Payer Specification Sheet
For Prime Therapeutics’ Commercial Clients
General information
Prime Therapeutics LLC
March 31, 2016
Plan Name
BCBS of Alabama
BCBS of Alabama Work Related Injury Benefit
BCBS of Florida
BCBS of North Carolina
BCBS of Illinois
BCBS of Illinois (Blue Script)
BCBS of New Mexico
BCBS of Oklahoma (Drug Card)
BCBS of Oklahoma (Comp Card)
BCBS of Texas
Horizon BCBS of New Jersey
Horizon BCBS of New Jersey Medigap
Horizon Casualty Services, Inc Personal Injury Protection
Horizon Casualty Services, Inc Workers’ Compensation
BCBS of Kansas
BCBS of Kansas
BCBS of Minnesota
BCBS of Minnesota
BCBS of Minnesota (Cenex Harvest)
NON BCBS Clients (Carve Out Groups)
BCBS of Montana
BCBS of North Dakota
BCBS of North Dakota (Noridian)
BCBS of Nebraska
BCBS of Nebraska (CITY OF OMAHA PF DISABLED)
Capital Health Plan
Capital Health Plan Dual Eligible
General Dynamics
Hormel Foods
IMA
JBS
Jennie-O Turkey Store
Johnson Controls, Inc
Medtronic-Covidien
Mississippi State and Employees Life and Health Plan
University of Minnesota UPlan
BCBS of Wyoming
BIN
ØØ4915
Ø12833
Ø159Ø5
Ø11552
PCN
Not Required
WRI
FLBC
Not Required
ILDR
ILSC
NMDR
1215
1217
BCTX
HZRX
Ø16499
61Ø455
8ØØØØ1
HZNPIP
HZNWC
KSBCS
BCBSKS
HMHS
PGIGN
PGNB1 or PGIGN
CARVE
HMBC
NDBCS
NORID
RXNEB
PPNI1
ADV
ADVD
GDEMP
HORMEL
IMAINC
JBSPP
JENNIE
JCEMP
MDT
CLAIMCR
UMEMP
WYBCS
Processor
Effective as of: Ø9/Ø1/2Ø11
NCPDP Telecommunication Standard
Version/Release #: D.Ø
NCPDP Data Dictionary Version Date: July 2ØØ7
NCPDP External Code List Version Date:
October 2Ø14
Contact/Information Source: Prime Contact Center Phone number 8ØØ.821.4795. Other reference
materials are available on Prime’s web site.
Page 1 of 9
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Commercial Clients © Prime Therapeutics LLC 07/11
http://www.primetherapeutics.com/pharmacistsindex.html
Other versions supported: Will continue to accept NCPDP Telecommunication version 5.1 based upon
the CMS statement of “Discretionary Enforcement” until Ø3/3Ø/2Ø12
OTHER TRANSACTIONS SUPPORTED
Transaction Code
B2
Transaction Name
Reversals
FIELD LEGEND FOR COLUMNS
Payer Usage
Value
Column
MANDATORY
M
Payer Situation
Column
No
Explanation
The Field is mandatory for the
Segment in the designated
Transaction.
REQUIRED
R
The Field has been designated with
No
the situation of "Required" for the
Segment in the designated
Transaction.
QUALIFIED REQUIREMENT
RW
“Required when”. The situations
Yes
designated have qualifications for
usage ("Required if x", "Not
required if y").
Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have
qualified requirements (i.e. not used) are excluded from the template.
CLAIM BILLING/CLAIM REBILL TRANSACTION
The following lists the segments and fields in a Claim Billing or Claim Rebill Transaction for the NCPDP
Telecommunication Standard Implementation Guide Version D.Ø.
Transaction Header Segment
Questions
This Segment is always sent
Source of certification IDs
required in Software
Vendor/Certification ID (11ØAK) is Not used
Check
Claim Billing/Claim Rebill
If Situational, Payer Situation
X
X
Transaction Header Segment
Field #
1Ø1-A1
NCPDP Field Name
BIN NUMBER
Value
Multiple
Payer Usage
M
1Ø2-A2
1Ø3-A3
1Ø4-A4
VERSION/RELEASE NUMBER
TRANSACTION CODE
PROCESSOR CONTROL NUMBER
DØ
B1
Multiple
M
M
M
1Ø9-A9
TRANSACTION COUNT
Ø1-Ø4
M
2Ø2-B2
SERVICE PROVIDER ID QUALIFIER
Ø1-NPI
M
Claim
Billing/Claim
Rebill
Payer Situation
BIN’s listed in
General
Information
Section
PCN’s listed in
General
Information
Section
Up to 4
transactions per
B1 transmissions
accepted
Page 2 of 9
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Commercial Clients © Prime Therapeutics LLC 07/11
2Ø1-B1
4Ø1-D1
11Ø-AK
SERVICE PROVIDER ID
DATE OF SERVICE
SOFTWARE VENDOR/CERTIFICATION
ID
Insurance Segment Questions
Check
This Segment is always sent
Field #
3Ø2-C2
3Ø6-C6
This Segment is always sent
Field#
3Ø4-C4
3Ø5-C5
31Ø-CA
CCYYMMDD
Use value for
Switch’s
requirements
Claim Billing/Claim Rebill
If Situational, Payer Situation
X
Insurance Segment
Segment Identification
(111-AM) = “Ø4”
NCPDP Field Name
CARDHOLDER ID
PATIENT RELATIONSHIP CODE
Patient Segment Questions
M
M
M
Value
Check
Payer Usage
M
RW
Claim
Billing/Claim
Rebill
Payer Situation
Payer Requirement:
Required for BCBS
of OK Comp Card
only, BIN Ø11552,
PCN 1217
Claim Billing/Claim Rebill
If Situational, Payer Situation
X
Patient Segment
Segment Identification
(111-AM) = “Ø1”
NCPDP Field Name
DATE OF BIRTH
PATIENT GENDER CODE
PATIENT FIRST NAME
Value
Claim
Billing/Claim
Rebill
Payer Situation
Payer Usage
R
R
RW
Payer Requirement
Required for:
BCBS of IL, BIN
Ø11552, PCN ILSC
This is required for
all other BCBS
plans when DOB
and gender are
identical
311-CB
PATIENT LAST NAME
Claim Segment Questions
This Segment is always sent
This payer does not support partial
fills
Field #
455-EM
R
Check
Claim Billing/Claim Rebill
If Situational, Payer Situation
X
X
Claim Segment
Segment Identification
(111-AM) = “Ø7”
NCPDP Field Name
PRESCRIPTION/SERVICE REFERENCE
NUMBER QUALIFIER
Value
1-Rx Billing
Payer Usage
M
Claim
Billing/Claim
Rebill
Payer Situation
Page 3 of 9
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Commercial Clients © Prime Therapeutics LLC 07/11
436-E1
Claim Segment
Segment Identification
(111-AM) = “Ø7”
NCPDP Field Name
PRESCRIPTION/SERVICE REFERENCE
NUMBER
PRODUCT/SERVICE ID QUALIFIER
407-D7
PRODUCT/SERVICE ID
Field #
4Ø2-D2
Value
Ø3-National
Drug Code
(NDC)
Payer Usage
M
M
M
Claim
Billing/Claim
Rebill
Payer Situation
If billing for a
Multi-Ingredient
Compound ,
value is “ØØ”Not Specified
NDC Number
If billing for a
Multi-Ingredient
Compound , value
is “Ø”
442-E7
4Ø3-D3
4Ø5-D5
4Ø6-D6
QUANTITY DISPENSED
FILL NUMBER
DAYS SUPPLY
COMPOUND CODE
4Ø8-D8
DISPENSE AS WRITTEN
(DAW)/PRODUCT SELECTION CODE
DATE PRESCRIPTION WRITTEN
PRESCRIPTION ORIGIN CODE
414-DE
419-DJ
354-NX
SUBMISSION CLARIFICATION CODE
COUNT
42Ø-DK
SUBMISSION CLARIFICATION CODE
1-Not a
Compound
2-Compound
R
R
R
R
See Compound
Segment for
support of multiingredient
compounds
R
1-Written
2-Telephone
3-Electronic
4-Facsimile
5-Pharmacy
Maximum
count of 3
8-Process
Compound for
Approved
Ingredients
42-Prescriber
ID Submitted
is valid and
prescribing
requirements
have been
validated.
43Prescriber's
DEA is active
with DEA
Authorized
Prescriptive
Right
R
R
RW
RW
Payer
Requirement:
Required if
Submission
Clarification Code
(42Ø-DK) is used
Payer
Requirement:
Applies for Multi –
Ingredient
Compound when
determined by
client or when for
Prescriber ID
clarification
Page 4 of 9
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Commercial Clients © Prime Therapeutics LLC 07/11
Field #
Claim Segment
Segment Identification
(111-AM) = “Ø7”
NCPDP Field Name
429-DT
SPECIAL PACKAGING INDICATOR
461-EU
PRIOR AUTHORIZATION TYPE CODE
RW
462-EV
PRIOR AUTHORIZATION NUMBER
SUBMITTED
RW
995-E2
ROUTE OF ADMINISTRATION
RW
Pricing Segment Questions
This Segment is always sent
Value
Payer Usage
45Prescriber’s
DEA is a valid
Hospital DEA
with Suffix
and has
prescriptive
authority for
this drug DEA
Schedule.
46Prescriber's
DEA has
prescriptive
authority for
this drug DEA
Schedule
49-Prescriber
does not
currently have
an active
Type 1 NPI
RW
Check
Claim
Billing/Claim
Rebill
Payer Situation
Payer
Requirement:
Applies for Multi –
Ingredient
Compound
Payer
Requirement:
Submit a value of
‘1’ when a PA
number is
submitted in field
462-EV
Payer
Requirement:
Situation
Determined by
Client
Payer
Requirement:
Applies for Multi –
Ingredient
Compound when
determined by
client
Claim Billing/Claim Rebill
If Situational, Payer Situation
X
Page 5 of 9
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Commercial Clients © Prime Therapeutics LLC 07/11
Field #
4Ø9-D9
438-E3
Pricing Segment
Segment Identification
(111-AM) = “11”
NCPDP Field Name
INGREDIENT COST SUBMITTED
INCENTIVE AMOUNT SUBMITTED
426-DQ
43Ø-DU
USUAL AND CUSTOMARY CHARGE
GROSS AMOUNT DUE
Prescriber Segment Questions
This Segment is always sent
Value
Check
Field #
466-EZ
411-DB
PRESCRIBER ID
R
R
Claim Billing/Claim Rebill
If Situational, Payer Situation
Value
Ø1-NPI
Payer Usage
R
R
Check
X
X
Claim
Billing/Claim
Rebill
Payer Situation
NPI Required
Payer
Requirement:
Applicable value
for the qualifier
used in 466-EZ
Claim Billing/Claim Rebill
If Situational, Payer Situation
Required only for secondary, tertiary, etc claims.
Coordination of Benefits/Other
Payments Segment
Segment Identification
(111-AM) = “Ø5”
Field #
NCPDP Field Name
Value
337-4C
COORDINATION OF BENEFITS/OTHER
PAYMENTS COUNT
OTHER PAYER COVERAGE TYPE
Maximum
count of 9
Ø1-PrimaryFirst
Ø2-SecondarySecond
Ø3-TertiaryThird
338-5C
Payer Requirement:
Required when field
44Ø-E5 is used
X
Prescriber Segment
Segment Identification (111-AM)
= “Ø3”
NCPDP Field Name
PRESCRIBER ID QUALIFIER
Coordination of Benefits/Other
Payments Segment Questions
This Segment is situational
Scenario 1 - Other Payer Amount Paid
Repetitions Only
Payer Usage
R
RW
Claim
Billing/Claim
Rebill
Payer Situation
Payer
Usage
M
Claim
Billing/Claim
Rebill
Scenario 1 Other Payer
Amount Paid
Repetitions Only
Payer Situation
M
Page 6 of 9
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Commercial Clients © Prime Therapeutics LLC 07/11
339-6C
34Ø-7C
443-E8
OTHER PAYER ID QUALIFIER
Ø3-Bank
Identification
Number (BIN)
99-Other
OTHER PAYER ID
341-HB
OTHER PAYER AMOUNT PAID COUNT
342-HC
OTHER PAYER AMOUNT PAID
QUALIFIER
431-DV
OTHER PAYER AMOUNT PAID
This is required
when Covered
Person’s of
BCBSMT’s
employer group
NorthWestern
Energy only has
secondary coverage
with BCBS of MT,
BIN 61Ø455, PCN
HMBC
RW
Claim
Billing/Claim
Rebill
Scenario 1 Other Payer
Amount Paid
Repetitions Only
Maximum count
of 9
Ø7-Drug Benefit
Claim Billing/Claim Rebill
If Situational, Payer Situation
Value
Maximum of 9
occurrences
REASON FOR SERVICE CODE
439-E4
PROFESSIONAL SERVICE CODE
441-E6
RESULT OF SERVICE CODE
RW
X
DUR/PPS Segment
Segment Identification (111-AM)
= “Ø8”
NCPDP Field Name
DUR/PPS CODE COUNTER
44Ø-E5
RW
RW
Check
This Segment is situational
Field #
473-7E
Payer Requirement:
RW
OTHER PAYER DATE
Coordination of Benefits/Other
Payments Segment
Segment Identification
(111-AM) = “Ø5”
DUR/PPS Segment Questions
RW
MA-Medication
Administration
Claim
Billing/Claim
Rebill
Payer Usage Payer Situation
RW
Payer
Requirement:
Required if
DUR/PPS Segment
is used
RW
Payer
Requirement:
Required if
DUR/PPS Segment
is used
RW
Payer
Requirement:
Required if
DUR/PPS Segment
is used
RW
Payer
Page 7 of 9
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Commercial Clients © Prime Therapeutics LLC 07/11
Field #
DUR/PPS Segment
Segment Identification (111-AM)
= “Ø8”
NCPDP Field Name
Compound Segment Questions
Check
This Segment is situational
Field #
45Ø-EF
X
Compound Segment
Segment Identification
(111-AM) = “1Ø”
NCPDP Field Name
Value
Claim
Billing/Claim
Rebill
Payer Usage Payer Situation
Requirement:
Required if
DUR/PPS Segment
is used
Claim Billing/Claim Rebill
If Situational, Payer Situation
Required when Compound Code is =2
Value
Payer
Usage
M
488-RE
COMPOUND DOSAGE FORM
DESCRIPTION CODE
COMPOUND DISPENSING UNIT FORM
INDICATOR
COMPOUND INGREDIENT COMPONENT
COUNT
COMPOUND PRODUCT ID QUALIFIER
489-TE
448-ED
449-EE
COMPOUND PRODUCT ID
COMPOUND INGREDIENT QUANTITY
COMPOUND INGREDIENT DRUG COST
M
M
R
49Ø–UE
COMPOUND INGREDIENT BASIS OF
COST DETERMINATION
R
451-EG
447-EC
Clinical Segment Questions
Check
This Segment is situational
Field #
491-VE
Clinical Segment
Segment Identification
(111-AM) = “13”
NCPDP Field Name
DIAGNOSIS CODE COUNT
492-WE
DIAGNOSIS CODE QUALIFIER
Claim
Billing/Claim
Rebill
Payer Situation
M
Maximum 25
ingredients
Ø1-Universal
Product Code
(UPC)
Ø3-National
Drug Code
(NDC)
M
M
Payer
Requirement:
Required for each
ingredient
Payer
Requirement:
Required for each
ingredient
Claim Billing/Claim Rebill
If Situational, Payer Situation
X
Value
Maximum
count of 5
Claim
Billing/Claim
Rebill
Payer Usage Payer Situation
RW
Payer Requirement:
Required When
instructed by POS
Messaging
RW
Payer Requirement:
Required When
instructed by POS
Messaging
Page 8 of 9
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Commercial Clients © Prime Therapeutics LLC 07/11
Field #
424-DO
Clinical Segment
Segment Identification
(111-AM) = “13”
NCPDP Field Name
DIAGNOSIS CODE
Value
Claim
Billing/Claim
Rebill
Payer Usage Payer Situation
RW
Payer Requirement:
Required When
instructed by POS
Messaging
Page 9 of 9
Materials reproduced with the consent of © National Council for Prescription Drug Programs, Inc.
3851-D Payer Specification Sheet for Commercial Clients © Prime Therapeutics LLC 07/11