Programs: Maryland Medical Assistance Program (MA)

Pharmacy Provider Segment: Optional - Not used by MADAP

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M/R/RW

Pharmacy Provider Segment: Optional - Not used by MADAP

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)
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 co-pay only. Amount must equal the amount in 430-DQ
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

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common -> Programs: Maryland Medical Assistance Program (MA)

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