Programs: Maryland Medical Assistance Program (MA)

Pharmacy Provider Segment: Optional - Not used by MDBCCDT

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M/R/RW
Compound Segment: Required When Submitting a Multi-Line Compound Claim

Pharmacy Provider Segment: Optional - Not used by MDBCCDT

Field #

NCPDP Field Name

Value

M/R/RW

Comment

Prescriber Segment: Required

Field #	NCPDP Field Name	Value	M/R/RW	Comment
111-AM	Segment Identification	Ø3	M	Prescriber Segment
466-EZ	Prescriber ID Qualifier	12 = DEA	R
411-DB	Prescriber ID	DEA Number	R	.

COB/Other Payments Segment: Optional

Field #	NCPDP Field Name	Value	M/R/RW	Comment
111-AM	Segment Identification	Ø5	M	COB/Other Payments Segment
337-4C	Coordination of Benefits/Other Payments Count		M
338-5C	Other Payer Coverage Type		M (Repeating)
339-6C	Other Payer Id Qualifier	Blank=Not Specified Ø1=National Payer ID Ø2=Health Industry Number Ø3=Bank Information Number (BIN) Ø4=National Association of Insurance Commissioners (NAIC) Ø9=Coupon 99-Other	R	Required when submitting a COB claim Valid Value = 99
340-7C	Other Payer ID		R	Only value required is when the recipient has Medicare D coverage and the Other Payer ID = 77777
443-E8	Other Payer Date	CCYYMMDD	R	Required when there is payment from another source
341-HB	Other Payer Amount Paid Count		R	Required when submitting this segment
342-HC	Other Payer Amount Paid Qualifier	Blank=Not specified Ø1=Delivery Ø2=Shipping Ø3=Postage Ø4=Administrative Ø5=Incentive Ø6=Cognitive Service Ø7=Drug Benefit Ø 8=Sum of all Reimbursement 98=Coupon 99=Other	R (Repeating)	Required when the re is payment from another source
431-DV	Other Payer Amount Paid		R	Required when there is payment from another source

DUR/PPS Segment: Optional

Field #	NCPDP Field Name	Value	M/R/RW	Comment
111-AM	Segment Identification	Ø8	M	DUR/PPS Segment
473-7E	DUR/PPS Code counter		M	Required when submitting this segment
439-E4	Reason For Service Code	See Attached list of valid values	R (Repeating)	Required when there is a conflict to resolve or reason for service to be explained
440-E5	Professional Service Code	See Attached list of valid values	R	Required when there is a professional service to be identified
441-E6	Result of Service Code	See attached list of valid values	R	Required when There is a result of service to be submitted

Pricing Segment: Mandatory

Field #	NCPDP Field Name	Value	M/R/RW	Comment
111-AM	Segment Identification	11	M	Pricing Segment
478-H7	Other Amount Claimed Submitted Count	Used with Other Coverage code 8	RW	Required when submitting a co-pay only claim
479-H8	Other Amount Claimed Submitted Qualifier		RW	Required when submitting a claim for a co-pay only
480-H9	Other Amount Claimed Submitted		RW	Required when submitting a claim for a copay only. This amount must equal Field 430-DU.
426-DQ	Usual and Customary Charge		R
430–DU	Gross Amount Due		R	For copay only claims – this amount must equal the amount in field 480-H9

Coupon Segment: Segment is not supported

Field #

NCPDP Field Name

Value

M/R/RW

Comment

Compound Segment: Required When Submitting a Multi-Line Compound Claim

Field #	NCPDP Field Name	Value	M/R/RW	Comment
111-AM	Segment Identification	1Ø	M	Compound Segment
45Ø-EF	Compound Dosage Form Description Code		M	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
451-EG	Compound Dispensing Unit Form Indicator		M	1=Each 2=Grams 3=Milliliters
452-EH	Compound Route of Administration		M	1=Buccal 2=Dental 3=Inhalation 4=Injection 5=Intraperitoneal 6=Irrigation 7=Mouth/Throat 8=Mucous Membrane 9=Nasal 1Ø=Ophthalmic 11=Oral 12=Other/Miscellaneous 13=Otic 14=Perfusion 15=Rectal 16=Sublingual 17=Topical 18=Transdermal 19=Translingual 2Ø=Urethral 21=Vaginal 22=Enteral
447-EC	Compound Ingredient Component (Count)		M (Repeating)
488-RE	Compound Product ID Qualifier		M (Repeating)	Ø3=National Drug Code (NDC)
489-TE	Compound Product ID		M (Repeating)
448-ED	Compound Ingredient Quantity		M (Repeating)
449-EE	Compound Ingredient Drug Cost		NA	Not used by MD BCCDT

Prior Authorization Segment: Not Used by MDBCCDT Medicaid

Field #

NCPDP Field Name

Value

M/R/RW

Comment

Clinical Segment: Optional for MDBCCDT

Field #	NCPDP Field Name	Value	M/R/RW	Comment
111-AM	Segment Identification	13	NA	Clinical Segment
491-VE	Diagnosis Code Count		RW	Required when a DX is used to determine coverage
492-WE	Diagnosis Code		RW	Required when a DX is used to determine coverage
424-DO	Diagnosis Code		RW	Required when a DX is used to determine coverage

APPENDIX B

OTHER CARRIER CODE LIST

OTHER_PAYER_ID OTHER_PAYER_NAME
I0288 ADVANCE PARADIGM

I1413 ADVANCED PCS

I1606 AETNA PHARMACY

I0340 AETNA PHARMACY MANAGEMENT

I1414 AETNA SERVICES INC

I1647 AETNA US HEALTHCARE

AT531 ALLIANCE PPO MAPST

I0255 AMERICAN COMMUNITY MUTUAL INS

I0411 ASSOCIATE PRESCRIPTION SERVICE

BB24D BC BS OF MD FED EMPLOYEES

AO655 BC/BS

I1758 BLUE CROSS BLUE SHIELD

I1174 CAREFIRST

BB24A CAREFIRST B/C B/S OF MD

AU146 CAREMARK

AY314 CAREMARK

I0530 CAREMARK

I0668 CAREMARK

I0691 CAREMARK

I1535 CAREMARK

AP622 CIGNA HEALTH CARE

I0534 CIGNA HEALTH CARE

AR983 CIGNA HEALTH PLAN

I1782 CIGNA PHARMACY

I1338 CIGNA RX

I1317 CLAIMS PRO

I0680 DIVERSIFIED PHARMACEUTICAL

I1329 ECKERD PHARMACY SERV

I1206 EXPRESS SCRIPT

I1061 EXPRESS SCRIPT VALUE RX

I0559 EXPRESS SCRIPTS

I0929 EXPRESS SCRIPTS

I1296 EXPRESS SCRIPTS

I1511 EXPRESS SCRIPTS

I1628 EXPRESS SCRIPTS

I1379 EXPRESS SCRIPTS/GOODYEAR

I0592 MEDCO

I0504 MEDCO BEHAVIORAL CARE

QD174 MEDCO MNG CARE-AIM COMP ASSOC

I0766 MERCK MEDCO

I1550 MERCK MEDCO

I0276 MERCK/MEDCO

I1783 MERCK/MEDCO

I1443 MERCK-MEDCO

I0907 MEREK MEDCO

AW076 MET LIFE

I1213 MMRX OF FLA

AT142 NATIONAL PRESCRIPTION ADM

I1214 NEIGHBOR CARE PHARMACY

I0262 NPA

I1158 NPA

I1778 PA BLUE SHIELD

AY653 PAID PRESCRIPTIONS

I0483 PAID PRESCRIPTIONS

I1074 PAID PRESCRIPTIONS

I1196 PAID PRESCRIPTIONS

I1259 PAID PRESCRIPTIONS

I1295 PAID PRESCRIPTIONS

I1579 PAID PRESCRIPTIONS

I1032 PAID PRESCRIPTIONS INC

I1180 PAID PRESCRIPTIONS INC

I0954 PCS

I1364 PCS

I0899 PCS HEALTH SYSTEM

QD185 PCS HEALTH SYSTEMS INC

I1106 PD PRESCRIPTIONS INS

I1250 PHARMACARE

I0856 PREFORM

I0498 PRO VANTAGE

AR076 PRUDENTIAL

I0323 RETAIL PHARMACY PROGRAM

I0244 RX PRIME

I1272 RX PRIME CUSSTOMER SERVICE

I1789 RX WEST

I0820 SCRIPT RX

I1621 SERVICE BENEFIT PLAN

AP070 TRIGON BC AND BS

I1330 UNITED CONCORDIA

I1439 UNITED HEALTH CARE

AT020 UNITED HEALTHCARE

I0491 VALUE RX

I0624 VALUE RX

I0824 VALUE RX

I0028 VALUE RX SERV

AY793 VALUE RX SERVICES

I1336 VSP

I1627 WELL POINT PHARMACY MANAGEMENT

88888 MEDICARE

99999 MEDICAID

PD999 MEDICARE D

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