count, when
Component Count                    the compound mixture.                                                                          processing a Compound
Compound Product ID       488-RE   Code qualifying the type of product       X(02)      SAME      See Listing for the
Qualifier                          dispensed.                                                     Product/Service ID Qualifier
                                                                                                  (436-E1) in the Claim Segment
*Part of External Code
List under D.0
Compound Product ID       489-TE   Product identification of an ingredient   X(19)      SAME      N/A                             Procedure Code, when
                                   used in the compound.                                                                          processing a Compound




           40
                                                            Transaction Compound Segment

                                                                                                                                   VMS Claim/CMN field
                                                                             Version   Version
NCPDP Data Dictionary     Field                                                                                                       that is currently
                                       NCPDP Definition of Field               5.1     D.0       Valid values per the Standard
       Name              Number                                                                                                     populated from this
                                                                             Format    Format
                                                                                                                                        information

Compound Ingredient      448-ED   Amount expressed in metric decimal        9(7)v999   SAME      N/A                              Metric Decimal Quantity,
Quantity                          units of the compound included in the                                                           when processing a
                                  compound mixture.                                                                               Compound
Compound Ingredient      449-EE   Ingredient cost of the metric decimal     s9(6)v99   SAME      N/A                              Submitted Charge, when
Drug Cost                         quantity of the product included in the                                                         processing a Compound
                                  compound mixture indicated in
                                  Compound Ingredient Quantity.
Compound Ingredient      490-UE   Code indicating the method by which       X(02)      SAME      00=Default                       N/A
Basis of Cost                     the cost of an ingredient used in a                            01=AWP (Average Wholesale
Determination                     compound was calculated.                                       Price).
                                                                                                 02=Local Wholesaler.
*Part of External Code                                                                           03=Direct.
List under D.0                                                                                   04=EAC (Estimated Acquisition
                                                                                                 Cost.
                                                                                                 05=Acquisition.
                                                                                                 06=MAC (Maximum Allowable
                                                                                                 Cost).
                                                                                                 07=Usual & Customary.
                                                                                                 *08=340B /Disproportionate
                                                                                                 Share Pricing/Public Health
                                                                                                 Service.
                                                                                                 09 Other.
                                                                                                 *10=ASP (Average Sales Price).
                                                                                                 *11=AMP (Average
                                                                                                 Manufacturer Price).
                                                                                                 *12=WAC (Wholesale
                                                                                                 Acquisition Cost).

                                                                                                 *New value under D.0




           41
                                                               Transaction Compound Segment

                                                                                                                                   VMS Claim/CMN field
                                                                              Version   Version
NCPDP Data Dictionary          Field                                                                                                  that is currently
                                           NCPDP Definition of Field            5.1     D.0       Valid values per the Standard
       Name                   Number                                                                                                populated from this
                                                                              Format    Format
                                                                                                                                        information

Compound Ingredient           362-2G   Code indicating the number of          N/A       9(2)      Maximum count is 10.            N/A
Modifier Code Count                    Compound Ingredient Modifier
                                       Code (363-2H).
*This replaces the
Ingredient Number that is
currently defined as a
subset of the Prior
Authorization Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use
by Medicare under 5.1
Compound Ingredient           363-2H   Identifies special circumstances       N/A       X(02)     CMS code set of HCPCS           N/A
Modifier Code                          related to the dispensing/payment of                       modifiers
                                       the product as identified in the
*This replaces the                     Compound Product ID (498-
Ingredient Modifier that is            TE).
currently defined as a
subset of the Prior
Authorization Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use
by Medicare under 5.1




            42
                                                                 Transaction Pricing Segment

                                                                                                                                        VMS Claim/CMN field
                                                                              Version   Version
NCPDP Data Dictionary        Field                                                                                                         that is currently
                                          NCPDP Definition of Field             5.1     D.0          Valid values per the Standard
       Name                 Number                                                                                                       populated from this
                                                                              Format    Format
                                                                                                                                             information

Segment Identification      111-AM   Identifies the segment in the request   X(02)      SAME         See Listing in the Transmission   N/A
                                     record.                                                         Patient Segment
Ingredient Cost Submitted   409-D9   Submitted product component cost of     s9(6)v99   SAME         N/A                               N/A
                                     the dispensed prescription. Included
                                     in the Gross Amount Due.
Dispensing Fee              412-DC   Dispensing fee submitted by             s9(6)v99   SAME         N/A                               N/A
Submitted                            pharmacy. Included in Gross Amount
                                     Due.                                                                                              *Used to generate
                                                                                                                                       HCPCS codes for
                                                                                                                                       dispensing fees
Professional Service Fee    477-BE   Amount submitted by the provider for    s9(6)v99   Not Used     N/A                               N/A
Submitted                            professional services rendered.                    in Billing
                                     Included in Gross Amount Due.                      Trans.
Patient Paid Amount         433-DX   Amount the pharmacy received from       s9(6)v99   SAME         N/A                               Beneficiary Paid Amount
Submitted                            the patient for the prescription
                                     dispensed.
Incentive Amount            438-E3   Amount represents the contractually     s9(6)v99   SAME         N/A                               N/A
Submitted                            agreed upon incentive fee paid for
                                     specific services rendered. Included                                                              *Used to generate
                                     in Gross Amount Due.                                                                              HCPCS codes for
                                                                                                                                       incentive fees
Other Amount Claimed        478-H7   Count of Other Amount Claimed           9(02)      SAME         Maximum count of 3.               N/A
Submitted Count                      Submitted occurrences.
Other Amount Claimed        479-H8   Code identifying the additional         X(02)      SAME         01=Delivery Cost                  N/A
Submitted Qualifier                  incurred cost claimed in Other                                  02=Shipping Cost
                                     Amount Claimed Submitted.                                       03=Postage Cost
*Part of External Code                                                                               04=Administrative Cost
List under D.0                                                                                       99=Other
Other Amount Claimed        480-H9   Amount representing the additional      s9(6)v99   SAME         N/A                               N/A
Submitted                            incurred costs for a dispensed
                                     prescription or service. Included in
                                     Gross Amount Due.




           43
                                                              Transaction Pricing Segment

                                                                                                                                       VMS Claim/CMN field
                                                                             Version     Version
NCPDP Data Dictionary     Field                                                                                                           that is currently
                                       NCPDP Definition of Field               5.1       D.0          Valid values per the Standard
       Name              Number                                                                                                         populated from this
                                                                             Format      Format
                                                                                                                                            information

Flat Sales Tax Amount    481-HA   Flat sales tax amount submitted for       s9(6)v99     SAME         N/A                             N/A
Submitted                         prescription. Included in Gross
                                  Amount Due
Percentage Sales Tax     482-GE   Percentage sales tax submitted.           s9(6)v99     SAME         N/A                             N/A
Amount Submitted                  Included in Gross Amount Due.
Percentage Sales Tax     483-HE   Percentage sales tax rate used to         s9(3)v9(4)   SAME         N/A                             N/A
Rate Submitted                    calculate Percentage Sales Tax
                                  Amount Submitted.
Percentage Sales Tax     484-JE   Code indicating the percentage sales      X(02)        SAME         Blank=Not Specified             N/A
Basis Submitted                   tax paid basis.                                                     **01=Gross Amount Due
                                                                                                      02=Ingredient Cost.
                                                                                                      03=Ingredient Cost +
                                                                                                      Dispensing Fee.

                                                                                                      **Not valid for D.0
Usual and Customary      426-DQ   Amount charged cash customers for         s9(6)v99     SAME         N/A                             N/A
Charge                            the prescription exclusive of sales tax
                                  or other amounts claimed.
Gross Amount Due         430-DU   Total price claimed from all sources.     s9(6)v99     SAME         N/A                             Submitted Charge
Basis of Cost            423-DN   Code indicating the method by which       X(02)        SAME         See Listing for the Compound    N/A
Determination                     Ingredient Cost Submitted was                                       Ingredient Basis of Cost
                                  calculated.                                                         Determination (490-UE) in the
*Part of External Code                                                                                Compound Segment
List under D.0
Medicaid Paid Amount     113-N3                                             N/A          Not Used     N/A                             N/A
                                                                                         in Billing
                                                                                         Trans.




           44
                                                          Transaction Prior Authorization Segment
                                             *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                        VMS Claim/CMN field
                                                                              Version   Version
NCPDP Data Dictionary        Field                                                                                                         that is currently
                                          NCPDP Definition of Field             5.1     D.0          Valid values per the Standard
       Name                 Number                                                                                                       populated from this
                                                                              Format    Format
                                                                                                                                             information

Segment Identification      111-AM   Identifies the segment in the request   X(02)       N/A         See Listing in the Transmission   N/A
                                     record.                                                         Patient Segment
Request Type                498-PA   Code identifying type of prior          X(01)       N/A         1=Initial.                        CMN Type (Initial,
                                     authorization request.                                          2=Reauthorization.                Recertification, or
*This functionality is                                                                               3=Deferred                        Revision)
addressed by the Request
Status (373-2U) in the
new Additional
Documentation Segment
under D.0

**Part of External Code
List under D.0

Request Period Date-        498-PB   The beginning date of need.             9(08)       N/A         Format = CCYYMMDD                 CMN Initial Date
Begin

*This functionality is
addressed by the Request
Period Begin Date (374-
2V) in the new Additional
Documentation Segment
under D.0




           45
                                                          Transaction Prior Authorization Segment
                                             *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                      VMS Claim/CMN field
                                                                               Version   Version
NCPDP Data Dictionary        Field                                                                                                       that is currently
                                          NCPDP Definition of Field              5.1     D.0         Valid values per the Standard
       Name                 Number                                                                                                     populated from this
                                                                               Format    Format
                                                                                                                                           information

Request Period Date-End     498-PC   Ending date for a prior authorization    9(08)      N/A         Format = CCYYMMDD               CMN Recert/Revise Date
                                     request.
*This functionality is
addressed by the Request
Period Begin Date (374-
2V) and Length of Need
(370-2R) in the new
Additional Documentation
Segment under D.0

Basis of Request            498-PD   Code describing the reason for prior     X(02)      N/A         ME=Medical                      N/A
                                     authorization request.                                          PR=Plan Requirement
*This functionality is                                                                               PL=Increase Plan Limitation
addressed by the addition
of the new Additional
Documentation, Facility,
and Narrative Segments
under D.0

**Part of External Code
List under D.0
Authorized                  498-PE   First name of the patient’s authorized   X(12)      N/A         N/A                             Rep Payee First Name
Representative First                 representative.
Name

*This functionality is
addressed by the Facility
Name (385-3Q) in the
new Facility Segment
under D.0




            46
                                                          Transaction Prior Authorization Segment
                                             *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                      VMS Claim/CMN field
                                                                              Version   Version
NCPDP Data Dictionary        Field                                                                                                       that is currently
                                          NCPDP Definition of Field             5.1     D.0          Valid values per the Standard
       Name                 Number                                                                                                     populated from this
                                                                              Format    Format
                                                                                                                                           information

Authorized                  498-PF   Last name of the patient’s authorized   X(15)      N/A          N/A                             Rep Payee Last Name
Representative Last                  representative.
Name

*This functionality is
addressed by the Facility
Name (385-3Q) in the
new Facility Segment
under D.0
Authorized                  498-PG   Free-form text for address              X(30)      N/A          N/A                             Rep Payee Address
Representative Street                information.
Address

*This functionality is
addressed by the Facility
Street Address (385-3U)
in the new Facility
Segment under D.0
Authorized                  498-PH   Free-form text for city name.           X(20)      N/A          N/A                             Rep Payee City
Representative City
Address

*This functionality is
addressed by the Facility
City Address (385-5J) in
the new Facility Segment
under D.0




            47
                                                          Transaction Prior Authorization Segment
                                             *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                      VMS Claim/CMN field
                                                                               Version   Version
NCPDP Data Dictionary        Field                                                                                                       that is currently
                                          NCPDP Definition of Field              5.1     D.0         Valid values per the Standard
       Name                 Number                                                                                                     populated from this
                                                                               Format    Format
                                                                                                                                           information

Authorized                  498-PJ   Standard state/province code as          X(02)      N/A         Standard United States and      Rep Payee State
Representative                       defined by appropriate government                               Canadian province two-letter
State/Province Address               agency.                                                         postal service abbreviations
                                                                                                     should be used.
*This functionality is
addressed by the Facility
State/Province Address
(387-3V) in the new
Facility Segment under
D.0
Authorized                  498-PK   Code defining international postal       X(15)      N/A         N/A                             Rep Payee Zip Code
Representative ZIP/Postal            zone excluding punctuation and
Zone                                 blanks (zip code for US).

*This functionality is
addressed by the Facility
Zip/Postal Zone (389-6D)
in the new Facility
Segment under D.0
Prior Authorization         498-PY   Unique number identifying the prior      9(11)      N/A         N/A                             N/A
Number-Assigned                      authorization assigned by the
                                     processor.
Authorization Number        503-F3   Number assigned by the processor to      X(20)      N/A         N/A                             N/A
                                     identify an authorized transaction.
Prior Authorization         498-PP   This space is being used to store        X(500)     N/A         N/A                             See descriptions of the
Supporting                           CMN information, Narrative                                                                      specific fields, following
Documentation                        information, Facility information, and                                                          this one, that are defined
                                     Compound Ingredient Modifiers that                                                              subsets of this field for
                                     are not available elsewhere in the                                                              uses.
                                     NCPDP format. Details on the fields
                                     are listed below.




            48
                                                            Transaction Prior Authorization Segment
                                              *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                       VMS Claim/CMN field
                                                                                 Version   Version
NCPDP Data Dictionary         Field                                                                                                       that is currently
                                           NCPDP Definition of Field               5.1     D.0        Valid values per the Standard
       Name                  Number                                                                                                     populated from this
                                                                                 Format    Format
                                                                                                                                            information

Authorization Information    N/A      Indicates that the Supporting             X(03)      N/A        N/A                             N/A
Qualifier                             Documentation that follows is
                                      Medicare required CMN information.
*This functionality is
addressed by the addition             * This field represents a subset of the
of the new Additional                 Prior Authorization Supporting
Documentation, Facility,              Documentation (498-PP), defined for
and Narrative Segments                use by Medicare under 5.1
under D.0
Form Identifier              N/A      CMN form being submitted.                 X(06)      N/A        N/A                             CMN Form

*This functionality is                * This field represents a subset of the
addressed by the                      Prior Authorization Supporting
Additional Documentation              Documentation (498-PP), defined for
Type ID (369-2Q) in the               use by Medicare under 5.1
new Additional
Documentation Segment
under D.0
Ordering Physician First     N/A      First name of the Prescriber. Note        X(12)      N/A        N/A                             Referring Physician First
Name                                  that the last name is already stored                                                            Name
                                      on the Prescriber segment.
*This functionality is
addressed by the new                  * This field represents a subset of the
Prescriber First Name                 Prior Authorization Supporting
(364-2J) in the Prescriber            Documentation (498-PP), defined for
Segment under D.0                     use by Medicare under 5.1




            49
                                                            Transaction Prior Authorization Segment
                                              *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                       VMS Claim/CMN field
                                                                                 Version   Version
NCPDP Data Dictionary         Field                                                                                                       that is currently
                                           NCPDP Definition of Field               5.1     D.0        Valid values per the Standard
       Name                  Number                                                                                                     populated from this
                                                                                 Format    Format
                                                                                                                                            information

Ordering Physician           N/A      Address of the prescribing physician.     X(30)      N/A        N/A                             CMN Referring Physician
Address                                                                                                                               Address
                                      * This field represents a subset of the
*This functionality is                Prior Authorization Supporting
addressed by the new                  Documentation (498-PP), defined for
Prescriber Street Address             use by Medicare under 5.1
(365-2K) in the Prescriber
Segment under D.0
Ordering Physician City      N/A      City of the prescribing physician.        X(20)      N/A        N/A                             CMN Referring Physician
                                                                                                                                      City
*This functionality is                * This field represents a subset of the
addressed by the new                  Prior Authorization Supporting
Prescriber City Address               Documentation (498-PP), defined for
(366-2M) in the Prescriber            use by Medicare under 5.1
Segment under D.0
Ordering Physician State     N/A      Standard state/province code as           X(02)      N/A        Standard United States and      CMN Referring Physician
                                      defined by appropriate government                               Canadian province two-letter    State
*This functionality is                agency.                                                         postal service abbreviations
addressed by the new                                                                                  should be used.
Prescriber State/Province             * This field represents a subset of the
Address (367-2N) in the               Prior Authorization Supporting
Prescriber Segment under              Documentation (498-PP), defined for
D.0                                   use by Medicare under 5.1
Ordering Physician ZIP       N/A      Code defining international postal        X(15)      N/A        N/A                             CMN Referring Physician
                                      zone excluding punctuation and                                                                  Zip Code
*This functionality is                blanks (zip code for US).
addressed by the new
Prescriber Zip/Postal                 * This field represents a subset of the
Zone (368-2P) in the                  Prior Authorization Supporting
Prescriber Segment under              Documentation (498-PP), defined for
D.0                                   use by Medicare under 5.1




            50
                                                             Transaction Prior Authorization Segment
                                               *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                        VMS Claim/CMN field
                                                                                   Version   Version
NCPDP Data Dictionary          Field                                                                                                       that is currently
                                            NCPDP Definition of Field                5.1     D.0       Valid values per the Standard
       Name                   Number                                                                                                     populated from this
                                                                                   Format    Format
                                                                                                                                             information

Certificate on File           N/A      This indicates whether or not the          X(01)      N/A       N/A                             CMN Certificate On File
Indicator                              supplier has a paper copy of the                                                                Indicator
                                       CMN on file and available for review.
*This functionality is
addressed by the new                   * This field represents a subset of the
value 11 – Certification on            Prior Authorization Supporting
File for the Submission                Documentation (498-PP), defined for
Clarification Code (420-               use by Medicare under 5.1
DK) in the Claim Segment
under D.0
Signature Date                N/A      For form 8.02, this is the date that the   X(08)      N/A       Format = CCYYMMDD               CMN Signature Date
                                       supplier signed the form.
*This functionality is
addressed by the                       * This field represents a subset of the
Prescriber/Supplier Date               Prior Authorization Supporting
Signed (372-2T) in the                 Documentation (498-PP), defined for
new Additional                         use by Medicare under 5.1
Documentation Segment
under D.0
Question 01A (CMN Form        N/A      The HCPCS code of the drug                 X(11)      N/A       N/A                             Response to Question
08.02)                                 prescribed.                                                                                     01A on CMN Form 08.02

*This functionality is                 * This field represents a subset of the
addressed by the                       Prior Authorization Supporting
Question Alphanumeric                  Documentation (498-PP), defined for
Response (383-4K) in the               use by Medicare under 5.1
new Additional
Documentation Segment
under D.0




             51
                                                          Transaction Prior Authorization Segment
                                            *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                     VMS Claim/CMN field
                                                                               Version   Version
NCPDP Data Dictionary       Field                                                                                                       that is currently
                                         NCPDP Definition of Field               5.1     D.0        Valid values per the Standard
       Name                Number                                                                                                     populated from this
                                                                               Format    Format
                                                                                                                                          information

Question 01B (CMN Form     N/A      Dosage in milligrams of the drug          9(04)      N/A        N/A                             Response to Question
08.02)                              prescribed in Question 01A.                                                                     01B on CMN Form 08.02

*This functionality is              * This field represents a subset of the
addressed by the                    Prior Authorization Supporting
Question Numeric                    Documentation (498-PP), defined for
Response (382-4J) in the            use by Medicare under 5.1
new Additional
Documentation Segment
under D.0
Question 01C (CMN Form     N/A      The frequency of administration of        9(02)      N/A        N/A                             Response to Question
08.02)                              the drug prescribed in Question 01A.                                                            01C on CMN Form 08.02
                                    Expressed as times per day.
*This functionality is
addressed by the                    * This field represents a subset of the
Question Numeric                    Prior Authorization Supporting
Response (382-4J) in the            Documentation (498-PP), defined for
new Additional                      use by Medicare under 5.1
Documentation Segment
under D.0
Question 02A (CMN Form     N/A      The HCPCS code of the drug                X(11)      N/A        N/A                             Response to Question
08.02)                              prescribed. Required if more than 1                                                             02A on CMN Form 08.02
                                    drug has been prescribed.
*This functionality is
addressed by the                    * This field represents a subset of the
Question Alphanumeric               Prior Authorization Supporting
Response (383-4K) in the            Documentation (498-PP), defined for
new Additional                      use by Medicare under 5.1
Documentation Segment
under D.0




           52
                                                          Transaction Prior Authorization Segment
                                            *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                     VMS Claim/CMN field
                                                                               Version   Version
NCPDP Data Dictionary       Field                                                                                                       that is currently
                                         NCPDP Definition of Field               5.1     D.0        Valid values per the Standard
       Name                Number                                                                                                     populated from this
                                                                               Format    Format
                                                                                                                                          information

Question 02B (CMN Form     N/A      Dosage in milligrams of the drug          9(04)      N/A        N/A                             Response to Question
08.02)                              prescribed in Question 02A. Required                                                            02B on CMN Form 08.02
                                    if Question 02A has been answered.
*This functionality is              * This field represents a subset of the
addressed by the                    Prior Authorization Supporting
Question Numeric                    Documentation (498-PP), defined for
Response (382-4J) in the            use by Medicare under 5.1
new Additional
Documentation Segment
under D.0
Question 02C (CMN Form     N/A      The frequency of administration of        9(02)      N/A        N/A                             Response to Question
08.02)                              the drug prescribed in Question 02A.                                                            02C on CMN Form 08.02
                                    Expressed as times per day.
*This functionality is              Required if Question 02A has been
addressed by the                    answered.
Question Numeric
Response (382-4J) in the            * This field represents a subset of the
new Additional                      Prior Authorization Supporting
Documentation Segment               Documentation (498-PP), defined for
under D.0                           use by Medicare under 5.1
Question 03A (CMN Form     N/A      The HCPCS code of the drug                X(11)      N/A        N/A                             Response to Question
08.02)                              prescribed. Required if more than 2                                                             03A on CMN Form 08.02
                                    drugs have been prescribed.
*This functionality is
addressed by the                    * This field represents a subset of the
Question Alphanumeric               Prior Authorization Supporting
Response (383-4K) in the            Documentation (498-PP), defined for
new Additional                      use by Medicare under 5.1
Documentation Segment
under D.0




           53
                                                          Transaction Prior Authorization Segment
                                            *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                     VMS Claim/CMN field
                                                                               Version   Version
NCPDP Data Dictionary       Field                                                                                                       that is currently
                                         NCPDP Definition of Field               5.1     D.0        Valid values per the Standard
       Name                Number                                                                                                     populated from this
                                                                               Format    Format
                                                                                                                                          information

Question 03B (CMN Form     N/A      Dosage in milligrams of the drug          9(04)      N/A        N/A                             Response to Question
08.02)                              prescribed in Question 03A. Required                                                            03B on CMN Form 08.02
                                    if Question 03A has been answered.
*This functionality is
addressed by the                    * This field represents a subset of the
Question Numeric                    Prior Authorization Supporting
Response (382-4J) in the            Documentation (498-PP), defined for
new Additional                      use by Medicare under 5.1
Documentation Segment
under D.0
Question 03C (CMN Form     N/A      The frequency of administration of        9(02)      N/A        N/A                             Response to Question
08.02)                              the drug prescribed in Question 03A.                                                            03C on CMN Form 08.02
                                    Expressed as times per day.
*This functionality is              Required if Question 03A has been
addressed by the                    answered.
Question Numeric
Response (382-4J) in the            * This field represents a subset of the
new Additional                      Prior Authorization Supporting
Documentation Segment               Documentation (498-PP), defined for
under D.0                           use by Medicare under 5.1
Question 04 (CMN Form      N/A      Indicates whether or not the patient      X(01)      N/A        N/A                             Response to Question 04
08.02)                              has had an organ transplant that was                                                            on CMN Form 08.02
                                    covered by Medicare.
*This functionality is              * This field represents a subset of the
addressed by the                    Prior Authorization Supporting
Question Alphanumeric               Documentation (498-PP), defined for
Response (383-4K) in the            use by Medicare under 5.1
new Additional
Documentation Segment
under D.0




           54
                                                          Transaction Prior Authorization Segment
                                            *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                     VMS Claim/CMN field
                                                                               Version   Version
NCPDP Data Dictionary       Field                                                                                                       that is currently
                                         NCPDP Definition of Field               5.1     D.0        Valid values per the Standard
       Name                Number                                                                                                     populated from this
                                                                               Format    Format
                                                                                                                                          information

Question 05A (CMN Form     N/A      Indicates which organ(s) have been        X(01)      N/A        N/A                             Response to Question
08.02)                              transplanted. The most recent one(s)                                                            05A on CMN Form 08.02
                                    should be listed.
*This functionality is
addressed by the                    * This field represents a subset of the
Question Alphanumeric               Prior Authorization Supporting
Response (383-4K) in the            Documentation (498-PP), defined for
new Additional                      use by Medicare under 5.1
Documentation Segment
under D.0
Question 05B (CMN Form     N/A      Indicates which organ(s) have been        X(01)      N/A        N/A                             Response to Question
08.02)                              transplanted. The most recent one(s)                                                            05B on CMN Form 08.02
                                    should be listed.
*This functionality is
addressed by the                    * This field represents a subset of the
Question Alphanumeric               Prior Authorization Supporting
Response (383-4K) in the            Documentation (498-PP), defined for
new Additional                      use by Medicare under 5.1
Documentation Segment
under D.0
Question 05C (CMN Form     N/A      Indicates which organ(s) have been        X(01)      N/A        N/A                             Response to Question
08.02)                              transplanted. The most recent one(s)                                                            05C on CMN Form 08.02
                                    should be listed.
*This functionality is
addressed by the                    * This field represents a subset of the
Question Alphanumeric               Prior Authorization Supporting
Response (383-4K) in the            Documentation (498-PP), defined for
new Additional                      use by Medicare under 5.1
Documentation Segment
under D.0




           55
                                                          Transaction Prior Authorization Segment
                                            *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                     VMS Claim/CMN field
                                                                               Version   Version
NCPDP Data Dictionary       Field                                                                                                       that is currently
                                         NCPDP Definition of Field               5.1     D.0        Valid values per the Standard
       Name                Number                                                                                                     populated from this
                                                                               Format    Format
                                                                                                                                          information

Question 11 (CMN Form      N/A      The date the patient was discharged       X(08)      N/A        N/A                             Response to Question 11
08.02)                              from the hospital following this                                                                on CMN Form 08.02
                                    transplant surgery.
*This functionality is
addressed by the                    * This field represents a subset of the
Question Date Response              Prior Authorization Supporting
(380-4G) in the new                 Documentation (498-PP), defined for
Additional Documentation            use by Medicare under 5.1
Segment under D.0
Question 12 (CMN Form      N/A      Indicates whether or not there was a      X(01)      N/A        N/A                             Response to Question 12
08.02)                              prior transplant of the same organ.                                                             on CMN Form 08.02

*This functionality is              * This field represents a subset of the
addressed by the                    Prior Authorization Supporting
Question Alphanumeric               Documentation (498-PP), defined for
Response (383-4K) in the            use by Medicare under 5.1
new Additional
Documentation Segment
under D.0




           56
                                                           Transaction Prior Authorization Segment
                                             *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                      VMS Claim/CMN field
                                                                                Version   Version
NCPDP Data Dictionary        Field                                                                                                       that is currently
                                          NCPDP Definition of Field               5.1     D.0        Valid values per the Standard
       Name                 Number                                                                                                     populated from this
                                                                                Format    Format
                                                                                                                                           information

Narrative Information       N/A      Free form text area                       X(80)      N/A        N/A                             CMN narrative
                                     When the T12 Authorization                                                                      information per DME
*This functionality is               Information Qualifier is CNA, CNF,                                                              Form 11.02 – Section C
addressed by the                     FAN, NAR, MNA, MNF, MAN, or                                                                     Continuation Form
Narrative Message (390-              MAR, move the T12 Narrative
BM) in the new Narrative             Information to the NOTE field on the
Segment under D.0                    VANS H152 and VANS VCL1
                                     screens.

                                     * This field represents a subset of the
                                     Prior Authorization Supporting
                                     Documentation (498-PP), defined for
                                     use by Medicare under 5.1
Facility Name               N/A      * This field represents a subset of the   X(27)      N/A        N/A                             CMN Facility Name
                                     Prior Authorization Supporting
*This functionality is               Documentation (498-PP), defined for
addressed by the Facility            use by Medicare under 5.1
Name (385-3Q) in the
new Facility Segment
under D.0
Facility Address            N/A      * This field represents a subset of the   X(30)      N/A        N/A                             CMN Facility Address
                                     Prior Authorization Supporting
*This functionality is               Documentation (498-PP), defined for
addressed by the Facility            use by Medicare under 5.1
Street Address (386-3U)
in the new Facility
Segment under D.0




            57
                                                           Transaction Prior Authorization Segment
                                             *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                      VMS Claim/CMN field
                                                                                Version   Version
NCPDP Data Dictionary        Field                                                                                                       that is currently
                                          NCPDP Definition of Field               5.1     D.0        Valid values per the Standard
       Name                 Number                                                                                                     populated from this
                                                                                Format    Format
                                                                                                                                           information

Facility City               N/A      * This field represents a subset of the   X(20)      N/A        N/A                             CMN Facility City
                                     Prior Authorization Supporting
*This functionality is               Documentation (498-PP), defined for
addressed by the Facility            use by Medicare under 5.1
City Address (386-5J) in
the new Facility Segment
under D.0
Facility State              N/A      Standard state/province code as           X(02)      N/A        Standard United States and      CMN Facility State
                                     defined by appropriate government                               Canadian province two-letter
*This functionality is               agency.                                                         postal service abbreviations
addressed by the Facility                                                                            should be used.
State/Province Address               * This field represents a subset of the
(387-3V) in the new                  Prior Authorization Supporting
Facility Segment under               Documentation (498-PP), defined for
D.0                                  use by Medicare under 5.1
Facility ZIP                N/A      Code defining international postal        X(15)      N/A        N/A                             CMN Facility Zip
                                     zone excluding punctuation and
*This functionality is               blanks (zip code for US).
addressed by the Facility
Zip/Postal Zone (389-6D)             * This field represents a subset of the
in the new Facility                  Prior Authorization Supporting
Segment under D.0                    Documentation (498-PP), defined for
                                     use by Medicare under 5.1




                58
                                                         Transaction Prior Authorization Segment
                                           *This segment is no longer valid for use in the Billing Transaction

                                                                                                                                    VMS Claim/CMN field
                                                                              Version   Version
NCPDP Data Dictionary      Field                                                                                                       that is currently
                                        NCPDP Definition of Field               5.1     D.0        Valid values per the Standard
       Name               Number                                                                                                     populated from this
                                                                              Format    Format
                                                                                                                                         information

Ingredient Number         N/A      * This field represents a subset of the   9(02)      N/A        Occurs 25 times                 N/A
                                   Prior Authorization Supporting
*This functionality is             Documentation (498-PP), defined for
addressed by the                   use by Medicare under 5.1
Compound Ingredient
Modifier Code Count
(362-2G) in the
Compound Segment
under D.0
Ingredient Modifier       N/A      * This field represents a subset of the   X(02)      N/A        Occurs 25 times                 HCPCS Modifier, when
                                   Prior Authorization Supporting                                                                  processing a Compound
* This functionality is            Documentation (498-PP), defined for
addressed by the                   use by Medicare under 5.1
Compound Ingredient
Modifier Code (363-2H)
under D.0




            59
                                                               Transaction Clinical Segment

                                                                                                                                    VMS Claim/CMN field
                                                                             Version   Version
NCPDP Data Dictionary       Field                                                                                                      that is currently
                                         NCPDP Definition of Field             5.1     D.0       Valid values per the Standard
       Name                Number                                                                                                    populated from this
                                                                             Format    Format
                                                                                                                                         information

Segment Identification     111-AM   Identifies the segment in the request   X(02)      SAME      See Listing in the Transmission   N/A
                                    record.                                                      Patient Segment
Diagnosis Code Count       491-VE   Count of diagnosis occurrences.         9(02)      SAME      Maximum count remains at 5        N/A
Diagnosis Code Qualifier   492-WE   Code qualifying the Diagnosis Code.     X(02)      SAME      00=Not Specified                  *Currently, only value 01
                                                                                                 01=ICD9                           (ICD9) is accepted in
*Part of External Code                                                                           02=ICD-10-CM                      VMS
List under D.0                                                                                   03=National Criteria Care
                                                                                                 Institute (NCCI)
                                                                                                 04=SNOMED
                                                                                                 05=Common Dental
                                                                                                 Terminology (CDT)
                                                                                                 06=Medi-Span Product Line
                                                                                                 Diagnosis Code
                                                                                                 07= DSM IV
                                                                                                 *08=First DataBank Disease
                                                                                                 Code (FDBDX)
                                                                                                 *09=First DataBank FML
                                                                                                 Disease Identifier (FDB DxID)
                                                                                                 99=Other

                                                                                                 *New value under D.0
Diagnosis Code             424-DO   Code identifying the diagnosis of the   X(15)      SAME      N/A                               Claim Header/Line
                                    patient.                                                                                       Diagnosis

                                                                                                                                   CMN Diagnosis
Clinical Information       493-XE   Counter number of clinical              9(02)      SAME      Maximum count remains at 5        N/A
Counter                             information measurement sets/logical
                                    groupings.
Measurement Date           494-ZE   Date clinical information was           9(08)      SAME      Format=CCYYMMDD                   N/A
                                    collected or measured.
Measurement Time           495-H1   Time clinical information was           9(04)      SAME      Format: HHMM                      N/A
                                    collected or measured.




            60
                                                             Transaction Clinical Segment

                                                                                                                                   VMS Claim/CMN field
                                                                            Version   Version
NCPDP Data Dictionary     Field                                                                                                       that is currently
                                       NCPDP Definition of Field              5.1     D.0       Valid values per the Standard
       Name              Number                                                                                                     populated from this
                                                                            Format    Format
                                                                                                                                        information

Measurement Dimension    496-H2   Code indicating the clinical domain of   X(02)      SAME      Blank=Not Specified               N/A
                                  the observed value in Measurement                             01=Blood Pressure (BP)
*Part of External Code            Value.                                                        02=Blood Glucose
                                                                                                03=Temperature
List under D.0
                                                                                                04=Serum Creatinine (SCr)
                                                                                                05=Glycosylated Hemoglobin
                                                                                                06=Sodium (Na+)
                                                                                                07=Potassium (K+)
                                                                                                08=Calcium (Ca++)
                                                                                                09=SGOT
                                                                                                10=SGPT
                                                                                                11=Alkaline Phosphatase
                                                                                                12=Theophylline
                                                                                                13=Digoxin
                                                                                                14=Weight
                                                                                                15=Body Surface Area (BSA)
                                                                                                16=Height
                                                                                                17=Creatinine Clearance (CrCl)
                                                                                                *18=Cholesterol
                                                                                                *19=Low Density Lipoprotein
                                                                                                *20=High Density Lipoprotein
                                                                                                *21=Triglycerides (TG)
                                                                                                *22=Bone Mineral Density
                                                                                                *23=Prothrombin Time (PT)
                                                                                                *24=Hemoglobin (Hb; Hgb)
                                                                                                *25=Hematocrit (Hct)
                                                                                                *26=White Blood Cell Count
                                                                                                *27=Red Blood Cell Count (RBC)
                                                                                                *28=Heart Rate
                                                                                                *29=Absolute Neutrophil Count
                                                                                                *30=APTT
                                                                                                *31=CD4 Count
                                                                                                *32=Partial Thromboplastin Time
                                                                                                *33=T-Cell Count
                                                                                                *34=INR
                                                                                                99=Other

                                                                                                *New value under D.0




           61
                                                             Transaction Clinical Segment

                                                                                                                                     VMS Claim/CMN field
                                                                           Version   Version
NCPDP Data Dictionary     Field                                                                                                         that is currently
                                       NCPDP Definition of Field             5.1     D.0       Valid values per the Standard
       Name              Number                                                                                                       populated from this
                                                                           Format    Format
                                                                                                                                          information

Measurement Unit         497-H3   Code indicating the metric or English   X(02)      SAME      Blank=Not Specified                  N/A
                                  units used with the clinical                                 01=Inches (In)
*Part of External Code            information.                                                 02=Centimeters (cm)
List under D.0                                                                                 03=Pounds (lb)
                                                                                               04=Kilograms (kg)
                                                                                               05=Celsius (C)
                                                                                               06=Fahrenheit (F)
                                                                                               07=Meters squared (m2)
                                                                                               08=Milligrams per deciliter
                                                                                               (mg/dl)
                                                                                               09=Units per milliliter (U/ml)
                                                                                               10=Millimeters of mercury
                                                                                               (mmHg)
                                                                                               11=Centimeters squared (cm2)
                                                                                               12=Milliliters per minute (ml/min)
                                                                                               13=Percent (%)
                                                                                               14=Milliequivalents per milliliter
                                                                                               15 =International units per liter
                                                                                               16=Micrograms per milliliter
                                                                                               17=Nanograms per milliliter
                                                                                               18=Milligrams per milliliter
                                                                                               *19=Ratio
                                                                                               *20=SI Units
                                                                                               *21=Millimoles (mmol/l
                                                                                               *22=Seconds
                                                                                               *23=Grams per deciliter (g/dl)
                                                                                               *24=Cells per cubic millimeter
                                                                                               *25=1,000,000 cells per cubic
                                                                                               millimeter (million cells/cu mm)
                                                                                               *26=Standard deviation
                                                                                               *27=Beats per minute

                                                                                               *New value under D.0




           62
                                                              Transaction Clinical Segment

                                                                                                                                VMS Claim/CMN field
                                                                          Version    Version
NCPDP Data Dictionary    Field                                                                                                     that is currently
                                      NCPDP Definition of Field             5.1      D.0       Valid values per the Standard
       Name             Number                                                                                                   populated from this
                                                                          Format     Format
                                                                                                                                     information

Measurement Value       499-H4   Actual value of clinical information.   X(15)       SAME      N/A                             CMN Beneficiary Height
                                                                                                                               CMN Beneficiary Weight




          63
                                                         Transaction Additional Documentation Segment
                                                                  *This is a new optional segment
**This segment will support CMN processing, similar to the 2440 FRM segment in the 837 format. However, the only current CMN form that is supported in VMS
 processing of NCPDP claims is DIF Form 08.02 for Immunosuppressives and that form is no longer required by CMS, per CR4241. Unless the universe of DME
  items allowed to be submitted in the NCPDP format expands beyond NDC codes or new CMNS forms for drugs are implemented, this optional segment will
                                                            likely not be needed for DME claims.

                                                                                                                                          VMS Claim/CMN field
                                                                                Version    Version
NCPDP Data Dictionary           Field                                                                                                        that is currently
                                             NCPDP Definition of Field            5.1      D.0       Valid values per the Standard
       Name                    Number                                                                                                      populated from this
                                                                                Format     Format
                                                                                                                                               information

Segment Identification         111-AM   Identifies the segment in the request   N/A        X(02)     See Listing in the Transmission     N/A
                                        record.                                                      Patient Segment
Additional Documentation       369-2Q   Unique identifier for the data being    N/A         X(03)    001=Medicare 01.02A Hospital Beds   N/A
Type ID                                 submitted.                                                   002=Medicare 01.02B Support
                                                                                                     Surfaces
                                                                                                     003=Medicare 02.03A Motorized
*This replaces the Form
                                                                                                     Wheel Chair
Identifier that is currently                                                                         004=Medicare 02.03B Manual
defined as a subset of the                                                                           Wheelchair
Prior Authorization                                                                                  005=Medicare 03.02 Continuous
Supporting                                                                                           Positive Airway Pressure (CPAP)
Documentation (498-PP)                                                                               006=Medicare 04.03B Lymphedema
on the Prior Authorization                                                                           Pumps
segment, defined for use                                                                             007=Medicare 04.03C Osteogenesis
                                                                                                     Stimulator
by Medicare under 5.1
                                                                                                     008=Medicare 06.02B
                                                                                                     Transcutaneous Electrical Nerve
**Part of External Code                                                                              Stimulator TENS)
List under D.0                                                                                       009=Medicare 07.02A Seat Lift
                                                                                                     Mechanisms
                                                                                                     010=Medicare 07.02B Power
                                                                                                     Operated Vehicles (POV)
                                                                                                     011=Medicare 08.02
                                                                                                     Immunosuppressive Drugs
                                                                                                     012=Medicare 09.02 Infusion Pump
                                                                                                     013=Medicare 10.02A Parenteral
                                                                                                     Nutrition
                                                                                                     014=Medicare 10.02B Enteral
                                                                                                     Nutrition
                                                                                                     015=Medicare 484.2 Oxygen




             64
                                                        Transaction Additional Documentation Segment
                                                                 *This is a new optional segment
**This segment will support CMN processing, similar to the 2440 FRM segment in the 837 format. However, the only current CMN form that is supported in VMS
 processing of NCPDP claims is DIF Form 08.02 for Immunosuppressives and that form is no longer required by CMS, per CR4241. Unless the universe of DME
  items allowed to be submitted in the NCPDP format expands beyond NDC codes or new CMNS forms for drugs are implemented, this optional segment will
                                                            likely not be needed for DME claims.

                                                                                                                                     VMS Claim/CMN field
                                                                               Version    Version
NCPDP Data Dictionary        Field                                                                                                      that is currently
                                           NCPDP Definition of Field             5.1      D.0       Valid values per the Standard
       Name                 Number                                                                                                    populated from this
                                                                               Format     Format
                                                                                                                                          information

Request Period Begin        375-2V    The beginning date of need.             N/A         9(08)     Format = CCYYMMDD               N/A
Date

*This replaces the
functionality of the
Request Period Date -
Begin (498-PB) on the
Prior Authorization
segment, as it is used by
Medicare under 5.1
Request Period              375-2W    The effective date of the revision or   N/A         9(08)     Format = CCYYMMDD               N/A
Recert/Revised Date                   re-certification provided by the
                                      certifying physician.
*This replaces the
functionality of the
Request Period Date –
End (498-PC) on the
Prior Authorization
segment, as it is used by
Medicare under 5.1




            65
                                                       Transaction Additional Documentation Segment
                                                                *This is a new optional segment
**This segment will support CMN processing, similar to the 2440 FRM segment in the 837 format. However, the only current CMN form that is supported in VMS
 processing of NCPDP claims is DIF Form 08.02 for Immunosuppressives and that form is no longer required by CMS, per CR4241. Unless the universe of DME
  items allowed to be submitted in the NCPDP format expands beyond NDC codes or new CMNS forms for drugs are implemented, this optional segment will
                                                            likely not be needed for DME claims.

                                                                                                                                    VMS Claim/CMN field
                                                                              Version    Version
NCPDP Data Dictionary         Field                                                                                                    that is currently
                                           NCPDP Definition of Field            5.1      D.0       Valid values per the Standard
       Name                  Number                                                                                                  populated from this
                                                                              Format     Format
                                                                                                                                         information

Request Status               373-2U   Code identifying type of request.      N/A         X(01)     0=Not Specified.                N/A
                                                                                                   1=Initial.
*This replaces the                                                                                 2=Revision.
functionality of the                                                                               3=Recertification.
Request Type (498-PA)
on the Prior Authorization
segment, as it is used by
Medicare under 5.1

**Part of External Code
List under D.0
Length of Need Qualifier     371-2S   Code qualifying the length of need.    N/A         9(02)     0=Not Specified                 N/A
                                                                                                   1=Hours
**Part of External Code                                                                            2=Days
List under D.0                                                                                     3=Weeks
                                                                                                   4=Months
                                                                                                   5=Years
                                                                                                   6=Lifetime
Length of Need               370-2R   Length of time the physician expects   N/A         9(03)     N/A                             N/A
                                      the patient to require use of the
                                      ordered item.




            66
                                                       Transaction Additional Documentation Segment
                                                                *This is a new optional segment
**This segment will support CMN processing, similar to the 2440 FRM segment in the 837 format. However, the only current CMN form that is supported in VMS
 processing of NCPDP claims is DIF Form 08.02 for Immunosuppressives and that form is no longer required by CMS, per CR4241. Unless the universe of DME
  items allowed to be submitted in the NCPDP format expands beyond NDC codes or new CMNS forms for drugs are implemented, this optional segment will
                                                            likely not be needed for DME claims.

                                                                                                                                     VMS Claim/CMN field
                                                                              Version    Version
NCPDP Data Dictionary         Field                                                                                                     that is currently
                                           NCPDP Definition of Field            5.1      D.0        Valid values per the Standard
       Name                  Number                                                                                                   populated from this
                                                                              Format     Format
                                                                                                                                          information

Prescriber/Supplier Date     372-2T   The date the form was completed         N/A        9(08)      Format = CCYYMMDD               N/A
Signed                                and signed by the ordering physician.

*This replaces the
Signature Date that is
currently defined as a
subset of the Prior
Authorization Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use
by Medicare under 5.1

Supporting                   376-2X   Free text message                       N/A        X(65)      N/A                             N/A
Documentation
Question Number/Letter       377-2Z   Count of Question Number/Letter         N/A        9(02)      Maximum count of 50.            N/A
Count                                 occurrences.
Question Number/Letter       378-4B   Identifies the question number/letter   N/A        X(03)      Values to be determined by      N/A
                                      that the question response applies to                         Trading Partner Agreement
                                      (part of the question information).
Question Percent             379-4D   Percent response to a question (part    N/A        9(3)v99    N/A                             N/A
Response                              of the question information).
Question Date Response       380-4G   Date response to a question (part of    N/A        9(08)      Format = CCYYMMDD               N/A
                                      the question information).
Question Dollar Amount       381-4H   Dollar Amount response to a             N/A        s9(9)v99   N/A                             N/A
Response                              question (part of the question
                                      information).



            67
                                                      Transaction Additional Documentation Segment
                                                               *This is a new optional segment
**This segment will support CMN processing, similar to the 2440 FRM segment in the 837 format. However, the only current CMN form that is supported in VMS
 processing of NCPDP claims is DIF Form 08.02 for Immunosuppressives and that form is no longer required by CMS, per CR4241. Unless the universe of DME
  items allowed to be submitted in the NCPDP format expands beyond NDC codes or new CMNS forms for drugs are implemented, this optional segment will
                                                            likely not be needed for DME claims.

                                                                                                                                    VMS Claim/CMN field
                                                                             Version    Version
NCPDP Data Dictionary      Field                                                                                                       that is currently
                                          NCPDP Definition of Field            5.1      D.0        Valid values per the Standard
       Name               Number                                                                                                     populated from this
                                                                             Format     Format
                                                                                                                                         information

Question Numeric         382-4J       Numeric response to a question (part   N/A        9(11)      N/A                             N/A
Response                              of the question information).
Question Alphanumeric    383-4K       Alphanumeric response to a question    N/A        X(30)      N/A                             N/A
Response                              (part of the question information).




          68
                                                                   Transaction Facility Segment
                                                                 *This is a new optional segment

                                                                                                                                       VMS Claim/CMN field
                                                                               Version    Version
NCPDP Data Dictionary          Field                                                                                                      that is currently
                                            NCPDP Definition of Field            5.1      D.0       Valid values per the Standard
       Name                   Number                                                                                                    populated from this
                                                                               Format     Format
                                                                                                                                            information

Segment Identification        111-AM   Identifies the segment in the request   N/A        (X02)     See Listing in the Transmission   N/A
                                       record.                                                      Patient Segment
Facility ID                   336-8C   ID assigned to the patient’s            N/A         X(10)    N/A                               N/A
                                       clinic/host party.
Facility Name                 385-3Q   Name identifying the location of the    N/A        X(30)     N/A                               N/A
                                       service rendered.
*This replaces the Facility
Name that is currently
defined as a subset of the
Prior Authorization
Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use
by Medicare under 5.1
Facility Street Address       386-3U   Free form text for Facility address     N/A        X(30)     N/A                               N/A
                                       information.
*This replaces the Facility
Address that is currently
defined as a subset of the
Prior Authorization
Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use
by Medicare under 5.1




              69
                                                                      Transaction Facility Segment
                                                                    *This is a new optional segment

                                                                                                                                        VMS Claim/CMN field
                                                                                  Version    Version
NCPDP Data Dictionary          Field                                                                                                       that is currently
                                            NCPDP Definition of Field               5.1      D.0       Valid values per the Standard
       Name                   Number                                                                                                     populated from this
                                                                                  Format     Format
                                                                                                                                             information

Facility City Address         388-5J   Free form text for facility city          N/A         X(20)     N/A                             N/A
                                       Name.
*This replaces the Facility
City that is currently
defined as a subset of the
Prior Authorization
Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use
by Medicare under 5.1
Facility State/Province       387-3V    Standard state/province code as          N/A         X(02)     Standard United States and      N/A
Address                                defined by appropriate government                               Canadian province two-letter
                                       agency.                                                         postal service abbreviations
*This replaces the Facility                                                                            should be used.
State that is currently
defined as a subset of the
Prior Authorization
Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use
by Medicare under 5.1




            70
                                                                  Transaction Facility Segment
                                                                 *This is a new optional segment

                                                                                                                                     VMS Claim/CMN field
                                                                               Version    Version
NCPDP Data Dictionary          Field                                                                                                    that is currently
                                            NCPDP Definition of Field            5.1      D.0       Valid values per the Standard
       Name                   Number                                                                                                  populated from this
                                                                               Format     Format
                                                                                                                                          information

Facility Zip/Postal Zone      389-6D   Code defining international postal     N/A         X(15)     N/A                             N/A
                                       zone excluding punctuation and
*This replaces the Facility            blanks (zip code for US).
Zip that is currently
defined as a subset of the
Prior Authorization
Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use
by Medicare under 5.1




            71
                                                                Transaction Narrative Segment
                                                                *This is a new optional segment
 **This segment will support the submission of narrative information per DME Form 11.02 – Section C Continuation Form. However, the only current CMN form
   that is supported in VMS processing of NCPDP claims is DIF Form 08.02 for Immunosuppressives and that form is no longer required by CMS, per CR4241.
 Unless the universe of DME items allowed to be submitted in the NCPDP format expands beyond NDC codes or new CMNS forms for drugs are implemented,
                                                this optional segment will likely not be needed for DME claims.

                                                                                                                                      VMS Claim/CMN field
                                                                              Version    Version
NCPDP Data Dictionary         Field                                                                                                      that is currently
                                           NCPDP Definition of Field            5.1      D.0       Valid values per the Standard
       Name                  Number                                                                                                    populated from this
                                                                              Format     Format
                                                                                                                                           information

Segment Identification       111-AM   Identifies the segment in the request   N/A        (X02)     See Listing in the Transmission   N/A
                                      record.                                                      Patient Segment
Narrative Message            390-BM   Free form text.                         N/A         X(200)   N/A                               N/A

*This replaces the
Narrative Information that
is currently defined as a
subset of the Prior
Authorization Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use
by Medicare under 5.1




            72
                                                                 Batch Trailer Segment

                                                                                                                                  VMS Claim/CMN field
NCPDP Data Dictionary     Field                                           Batch 1.1   Batch 1.2                                      that is currently
                                       NCPDP Definition of Field                                  Valid values per the Standard
       Name              Number                                            Format     Format                                       populated from this
                                                                                                                                       information

Segment Identification   111-AM   Identifies the segment in the request   X(02)       SAME        99 = File Control (trailer)     N/A
                                  record.
Batch Number             806-5C   Number assigned by processor.           9(07)       SAME        Matches Header                  N/A
                                  Matches header.
Record Count             751      Record count within batch file.         9(10)       SAME        N/A                             N/A
Message                  504-F4   Free form message.                      X(35)       SAME        N/A                             N/A




           73

				
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posted:12/11/2011
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