Pharmacy Online Processing System _POPS_ Billing Guide

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Pharmacy Online Processing System _POPS_ Billing Guide Powered By Docstoc
					               Commonwealth of Massachusetts
            Executive Office of Health and Human Services
June 2011                                               Version 12.0




    Pharmacy Online Processing System
          (POPS) Billing Guide
                NCPDP Telecommunications Standard D.0
                      (Effective January 1, 2012)
                          Commonwealth of Massachusetts
                 Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                                                                Version 12.0
                                                                  Table of Contents
1.0     Introduction ................................................................................................................... 2
2.0     Claim Submission Formats – B1 and B3 ................................................................... 2
  2.1      Request Claim Billing/Claim Rebill Payer Sheet ..................................................................................................... 2
  2.2      Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response......................................................32
  2.3      Claim Billing/Claim Rebill Accepted/Rejected Response ....................................................................................38
  2.4      Claim Billing/Claim Rebill Rejected/Rejected Response......................................................................................42

3.0     Claim Submission Format – B2 ................................................................................ 45
  3.1      Request for Claim Reversal Payer Sheet................................................................................................................45
  3.2      Claim Reversal Accepted/Approved Response ....................................................................................................49
  3.3      Claim Reversal Accepted/Rejected Response ......................................................................................................50
  3.4      Claim Reversal Rejected/Rejected Response........................................................................................................53

4.0     Claim Submission Formats – S1 and S3 ................................................................. 55
  4.1      Service Billing/Service Rebill Request....................................................................................................................55
  4.2      Service Billing/Service Rebill Accepted/Paid (or Duplicate of Paid) Response ...............................................73
  4.3      Service Billing/Service Rebill Accepted/Rejected Response ..............................................................................79
  4.4      Service Billing/Service Rebill Rejected/Rejected Response ...............................................................................83

5.0     Claim Submission Format – S2................................................................................. 85
  5.1      Service Reversal Request.........................................................................................................................................85
  5.2      Service Reversal Accepted/Approved Response .................................................................................................88
  5.3      Service Reversal Accepted/Rejected Response ...................................................................................................90
  5.4      Service Reversal Rejected/Rejected Response ....................................................................................................91

6.0     TPL Billing ................................................................................................................... 94
7.0     90-Day-Waiver Procedures ........................................................................................ 94
8.0     Claims Over $99,999.99.............................................................................................. 95
9.0     Special Topics and References ................................................................................ 95
10.0 Version Table............................................................................................................... 95
11.0 Where to Get Help....................................................................................................... 95
Appendix A – Pharmacy 90-day Waiver Form .................................................................. 98




                                                                                  -i-
                    Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                              Version 12.0


1.0     Introduction
Effective January 1, 2012, ACS State Healthcare will accept claims for MassHealth in the NCPDP
version D.Ø format. All MassHealth pharmacy claims must be sent via the Pharmacy Online
Processing System (POPS). ACS operates POPS under the general framework of standards and
protocols established by the National Council for Prescription Drug Programs (NCPDP). Pharmacy
providers must work with their software and switch vendors to ensure compliance such that all
practice management software must be capable of submitting the following transactions to the
MassHealth POPS: B1/B3, S1/S3, B2, and S2.
Switches
 eRX: 1-866-379-6389
 NDCHealth: 1-800-388-2316
 QS1: 1-800-231-7776
This billing guide includes the D. Ø payer sheets and also contains pertinent information for
submitting pharmacy drug and service claims to the MassHealth POPS. This document is updated
regularly. The revision date above represents the most recent date that this document was updated.
Please ensure that you are using the most current version of this document. For detailed information
concerning updates to this document, please refer to the version table in Section 10.0 at the end of this
document.

        MassHealth has utilized the NCPDP D.Ø payer sheet templates as the basis for our
        payer sheets. (Materials are reproduced with the consent of the National Council for
        Prescription Drug Programs, Inc. 2010 NCPDP.)


2.0     Claim Submission Formats – B1 and B3

 BIN NUMBER         ØØ9555
 DESTINATION        ACS STATE HEALTHCARE
 ACCEPTING          CLAIM ADJUDICATION (B1-BILLING AND B3-REBILL TRANSACTIONS)
 FORMAT             NCPDP D.Ø


2.1 Request Claim Billing/Claim Rebill Payer Sheet
Field Legend for Columns
  Payer Usage       Value                                      Explanation                                            Payer Situation
    Column                                                                                                               Column
 Mandatory           M      The field is mandatory for the segment in the designated transaction.                           No
 Required            R      The field has been designated with the situation of ”required” for the segment in the          Yes
                            designated transaction.
 Qualified           Q      The situations designated have qualifications for usage (required if x, not required if        Yes
 Requirement                y).
 Qualified          QM      The situations designated have qualifications for usage (required if x, not required if        Yes
 Requirement for            y) for Medicaid subrogation.
 Medicaid
 Subrogation Only

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                        Commonwealth of Massachusetts
                 Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                                       Version 12.0

   Payer Usage      Value                                              Explanation                                            Payer Situation
      Column                                                                                                                     Column
 Informational Only   I           The field is for informational purposes only for the transaction.                                Yes
 Not Used                 N       The field is not used for the segment for the transaction.                                         No
 Repeating             ***R***    The three asterisks, R, and three asterisks designates a field is repeating.                       Yes
                                  Example: Q***R*** means a situationally qualified field that repeats.
                                  Example: N***R*** means a not used field that repeats when used.
Please Note: Fields that are not used in the claim billing/claim rebill transactions, and those that do not have qualified requirements (i.e.,
not used) for this payer are excluded from the template.

Claim Billing/Claim Rebill Transaction
The following lists the segments and fields applicable to MassHealth in a claim billing or claim rebill
transaction for the NCPDP version D.Ø. Claim billing includes pharmacy billing transactions B1 and
B3.
 Transaction Header Segment                       Check                  Claim Billing/Claim Rebill
 Questions                                                               If Situational, Payer Situational
 This segment is always sent.                              X
 Source of certification IDs required in                   X
 software vendor/certification ID (11Ø-AK)
 is payer issued.
 Source of certification IDs required in
 software vendor/certification ID (11Ø-AK)
 is switch/VAN issued.
 Source of certification IDs required in
 software vendor/certification ID (11Ø-AK)
 is not used.

              Transaction Header                                                            Claim Billing/Claim
              Segment                                                                       Rebill
 Field #      NCPDP Field Name                   Value                           Payer      Payer Situation              Field Format
                                                                                 Usage
 1Ø1-A1       BIN NUMBER                         ØØ9555                            M                                     9(6)
 1Ø2-A2       VERSION/RELEASE                    DØ                                M                                     X(2)
              NUMBER
 1Ø3-A3       TRANSACTION CODE                   B1,B3                              M                                    X(2)
 1Ø4-A4       PROCESSOR CONTROL                  MASSPROD for                       M                                    X(1Ø)
              NUMBER                             production transactions
 1Ø9-A9       TRANSACTION COUNT                  1=One occurrence                   M                                    X(1)
                                                 2=Two occurrences
                                                 3=Three occurrences
                                                 4=Four occurrences
 2Ø2-B2       SERVICE PROVIDER ID                Ø 1 – National provider            M                                    X(2)
              QUALIFIER                          identifier
 2Ø1-B1       SERVICE PROVIDER ID                                                   M                                    X(15)
 4Ø1-D1       DATE OF SERVICE                    CCYYMMDD                           M                                    9(8)
 11Ø-AK       SOFTWARE                                                              M       The MassHealth               X(1Ø)
              VENDOR/CERTIFICATION                                                          registration number
              ID                                                                            assigned to software
                                                                                            as part of initial
                                                                                            certification.

 Insurance Segment Questions                      Check                  Claim Billing/Claim Rebill
                                                                         If Situational, Payer Situation
 This segment is always sent.                              X




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                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                        Version 12.0


            Insurance Segment                                                   Claim Billing/Claim
            Segment Identification                                              Rebill
            (111-AM) = Ø4
 Field #    NCPDP FIELD NAME             Value                       Payer      Payer Situation          Field Format
                                                                     Usage
111-AM      SEGMENT                                                    M                                 X(2)
            IDENTIFICATION
3Ø2-C2      CARDHOLDER ID                                               M      The 12-digit MassHealth   X(2Ø)
                                                                               member ID number
312-CC      CARDHOLDER FIRST                                            R                                X(12)
            NAME
313-CD      CARDHOLDER LAST NAME                                        R                                X(15)
314-CE      HOME PLAN                                                   N
524-FO      PLAN ID                                                     Q
3Ø9-C9      ELIGIBILITY                                                 N
            CLARIFICATION CODE
3Ø1-C1      GROUP ID                     MassHealth                     R                                X(15)
                                         HSN
3Ø3-C3      PERSON CODE                                                 N
3Ø6-C6      PATIENT RELATIONSHIP         Ø=Not specified                N
            CODE                         1=Cardholder
359-2A      MEDIGAP ID                                                 QM                                X(2Ø)
36Ø-2B      MEDICAID INDICATOR                                         QM                                X(2)
361-2D      PROVIDER ACCEPT              Y=CMS qualified facility      QM                                X(1)
            ASSIGNMENT INDICATOR         N=Not a CMS qualified
                                         facility
997-G2      CMS PART D DEFINED           Y=assigned                    QM                                X(1)
            QUALIFIED FACILITY           N=not assigned
115-N5      MEDICAID ID NUMBER                                         QM                                X(2Ø)
116-N6      MEDICAID AGENCY                                             N
            NUMBER

 Patient Segment Questions              Check                 Claim Billing/Claim Rebill
                                                              If Situational, Payer Situation
 This segment is always sent.                      X
 This segment is situational.

            Patient Segment                                                     Claim Billing/Claim Rebill
            Segment Identification (111-AM) = Ø1
 Field      NCPDP Field Name             Value                       Payer      Payer Situation          Field Format
                                                                     Usage
111-AM      SEGMENT                                                    M                                 X(2)
            IDENTIFICATION
331-CX      PATIENT ID QUALIFIER                                       N                                 X(2)
332-CY      PATIENT ID                                                 N
3Ø4-C4      DATE OF BIRTH                CCYYMMDD                      R                                 9(8)
3Ø5-C5      PATIENT GENDER CODE          1=Male                        R                                 9(1)
                                         2=Female
31Ø-CA      PATIENT FIRST NAME                                         I                                 X(12)
311-CB      PATIENT LAST NAME                                          I                                 X(15)
322-CM      PATIENT STREET                                             N
            ADDRESS
323-CN      PATIENT CITY ADDRESS                                       N
324-CO      PATIENT STATE /                                            N
            PROVINCE ADDRESS
325-CP      PATIENT ZIP/POSTAL                                         N
            ZONE
326-CQ      PATIENT PHONE NUMBER                                       N

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                  Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                  Version 12.0

         Patient Segment                                                   Claim Billing/Claim Rebill
         Segment Identification (111-AM) = Ø1
 Field   NCPDP Field Name             Value                        Payer   Payer Situation          Field Format
                                                                   Usage
3Ø7-C7   PLACE OF SERVICE              1=Pharmacy                    I                              9(2)
         (formerly patient location)   2=Unassigned
                                       3=School
                                       4=Homeless Shelter
                                       5= Indian Health Service
                                       Free-standing Facility
                                       6= Indian Health Service
                                       Provider-based Facility
                                       7= Tribal 638 Free-
                                       standing
                                       Facility
                                       8= Tribal 638 Provider-
                                       based
                                       Facility
                                       9-10=Prison/Correctional
                                       Facility
                                       11=Office
                                       12=Home
                                       13= Assisted Living
                                       Facility
                                       14=Group Home
                                       15=Mobile Unit
                                       16= Temporary Lodging
                                       17= Walk-in Retail Health
                                       Clinic
                                       18-19=Unassigned
                                       2Ø =Urgent Care Facility
                                       21=Inpatient Hospital
                                       22=Outpatient Hospital
                                       23=Emergency Room –
                                       Hospital
                                       24=Ambulatory Surgical
                                       Center
                                       25=Birthing Center
                                       26=Military Treatment
                                       Facility
                                       27-3Ø =Unassigned
                                       31=Skilled Nursing
                                       Facility
                                       32=Nursing Facility
                                       33=Custodial Care
                                       Facility
                                       34=Hospice
                                       35-4Ø =Unassigned
                                       41=Ambulance - Land
                                       42=Ambulance – Air or
                                       Water
                                       43-48=Unassigned
                                       49=Independent Clinic
                                       5Ø =Federally Qualified
                                       Health Center
                                       51=Inpatient Psychiatric
                                       Facility
                                       52=Psychiatric Facility-
                                       Partial Hospitalization
                                       53=Community Mental
                                       Health Center
                                       54=Intermediate Care
                                       Facility/Mentally

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                 Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                  Version 12.0

         Patient Segment                                                   Claim Billing/Claim Rebill
         Segment Identification (111-AM) = Ø1
 Field   NCPDP Field Name             Value                        Payer   Payer Situation          Field Format
                                                                   Usage
                                      Retarded
                                      55=Residential
                                      Substance Abuse
                                      Treatment Facility
                                      56=Psychiatric
                                      Residential Treatment
                                      57=Non-residential
                                      Substance Abuse
                                      Treatment Facility
                                      58-59=Unassigned
                                      6Ø =Mass Immunization
                                      Center
                                      61=Comprehensive
                                      Inpatient Rehabilitation
                                      Facility
                                      62=Comprehensive
                                      Outpatient Rehabilitation
                                      Facility
                                      63-64=Unassigned
                                      65=End-Stage Renal
                                      Disease Treatment
                                      Facility
                                      66-7Ø =Unassigned
                                      71=Public Health Clinic
                                      72=Rural Health Clinic
                                      73-8Ø =Unassigned
                                      81=Independent
                                      Laboratory
                                      82-98=Unassigned
                                      99=Other Place of
                                      Service
333-CZ   EMPLOYER ID                                                N

334-1C   SMOKER/NONSMOKER             Yes=Smoker                    Q                               X(1)
         CODE                         No=Nonsmoker
335-2C   PREGNANCY INDICATOR          Blank=Not specified           Q                               X(1)
                                      1=Not pregnant
                                      2=Pregnant
35Ø-HN   PATIENT E-MAIL ADDRESS                                     N
384-4X   PATIENT RESIDENCE            Ø=Not Specified               R                               9(2)
                                      1=Home
                                      2=Skilled Nursing Facility
                                      3=Nursing
                                      4=Assisted Living Facility
                                      5=Custodial Care Facility
                                      6=Group Home
                                      7=Inpatient Psychiatric
                                      Facility
                                      8=Psychiatric Facility
                                      9=Intermediate Care
                                      Facility/Mentally
                                      Retarded
                                      1Ø=Residential
                                      Substance Abuse
                                      Treatment Facility
                                      11=Hospice
                                      12=Psychiatric
                                      Residential Treatment
                                      Facility
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                          Commonwealth of Massachusetts
                   Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                             Version 12.0

                Patient Segment                                                         Claim Billing/Claim Rebill
                Segment Identification (111-AM) = Ø1
    Field       NCPDP Field Name             Value                           Payer      Payer Situation          Field Format
                                                                             Usage
                                                 13=Comprehensive
                                                 Inpatient Rehabilitation
                                                 Facility
                                                 14=Homeless Shelter
                                                 15=Correctional Institute

    Claim Segment Questions                      Check                 Claim Billing/Claim Rebill
                                                                       If Situational, Payer Situation
    This segment is always sent.                         X
    This payer supports partial fills.                   X
    This payer does not support partial fills.


Partial Fills
The claim segment describes scenarios about partial fills and completion fills. A partial fill occurs
when a pharmacy does not have the full quantity of a drug specified by a prescription to dispense to a
patient. The pharmacy dispenses the available quantity. A claim may be submitted for this type of fill,
known as a partial fill, whether or not the patient returns to obtain the remainder of the drug quantity
(sometimes the patient does not return for the remainder). If the patient does return and receives the
remainder of the drug quantity, a claim submitted for this transaction is known as a completion fill.
A pharmacy can submit the following types of claims:
      partial – whenever there is a partial fill on a covered drug;
      completion with a previous partial claim – whenever a partial fill for which a previous claim was
       submitted has a completion fill; and
      completion without a previous partial.
The table below lists the fields that are required for partial-fill transactions, completion-fill
transactions, or both.
                                      Field Field Name Used with Partial, Completion, or Both
    456-EN (Associated prescription/service reference number) Completion
    457-EP (Associated prescription/service date) Completion
    343-HD (Dispensing status) Both
    344-HF (Quantity intended to be dispensed) Both
    345-HG (Days’ supply intended to be dispensed) Both




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                 Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                           Version 12.0


           Claim Segment                                              Claim Billing/Claim
           Segment Identification                                     Rebill
           (111-AM) = Ø7
Field #    NCPDP Field Name         Value                     Payer   Payer Situation             Field Format
                                                              Usage
111-AM    SEGMENT                                               M                                 X(2)
          IDENTIFICATION
455-EM    PRESCRIPTION/SERVICE      1=Rx billing               M                                  X(1)
          REFERENCE NUMBER
          QUALIFIER
4Ø2-D2    PRESCRIPTION/SERVICE                                 M                                  9(12)
          REFERENCE NUMBER
436-E1    PRODUCT/SERVICE ID        Ø1=Universal Product       M                                  X(2)
          QUALIFIER                 Code (UPC)
                                    Ø2=Health-related item
                                    (HRI)
                                    Ø3=National Drug Code
                                    (NDC)
4Ø7-D7    PRODUCT/SERVICE ID                                   M      If CC, this field           X(19)
                                                                      should be zero filled.
456-EN    ASSOCIATED                                           Q      Required if the          9(12)
          PRESCRIPTION/SERVICE                                        completion
          REFERENCE NUMBER                                            transaction in a partial
                                                                      fill (dispensing status
                                                                      (343-HD) = C
                                                                      (completed)).

                                                                      Required if the
                                                                      dispensing status
                                                                      (343-HD) = P (partial
                                                                      fill) and there are
                                                                      multiple occurrences
                                                                      of partial fills for this
                                                                      prescription.
457-EP    ASSOCIATED                CCYYMMDD                   Q      Required if the           9(8)
          PRESCRIPTION/SERVICE                                        completion
          DATE                                                        transaction in a partial
                                                                      fill (dispensing status
                                                                      (343-HD) = C
                                                                      (completed)).

                                                                      Required if
                                                                      associated
                                                                      prescription/service
                                                                      reference number
                                                                      (456-EN) is used.

                                                                      Required if the
                                                                      dispensing status
                                                                      (343-HD) = P (partial
                                                                      fill) and there are
                                                                      multiple occurrences
                                                                      of partial fills for this
                                                                      prescription.
458-SE    PROCEDURE CODE                                       N
          COUNT
459-ER    PROCEDURE MODIFIER                                   N
          CODE
442-E7    QUANTITY DISPENSED        Metric decimal quantity    R      For CC, enter the       s9(7)v999
                                                                      quantity of the drug in
                                                                      its compounded form.

                                                    -8-
                 Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                Version 12.0

           Claim Segment                                                       Claim Billing/Claim
           Segment Identification                                              Rebill
           (111-AM) = Ø7
Field #    NCPDP Field Name         Value                           Payer      Payer Situation         Field Format
                                                                    Usage
4Ø3-D3    FILL NUMBER               Ø=Original dispensing 1 to        R                                9(2)
                                    11=Refill number
4Ø5-D5    DAYS SUPPLY                                                  R       On partial-fill         9(3)
                                                                               transactions, specify
                                                                               only whole days
                                                                               Dispensed.
4Ø6-D6    COMPOUND CODE             Ø=Not specified                    R                               9(1)
                                    1=Not a compound
                                    2= Compound code
4Ø8-D8    DISPENSE AS WRITTEN       Ø=No product selection             R                               X(1)
          (DAW)/PRODUCT             indicated
          SELECTION CODE            1=Physician request
                                    5=Brand used as generic
414-DE    DATE PRESCRIPTION         CCYYMMDD                           R                               9(8)
          WRITTEN
415-DF    NUMBER OF REFILLS         Ø through 11                       R                               9(2)
          AUTHORIZED
419-DJ    PRESCRIPTION ORIGIN       1=Written on tamper-               R                               9(1)
          CODE                      resistant prescription pad
                                    2=Telephone
                                    3=Electronic
                                    4=Facsimile
                                    5=Transfers
354-NX    SUBMISSION                Maximum count of three             R                               9(1)
          CLARIFICATION CODE
          COUNT
42Ø-DK    SUBMISSION                ØØ =Not specified               R***R***   MassHealth               9(2)
          CLARIFICATION CODE        Ø1=No override                             evaluates the use of
                                    Ø2=Other Override                          this field on a case by
                                    Ø3=Vacation Supply-The                     case basis and will
                                    pharmacist is indicating that              deny with NCPDP
                                    the cardholder has                         reject code 8R if
                                    requested a vacation                       submitted value is not
                                    supply of the medicine.                    permitted. Value of
                                    Ø4=Lost Prescription-The                   Ø8 allows for
                                    pharmacist is indicating that              processing the
                                    the cardholder has                         compound claim with
                                    requested a replacement of                 all (covered and
                                    medication that has been                   noncovered)
                                    lost.                                      ingredients.
                                    Ø5=Therapy Change-The                      To select submission
                                    pharmacist is indicating that              clarification code of
                                    the physician has                          08, the compound
                                    determined that a change                   code value must be
                                    in therapy was required;                   2. If the submitter
                                    either that the medication                 chooses not to
                                    was used faster than                       transmit this field, the
                                    expected, or a different                   submitter is
                                    dosage form is needed, etc.                representing to
                                    Ø6=Starter Dose-The                        MassHealth an
                                    pharmacist is indicating that              implied not specified
                                    the previous medication                    situation.
                                    was a starter dose and now                 99=Other:
                                    additional medication is                   drug/product is
                                    needed to continue                         exempt from
                                    treatment.                                 Medicare D wrap
                                    Ø7=Medically Necessary-                    threshold.
                                    The pharmacist is indicating
                                                     -9-
                 Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                            Version 12.0

           Claim Segment                                                     Claim Billing/Claim
           Segment Identification                                            Rebill
           (111-AM) = Ø7
Field #    NCPDP Field Name         Value                            Payer   Payer Situation       Field Format
                                                                     Usage
                                    that this medication has
                                    been determined by the
                                    physician to be medically
                                    necessary.
                                    Ø8=Process Compound for
                                    Approved Ingredients
                                    Ø9=Encounters
                                    1Ø =Meets Plan Limitations
                                    -The pharmacy certifies that
                                    the transaction is in
                                    compliance with the
                                    program’s policies and
                                    rules that are specific to the
                                    particular product being
                                    billed.
                                    11=Certification on File -
                                    The supplier’s guarantee
                                    that a copy of the paper
                                    certification, signed and
                                    dated by the physician, is
                                    on file at the supplier’s
                                    office.
                                    12=DME Replacement
                                    Indicator – Indicator that
                                    this certification is for a
                                    DME item replacing a
                                    previously purchased DME
                                    item.
                                    13=Payer-Recognized
                                    Emergency/Disaster
                                    Assistance Request - The
                                    pharmacist is indicating that
                                    an override is needed
                                    based on an
                                    emergency/disaster
                                    situation recognized by the
                                    payer.
                                    14=Long-Term-Care (LTC)
                                    Leave of Absence - The
                                    pharmacist is indicating that
                                    the cardholder requires a
                                    short-fill of a prescription
                                    due to a leave of absence
                                    from the LTC facility.
                                    15=LTC Replacement
                                    Medication - Medication
                                    has been contaminated
                                    during administration in a
                                    LTC setting.
                                    16=LTC Emergency Box
                                    (kit) or Automated
                                    Dispensing Machine -
                                    Indicates that the
                                    transaction is a
                                    replacement supply for
                                    doses previously dispensed
                                    to the patient after hours.
                                    17=LTC Emergency Supply

                                                     -10-
                 Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                           Version 12.0

           Claim Segment                                                    Claim Billing/Claim
           Segment Identification                                           Rebill
           (111-AM) = Ø7
Field #    NCPDP Field Name         Value                           Payer   Payer Situation       Field Format
                                                                    Usage
                                    Remainder - Indicates that
                                    the transaction is for the
                                    remainder of the drug
                                    originally begun from an
                                    emergency kit.
                                    18=LTC Patient
                                    Admit/Readmit Indicator -
                                    Indicates that the
                                    transaction is for a new
                                    dispensing of medication
                                    due to the patient’s
                                    admission or readmission
                                    status.
                                    19=remainder billed to a
                                    subsequent payer when
                                    Medicare Part A expires.
                                    Used only in LTC settings.
                                    2Ø=34ØB - Indicates that,
                                    prior to providing service,
                                    the pharmacy has
                                    determined the product
                                    being billed is purchased,
                                    pursuant to rights available
                                    under Section 34ØB of the
                                    Public Health Act of 1992,
                                    including sub-ceiling
                                    purchases authorized by
                                    Section 34ØB (a)(1Ø) and
                                    those made through the
                                    Prime Vendor Program
                                    (Section 34ØB(a)(8)).
                                    21=LTC Dispensing: Seven
                                    days or less not applicable -
                                    Seven day or less
                                    dispensing is not applicable
                                    due to CMS exclusion
                                    and/or manufacturer
                                    packaging may not be
                                    broken or special
                                    dispensing methodology
                                    (i.e., vacation supply, leave
                                    of absence, ebox, spitter
                                    dose). Medication
                                    quantities are dispensed as
                                    billed.
                                    22=LTC Dispensing: Seven
                                    days - Pharmacy dispenses
                                    medication in seven-day
                                    supplies.
                                    23=LTC Dispensing: Four
                                    days - Pharmacy dispenses
                                    medication in four-day
                                    supplies.
                                    24=LTC Dispensing: Three
                                    days - Pharmacy dispenses
                                    medication in three-day
                                    supplies
                                    25=LTC Dispensing: Two

                                                    -11-
                 Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                          Version 12.0

           Claim Segment                                                   Claim Billing/Claim
           Segment Identification                                          Rebill
           (111-AM) = Ø7
Field #    NCPDP Field Name         Value                          Payer   Payer Situation       Field Format
                                                                   Usage
                                    days - Pharmacy dispenses
                                    medication in two-day
                                    supplies.
                                    26=LTC Dispensing: One
                                    day - Pharmacy or remote
                                    (multiple shifts) dispenses
                                    medication in one-day
                                    supplies.
                                    27=LTC Dispensing: 4-3
                                    days - Pharmacy dispenses
                                    medication in four-day, then
                                    three-day supplies.
                                    28=LTC Dispensing: 2-2-3
                                    days - Pharmacy dispenses
                                    medication in two-day, then
                                    two-day, then three-day
                                    supplies.
                                    29=LTC Dispensing: Daily
                                    and three-day weekend -
                                    Pharmacy or remote
                                    dispensed daily during the
                                    week and combines
                                    multiple days dispensing for
                                    weekends.
                                    3Ø =LTC Dispensing: Per
                                    shift dispensing - Remote
                                    dispensing per shift
                                    (multiple med passes).
                                    31=LTC Dispensing: Per
                                    med pass dispensing -
                                    Remote dispensing per
                                    med pass.
                                    32=LTC Dispensing: PRN
                                    on-demand - Remote
                                    dispensing on demand as
                                    needed.
                                    33=LTC Dispensing:
                                    Seven-day or less
                                    dispensing method not
                                    listed above - Cycle not
                                    represented in codes 22-
                                    31.
                                    99=Other




                                                    -12-
                 Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                              Version 12.0

           Claim Segment                                                      Claim Billing/Claim
           Segment Identification                                             Rebill
           (111-AM) = Ø7
Field #    NCPDP Field Name          Value                            Payer   Payer Situation        Field Format
                                                                      Usage
3Ø8-C8    OTHER COVERAGE CODE        ØØ=Not specified                   R     If the submitter        9(2)
                                     Ø1=No other coverage has                 chooses not to
                                     been identified.                         transmit this field,
                                     Ø2=Other coverage exists.                they are representing
                                     Payment was collected.                   to MassHealth that
                                     Ø3=Other coverage exists.                there is no other
                                     This claim is not covered.               insurance. Therefore,
                                     Ø8=Claim is a billing for a              a not specified
                                     copayment.                               situation is implied.
                                                                              MassHealth will reject
                                                                              the transaction if a
                                                                              COB segment is
                                                                              present. Values other
                                                                              than ØØ require a
                                                                              valid COB segment.
                                                                              A value of Ø8 must
                                                                              be used only when
                                                                              the other insurer has
                                                                              applied 100% of the
                                                                              billed amount to the
                                                                              patient responsibility.
429-DT    SPECIAL PACKAGING          Ø=Not specified                    I                             9(1)
          INDICATOR (Formerly Unit   1=Not unit dose
          Dose Indicator)            2=Manufacturer unit dose
                                     3=Pharmacy unit dose
                                     4=Custom packaging
                                     5=Multi-drug compliance
                                     packaging
                                     6=Remote Device Unit
                                     Dose - Drug is dispensed at
                                     the facility, via a remote
                                     device, in a unit of use
                                     package.
                                     7=Remote Device Multi-
                                     drug Compliance - Drug is
                                     dispensed at the facility, via
                                     a remote device, with
                                     packaging that may contain
                                     drugs from multiple
                                     manufacturers combined to
                                     ensure compliance and
                                     safe administration.
                                     8=Manufacturer Unit of Use
                                     Package (not unit dose) -
                                     Drug is dispensed by
                                     pharmacy in original
                                     manufacturer’s package
                                     and relabeled for use.
                                     Applicable in long term care
                                     claims.
453-EJ    ORIGINALLY PRESCRIBED      Ø1=Universal Product              N
          PRODUCT/SERVICE ID         Code (UPC)
          QUALIFIER                  Ø2=Health-related item
                                     (HRI)
                                     Ø3=National Drug Code
                                     (NDC)
445-EA    ORIGINALLY PRESCRIBED                                        N
          PRODUCT/SERVICE CODE
                                                      -13-
                 Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                      Version 12.0

           Claim Segment                                            Claim Billing/Claim
           Segment Identification                                   Rebill
           (111-AM) = Ø7
Field #    NCPDP Field Name         Value                   Payer   Payer Situation          Field Format
                                                            Usage
446-EB    ORIGINALLY PRESCRIBED                               Q                              s9(7)v999
          QUANTITY
330-CW    ALTERNATE ID                                       N
454-EK    SCHEDULED                                          N
          PRESCRIPTION ID
          NUMBER
6ØØ-28    UNIT OF MEASURE           EA=Each                   I     Not required for      X(2)
                                    GM=Grams                        compound claim- Use
                                    ML=Milliliters                  field 451-EG instead.
418-DI    LEVEL OF SERVICE          Ø3=Emergency             Q                            9(2)
461-EU    PRIOR AUTHORIZATION       Ø=Not specified          Q                            9(1)
          TYPE CODE                 1=Prior authorization
462-EV    PRIOR AUTHORIZATION                                Q      1) Required entry for 9(11)
          NUMBER SUBMITTED                                          claims submitted on
                                                                    behalf of 34ØB clinics
                                                                    for indirect billing.
                                                                    Authorization number
                                                                    is provided during
                                                                    registration; and
                                                                    2) Required on B3
                                                                    transactions for return
                                                                    to stock program.
463-EW    INTERMEDIARY                                       N
          AUTHORIZATION TYPE ID
464-EX    INTERMEDIARY                                       N
          AUTHORIZATION ID
343-HD    DISPENSING STATUS         Blank=Not specified      Q      This field is used and X(1)
                                    P =Partial                      required only for
                                    C=Completion                    partial-fill/complete
                                                                    actions. A value of P
                                                                    is required along with
                                                                    the quantity and days’
                                                                    supply intended to be
                                                                    dispensed on the
                                                                    initial fill. A value of C
                                                                    will be required on the
                                                                    completion fill along
                                                                    with the associated
                                                                    pharmacy/service
                                                                    reference number
                                                                    and associated
                                                                    pharmacy/service
                                                                    date.
                                                                    If transaction is a B3-
                                                                    rebill, you cannot
                                                                    submit a dispensing
                                                                    status of P (partial) or
                                                                    C (completion).
                                                                    Values of P and C
                                                                    are valid only for B1.
344-HF    QUANTITY INTENDED TO                               Q      Required for the           s9(7)v999
          BE DISPENSED                                              partial fill or the
                                                                    completion fill of a
                                                                    prescription.
345-HG    DAYS SUPPLY INTENDED                                      Required for the           9(3)
          TO BE DISPENSED                                    Q      partial fill or the
                                                                    completion fill of a

                                                    -14-
                 Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                              Version 12.0

           Claim Segment                                                   Claim Billing/Claim
           Segment Identification                                          Rebill
           (111-AM) = Ø7
Field #    NCPDP Field Name         Value                          Payer   Payer Situation           Field Format
                                                                   Usage
                                                                           prescription.
357-NV    DELAY REASON CODE         1=Proof of eligibility          Q      Required when             9(2)
                                    unknown or unavailable.                needed to specify the
                                    2=Litigation                           reason that
                                    3=Authorization delay                  submission of the
                                    4=Delay in certifying                  transaction has been
                                    provider                               delayed.
                                    5=Delay in supplying billing
                                    forms
                                    7=Third-party processing
                                    delay
                                    8=Delay in eligibility
                                    determination
                                    9=Original claims rejected
                                    1Ø=Administrative delay in
                                    the prior approval process.
                                    11=Other
                                    12=Received late with no
                                    exceptions.
391-MT    PATIENT ASSIGNMENT                                        N
          INDICATOR (DIRECT
          MEMBER
          REIMBURSEMENT
          INDICATOR)
995-E2    ROUTE OF              54471ØØ7= Buccal                    Q       For a multi-ingredient   X(11)
          ADMINISTRATION        372449ØØ4=Dental                            compound, it is the
                                112239ØØ3=Inhalation                        route of the complete
                                385218ØØ9=Injection                         compound mixture.
                                38239ØØ2=Intraperitoneal                    NCPDP has adopted
                                47Ø56ØØ1=Irrigation                         industry standard
                                26643ØØ8=Mouth/throat                       SNOWMED CT
                                419874ØØ9=Mucous                            values.
                                Membrane
                                46713ØØ6=Nasal
                                54485ØØ2=Ophthalmic
                                26643ØØ6=Oral
                                NA=Other/Miscellaneous
                                1Ø547ØØ7=Otic
                                C444364=Perfusion
                                37161ØØ4=Rectal
                                37839ØØ7=Sublingual
                                419464ØØ1=Topical
                                372464ØØ4=Transdermal
                                37839ØØ7=Translingual
                                16857ØØ9=Vaginal
                                417985ØØ1=Enteral
                                9ØØ28ØØ8=Urethral
996-G1    COMPOUND TYPE         Ø1=Anti-infective                   Q      Required when             X(2)
                                Ø2=Ionotropic                              compound code
                                Ø3=Chemotherapy                            (CC)=2
                                Ø4=Pain management
                                Ø5=TPN/PPN
                                Ø6=Hydration
                                Ø7=Ophthalmic
                                99=Other
147-U7    PHARMACY SERVICE TYPE 1=Community/retail                  Q      Required for members      9(2)
                                pharmacy services                          with commercial

                                                    -15-
                    Commonwealth of Massachusetts
              Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                          Version 12.0

              Claim Segment                                                          Claim Billing/Claim
              Segment Identification                                                 Rebill
              (111-AM) = Ø7
Field #       NCPDP Field Name            Value                         Payer        Payer Situation             Field Format
                                                                        Usage
                                          2=Compounding pharmacy                   insurance that use
                                          services                                 mail order pharmacies.
                                          3=Home infusion therapy
                                          provider services
                                          4=Institutional pharmacy
                                          services.
                                          5=LTC pharmacy services
                                          6=Mail order pharmacy
                                          services
                                          7=Managed care
                                          organization pharmacy
                                          services
                                          8=Specialty care pharmacy
                                          services
                                          99=Other

Pricing Segment Questions                   Check           Claim Billing/Claim Rebill
                                                            If Situational, Payer Situation
This segment is always sent.                        X

           Pricing Segment
                                                                                   Claim Billing/Claim
           Segment Identification (111-
                                                                                   Rebill
           AM) = 11
                                                                       Payer
Field #    NCPDP Field Name                 Value                                  Payer Situation                Field Format
                                                                       Usage
111-AM     SEGMENT IDENTIFICATION                                        M                                        X(2)
4Ø9-D9     INGREDIENT COST SUBMITTED                                     R                                        s9(6)v99
412-DC     DISPENSING FEE SUBMITTED                                      R                                        s9(6)v99
           PROFESSIONAL SERVICE FEE
 477-BE                                                                   N
           SUBMITTED
           PATIENT PAID AMOUNT                                                     MassHealth copay
           SUBMITTED                                                               amount the pharmacy
 433-DX                                                                   R        received from the              s9(6)v99
                                                                                   patient for the
                                                                                   prescription dispensed.
           INCENTIVE AMOUNT                                                        Required if its value has
           SUBMITTED                                                               an effect on the gross
 438-E3                                                                  Q                                        s9(6)v99
                                                                                   amount due (43Ø-DU)
                                                                                   calculation.
           OTHER AMOUNT CLAIMED                                                    Used for return to stock
 478-H7                                     Maximum count of three       Q                                        9(1)
           SUBMITTED COUNT                                                         and 340B programs.
           OTHER AMOUNT CLAIMED             Blank=Not specified                    A value of Ø4 should be
           SUBMITTED QUALIFIER              Ø4=Administrative cost                 used only if you are
 479-H8                                                               Q***R***     participating in               X(2)
                                                                                   MassHealth return to
                                                                                   stock program.
           OTHER AMOUNT CLAIMED                                                    If you are participating in
           SUBMITTED                                                               MassHealth return to
48Ø-H9                                                                Q***R***     stock program, enter the       s9(6)v99
                                                                                   administrative fee in
                                                                                   this field.
        FLAT SALES TAX AMOUNT
 481-HA                                                                   N
        SUBMITTED
        PERCENTAGE SALES TAX
 482-GE                                                                   N
        AMOUNT SUBMITTED
 483-HE PERCENTAGE SALES TAX RATE                                         N

                                                        -16-
                    Commonwealth of Massachusetts
              Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                    Version 12.0

           Pricing Segment
                                                                                  Claim Billing/Claim
           Segment Identification (111-
                                                                                  Rebill
           AM) = 11
                                                                      Payer
Field #    NCPDP Field Name               Value                                   Payer Situation            Field Format
                                                                      Usage
       SUBMITTED
       PERCENTAGE SALES TAX                                              N
484-JE
       BASIS SUBMITTED
426-DQ USUAL AND CUSTOMARY                                               R
                                                                                                             s9(6)v99
       CHARGE
43Ø-DU GROSS AMOUNT DUE                                                  R        When billing for both
                                                                                  vaccine serum obtained
                                                                                  at a cost to the
                                                                                  pharmacy and vaccine       s9(6)v99
                                                                                  administration, use this
                                                                                  field for the vaccine
                                                                                  administration fee.
 423-DN BASIS OF COST                     ØØ=Default
        DETERMINATION                     Ø1= Average wholesale
                                          price (AWP)*
                                          Ø2=Local wholesaler
                                          Ø3=Direct
                                          Ø4=Estimated
                                          acquisition cost (EAC)
                                          Ø5=Acquisition
                                          Ø6=Maximum allowable
                                          cost (MAC)
                                          Ø7= Usual and
                                          customary – The
                                          pharmacy’s price for the
                                          medication for a cash
                                                                                  *MassHealth will follow
                                          paying person on the
                                                                                  industry direction and
                                          day of dispensing.
                                                                        Q         retire AWP the pricing     X(2)
                                          Ø8=34ØB/
                                                                                  basis effective
                                          disproportionate share
                                                                                  September 26, 2011.
                                          pricing/public health
                                          Ø9=Other
                                          1Ø=Average sales price
                                          (ASP)
                                          11=Average
                                          manufacturer price
                                          (AMP)
                                          12=Wholesale
                                          acquisition cost (WAC)
                                          13=Special patient
                                          pricing – The cost
                                          calculated by the
                                          pharmacy for the drug
                                          for this special patient.

Pharmacy Provider Segment Questions       Check            Claim Billing/Claim Rebill
                                                           If Situational, Payer Situation
This segment is always sent.
This segment is situational.                      X        The segment is submitted to indicate situations where an
                                                           authorized pharmacist has entered into written agreements with
                                                           supervising physicians to engage in Collaborative Drug
                                                           Therapy Management (CDTM) in the Commonwealth of
                                                           Massachusetts. Refer to 247 CMR 16.00.




                                                       -17-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                              Version 12.0


           Pharmacy Provider Segment                                             Claim Billing/Claim
           Segment Identification (111-                                          Refill
           AM) = Ø2
 Field #   NCPDP Field Name               Value                      Payer       Payer Situation       Field Format
                                                                     Usage
 111-AM    SEGMENT IDENTIFICATION                                      M                               X(2)
 465-EY    PROVIDER ID QUALIFIER          Ø5=National provider         R                               X(2)
                                          identifier (NPI)
 444-E9    PROVIDER ID                                                 R                               X(15)

 Prescriber Segment Questions             Check           Claim Billing/Claim Rebill
                                                          If Situational, Payer Situation
 This segment is always sent.                     X
 This segment is situational.

           Prescriber Segment                                                    Claim Billing/Claim
           Segment Identification (111-                                          Rebill
           AM) = Ø3
 Field #   NCPDP Field Name               Value                      Payer       Payer Situation       Field Format
                                                                     Usage
 111-AM    SEGMENT IDENTIFICATION                                      M                               X(2)
 466-EZ    PRESCRIBER ID QUALIFIER        Ø1= National provider        R                               X(2)
                                          identifier (NPI)
 411-DB    PRESCRIBER ID                                                R                              X(15)
 427-DR    PRESCRIBER LAST NAME                                         R                              X(15)
 498-PM    PRESCRIBER PHONE NUMBER                                      I                              9(1Ø)
 468-2E    PRIMARY CARE PROVIDER ID       Blank=Not specified           I                              X(2)
           QUALIFIER                      Ø1=National provider
                                          identifier (NPI)
                                          Ø2=Blue Cross
                                          Ø3=Blue Shield
                                          Ø4=Medicare
                                          Ø5=Medicaid
                                          Ø6=UPIN
                                          Ø7=NCPDP provider ID
                                          Ø8=State license
                                          Ø9=TriCare
                                          1Ø=Health industry
                                          number (HIN)
                                          11=Federal tax ID
                                          12=Drug Enforcement
                                          Administration (DEA)
                                          13=State issued
                                          14=Plan specific
                                          99=Other
 421-DL    PRIMARY CARE PROVIDER ID                                     I                              X(15)
 47Ø-4E    PRIMARY CARE PROVIDER                                        I                              X(15)
           LAST NAME
 364-2J    PRESCRIBER FIRST NAME                                        I
 365-2K    PRESCRIBER STREET                                            N
           ADDRESS
 366-2M    PRESCRIBER CITY ADDRESS                                      N
 367-2N    PRESCRIBER                                                   N
           STATE/PROVINCE ADDRESS
 368-2P    PRESCRIBER ZIP/POSTAL                                        N
           ZONE




                                                       -18-
                       Commonwealth of Massachusetts
                Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                                     Version 12.0

 Coordination of Benefits/Other Payments            Check              Claim Billing/Claim Rebill
 Segment Questions                                                     If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                              X           Required only for secondary, tertiary, etc., claims.

 Scenario 1 - Other payer amount paid,
 repetitions only.
 Scenario 2 - Other payer-patient
 responsibility amount repetitions, and benefit
 stage repetitions only.
 Scenario 3 - Other payer amount paid, other               X
 payer-patient responsibility amount, and
 benefit stage repetitions present
 (government programs).

All pharmacy claims submitted to POPS are adjudicated for other insurance coverage, also known as
third-party liability (TPL). The billing pharmacy must indicate that the member’s other insurance was
billed prior to submitting the claim to MassHealth. Therefore, all billing pharmacies must have online
split-billing capability. After billing the primary payer, enter the appropriate information for the
required split-billing fields on the claim submission (see below).
               Coordination of                                                               Claim Billing/Claim Rebill
               Benefits/Other Payments                                                       Scenario 3 - Other Payer
               Segment                                                                       Amount Paid, Other Payer-
               Segment Identification                                                        Patient Responsibility
               (111-AM) = Ø5                                                                 Amount, and Benefit Stage
                                                                                             Repetitions Present
                                                                                             (Government Programs)
 Field #       NCPDP Field Name                   Value                         Payer        Payer Situation                   Field Format
                                                                                Usage
 111-AM       SEGMENT                                                             M                                            X(2)
              IDENTIFICATION
 337-4C       COORDINATION OF                     Maximum count of nine            M                                           9(1)
              BENEFITS/OTHER
              PAYMENTS COUNT
 338-5C       OTHER PAYER                         Blank=Not specified          M***R***                                        X(2)
              COVERAGE TYPE                       Ø1=Primary
                                                  Ø2=Secondary
                                                  Ø3=Tertiary
                                                  Ø4=Quaternary– fourth
                                                  Ø5=Quinary – fifth
                                                  Ø6=Senary – sixth
                                                  Ø7=Septenary- seventh
                                                  Ø8=Octonary – eighth
                                                  Ø9=Nonary – ninth
 339-6C       OTHER PAYER ID                      3=BIN                        R***R***                                        X(2)
              QUALIFIER                           99=Other
 34Ø-7C       OTHER PAYER ID                                                       R                                           X(1Ø)

 443-E8       OTHER PAYER DATE                    CCYYMMDD                         I                                           9(8)

 341-HB       OTHER PAYER AMOUNT                  Maximum count of nine.           Q                                           9(1)
              PAID COUNT
 342-HC       OTHER PAYER AMOUNT                  Blank=not specified          Q***R***      MassHealth requires that          X(2)
              PAID QUALIFIER                      Ø1=Delivery Cost - An                      one of these occurrences
                                                  indicator which signifies                  must contain the payment
                                                  the amount claimed for                     dollars associated with the
                                                  the costs related to the                   drug benefit (Ø7=Drug
                                                  delivery of a product or                   Benefit)
                                                  service.
                                                                   -19-
                Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                              Version 12.0

           Coordination of                                                Claim Billing/Claim Rebill
           Benefits/Other Payments                                        Scenario 3 - Other Payer
           Segment                                                        Amount Paid, Other Payer-
           Segment Identification                                         Patient Responsibility
           (111-AM) = Ø5                                                  Amount, and Benefit Stage
                                                                          Repetitions Present
                                                                          (Government Programs)
 Field #   NCPDP Field Name          Value                        Payer   Payer Situation               Field Format
                                                                  Usage
                                     Ø2=Shipping Cost - The
                                     amount claimed for
                                     transportation of an item.
                                     Ø3=Postage Cost - The
                                     amount claimed for the
                                     mailing of an item.
                                     Ø4=Administrative Cost
                                     - An indicator conveying
                                     the following amount is
                                     related to the cost of
                                     activities such as
                                     utilization review,
                                     premium collection,
                                     claims processing,
                                     quality assurance, and
                                     risk management for
                                     purposes of insurance.
                                     Ø5=Incentive - An
                                     indicator that signifies
                                     the dollar amount paid
                                     by the other payer,
                                     which is related to
                                     additional fees or
                                     compensations paid as
                                     an inducement for an
                                     action taken by the
                                     provider (e.g., collection
                                     of survey data,
                                     counseling plan
                                     enrollees, vaccine
                                     administration).
                                     Ø6=Cognitive Service -
                                     An indicator that
                                     signifies the dollar
                                     amount paid by the
                                     other payer, which is
                                     related to the
                                     pharmacist's
                                     interaction with a
                                     patient or caregiver
                                     that is beyond the
                                     traditional
                                     dispensing/patient
                                     instruction activity
                                     (e.g., therapeutic
                                     regiment review;
                                     recommendation for
                                     additional, fewer or
                                     different therapeutic
                                     choices).
                                     Ø7=Drug Benefit - An
                                     indicator that signifies
                                     the dollar amount paid
                                     by the other payer,
                                                     -20-
                Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                Version 12.0

           Coordination of                                                  Claim Billing/Claim Rebill
           Benefits/Other Payments                                          Scenario 3 - Other Payer
           Segment                                                          Amount Paid, Other Payer-
           Segment Identification                                           Patient Responsibility
           (111-AM) = Ø5                                                    Amount, and Benefit Stage
                                                                            Repetitions Present
                                                                            (Government Programs)
 Field #   NCPDP Field Name          Value                       Payer      Payer Situation               Field Format
                                                                 Usage
                                     which is related to the
                                     plan's drug benefit.
                                     Ø9=Compound
                                     Preparation Cost
                                     Submitted - The
                                     amount claimed for the
                                     preparation of the
                                     compound.
                                     1Ø =Sales Tax - An
                                     Indicator that signifies
                                     the dollar amount paid
                                     by the other payer,
                                     which is related to sales
                                     tax.
 431-DV    OTHER PAYER AMOUNT        s$$$$$$cc                   Q***R***   Step 1/occurance one:        s9(6)v99
           PAID                                                             When payment from other
                                                                            insurance is returned, use
                                                                            value of Ø7-drug benefit in
                                                                            Field 342 and put the $$
                                                                            amount returned (in Field
                                                                            509) into this field (431).
 471-5E    OTHER PAYER REJECT        Maximum count of five          Q       Only populated when claim 9(2)
           COUNT                                                            denies from other insurance
                                                                            (Medicare or private).
 472-6E    OTHER PAYER REJECT                                    Q***R***   MassHealth requires the      X(3)
           CODE                                                             NCPDP reject code from
                                                                            the other payer when the
                                                                            other payer denies the claim
                                                                            (OCC3). MassHealth
                                                                            periodically notifies
                                                                            submitters of supported
                                                                            values.
 353-NR    OTHER PAYER-PATIENT       Maximum count of 25            R                                    9(2)
           RESPONSIBILITY AMOUNT
           COUNT
 351-NP    OTHER PAYER-PATIENT       Ø1=Deductible               R***R***   Submit a separate             X(2)
           RESPONSIBILITY AMOUNT     Ø5=Copay                               occurrence with the
           QUALIFIER                 Ø7=Coinsurance                         applicable qualifier (351)
                                                                            and corresponding $$
                                                                            amount (352) when other
                                                                            payer has communicated
                                                                            the patient financial
                                                                            responsibility.
 352-NQ    OTHER PAYER-PATIENT                                   R***R***                                 s9(8)v99
           RESPONSIBILITY AMOUNT
 392-MU    BENEFIT STAGE COUNT       Maximum count of four.         Q                                     9(1)
 393-MV    BENEFIT STAGE             Blank not specified         Q***R***                                 X(2)
           QUALIFIER                 Ø1=Deductible
                                     Ø2=Initial benefit
                                     Ø3= Coverage gap
                                     (donut hole)
                                     Ø4=Catastrophic
                                     coverage

                                                     -21-
                 Commonwealth of Massachusetts
            Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                             Version 12.0

            Coordination of                                              Claim Billing/Claim Rebill
            Benefits/Other Payments                                      Scenario 3 - Other Payer
            Segment                                                      Amount Paid, Other Payer-
            Segment Identification                                       Patient Responsibility
            (111-AM) = Ø5                                                Amount, and Benefit Stage
                                                                         Repetitions Present
                                                                         (Government Programs)
 Field #    NCPDP Field Name          Value                 Payer        Payer Situation               Field Format
                                                            Usage
 394-MW    BENEFIT STAGE AMOUNT                            Q***R***                                    s9(8)v99

 Workers’ Compensation Segment        Check          Claim Billing/Claim Rebill
 Questions                                           If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                        Segment not supported.

           Workers’ Compensation                                         Claim Billing/Claim Rebill
           Segment
           Segment Identification
           (111-AM) = Ø6
Field #    NCPDP Field Name           Value                 Payer        Payer Situation               Field Format
                                                            Usage
111-AM     SEGMENT                                            M                                       X(2)
           IDENTIFICATION
434-DY     DATE OF INJURY                                      M
315-CF     EMPLOYER NAME
316-CG     EMPLOYER STREET
           ADDRESS
317-CH     EMPLOYER CITY
           ADDRESS
318-CI     EMPLOYER
           STATE/PROVINCE
           ADDRESS
319-CJ     EMPLOYER ZIP/POSTAL
           ZONE
32Ø-CK     EMPLOYER PHONE
           NUMBER
321-CL     EMPLOYER CONTACT
           NAME
327-CR     CARRIER ID
435-DZ     CLAIM/REFERENCE ID
117-TR     BILLING ENTITY TYPE                                 R
           INDICATOR
118-TS     PAY TO QUALIFIER
119-TT     PAY TO ID
12Ø-TU     PAY TO NAME
121-TV     PAY TO STREET ADDRESS
122-TW     PAY TO CITY ADDRESS
123-TX     PAY TO STATE/PROVINCE
           ADDRESS
124-TY     PAY TO ZIP/POSTAL ZONE
125-TZ     GENERIC EQUIVALENT
           PRODUCT ID QUALIFIER
126-UA     GENERIC EQUIVALENT
           PRODUCT ID




                                              -22-
                     Commonwealth of Massachusetts
              Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                      Version 12.0

 DUR/PPS Segment Questions            Check             Claim Billing/Claim Rebill
                                                        If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                 X

             DUR/PPS Segment                                                      Claim Billing/Claim Rebill
             Segment Identification
             (111-AM) = Ø8
 Field #     NCPDP Field Name         Value                        Payer          Payer Situation              Field Format
                                                                   Usage
 111-AM      SEGMENT IDENTIFICATION                                  M                                          X(2)
 473-7E      DUR/PPS CODE COUNTER     Maximum of nine                R                                          9(1)
                                      occurrences
 439-E4      REASON FOR SERVICE       DD=Drug-drug                R***R***
             CODE (ALSO KNOWN AS      interaction
             THE DUR CONFLICT CODE)   HD=High dose
                                      ID=Ingredient
                                      duplication
                                      TD=Therapeutic
                                      duplication
                                      ER=Early refill
 44Ø-E5      PROFESSIONAL SERVICE     MA= Medication              R***R***    .                                 X(2)
             CODE                     administration
                                      MØ=Prescriber
                                      consulted
                                      RØ=Pharmacist
                                      consulted other source
 441-E6      RESULT OF SERVICE        1A=Filled as is, false      R***R***                                      X(2)
             CODE                     positive
             (ALSO KNOWN AS THE       1B=Filled prescription as
             DUR OUTCOME CODE)        is
                                      1C=Filled, with different
                                      dose
                                      1D=Filled, with different
                                      directions
                                      1E=Filled, with different
                                      drug
                                      1F=Filled, with different
                                      quantity
                                      1G=Filled, with
                                      prescriber approval
 474-8E      DUR/PPS LEVEL OF         ØØ =Not specified           I***R***                                      9(2)
             EFFORT                   11=Level 1 – Less than
                                      five min.
                                      12=Level 2 – Less than
                                      15 min.
                                      13=Level 3 – Less than
                                      3Ø min.
                                      14=Level 4 – Less than
                                      one hour
                                      15=Level 5 – Greater
                                      than one hour
 475-J9      DUR CO-AGENT ID          Ø1=Universal Product        I***R***                                      X(2)
             QUALIFIER                Code (UPC)
                                      Ø2=Health-related item
                                      (HRI)
                                      Ø3=National Drug Code
                                      (NDC)
                                      Ø4=Universal product
                                      number (UPN)
                                      Ø5=Department of
                                      Defense (DOD)

                                                      -23-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                    Version 12.0

             DUR/PPS Segment                                                    Claim Billing/Claim Rebill
             Segment Identification
             (111-AM) = Ø8
 Field #     NCPDP Field Name         Value                        Payer        Payer Situation              Field Format
                                                                   Usage
                                      Ø7=Common procedure
                                      terminology (CPT4)
                                      Ø8=Common procedure
                                      terminology (CPT5)
                                      Ø9=Health Care
                                      Financing Administration
                                      Common
                                      Procedural Coding
                                      System (HCPCS)
                                      11=National
                                      Pharmaceutical Product
                                      Interface code
                                      (NAPPI)
                                      12=International article
                                      numbering system
                                      (EAN)
                                      13=Drug Identification
                                      number (DIN)
                                      14=Medi-Span GPI
                                      15=First DataBank GCN
                                      16=Medical Economics
                                      GPO
                                      17=Medi-Span DDID
                                      18=First DataBank
                                      SmartKey
                                      19=Medical Economics
                                      GM
                                      2Ø =International
                                      classification of diseases
                                      (ICD9)
                                      21=International
                                      classification of diseases
                                      (ICD1Ø)
                                      22=Medi-Span
                                      diagnosis code
                                      23=National Criteria
                                      Care Institute (NCCI)
                                      24=The Systematized
                                      Nomenclature of Human
                                      and Veterinary Medicine
                                      (SNOMED)
                                      25=Common dental
                                      terminology (CDT)
                                      26=American
                                      Psychiatric Association
                                      Diagnostic
                                      Statistical Manual of
                                      Mental Disorders (DSM
                                      IV)
                                      99=Other
 476-H6     DUR CO-AGENT ID                                        I***R***                                  X(19)

 Coupon Segment Questions             Check             Claim Billing/Claim Rebill
                                                        If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                           Segment not supported.


                                                      -24-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                     Version 12.0


              Coupon Segment                                                            Claim Billing/Claim
              Segment Identification                                                    Rebill
              (111-AM) = Ø9
    Field #   NCPDP Field Name               Value                     Payer Usage      Payer Situation         Field Format
    111-AM    SEGMENT                                                       M                                   X(2)
              IDENTIFICATION
    485-KE    COUPON TYPE                                                    M                                  X(2)
    486-ME    COUPON NUMBER                                                  M                                  X(15)
    487-NE    COUPON VALUE                                                   Q                                  s9(6)v99
              AMOUNT

 Compound Segment Questions                      Check          Claim Billing/Claim Rebill
                                                                If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                          X        Segment is required when provided medication involves the
                                                                compounding of two or more drugs. Refer to information below
                                                                for specifics.

Compound Claims
Pharmacy compound claims must be submitted through POPS for payment. All compounds must be
submitted online and must contain more than one ingredient. Each ingredient of the compound must
be submitted.
     Each compound claim is limited to a maximum of 15 ingredient lines. Providers can submit only a
      single compound transaction within a single transmission.
     Noncovered ingredients will cause a claim to deny. Each ingredient is subjected to the edits and
      audits within claim adjudication. If a claim is denied because of a noncovered ingredient, the
      provider may agree to accept payment for the approved ingredients making up the compound. To
      do this, place an 8 in the Submission Clarification Code (Field 420-DK). This allows the system to
      process the compound for the approved ingredients and indicates that, although all the ingredients
      are not covered, you will accept payment for the approved ingredients only. Compound reversals
      are processed like other D.Ø transactions.
     Compounds may not be submitted as partial fills.
              Compound Segment                                                        Claim Billing/Claim
              Segment Identification (111-                                            Rebill
              AM) = 1Ø
Field #       NCPDP Field Name                 Value                      Payer       Payer Situation          Field Format
                                                                          Usage
111-AM        SEGMENT IDENTIFICATION                                        M                                  X(2)
45Ø-EF        COMPOUND DOSAGE                  Blank=Not specified          M                                  X(2)
              FORM DESCRIPTION CODE            Ø1=Capsule
                                               Ø2=Ointment
                                               Ø3=Cream
                                               Ø4=Suppository
                                               Ø5=Powder
                                               Ø6=Emulsion
                                               Ø7=Liquid
                                               1Ø=Tablet
                                               11=Solution
                                               12=Suspension
                                               13=Lotion
                                               14=Shampoo
                                               15=Elixir
                                               16=Syrup
                                                            -25-
                     Commonwealth of Massachusetts
              Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                         Version 12.0

             Compound Segment                                                         Claim Billing/Claim
             Segment Identification (111-                                             Rebill
             AM) = 1Ø
Field #      NCPDP Field Name                Value                        Payer       Payer Situation             Field Format
                                                                          Usage
                                             17=Lozenge
                                             18=Enema
451-EG       COMPOUND DISPENSING             1=Each                         M                                     9(1)
             UNIT FORM INDICATOR             2=Grams
                                             3=Milliliters
447-EC       COMPOUND INGREDIENT             Maximum 15                     M                                     9(2)
             COMPONENT COUNT                 ingredients
488-RE       COMPOUND PRODUCT ID             Ø1=Universal Product        M***R***                                 X(2)
             QUALIFIER                       Code (UPC)
                                             Ø2=Health-related
                                             item (HRI)
                                             Ø3=National Drug
                                             Code (NDC) (default)
489-TE       COMPOUND PRODUCT ID                                         M***R***                                 X(19)

448-ED       COMPOUND INGREDIENT                                         M***R***     Metric decimal              s9(7)v999
             QUANTITY                                                                 Equivalent
449-EE       COMPOUND INGREDIENT                                         R***R***                                 s9(7)v99
             DRUG COST
49Ø-UE       COMPOUND INGREDIENT             ØØ=Default                  R***R***     *MassHealth will follow     X(2)
             BASIS OF COST                                                            industry direction and
                                             Ø1=Average wholesale
             DETERMINATION                                                            retire this pricing basis
                                             price (AWP)*
                                                                                      effective September 26,
                                             Ø2=Local wholesaler
                                                                                      2011.
                                             Ø3=Direct
                                             Ø4=Estimated
                                             acquisition cost (EAC)
                                             Ø5=Acquisition
                                             Ø6=Maximum
                                             allowable cost (MAC)
                                             Ø7=Usual and
                                             customary (default)
                                             Ø8=34ØB Drug
                                             pricing
                                             Ø9=Other
                                             1Ø=Average sales
                                             price (ASP)
                                             11=Average
                                             manufacturer price
                                             (AMP)
                                             12=Wholesale
                                             acquisition cost (WAC)
                                             13=Special patient
                                             pricing
 362-2G      COMPOUND INGREDIENT            Maximum count of 1Ø              I                                    9(2)
             MODIFIER CODE COUNT
 363-2H      COMPOUND INGREDIENT                                         I***R***                                 X(2)
             MODIFIER CODE


Clinical Segment Questions                     Check            Claim Billing/Claim Rebill
                                                                If Situational, Payer Situation
This segment is always sent.
This segment is situational.                         X




                                                             -26-
                 Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                           Version 12.0


          Clinical Segment                                                    Claim Billing/Claim
          Segment Identification (111-                                        Rebill
          AM) = 13
Field #   NCPDP Field Name               Value                      Payer     Payer Situation        Field Format
                                                                    Usage
 111-AM    SEGMENT IDENTIFICATION                                     M                              X(2)
 491-VE    DIAGNOSIS CODE COUNT          Maximum count of five        N
 492-WE    DIAGNOSIS CODE                                          N***R***
           QUALIFIER
 424-DO    DIAGNOSIS CODE                                          N***R***
 493-XE    CLINICAL INFORMATION          Maximum five                 Q                              9(1)
           COUNTER                       occurrences supported
 494-ZE    MEASUREMENT DATE              CCYYMMDD                  Q***R***                          9(8)
 495-H1    MEASUREMENT TIME              HHMM                      Q***R***                          9(4)
 496-H2    MEASUREMENT DIMENSION         Blank=Not specified       Q***R***                          X(2)
                                         Ø1=Blood pressure (BP)
                                         Ø2=Blood glucose level
                                         Ø3=Temperature
                                         Ø4=Serum creatinine
                                         (SCr)
                                         Ø5=HbA1c
                                         Ø6=Sodium (Na+)
                                         Ø7=Potassium (K+)
                                         Ø8=Calcium (Ca++)
                                         Ø9=Serum glutamic-
                                         oxaloacetic
                                         transaminase
                                         (SGOT)
                                         1Ø=Serum glutamic-
                                         pyruvic transaminase
                                         (SGPT)
                                         11=Alkaline
                                         phosphatase
                                         12=Serum theophylline
                                         level
                                         13=Serum digoxin level
                                         14=Weight
                                         15=Body surface area
                                         (BSA)
                                         16=Height
                                         17=Creatinine clearance
                                         (CrCl)
                                         18=Cholesterol
                                         19=Low-density
                                         lipoprotein (LDL)
                                         2Ø=High-density
                                         lipoprotein (HDL)
                                         21=Triglycerides (TG)
                                         22=Bone mineral
                                         density (BMD T-Score)
                                         23=Prothrombin time
                                         (PT)
                                         24=Hemoglobin (Hb;
                                         Hgb)
                                         25=Hematocrit (Hct)
                                         26=White blood cell
                                         count (WBC)
                                         27=Red blood cell count
                                         (RBC)
                                         28=Heart rate
                                         29=Absolute neutrophil
                                                     -27-
                 Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                            Version 12.0

          Clinical Segment                                                     Claim Billing/Claim
          Segment Identification (111-                                         Rebill
          AM) = 13
Field #   NCPDP Field Name               Value                      Payer      Payer Situation        Field Format
                                                                    Usage
                                         count (ANC)
                                         3Ø=Activated partial
                                         thromboplastin time
                                         (APTT)
                                         31=CD4 count
                                         32=Partial
                                         thromboplastin time
                                         (PTT)
                                         33=T-cell count
                                         34=International
                                         Normalized Ratio (INR)
                                         99=Other
 497-H3    MEASUREMENT UNIT              Blank=Not specified        Q***R***                          X(2)
                                         Ø1=Inches (in)
                                         Ø2=Centimeters (cm)
                                         Ø3=Pounds (lb)
                                         Ø4=Kilograms (kg)
                                         Ø5=Celsius (C)
                                         Ø6=Fahrenheit (F)
                                         Ø7=Meters squared
                                         (m2)
                                         Ø8=Milligrams per
                                         deciliter (mg/dl)
                                         Ø9=Units per milliliter
                                         (U/ml)
                                         1Ø=Millimeters of
                                         mercury (mmHg)
                                         11=Centimeters
                                         squared (cm2)
                                         12=Millimeters per
                                         minute (ml/min)
                                         13=Percentage (%)
                                         14=Milliequivalent
                                         (mEq/ml)
                                         15=International units
                                         per liter (IU/l)
                                         16=Micrograms per
                                         milliliter (mcg/ml)
                                         17=Nanograms per
                                         milliliter (ng/ml)
                                         18=Milligrams per
                                         milliliter (mg/ml)
                                         19=Ratio
                                         2Ø=SI units
                                         21=Millimoles (mmol/l)
                                         22=Seconds
                                         23=Grams per deciliter
                                         (g/dl)
                                         24=Cells per cubic
                                         millimeter (cells/cu mm)
                                         25=1,ØØØ,ØØØ cells
                                         per cubic millimeter
                                         (million cells/cu
                                         mm)
                                         26=Standard deviation
                                         27=Beats per minute
 499-H4    MEASUREMENT VALUE             Blood pressure entered     Q***R***                          X(15)
                                         in XXX/YYY format in
                                                      -28-
                  Commonwealth of Massachusetts
            Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                              Version 12.0

           Clinical Segment                                                      Claim Billing/Claim
           Segment Identification (111-                                          Rebill
           AM) = 13
Field #    NCPDP Field Name               Value                      Payer       Payer Situation        Field Format
                                                                     Usage
                                          which XXX=systolic,
                                          /=divider, and YYY is
                                          diastolic.
                                          Temperature entered in
                                          XXX.X format always
                                          includes
                                          decimal point.
                                          Request clinical
                                          segment.

Additional Documentation Segment          Check           Claim Billing/Claim Rebill
Questions                                                 If Situational, Payer Situation
This segment is always sent.
This segment is situational.                              Segment not supported.




                                                      -29-
                     Commonwealth of Massachusetts
              Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                 Version 12.0

             Additional Documentation                                               Claim Billing/Claim
             Segment                                                                Rebill
             Segment Identification (111-
             AM) = 14
Field #      NCPDP Field Name               Value                       Payer       Payer Situation        Field Format
                                                                        Usage
111-AM       SEGMENT IDENTIFICATION                                       M                                X(2)
369-2Q       ADDITIONAL                                                   M
             DOCUMENTATION TYPE ID
374-2V       REQUEST PERIOD BEGIN
             DATE
375-2W       REQUEST PERIOD
             RECERT/REVISED DATE
373-2U       REQUEST STATUS
371-2S       LENGTH OF NEED
             QUALIFIER
37Ø-2R       LENGTH OF NEED
372-2T       PRESCRIBER/SUPPLIER
             DATE SIGNED
376-2X       SUPPORTING
             DOCUMENTATION
377-2Z       QUESTION NUMBER/LETTER         Maximum count of 5Ø
             COUNT
378-4B       QUESTION NUMBER/LETTER
379-4D       QUESTION PERCENT
             RESPONSE
38Ø-4G       QUESTION DATE RESPONSE
381-4H       QUESTION DOLLAR
             AMOUNT RESPONSE
382-4J       QUESTION NUMERIC
             RESPONSE
383-4K       QUESTION ALPHANUMERIC
             RESPONSE

Facility Segment Questions                  Check                 Claim Billing/Claim Rebill
                                                                  If Situational, Payer Situation
This segment is always sent.
This segment is situational.                                      Segment not supported.

             Facility Segment                                                       Claim Billing/Claim
             Segment Identification (111-                                           Rebill
             AM) = 15
 Field #     NCPDP Field Name               Value                       Payer       Payer Situation        Field Format
                                                                        Usage
 111-AM      SEGMENT IDENTIFICATION                                       M                                X(2)
 336-8C      FACILITY ID
 385-3Q      FACILITY NAME
 386-3U      FACILITY STREET ADDRESS
 388-5J      FACILITY CITY ADDRESS
 387-3V      FACILITY STATE/PROVINCE
             ADDRESS
 389-6D      FACILITY ZIP/POSTAL ZONE

Narrative Segment Questions                 Check          Claim Billing/Claim Rebill
                                                           If Situational, Payer Situation
This segment is always sent.
This segment is situational.                               Segment not supported.


                                                       -30-
                   Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                           Version 12.0

            Narrative Segment                                                 Claim Billing/Claim
            Segment Identification (111-                                      Rebill
            AM) = 16
  Field #   NCPDP Field Name               Value                    Payer     Payer Situation        Field Format
                                                                    Usage
 111-AM     SEGMENT IDENTIFICATION                                    M                              X(2)
 39Ø-BM     NARRATIVE MESSAGE

                        ** End of Request Claim Billing/Claim Rebill (B1/B3) Payer Sheet **




                                                       -31-
                     Commonwealth of Massachusetts
              Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                      Version 12.0


2.2 Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid)
    Response
The following lists the segments and fields in a claim billing or claim rebill response (paid or duplicate
of paid) transaction for the NCPDP version D.Ø. Claim billing includes pharmacy billing transactions
B1 and B3.
Response Transaction Header Segment         Check              Claim Billing/Claim Rebill
Questions                                                      Accepted/Paid (or Duplicate of Paid)
                                                               If Situational, Payer Situation
This segment is always sent.                        X

             Response Transaction                                                   Claim Billing/Claim
             Header Segment                                                         Rebill – Accepted/Paid
                                                                                    (or Duplicate of Paid)
Field #      NCPDP Field Name               Value                        Payer      Payer Situation             Field Format
                                                                         Usage
1Ø2-A2       VERSION/RELEASE                DØ                             M                                    X(2)
             NUMBER
1Ø3-A3       TRANSACTION CODE               B1, B3                          M                                   X(2)
1Ø9-A9       TRANSACTION COUNT              1=One occurrence                M                                   X(1)
                                            2=Two occurrences
                                            3=Three occurrences
                                            4=Four occurrences
5Ø1-F1       HEADER RESPONSE                A=Accepted                      M                                   X(1)
             STATUS
2Ø2-B2       SERVICE PROVIDER ID            Ø1 – National provider          M                                   X(2)
             QUALIFIER                      identifier
2Ø1-B1       SERVICE PROVIDER ID                                            M                                   X(15)
4Ø1-D1       DATE OF SERVICE                CCYYMMDD                        M                                   9(8)

Response Message Segment Questions          Check              Claim Billing/Claim Rebill
                                                               Accepted/Paid (or Duplicate of Paid)
                                                               If Situational, Payer Situation
This segment is always sent.                        X
This segment is situational.                                   Provide general information when used for transmission-level
                                                               messaging.

             Response Message                                                       Claim Billing/Claim
             Segment                                                                Rebill – Accepted/Paid
             Segment Identification (111-                                           (or Duplicate of Paid)
             AM) = 2Ø
Field #      NCPDP Field Name               Value                        Payer      Payer Situation             Field Format
                                                                         Usage
111-AM       SEGMENT IDENTIFICATION                                        M                                    X(2)
5Ø4-F4       MESSAGE                                                       Q                                    X(2ØØ)
Response Insurance Segment                  Check              Claim Billing/Claim Rebill
Questions                                                      Accepted/Paid (or Duplicate of Paid)
                                                               If Situational, Payer Situation
This segment is always sent.                        X
This segment is situational.




                                                           -32-
                    Commonwealth of Massachusetts
              Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                  Version 12.0

             Response Insurance                                                   Claim Billing/Claim
             Segment                                                              Rebill – Accepted/Paid
             Segment Identification (111-                                         (or Duplicate of Paid)
             AM) = 25
Field #      NCPDP Field Name               Value                       Payer     Payer Situation          Field Format
                                                                        Usage
111-AM       SEGMENT IDENTIFICATION                                       M                                X(2)
3Ø1-C1       GROUP ID                       MassHealth                    R                                X(15)
                                            HSN
524-FO       PLAN ID                                                      Q
545-2F       NETWORK                                                      N
             REIMBURSEMENT ID
568-J7       PAYER ID QUALIFIER                                           N
569-J8       PAYER ID                                                     N
115-N5       MEDICAID ID NUMBER                                           N
116-N6       MEDICAID AGENCY                                              N
             NUMBER
3Ø2-C2       CARDHOLDER ID                                                N

Response Patient Segment Questions          Check             Claim Billing/Claim Rebill
                                                              Accepted/Paid (or Duplicate of Paid)
                                                              If Situational, Payer Situation
This segment is always sent.                        X
This segment is situational.

             Response Patient Segment                                             Claim Billing/Claim
             Segment Identification (111-                                         Rebill – Accepted/Paid
             AM) = 29                                                             (or Duplicate of Paid)
Field #      NCPDP Field Name               Value                       Payer     Payer Situation          Field Format
                                                                        Usage
111-AM       SEGMENT IDENTIFICATION                                       M                                X(2)
31Ø-CA       PATIENT FIRST NAME                                           R                                X(12)
311-CB       PATIENT LAST NAME                                            R                                X(15)
3Ø4-C4       DATE OF BIRTH                  CCYYMMDD                      R                                9(8)

Response Status Segment Questions           Check             Claim Billing/Claim Rebill
                                                              Accepted/Paid (or Duplicate of Paid)
                                                              If Situational, Payer Situation
This segment is always sent.                        X

             Response Status Segment                                              Claim Billing/Claim
             Segment Identification (111-                                         Rebill – Accepted/Paid
             AM) = 21                                                             (or Duplicate of Paid)
Field #      NCPDP Field Name               Value                       Payer     Payer Situation          Field Format
                                                                        Usage
111-AM      SEGMENT IDENTIFICATION                                        M                                X(2)
112-AN      TRANSACTION RESPONSE            P=Paid                        M                                X(1)
            STATUS                          D=Duplicate of paid
5Ø3-F3      AUTHORIZATION NUMBER                                          R                                X(2Ø)
547-5F      APPROVED MESSAGE                Maximum count of five         N
            CODE COUNT
548-6F      APPROVED MESSAGE                                           N***R***
            CODE
13Ø-UF      ADDITIONAL MESSAGE              Maximum count of eight        Q                                9(2)
            INFORMATION COUNT
132-UH      ADDITIONAL MESSAGE              Ø1                         Q***R***                            X(2)
            INFORMATION QUALIFIER
526-FQ      ADDITIONAL MESSAGE                                         Q***R***                            X(4Ø)
            INFORMATION

                                                          -33-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                  Version 12.0

             Response Status Segment                                              Claim Billing/Claim
             Segment Identification (111-                                         Rebill – Accepted/Paid
             AM) = 21                                                             (or Duplicate of Paid)
Field #      NCPDP Field Name               Value                       Payer     Payer Situation          Field Format
                                                                        Usage
131-UG       ADDITIONAL MESSAGE             +                          Q***R***                            X(1)
             INFORMATION
             CONTINUITY
549-7F       HELP DESK PHONE                                              N
             NUMBER QUALIFIER
550-8F       HELP DESK PHONE                                              N
             NUMBER

Response Claim Segment Questions            Check             Claim Billing/Claim Rebill
                                                              Accepted/Paid (or Duplicate of Paid)
                                                              If Situational, Payer Situation
This segment is always sent.                        X

             Response Claim Segment                                               Claim Billing/Claim
             Segment Identification (111-                                         Rebill – Accepted/Paid
             AM) = 22                                                             (or Duplicate of Paid)
Field #      NCPDP Field Name               Value                       Payer     Payer Situation          Field Format
                                                                        Usage
111-AM       SEGMENT IDENTIFICATION                                       M                                X(2)

455-EM       PRESCRIPTION/SERVICE           1=Rx billing                  M                                X(1)
             REFERENCE NUMBER
             QUALIFIER
4Ø2-D2       PRESCRIPTION/SERVICE                                         M                                9(12)
             REFERENCE NUMBER
551-9F       PREFERRED PRODUCT              Maximum count of six          N
             COUNT
552-AP       PREFERRED PRODUCT ID                                      N***R***
             QUALIFIER
553-AR       PREFERRED PRODUCT ID                                      N***R***
554-AS       PREFERRED PRODUCT                                         N***R***
             INCENTIVE
555-AT       PREFERRED PRODUCT                                         N***R***
             COST SHARE INCENTIVE
556-AU       PREFERRED PRODUCT                                         N***R***
             DESCRIPTION

 Response Pricing Segment Questions         Check             Claim Billing/Claim Rebill
                                                              Accepted/Paid (or Duplicate of Paid)
                                                              If Situational, Payer Situation
 This segment is always sent.                       X




                                                           -34-
                  Commonwealth of Massachusetts
            Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                 Version 12.0

           Response Pricing Segment                                           Claim Billing/Claim
           Segment Identification (111-                                       Rebill – Accepted/Paid
           AM) = 23                                                           (or Duplicate of Paid)
 Field #   NCPDP Field Name               Value                    Payer      Payer Situation             Field Format
                                                                   Usage
 111-AM    SEGMENT IDENTIFICATION                                    M                                    X(2)
 5Ø5-F5    PATIENT PAY AMOUNT                                        R                                    s9(6)v99
 5Ø6-F6    INGREDIENT COST PAID                                      Q                                    s9(6)v99
 5Ø7-F7    DISPENSING FEE PAID                                       Q                                    s9(6)v99
 557-AV    TAX EXEMPT INDICATOR                                      N
 558-AW    FLAT SALES TAX AMOUNT                                     N
           PAID
 559-AX    PERCENTAGE SALES TAX                                       N
           AMOUNT PAID
 56Ø-AY    PERCENTAGE SALES TAX                                       N
           RATE PAID
 561-AZ    PERCENTAGE SALES TAX                                       N
           BASIS PAID
 521-FL    INCENTIVE AMOUNT PAID                                      Q
 562-J1    PROFESSIONAL SERVICE                                       N
           PAID
 563-J2    OTHER AMOUNT PAID              Maximum count of three      Q                                   9(1)
           COUNT
 564-J3    OTHER AMOUNT PAID              Ø4=Administrative        Q***R***   For Ø4=Masshealth           X(2)
           QUALIFIER                      Ø9=Compound                         administrative fee
                                          preparation cost                    associated with return to
                                                                              stock program.

                                                                              For Ø9=Compound
                                                                              prescription cost, this
                                                                              field contains the
                                                                              additional cost for the
                                                                              dispensing of
                                                                              compounds as per
                                                                              MassHealth regulation.
 565-J4    OTHER AMOUNT PAID                                       Q***R***                               s9(6)v99
 566-J5    OTHER PAYER AMOUNT                                         Q                                   s9(6)v99
           RECOGNIZED
 5Ø9-F9    TOTAL AMOUNT PAID                                          R                                   s9(6)v99
 522-FM    BASIS OF                                                   R                                   9(2)
           REIMBURSEMENT
           DETERMINATION
 523-FN    AMOUNT ATTRIBUTED TO                                       N
           SALES TAX
 512-FC    ACCUMULATED                                                N
           DEDUCTIBLE AMOUNT
 513-FD    REMAINING DEDUCTIBLE                                       N
           AMOUNT
 514-FE    REMAINING BENEFIT              999999.ØØ                   R                                   s9(6)v99
           AMOUNT
 517-FH    AMOUNT APPLIED TO                                          N
           PERIODIC DEDUCTIBLE
 518-FI    AMOUNT OF COPAY                                            Q                                   s9(6)v99
 52Ø-FK    AMOUNT EXCEEDING                                           N
           PERIODIC BENEFIT
           MAXIMUM
 346-HH    BASIS OF CALCULATION—                                      N
           DISPENSING FEE




                                                        -35-
                  Commonwealth of Massachusetts
            Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                Version 12.0

           Response Pricing Segment                                             Claim Billing/Claim
           Segment Identification (111-                                         Rebill – Accepted/Paid
           AM) = 23                                                             (or Duplicate of Paid)
 Field #   NCPDP Field Name               Value                      Payer      Payer Situation          Field Format
                                                                     Usage
 347-HJ    BASIS OF CALCULATION—          Ø1=Quantity dispensed        Q                                 X(2)
           COPAY                          Ø2=Quantity intended to
                                          be dispensed
                                          Ø3=Usual and
                                          customary/prorated
                                          Ø4=Waived due to partial
                                          fill
                                          99=Other
 348-HK    BASIS OF CALCULATION—                                        N
           FLAT SALES TAX
 349-HM    BASIS OF CALCULATION—                                        N
           PERCENTAGE SALES TAX
 571-NZ    AMOUNT ATTRIBUTED TO                                         N
           PROCESSOR FEE
 575-EQ    PATIENT SALES TAX                                            N
           AMOUNT
 574-2Y    PLAN SALES TAX AMOUNT                                        N
 572-4U    AMOUNT OF                                                    N
           COINSURANCE
 573-4V    BASIS OF CALCULATION—                                        N
           COINSURANCE
 392-MU    BENEFIT STAGE COUNT            Maximum count of four.        Q                                9(1)
 393-MV    BENEFIT STAGE                  Blank=Not specified        Q***R***                            X(2)
           QUALIFIER                      Ø1=Deductible
                                          Ø2 Initial benefit
                                          Ø3 Coverage gap (donut
                                          hole)
                                          Ø4 Catastrophic
                                          coverage
 394-MW    BENEFIT STAGE AMOUNT                                      Q***R***                            s9(6)v99
 577-G3    ESTIMATED GENERIC                                            N
           SAVINGS
 128-UC    SPENDING ACCOUNT                                             N
           AMOUNT REMAINING
 129-UD    HEALTH PLAN-FUNDED                                           N
           ASSISTANCE AMOUNT
 133-UJ    AMOUNT ATTRIBUTED TO                                         N
           PROVIDER NETWORK
           SELECTION
 134-UK    AMOUNT ATTRIBUTED TO                                         N
           PRODUCT
           SELECTION/BRAND DRUG
 135-UM    AMOUNT ATTRIBUTED TO                                         N
           PRODUCT
           SELECTION/NONPREFERR
           ED FORMULARY
           SELECTION
 136-UN    AMOUNT ATTRIBUTED TO                                         N
           PRODUCT
           SELECTION/BRAND
           NONPREFERRED
           FORMULARY SELECTION
 137-UP    AMOUNT ATTRIBUTED TO                                         N
           COVERAGE GAP
 148-U8    INGREDIENT COST                                              N
           CONTRACTED/
           REIMBURSABLE AMOUNT

                                                        -36-
                     Commonwealth of Massachusetts
              Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                   Version 12.0

             Response Pricing Segment                                              Claim Billing/Claim
             Segment Identification (111-                                          Rebill – Accepted/Paid
             AM) = 23                                                              (or Duplicate of Paid)
 Field #     NCPDP Field Name               Value                        Payer     Payer Situation          Field Format
                                                                         Usage
 149-U9      DISPENSING FEE                                                N
             CONTRACTED/
             REIMBURSABLE AMOUNT

Response DUR/PPS Segment Questions          Check              Claim Billing/Claim Rebill
                                                               Accepted/Paid (or Duplicate of Paid)
                                                               If Situational, Payer Situation
This segment is always sent.
This segment is situational.                        X

             Response DUR/PPS                                                      Claim Billing/Claim
             Segment                                                               Rebill – Accepted/Paid
             Segment Identification (111-                                          (or Duplicate of Paid)
             AM) = 24
Field #      NCPDP Field Name               Value                        Payer     Payer Situation          Field Format
                                                                         Usage
111-AM      SEGMENT IDENTIFICATION                                         M                                X(2)
567-J6      DUR/PPS RESPONSE                Maximum nine                   Q                                9(1)
            CODE COUNTER                    occurrences supported.
439-E4      REASON FOR SERVICE              DD=Drug-drug interaction    Q***R***                            X(2)
            CODE (also known as the         HD=High dose
            DUR conflict code)              ID=Ingredient duplication
                                            TD=Therapeutic
                                            duplication
                                            ER=Early refill
528-FS      CLINICAL SIGNIFICANCE                                       Q***R***                            X(1)
            CODE
529-FT      OTHER PHARMACY                                              Q***R***                            9(1)
            INDICATOR
53Ø-FU      PREVIOUS DATE OF FILL                                       Q***R***                            9(8)
531-FV      QUANTITY OF PREVIOUS                                        Q***R***                            s9(7)v999
            FILL
532-FW      DATABASE INDICATOR                                          Q***R***                            X(1)
533-FX      OTHER PRESCRIBER                                            Q***R***                            9(1)
            INDICATOR
544-FY      DUR FREE TEXT MESSAGE                                       Q***R***                            X(3Ø)
57Ø-NS      DUR ADDITIONAL TEXT                                         Q***R***                            X(1ØØ)

Response Coordination of Benefits/Other     Check             Claim Billing/Claim Rebill
Payers Segment Questions                                      Accepted/Paid (or Duplicate of Paid)
                                                              If Situational, Payer Situation
This segment is always sent..
This segment is situational.                        X




                                                           -37-
                  Commonwealth of Massachusetts
            Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                Version 12.0

           Response Coordination of                                             Claim Billing/Claim
           Benefits/Other Payers                                                Rebill – Accepted/Paid
           Segment                                                              (or Duplicate of Paid)
           Segment Identification (111-
           AM) = 28
 Field #   NCPDP Field Name               Value                      Payer      Payer Situation          Field Format
                                                                     Usage
 111-AM    SEGMENT IDENTIFICATION                                      M                                 X(2)
 355-NT    OTHER PAYER ID COUNT           Maximum count of             M                                 9(1)
                                          three

 338-5C    OTHER PAYER COVERAGE           Blank=Not specified       M***R***                             X(2)
           TYPE                           Ø1=Primary
                                          Ø2=Secondary
                                          Ø3=Tertiary
 339-6C    OTHER PAYER ID                 Blank=Not specified       Q***R***                             X(2)
           QUALIFIER                      3=BIN
                                          99=Other
 34Ø-7C    OTHER PAYER ID                                           Q***R***                             X(1Ø)
 991-MH    OTHER PAYER                                              Q***R***                             X(1Ø)
           PROCESSOR CONTROL                                                    :
           NUMBER
 356-NU    OTHER PAYER                                               N***R***
           CARDHOLDER ID
 992-MJ    OTHER PAYER GROUP ID                                     Q***R***                             X(15)
 142-UV    OTHER PAYER PERSON                                       N***R***
           CODE
 127-UB    OTHER PAYER HELP DESK                                     N***R***
           PHONE NUMBER
 143-UW    OTHER PAYER PATIENT                                       N***R***
           RELATIONSHIP CODE
 144-UX    OTHER PAYER BENEFIT                                       N***R***
           EFFECTIVE DATE
 145-UY    OTHER PAYER BENEFIT                                       N***R***
           TERMINATION DATE


2.3 Claim Billing/Claim Rebill Accepted/Rejected Response
The following lists the segments and fields in a claim billing or claim rebill response (accepted or
rejected) transaction for the NCPDP version D.Ø. Claim billing includes pharmacy billing transactions
B1 and B3.

 Response Transaction Header              Check              Claim Billing/Claim Rebill Accepted/Rejected
 Segment Questions                                           If Situational, Payer Situation
 This segment is always sent.                     X

           Response Transaction                                                 Claim Billing/Claim
           Header Segment                                                       Rebill
                                                                                Accepted/Rejected
 Field #   NCPDP Field Name               Value                      Payer      Payer Situation          Field Format
                                                                     Usage
 1Ø2-A2    VERSION/RELEASE                DØ                           M                                 X(2)
           NUMBER
 1Ø3-A3    TRANSACTION CODE               B1, B3                        M                                X(2)
 1Ø9-A9    TRANSACTION COUNT              1=One occurrence              M                                X(1)
                                          2=Two occurrences
                                          3=Three occurrences
                                          4=Four occurrences

                                                       -38-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                  Version 12.0

             Response Transaction                                               Claim Billing/Claim
             Header Segment                                                     Rebill
                                                                                Accepted/Rejected
 Field #     NCPDP Field Name               Value                    Payer      Payer Situation            Field Format
                                                                     Usage
 5Ø1-F1      HEADER RESPONSE                A=Accepted                 M                                   X(1)
             STATUS
 2Ø2-B2      SERVICE PROVIDER ID                                       M                                   X(15)
             QUALIFIER
 2Ø1-B1      SERVICE PROVIDER ID                                       M                                   X(15)
 4Ø1-D1      DATE OF SERVICE                CCYYMMDD                   M                                   9(8)

 Response Message Segment Questions         Check           Claim Billing/Claim Rebill Accepted/Rejected
                                                            If Situational, Payer Situation
 This segment is always sent.                       X
 This segment is situational.

             Response Message Segment                                           Claim Billing/Claim
             Segment Identification (111-                                       Rebill
             AM) = 2Ø                                                           Accepted/Rejected
 Field #     NCPDP Field Name               Value                    Payer      Payer Situation            Field Format
                                                                     Usage
 111-AM      SEGMENT IDENTIFICATION                                    M                                   X(2)
 5Ø4-F4      MESSAGE                                                   Q                                   X(2ØØ)

 Response Insurance Segment Questions       Check           Claim Billing/Claim Rebill Accepted/Rejected
                                                            If Situational, Payer Situation
 This segment is always sent.                       X
 This segment is situational.

             Response Insurance                                                 Claim Billing/Claim
             Segment                                                            Rebill
             Segment Identification (111-                                       Accepted/Rejected
             AM) = 25
 Field #     NCPDP Field Name               Value                    Payer      Payer Situation            Field Format
                                                                     Usage
 111-AM      SEGMENT IDENTIFICATION                                    M                                   X(2)
 3Ø1-C1      GROUP ID                       MassHealth                 R                                   X(15)
                                            HSN
 524-FO      PLAN ID                                                   Q
 545-2F      NETWORK                                                   N
             REIMBURSEMENT ID
 568-J7      PAYER ID QUALIFIER                                        N
 569-J8      PAYER ID                                                  N

 Response Patient Segment Questions         Check           Claim Billing/Claim Rebill Accepted/Rejected
                                                            If Situational, Payer Situation
 This segment is always sent.                       X
 This segment is situational.




                                                         -39-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                    Version 12.0

             Response Patient Segment                                             Claim Billing/Claim
             Segment Identification (111-                                         Rebill
             AM) = 29                                                             Accepted/Rejected
 Field #     NCPDP Field Name               Value                      Payer      Payer Situation            Field Format
                                                                       Usage
 111-AM      SEGMENT IDENTIFICATION                                      M                                   X(2)
 31Ø-CA      PATIENT FIRST NAME                                          Q                                   X(12)
 311-CB      PATIENT LAST NAME                                           Q                                   X(15)
 3Ø4-C4      DATE OF BIRTH                  CCYYMMDD                     Q                                   9(8)

 Response Status Segment Questions          Check             Claim Billing/Claim Rebill Accepted/Rejected
                                                              If Situational, Payer Situation
 This Segment is always sent.                       X

             Response Status Segment                                              Claim Billing/Claim
             Segment Identification (111-                                         Rebill
             AM) = 21                                                             Accepted/Rejected
 Field #     NCPDP Field Name               Value                      Payer      Payer Situation            Field Format
                                                                       Usage
 111-AM      SEGMENT IDENTIFICATION                                      M                                   X(2)
 112-AN      TRANSACTION RESPONSE           R=Rejected                   M                                   X(1)
             STATUS
 5Ø3-F3      AUTHORIZATION NUMBER                                        R                                   X(2Ø)
 51Ø-FA      REJECT COUNT                   Maximum count of five        R                                   9(2)
 511-FB      REJECT CODE                                              R***R***   This field is mandatory     X(3)
                                                                                 when a reject response
                                                                                 is returned.
 546-4F      REJECT FIELD                                             Q***R***   This is the number of       9(2)
             OCCURRENCE INDICATOR                                                rejected fields.
 547-5F      APPROVED MESSAGE                                            N
             CODE COUNT
 548-6F      APPROVED MESSAGE                                         N***R***
             CODE
 13Ø-UF      ADDITIONAL MESSAGE             Maximum count of eight       Q                                   9(2)
             INFORMATION COUNT
 132-UH      ADDITIONAL MESSAGE             Ø1                        Q***R***                               X(2)
             INFORMATION QUALIFIER
 526-FQ      ADDITIONAL MESSAGE                                       Q***R***                               X(4Ø)
             INFORMATION
 131-UG      ADDITIONAL MESSAGE             +                         Q***R***                               X(1)
             INFORMATION CONTINUITY
 549-7F      HELP DESK PHONE                                             N
             NUMBER QUALIFIER
 55Ø-8F      HELP DESK PHONE                                             N
             NUMBER

 Response Claim Segment Questions           Check             Claim Billing/Claim Rebill Accepted/Rejected
                                                              If Situational, Payer Situation
 This segment is always sent.                       X

             Response Claim Segment                                               Claim Billing/Claim
             Segment Identification (111-                                         Rebill
             AM) = 22                                                             Accepted/Rejected
 Field #     NCPDP Field Name               Value                      Payer      Payer Situation            Field Format
                                                                       Usage
 111-AM      SEGMENT IDENTIFICATION                                      M                                   X(2)
 455-EM      PRESCRIPTION/SERVICE           1=Rx billing                 M                                   X(1)
             REFERENCE NUMBER
             QUALIFIER

                                                           -40-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                  Version 12.0

             Response Claim Segment                                             Claim Billing/Claim
             Segment Identification (111-                                       Rebill
             AM) = 22                                                           Accepted/Rejected
 Field #     NCPDP Field Name               Value                    Payer      Payer Situation            Field Format
                                                                     Usage
 4Ø2-D2      PRESCRIPTION/SERVICE                                      M                                   9(12)
             REFERENCE NUMBER
 551-9F      PREFERRED PRODUCT              Maximum count of six       N
             COUNT
 552-AP      PREFERRED PRODUCT ID                                   N***R***
             QUALIFIER
 553-AR      PREFERRED PRODUCT ID                                   N***R***
 554-AS      PREFERRED PRODUCT                                      N***R***
             INCENTIVE
 555-AT      PREFERRED PRODUCT                                      N***R***
             COST SHARE INCENTIVE
 556-AU      PREFERRED PRODUCT                                      N***R***
             DESCRIPTION
 114-N4      MEDICAID SUBROGRATION                                     N
             INTERNAL CONTROL
             NUMBER/TRANSACTION
             CONTROL NUMBER
             (ICN/TCN)

 Response DUR/PPS Segment Questions         Check           Claim Billing/Claim Rebill Accepted/Rejected
                                                            If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                       X

             Response DUR/PPS                                                   Claim Billing/Claim
             Segment                                                            Rebill
             Segment Identification (111-                                       Accepted/Rejected
             AM) = 24
 Field #     NCPDP Field Name               Value                    Payer      Payer Situation            Field Format
                                                                     Usage
 111-AM      SEGMENT IDENTIFICATION                                    M                                   X(2)
 567-J6      DUR/PPS RESPONSE CODE          Maximum nine               Q                                   9(1)
             COUNTER                        occurrences supported
 439-E4      REASON FOR SERVICE             DD=Drug-drug            Q***R***                               X(2)
             CODE                           interaction
                                            HD=High dose
                                            ID=Ingredient
                                            duplication
                                            TD=Therapeutic
                                            duplication
                                            ER=Early refill
 528-FS      CLINICAL SIGNIFICANCE                                  Q***R***                               X(1)
             CODE
 529-FT      OTHER PHARMACY                                         Q***R***                               9(8)
             INDICATOR
 53Ø-FU      PREVIOUS DATE OF FILL                                  Q***R***                               9(8)
 531-FV      QUANTITY OF PREVIOUS                                   Q***R***                               s9(7)v999
             FILL
 532-FW      DATABASE INDICATOR                                     Q***R***                               X(1)
 533-FX      OTHER PRESCRIBER                                       Q***R***                               9(1)
             INDICATOR
 544-FY      DUR FREE TEXT MESSAGE                                  Q***R***                               X(3Ø)
 57Ø-NS      DUR ADDITIONAL TEXT                                    Q***R***




                                                         -41-
                   Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                     Version 12.0

 Response Coordination of Benefits/Other   Check               Claim Billing/Claim Rebill Accepted/Rejected
 Payers Segment Questions                                      If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                       X

            Response Coordination of                                                Claim Billing/Claim
            Benefits/Other Payers                                                   Rebill
            Segment                                                                 Accepted/Rejected
            Segment Identification (111-
            AM) = 28
 Field #    NCPDP Field Name               Value                         Payer      Payer Situation           Field Format
                                                                         Usage
 111-AM     SEGMENT IDENTIFICATION                                         M                                  X(2)
 355-NT     OTHER PAYER ID COUNT           Maximum count of                M
                                           three.
 338-5C     OTHER PAYER COVERAGE           Blank=Not specified          M***R***                              X(2)
            TYPE                           Ø1=Primary
                                           Ø2=Secondary
                                           Ø3=Tertiary
 339-6C     OTHER PAYER ID                 Blank=Not specified          Q***R***                              X(2)
            QUALIFIER                      3=BIN
                                           99=Other
 34Ø-7C     OTHER PAYER ID                                              Q***R***                              X(1Ø)
 991-MH     OTHER PAYER                                                 Q***R***                              X(1Ø)
            PROCESSOR CONTROL
            NUMBER
 356-NU     OTHER PAYER                                                 N***R***
            CARDHOLDER ID
 992-MJ     OTHER PAYER GROUP ID                                        Q***R***                              X(15)
 142-UV     OTHER PAYER PERSON                                          N***R***
            CODE
 127-UB     OTHER PAYER HELP DESK                                       N***R***
            PHONE NUMBER
 143-UW     OTHER PAYER PATIENT                                         N***R***
            RELATIONSHIP CODE
 144-UX     OTHER PAYER BENEFIT                                         N***R***
            EFFECTIVE DATE
 145-UY     OTHER PAYER BENEFIT                                         N***R***
            TERMINATION DATE


2.4 Claim Billing/Claim Rebill Rejected/Rejected Response
The following lists the segments and fields in a claim billing or claim rebill response (rejected/rejected)
transaction for the NCPDP version D.Ø. Claim billing includes pharmacy billing transactions B1 and B3.

 Response Transaction Header Segment       Check                   Claim Billing/Claim Rebill Rejected/Rejected
 Questions                                                         If Situational, Payer Situation
 This segment is always sent.                           X

            Response Transaction                                                    Claim Billing/Claim
            Header Segment                                                          Rebill
                                                                                    Rejected/Rejected
 Field #    NCPDP Field Name               Value                         Payer      Payer Situation           Field Format
                                                                         Usage
 1Ø2-A2     VERSION/RELEASE                DØ                              M                                  X(2)
            NUMBER
 1Ø3-A3     TRANSACTION CODE               B1, B3                          M                                  X(2)



                                                            -42-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                   Version 12.0

             Response Transaction                                                Claim Billing/Claim
             Header Segment                                                      Rebill
                                                                                 Rejected/Rejected
 Field #     NCPDP Field Name               Value                     Payer      Payer Situation            Field Format
                                                                      Usage
 1Ø9-A9      TRANSACTION COUNT              1=One occurrence            M                                   X(1)
                                            2=Two occurrences
                                            3=Three occurrences
                                            4=Four occurrences
 5Ø1-F1      HEADER RESPONSE                R=Rejected                   M                                  X(1)
             STATUS
 2Ø2-B2      SERVICE PROVIDER ID            Ø1– National provider        M                                  X(2)
             QUALIFIER                      identifier
 2Ø1-B1      SERVICE PROVIDER ID                                         M                                  X(15)
 4Ø1-D1      DATE OF SERVICE                CCYYMMDD                     M                                  9(8)

 Response Message Segment Questions         Check            Claim Billing/Claim Rebill Rejected/Rejected
                                                             If Situational, Payer Situation
 This segment is always sent.                       X
 This segment is situational.

             Response Message Segment                                            Claim Billing/Claim
             Segment Identification (111-                                        Rebill
             AM) = 2Ø                                                            Rejected/Rejected
 Field #     NCPDP Field Name               Value                     Payer      Payer Situation            Field Format
                                                                      Usage
 111-AM      SEGMENT IDENTIFICATION                                     M
 5Ø4-F4      MESSAGE                                                    Q                                   X(2ØØ)

 Response Status Segment Questions          Check            Claim Billing/Claim Rebill Rejected/Rejected
                                                             If Situational, Payer Situation
 This Segment is always sent.                       X

             Response Status Segment                                             Claim Billing/Claim
             Segment Identification (111-                                        Rebill
             AM) = 21                                                            Rejected/Rejected
 Field #     NCPDP Field Name               Value                     Payer      Payer Situation            Field Format
                                                                      Usage
 111-AM      SEGMENT IDENTIFICATION                                     M                                   X(2)
 112-AN      TRANSACTION RESPONSE           R=Rejected                  M                                   X(1)
             STATUS
 5Ø3-F3      AUTHORIZATION NUMBER                                       R                                   X(2Ø)
 51Ø-FA      REJECT COUNT                   Maximum count of five       R                                   9(2)
 511-FB      REJECT CODE                                             R***R***                               X(3)
 546-4F      REJECT FIELD                                            Q***R***                               X(3)
             OCCURRENCE INDICATOR
 13Ø-UF      ADDITIONAL MESSAGE             Maximum count of eight       Q                                  9(2)
             INFORMATION COUNT
 132-UH      ADDITIONAL MESSAGE             01                       Q***R***                               X(2)
             INFORMATION QUALIFIER
 526-FQ      ADDITIONAL MESSAGE                                      Q***R***                               X(4Ø)
             INFORMATION




                                                         -43-
                  Commonwealth of Massachusetts
            Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                          Version 12.0

           Response Status Segment                                           Claim Billing/Claim
           Segment Identification (111-                                      Rebill
           AM) = 21                                                          Rejected/Rejected
 Field #   NCPDP Field Name               Value                    Payer     Payer Situation       Field Format
                                                                   Usage
 131-UG    ADDITIONAL MESSAGE             +                       Q***R***                         X(1)
           INFORMATION CONTINUITY
 549-7F    HELP DESK PHONE                                           N
           NUMBER QUALIFIER
 55Ø-8F    HELP DESK PHONE                                           N
           NUMBER

                       ** End of Response Claim Billing/Claim Rebill (B1/B3) Payer Sheet **




                                                      -44-
                       Commonwealth of Massachusetts
                Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                              Version 12.0


3.0        Claim Submission Format – B2
BIN NUMBER ØØ9555
DESTINATION ACS STATE HEALTHCARE
ACCEPTING CLAIM ADJUDICATION (B2 REVERSAL TRANSACTIONS)
FORMAT NCPDP D.Ø


3.1 Request for Claim Reversal Payer Sheet
Field Legend for Columns
      Payer Usage                  Value                                Explanation                                 Payer Situation
        Column                                                                                                         Column
 MANDATORY                           M     The field is mandatory for the segment in the designated                       No
                                           transaction.
 REQUIRED                            R     The field has been designated with the situation of ‘required’ for the         No
                                           segment in the designated transaction.
 QUALIFIED REQUIREMENT               Q     The situations designated have qualifications for usage (required if          Yes
                                           x, not required if y).
 INFORMATIONAL ONLY                  I     The field is for informational purposes only for the transaction.             Yes
 NOT USED                            N     The field is not used for the segment for the transaction.                    No
 REPEATING                        ***R*** The three asterisks, R, and three asterisks designates a field is              Yes
                                          repeating.
                                          Example: Q***R*** means a situationally qualified field that repeats.
                                          Example: N***R*** means a not used field that repeats when used.

Claim Reversal Transaction
The following lists the segments and fields in a claim reversal transaction for the NCPDP version
D.Ø. Claim reversal transaction includes pharmacy billing transactions B2.
 Transaction Header Segment Questions                Check              Claim Reversal
                                                                        If Situational, Payer Situation
 This segment is always sent.                                X
 Source of certification IDs required in software            X
 vendor/certification ID (11Ø-AK) is payer
 issued.
 Source of certification IDs required in software
 vendor/certification ID (11Ø-AK) is switch/VAN
 issued.
 Source of certification IDs required in software
 vendor/certification ID (11Ø-AK) is not used.

               Transaction Header Segment                                                     Claim Reversal
 Field #       NCPDP Field Name                      Value                        Payer       Payer Situation           Field Format
                                                                                  Usage
 1Ø1-A1        BIN NUMBER                            ØØ9555                         M                                   9(6)
 1Ø2-A2        VERSION/RELEASE NUMBER                DØ                             M                                   X(2)
 1Ø3-A3        TRANSACTION CODE                      B2                             M                                   X(2)
 1Ø4-A4        PROCESSOR CONTROL                     MASSPROD for                   M                                   X(1Ø)
               NUMBER                                production
                                                     transactions




                                                                 -45-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                         Version 12.0

              Transaction Header Segment                                             Claim Reversal
 Field #      NCPDP Field Name               Value                       Payer       Payer Situation              Field Format
                                                                         Usage
 1Ø9-A9       TRANSACTION COUNT              1=One occurrence              M         For B2/S2 (reversal)         X(1)
                                             2=Two occurrences                       transactions,
                                             3=Three occurrences                     transaction count must
                                             4=Four occurrences                      be a value of 1, 2, 3, or
                                                                                     4.

                                                                                     If this transaction is for
                                                                                     a compound claim, the
                                                                                     transaction count value
                                                                                     must be 1.
 2Ø2-B2       SERVICE PROVIDER ID            Ø1=National provider          M                                      X(2)
              QUALIFIER                      identifier (NPI)
 2Ø1-B1       SERVICE PROVIDER ID                                          M                                      X(15)
 4Ø1-D1       DATE OF SERVICE                CCYYMMDD                      M                                      9(8)
 11Ø-AK       SOFTWARE                                                     M         The MassHealth               X(1Ø)
              VENDOR/CERTIFICATION ID                                                registration number
                                                                                     assigned to software as
                                                                                     part of initial
                                                                                     certification.

 Insurance Segment Questions                 Check               Claim Reversal
                                                                 If Situational, Payer Situation
 This segment is always sent.                        X
 This segment is situational.

              Insurance Segment                                                       Claim Reversal
              Segment Identification (111-
              AM) = Ø4
 Field #      NCPDP Field Name               Value                       Payer        Payer Situation             Field Format
                                                                         Usage
 111-AM       SEGMENT IDENTIFICATION                                       M                                      X(2)
 3Ø2-C2       CARDHOLDER ID                                                M        12-digit MassHealth ID        X(2Ø)
                                                                                    number
 3Ø1-C1       GROUP ID                       MassHealth                     R                                     X(15)
                                             HSN

 Claim Segment Questions                     Check               Claim Reversal
                                                                 If Situational, Payer Situation
 This segment is always sent.                        X




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                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                       Version 12.0


              Claim Segment                                                             Claim Reversal
              Segment Identification (111-
              AM) = Ø7
 Field #      NCPDP Field Name                  Value                      Payer        Payer Situation         Field
                                                                           Usage                                Format
 111-AM       SEGMENT IDENTIFICATION                                          M                                 X(2)
 455-EM       PRESCRIPTION/SERVICE              1=Rx billing                  M                                 X(1)
              REFERENCE NUMBER
              QUALIFIER
 4Ø2-D2       PRESCRIPTION/SERVICE                                            M                                 9(12)
              REFERENCE NUMBER
 436-E1       PRODUCT/SERVICE ID                Ø1=Universal                  M                                 X(2)
              QUALIFIER                         Product Code (UPC)
                                                Ø2=Health-related
                                                item (HRI)
                                                Ø3=National Drug
                                                Code (NDC)
 4Ø7-D7       PRODUCT/SERVICE ID                                              M                                 X(19)
 4Ø3-D3       FILL NUMBER                                                     Q                                 9(2)
 3Ø8-C8       OTHER COVERAGE CODE                                             Q                                 9(2)
 147-U7       PHARMACY SERVICE TYPE                                           Q       Required for members
                                                                                      with commercial
                                                                                      insurance that use mail
                                                                                      order pharmacies.


 Pricing Segment Questions                      Check              Claim Reversal
                                                                   If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                                      Segment not supported.

              Pricing Segment                                                           Claim Reversal
              Segment Identification (111-
              AM) = 11
 Field #      NCPDP Field Name                  Value                      Payer        Payer Situation         Field Format
                                                                           Usage
 111-AM       SEGMENT IDENTIFICATION                                         M                                  X(2)
 438-E3       INCENTIVE AMOUNT                                               Q
              SUBMITTED
 43Ø-DU       GROSS AMOUNT DUE

 Coordination of Benefits/Other Payments        Check              Claim Reversal
 Segment Questions                                                 If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                                      Segment not supported.

               Coordination of Benefits/Other                                           Claim Reversal
               Payments Segment
               Segment Identification (111-
               AM) = Ø5
 Field #      NCPDP Field Name                  Value                      Payer        Payer Situation         Field Format
                                                                           Usage
 111-AM       SEGMENT IDENTIFICATION                                         M                                  X(2)
 337-4C       COORDINATION OF                   Maximum count of             M                                  9(1)
              BENEFITS/OTHER PAYMENTS           nine
              COUNT
 338-5C       OTHER PAYER COVERAGE                                            M                                 9(1)
              TYPE

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                    Commonwealth of Massachusetts
              Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                             Version 12.0


 DUR/PPS Segment Questions                     Check             Claim Reversal
                                                                 If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                                    Segment not supported.

             DUR/PPS Segment                                                        Claim Reversal
             Segment Identification (111-
             AM) = Ø8
 Field #     NCPDP Field Name                  Value                     Payer      Payer Situation   Field Format
                                                                         Usage
 111-AM      SEGMENT IDENTIFICATION                                        M                          X(2)
 473-7E      DUR/PPS CODE COUNTER              Maximum of nine                                        9(1)
                                               occurrences
 439-E4      REASON FOR SERVICE CODE                                                                  X(2)
             (also known as the DUR conflict
             code)
 44Ø-E5      PROFESSIONAL SERVICE                                                                     X(2)
             CODE
 441-E6      RESULT OF SERVICE CODE                                                                   X(2)

                                ** End of Request Claim Reversal (B2) Payer Sheet **




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                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                       Version 12.0


3.2 Claim Reversal Accepted/Approved Response
The following lists the segments and fields in a claim reversal response (accepted/approved)
transaction for the NCPDP version D.Ø.
 Response Transaction Header Segment         Check              Claim Reversal – Accepted/Approved
 Questions                                                      If Situational, Payer Situation
 This segment is always sent.                        X

              Response Transaction Header                                          Claim Reversal –
              Segment                                                              Accepted/Approved
 Field #      NCPDP Field Name               Value                       Payer     Payer Situation              Field Format
                                                                         Usage
 1Ø2-A2       VERSION/RELEASE NUMBER         DØ                            M                                    X(2)
 1Ø3-A3       TRANSACTION CODE               B2                            M                                    X(2)
 1Ø9-A9       TRANSACTION COUNT              1=One occurrence              M       For B2 (reversal)            X(1)
                                             2=Two occurrences                     transactions,
                                             3=Three occurrences                   transaction count will be
                                             4=Four occurrences                    a value of 1, 2, 3, or 4.

                                                                                   If this transaction is for
                                                                                   a compound claim, the
                                                                                   transaction count value
                                                                                   must be 1.
 5Ø1-F1       HEADER RESPONSE STATUS         A=Accepted                    M                                    X(1)
 2Ø2-B2       SERVICE PROVIDER ID            Ø1 – National                 M                                    X(2)
              QUALIFIER                      provider identifier
                                             (NPI)
 2Ø1-B1       SERVICE PROVIDER ID                                          M                                    X(15)
 4Ø1-D1       DATE OF SERVICE                CCYYMMDD                      M                                    9(8)

 Response Message Segment Questions          Check              Claim Reversal – Accepted/Approved
                                                                If Situational, Payer Situation
 This segment is always sent.                        X
 This segment is situational.

              Response Message Segment                                             Claim Reversal –
              Segment Identification (111-                                         Accepted/Approved
              AM) = 2Ø
 Field #      NCPDP Field Name               Value                       Payer     Payer Situation              Field Format
                                                                         Usage
 111-AM       SEGMENT IDENTIFICATION                                       M                                    X(2)
 5Ø4-F4       MESSAGE                                                      Q                                    X(2ØØ)

 Response Status Segment Questions           Check                 Claim Reversal – Accepted/Approved
                                                                   If Situational, Payer Situation
 This segment is always sent.                        X

              Response Status Segment                                              Claim Reversal –
              Segment Identification (111-                                         Accepted/Approved
              AM) = 21
 Field #      NCPDP Field Name               Value                       Payer     Payer Situation              Field Format
                                                                         Usage
 111-AM      SEGMENT IDENTIFICATION                                        M                                    X(2)
 112-AN      TRANSACTION RESPONSE            A=Approved                    M                                    X(1)
             STATUS
 5Ø3-F3      AUTHORIZATION NUMBER                                          R                                    X(2Ø)

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                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                            Version 12.0

              Response Status Segment                                            Claim Reversal –
              Segment Identification (111-                                       Accepted/Approved
              AM) = 21
 Field #      NCPDP Field Name               Value                     Payer     Payer Situation     Field Format
                                                                       Usage
 547-5F       APPROVED MESSAGE CODE          Maximum count of            N
              COUNT                          five
 548-6F       APPROVED MESSAGE CODE                                   N***R***
 13Ø-UF       ADDITIONAL MESSAGE             Maximum count of            Q                           9(2)
              INFORMATION COUNT              eight
 132-UH       ADDITIONAL MESSAGE             Ø1                       Q***R***                       X(2)
              INFORMATION QUALIFIER
 526-FQ       ADDITIONAL MESSAGE                                      Q***R***                       X(4Ø)
              INFORMATION
 131-UG       ADDITIONAL MESSAGE             +                        Q***R***                       X(1)
              INFORMATION CONTINUITY
 549-7F       HELP DESK PHONE NUMBER                                     N
              QUALIFIER
 55Ø-8F       HELP DESK PHONE NUMBER                                     N

 Response Claim Segment Questions            Check              Claim Reversal – Accepted/Approved
                                                                If Situational, Payer Situation
 This segment is always sent.                        X

              Response Claim Segment                                             Claim Reversal –
              Segment Identification (111-                                       Accepted/Approved
              AM) = 22
 Field #      NCPDP Field Name               Value                     Payer     Payer Situation     Field Format
                                                                       Usage
 111-AM       SEGMENT IDENTIFICATION                                     M                           X(2)
 455-EM       PRESCRIPTION/SERVICE           1=Rx billing                M                           X(1)
              REFERENCE NUMBER
              QUALIFIER
 4Ø2-D2       PRESCRIPTION/SERVICE                                       M                           9(12)
              REFERENCE NUMBER

 Response Pricing Segment Questions          Check              Claim Reversal – Accepted/Approved
                                                                If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                                   Segment not supported.

              Response Pricing Segment                                           Claim Reversal –
              Segment Identification (111-                                       Accepted/Approved
              AM) = 23
 Field #      NCPDP Field Name               Value                     Payer     Payer Situation     Field Format
                                                                       Usage
 111-AM       SEGMENT IDENTIFICATION                                     M                           X(2)
 521-FL       INCENTIVE AMOUNT PAID                                      Q
 5Ø9-F9       TOTAL AMOUNT PAID


3.3 Claim Reversal Accepted/Rejected Response

The following lists the segments and fields in a claim reversal response (accepted/rejected)
transaction for the NCPDP version D.Ø.



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                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                         Version 12.0

              Response Transaction Header                                            Claim Reversal –
              Segment                                                                Accepted/Rejected
Field #       NCPDP Field Name                Value                       Payer      Payer Situation              Field Format
                                                                          Usage
1Ø2-A2        VERSION/RELEASE NUMBER          DØ                            M                                     X(2)
1Ø3-A3        TRANSACTION CODE                B2                            M                                     X(2)
1Ø9-A9        TRANSACTION COUNT               1=One occurrence              M        For B2 (reversal)            X(1)
                                              2=Two occurrences                      transactions,
                                              3=Three occurrences                    transaction count will be
                                              4=Four occurrences                     a value of 1, 2, 3, or 4.
                                                                                     If this transaction is for
                                                                                     a compound claim, the
                                                                                     transaction count value
                                                                                     must be 1.
5Ø1-F1        HEADER RESPONSE STATUS          A=Accepted                     M                                    X(1)

2Ø2-B2        SERVICE PROVIDER ID             01 – National                  M                                    X(2)
              QUALIFIER                       provider identifier
                                              (NPI)
2Ø1-B1        SERVICE PROVIDER ID                                            M                                    X(15)
4Ø1-D1        DATE OF SERVICE                 CCYYMMDD                       M                                    9(8)

 Response Message Segment Questions           Check                 Claim Reversal - Accepted/Rejected
                                                                    If Situational, Payer Situation
 This segment is always sent.                         X
 This segment is situational.

            Response Message Segment                                                 Claim Reversal –
            Segment Identification (111-AM)                                          Accepted/Rejected
            = “2Ø”
 Field #    NCPDP Field Name                  Value                       Payer      Payer Situation              Field Format
                                                                          Usage
 111-AM     SEGMENT IDENTIFICATION                                          M                                     X(2)
 5Ø4-F4     MESSAGE                                                         Q                                     X(2ØØ)

 Response Status Segment Questions            Check                 Claim Reversal - Accepted/Rejected
                                                                    If Situational, Payer Situation
 This segment is always sent.                         X




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                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                              Version 12.0


            Response Status Segment                                         Claim Reversal –
            Segment Identification                                          Accepted/Rejected
            (111-AM) = 21
 Field #    NCPDP Field Name          Value                       Payer     Payer Situation            Field Format
                                                                  Usage
 111-AM     SEGMENT                                                 M                                  X(2)
            IDENTIFICATION
 112-AN     TRANSACTION               R=Rejected                    M                                  X(1)
            RESPONSE STATUS
 5Ø3-F3     AUTHORIZATION                                           R                                  X(2Ø)
            NUMBER
 51Ø-FA     REJECT COUNT                                            R                                  9(2)
 511-FB     REJECT CODE                                          R***R***                              X(3)
 546-4F     REJECT FIELD                                         Q***R***                              9(2)
            OCCURRENCE
            INDICATOR
 13Ø-UF     ADDITIONAL MESSAGE        Maximum count of eight        Q                                  9(2)
            INFORMATION COUNT
 132-UH     ADDITIONAL MESSAGE        Ø1                         Q***R***                              X(2)
            INFORMATION QUALIFIER
 526-FQ     ADDITIONAL MESSAGE                                   Q***R***                              X(4Ø)
            INFORMATION
 131-UG     ADDITIONAL MESSAGE        +                          Q***R***                              X(1)
            INFORMATION
            CONTINUITY
 549-7F     HELP DESK PHONE                                         N
            NUMBER QUALIFIER
 55Ø-8F     HELP DESK PHONE                                         N
            NUMBER

 Response Claim Segment Questions     Check               Claim Reversal - Accepted/Rejected
                                                          If Situational, Payer Situation
 This segment is always sent.                 X

            Response Claim Segment                                          Claim Reversal –
            Segment Identification                                          Accepted/Rejected
            (111-AM) = 22
 Field #    NCPDP Field Name          Value                       Payer     Payer Situation            Field Format
                                                                  Usage
 111-AM     SEGMENT                                                 M                                  X(2)
            IDENTIFICATION
 455-EM     PRESCRIPTION/SERVICE      1=Rx billing                  M       For transaction code of    X(1)
            REFERENCE NUMBER                                                B2 in the response claim
            QUALIFIER                                                       segment, the
                                                                            prescription/service
                                                                            reference number
                                                                            qualifier (455-EM) is 1
                                                                            (Rx billing)
 4Ø2-D2     PRESCRIPTION/SERVICE                                    M                                  9(12)
            REFERENCE NUMBER




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                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                      Version 12.0


3.4 Claim Reversal Rejected/Rejected Response
The following lists the segments and fields in a claim reversal response (rejected) transaction for
the NCPDP version D.Ø.
 Response Transaction Header         Check                    Claim Reversal - Rejected/Rejected
 Segment Questions                                            If Situational, Payer Situation
 This segment is always sent.                 X

            Response Transaction                                                Claim Reversal –
            Header Segment                                                      Rejected/Rejected
 Field #    NCPDP Field Name         Value                            Payer     Payer Situation                Field Format
                                                                      Usage
 1Ø2-A2     VERSION/RELEASE          DØ                                 M                                      X(2)
            NUMBER
 1Ø3-A3     TRANSACTION CODE         B2                                 M                                      X(2)

 1Ø9-A9     TRANSACTION COUNT        1=One occurrence                   M       For B2 (reversal)              X(1)
                                     2=Two occurrences                          transactions,
                                     3=Three occurrences                        transaction count will be a
                                     4=Four occurrences                         value of 1, 2, 3, or 4.

                                                                                If this transaction is for a
                                                                                compound claim, the
                                                                                transaction
                                                                                count value must be 1.
 5Ø1-F1     HEADER RESPONSE          R=Rejected                         M                                      X(1)
            STATUS
 2Ø2-B2     SERVICE PROVIDER ID      01 – National provider             M                                      X(2)
            QUALIFIER                identifier (NPI)
 2Ø1-B1     SERVICE PROVIDER ID                                         M                                      X(15)
 4Ø1-D1     DATE OF SERVICE          CCYYMMDD                           M                                      9(8)

 Response Message Segment            Check                    Claim Reversal – Rejected/Rejected
 Questions                                                    If Situational, Payer Situation
 This segment is always sent                  X
 This segment is situational

            Response Message                                                    Claim Reversal –
            Segment                                                             Rejected/Rejected
            Segment Identification
            (111-AM) = 2Ø
 Field #    NCPDP Field Name         Value                            Payer     Payer Situation                Field Format
                                                                      Usage
 111-AM     SEGMENT                                                     M                                      X(2)
            IDENTIFICATION
 5Ø4-F4     MESSAGE                                                     Q                                      X(2ØØ)

 Response Status Segment             Check                    Claim Reversal - Rejected/Rejected
 Questions                                                    If Situational, Payer Situation
 This segment is always sent.                 X




                                                        -53-
                   Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                      Version 12.0


           Response Status                                                 Claim Reversal –
           Segment                                                         Rejected/Rejected
           Segment Identification
           (111-AM) = 21
 Field #   NCPDP Field Name          Value                       Payer     Payer Situation     Field Format
                                                                 Usage
 111-AM    SEGMENT                                                 M                           X(2)
           IDENTIFICATION
 112-AN    TRANSACTION               R=Rejected                    M                           X(1)
           RESPONSE STATUS
 5Ø3-F3    AUTHORIZATION                                           R                           X(2Ø)
           NUMBER
 51Ø-FA    REJECT COUNT              Maximum count of five         R                           9(2)
 511-FB    REJECT CODE                                          R***R***                       X(3)
 546-4F    REJECT FIELD                                            N
           OCCURRENCE
           INDICATOR
 13Ø-UF    ADDITIONAL MESSAGE        Maximum count of eight        Q                           9(2)
           INFORMATION COUNT
 132-UH    ADDITIONAL MESSAGE        Ø1                         Q***R***                       X(2)
           INFORMATION
           QUALIFIER
 526-FQ    ADDITIONAL MESSAGE                                   Q***R***                       X(4Ø)
           INFORMATION
 131-UG    ADDITIONAL MESSAGE        +                          Q***R***                       X(1)
           INFORMATION
           CONTINUITY
 549-7F    HELP DESK PHONE                                         N
           NUMBER QUALIFIER
 55Ø-8F    HELP DESK PHONE                                         N
           NUMBER

                              ** End of Claim Reversal (B2) Response Payer Sheet **




                                                      -54-
                         Commonwealth of Massachusetts
                 Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                                       Version 12.0


4.0        Claim Submission Formats – S1 and S3
 BIN NUMBER ØØ9555
 DESTINATION ACS STATE HEALTHCARE
 ACCEPTING CLAIM ADJUDICATION (S1 SERVICE BILLING AND S3-SERVICE REBILL TRANSACTIONS)
 FORMAT NCPDP D. Ø


4.1 Service Billing/Service Rebill Request
Field Legend for Columns
        Payer Usage                         Value                                Explanation                                  Payer Situation
          Column                                                                                                                 Column
 MANDATORY                                     M       The field is mandatory for the segment in the designated                     No
                                                       transaction.
 REQUIRED                                      R       The field has been designated with the situation of “required”                Yes
                                                       for the segment in the designated transaction.
 QUALIFIED REQUIREMENT                         Q       The situations designated have qualifications for usage                       Yes
                                                       (required if x, not required if y).
 QUALIFIED REQUIREMENT FOR                    QM       The situations designated have qualifications for usage                       Yes
 MEDICAID SUBROGATION ONLY                             (required if x, not required if y) for Medicaid subrogation.
 INFORMATIONAL ONLY                            I       The field is for informational purposes only for the transaction.             Yes
 NOT USED                                      N        The field is not used for the segment for the transaction.                   No
 REPEATING                                  ***R***     The three asterisks, R, and three asterisks designates a field is            Yes
                                                        repeating.
                                                        Example: Q***R*** means a situationally qualified field that
                                                        repeats.
                                                        Example: N***R*** means a not used field that repeats when
                                                        used.
Please Note: Fields that are not used in the service billing/service rebill transactions and those that do not have qualified requirements (i.e.,
not used) for this payer are excluded from the template.

Service Billing/Service Rebill Transaction
The following lists the segments and fields in a service billing or service rebill transaction for the
NCPDP version D.Ø. Service billing includes billing transactions S1 and S3.
 Transaction Header Segment Questions                 Check                   Service Billing/Service Rebill
                                                                              If Situational, Payer Situation
 This segment is always sent.                                  X
 Source of certification IDs required in                       X
 software vendor/certification ID (11Ø-AK) is
 payer issued.
 Source of certification IDs required in
 software vendor/certification ID (11Ø-AK) is
 switch/VAN issued.
 Source of certification IDs required in
 software vendor/certification ID (11Ø-AK) is
 not used.




                                                                     -55-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                      Version 12.0

            Transaction Header Segment                                                  Service
                                                                                        Billing/Service
                                                                                        Rebill
 Field #    NCPDP Field Name               Value                       Payer Usage      Payer Situation         Field Format
 1Ø1-A1     BIN NUMBER                     ØØ9555                           M                                   9(6)
 1Ø2-A2     VERSION/RELEASE NUMBER         DØ                               M                                   X(2)
 1Ø3-A3     TRANSACTION CODE               S1, S3                           M                                   X(2)
 1Ø4-A4     PROCESSOR CONTROL              MASSPROD for                     M                                   X(1Ø)
            NUMBER                         production transactions
 1Ø9-A9     TRANSACTION COUNT              1=One occurrence                  M                                  X(1)
                                           2=Two occurrences
                                           3=Three occurrences
                                           4=Four occurrences
 2Ø2-B2     SERVICEPROVIDER ID             Ø1 – National provider            M                                  X(2)
            QUALIFIER                      identifier(NPI)
 2Ø1-B1     SERVICE PROVIDER ID                                              M                                  X(15)
 4Ø1-D1     DATE OF SERVICE                CCYYMMDD                          M                                  9(8)
 11Ø-AK     SOFTWARE                                                         M          The MassHealth          X(1Ø)
            VENDOR/CERTIFICATION ID                                                     registration number
                                                                                        assigned to software
                                                                                        as part of initial
                                                                                        certification.

 Insurance Segment Questions               Check                Service Billing/Service Rebill
                                                                If Situational, Payer Situation
 This segment is always sent.                      X

            Insurance Segment                                                           Service
            Segment Identification (111-                                                Billing/Service
            AM) = Ø4                                                                    Rebill
Field #     NCPDP Field Name               Value                       Payer Usage      Payer Situation         Field Format
111-AM      SEGMENT IDENTIFICATION                                          M                                   X(2)
3Ø2-C2      CARDHOLDER ID                                                   M           The 12-digit            X(2Ø)
                                                                                        MassHealth member
                                                                                        ID number
312-CC      CARDHOLDER FIRST NAME                                            R                                  X(12)
313-CD      CARDHOLDER LAST NAME                                             R                                  X(15)
314-CE      HOME PLAN                                                        N
524-FO      PLAN ID                                                          Q
3Ø9-C9      ELIGIBILITY CLARIFICATION                                        N
            CODE
3Ø1-C1      GROUP ID                       MassHealth                        R                                  X(15)
                                           HSN
3Ø3-C3      PERSON CODE                                                      N
3Ø6-C6      PATIENT RELATIONSHIP           Ø=Not specified                   N
            CODE                           1=Cardholder
359-2A      MEDIGAP ID                                                      QM                                  X(2Ø)
36Ø-2B      MEDICAID INDICATOR                                              QM                                  X(2)
361-2D      PROVIDER ACCEPT                Y=CMS qualified facility         QM                                  X(1)
            ASSIGNMENT INDICATOR           N=Not a CMS qualified
                                           facility

 Patient Segment Questions                 Check                Service Billing/Service Rebill
                                                                If Situational, Payer Situation
 This segment is always sent.                      X
 This segment is situational.



                                                         -56-
                       Commonwealth of Massachusetts
                Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                     Version 12.0

             Patient Segment                                                                Service
             Segment Identification (111-                                                   Billing/Service
             AM) = Ø1                                                                       Rebill
 Field #     NCPDP Field Name                 Value                        Payer Usage      Payer Situation    Field Format
 111-AM      SEGMENT IDENTIFICATION                                             M                              X(2)
 331-CX      PATIENT ID QUALIFIER                                               N
 332-CY      PATIENT ID                                                         N
 3Ø4-C4      DATE OF BIRTH                    CCYYMMDD                          R                              9(8)
 3Ø5-C5      PATIENT GENDER CODE              1=Male                            R                              9(1)
                                              2=Female
 31Ø-CA      PATIENT FIRST NAME                                                  I                             X(12)
 311-CB      PATIENT LAST NAME                                                   I                             X(15)
 322-CM      PATIENT STREET ADDRESS                                              N
 323-CN      PATIENT CITY ADDRESS                                                N
 324-CO      PATIENT STATE / PROVINCE                                            N
             ADDRESS
 325-CP      PATIENT ZIP/POSTAL ZONE                                             N
 326-CQ      PATIENT PHONE NUMBER                                                N
 3Ø7-C7      PLACE OF SERVICE                 Ø1=Pharmacy                        R                             9(2)
             (formerly patient location)
 333-CZ      EMPLOYER ID                                                         N
 334-1C      SMOKER/NONSMOKER CODE            Yes = Smoker                       Q                             X(1)
                                              No= Nonsmoker
 335-2C       PREGNANCY INDICATOR             Blank=Not specified                Q                             X(1)
                                              1=Not pregnant
                                              2=Pregnant
 35Ø-HN      PATIENT E-MAIL ADDRESS                                              N
 384-4X      PATIENT RESIDENCE                Ø=Not specified                    R                             9(2)
                                              1=Home
                                              2=Skilled nursing facility
                                              3=Nursing
                                              4=Assisted living facility
                                              5=Custodial care facility
                                              6=Group home
                                              7=Inpatient psychiatric
                                              facility
                                              8=Psychiatric facility
                                              9=Intermediate care
                                              facility/mentally retarded
                                              1Ø=Residential
                                              substance abuse
                                              treatment facility
                                              11=Hospice
                                              12=Psychiatric
                                              residential treatment
                                              facility
                                              13=Comprehensive
                                              Inpatient rehabilitation
                                              facility
                                              14=Homeless shelter
                                              15=Correctional institute

 Claim Segment Questions                      Check                 Service Billing/Service Rebill
                                                                    If Situational, Payer Situation
 This segment is always sent.                         X
 This payer supports partial fills.
 This payer does not support partial fills.




                                                             -57-
                    Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                         Version 12.0

            Claim Segment                                                            Service
            Segment Identification (111-                                             Billing/Service
            AM) = Ø7                                                                 Rebill
 Field #    NCPDP Field Name               Value                       Payer Usage   Payer Situation               Field Format
 111-AM    SEGMENT IDENTIFICATION                                           M                                      X(2)
 455-EM    PRESCRIPTION/SERVICE            2=Service billing                M                                      X(1)
           REFERENCE NUMBER
           QUALIFIER
 4Ø2-D2    PRESCRIPTION/SERVICE                                            M                                       9(12)
           REFERENCE NUMBER
 436-E1    PRODUCT/SERVICE ID              Ø9=HCPCS                        M                                       X(2)
           QUALIFIER
 4Ø7-D7    PRODUCT/SERVICE ID                                              M         For vaccine                   X(19)
                                                                                     administration, where
                                                                                     the vaccine is
                                                                                     obtained at no cost to
                                                                                     the pharmacy, enter
                                                                                     the HCPCS code for
                                                                                     the vaccine
                                                                                     administered.
 456-EN    ASSOCIATED                                                      N
           PRESCRIPTION/SERVICE
           REFERENCE NUMBER
 457-EP    ASSOCIATED                                                      N
           PRESCRIPTION/SERVICE
           DATE
 458-SE    PROCEDURE MODIFIER CODE         Maximum count of 1Ø             Q                                       9(2)
           COUNT
 459-ER    PROCEDURE MODIFIER CODE                                      Q***R***                                   X(2)
 442-E7    QUANTITY DISPENSED              Metric decimal quantity         Q                                       s9(7)v999
 4Ø3-D3    FILL NUMBER                                                     N
 4Ø5-D5    DAYS SUPPLY                                                     Q                                       9(3)
 414-DE    DATE PRESCRIPTION               CCYYMMDD                        Q                                       9(8)
           WRITTEN
 415-DF    NUMBER OF REFILLS                                               N
           AUTHORIZED
 46Ø-ET    QUANTITY PRESCRIBED                                             Q                                       s9(7)v99
 3Ø8-C8    OTHER COVERAGE CODE             ØØ=Not specified                Q         If the submitter              9(2)
                                           Ø1=No other coverage                       chooses not to
                                           has been identified.                       transmit this field, they
                                           Ø2=Other coverage                          are representing to
                                           exists. Payment was                        MassHealth that there
                                           collected.                                 is no other insurance.
                                           Ø3=Other coverage                          Therefore, a “not
                                           exists. This claim is not                  specified” situation is
                                           covered.                                   implied. MassHealth
                                           Ø8=Claim is a billing for                  will reject the
                                           a copayment.                               transaction if a COB
                                                                                      segment is present.
                                                                                      Values other than ØØ
                                                                                      require a valid COB
                                                                                      segment.
                                                                                     A value of Ø8 must be
                                                                                      used only when the
                                                                                      other insurer has
                                                                                      applied 100% of the
                                                                                      billed amount to the
                                                                                      patient responsibility.
 453-EJ    ORIGINALLY PRESCRIBED                                           N
           PRODUCT/SERVICE ID
           QUALIFIER

                                                          -58-
                   Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                     Version 12.0

            Claim Segment                                                            Service
            Segment Identification (111-                                             Billing/Service
            AM) = Ø7                                                                 Rebill
 Field #    NCPDP Field Name               Value                      Payer Usage    Payer Situation           Field Format
 445-EA    ORIGINALLY PRESCRIBED                                           N
           PRODUCT/SERVICE CODE
 446-EB    ORIGINALLY PRESCRIBED                                          N
           QUANTITY
 454-EK    SCHEDULED PRESCRIPTION                                         N
           ID NUMBER
 418-DI    LEVEL OF SERVICE                Ø3=Emergency                   Q                                    9(2)
 461-EU    PRIOR AUTHORIZATION TYPE        Ø=Not specified                Q                                    9(1)
           CODE                            1=Prior authorization
 462-EV    PRIOR AUTHORIZATION                                            Q                                    9(11)
           NUMBER SUBMITTED
 463-EW    INTERMEDIARY                                                   N
           AUTHORIZATION TYPE ID
 464-EX    INTERMEDIARY                                                   N
           AUTHORIZATION ID
 357-NV    DELAY REASON CODE               1=Proof of eligibility         Q          Required when             9(2)
                                           unknown or unavailable                    needed to specify the
                                           2=Litigation                              reason that
                                           3=Authorization delay                     submission of the
                                           4=Delay in certifying                     transaction has been
                                           provider                                  delayed.
                                           5=Delay in supplying
                                           billing forms
                                           7=Third party processing
                                           delay
                                           8=Delay in eligibility
                                           determination
                                           9=Original claims
                                           rejected
                                           1Ø=Administrative delay
                                           in the prior approval
                                           process
                                           11=Other
                                           12=Received late with
                                           no exceptions
 391-MT    PATIENT ASSIGNMENT                                             N
           INDICATOR (DIRECT MEMBER
           REIMBURSEMENT
           INDICATOR)
 147-U7    PHARMACY SERVICE TYPE           1=Community/retail              I        Required for members       9(2)
                                           pharmacy services                        with commercial
                                           2=Compounding                            insurance that use mail
                                           pharmacy services                        order pharmacies.
                                           3=Home infusion therapy
                                           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


                                                         -59-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                         Version 12.0

 Pricing Segment Questions      Check                 Service Billing/Service Rebill
                                                      If Situational, Payer Situation
 This segment is always sent.             X

           Pricing Segment                                                               Service
           Segment Identification (111-                                                  Billing/Service
           AM) = 11                                                                      Rebill
 Field #   NCPDP Field Name                   Value                      Payer Usage     Payer Situation           Field Format
 111-AM    SEGMENT IDENTIFICATION                                             M                                    X(2)
 477-BE    PROFESSIONAL SERVICE FEE                                           R          Use this field for the    s9(6)v99
           SUBMITTED                                                                     vaccine administration
                                                                                         fee when the vaccine
                                                                                         serum is obtained at
                                                                                         no cost.
 433-DX    PATIENT PAID AMOUNT                                                 R         The MassHealth copay s9(6)v99
           SUBMITTED                                                                     amount the pharmacy
                                                                                         received from the
                                                                                         patient for the
                                                                                         prescription dispensed.
 478-H7    OTHER AMOUNT CLAIMED               Maximum count of three          Q                                  9(1)
           SUBMITTED COUNT
 479-H8    OTHER AMOUNT CLAIMED                                               NR                                   X(2)
           SUBMITTED QUALIFIER
 48Ø-H9    OTHER AMOUNT CLAIMED                                               NR                                   s9(6)v99
           SUBMITTED
 481-HA    FLAT SALES TAX AMOUNT                                               N
           SUBMITTED
 482-GE    PERCENTAGE SALES TAX                                                N
           AMOUNT SUBMITTED
 483-HE    PERCENTAGE SALES TAX                                                N
           RATE SUBMITTED
 426-DQ    USUAL AND CUSTOMARY                                                 R                                   s9(6)v99
           CHARGE
43Ø-DU     GROSS AMOUNT DUE                                                    R                                   s9(6)v99

 Pharmacy Provider Segment Questions          Check             Service Billing/Service Rebill
                                                                If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                         X

           Pharmacy Provider Segment                                                     Service
           Segment Identification (111-                                                  Billing/Service Refill
           AM) = Ø2
 Field #   NCPDP Field Name                   Value                      Payer Usage     Payer Situation           Field Format
 111-AM    SEGMENT IDENTIFICATION                                             M                                    X(2)
 465-EY    PROVIDER ID QUALIFIER              Ø5=National provider            Q                                    X(2)
                                              identifier (NPI)
 444-E9    PROVIDER ID                                                        Q                                    X(15)

 Prescriber Segment Questions                 Check             Service Billing/Service Rebill
                                                                If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                                   Segment not supported.




                                                            -60-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                           Version 12.0

           Prescriber Segment                                                              Service
           Segment Identification (111-                                                    Billing/Service
           AM) = Ø3                                                                        Rebill
 Field #   NCPDP Field Name                    Value                      Payer Usage      Payer Situation            Field Format
 111-AM    SEGMENT IDENTIFICATION                                              M                                      X(2)
 466-EZ    PRESCRIBER ID QUALIFIER             Ø1= National provider           R                                      X(2)
                                               identifier (NPI)
 411-DB    PRESCRIBER ID                                                        R                                     X(15)
 427-DR    PRESCRIBER LAST NAME                                                 R                                     X(15)
 498-PM    PRESCRIBER PHONE                                                     I                                     9(1Ø)
           NUMBER
 468-2E    PRIMARY CARE PROVIDER ID            Blank=Not specified              I                                     X(2)
           QUALIFIER                           Ø1=National provider
                                               identifier (NPI)
                                               Ø2=Blue Cross
                                               Ø3=Blue Shield
                                               Ø4=Medicare
                                               Ø5=Medicaid
                                               Ø6=UPIN
                                               Ø7=NCPDP provider ID
                                               Ø8=State license
                                               Ø9=TriCare
                                               1Ø=Health industry
                                               number (HIN)
                                               11=Federal tax ID
                                               12=Drug Enforcement
                                               Administration (DEA)
                                               13=State issued
                                               14=Plan specific
                                               99=Other
 421-DL PRIMARY CARE PROVIDER ID                                                I                                     X(15)
 47Ø-4E PRIMARY CARE PROVIDER                                                   I                                     X(15)
        LAST NAME
 364-2J PRESCRIBER FIRST NAME                                                   I
 365-2K PRESCRIBER STREET                                                       N
        ADDRESS
 366-2M PRESCRIBER CITY ADDRESS                                                 N

 367-2N PRESCRIBER                                                              N
        STATE/PROVINCE ADDRESS
 368-2P PRESCRIBER ZIP/POSTAL                                                   N
        ZONE

 Coordination of Benefits/Other                Check                   Service Billing/Service Rebill
 Payments Segment Questions                                            If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                           X              Required only for secondary, tertiary, etc., claims.

 Scenario 1 - Other payer amount paid
 repetitions only.
 Scenario 2 - Other payer-patient
 responsibility amount repetitions, and
 benefit stage repetitions only.
 Scenario 3 - Other payer amount paid, other            X
 payer-patient responsibility amount, and
 benefit stage repetitions present
 (government programs).




                                                            -61-
                  Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                    Version 12.0

All service claims submitted to POPS are adjudicated for other insurance coverage, also known as
third-party liability (TPL). If primary insurance is listed in the MassHealth member eligibility file, the
billing entity must indicate that the insurance was billed prior to submitting the claim to MassHealth.
Therefore, all billers must have online split-billing capability. After billing the primary payer, enter the
appropriate information for the required split-billing fields on the claim submission (see below).
           Coordination of                                                       Service Billing/Service
           Benefits/Other                                                        Rebill
           Payments Segment
           Segment Identification                                                Scenario 3 - Other Payer
           (111-AM) = Ø5                                                         Amount Paid, Other
                                                                                 Payer-Patient
                                                                                 Responsibility Amount,
                                                                                 and Benefit Stage
                                                                                 Repetitions Present
                                                                                 (Government Programs)
Field #    NCPDP Field Name         Value                          Payer Usage   Payer Situation             Field Format
111-AM    SEGMENT                                                       M                                    X(2)
          IDENTIFICATION
 337-4C   COORDINATION OF           Maximum count of nine              M                                     9(1)
          BENEFITS/OTHER
          PAYMENTS COUNT
 338-5C   OTHER PAYER               Blank=Not specified             M***R***                                 X(2)
          COVERAGE TYPE             Ø1=Primary
                                    Ø2=Secondary
                                    Ø3=Tertiary
                                    Ø4=Quaternary – fourth
                                    Ø5=Quinary – fifth
                                    Ø6=Senary – sixth
                                    Ø7=Septenary - seventh
                                    Ø8=Octonary – eighth
                                    Ø9=Nonary – ninth
 339-6C   OTHER PAYER ID            3=BIN                           R***R***                                  X(2)
          QUALIFIER                 99=Other
 34Ø-7C   OTHER PAYER ID                                            R***R***                                  X(1Ø)
 443-E8   OTHER PAYER DATE          CCYYMMDD                        I***R***                                  9(8)
 341-HB   OTHER PAYER AMOUNT        Maximum count of nine               Q                                     9(1)
          PAID COUNT
 342-HC   OTHER PAYER AMOUNT        Blank=not specified             Q***R***     MassHealth requires that     X(2)
          PAID QUALIFIER            Ø1=Delivery Cost - An                        one of these occurrences
                                    indicator that signifies the                 must contain the
                                    amount claimed for the                       payment dollars
                                    costs related to the                         associated with the drug
                                    delivery of a product or                     benefit (Ø7=Drug Benefit)
                                    service.
                                    Ø2=Shipping Cost - The
                                    amount claimed for
                                    transportation of an item.
                                    Ø3=Postage Cost - The
                                    amount claimed for the
                                    mailing of an item.
                                    Ø4=Administrative Cost -
                                    An indicator conveying the
                                    following amount is related
                                    to the cost of activities
                                    such as utilization review,
                                    premium collection, claims
                                    processing, quality
                                    assurance, and risk
                                    management for purposes
                                    of insurance.
                                                        -62-
                  Commonwealth of Massachusetts
            Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                     Version 12.0

           Coordination of                                                      Service Billing/Service
           Benefits/Other                                                       Rebill
           Payments Segment
           Segment Identification                                               Scenario 3 - Other Payer
           (111-AM) = Ø5                                                        Amount Paid, Other
                                                                                Payer-Patient
                                                                                Responsibility Amount,
                                                                                and Benefit Stage
                                                                                Repetitions Present
                                                                                (Government Programs)
 Field #   NCPDP Field Name         Value                         Payer Usage   Payer Situation               Field Format
                                    Ø5=Incentive - An
                                    indicator that signifies the
                                    dollar amount paid by the
                                    other payer, which is
                                    related to additional fees
                                    or compensations paid as
                                    an inducement for an
                                    action taken by the
                                    provider (e.g., collection of
                                    survey data, counseling
                                    plan enrollees, vaccine
                                    administration).
                                    Ø6=Cognitive Service - An
                                    indicator that signifies the
                                    dollar amount paid by the
                                    other payer, which is
                                    related to the pharmacist's
                                    interaction with a patient or
                                    caregiver that is beyond
                                    the traditional
                                    dispensing/patient
                                    instruction activity (e.g.,
                                    therapeutic regimen
                                    review; recommendation
                                    for additional, fewer or
                                    different therapeutic
                                    choices).
                                    Ø7=Drug Benefit - An
                                    indicator that signifies the
                                    dollar amount paid by the
                                    other payer, which is
                                    related to the plan's drug
                                    benefit.
                                    Ø9=Compound
                                    Preparation Cost
                                    Submitted - The amount
                                    claimed for the preparation
                                    of the compound.
                                    1Ø=Sales Tax - An
                                    Indicator that signifies the
                                    dollar amount paid by the
                                    other payer, which is
                                    related to sales tax.
 431-DV    OTHER PAYER AMOUNT       s$$$$$$cc                       Q***R***    When payment from              s9(6)v99
           PAID                                                                 other insurance is
                                                                                returned, use value of
                                                                                Ø7-drug benefit” in Field
                                                                                342 and put the $$
                                                                                amount returned (in Field
                                                                                509) into this field (431).
 471-5E    OTHER PAYER REJECT       Maximum count of five            Q          Only populated when            9(2)
           COUNT                                                                claim denies from other
                                                       -63-
                  Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                  Version 12.0

           Coordination of                                                      Service Billing/Service
           Benefits/Other                                                       Rebill
           Payments Segment
           Segment Identification                                               Scenario 3 - Other Payer
           (111-AM) = Ø5                                                        Amount Paid, Other
                                                                                Payer-Patient
                                                                                Responsibility Amount,
                                                                                and Benefit Stage
                                                                                Repetitions Present
                                                                                (Government Programs)
 Field #   NCPDP Field Name         Value                      Payer Usage      Payer Situation            Field Format
                                                                                 insurance
                                                                                 (Medicare or private).
 472-6E    OTHER PAYER REJECT                                    Q***R***       MassHealth requires the     X(3)
           CODE                                                                 NCPDP reject code from
                                                                                the other payer when the
                                                                                other payer denies the
                                                                                claim (OCC3).
 353-NR    OTHER PAYER-PATIENT      Maximum count of 25          R***R***                                   9(2)
           RESPONSIBILITY
           AMOUNT COUNT
 351-NP    OTHER PAYER-PATIENT      Ø1=Deductible                R***R***       Submit a separate          X(2)
           RESPONSIBILITY           Ø5=Copay                                    occurrence with the
           AMOUNT QUALIFIER         Ø7=Coinsurance                              applicable qualifier (351)
                                                                                and corresponding $$
                                                                                amount (352) when other
                                                                                payer has communicated
                                                                                the patient financial
                                                                                responsibility.
 352-NQ    OTHER PAYER-PATIENT                                   R***R***                                  s9(6)V99
           RESPONSIBILITY
           AMOUNT
 392-MU    BENEFIT STAGE COUNT      Maximum count of four           Q                                       9(1)
 393-MV    BENEFIT STAGE            Blank not specified          Q***R***                                   X(2)
           QUALIFIER                Ø1=Deductible
                                    Ø2=Initial benefit
                                    Ø3= Coverage gap (donut
                                    hole)
                                    Ø4=Catastrophic coverage
 394-MW    BENEFIT STAGE AMOUNT                                  Q***R***                                   s9(6)V99

 Workers’ Compensation Segment      Check                 Service Billing/Service Rebill
 Questions                                                If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                             Segment not supported.

           Workers’ Compensation                                                Service Billing/Service
           Segment                                                              Rebill
           Segment Identification
           (111-AM) = Ø6
 Field #   NCPDP Field Name         Value                      Payer Usage      Payer Situation            Field Format
 111-AM    SEGMENT                                                  M                                      X(2)
           IDENTIFICATION
 434-DY    DATE OF INJURY                                            M
 315-CF    EMPLOYER NAME
 316-CG    EMPLOYER STREET
           ADDRESS
 317-CH    EMPLOYER CITY
           ADDRESS
 318-CI    EMPLOYER
           STATE/PROVINCE
                                                     -64-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                    Version 12.0

            Workers’ Compensation                                                  Service Billing/Service
            Segment                                                                Rebill
            Segment Identification
            (111-AM) = Ø6
 Field #    NCPDP Field Name         Value                       Payer Usage       Payer Situation           Field Format
            ADDRESS
 319-CJ     EMPLOYER ZIP/POSTAL
            ZONE
 32Ø-CK     EMPLOYER PHONE
            NUMBER
 321-CL     EMPLOYER CONTACT
            NAME
 327-CR     CARRIER ID
 435-DZ     CLAIM/REFERENCE ID
 117-TR     BILLING ENTITY TYPE                                       R
            INDICATOR
 118-TS     PAY TO QUALIFIER
 119-TT     PAY TO ID
 12Ø-TU     PAY TO NAME
 121-TV     PAY TO STREET
            ADDRESS
 122-TW     PAY TO CITY ADDRESS
 123-TX     PAY TO
            STATE/PROVINCE
            ADDRESS
 124-TY     PAY TO ZIP/POSTAL
            ZONE
 125-TZ     GENERIC EQUIVALENT
            PRODUCT ID QUALIFIER
 126-UA     GENERIC EQUIVALENT
            PRODUCT ID

 DUR/PPS Segment Questions           Check                 Service Billing/Service Rebill
                                                           If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                              Segment not supported.

            DUR/PPS Segment                                                        Service Billing/Service
            Segment Identification                                                 Rebill
            (111-AM) = Ø8
 Field #    NCPDP Field Name         Value                       Payer Usage       Payer Situation           Field Format
 111-AM     SEGMENT                                                   M                                      X(2)
            IDENTIFICATION
 473-7E     DUR/PPS CODE             Maximum of nine                  R                                       9(1)
            COUNTER                  occurrences
 439-E4     REASON FOR SERVICE       DD=Drug-drug interaction     R***R***
            CODE                     HD=High dose
            (also known as the DUR   ID=Ingredient duplication
            conflict code)           TD=Therapeutic
                                     duplication
                                     ER=Early refill
 44Ø-E5     PROFESSIONAL             MA= Medication               R***R***     .                              X(2)
            SERVICE CODE             administration
                                     MØ=Prescriber consulted
                                     RØ=Pharmacist consulted
                                     other source
 441-E6     RESULT OF SERVICE        1A=Filled as is, false       R***R***                                    X(2)
            CODE                     positive
            (also known as the DUR   1B=Filled prescription as
            outcome code)            is
                                                       -65-
                   Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                Version 12.0

           DUR/PPS Segment                                                     Service Billing/Service
           Segment Identification                                              Rebill
           (111-AM) = Ø8
 Field #   NCPDP Field Name         Value                        Payer Usage   Payer Situation           Field Format
                                    1C=Filled, with different
                                    dose
                                    1D=Filled, with different
                                    directions
                                    1E=Filled, with different
                                    drug
                                    1F=Filled, with different
                                    quantity
                                    1G=Filled, with prescriber
                                    approval
 474-8E    DUR/PPS LEVEL OF         ØØ =Not specified              I***R***                               9(2)
           EFFORT                   11=Level 1 – Less than
                                    five min.
                                    12=Level 2 – Less than 15
                                    min.
                                    13=Level 3 – Less than 30
                                    min.
                                    14=Level 4 – Less than
                                    one hour
                                    15=Level 5 – Greater than
                                    one hour
 475-J9    DUR COAGENT ID           Ø1=Universal Product           I***R***                               X(2)
           QUALIFIER                Code (UPC)
                                    Ø2=Health-related item
                                    (HRI)
                                    Ø3=National Drug Code
                                    (NDC)
                                    Ø4=Universal product
                                    number (UPN)
                                    Ø5=Department of
                                    Defense (DOD)
                                    Ø7=Common procedure
                                    terminology CPT4)
                                    Ø8=Common procedure
                                    terminology (CPT5)
                                    Ø9=Health Care
                                    Financing Administration
                                    Common
                                    Procedural Coding
                                    System (HCPCS)
                                    11=National
                                    Pharmaceutical Product
                                    Interface code
                                    (NAPPI)
                                    12=International article
                                    numbering system (EAN)
                                    13=Drug identification
                                    number (DIN)
                                    14=Medi-Span GPI
                                    15=First DataBank GCN
                                    16=Medical economics
                                    GPO
                                    17=Medi-Span DDID
                                    18=First DataBank
                                    SmartKey
                                    19=Medical economics
                                    GM
                                    20=International
                                    classification of diseases
                                                       -66-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                     Version 12.0

            DUR/PPS Segment                                                       Service Billing/Service
            Segment Identification                                                Rebill
            (111-AM) = Ø8
 Field #    NCPDP Field Name         Value                        Payer Usage     Payer Situation              Field Format
                                     (ICD-9)
                                     21=International
                                     classification of diseases
                                     (ICD1Ø)
                                     22=Medi-Span diagnosis
                                     code
                                     23=National Criteria Care
                                     Institute (NCCI)
                                     24=The Systematized
                                     Nomenclature of Human
                                     and
                                     Veterinary Medicine
                                     (SNOMED)
                                     25=Common dental
                                     terminology (CDT)
                                     26=American Psychiatric
                                     Association Diagnostic
                                     Statistical Manual of
                                     Mental Disorders (DSM
                                     IV)
                                     99=Other
 476-H6    DUR COAGENT ID                                            I***R***                                   X(19)

 Coupon Segment Questions            Check                 Service Billing/Service Rebill
                                                           If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                              Segment not supported.

            Coupon Segment                                                        Service Billing/Service
            Segment Identification                                                Rebill
            (111-AM) = Ø9
 Field #    NCPDP Field Name         Value                        Payer Usage     Payer Situation              Field Format
 111-AM     SEGMENT                                                    M                                       X(2)
            IDENTIFICATION
 485-KE     COUPON TYPE                                                M                                       X(2)
 486-ME     COUPON NUMBER                                              M                                       X(15)
 487-NE     COUPON VALUE                                               Q                                       s9(6)v99
            AMOUNT

 Compound Segment Questions           Check                                         Service Billing/Service Rebill
                                                                                    If Situational, Payer Situation
 This segment is always sent.                                                       1
 This segment is situational.                                                       Segment not supported.




                                                        -67-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                     Version 12.0

            Compound Segment                                                         Service
            Segment Identification (111-                                             Billing/Service Rebill
            AM) = 1Ø
 Field #    NCPDP Field Name               Value                        Payer        Payer Situation          Field Format
                                                                        Usage
 111-AM     SEGMENT IDENTIFICATION                                        M                                   X(2)
 45Ø-EF     COMPOUND DOSAGE                Blank=Not specified            M                                   X(2)
            FORM DESCRIPTION CODE          Ø1=Capsule
                                           Ø2=Ointment
                                           Ø3=Cream
                                           Ø4=Suppository
                                           Ø5=Powder
                                           Ø6=Emulsion
                                           Ø7=Liquid
                                           1Ø=Tablet
                                           11=Solution
                                           12=Suspension
                                           13=Lotion
                                           14=Shampoo
                                           15=Elixir
                                           16=Syrup
                                           17=Lozenge
                                           18=Enema

 Clinical Segment Questions                Check                 Service Billing/Service Rebill
                                                                 If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                      X

            Clinical Segment                                                           Service
            Segment Identification (111-                                               Billing/Service
            AM) = 13                                                                   Rebill
Field #     NCPDP Field Name               Value                      Payer Usage      Payer Situation        Field Format
111-AM      SEGMENT IDENTIFICATION                                         M                                  X(2)
491-VE      DIAGNOSIS CODE COUNT           Maximum count of five           N
492-WE      DIAGNOSIS CODE                                              N***R***
            QUALIFIER
424-DO      DIAGNOSIS CODE                                               N***R***
493-XE      CLINICAL INFORMATION           Maximum five                     Q                                 9(1)
            COUNTER                        occurrences supported
494-ZE      MEASUREMENT DATE               CCYYMMDD                     Q***R***                              9(8)
495-H1      MEASUREMENT TIME               HHMM                         Q***R***                              9(4)
496-H2      MEASUREMENT                    Blank=Not specified          Q***R***                              X(2)
            DIMENSION                      Ø1=Blood pressure (BP)
                                           Ø2=Blood glucose level
                                           Ø3=Temperature
                                           Ø4=Serum creatinine
                                           (SCr)
                                           Ø5=HbA1c
                                           Ø6=Sodium (Na+)
                                           Ø7=Potassium (K+)
                                           Ø8=Calcium (Ca++)
                                           Ø9=Serum glutamic-
                                           oxaloacetic
                                           transaminase
                                           (SGOT)
                                           1Ø=Serum glutamic-
                                           pyruvic transaminase
                                           (SGPT)
                                           11=Alkaline

                                                          -68-
                   Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                           Version 12.0

           Clinical Segment                                                       Service
           Segment Identification (111-                                           Billing/Service
           AM) = 13                                                               Rebill
 Field #   NCPDP Field Name               Value                     Payer Usage   Payer Situation   Field Format
                                          phosphatase
                                          12=Serum theophylline
                                          level
                                          13=Serum digoxin level
                                          14=Weight
                                          15=Body surface area
                                          (BSA)
                                          16=Height
                                          17=Creatinine clearance
                                          (CrCl)
                                          18=Cholesterol
                                          19=Low-density
                                          lipoprotein (LDL)
                                          2Ø=High-density
                                          lipoprotein (HDL)
                                          21=Triglycerides (TG)
                                          22=Bone mineral density
                                          (BMD T-Score)
                                          23=Prothrombin time
                                          (PT)
                                          24=Hemoglobin (Hb;
                                          Hgb)
                                          25=Hematocrit (Hct)
                                          26=White blood cell
                                          count (WBC)
                                          27=Red blood cell count
                                          (RBC)
                                          28=Heart rate
                                          29=Absolute neutrophil
                                          count (ANC)
                                          3Ø=Activated partial
                                          thromboplastin time
                                          (APTT)
                                          31=CD4 count
                                          32=Partial
                                          thromboplastin time
                                          (PTT)
                                          33=T-cell count
                                          34=International
                                          normalized ratio (INR)
                                          99=Other
 497-H3    MEASUREMENT UNIT               Blank=Not specified        Q***R***                       X(2)
                                          Ø1=Inches (in)
                                          Ø2=Centimeters (cm)
                                          Ø3=Pounds (lb)
                                          Ø4=Kilograms (kg)
                                          Ø5=Celsius (C)
                                          Ø6=Fahrenheit (F)
                                          Ø7=Meters squared (m2)
                                          Ø8=Milligrams per
                                          deciliter (mg/dl)
                                          Ø9=Units per milliliter
                                          (U/ml)
                                          1Ø=Millimeters of
                                          mercury (mmHg)
                                          11=Centimeters squared
                                          (cm2)
                                          12=Millimeters per
                                          minute (ml/min)

                                                        -69-
                   Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                Version 12.0

           Clinical Segment                                                            Service
           Segment Identification (111-                                                Billing/Service
           AM) = 13                                                                    Rebill
 Field #   NCPDP Field Name               Value                       Payer Usage      Payer Situation   Field Format
                                          13=Percentage (%)
                                          14=Milliequivalent
                                          (mEq/ml)
                                          15=International units
                                          per liter (IU/l)
                                          16=Micrograms per
                                          milliliter (mcg/ml)
                                          17=Nanograms per
                                          milliliter (ng/ml)
                                          18=Milligrams per
                                          milliliter (mg/ml)
                                          19=Ratio
                                          2Ø=SI units
                                          21=Millimoles (mmol/l)
                                          22=Seconds
                                          23=Grams per deciliter
                                          (g/dl)
                                          24=Cells per cubic
                                          millimeter (cells/cu mm)
                                          25=1,ØØØ,ØØØ cells
                                          per cubic millimeter
                                          (million cells/cu
                                          mm)
                                          26=Standard deviation
                                          27=Beats per minute
 499-H4    MEASUREMENT VALUE              Blood pressure entered        Q***R***                         X(15)
                                          in XXX/YYY format in
                                          which
                                          XXX=systolic, /=divider,
                                          and YYY is diastolic.
                                          Temperature entered in
                                          XXX.X format always
                                          includes
                                          decimal point.
                                          Request clinical
                                          segment.

 Additional Documentation Segment         Check                  Service Billing/Service Rebill
 Questions                                                       If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                                    Segment not supported.

           Additional Documentation                                                    Service
           Segment                                                                     Billing/Service
           Segment Identification (111-                                                Rebill
           AM) = 14
Field #    NCPDP Field Name               Value                       Payer Usage      Payer Situation   Field Format
111-AM     SEGMENT IDENTIFICATION                                         M                              X(2)
369-2Q     ADDITIONAL                                                      M
           DOCUMENTATION TYPE ID
374-2V     REQUEST PERIOD BEGIN
           DATE
375-2W     REQUEST PERIOD
           RECERT/REVISED DATE
373-2U     REQUEST STATUS
371-2S     LENGTH OF NEED
           QUALIFIER

                                                          -70-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                              Version 12.0

            Additional Documentation                                                 Service
            Segment                                                                  Billing/Service
            Segment Identification (111-                                             Rebill
            AM) = 14
 Field #    NCPDP Field Name               Value                    Payer Usage      Payer Situation   Field Format
 37Ø-2R     LENGTH OF NEED
 372-2T     PRESCRIBER/SUPPLIER
            DATE SIGNED
 376-2X     SUPPORTING
            DOCUMENTATION
 377-2Z     QUESTION                       Maximum count of 5Ø
            NUMBER/LETTER COUNT
 378-4B     QUESTION
            NUMBER/LETTER
 379-4D     QUESTION PERCENT
            RESPONSE
 38Ø-4G     QUESTION DATE
            RESPONSE
 381-4H     QUESTION DOLLAR
            AMOUNT RESPONSE
 382-4J     QUESTION NUMERIC
            RESPONSE
 383-4K     QUESTION ALPHANUMERIC
            RESPONSE

 Facility Segment Questions                Check               Service Billing/Service Rebill
                                                               If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                                  Segment not supported.

              Facility Segment                                                       Service
              Segment Identification                                                 Billing/Service
              (111-AM) = 15                                                          Rebill
 Field #      NCPDP Field Name             Value                    Payer Usage      Payer Situation   Field Format
 111-AM       SEGMENT                                                    M                             X(2)
              IDENTIFICATION
 336-8C       FACILITY ID
 385-3Q       FACILITY NAME
 386-3U       FACILITY STREET
              ADDRESS
 388-5J       FACILITY CITY ADDRESS
 387-3V       FACILITY
              STATE/PROVINCE
              ADDRESS
 389-6D       FACILITY ZIP/POSTAL
              ZONE

 Narrative Segment Questions               Check               Service Billing/Service Rebill
                                                               If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                                  Segment not supported.




                                                        -71-
                 Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                       Version 12.0

           Narrative Segment                                                  Service
           Segment Identification                                             Billing/Service
           (111-AM) = 16                                                      Rebill
 Field #   NCPDP Field Name           Value                    Payer Usage    Payer Situation   Field Format
 111-AM    SEGMENT                                                  M                           X(2)
           IDENTIFICATION
 39Ø-BM    NARRATIVE MESSAGE

                     ** End of Request Service Billing/Service Rebill (S1/S3) Payer Sheet **




                                                     -72-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                 Version 12.0


4.2 Service Billing/Service Rebill Accepted/Paid (or Duplicate of Paid)
    Response
The following lists the segments and fields in a service billing or service rebill response (paid or
duplicate of paid) transaction for the NCPDP version D.Ø. Service billing includes service billing
transactions S1 and S3.
 Response Transaction Header         Check                  Service Billing/Service Rebill
 Segment Questions                                          Accepted/Paid (or Duplicate of Paid)
                                                            If Situational, Payer Situation
 This segment is always sent.                X

              Response Transaction                                                Service
              Header Segment                                                      Billing/Claim Rebill
                                                                                  – Accepted/Paid (or
                                                                                  Duplicate of Paid)
 Field #      NCPDP Field Name       Value                       Payer Usage      Payer Situation         Field Format
 1Ø2-A2       VERSION/RELEASE        DØ                               M                                   X(2)
              NUMBER
 1Ø3-A3       TRANSACTION CODE       S1, S3                            M                                  X(2)
 1Ø9-A9       TRANSACTION COUNT      1=One occurrence                  M                                  X(1)
                                     2=Two occurrences
                                     3=Three occurrences
                                     4=Four occurrences
 5Ø1-F1       HEADER RESPONSE        A=Accepted                        M                                  X(1)
              STATUS
 2Ø2-B2       SERVICE PROVIDER ID    Ø1 – National provider            M                                  X(2)
              QUALIFIER              identifier (NPI)
 2Ø1-B1       SERVICE PROVIDER ID                                      M                                  X(15)
 4Ø1-D1       DATE OF SERVICE        CCYYMMDD                          M                                  9(8)

 Response Message Segment            Check                  Service Billing/Claim Rebill
 Questions                                                  Accepted/Paid (or Duplicate of Paid)
                                                            If Situational, Payer Situation
 This segment is always sent.                X
 This segment is situational.                               Provide general information when used for transmission-level
                                                            messaging.




                                                     -73-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                 Version 12.0

              Response Message                                                     Service
              Segment                                                              Billing/Claim Rebill
              Segment Identification                                               – Accepted/Paid (or
              (111-AM) = 2Ø                                                        Duplicate of Paid)
 Field #      NCPDP Field Name             Value                    Payer Usage    Payer Situation        Field Format
 111-AM       SEGMENT                                                    M                                X(2)
              IDENTIFICATION
 5Ø4-F4       MESSAGE                                                    Q                                X(2ØØ)

 Response Insurance Segment                Check               Service Billing/Service Rebill
 Questions                                                     Accepted/Paid (or Duplicate of Paid)
                                                               If Situational, Payer Situation
 This segment is always sent.                      X
 This segment is situational.

            Response Insurance                                                     Service
            Segment                                                                Billing/Service
            Segment Identification (111-                                           Rebill –
            AM) = 25                                                               Accepted/Paid (or
                                                                                   Duplicate of Paid)
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation        Field Format
 111-AM     SEGMENT IDENTIFICATION                                      M                                 X(2)
 3Ø1-C1     GROUP ID                       MassHealth                    R                                X(15)
                                           HSN
 524-FO     PLAN ID                                                      Q
 545-2F     NETWORK                                                      N
            REIMBURSEMENT ID
 568-J7     PAYER ID QUALIFIER                                           N
 569-J8     PAYER ID                                                     N
 115-N5     MEDICAID ID NUMBER                                           N
 116-N6     MEDICAID AGENCY                                              N
            NUMBER
 3Ø2-C2     CARDHOLDER ID                                                N

 Response Patient Segment Questions        Check               Service Billing/Service Rebill
                                                               Accepted/Paid (or Duplicate of Paid)
                                                               If Situational, Payer Situation
 This segment is always sent.                      X
 This segment is situational.

            Response Patient Segment                                               Service
            Segment Identification (111-                                           Billing/Claim Rebill
            AM) = 29                                                               – Accepted/Paid (or
                                                                                   Duplicate of Paid)
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation        Field Format
 111-AM     SEGMENT IDENTIFICATION                                      M                                 X(2)
 31Ø-CA     PATIENT FIRST NAME                                           R                                X(12)
 311-CB     PATIENT LAST NAME                                            R                                X(15)
 3Ø4-C4     DATE OF BIRTH                  CCYYMMDD                      R                                9(8)

 Response Status Segment Questions         Check               Service Billing/Service Rebill
                                                               Accepted/Paid (or Duplicate of Paid)
                                                               If Situational, Payer Situation
 This segment is always sent.                      X




                                                        -74-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                      Version 12.0

            Response Status Segment                                                       Service
            Segment Identification (111-                                                  Billing/Service
            AM) = 21                                                                      Rebill –
                                                                                          Accepted/Paid (or
                                                                                          Duplicate of Paid)
 Field #    NCPDP Field Name               Value                           Payer Usage    Payer Situation      Field Format
 111-AM     SEGMENT IDENTIFICATION                                             M                               X(2)
 112-AN     TRANSACTION RESPONSE           P=Paid                               M                              X(1)
            STATUS                         D=Duplicate of paid
 5Ø3-F3     AUTHORIZATION NUMBER                                                R                              X(2Ø)
 547-5F     APPROVED MESSAGE               Maximum count of five                N
            CODE COUNT
 548-6F     APPROVED MESSAGE                                                 N***R***
            CODE
 13Ø-UF     ADDITIONAL MESSAGE             Maximum count of eight               Q                              9(2)
            INFORMATION COUNT
 132-UH     ADDITIONAL MESSAGE             Ø1                                Q***R***                          X(2)
            INFORMATION QUALIFIER
 526-FQ     ADDITIONAL MESSAGE                                               Q***R***                          X(4Ø)
            INFORMATION
 131-UG     ADDITIONAL MESSAGE             +                                 Q***R***                          X(1)
            INFORMATION
            CONTINUITY
 549-7F     HELP DESK PHONE                                                     N
            NUMBER QUALIFIER

 Response Claim Segment Questions          Check                      Service Billing/Service Rebill
                                                                      Accepted/Paid (or Duplicate of Paid)
                                                                      If Situational, Payer Situation
 This segment is always sent.                       X

            Response Claim Segment                                                        Service
            Segment Identification (111-                                                  Billing/Service
            AM) = 22                                                                      Rebill –
                                                                                          Accepted/Paid (or
                                                                                          Duplicate of Paid)
 Field #    NCPDP Field Name               Value                           Payer Usage    Payer Situation      Field Format
 111-AM     SEGMENT IDENTIFICATION                                             M                               X(2)
 455-EM     PRESCRIPTION/SERVICE           2=Service billing                    M                              X(1)
            REFERENCE NUMBER
            QUALIFIER
 4Ø2-D2     PRESCRIPTION/SERVICE                                                M                              9(12)
            REFERENCE NUMBER
 551-9F     PREFERRED PRODUCT              Maximum count of six                 N
            COUNT
 552-AP     PREFERRED PRODUCT ID                                             N***R***
            QUALIFIER
 553-AR     PREFERRED PRODUCT ID                                             N***R***
 554-AS     PREFERRED PRODUCT                                                N***R***
            INCENTIVE
 555-AT     PREFERRED PRODUCT                                                N***R***
            COST SHARE INCENTIVE
 556-AU     PREFERRED PRODUCT                                                N***R***
            DESCRIPTION

 Response Pricing Segment Questions        Check                      Service Billing/Service Rebill
                                                                      Accepted/Paid (or Duplicate of Paid)
                                                                      If Situational, Payer Situation
 This segment is always sent.                       X


                                                               -75-
                   Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                Version 12.0


           Response Pricing Segment                                            Service
           Segment Identification (111-AM)                                     Billing/Service
           = 23                                                                Rebill –
                                                                               Accepted/Paid (or
                                                                               Duplicate of Paid)
 Field #   NCPDP Field Name                  Value               Payer Usage   Payer Situation            Field Format
 111-AM    SEGMENT IDENTIFICATION                                     M                                   X(2)
 5Ø5-F5    PATIENT PAY AMOUNT                                         R                                   s9(6)v99
 5Ø6-F6    INGREDIENT COST PAID                                       Q                                   s9(6)v99
 5Ø7-F7    DISPENSING FEE PAID                                        Q                                   s9(6)v99
 557-AV    TAX EXEMPT INDICATOR                                       N
 558-AW    FLAT SALES TAX AMOUNT PAID                                 N
 559-AX    PERCENTAGE SALES TAX                                       N
           AMOUNT PAID
 56Ø-AY    PERCENTAGE SALES TAX                                      N
           RATE PAID
 561-AZ    PERCENTAGE SALES TAX                                      N
           BASIS PAID
 521-FL    INCENTIVE AMOUNT PAID                                     Q
 562-J1    PROFESSIONAL SERVICE PAID                                 R                                    s9(6)v99

 563-J2    OTHER AMOUNT PAID COUNT           Maximum count of        Q                                    9(1)
                                             three
 564-J3    OTHER AMOUNT PAID                 Ø4=Administrative    Q***R***     For Ø4=MassHealth          X(2)
           QUALIFIER                         Ø9=Compound                       administrative fee
                                             preparation cost                  associated with
                                                                               return to stock
                                                                               program.

                                                                               For Ø9= Compound
                                                                               prescription cost, this
                                                                               field contains the
                                                                               additional cost for the
                                                                               dispensing of
                                                                               compounds as per
                                                                               MassHealth
                                                                               regulation.
 565-J4    OTHER AMOUNT PAID                                      Q***R***                                s9(6)v99
 566-J5    OTHER PAYER AMOUNT                                        Q                                    s9(6)v99
           RECOGNIZED
 5Ø9-F9    TOTAL AMOUNT PAID                                         R                                    s9(6)v99

 522-FM    BASIS OF REIMBURSEMENT                                    R                                    9(2)
           DETERMINATION
 523-FN    AMOUNT ATTRIBUTED TO                                      N
           SALES TAX
 512-FC    ACCUMULATED DEDUCTIBLE                                    N
           AMOUNT
 513-FD    REMAINING DEDUCTIBLE                                      N
           AMOUNT
 514-FE    REMAINING BENEFIT AMOUNT          999999.ØØ               R                                    s9(6)v99

 517-FH    AMOUNT APPLIED TO                                         N
           PERIODIC DEDUCTIBLE
 518-FI    AMOUNT OF COPAY                                           Q                                    s9(6)v99

 52Ø-FK    AMOUNT EXCEEDING                                          N
           PERIODIC BENEFIT MAXIMUM
 346-HH    BASIS OF CALCULATION—                                     N
           DISPENSING FEE

                                                       -76-
                   Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                              Version 12.0

           Response Pricing Segment                                               Service
           Segment Identification (111-AM)                                        Billing/Service
           = 23                                                                   Rebill –
                                                                                  Accepted/Paid (or
                                                                                  Duplicate of Paid)
 Field #   NCPDP Field Name                  Value                  Payer Usage   Payer Situation       Field Format
 347-HJ    BASIS OF CALCULATION—             Ø1=Quantity                 Q                              X(2)
           COPAY                             dispensed
                                             Ø2=Quantity intended
                                             to be dispensed
                                             Ø3=Usual and
                                             customary/prorated
                                             Ø4=Waived due to
                                             partial fill
                                             99=Other
 348-HK    BASIS OF CALCULATION—FLAT                                    N
           SALES TAX
 349-HM    BASIS OF CALCULATION—                                        N
           PERCENTAGE SALES TAX
 571-NZ    AMOUNT ATTRIBUTED TO                                         N
           PROCESSOR FEE
 575-EQ    PATIENT SALES TAX AMOUNT                                     N
 574-2Y    PLAN SALES TAX AMOUNT                                        N
 572-4U    AMOUNT OF COINSURANCE                                        N
 573-4V    BASIS OF CALCULATION-                                        N
           COINSURANCE
 392-MU    BENEFIT STAGE COUNT               Maximum count of           Q                               9(1)
                                             four.
 393-MV    BENEFIT STAGE QUALIFIER           Blank=Not specified     Q***R***                           X(2)
                                             Ø1=Deductible
                                             Ø2 Initial benefit
                                             Ø3 Coverage gap
                                             (donut hole)
                                             Ø4 Catastrophic
                                             coverage
 394-MW    BENEFIT STAGE AMOUNT                                      Q***R***                           s9(6)v99
 577-G3    ESTIMATED GENERIC SAVINGS                                    N
 128-UC    SPENDING ACCOUNT AMOUNT                                      N
           REMAINING
 129-UD    HEALTH PLAN-FUNDED                                           N
           ASSISTANCE AMOUNT
 133-UJ    AMOUNT ATTRIBUTED TO                                         N
           PROVIDER NETWORK
           SELECTION
 134-UK    AMOUNT ATTRIBUTED TO                                         N
           PRODUCT SELECTION/BRAND
           DRUG
 135-UM    AMOUNT ATTRIBUTED TO                                         N
           PRODUCT
           SELECTION/NONPREFERRED
           FORMULARY SELECTION
 136-UN    AMOUNT ATTRIBUTED TO                                         N
           PRODUCT SELECTION/BRAND
           NONPREFERRED FORMULARY
           SELECTION
 137-UP    AMOUNT ATTRIBUTED TO                                         N
           COVERAGE GAP
 148-U8    INGREDIENT COST                                              N
           CONTRACTED/REIMBURSABLE
           AMOUNT



                                                        -77-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                      Version 12.0

            Response Pricing Segment                                                      Service
            Segment Identification (111-AM)                                               Billing/Service
            = 23                                                                          Rebill –
                                                                                          Accepted/Paid (or
                                                                                          Duplicate of Paid)
 Field #    NCPDP Field Name                   Value                    Payer Usage       Payer Situation        Field Format
 149-U9     DISPENSING FEE                                                   N
            CONTRACTED/REIMBURSABLE
            AMOUNT

 Response DUR/PPS Segment                  Check                 Service Billing/Service Rebill
 Questions                                                       Accepted/Paid (or Duplicate of Paid)
                                                                 If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                                    Segment not supported.

            Response DUR/PPS                                                          Service
            Segment                                                                   Billing/Service
            Segment Identification (111-                                              Rebill –
            AM) = 24                                                                  Accepted/Paid (or
                                                                                      Duplicate of Paid)
 Field #    NCPDP Field Name               Value                      Payer Usage     Payer Situation          Field Format
 111-AM     SEGMENT IDENTIFICATION                                        M                                    X(2)
 567-J6     DUR/PPS RESPONSE               Maximum nine                    Q                                   9(1)
            CODE COUNTER                   occurrences supported
 439-E4     REASON FOR SERVICE             DD=Drug-drug                 Q***R***                               X(2)
            CODE (also known as the        interaction
            DUR conflict code)             HD=High dose
                                           ID=Ingredient
                                           duplication
                                           TD=Therapeutic
                                           duplication
                                           ER=Early refill
 528-FS     CLINICAL SIGNIFICANCE                                       Q***R***                               X(1)
            CODE
 529-FT     OTHER PHARMACY                                              Q***R***                               9(1)
            INDICATOR
 53Ø-FU     PREVIOUS DATE OF FILL                                       Q***R***                               9(8)
 531-FV     QUANTITY OF PREVIOUS                                        Q***R***                               s9(7)v999
            FILL
 532-FW     DATABASE INDICATOR                                          Q***R***                               X(1)
 533-FX     OTHER PRESCRIBER                                            Q***R***                               9(1)
            INDICATOR
 544-FY     DUR FREE TEXT MESSAGE                                       Q***R***                               X(3Ø)
 57Ø-NS     DUR ADDITIONAL TEXT                                         Q***R***                               X(1ØØ)

 Response Coordination of                  Check                 Service Billing/Service Rebill
 Benefits/Other Payers Segment                                   Accepted/Paid (or Duplicate of Paid)
 Questions                                                       If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                      X

            Response Coordination of                                                  Service
            Benefits/Other Payers                                                     Billing/Service
            Segment                                                                   Rebill –
            Segment Identification (111-                                              Accepted/Paid (or
            AM) = 28                                                                  Duplicate of Paid)
 Field #    NCPDP Field Name               Value                      Payer Usage     Payer Situation          Field Format
 111-AM     SEGMENT IDENTIFICATION                                        M                                    X(2)
 355-NT     OTHER PAYER ID COUNT           Maximum count of three         M                                    9(1)

                                                          -78-
                   Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                  Version 12.0

           Response Coordination of                                                 Service
           Benefits/Other Payers                                                    Billing/Service
           Segment                                                                  Rebill –
           Segment Identification (111-                                             Accepted/Paid (or
           AM) = 28                                                                 Duplicate of Paid)
 Field #   NCPDP Field Name               Value                      Payer Usage    Payer Situation         Field Format
 338-5C    OTHER PAYER COVERAGE           Blank=Not specified         M***R***                              X(2)
           TYPE                           Ø1=Primary
                                          Ø2=Secondary
                                          Ø3=Tertiary
 339-6C    OTHER PAYER ID                 Blank=Not specified          Q***R***                             X(2)
           QUALIFIER                      3=BIN
                                          99=Other
 34Ø-7C    OTHER PAYER ID                                              Q***R***                             X(1Ø)
 991-MH    OTHER PAYER                                                 Q***R***                             X(1Ø)
           PROCESSOR CONTROL
           NUMBER
 356-NU    OTHER PAYER                                                 N***R***
           CARDHOLDER ID
 992-MJ    OTHER PAYER GROUP ID                                        Q***R***                             X(15)
 142-UV    OTHER PAYER PERSON                                          N***R***
           CODE
 127-UB    OTHER PAYER HELP DESK                                       N***R***
           PHONE NUMBER
 143-UW    OTHER PAYER PATIENT                                         N***R***
           RELATIONSHIP CODE
 144-UX    OTHER PAYER BENEFIT                                         N***R***
           EFFECTIVE DATE
 145-UY    OTHER PAYER BENEFIT                                         N***R***
           TERMINATION DATE


4.3 Service Billing/Service Rebill Accepted/Rejected Response

The following lists the segments and fields in a service billing/service rebill response
(accepted/rejected) transaction for the NCPDP version D.Ø.
 Response Transaction Header              Check                 Service Billing/Service Rebill Accepted/Rejected
 Segment Questions                                              If Situational, Payer Situation
 This segment is always sent.                     X

           Response Transaction                                                     Service
           Header Segment                                                           Billing/Claim Rebill
                                                                                    Accepted/Rejected
 Field #   NCPDP Field Name               Value                      Payer Usage    Payer Situation         Field Format
 1Ø2-A2    VERSION/RELEASE                DØ                              M                                 X(2)
           NUMBER
 1Ø3-A3    TRANSACTION CODE               S1, S3                          M                                 X(2)
 1Ø9-A9    TRANSACTION COUNT              1=One occurrence                M                                 X(1)
                                          2=Two occurrences
                                          3=Three occurrences
                                          4=Four occurrences
 5Ø1-F1    HEADER RESPONSE                A=Accepted                      M                                 X(1)
           STATUS
 2Ø2-B2    SERVICE PROVIDER ID                                            M                                 X(15)
           QUALIFIER
 2Ø1-B1    SERVICE PROVIDER ID                                            M                                 X(15)
 4Ø1-D1    DATE OF SERVICE                CCYYMMDD                        M                                 9(8)



                                                         -79-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                 Version 12.0

 Response Message Segment                  Check               Service Billing/Service Rebill Accepted/Rejected
 Questions                                                     If Situational, Payer Situation
 This segment is always sent.                      X
 This segment is situational.

            Response Message                                                       Service
            Segment                                                                Billing/Service
            Segment Identification (111-                                           Rebill
            AM) = “2Ø”                                                             Accepted/Rejected
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation         Field Format
 111-AM     SEGMENT IDENTIFICATION                                      M                                  X(2)
 5Ø4-F4     MESSAGE                                                      Q                                 X(2ØØ)

 Response Insurance Segment                Check               Service Billing/Service Rebill Accepted/Rejected
 Questions                                                     If Situational, Payer Situation
 This segment is always sent.                      X
 This segment is situational.

            Response Insurance                                                     Service
            Segment                                                                Billing/Service
            Segment Identification (111-                                           Rebill
            AM) = 25                                                               Accepted/Rejected
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation         Field Format
 111-AM     SEGMENT IDENTIFICATION                                      M                                  X(2)
 3Ø1-C1     GROUP ID                       MassHealth                    R                                 X(15)
                                           HSN
 524-FO     PLAN ID                                                      N
 545-2F     NETWORK                                                      N
            REIMBURSEMENT ID
 568-J7     PAYER ID QUALIFIER                                           N
 569-J8     PAYER ID                                                     N

 Response Patient Segment Questions        Check               Service Billing/Service Rebill Accepted/Rejected
                                                               If Situational, Payer Situation
 This segment is always sent.                      X
 This segment is situational.

            Response Patient Segment                                               Service
            Segment Identification (111-                                           Billing/Service
            AM) = 29                                                               Rebill
                                                                                   Accepted/Rejected
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation        Field Format
 111-AM     SEGMENT IDENTIFICATION                                      M                                 X(2)
 31Ø-CA     PATIENT FIRST NAME                                           Q                                X(12)
 311-CB     PATIENT LAST NAME                                            Q                                X(15)
 3Ø4-C4     DATE OF BIRTH                  CCYYMMDD                      Q                                9(8)

 Response Status Segment Questions         Check               Service Billing/Service Rebill Accepted/Rejected
                                                               If Situational, Payer Situation
 This segment is always sent.                      X

            Response Status Segment                                                Service
            Segment Identification (111-                                           Billing/Service
            AM) = 21                                                               Rebill
                                                                                   Accepted/Rejected
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation        Field Format
 111-AM     SEGMENT IDENTIFICATION                                      M                                 X(2)
 112-AN     TRANSACTION RESPONSE           R=Rejected                    M                                X(1)
            STATUS
                                                        -80-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                         Version 12.0

            Response Status Segment                                                       Service
            Segment Identification (111-                                                  Billing/Service
            AM) = 21                                                                      Rebill
                                                                                          Accepted/Rejected
 Field #    NCPDP Field Name               Value                           Payer Usage    Payer Situation         Field Format
 5Ø3-F3     AUTHORIZATION NUMBER                                                R                                 X(2Ø)

 51Ø-FA     REJECT COUNT                   Maximum count of five                R                                 9(2)
 511-FB     REJECT CODE                                                      R***R***     This field is           X(3)
                                                                                          mandatory when a
                                                                                          reject response is
                                                                                          returned.
 546-4F     REJECT FIELD                                                     Q***R***     This is the number of   9(2)
            OCCURRENCE INDICATOR                                                          rejected fields.
 13Ø-UF     ADDITIONAL MESSAGE             Maximum count of eight               Q                                 9(2)
            INFORMATION COUNT
 132-UH     ADDITIONAL MESSAGE             Ø1                                Q***R***                             X(2)
            INFORMATION QUALIFIER
 526-FQ     ADDITIONAL MESSAGE                                               Q***R***                             X(4Ø)
            INFORMATION
 131-UG     ADDITIONAL MESSAGE             +                                 Q***R***                             X(1)
            INFORMATION
            CONTINUITY
 549-7F     HELP DESK PHONE                                                     N
            NUMBER QUALIFIER
 55Ø-8F     HELP DESK PHONE                                                     N
            NUMBER

 Response Claim Segment Questions          Check                      Service Billing/Service Rebill Accepted/Rejected
                                                                      If Situational, Payer Situation
 This segment is always sent.                       X

            Response Claim Segment                                                        Service
            Segment Identification (111-                                                  Billing/Service
            AM) = “22”                                                                    Rebill
                                                                                          Accepted/Rejected
 Field #    NCPDP Field Name               Value                           Payer Usage    Payer Situation         Field Format
 111-AM     SEGMENT IDENTIFICATION                                             M                                  X(2)
 455-EM     PRESCRIPTION/SERVICE           2=Service billing                    M                                 X(1)
            REFERENCE NUMBER
            QUALIFIER
 4Ø2-D2     PRESCRIPTION/SERVICE                                                M                                 9(12)
            REFERENCE NUMBER

 Response DUR/PPS Segment                  Check                      Service Billing/Service Rebill Accepted/Rejected
 Questions                                                            If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                                         Segment not supported.




                                                               -81-
                   Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                  Version 12.0


           Response DUR/PPS                                                         Service
           Segment                                                                  Billing/Service
           Segment Identification (111-                                             Rebill
           AM) = 24                                                                 Accepted/Rejected
 Field #   NCPDP Field Name               Value                      Payer Usage    Payer Situation        Field Format
 111-AM    SEGMENT IDENTIFICATION                                        M                                 X(2)
 567-J6    DUR/PPS RESPONSE               Maximum nine                    Q                                9(1)
           CODE COUNTER                   occurrences supported
 439-E4    REASON FOR SERVICE             DD=Drug-drug                 Q***R***                            X(2)
           CODE                           interaction
                                          HD=High dose
                                          ID=Ingredient
                                          duplication
                                          TD=Therapeutic
                                          duplication
                                          ER=Early refill

 Response Coordination of                 Check                 Service Billing/Service Rebill Accepted/Rejected
 Benefits/Other Payers Segment                                  If Situational, Payer Situation
 Questions
 This segment is always sent.
 This segment is situational.                     X

           Response Coordination of                                                 Service
           Benefits/Other Payers                                                    Billing/Service
           Segment                                                                  Rebill
           Segment Identification (111-                                             Accepted/Rejected
           AM) = 28
 Field #   NCPDP Field Name               Value                      Payer Usage    Payer Situation        Field Format
 111-AM    SEGMENT IDENTIFICATION                                        M                                 X(2)
 355-NT    OTHER PAYER ID COUNT           Maximum count of three         M
 338-5C    OTHER PAYER COVERAGE           Blank=Not specified         M***R***                             X(2)
           TYPE                           Ø1=Primary
                                          Ø2=Secondary
                                          Ø3=Tertiary
 339-6C    OTHER PAYER ID                 Blank=Not specified          Q***R***                            X(2)
           QUALIFIER                      3=BIN
                                          99=Other
 34Ø-7C    OTHER PAYER ID                                              Q***R***                            X(1Ø)
 991-MH    OTHER PAYER                                                 Q***R***
           PROCESSOR CONTROL
           NUMBER
 356-NU    OTHER PAYER                                                 N***R***
           CARDHOLDER ID
 992-MJ    OTHER PAYER GROUP ID                                        Q***R***                            X(15)
 142-UV    OTHER PAYER PERSON                                          N***R***
           CODE
 127-UB    OTHER PAYER HELP DESK                                       N***R***
           PHONE NUMBER
 143-UW    OTHER PAYER PATIENT                                         N***R***
           RELATIONSHIP CODE
 144-UX    OTHER PAYER BENEFIT                                         N***R***
           EFFECTIVE DATE
 145-UY    OTHER PAYER BENEFIT                                         N***R***
           TERMINATION DATE




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                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                      Version 12.0

4.4 Service Billing/Service Rebill Rejected/Rejected Response
The following lists the segments and fields in a service billing/service rebill response
(rejected/rejected) transaction for the NCPDP version D.Ø.
 Response Transaction Header               Check                  Service Billing/Service Rebill Rejected/Rejected
 Segment Questions                                                If Situational, Payer Situation
 This segment is always sent.                      X

            Response Transaction                                                      Service
            Header Segment                                                            Billing/Service Rebill
                                                                                      Rejected/Rejected
 Field #    NCPDP Field Name               Value                       Payer Usage    Payer Situation           Field Format
 1Ø2-A2     VERSION/RELEASE                DØ                               M                                   X(2)
            NUMBER
 1Ø3-A3     TRANSACTION CODE               S1, S3                           M                                   X(2)
 1Ø9-A9     TRANSACTION COUNT              1=One occurrence                 M                                   X(1)
                                           2=Two occurrences
                                           3=Three occurrences
                                           4=Four occurrences
 5Ø1-F1     HEADER RESPONSE                R=Rejected                       M                                   X(1)
            STATUS
 2Ø2-B2     SERVICE PROVIDER ID            Ø1 – National provider           M                                   X(2)
            QUALIFIER                      identifier (NPI)
 2Ø1-B1     SERVICE PROVIDER ID                                             M                                   X(15)
 4Ø1-D1     DATE OF SERVICE                CCYYMMDD                         M                                   9(8)

 Response Message Segment                  Check                  Service Billing/Service Rebill Rejected/Rejected
 Questions                                                        If Situational, Payer Situation
 This segment is always sent.                      X
 This segment is situational.

            Response Message                                                          Service
            Segment                                                                   Billing/Service Rebill
            Segment Identification (111-                                              Rejected/Rejected
            AM) = 2Ø
 Field #    NCPDP Field Name               Value                       Payer Usage    Payer Situation           Field Format
 111-AM     SEGMENT IDENTIFICATION                                          M
 5Ø4-F4     MESSAGE                                                         Q                                   X(2ØØ)

 Response Status Segment Questions         Check                  Service Billing/Service Rebill Rejected/Rejected
                                                                  If Situational, Payer Situation
 This segment is always sent.                      X




                                                           -83-
                   Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                 Version 12.0

           Response Status Segment                                               Service
           Segment Identification (111-                                          Billing/Service Rebill
           AM) = 21                                                              Rejected/Rejected
 Field #   NCPDP Field Name               Value                    Payer Usage   Payer Situation           Field Format
 111-AM    SEGMENT IDENTIFICATION                                       M                                  X(2)
 112-AN    TRANSACTION RESPONSE           R=Rejected                    M                                  X(1)
           STATUS
 5Ø3-F3    AUTHORIZATION NUMBER                                        R                                   X(2Ø)
 51Ø-FA    REJECT COUNT                   Maximum count of five        R                                   9(2)
 511-FB    REJECT CODE                                              R***R***                               X(3)
 546-4F    REJECT FIELD                                             Q***R***                               X(3)
           OCCURRENCE INDICATOR
13Ø-UF     ADDITIONAL MESSAGE             Maximum count of eight       Q                                   9(2)
           INFORMATION COUNT
 132-UH    ADDITIONAL MESSAGE             Ø1                        Q***R***                               X(2)
           INFORMATION QUALIFIER
 526-FQ    ADDITIONAL MESSAGE                                       Q***R***                               X(4Ø)
           INFORMATION
 131-UG    ADDITIONAL MESSAGE             +                         Q***R***                               X(1)
           INFORMATION
           CONTINUITY
                      ** End of Response Service Billing/Service Rebill (S1/S3) Payer Sheet**




                                                         -84-
                       Commonwealth of Massachusetts
                Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                             Version 12.0


5.0      Claim Submission Format – S2
BIN NUMBER ØØ9555
DESTINATION ACS STATE HEALTHCARE
ACCEPTING CLAIM ADJUDICATION (S2 REVERSAL TRANSACTIONS)
FORMAT NCPDP D.Ø


5.1 Service Reversal Request
Field Legend for Columns
     Payer Usage                          Value                               Explanation                          Payer Situation
       Column                                                                                                         Column
 MANDATORY                                  M               The field is mandatory for the segment in the                No
                                                            designated transaction.
 REQUIRED                                   R               The field has been designated with the situation of          No
                                                            “required” for the segment in the designated
                                                            transaction.
 QUALIFIED REQUIREMENT                      Q               The situations designated have qualifications for           Yes
                                                            usage (required if x, not required if y).
 INFORMATIONAL ONLY                          I              The field is for informational purposes only for the        Yes
                                                            transaction.
 NOT USED                                   N               The field is not used for the segment for the                No
                                                            transaction.
 REPEATING                                ***R***           The three asterisks, R, and three asterisks                 Yes
                                                            designates a field is repeating.
                                                            Example: Q***R*** means a situationally qualified
                                                            field that repeats.
                                                            Example: N***R*** means a not used field that
                                                            repeats when used.

Service Reversal Transaction
The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP version
D.Ø. Claim reversal transaction includes service billing transactions S2.
 Transaction Header Segment Questions               Check               Service Reversal
                                                                        If Situational, Payer Situation
 This segment is always sent.                               X
 Source of certification IDs required in software           X
 vendor/certification ID (11Ø-AK) is payer
 issued.
 Source of certification IDs required in software
 vendor/certification ID (11Ø-AK) is switch/VAN
 issued.
 Source of certification IDs required in software
 vendor/certification ID (11Ø-AK) is not used.




                                                                -85-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                                Version 12.0

            Transaction Header                                                         Service Reversal
            Segment
 Field #    NCPDP Field Name               Value                     Payer Usage       Payer Situation                    Field Format
 1Ø1-A1     BIN NUMBER                     ØØ9555                         M                                               9(6)
 1Ø2-A2     VERSION/RELEASE                DØ                             M                                               X(2)
            NUMBER
 1Ø3-A3     TRANSACTION CODE               S2                              M                                              X(2)
 1Ø4-A4     PROCESSOR CONTROL              MASSPROD for                    M                                              X(1Ø)
            NUMBER                         production
                                           transactions
 1Ø9-A9     TRANSACTION COUNT              1=One occurrence                M           For S2 (reversal)                  X(1)
                                           2=Two occurrences                           transactions, transaction
                                           3=Three ccurrences                          count must be a value of 1,
                                           4=Four occurrences                          2, 3, or 4. If this transaction
                                                                                       is for a compound claim,
                                                                                       the transaction count value
                                                                                       must be 1.
 2Ø2-B2     SERVICE PROVIDER ID            Ø1=National                     M                                              X(2)
            QUALIFIER                      provider identifier
 2Ø1-B1     SERVICE PROVIDER ID                                            M                                              X(15)
 4Ø1-D1     DATE OF SERVICE                CCYYMMDD                        M                                              9(8)
 11Ø-AK     SOFTWARE                                                       M           The MassHealth                     X(1Ø)
            VENDOR/CERTIFICATION ID                                                    registration number
                                                                                       assigned to software as
                                                                                       part of initial certification.

 Insurance Segment Questions               Check                 Service Reversal
                                                                 If Situational, Payer Situation
 This segment is always sent.                      X
 This segment is situational.

            Insurance Segment                                                          Service Reversal
            Segment Identification (111-
            AM) = Ø4
Field #     NCPDP Field Name               Value                     Payer Usage       Payer Situation                    Field Format
111-AM      SEGMENT IDENTIFICATION                                       M                                                X(2)
3Ø2-C2      CARDHOLDER ID                                                M            12-digit MassHealth ID              X(2Ø)
                                                                                      number
3Ø1-C1      GROUP ID                       MassHealth                      R                                              X(15)
                                           HSN

 Claim Segment Questions                   Check                 Service Reversal
                                                                 If Situational, Payer Situation
 This segment is always sent.                      X

             Claim Segment                                                             Service Reversal
             Segment Identification
             (111-AM) = Ø7
 Field #    NCPDP Field Name               Value                     Payer Usage       Payer Situation                    Field Format
 111-AM     SEGMENT IDENTIFICATION                                       M                                                X(2)
 455-EM     PRESCRIPTION/SERVICE           2=Service billing              M                                               X(1)
            REFERENCE NUMBER
            QUALIFIER
 4Ø2-D2     PRESCRIPTION/SERVICE                                           M                                              9(12)
            REFERENCE NUMBER
 436-E1     PRODUCT/SERVICE ID             Ø9=HCPCS                        M                                              X(2)
            QUALIFIER
4Ø7-D7      PRODUCT/SERVICE ID                                             M                                              X(19)
4Ø3-D3      FILL NUMBER                                                    N
3Ø8-C8      OTHER COVERAGE CODE                                            N

                                                            -86-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                               Version 12.0

             Claim Segment                                                           Service Reversal
             Segment Identification
             (111-AM) = Ø7
Field #     NCPDP Field Name                Value                  Payer Usage       Payer Situation     Field Format
147-U7      PHARMACY SERVICE TYPE                                       N

 Pricing Segment Questions                  Check                Service Reversal
                                                                 If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                                    Segment not supported.

            Pricing Segment                                                          Service Reversal
            Segment Identification (111-
            AM) = 11
Field #     NCPDP Field Name                Value                  Payer Usage       Payer Situation     Field Format
111-AM      SEGMENT IDENTIFICATION                                      M                                X(2)
438-E3      INCENTIVE AMOUNT
            SUBMITTED
43Ø-DU      GROSS AMOUNT DUE

 Coordination of Benefits/Other             Check                Service Reversal
 Payments Segment Questions                                      If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                                    Segment not supported.

             Coordination of                                                         Service Reversal
             Benefits/Other Payments
             Segment
             Segment Identification
             (111-AM) = Ø5
 Field #    NCPDP Field Name                Value                  Payer Usage       Payer Situation     Field Format
 111-AM     SEGMENT IDENTIFICATION                                     M                                 X(2)
 337-4C     COORDINATION OF                 Maximum count of            M                                9(1)
            BENEFITS/OTHER                  nine
            PAYMENTS COUNT
 338-5C     OTHER PAYER COVERAGE                                     M***R***                            X(2)
            TYPE

 DUR/PPS Segment Questions                  Check              Service Reversal
                                                               If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                                  Segment not supported.

            DUR/PPS Segment                                                          Service Reversal
            Segment Identification (111-
            AM) = Ø8
Field #     NCPDP Field Name                Value                  Payer Usage       Payer Situation     Field Format
111-AM      SEGMENT IDENTIFICATION                                     M                                 X(2)
473-7E      DUR/PPS CODE COUNTER            Maximum of nine                                              9(1)
                                            occurrences
439-E4      REASON FOR SERVICE                                                                           X(2)
            CODE (also known as the DUR
            conflict code)
44Ø-E5      PROFESSIONAL SERVICE                                                                         X(2)
            CODE
441-E6      RESULT OF SERVICE CODE                                                                       X(2)
                                  ** End of Request Service Reversal (S2) Payer Sheet **


                                                          -87-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                         Version 12.0

5.2 Service Reversal Accepted/Approved Response

The following lists the segments and fields in a claim reversal response (accepted/approved)
transaction for the NCPDP version D.Ø.
 Response Transaction Header               Check                   Service Reversal – Accepted/Approved
 Segment Questions                                                 If Situational, Payer Situation
 This segment is always sent.                       X

            Response Transaction                                                   Service Reversal –
            Header Segment                                                         Accepted/Approved
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation                 Field Format
 1Ø2-A2     VERSION/RELEASE                DØ                            M                                         X(2)
            NUMBER
 1Ø3-A3     TRANSACTION CODE               S2                            M                                         X(2)
 1Ø9-A9     TRANSACTION COUNT              1=One occurrence              M         For S2 (reversal)               X(1)
                                           2=Two occurrences                       transactions, transaction
                                           3=Three ccurrences                      count will be a value of 1,
                                           4=Four occurrences                      2, 3, or 4.

                                                                                   If this transaction is for a
                                                                                   compound claim, the
                                                                                   transaction count value
                                                                                   must be 1.
 5Ø1-F1     HEADER RESPONSE                A=Accepted                    M
            STATUS
 2Ø2-B2     SERVICE PROVIDER ID            Ø1 – National                 M                                         X(2)
            QUALIFIER                      provider identifier
                                           (NPI)
 2Ø1-B1     SERVICE PROVIDER ID                                          M
 4Ø1-D1     DATE OF SERVICE                CCYYMMDD                      M                                         9(8)

 Response Message Segment                  Check                   Service Reversal – Accepted/Approved
 Questions                                                         If Situational, Payer Situation
 This segment is always sent.                       X
 This segment is situational.

            Response Message                                                       Service Reversal –
            Segment                                                                Accepted/Approved
            Segment Identification (111-
            AM) = 2Ø
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation                 Field Format
 111-AM     SEGMENT IDENTIFICATION                                      M                                          X(2)
 5Ø4-F4     MESSAGE                                                      Q                                         X(2ØØ)

 Response Status Segment Questions         Check                   Service Reversal – Accepted/Approved
                                                                   If Situational, Payer Situation
 This segment is always sent.                       X

            Response Status Segment                                                Service Reversal –
            Segment Identification (111-                                           Accepted/Approved
            AM) = 21
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation                 Field Format
 111-AM     SEGMENT IDENTIFICATION                                      M                                          X(2)
 112-AN     TRANSACTION RESPONSE           A=Approved                    M                                         X(1)
            STATUS
 5Ø3-F3     AUTHORIZATION NUMBER                                         R                                         X(2Ø)


                                                            -88-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                Version 12.0

            Response Status Segment                                                Service Reversal –
            Segment Identification (111-                                           Accepted/Approved
            AM) = 21
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation        Field Format
 547-5F     APPROVED MESSAGE               Maximum count of              N
            CODE COUNT                     five
 548-6F     APPROVED MESSAGE                                          N***R***
            CODE
 13Ø-UF     ADDITIONAL MESSAGE             Maximum count of              Q                                9(2)
            INFORMATION COUNT              eight
 132-UH     ADDITIONAL MESSAGE             Ø1                         Q***R***                            X(2)
            INFORMATION QUALIFIER
 526-FQ     ADDITIONAL MESSAGE                                        Q***R***                            X(4Ø)
            INFORMATION
 131-UG     ADDITIONAL MESSAGE             +                          Q***R***                            X(1)
            INFORMATION CONTINUITY
 549-7F     HELP DESK PHONE                                              N
            NUMBER QUALIFIER
 55Ø-8F     HELP DESK PHONE                                              N
            NUMBER
 88Ø -K5    TRANSACTION                                                  N
            REFERENCE NUMBER
 993-A7     INTERNAL CONTROL                                             N
            NUMBER
 987-MA     URL                                                          N

 Response Claim Segment Questions          Check                  Service Reversal – Accepted/Approved
                                                                  If Situational, Payer Situation
 This segment is always sent.                       X

            Response Claim Segment                                                 Service Reversal –
            Segment Identification (111-                                           Accepted/Approved
            AM) = 22
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation        Field Format
 111-AM     SEGMENT IDENTIFICATION                                      M                                 X(2)
 455-EM     PRESCRIPTION/SERVICE           2=Service billing             M                                X(1)
            REFERENCE NUMBER
            QUALIFIER
 4Ø2-D2     PRESCRIPTION/SERVICE                                         M                                9(12)
            REFERENCE NUMBER

 Response Pricing Segment Questions        Check                  Service Reversal – Accepted/Approved
                                                                  If Situational, Payer Situation
 This segment is always sent.
 This segment is situational.                                     Segment not supported.

            Response Pricing Segment                                               Service Reversal –
            Segment Identification (111-                                           Accepted/Approved
            AM) = 23
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation        Field Format
 111-AM     SEGMENT IDENTIFICATION                                      M                                 X(2)
 521-FL     INCENTIVE AMOUNT PAID                                        Q
 5Ø9-F9     TOTAL AMOUNT PAID




                                                           -89-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                          Version 12.0


5.3 Service Reversal Accepted/Rejected Response
The following lists the segments and fields in a claim reversal response (accepted/rejected) transaction
for the NCPDP version D.Ø.
 Response Transaction Header               Check                   Service Reversal - Accepted/Rejected
 Segment Questions                                                 If Situational, Payer Situation
 This segment is always sent.                       X

            Response Transaction                                                    Service Reversal –
            Header Segment                                                          Accepted/Rejected
 Field #    NCPDP Field Name               Value                     Payer Usage    Payer Situation                 Field Format
 1Ø2-A2     VERSION/RELEASE                DØ                             M                                         X(2)
            NUMBER
 1Ø3-A3     TRANSACTION CODE               S2                             M                                         X(2)
 1Ø9-A9     TRANSACTION COUNT              1=One occurrence               M         For S2 (reversal)               X(1)
                                           2=Two occurrences                        transactions, transaction
                                           3=Three ccurrences                       count will be a value of 1,
                                           4=Four occurrences                       2, 3, or 4.

                                                                                    If this transaction is for a
                                                                                    compound claim, the
                                                                                    transaction count value
                                                                                    must be 1.
 5Ø1-F1     HEADER RESPONSE                A=Accepted                     M                                         X(1)
            STATUS
 2Ø2-B2     SERVICE PROVIDER ID            Ø1 – National                  M                                         X(2)
            QUALIFIER                      provider identifier
                                           (NPI)
 2Ø1-B1     SERVICE PROVIDER ID                                           M                                         X(15)
 4Ø1-D1     DATE OF SERVICE                CCYYMMDD                       M                                         9(8)

 Response Message Segment                  Check                   Service Reversal - Accepted/Rejected
 Questions                                                         If Situational, Payer Situation
 This segment is always sent.                       X
 This segment is situational.

            Response Message                                                        Service Reversal –
            Segment                                                                 Accepted/Rejected
            Segment Identification (111-
            AM) = 2Ø
 Field #    NCPDP Field Name               Value                     Payer Usage    Payer Situation                 Field Format
 111-AM     SEGMENT IDENTIFICATION                                       M                                          X(2)
 5Ø4-F4     MESSAGE                                                       Q                                         X(2ØØ)

 Response Status Segment Questions         Check                   Service Reversal - Accepted/Rejected
                                                                   If Situational, Payer Situation
 This segment is always sent.                       X

            Response Status Segment                                                 Service Reversal –
            Segment Identification (111-                                            Accepted/Rejected
            AM) = 21
 Field #    NCPDP Field Name               Value                     Payer Usage    Payer Situation                 Field Format
 111-AM     SEGMENT IDENTIFICATION                                       M                                          X(2)
 112-AN     TRANSACTION RESPONSE           R=Rejected                     M                                         X(1)
            STATUS
 5Ø3-F3     AUTHORIZATION NUMBER                                          R                                         X(2Ø)
                                                            -90-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                       Version 12.0

            Response Status Segment                                                Service Reversal –
            Segment Identification (111-                                           Accepted/Rejected
            AM) = 21
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation               Field Format
 51Ø-FA     REJECT COUNT                   M                             R                                       9(2)
 511-FB     REJECT CODE                                               R***R***                                   X(3)
 546-4F     REJECT FIELD                                              Q***R***                                   9(2)
            OCCURRENCE INDICATOR
 13Ø-UF     ADDITIONAL MESSAGE             Maximum count of              Q                                       9(2)
            INFORMATION COUNT              eight
 132-UH     ADDITIONAL MESSAGE             Ø1                         Q***R***                                   X(2)
            INFORMATION QUALIFIER
 526-FQ     ADDITIONAL MESSAGE                                        Q***R***                                   X(4Ø)
            INFORMATION
 131-UG     ADDITIONAL MESSAGE             +                          Q***R***                                   X(1)
            INFORMATION CONTINUITY
 549-7F     HELP DESK PHONE                                              N
            NUMBER QUALIFIER
 55Ø-8F     HELP DESK PHONE                                              N
            NUMBER

 Response Claim Segment Questions          Check                  Service Reversal - Accepted/Rejected
                                                                  If Situational, Payer Situation
 This segment is always sent.                      X

            Response Claim Segment                                                 Service Reversal –
            Segment Identification (111-                                           Accepted/Rejected
            AM) = 22
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation               Field Format
 111-AM     SEGMENT IDENTIFICATION                                      M                                        X(2)
 455-EM     PRESCRIPTION/SERVICE           2=Service billing             M         For transaction code of S2
            REFERENCE NUMBER                                                       in the response claim
            QUALIFIER                                                              segment, the
                                                                                   prescription/service
                                                                                   reference number qualifier
                                                                                   (455-EM) is 2 (services
                                                                                   billing).
 4Ø2-D2     PRESCRIPTION/SERVICE                                         M                                       9(12)
            REFERENCE NUMBER


5.4 Service Reversal Rejected/Rejected Response
 Response Transaction Header               Check                  Service Reversal - Rejected/Rejected
 Segment Questions                                                If Situational, Payer Situation
 This segment is always sent.                      X

            Response Transaction                                                   Service Reversal –
            Header Segment                                                         Rejected/Rejected
 Field #    NCPDP Field Name               Value                    Payer Usage    Payer Situation               Field Format
 1Ø2-A2     VERSION/RELEASE                DØ                            M                                       X(2)
            NUMBER
 1Ø3-A3     TRANSACTION CODE               S2                            M                                       X(2)




                                                           -91-
                     Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                          Version 12.0

            Response Transaction                                                    Service Reversal –
            Header Segment                                                          Rejected/Rejected
 Field #    NCPDP Field Name               Value                     Payer Usage    Payer Situation                 Field Format
 1Ø9-A9     TRANSACTION COUNT              1=One occurrence               M         For S2 ( reversal)              X(1)
                                           2=Two occurrences                        transactions, transaction
                                           3=Three ccurrences                       count will be a value of 1,
                                           4=Four occurrences                       2, 3, or 4.

                                                                                    If this transaction is for a
                                                                                    compound claim, the
                                                                                    transaction count value
                                                                                    must be 1.
 5Ø1-F1     HEADER RESPONSE                R=Rejected                     M                                         X(1)
            STATUS
 2Ø2-B2     SERVICE PROVIDER ID            Ø1 – National                  M                                         X(2)
            QUALIFIER                      provider identifier
                                           (NPI)
 2Ø1-B1     SERVICE PROVIDER ID                                           M                                         X(15)
 4Ø1-D1     DATE OF SERVICE                CCYYMMDD                       M                                         9(8)

 Response Message Segment                  Check                   Service Reversal – Rejected/Rejected
 Questions                                                         If Situational, Payer Situation
 This segment is always sent.                       X
 This segment is situational.

            Response Message                                                        Service Reversal –
            Segment                                                                 Rejected/Rejected
            Segment Identification (111-
            AM) = 2Ø
 Field #    NCPDP Field Name               Value                     Payer Usage    Payer Situation                 Field Format
 111-AM     SEGMENT IDENTIFICATION                                       M                                          X(2)
 5Ø4-F4     MESSAGE                                                       Q                                         X(2ØØ)

 Response Status Segment Questions         Check                   Service Reversal - Rejected/Rejected
                                                                   If Situational, Payer Situation
 This segment is always sent.                       X

            Response Status Segment                                                 Service Reversal –
            Segment Identification (111-                                            Rejected/Rejected
            AM) = 21
 Field #    NCPDP Field Name               Value                     Payer Usage    Payer Situation                 Field Format
 111-AM     SEGMENT IDENTIFICATION                                       M                                          X(2)
 112-AN     TRANSACTION RESPONSE           R=Rejected                     M                                         X(1)
            STATUS
 5Ø3-F3     AUTHORIZATION NUMBER                                          R                                         X(2Ø)
 51Ø-FA     REJECT COUNT                   Maximum count of               R                                         9(2)
                                           five
 511-FB     REJECT CODE                                                R***R***                                     X(3)
 546-4F     REJECT FIELD                                                  N
            OCCURRENCE INDICATOR
 13Ø-UF     ADDITIONAL MESSAGE             Maximum count of               Q                                         9(2)
            INFORMATION COUNT              eight
 132-UH     ADDITIONAL MESSAGE             Ø1                          Q***R***                                     X(2)
            INFORMATION QUALIFIER
 526-FQ     ADDITIONAL MESSAGE                                         Q***R***                                     X(4Ø)
            INFORMATION
 131-UG     ADDITIONAL MESSAGE             +                           Q***R***                                     X(1)
            INFORMATION CONTINUITY
 549-7F     HELP DESK PHONE                                               N
            NUMBER QUALIFIER

                                                            -92-
                   Commonwealth of Massachusetts
             Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                        Version 12.0

           Response Status Segment                                          Service Reversal –
           Segment Identification (111-                                     Rejected/Rejected
           AM) = 21
 Field #   NCPDP Field Name               Value               Payer Usage   Payer Situation       Field Format
 55Ø-8F    HELP DESK PHONE                                         N
           NUMBER

                              ** End of Service Reversal Response (S2) Payer Sheet **




                                                       -93-
                  Commonwealth of Massachusetts
            Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                 Version 12.0


6.0     TPL Billing
If the pharmacy becomes aware that the MassHealth member has other pharmacy insurance coverage,
the pharmacy must complete the TPL indicator form, available via the link below, and submit the
form to MassHealth for verification. To access the TPL indicator form, go to
www.mass.gov/masshealth. In the lower right panel, under Publications, click on MassHealth
Provider Forms. The form will be listed as Third Party Liability Indicator.
When submitters communicate other insurance information to MassHealth, submitters can provide
their bank information number (BIN) or the MassHealth-specific carrier code assigned to the
Pharmacy Benefit Manager (PBM) associated with the drug benefit. BIN is preferred in D.Ø. TPL
carrier-code information is available on the Web at www.mass.gov/masshealth. Click on MassHealth
Regulations and Other Publications then Provider Library. Click on Appendices for All Provider
Manuals. Choose Appendix C: Third Party Liability Codes. Claims submitted for services for which a
member has other pharmacy coverage insurance will be denied unless the claim has been previously
submitted to other payers.
If the claim is denied, the billing pharmacy receives either NCPDP reject code 41 or AZ with an
additional explanation of benefits (EOB) reason code and additional message text. For Medicare Part
D, refer to MassHealth regulations at 130 CMR 406.414(C) for guidance.
Based upon MassHealth regulations at 130 CMR 450.317, MassHealth will pay the lowest of:
   the member's liability as reported in the patient paid amount by the other insurers including
    coinsurance, deductibles, and copayments;
   the provider's charges minus the other insurer’s payments; or
   the maximum allowable amount payable under MassHealth payment methodology minus the
    other insurer’s payments.
If additional assistance is required, please contact the ACS Pharmacy Technical Help Desk at
1-866-246-8503.
7.0     90-Day-Waiver Procedures
POPS claims received more than 90 days from the date of service, but less than 12 months, will
receive NCPDP reject code 81 (claim exceeds filing limit). The billing pharmacy can obtain a 90-day
waiver form from the ACS Pharmacy Technical Help Desk at 1-866-246-8503. This form is included
in Appendix A and can be photocopied. The completed form and supporting information can also be
faxed to ACS at 1-866-566-9315. If approved, the billing pharmacy will receive notification that the
claim can be submitted to POPS.
Please Note: TPL or split-bill claims submitted within 90 days of the primary carrier’s EOB date do
not require a 90-day waiver.
Providers may apply for a 90-day waiver only in the following circumstances:
   reprocessing of a claim (originally paid or denied);
   retroactive member enrollment; and
   retroactive provider enrollment.

                                                  -94-
                   Commonwealth of Massachusetts
               Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                                  Version 12.0


8.0     Claims Over $99,999.99
Claims greater than $99,999.99 can be billed online, but these claims will require MassHealth
approval. Providers must contact the ACS Pharmacy Technical Help Desk at 1-866-246-8503 to
initiate the request.
9.0     Special Topics and References
Some aspects of the billing process are of a narrower perspective than is the target of this billing
guide. As such, the more commonly mentioned ones are identified below and an authoritative source
of information is identified.
                          Topic                                                          Reference
 Return to Stock                                                 MassHealth pharmacy regulations at 130 CMR 406.446

 MassHealth 340B Program                                         MassHealth pharmacy regulations at 130 CMR 406.404

To view the MassHealth pharmacy regulations, go to www.mass.gov/masshealth. Click on
Masshealth Regulations under Publications in the lower right panel. Click on MassHealth Provider
Regulations then scroll down the page to the pharmacy regulations.
10.0 Version Table
Vers      Date                     Section                                              Description
i1.0    2001       Original document created                     Internal document developed.

 2.0    10/03      First major revision of publication           Implemented NCPDP version 5.1 format. Internal document
                                                                 developed.
 3.0    11/06      Section 3.7 payment segment updated.          First production version issued.
                   Deleted text in Sections 7 (Payer Sheet
                   E1) and 8 (Response E1).
 4.0    08/07      Sections 2.1, 2.4, 2.7, 2.10, 3.1-3.2, 4.1,   Production version issued.
                   and 5.1.1 have been updated with new
                   NPI information.
 5.0    07/08      Sections 2.4 and 2.6 have been                Production version issued.
                   updated to reflect two new CMS
                   initiatives – Tamper-proof prescription
                   pads and NPI.
 6.0    03/09      Sections 2.0, 2.4, and 9.0 have been          Production version issued.
                   updated to reflect changes in Coverage
                   Code 4. This code is no longer
                   permitted. There will be a change to the
                   current software to reflect this code
                   removal.
 7.0    05/09      Various segments in Sections 2.0,             Production version issued.
                   3.0, and 4.0 have been updated to
                   reflect software changes in support
                   for NewMMIS go live. Section 9.0 has
                   also been updated to provide links to
                   the TPL indicator form and carrier
                   code information.
 8.0    08/09      Section 9.0                                   TPL billing code descriptions revised.



                                                             -95-
                Commonwealth of Massachusetts
            Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                              Version 12.0

Vers     Date                  Section                                          Description
i9.0    02/10   New Section 13.0 – Pharmacy               Production version issued.
                Administered Flu Vaccines was
                added to the billing guide. Two field
                value changes were made to Section
                2.9 – DUR/PPS Segment 08, and
                Section 3.1.4 – Response Pricing
                Segment 23, to reflect the new
                Section 13.0. These two section
                changes also apply to Payer sheet
                B1/B3.
 10.0   08/10   Appendix B has been updated.              Production version issued.
 11.0   11/10   Section 8.0 – Temporary ID                Production version issued.
                Cards/Newborn IDs has been
                removed and all subsequent sections
                have been renumbered. Section 12.0
                – Pharmacy Administered Flu
                Vaccines has been updated. Section
                14.0 – Where to Get Help has been
                updated. Section 15.0 - Appendix B
                has been removed.
 12.0   06/11   Full document revision to reflect NCPDP   Billing Guide for NCPDP version D.Ø effective January 1,
                Telecommunications Standard D. Ø.         2012.

11.0 Where to Get Help
For Assistance with Billing and Claims:
ACS Pharmacy Technical Help Desk: 1-866-246-8503 (available 24/7)
ID Card Request Forms Fax: 1-866-556-9313
ACS Provider Relations: 1-617-423-9841
ACS Provider Relations: MassHealth.Providerrelations@acs-inc.com
Member Eligibility:
MassHealth Customer Service: 1-800-841-2900
Automated Voice Response (AVR): 1-800-554-0042
Prior Authorization:
University of Massachusetts Medical School
Phone: 1-800-745-7318
Fax: 1-877-208-7428
Drug Utilization Review Program
Commonwealth Medicine
University of Massachusetts Medical School
100 Century Drive
Worcester, MA 01606




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                 Commonwealth of Massachusetts
            Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                                                  Version 12.0

Prior authorization requests for nonpharmacy services including nutritional products, enteral products,
diapers, medical/hospital equipment, private duty nursing, and personal care attendants should be sent
made to the following address.
MassHealth Prior Authorization Unit
P.O. Box 9154
Hingham, MA 02043
Phone: 1-800-862-8341
Fax: 617-847-3795
Provider Enrollment and Credentialing:
1-800-322-2909
Providersupport@mahealth.net




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                Commonwealth of Massachusetts
           Executive Office of Health and Human Services
POPS Billing Guide
June 2011                                                  Version 12.0

Appendix A – Pharmacy 90-day Waiver Form




                                -98-

				
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