Programs: Maryland Medical Assistance Program (MA)


Pharmacy Provider Segment: Optional - Not used by MDBCCDT



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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



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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