2.9 NCPDP/MEVS Transaction Types (Rev. 02/04)

NCPDP Field 103-A3, Transaction Code will be used to identify the type of MEVS/ProDUR transaction being submitted.

Eligibility Transactions

· Use NCPDP Field 103-A3 value E1 to submit.

· The variable eligibility format layout can be found in a subsequent section of this document.

· Pharmacy DME (specialty code 307) can NOT be submitted using an eligibility transaction.

Service Authorizations – Prescription Billing Transactions

· Use NCPDP Field 103-A3 value B1.

· Prescriptions require a service authorization.

· All Compounds require a service authorization.

· All Product Supply Codes require a service authorization. A Product Supply Code is a code that could normally be submitted on the pharmacy claim form and not the DME claim form C. These codes are in the MMIS Pharmacy Provider Manual in sections 4.2 and 4.3.

· ECCA is allowed for Compounds.

· Pharmacy DME transactions require a service authorization. A pharmacy DME supply is identified by specialty code 307 or category of service 0442. These types of transactions must be submitted using the 837 Professional ASC X12N.

· ECCA is not allowed for pharmacy DME, but is billed on the DME Claim Form C.

Dispensing Validation System Transactions

- Use NCPDP Field 103-A3, value B1. Although multiple line transactions (Transaction Count 2 – 4; Field 109-A9) can be submitted, only one DVS line item can be submitted per transaction and the DVS line must be the first line item within the transaction.

- Only items reimbursable under Category of Service 0288, 0161, and 0441 (RX) will be processed through ECCA. Items which are only reimbursable under Category of Service 0442 (DME) must be billed on DME Claim Form C or 837 Professional ASC X12N. Be sure to put the DVS number on the claim form. For ECCA claims, the DVS number will remain with the claim for adjudication purposes. Pharmacies should record the DVS number that is returned in the response.

Note: There may be some non-drug items where you are specifically instructed by New York State to use the 11 digit National Drug Code. If this occurs, use field 407-D7 (Product/Service ID) to enter the NDC and field 436-E1 to enter the Qualifier of 03. Field 406-D6 value should then be 1. The New York State Department of Health has also designated certain prescription drugs as requiring a DVS number. Field 407-D7 is used to enter these drugs.

- No UT, Post and Clear or DUR processing will occur for DVS item/HCPCS transactions. Prescription Drugs requiring a DVS number will be processed through the UT, Post and Clear and DUR programs.

- Only Current Dates of Service will be accepted for DVS Transactions.

Reversal/Cancel Transactions

- Use NCPDP Field 103-A3 value B2.

- Reversals can be submitted for service dates up to two years old if the original transaction was submitted directly to the eMedNY contractor. This includes paper and magnetic media, as well as online claim submissions.

- If the reversal is negating a paid claim, the reversal will appear on your remittance statement.

- If the reversal is negating a paid claim, you must complete the Processor Control Number field.

- If the reversal is negating a non-ECCA transaction, the reversal will not appear on your remittance statement.

Rebill/Adjustment Transactions

- Use NCPDP Field 103-A3 value B3. Data field requirements are otherwise identical to Prescription Billing requirements (B1).

- Rebill transactions can be submitted for service dates up to two years old if the original transaction was submitted directly to the eMedNY contractor. This includes paper and magnetic media, as well as online claim submissions.

- If the rebill is adjusting a paid claim, the rebill will appear on your remittance statement.

- If the rebill is adjusting a paid claim, you must complete the Processor Control Number field.

- You cannot adjust a non-ECCA claim to become an ECCA claim. The adjustment will apply any updated information, but the adjustment claim will remain a non-ECCA claim.

- If the rebill is adjusting a non-ECCA transaction, the rebill will not appear on your remittance statement.

- Rebills will not affect previously established service authorization limits.

- Rebills will not be allowed for original claims that generated a DVS prior approval. If a change is needed to a paid DVS claim, then you can submit the adjustment on paper or magnetic media. You may also reverse the original claim and then submit another original transaction with the corrected information.

Duplicate Claim Transactions

When an online claim transaction is sent to the MEVS, it will be matched against previously captured (approved) claims. If the transaction is determined to be an exact duplicate of a previously approved claim, the MEVS will return a “C” in the Transaction Response Status (112-AN) field. The remaining response fields will contain the data that was returned in the original response. The following fields will be examined to determine if the original captured response will be issued:

· Service Provider Number (201-B1 positions 21-28 on Transaction Header Segment)

· Cardholder ID Number (302-C2 on Insurance Segment)

· Date of Service (401-D1 positions 39-46 on Transaction Header Segment)

· Prescription/Service Reference # (402-D2 on Claim Segment)

· Fill Number (403-D3 on Claim Segment)

· Prior Auth Number Submitted (462-EV on Claim Segment)

· Product/Service ID (4Ø7-D7 on Claim Segment)

If identical data exists only in certain subsets of the above fields, your claim will be rejected for NCPDP Reject Code 83 “Duplicate Paid/Captured Claim” unless prior approval was obtained for one of the two conflicting transactions (meaning Prior Auth Number Submitted (462-EV) would need to contain a PA Number on one claim, and no PA Number for the other claim.)

For example, a NCPDP Reject Code of 83 “Duplicate Paid/Captured Claim” is returned when a claim is submitted and the Service Provider Number, Cardholder ID, and Prior Approval Number fields match a previous paid claim and one of the following conditions also exists:

· Prescription Service Reference Number matches, but NDC/HCPCS is different.

· NDC/HCPCS matches, but Prescription Service Reference Number is different.

· Prescription Service Reference Number and Fill Number are the same, but the Date of Service is different.

If the original transaction was non-ECCA and the duplicate transaction is ECCA, the transaction response will be the original non-ECCA response. No adjudication process will occur.

Chart 1 – Recipient with Coverage Codes H, K, M, O or ALL on file

Field 308-C8 Value	Field 431-DV Value	NCPDP Format Version	Field 104-A4 Value	Claim Status
0, 1, 2, 3, 4, 5, 6, 7, 8	431-DV is Not sent	51	Non-ECCA (Processor Control Number not sent) or ECCA (Processor Control Number sent)	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
0, 1, 4 or 7	Zeros or greater	51	ECCA or Non-ECCA	The transaction will be rejected. NCPDP Reject Code: 13 “M/I Other Coverage Code” and Response Code: 717 “Client Has Other Insurance” will be returned online.
2 or 8	Zeros	51	ECCA or Non-ECCA	The transaction will be rejected. NCPDP Reject Code 13 “M/I Other Coverage Code” and Response Code 715 ‘Other Payor Amount Must Be Greater Than 0’ will be returned.
2 or 8	Greater than Zero	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned). Other payor amount will be subtracted from the claim’s payment amount.
2 or 8	Greater than Zero	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
3, 5 or 6	Zeros, blank or not sent	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
3, 5 or 6	Zeros	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
3, 5 or 6	Greater than Zero	51	ECCA or Non-ECCA	The transaction will be rejected. NCPDP Reject Code “13 M/I Other Coverage Code” and Response Code “716 ‘ Other Payor Amount Must Be Equal to 0” will be returned.

Chart 2 – Recipient without Coverage Codes on file

Field 308-C8 Value	Field 431-DV Value	NCPDP Format Version	Field 104-A4 Value	Claim Status
0, 1, 2, 3, 5, 6, 7 or 8	Not sent	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
0, 1 or 7	Not sent	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
0, 1, 3, 5, 6 or 7	Zeros	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
0, 1or 7	Zeros	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
3, 5 or 6	Zeros, blank or not sent	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
0, 1, 3, 4, 5, 6 or 7	Greater than Zero	51	Non-ECCA or ECCA	The transaction will be rejected. NCPDP Reject Code “DV - M/I Other Payor Amount” and Response Code “510 – Other Insurance Information Inconsistent” will be returned.
2, 3, 5, 6, or 8	Not sent	51	Non-ECCA or ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
4	Not sent or zeros	51	Non-ECCA or ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
2 or 8	Greater than Zero	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
2 or 8	Greater than Zero	51	ECCA	If all other edits are passed, the transaction will be accepted for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
2 or 8	Zeros	51	Non-ECCA or ECCA	The claim will reject. NCPDP Reject Code “13 M/I Other Coverage Code” and Response Code “715 Other Payor Amount Must Be Greater Than 0” will be returned.

Eligibility Clarification Code – (Insurance Segment) Field 309-C9

This field is used to submit overrides for Excess Income/Spenddown or Nursing Home Resident denials.

This field will be used in conjunction with Field 433-DX, Patient Paid Amount (Pricing Segment), to allow pharmacies to have their claims electronically captured and adjudicated for Excess Income/Spenddown recipients. This field is used when the recipient’s eligibility has not yet been updated on file at the eMedNY contractor.

Only recognized entry is:

2 = Override (replaces SA Exception Code M – Temporary Medicaid Authorization/Excess Income - Spenddown) or Nursing Home Override

Note: The eMedNY will allow all NCPDP identified values (0 through 6). However, “2” is the only value utilized by the NYS Medicaid.

If field 309-C9 contains a value of “2” (to override Excess Income/ Spenddown) Field 433-DX must contain zeros or a dollar amount. Field 433-DX should only contain zeros when the recipient has already met their spenddown but eligibility has not yet been updated on the file at the eMedNY contractor. In all other cases, Field 433-DX should contain the dollar amount incurred or paid to the pharmacy by the recipient.

Excess Income claims will bypass eligibility editing but will be processed through the DUR edits. If the claim passes all edits, the recipient’s DUR drug profile will be updated and the entry in Field 433-DX will be included in the Other Insurance Paid field on your remittance statement.

Note: An approved Excess Income override claim will pend for thirty days waiting for the eligibility update to occur. The online response will be Table 10 response code 317 (Claim Pending: Excess Income/Spenddown). If the necessary update does not occur within the thirty-day period, your claim will be denied. More information on Table 10 Pend Response codes can be found under the Additional Message Field 526-FQ in this section.

The Eligibility Clarification Code (309-C9) field may also be used to report a Nursing Home Override in those instances where the Client’s file shows residency within an In-State Skilled Nursing Facility that covers pharmacy services. The override procedure may be used to resubmit a previously denied claim. If the Client has been discharged but the eMedNY Contractors’ file shows that the Client still resides in the Skilled Nursing Facility, you may submit an override. This will result in a pend status which will give the local districts time to update the Client’s file. If the update is not received within 30 days, the claim will deny.

Compound Code – (Claim Segment) Field 406-D6

This is a one (1) position field and will be used to alert the system as to the type of editing to perform. The allowable values are:

0 = Should be entered when dispensing any five (5) character alpha numeric Product Supply Code from sections 4.2 and 4.3 in the MMIS Pharmacy Provider Manual. Claim can be captured for adjudication and will be considered as one unit for UT and P & C. No DUR processing will occur. This value should also be used for DVS transactions.

1 = Should be entered when dispensing a prescription with an NDC code. Claim can be captured for adjudication and all processing will occur. May also be entered when dispensing a Product Supply Code as described above.

2 = Should be entered when dispensing a compound drug code. Claim will be considered as one unit for UT and P & C. No DUR processing will occur.

Prior Auth Type Code – (Claim Segment) Field 461-EU

This field is a two (2) position numeric field. There are three possible values for this field:

00 = Not specified

01 = Prior Authorization/Prior Approval. If this value is used, field 462-EV must contain the prior approval number.

04 = Exemption from co-pay. Use to indicate the recipient is exempt.

Prior Auth Number Submitted – (Claim Segment) Field 462-EV

This field is an eleven (11) position numeric field. This field should be filled with the Prior Approval Number followed by three zeros.

If a claim requires prior approval and the recipient is also exempt from co-pay, use a value of four (4) in Field 461-EU and the Prior Authorization Number in Field 462-EV. If submitting a DVS transaction and the recipient is also exempt from co-pay, use a value of four (4) Field 461-EU and do not submit anything in Prior Authorization Number in Field 462-EV All possible entry combinations are listed in the “Value/Comments” column of the formats.

Submission Clarification Code (Claim Segment) Field 420-DK

This is a two (2) position field and will be used to replace the SA (Service Authorization) Exception Code Field currently being used for UT overrides. This field must contain the same value for each claim submitted in the same transaction for the recipient. The recognized values are:

00 = Not Specified (NCPDP default value)

01 = No Override (No SA Exception Code)

02 = Other Override (use in place of SA Exception Code P – pending an override)

07 = Medically Necessary (use in place of SA Exception Codes J & L – Immediate Urgent Care & Emergency)

Reason for Service Code (DUR/PPS Segment) Field 439-E4

For a rejected transaction, the response may contain a DUR Conflict Code for a DUR edit that failed. If this is the case, an override may be submitted. To override a DUR reject, the DUR Conflict Code received in the response of the original transaction must be submitted with the transaction attempting the override. The DUR Conflict Code being sent in the override must match the DUR Conflict Code received in the response of the original transaction. A corresponding entry must also be entered in the DUR Outcome Code.

Result of Service Code – (DUR/PPS Segment) Field 441-E6

If a DUR override is being submitted, an entry in Field 441-E6, DUR Outcome Code, is required. The authorized values are detailed in each format and reflect the action taken by the pharmacist.

Authorization Number – (Response Status Segment) Field 503-F3

This field will contain a nine (9) digit invoice number assigned to the transaction (up to four claims) if the provider has elected to have the claim captured and adjudicated. The invoice number can be used to track the claim at the eMedNY contractor. If a claim will not be captured for adjudication by the system because it is too old or for other reasons, this field will contain “NO CLAIM TO FA”, meaning a claim has not been captured for adjudication. These claims need to be submitted to the eMedNY contractor via paper, magnetic media or Batch Pharmacy Dial-Up.

Message – (Response Message Segment) Field 504-F4 & Additional Message – (Response Status Segment) Field 526-FQ

Dependent on which NCPDP format was submitted, these fields will contain MEVS specific Eligibility, UT, Post & Clear, Co-pay, Denial responses, Pend responses, Drug Plan File price, DVS Number, Medicare, Restriction, Miscellaneous and other Insurance data. Refer to the formats for details concerning these fields.

Pend messages from Table 10 will be returned in Field 526-FQ, positions 1-3. These field positions normally contain the Eligibility Accepted Codes from Table 1. Table 1 codes will not be returned when a Table 10 response is necessary. Additionally, if a claim passes all other editing but requires pending for one of the reasons listed in Table 10, the:

· Header Response Status (Field 501-F1) will contain an ‘A’ (Accepted).

· Response Status (Field 112-AN) will contain a ‘C’ (Captured).

· Authorization Number (Field 503-F3) will contain an Invoice Number.

Note: Once a pend is resolved, the results can be found on the provider’s remittance statement.

3.2 Variable “5.1” Request Format (Rev. 09/03)

3.2.1 Transaction Header Segment (Rev. 09/03)

Required Transaction Header Segment Information

This segment is fixed in length (56 positions) and must always be submitted with all transactions.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
101		BIN Number	N	6	1-6	R	004740 = New York’s Assigned Number
102		Version/Release Number	A/N	2	7-8	R	51 = Variable Format
103		Transaction Code	A/N	2	9-10	R	This field identifies the type of transaction and number of prescriptions being submitted. Acceptable TRANSACTION TYPES: E1 = Eligibility Verification Format described in Section 4.0 on page 4.0.1. B1 = 1-4 Rx Billings Used for original claim billings and for pharmacists’ responses (overrides) to Drug Conflict Alerts. B2 = 1 Rx Reversal. Used to cancel a previous transaction. Format described in Section 6.0 on page6.0.1. B3 = 1-4 Rx Rebillings Used to adjust a previously paid claim. Format is otherwise identical to an Rx Billing. P1 = 1-4 PA Requests and Rx Billings Used for original claim billings where a Prior Approval number is being requested and for pharmacists’ responses (overrides) to Drug Conflict Alerts P2 = 1 Prior Authorization Reversal Used to cancel a previous transaction. Format described in Section 6.0 on page6.0.1. P4 = 1-4 PA Requests Only (non-ECCA claims requesting PA) Used for original claim billings requiring Prior Authorization and for pharmacists’ responses (overrides) to Drug Conflict Alerts N1 = 1 –4 Rx DURs Used to supply DUR information only for purposes of updating recipient’s drug history file when no claim submission or reimbursement is allowed or expected. At a minimum the reject code “84” (Claim not Paid/Captured) will be returned. For example: A pharmacist may wish to update a recipient’s DUR history file even though the drug is not reimbursable by New York State. N2 = 1 Rx DUR Reversal. Used to cancel a previous DUR transaction. Format described in Section 6.0 on page6.0.1. N3 = 1-4 Rx DUR Rebillings Used to adjust a previously paid DUR claim. Format is otherwise identical to an Rx Billing.
104		Processor Control Number	A/N	10	11-20	R	If using Electronic Claims Capture and Adjudication, field entry consists of:
				1	11-11		Y (yes) or N (no) – indicates whether the provider has read and attests to the data in the certification statement found in Section 7.0 on page 7.0.1.
				2	12-13		Submitter’s Initials – the first and last initial of the pharmacist submitting the claim (2 alpha characters.
				4	14-17		PIN – The four digit numeric Personal Identification Number previously selected by the provider and submitted to the Dept. of Health.
				3	18-20		ETIN – The three character (alpha, numeric or alphanumeric) Electronic Transmission Identification Number previously assigned to the provider by eMedNY contractor. For non-ECCA, the field must contain spaces.
109		Transaction Count	N	1	21	R	Blank=Not Specified 1=One Occurrence 2=Two Occurrences 3=Three Occurrences 4=Four Occurrences
202		Service Provider ID Qualifier	N	2	22-23	R	Ø5=Medicaid
201		Service Provider ID	A/N	15	21-38	R	Field Entry consists of: The eight digit Medicaid Provider Identification Number assigned to the Pharmacy by the Dept. of Health. Must left justify, space fill.
401		Date of Service	N	8	39-46	R	The date of service the prescription was filled. Format = CCYYMMDD. DVS transactions require a current date entry.
110		Software Vendor/Certification ID	A/N	10	47-56	R	This field must be space filled.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’ segment separator
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	Ø4=Insurance
FS	C2			3	variable	R	x’1C’ C2
302		Cardholder ID Number	A/N	20	variable	R	The eight character alpha numeric Medicaid Recipient Number (CIN). Left justify and space fill.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
FS	C3			3	variable	R	x’1C’ C3
303		Person Code	A/N	3	variable	R	The 2 digit numeric Medicaid Card Sequence Number (SEQ). Left justify and space fill.
FS	C9			3	variable	O	x’1C’ C9
309		Eligibility Clarification Code	N	1	variable	O	Use for Excess Income/ Spenddown recipients or for Nursing Home Override. Recognized value is: 2 = Override Note: Any other value from 0 to 6 will be ignored. For further explanation see page 2.10.6

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	Ø1=Patient

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
FS	C4			3	variable	R	x’1C’ C4
304		Date of Birth	N	8	variable	R	The Recipient’s birth date. Format = CCYYMMDD.
FS	C5			3	variable	R	x’1C’ C5
305		Patient Gender Code	N	1	variable	R	The Recipient’s gender. Acceptable values are: 1 = Male 2 = Female
FS	2C			3	variable	O	x’1C’ 2C
335		Pregnancy Indicator	A/N	1	variable	O	Used to indicate whether the client is pregnant or not. Acceptable values are: Blank = not specified 1 = not pregnant 2 = pregnant

3.2.4 Claim Segment (Rev. 02/04)

Note: This group separator must appear prior to each group of segments pertaining to a single claim line. From 1 to 4 claim segments with the other associated corresponding segments comprise a group. Only one of each of the associated segments may appear in a group. The Transaction Count field (109-A9) on the Transaction Header Segment indicates the number of claim line groups that will occur within a transaction.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
GS				1	variable	R	x’1D’

Required Claim Segment Information

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’ segment separator
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	Ø7=Claim
FS	EM			3	variable	R	X’1C’ EM
455		Prescription/Service Reference Number Qualifier	A/N	1	variable	R	Use this field to identify the type of billing submitted. Acceptable value: 1 = Rx Billing
FS	D2			3	variable	R	x’1C’ D2
402		Prescription/Service Reference Number	N	7	variable	R	The prescription number assigned by the pharmacy. Right justify and zero fill.
FS	E1			3	variable	R	x’1C’ E1
436		Product/Service ID Qualifier	A/N	2	variable	R	Use this field to identify the Product Type dispensed. This field is used when the item dispensed is a product supply item (section 4.2 and 4.3 of MMIS Pharmacy Provider Manual), when an NDC code is submitted or for a DVS transaction. Acceptable values are: 03 = NDC 09 = HCPCS
FS	D7			3	variable	R	x’1C’ D7
407		Product/Service ID	A/N	19	variable	R	Use this field to enter either the NDC code or the HCPCS Code. When entering the National Drug Code identifying the dispensed drug, only an 11 digit numeric entry is acceptable. When billing compounds use code 99999999999 when billing multiple ingredients where the most costly element is not covered by Medicaid. Otherwise compounds must be billed by individual components using the appropriate NDC code. Regulated drug components such as narcotics and other Schedule class drugs must be billed as separate components using a valid NDC code with a valid quantity which requires the use of multiple claim lines for each of the billed components. When submitting HCPCS codes, enter a 7 character field (beginning with an alpha and ending with 2 blanks). A two position modifier can replace the 2 blanks if it applies, e.g. BO. If a HCPCS code is entered, Field 436-E1 must be equal to 09.

Optional Claim Segment Information

Any fields entered in the Optional Claim Segment Information section will be ignored by MEVS except the following, which are required by NYSDOH for processing:

Fld#

Field Name

Format

Length

Position

Req

Value/Comments

variable

x’1C’ C8

308

Other Coverage Code

variable

Code indicating whether or not the Patient (Recipient) has other insurance coverage.

Acceptable values are:

00	Not Specified – Use for Medicare
01/07	No Other Coverage identified
02/08	Other Coverage Exists – Payment Collected
03/05/06	Other Coverage Exists – This Claim Not Covered
04	Other Coverage Exists – Payment Not Collected (ECCA not allowed)

Note: For further explanation see page 2.10.2

variable

x’1C’ D5

405

Days Supply

variable

Estimated number of days that the prescription will last. Maximum allowed is 366. Right justify and zero fill.

Note: When prescription’s directions state, “take as directed” (PRN), it is strongly advised “180” be entered.

variable

x’1C’ D6

406

Compound Code

variable

Acceptable values are:

0 = Not specified. This is also the value to use for DVS transactions.

1 = Not a compound – use when dispensing any prescription drug with an 11 digit NDC code.

2 = Compound – use when dispensing a compound drug code.

Note: “0” or “1” may be used for sickroom supplies, etc., when dispensing any 5 character alpha numeric supply code contained in sections 4.2 and 4.3 of the MMIS Pharmacy Provider Manual.

Example: Sickroom Supply Code Z2500 (gauze pads)

variable

x’1C’ D8

408

Dispense As Written (DAW)/Product Selection Code

A/N

variable

Acceptable values are:

0 = No Product Selection Indicated.

1 = Substitution not allowed by Prescriber.

4 = Substitution allowed – Generic Drug not in stock.

5 = Substitution allowed –Brand Drug dispensed as a Generic.

7 = Substitution not allowed – Brand Drug mandated by Law.

8 = Substitution allowed – Generic Drug not available in Marketplace.

variable

x’1C’ DE

414

Date Prescription Written

variable

Format = CCYYMMDD

variable

x’1C’ DF

415

Number of Refills Authorized

variable

Acceptable values are:

00 = No Refills Authorized

01 = 1 Refill

02 = 2 Refills

03 = 3 Refills

04 = 4 Refills

05 = 5 Refills

New York State only allows a maximum of 5 refills. The value in this field must be greater or equal to the Fill Number (field 403-D3).

variable

x’1C’ DK

420

Submission Clarification Code

variable

This field is used to indicate an Utilization Threshold override and replaces the use of the SA Exception Code.

Acceptable values are:

00 = Not Specified

01 = No Override

02 = Other Override – use to replace SA Exception Code P (pending an override)

07 = Medically Necessary – use to replace SA Exception Code J & L (Immediate Urgent Care & Emergency)

Note: These are the only values accepted for UT Override by NYSDOH when using the NCPDP format. Any other value entered in this field will be ignored.

variable

x’1C’ E7

442

Quantity Dispensed

variable

The total number of Decimal Units dispensed for the prescription. Right justify and zero fill. This is a required field for DVS transactions.

For enteral products, enter caloric units. For example, a prescription is for Regular Ensure 1-8oz. Can daily, 30 cans with five refills. There are 75 caloric units per 30 cans (one month supply). The correct entry for current date of service is 0000075000. Do not include refills.

variable

x’1C’ D3

403

Fill Number

variable

Acceptable values are:

00 = New Prescription

01 = First Refill

02 = Second Refill

03 = Third Refill

04 = Fourth Refill

05 = Fifth Refill

The maximum number of refills allowed = 5.

variable

x’1C’ EU

461

Prior Auth Type Code

variable

Acceptable values are:

00 = Not Specified

01 = Prior Authorization (use if no Copay exemption exists)

04 = Exemption from copay

variable

x’1C’ EV

462

Prior Auth Number Submitted

variable

Use this field to indicate prior approval.

Format = NNNNNNNNZZZ

1-8

NNNNNNNN = Prior Approval Number

9-11

ZZZ = zero fill

3.2.5 Prescriber Segment (Rev. 12/03)

Required Prescriber Segment Information

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’ segment separator
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	Ø3=Prescriber

Optional Prescriber Segment Information

Any fields entered in the Optional Prescriber Segment Information section will be ignored by MEVS except the following, which are required by NYSDOH for processing:

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
FS	DL			3	variable	O	x’1C’ DL
421		Primary Care Provider ID	A/N	10	variable	O	Use to enter the 8 digit MMIS Provider ID Number of the Referring Provider. Left justify, space fill. If the claim is for a restricted recipient, the primary provider’s provider number must be entered.
FS	2E			3	variable	O	x’1C’ 2E
468		Primary Care Provider ID Qualifier	A/N	2	variable	O	Blank=Not Specified Ø5=Medicaid
FS	EZ			3	variable	R	x’1C’ EZ
466		Prescriber ID Qualifier	A/N	2	variable	R	Ø5=Medicaid Ø8=State License
FS	DB			3	variable	R	x’1C’ DB
411		Prescriber ID	A/N	15	variable	R	The *Ordering Provider* who wrote the prescription. Either the Ordering Provider’s MMIS Provider ID number or license type and license number must be entered. If entering the 8 digit numeric Provider ID number, left justify; space fill. If entering the license type and number, enter: License Type in field position 1 & 2 (see Provider Manual for list of valid License Types). Zeros in position 3 & 4. Six digit license number in Position 5 – 10. If entering an Out of State license number, replace the two zeros in position 3 & 4 with the two character alpha state code. NYS Nurse Practitioners who are allowed to prescribe will have an F preceding their license number. NYS Optometrists who are allowed to prescribe will have a U or V preceding their license numbers. When entering their license numbers, enter the license type followed by a zero, the alpha character and the six-digit license number. Note: When entering a license number, the last six positions of the entry should be the actual numeric license number. If the license number does not contain six numbers, zero fill the appropriate positions preceding the actual license number. For example, an entry for an Optometrist whose license number is U867 would be: 250U000867. Examples: MMIS Provider Id # 01234567 New York license # 0100987654 Out of State license # 11NJ345678 Nurse Practitioner # 290F121212 Optometrist # 250U343434 This is a required field for all NCPDP transactions except eligibility.
FS	DL			3	variable	O	x’1C’ DL
421		Primary Prescriber	A/N	10	variable	O	Use to enter the 8 digit MMIS Provider ID Number of the Referring Provider. Left justify, space fill. If the claim is for a restricted recipient, the primary provider’s provider number must be entered.
FS	EZ			3	variable	R	x’1C’ EZ
466		Prescriber ID Qualifier	A/N	2	variable	R	Ø5=Medicaid Ø8=State License
FS	2E			3	variable	O	x’1C’ 2E
468		Primary Care Provider ID Qualifier	A/N	2	variable	O	Blank=Not Specified Ø5=Medicaid

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’ segment separator
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	11=Pricing

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
FS	DQ			3	variable	R	x’1C’ DQ
426		Usual and Customary Charge	D	8	variable	R	Entry Required for Electronic Claims Capture and Adjudication. Enter amount charged for the prescription. Right justify and zero fill.
FS	DX			3	variable	O	x’1C’ DX
433		Patient Paid Amount Submitted	D	8	variable	O	Amount received from the Excess Income/Spenddown recipient for the prescription dispensed. Note: Must have numeric value (zero or greater) if Field 309 has value of “2”.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’ segment separator
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	Ø8=DUR/PPS

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
FS	7E			3	variable	O	x’1C’ 7E
473		DUR/PPS Code Counter	N	1	variable	O	This will be a counter of each repeatable segment entered.
FS	E4			3	variable	O	x’1C’ E4
439		Reason for Service Code	A/N	2	variable	O	This code identifies the type of conflict. One of the following codes is required to override a DUR reject. Acceptable values are: TD = Therapeutic Duplication DD = Drug-Drug Interactions
FS	E6			3	variable	O	x’1C’ E6
441		Result of Service Code	A/N	2	variable	O	Action taken by pharmacist. Required if Field 439-E4 is used. Acceptable values are: 1A = Filled as is, false positive 1B = Filled, Prescription as 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

3.2.8 Coordination of Benefits/Other Payments Segment (Rev. 04/04)

Required Coordination of Benefits/Other Payments Segment Information

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’ segment separator
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	05=COB/Other Payments
FS	4C			3	variable	R	x’1C’4C
337		COB/Other Payments Count	N	1	variable	R	Enter the number of Other Payer occurrences.
The following fields (both required and optional can occur as a group up to 9 times:
							338-5C 339-6C 340-7C 341-HB 443-E8
The following fields can occur up to 9 times for each of the 9 occurrences listed above:
							342-HC 431-DV 471-5E 472-6E
FS	5C			3	Variable	R	x’1C’5C
338		Other Payer Coverage Type	A/N	2	variable	R	Enter one of the following values: Blank = not specified 01 = Primary 02 = Secondary 03 = Tertiary

Optional Coordination of Benefits/Other Payments Segment Information

Any fields entered in the Optional Coordination of Benefits/Other Payments Segment Information section will be ignored by MEVS except the following, which are required by NYSDOH for processing:

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
FS	6C			3	variable	O	x’1C’ 6C
339		Other Payer ID Qualifier	A/N	2	variable	O	Enter any valid code qualifiying the Other Payer Id. Examples would be, but not limited to the following: 01 = National Payer Id 02 = Health Industry Number (HIN) 03 = Bin Number (BIN) 99 = Other For Medicare Claims a value of “99” must be used.
FS	7C			3	variable	O	x’1C’ 7C
340		Other Payer ID	A/N	10	variable	O	Enter any valid value that identifies the Third Party Payer. For Medicare Claims enter a value of 13 (Medicare Part B)
FS	HB			3	variable	O	x’1C’ HB
341		Other Payer Amount Paid Count	N	1	variable	O	Enter the count of the payer amount paid occurrences. (342-HC/431-DV)
FS	E8			3	variable	O	x’1C’ E8
443		Other Payer Date	N	8	variable	O	Enter the date the payment was made or denied. Format=CCYYMMDD
The following two fields can occur up to 9 times with the above segment.
FS	HC			3	variable	O	x’1C’ HC
342		Other Payer Amount Paid Qualifier	A/N	2	variable	O	Enter the following value to report Third Party Information. 07=Drug Benefit If reporting Medicare Approved and paid amounts, the following values must be entered: 07=Medicare Approved 08=Medicare Paid 99=(1^st Occurrence) Deductible Amount 99=(2^nd Occurrence) Coinsurance Amount 99=(3^rd Occurrence) Co-Payment Amount
Enter the following field if payment was made by Third Party payer.
FS	DV			3	variable	O	x’1C’ DV
431		Other Payer Amount Paid	D	8	variable	O	Enter the dollar amount of payment known by the pharmacy from other sources. The dollar amount should reflect the amount identified by field 342-HC. For example, if a third party amount is being reported, Field 342-HC will have a value of 07 (Drug Benefit) and field 431-DV will have the amount paid by the Third Party Insurance. If a rejection from the primary payer has been received, either zeros or blanks may be entered in this field. You may also choose not to send the Other Payer Amount Paid field 431-DV, if the Other Coverage Code field 308-C8, contains a “3”, and the third party insurance has denied the claim. Note: When reporting payment from Third Party Insurance payer field 308-C8 must also be populated. Refer to page 2.10.2.
Enter the following two fields if a Third Party denial was made. Field 472-6E can be repeated if more than one reject code was reported by the Third Party payer.
Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
FS	5E			3	variable	O	x’1C’ 5E
471		Other Payer Reject Code	N	2	variable	O	Enter the total count of the Other Payer Reject codes reported below.
FS	6E			3	variable	O	x’1C’ 6E
472		Other Payer Reject Code	A/N	3	variable	O	Enter the Reject code received from Third Party Payer.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’ segment separator
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	12=Prior Authorization
FS	PA			3	variable	R	x’1C’PA
498		Request Type	A/N	1	variable		Code Identifying type of Prior Authorization Request. Acceptable value is: 1 = Initial
FS	PB			3	variable	R	x’1C’PB
498		Request Period Date-Begin	N	8	variable	R	Enter the Date of Service. Format: CCYYMMDD
FS	PC			3	variable	R	x’1C’PC
498		Request Period Date-End	N	8	variable	R	Enter the Date of Service. Format: CCYYMMDD
FS	PD			3	variable	R	x’1C’PD
498		Basis of Request	A/N	2	variable	R	Describes the reason for Prior Authorization. Acceptable value is: PR = Plan Requirement

3.3 Variable “5.1” Response Overview (Rev. 09/03)

Responses for transactions in a variable format will be returned in the rejected format or in the approved Claim Captured transaction format. Each of the formats will contain the MEVS response data in field 526-FQ, Additional Message. Data in the Additional Message field will be returned for each claim.

3.4 Claim Capture Response Format (Rev. 04/04)

Response Header Segment

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
102		Version/Release Number	A/N	2	1-2	R	51 (same as input)
103		Transaction Code	N	2	3-4	R	B1, B3, P1, P4, N1, or N3 (same as input)
109		Transaction Count	A/N	1	5-5	R	1 = 1 Rx Response 2 = 2 Rx Responses 3 = 3 Rx Responses 4 = 4 Rx Responses
501		Header Response Status	A/N	1	6-6	R	A = Acceptable
202		Service Provider ID Qualifier	A/N	2	7-8	R	Returns the same value that was entered.
201		Service Provider ID	A/N	15	9-23	R	Returns the same value that was entered.
401		Date of Service	N	8	24-31	R	Returns the same value that was entered.

Response Message Segment

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’ segment separator
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	20=Response Message
FS	F4			3	variable	R	x’1C’F4
504		Message	A/N	37	variable	R	*Will be in the following format*:
				8	1-8		Recipient's Medicaid Number (CIN)
				1	9-9		space
				2	10-11		Recipient's County Code
				1	12-12		value = * (Used to separate fields)
				2	13-14		Anniversary Month (values: 01-12)
				1	15-15		space
				1	16-16		Sex Code (values: M or F)
				3	17-19		Date of Birth (Format = CYY)
				1	20-20		space
				1	21-21		Category of Assistance
				1	22-22		space
				2	23-24		Re-certification Month (values: 01-12)
				1	25-25		space
				3	26-28		Office Number
				1	29-29		value = & (Used to separate fields)
				8	30-37		Service Date "ccyymmdd"

Response Status Segment

Note: This group separator must appear prior to each group of segments pertaining to a single response status.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
GS				1	variable	R	x’1D’

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’ segment separator
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	21=Response Status
FS	AN			3	variable	R	x’1C’AN
112		Transaction Response Status	A/N	1		R	C = Claim Captured This response value means the claim has been accepted. If Electronic Claims Capture and Adjudication was selected, this field is used in conjunction with the Authorization Number field to indicate whether the claim has been captured for adjudication. Note: A for Approved is returned on a P4.
FS	F3			3	variable	R	x’1C’F3
503		Authorization Number	A/N	20	variable	R	If Electronic Claims Capture and Adjudication was selected, a nine digit invoice number will be returned in the first nine positions of this field. Only one invoice number will be issued per transaction, which can include up to four NDC claim segments. This field will contain the message “NO CLAIM TO FA” if ECCA was requested but the claim was not captured for Adjudication.
FS	FQ			3	variable	R	x'1C' FQ
526		Additional Message Information	A/N	108	variable	R	Will be in the following format:
				3	1-3		MEVS Accepted or Pend Codes (see Section 8.0, Table 1 on page 8.0.1 and Table 10 on page 8.0.8, for values)
				1	4-4		Space used to separate fields
				2	5-6		Utilization Threshold/Post & Clear Code (see Section 8.0, Table 8 on page 8.0.6 for values)
				1	7-7		value = $ (Used to separate fields)
				9	8-16		Maximum Per Unit Price. This is a 9 digit field with a floating decimal. Examples are as follows: “999.99999" “9999.9999"
				1	17-17		value = % (Used to separate fields)
				3	18-20		Co-Payment Code (see Section 8.0, Table 6 on page 8.0.4 for values) or spaces
				1	21-21		Space used to separate fields
				8	22-29		Co-Pay Met Date "ccyymmdd" or spaces
				3	30-32		DVS Reason Code
				1	33-33		Value of = (Used to separate fields)
				2	34-35		Medicare Coverage
				1	36-36		Space used to separate fields
				12	37-48		HIC Number
				1	49-49		value = # (Used to separate fields)
				2	50-51		First Insurance Carrier Code
				1	52-52		value = / (Used to separate fields)
				14	53-66		First Insurance Coverage Codes
				1	67-67		value = @ (Used to separate fields)
				2	68-69		Second Insurance Carrier Code
				1	70-70		value = / (Used to separate fields)
				14	71-84		Second Insurance Coverage Codes
				1	85-85		value = + (Used to separate fields)
				2	86-87		Indication of Additional Coverage
				1	88-88		value = * (Used to separate fields)
				11	89-99		Restriction Information - Exception Codes: "xx xx xx xx"
				1	100-100		value = } (Used to separate fields)
				8	101-108		DVS Number. This number will be entered on your ECCA claim. If billing manually, this number must be put on your claim form.

Response Claim Segment

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x'1E' segment separator
FS	AM			3	variable	R	x'1C' AM
111		Segment Identification	N	2	variable	R	22 = Response Claim
FS	EM			3	variable	R	x'1C' EM
455		Prescription/Service Reference Number Qualifier	A/N	1	variable	R	Returns the same value that was entered.
FS	D2			3	variable	R	x'1C' D2
402		Prescription/Service Reference Number	A/N	7	variable	R	The Prescription Number that was entered will be returned in this field.

Response Pricing Segment

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x'1E' segment separator
FS	AM			3	variable	R	x'1C' AM
111		Segment Identification	N	2	variable	R	23 = Response Pricing
FS	FI			3	variable	O	x'1C' FI
518		Amount of Copay/co-Insurance	D	8	variable	O	The amount of copay that should be taken will be reported back in this field.
FS	FI			3	variable	O	x'1C' F5
505		Patient Pay Amount	D	8	variable	O	The amount of copay that should be taken will be reported back in this field.

Response DUR/PPS Segment

Refer to Section 5.0 on page 5.0.1, for a description of this segment.

Response Prior Authorization Segment

This segment will only be sent when a P4 Prior Authorization Request is submitted.

Only a single activity line can be processed within a P4 Prior Authorization transaction.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x'1E' segment separator
FS	AM			3	variable	R	x'1C' AM
111		Segment Identification	N	2	variable	R	26 = Response Prior Authorization
FS	PY			3	variable	O	x'1C' PY
498		Prior Authorization Number - Assigned	N	11	variable	O	Unique number identifying the prior authorization assigned by the processor.

Second Response Claim Information

Fld#

Field Name

Format

Length

Position

Req

Value/Comments

variable

x'1D'

2^nd Prescription – Required and Optional Segments as per claim requirements:

· Response Status Segment

· Response Claim Segment

· Response Pricing Segment

· Response DUR/PPS Segment

variable

Fields and format are the same as described on previous pages.

Third Response Claim Information

Fld#

Field Name

Format

Length

Position

Req

Value/Comments

variable

x'1D'

3rd Prescription – Required and Optional Segments as per claim requirements:

· Response Status Segment

· Response Claim Segment

· Response Pricing Segment

· Response DUR/PPS Segment

variable

Fields and format are the same as described on previous pages.

Fourth Response Claim Information

Fld#

Field Name

Format

Length

Position

Req

Value/Comments

variable

x'1D'

4th Prescription – Required and Optional Segments as per claim requirements:

· Response Status Segment

· Response Claim Segment

· Response Pricing Segment

· Response DUR/PPS Segment

variable

Fields and format are the same as described on previous pages.

3.5 Rejected Response Format (Rev. 12/03)

Response Header Segment

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
102		Version/Release Number	A/N	2	1-2	R	51 (same as input)
103		Transaction Code	N	2	3-4	R	B1, B3, P1, P4, N1, or N3 (same as input)
109		Transaction Count	A/N	1	5-5	R	1 = 1 Rx Response 2 = 2 Rx Responses 3 = 3 Rx Responses 4 = 4 Rx Responses
501		Header Response Status	A/N	1	6-6	R	A = Acceptable R = Rejected
202		Service Provider ID Qualifier	A/N	2	7-8	R	Returns the same value that was entered.
201		Service Provider ID	A/N	15	9-23	R	Returns the same value that was entered.
401		Date of Service	N	8	24-31	R	Returns the same value that was entered.

Response Status Segment

Note: This group separator will appear prior to each group of segments pertaining to a single response status.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
GS				1	variable	R	x’1D’

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x'1E' segment separator
FS	AM			3	variable	R	x'1C' AM
111		Segment Identification	N	2	variable	R	21 = Response Status
FS	AN			3	variable	R	x'1C' AN
112		Transaction Response Status	A/N	1	variable	R	R = Rejected or Unacceptable.
The following Four fields can be repeated up to 20 times:
FS	FA			3	variable	R	x'1C' FA
510		Reject Count	N	2	variable	R	Will contain the number of NCPDP Reject Codes listed in the following fields.
FS	FB			3	variable	R	x'1C' FB
511		Reject Code	A/N	2	variable	R	Will contain the NCPDP Reject Code applicable to the error. See Section 9.0 on page 9.0.1, for values.

FS	FQ			3	variable	R	x'1C' FQ
526		Additional Message Information	A/N	14	variable	R
				3	1-3	R	MEVS error codes will be returned here. See Table 2 (page 8.0.2), Table 7 (page 8.0.5) and Table 8 (page 8.0.6) in Section 8.0 for values. Note: Both Field 504 and 511 should always be reviewed in order to ascertain all applicable reject reasons. Field will be in the following format:
				1	4-4		Space used to separate fields
				3	5-7		Rx Denial Code (see Section 8.0, Table 7 on page 8.0.5, for values)
				1	8-8		Space used to separate fields
				2	9-10		Utilization Threshold/Post & Clear Code (see Section 8.0, Table 8 on page 8.0.6, for values)
				1	11-11		Space used to separate fields
				3	12-14		DVS Reason Code (see Section 8.0, Table 9 on page 8.0.7, for values)

Response Claim Segment

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x'1E' segment separator
FS	AM			3	variable	R	x'1C' AM
111		Segment Identification	N	2	variable	R	22 = Response Claim
FS	EM			3	variable	R	x'1C' EM
455		Prescription/Service Reference Number Qualifier	A/N	1	variable	R	Returns the same value that was entered.
FS	D2			3	variable	R	x'1C' D2
402		Prescription/Service Reference Number	A/N	7	variable	R	The Prescription Number that was entered will be returned in this field.

Response DUR/PPS Segment

Refer to Section 5.0 on page 5.0.1, for a description of this segment.

Second Response Claim Information

Fld#

Field Name

Format

Length

Position

Req

Value/Comments

variable

x'1D'

2nd Prescription – Required and Optional Segments as per claim requirements:

· Response Status Segment

· Response Claim Segment

· Response DUR/PPS Segment

variable

Fields and format are the same as described on previous pages.

Third Response Claim Information

Fld#

Field Name

Format

Length

Position

Req

Value/Comments

variable

x'1D'

3rd Prescription – Required and Optional Segments as per claim requirements:

· Response Status Segment

· Response Claim Segment

· Response DUR/PPS Segment

variable

Fields and format are the same as described on previous pages.

Fourth Response Claim Information

Fld#

Field Name

Format

Length

Position

Req

Value/Comments

variable

x'1D'

4th Prescription – Required and Optional Segments as per claim requirements:

· Response Status Segment

· Response Claim Segment

· Response DUR/PPS Segment

variable

Fields and format are the same as described on previous pages.

4.1 Variable "5.1" Eligibility Verification Request (Rev. 09/03)

There are only two segments that are required in order to process an Eligibility Transaction. They are the Transaction Header Segment and the Insurance Segment.

Transaction Header Segment

Required Transaction Header Segment

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
101		BIN Number	N	6	1-6	R	004740 = New York’s Assigned Number
102		Version/Release Number	A/N	2	7-8	R	51 = Variable Format
103		Transaction Code	N	2	9-10	R	This field identifies the type of transaction and number of prescriptions being submitted. Acceptable TRANSACTION TYPES: E1 = Eligibility Verification
104		Processor Control Number	A/N	10	11-20	R	NCPDP required field. Any data entered will be ignored.
109		Transaction Count	N	1	21	R	Blank=Not Specified 1=One Occurrence
202		Service Provider ID Qualifier	N	2	22-23	R	Ø5=Medicaid
201		Service Provider ID	A/N	15	21-38	R	Field Entry consists of: The eight digit Medicaid Provider Identification Number assigned to the Pharmacy by the Dept. of Health. Must left justify, space fill.
401		Date of Service	N	8	39-46	R	The date of service the prescription was filled. Format = CCYYMMDD.
110		Software Vendor/Certification ID	A/N	10	47-56	R	Leave this field blank.

Insurance Segment

Required Insurance Segment

Fld#	Id	Field Name	Format	Length		Position		Req		Value/Comments
SS				1	variable		R		x’1E’ segment separator
FS	AM			3	variable		R		x’1C’AM
111		Segment Identification	N	2	variable		R		Ø4=Insurance
FS	C2			3	variable		R		x’1C’ C2
302		Cardholder ID Number	A/N	20	variable		R		The eight character alpha numeric Medicaid Recipient Number (CIN). Left justify and space fill.

Optional Insurance Segment

Any fields entered in the Optional Insurance Segment Information section will be ignored by MEVS except the following, which are required by NYSDOH for processing:

Fld#	Id	Field Name	Format	Length		Position		Req		Value/Comments
FS	C3			3	variable		O		x’1C’ C3
303		Person Code	A/N	3	variable		O		The 2 digit numeric Medicaid Card Sequence Number (SEQ). Left justify and space fill.

4.2 Eligibility Verification Accepted Response Format (Rev. 02/04)

Response Header Segment

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
102		Version/Release Number	A/N	2	1-2	R	51 (same as input)
103		Transaction Code	N	2	3-4	R	E1 (same as input)
109		Transaction Count	A/N	1	5-5	R	1 = 1 Eligibility Response
501		Header Response Status	A/N	1	6-6	R	A = Acceptable
202		Service Provider ID Qualifier	A/N	2	7-8	R	Returns the same value that was entered.
201		Service Provider ID	A/N	15	9-23	R	Returns the same value that was entered.
401		Date of Service	N	8	24-31	R	Returns the same value that was entered.

Response Message Segment

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’ segment separator
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	20=Response Message
FS	F4			3	variable	R	x’1C’F4
504		Message	A/N	37	variable	R	*Will be in the following format*:
				8	1-8		Recipient's Medicaid Number (CIN)
				1	9-9		Space used to separate fields
				2	10-11		Recipient's County Code
				1	12-12		Value = * (Used to separate fields)
				2	13-14		Anniversary Month (values: 01-12)
				1	15-15		Space used to separate fields
				1	16-16		Sex Code (values: M or F)
				3	17-19		Date of Birth (Format = CYY)
				1	20-20		Space used to separate fields
				1	21-21		Category of Assistance
				1	22-22		Space used to separate fields
				2	23-24		Re-certification Month (values: 01-12)
				1	25-25		Space used to separate fields
				3	26-28		Office Number
				1	29-29		Value = & (Used to separate fields)
				8	30-37		Service Date "ccyymmdd"

Response Status Segment

Note: This group separator must appear prior to each group of segments pertaining to a single response status.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
GS				1	variable	R	x’1D’

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’ segment separator
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	21=Response Status
FS	AN			3	variable	R	x’1C’AN
112		Transaction Response Status	A/N	1		R	A = Acceptable
FS	FQ			3	variable	R	x’1C’FQ
526		Additional Message Information	A/N	96	variable	R	Will be in the following format:
				3	1-3		MEVS Eligibility Codes (see Section 8.0, Table 1)
				1	4-4		Space field separator
				2	5-6		Utilization Threshold/Post & Clear Code (see Section 8.0, Table 8 on page 8.0.6, for values)
				1	7-7		Value = $ (Used to separate fields)
				9	8-16		Maximum Per Unit Price “999.99999"
				1	17-17		Value = % (Used to separate fields)
				3	18-20		Co-Payment Code (see Section 8.0, Table 6 on page 8.0.4, for values) or spaces
				1	21-21		Space field separator
				8	22-29		Copay Met Date
				1	30-30		Value of (=) equal sign (Used to separate fields)
				2	31-32		Medicare Coverage Code
				1	33-33		Space field separator
				12	34-45		HIC Number
				1	46-46		Value = # (Used to separate fields)
				2	47-48		First Insurance Carrier Code
				1	49-49		Value = / (Used to separate fields)
				14	50-63		First Insurance Coverage Codes
				1	64-64		Value = @ (Used to separate fields)
				2	65-66		Second Insurance Carrier Code
				1	67-67		Value = / (Used to separate fields)
				14	68-81		Second Insurance Coverage Codes
				1	82-82		Value = + (Used to separate fields)
				2	83-84		Indication of Additional Coverage
				1	85-85		Value = * (Used to separate fields)
				11	86-96		Restriction Information - Exception Codes: "xx xx xx xx"

4.3 Eligibility Verification Rejected Response Format (Rev. 12/03)

Response Header Segment

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
102		Version/Release Number	A/N	2	1-2	R	51 (same as input)
103		Transaction Code	N	2	3-4	R	E1 (same as input)
109		Transaction Count	A/N	1	5-5	R	1 = 1 Eligibility Response
501		Header Response Status	A/N	1	6-6	R	R = Rejected
202		Service Provider ID Qualifier	A/N	2	7-8	R	Returns the same value that was entered.
201		Service Provider ID	A/N	15	9-23	R	Returns the same value that was entered.
401		Date of Service	N	8	24-31	R	Returns the same value that was entered.

Response Status Segment

Note: This group separator will appear prior to each group of segments pertaining to a single response status.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
GS				1	variable	R	x’1D’

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’ segment separator
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	21=Response Status
FS	AN			3	variable	R	x’1C’AN
112		Transaction Response Status	A/N	1	variable	R	R = Rejected
The following fields can be repeated up to 20 times:
FS	FA			3	variable	R	x'1C' FA
510		Reject Count	N	2	variable	R	Will contain the number of NCPDP Reject Codes listed in the following fields.
FS	FB			3	variable	R	x'1C' FB
511		Reject Code	A/N	2	variable	R	Will contain the NCPDP Reject Code applicable to the error. See Section 9.0 on page 9.0.1, for values.

FS	FQ			3	variable	R	x’1C’FQ
526		Additional Message Information	A/N	3	variable	R	*Will be in the following format*:
				3	1-3		MEVS Denial Code (see Section 8.0, Table 2 on page 8.0.2, for values)

5.0 DUR/PPS Response Segment (Rev. 02/04)

The DUR Response Data contains various data elements which facilitate the communication of clinical drug therapy information. Some of the responses (those with a Reason for Service Code of PG, PA, LD, and HD) will not return fields 529-FT, 530-FU or 531-FV.

The positions shown on the following pages are relative to the location of the DUR/PPS Response Segment in the transaction format. Refer to the transaction format to determine actual field positions.

Required Response DUR/PPS Segment

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’ segment separator
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	24=Response DUR/PPS
The following fields can be repeated up to 3 times depending on the number of DUR Rejects and/or Warnings issued:
FS	J6			3	variable	O	x'1C' J6
567		DUR/PPS Response Code Counter	N	1	variable	O	Indicates the number of DUR messages.
FS	E4			3	variable	O	x'1C' E4
439		Reason for Service Code	A/N	3	variable	O	The source code that will be generated and sent back to the pharmacy when a conflict is detected. Acceptable values are: TD = Therapeutic Duplication DD = Drug-Drug Interactions DC = Inferred Drug Disease Precaution PG = Drug Pregnancy Alert PA = Drug Age Precaution LD = Low Dose Alert HD = High Dose Alert
FS	FS			3	variable	O	x'1C' FS
528		Clinical Significance Code	A/N	1	variable	O	Indicates how critical the conflict is. This field reflects the severity the originating database has assigned to an interaction.
FS	FT			3	variable	O	x'1C' FT
529		Other Pharmacy Indicator	A/N	1	variable	O	Indicates the source of the previous prescription that forms the basis for the conflict with the present prescription. Acceptable values are: 0 = Not Specified 1 = Your Pharmacy 3 = Other Pharmacy
FS	FU			3	variable	O	x'1C' FU
530		Previous Date of Fill	N	8	variable	O	Previous date prescription was filled. Format = CCYYMMDD
FS	FV			3	variable	O	x'1C' FV
531		Quantity of Previous Fill	D	10	variable	O	Indicates the quantity of the conflicting agent that was previously filled.
FS	FW			3	variable	O	x'1C' FW
532		Database Indicator	A/N	1	variable	O	Identifies the source of the message Acceptable value is: 1 = First DataBank
FS	FX			3	variable	O	x'1C' FX
533		Other Prescriber Indicator	N	1	variable	O	Compares the prescriber of the current prescriptions to the prescriber of the previously filled conflicting prescription. Acceptable values are: 0 = Not Specified 1 = Same prescriber 2 = Other Prescriber
FS	FY			3	variable	O	x'1C' FY
544		DUR Free Text Message	A/ N	30	variable	O	Will contain data to assist the pharmacist in further identifying the DUR Conflict.

6.3 Reversal Response Accepted Format (Rev. 12/03)

Response Header Segment

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
102		Version/Release Number	A/N	2	1-2	R	51 (same as input)
103		Transaction Code	N	2	3-4	R	B2, N2, or P2 (same as input)
109		Transaction Count	A/N	1	5-5	R	1 = 1 Reversal Response
501		Header Response Status	A/N	1	6-6	R	A = Accepted This response value means the reversal has been accepted.
202		Service Provider ID Qualifier	A/N	2	7-8	R	Returns the same value that was entered.
201		Service Provider ID	A/N	15	9-23	R	Returns the same value that was entered.
401		Date of Service	N	8	24-31	R	Returns the same value that was entered.

Response Status Segment

Note: This group separator will appear prior to each group of segments pertaining to a single response status.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
GS				1	variable	R	x’1D’

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x’1E’ segment separator
FS	AM			3	variable	R	x’1C’AM
111		Segment Identification	N	2	variable	R	21=Response Status
FS	AN			3	variable	R	x’1C’AN
112		Transaction Response Status	A/N	1		R	A = Acceptable
FS	F3			3	variable	O	x’1C’F3
503		Authorization Number	A/N	20	variable	O	The nine digit invoice number assigned to the reversal will be returned in this field.
FS	FQ			3	variable	R	x’1C’FQ
526		Additional Message Information	A/N	3	variable	R	*Will be in the following format*:
					1-3		MEVS Accepted Codes (see Section 8.0, Table 1 on page 8.0.2 for values)

6.4 Reversal Response Rejected Format (Rev. 12/03)

Response Header Segment

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
102		Version/Release Number	A/N	2	1-2	R	51 (same as input)
103		Transaction Code	N	2	3-4	R	B2, N2, or P2 (same as input)
109		Transaction Count	A/N	1	5-5	R	1 = 1 Reversal Response
501		Header Response Status	A/N	1	6-6	R	R = Rejected or Unacceptable
202		Service Provider ID Qualifier	A/N	2	7-8	R	Returns the same value that was entered.
201		Service Provider ID	A/N	15	9-23	R	Returns the same value that was entered.
401		Date of Service	N	8	24-31	R	Returns the same value that was entered.

Response Status Segment

Note: This group separator will appear prior to each group of segments pertaining to a single response status.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
GS				1	variable	R	x’1D’

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x'1E' segment separator
FS	AM			3	variable	R	x'1C' AM
111		Segment Identification	N	2	variable	R	21 = Response Status
FS	AN			3	variable	R	x'1C' AN
112		Transaction Response Status	A/N	1	variable	R	R = Rejected or Unacceptable.
The following fields can be repeated up to 20 times:
FS	FA			3	variable	O	x'1C' FA
510		Reject Count	N	2	variable	O	Will contain the number of NCPDP Reject Codes listed in the following fields.
FS	FB			3	variable	O	x'1C' FB
511		Reject Code	A/N	2	variable	O	Will contain the NCPDP Reject Code applicable to the error. See Section 9.0, on page 9.0.1, for values.

FS	FQ			3	variable	O	x'1C' FQ
526		Additional Message Information	A/N	3-15	variable	O
					1-3	O	MEVS Denial Code (see Section 8.0, Table 2 on page 8.0.2, for values)
					1-51	O	If more than 1 reversal transaction is submitted, the message “Resubmit Additional Reversal Transaction separately” is displayed.

Response Claim Segment

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
SS				1	variable	R	x'1E' segment separator
FS	AM			3	variable	R	x'1C' AM
111		Segment Identification	N	2	variable	R	22 = Response Claim
FS	EM			3	variable	R	x'1C' EM
455		Prescription/Service Reference Number Qualifier	A/N	1	variable	R	Returns the same value that was entered.
FS	D2			3	variable	R	x'1C' D2
402		Prescription/Service Reference Number	A/N	7	variable	R	The Prescription Number that was entered will be returned in this field.

10.0 NCPDP 1.1 Batch Transaction Record Structure (Rev. 02/04)

Note: The following pages are only required for providers and vendors that will submit batch transactions via magnetic media (tape / diskette) or Electronic Batch Dial-up. If your organization will not submit NCPDP 1.1 transactions, please ignore all pages beyond this point. Please refer to the NYSDOH Technical Supplementary Companion Guide and/or the NCPDP Batch Pharmacy Dial-Up User Manual for further formatting information and submission requirements.

Special Considerations for NCPDP Batch 1.1

System Availability

The NYS Medicaid batch transaction submission system is available to providers 24 hours a day, seven days a week. Transactions sent in after 5 PM will be processed in the following daily cycle.

Notification of Errors and Problems

If a provider has any questions, they may contact the Help Desk personnel who can assist with problem resolution. The Help Desk Unit will be available to answer questions and to address any problems that may occur during normal business hours. Please contact the Help Desk at (866) 840-3445.

Transaction Format Information

The NYS Medicaid will accept Batch Standard Format Version 1.1. Version 1.1 is the envelope structure used to transmit Version 5.1 transactions as described in this document within a batch mode. Each batch transmission must contain a Batch Header Record, one or many Transaction Detail Data Records which contain the NCPCP 5.1 information, and a Batch Trailer Record.

Batch Header Record (Request File)

The required batch header record is a fixed length record 75 bytes long.

The following is the layout for submitting the batch header record.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
880	K4	Text Indicator	A/N	1	1-1	R	Enter a value of x’02’ to indicate the Start of the text.
701		Segment Identifier	A/N	2	2-3	R	00 = File Control (header)
880	K6	Transmission Type	A/N	1	4-4	R	T = Transaction
880	K1	Sender ID	A/N	24	5-28	R	The first three positions must be the ETIN (formerly the Tape Supplier Number) followed by an eight digit Medicaid Provider ID. The remaining field positions must be space filled.
806	5C	Batch Number	N	7	29-35	R	Enter the date the batch was created in Julian Date Format. Format=CCYYDDD CC= Century YY = Year DDD = Julian Date i.e. 2003230 = August 18, 2003 This number must match the Batch Number in the Trailer Record.
880	K2	Creation Date	N	8	36-43	R	Enter date file created in CCYYMMDD format
880	K3	Creation Time	N	4	44-47	R	Enter time file created in HHMM format.
702		File Type	A/N	1	48-48	R	P = Production T = Test
102	A2	Version/Release Number	A/N	2	49-50	R	11 = Version 1.1
880	K7	Receiver ID	A/N	24	51-74	R	Enter EMEDNYBAT in this field followed by space fill to end.
880	K4	Text Indicator	A/N	1	75-75	R	Enter a value of x’03’ to indicate the End of the text.

Transaction Detail Header

The transaction detail header record is a 13 byte fixed length record, which identifies and prefixes each 5.1 variable transaction detail record in the batch. Each detail record is terminated with the End of Text indicator x’03’.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
880	K4	Text Indicator	A/N	1	1-1	R	Enter a value of x’02’ to indicate the Start of the text.
701		Segment Identifier	A/N	2	2-3	R	G1 = Detail Data Record
880	K5	Transaction Reference Number	A/N	10	4-13	R	This number is assigned by the Pharmacy. This number uniquely identifies each claim within the submission.
		NCPDP Data Record	varies	14	variable	R	The NCPDP 5.1 Standard data stream is inserted here starting with the 5.1 Transaction Header Segment as defined in Section 3.0 on page 3.0.1.
880	K4	Text Indicator	A/N	1	variable	R	Enter a value of x’03’ to indicate the End of the text.

Batch Trailer Record

The required batch trailer record is a fixed length record 56 bytes long.

The following is the layout for submitting the batch trailer record.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
880	K4	Text Indicator	A/N	1	1-1	R	Enter a value of x’02’ to indicate the Start of the text.
701		Segment Identifier	A/N	2	2-3	R	99 = File Trailer
806	5C	Batch Number	N	7	4-10	R	Enter the same Batch Number that is on the Batch Header Record. Format=CCYYDDD CC= Century YY = Year DDD = Julian Date i.e.2003230 = August 18, 2003
751		Record Count	N	10	11-20	R	Enter the total number of records within the batch, including the batch header and trailer records.
504	F4	Message	A/N	35	21-55	R	Free form text or blank fill for 35 positions.
880	K4	Text Indicator	A/N	1	56-56	R	Enter a value of x’03’ to indicate the End of the text.

Batch Header Record (Response file)

The required batch header response record is a fixed length record 75 bytes long.

The following is the layout for the batch header response record.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
880	K4	Text Indicator	A/N	1	1-1	R	Enter a Value of x’02’ to indicate the Start of the text.
701		Segment Identifier	A/N	2	2-3	R	00 = File Control (header)
880	K6	Transmission Type	A/N	1	4-4	R	R = Response
880	K1	Sender ID	A/N	24	5-28	R	Returns EMEDNYBAT in this field followed by space filler to end.
806	5C	Batch Number	N	7	29-35	R	Returns the same batch number as submitted from the inbound batch. This number will match the batch number in the Trailer Record.
880	K2	Creation Date	N	8	36-43	R	Enter Date file created in CCYYMMDD format
880	K3	Creation Time	N	4	44-47	R	Enter Time file created in HHMM format.
702		File Type	A/N	1	48-48	R	P = Production T= Test
102	A2	Version/Release Number	A/N	2	49-50	R	11 = Version 1.1
880	K7	Receiver ID	A/N	24	51-74	R	Returns the number submitted from the Sender ID field with the outbound responses.
880	K4	Text Indicator	A/N	1	75-75	R	Value of x’03’ to indicate the End of the text.

Transaction Detail Header

The transaction detail header record is a 13 byte fixed length record, which identifies and prefixes each 5.1 variable transaction response detail record in the batch. Each detail record is terminated with the End of Text indicator x’03’.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
880	K4	Text Indicator	A/N	1	1-1	R	Value of x’02’ to indicate the Start of the text.
701		Segment Identifier	A/N	2	2-3	R	G1 = Detail Data Record
880	K5	Transaction Reference Number	A/N	10	4-13	R	The number assigned by the provider to uniquely identify each claim transaction within the batch will be returned with the correlated response to the transaction submitted.
		NCPDP Transaction Data Record	varies	14	variable	R	The NCPDP 5.1 Standard data stream response is inserted here starting with the 5.1 Response Header Segment as defined in Section 3.4
880	K4	Text Indicator	A/N	1	variable	R	Value of x’03’ to indicate the End of the text.

Batch Trailer Record

The required batch trailer record is a fixed length record 56 bytes long.

The following is the layout for the batch trailer record.

Fld#	Id	Field Name	Format	Length	Position	Req	Value/Comments
880	K4	Text Indicator	A/N	1	1-1	R	Value of x’02’ to indicate the Start of the text.
701		Segment Identifier	A/N	2	2-3	R	99 = File Trailer
806	5C	Batch Number	N	7	4-10	R	Returns the same batch number as submitted from the inbound batch. This number will match the batch number in the Header Record.
751		Record Count	N	10	11-20	R	The total number of response records within the batch, including the batch header and trailer records.
504	F4	Message	A/N	35	21-55	R	Free form text or blank fill for 35 positions.
880	K4	Text Indicator	A/N	1	56-56	R	Value of x’03’ to indicate the End of the text.

SEGMENT	ID	ELIG	Billing	Rev	Rebill	P/A Req & Billing	P/A Rev	P/A Req Only	Info Rptg	Info Rptg Rev	Info Rptg Rebill

Transaction Code	AM	E1	B1	B2	B3	P1	P2	P4	N1	N2	N3

Header	--	M	M	M	M	M	M	M	M	M	M
Patient	01	O	ONY	O	ONY	ONY	O	ONY	ONY	O	ONY
Insurance	04	M	M	O	M	M	O	M	M	O	M
Claim	07	N	M	M	M	M	M	M	M	M	M
Prescriber	03	N	ONY	N	ONY	ONY	O	ONY	ONY	N	ONY
COB/Other Payments	05	N	ONY	N	ONY	ONY	N	ONY	O	N	O
Pricing	11	N	M	O	M	M	O	O	O	O	O
Prior Authorization	12	N	O	N	O	M	O	M	N	N	N
DUR/PPS	08	N	O	O	O	O	O	O	O	O	O

Code	Description
002	MA Eligible
003	Eligible Only Outpatient Care
005	Eligible Capitation Guarantee Only
006	Eligible PCP
007	Emergency Services Only
008	Presumptive Eligible Long-Term/Hospice
009	Medicare Coinsurance Deductible Only
010	Eligible Except Long-Term Care
013	Presumptive Eligibility Prenatal A
014	Presumptive Eligibility Prenatal B
015	Perinatal Family
016	MA Eligible-HR-Utilization Threshold
017	Family Health Plus Services Only
018	Family Planning Services Only
021	Record Canceled – Cancels a Previously Accepted Claim

Code	Description
001	Not MA Eligible
030	Expired Temporary Card
031	Invalid Plastic Card Status
033	Non-current Card
045	No Authorization Found
050	Alternate Access Not Allowed
051	Invalid Provider Number
052	Provider Not on File
053	SSN Access Not Allowed
054	Provider Cannot Access by Account Type
055	Provider Not Eligible
056	Reenter Ordering Provider Number
059	Invalid License Type
061	Invalid Access Number
062	Invalid Medicaid Number
063	Invalid Sequence Number
065	Recipient Not on File
066	Disqualified Ordering Provider
067	Deceased Ordering Provider
068	Invalid Ordering Provider
071	Invalid Date
092	Invalid Specialty Code
100	Invalid Referring Provider Number
101	Restricted Recipient No Auth
103	No Coverage: Pending Family Health Plus
104	No Coverage-Excess Income
105	QMB Requires Medicare Approval
118	MCCP Recipient No Auth
300	Service Date Prior to Birth Date
302	Provider Ineligible Service on Date Performed
303	Prior Approval Indicated Denied/Rejected by NYS
304	Recipient ID Unequal to Prior Approval File
305	Child Care Recipient - Bill Agency
307	Prior Approval Units or Payment Amount Exceeded
308	Service Date Not Within Prior Approval Range
309	Claim Type Unequal to Prior Approval Record Class
312	Pregnancy Indicated – Invalid for Recipient Sex or Age
313	Provider Reimbursed for Medicare Only
314	Recipient Not QMB, Services Not Reimbursable
315	Recipient Not Medicare, Services Not Reimbursable
316	Claim Previously Paid Using Another Provider Number
318	Prescribing Provider License not in Active Status
320	Other Insurance Information Inconsistent
321	Pharmacy Service Included in Out-of-State Facility Rate
322	Online Adjustments/Rebills Not Allowed For DVS Items/Drugs
323	Processor Control Number Needed for Rebill/Reversal of Paid Claim
324	The system or file necessary to process the transaction is currently unavailable. Please call Provider Services at 800-343-9000 for system status or resubmit the transaction at a later time
325	Pharmacy Service Included in In-State Facility Rate
700	Year of Birth Not Equal to File
701	Sex Not Equal to File
702	ECCA Not Allowed
703	Invalid PIN
704	Invalid ETIN
999	Header Field Error

Code	Description
127	Co-payment Requirements Have Been Met
128	No Co-payment Required – Recipient Under Age 21 or Exempt

Code	Description
132	Missing/Invalid item/NDC code
133	Item not covered for patient gender
134	Patient age exceeds maximum age
135	Patient age precedes minimum age
136	Requested item exceeds frequency limitation
137	Missing/Invalid quantity dispensed
140	Category of service not valid for item / NDC code
142	Missing/Invalid category of service
705	NDC/HCPCS Not Covered
706	Refill Code Exceeds Number of Refills Authorized
707	Previously Filled Refill
708	Exceeds NY Allowable Refill Maximum
709	Maximum Days Supply Exceeded
710	Maximum Quantity Exceeded
711	Date Filled Prior to Date Rx Written
712	Override Denied-UT not at limit
713	Refill over 180 days old from date Rx Written
714	Date Filled More than 60 days from Date Rx Written
715	Other Insurance Amount must be greater than Zero
716	Other Insurance Amount must be equal to Zero
717	Recipient has Other Insurance
718	HR Recipient-No Rebate Agreement
719	MA Only Covers Family Planning
720	Days Supply is less than Minimum Required
722	Family Health Plus Denial

Code	Description
AA	UT Approved P&C Approved
AD	UT Approved, Services Not Ordered
AN	UT Approved, P&C Not Invoked
DA	UT At Service Limit, P&C Approved
DD	UT At Service Limit, Services Not Ordered
DN	UT at Service Limit, P&C Not Invoked
LA	UT Approved Near Limit, P&C Approved
LD	UT Approved Near Limit, Services Not Ordered
LN	UT Approved Near Limit, P&C Not Invoked
NA	UT Not Invoked, P&C Approved
ND	UT Not Invoked, Services Not Ordered
NN	UT Not Invoked, P&C Not Invoked
PA	UT Override Denied, P&C Approved
PD	UT Override Denied, Services Not Ordered
PN	UT Override Denied, P&C Not Invoked
XX	DUR Denial

Code	Description
129	Duplicate/Redundant DVS request
130	DVS process was not invoked
131	Item approved/DVS number Issued
132	Missing/Invalid item/NDC code
133	Item not covered for patient gender
134	Patient age exceeds maximum age
135	Patient age precedes minimum age
136	Requested item exceeds frequency limitation
137	Missing/Invalid quantity dispensed
139	DVS requires current date entry
140	Category of service not valid for item/NDC code
142	Missing/Invalid Category of Service
705	NDC/HCPCS not Covered
710	Maximum Order Quantity Exceeded

Code	Description
301	Pending for Manual Pricing (NDC requires Manual Review and pricing)
306	Item Requires Manual Review (NDC requires Manual Review prior to payment)
310	Pharmacy Service Included in In-State Facility Rate
311	PCP Plan Code Not on Contract File – Call Provider Services 800-343-9000
317	Claim Pending: Excess Income/Spenddown
319	Prior Approval Not on or Removed From File

Code	Description
	M/I=Missing Invalid
01	M/I BIN
04	M/I Processor Control Number
05	M/I Pharmacy Number
07	M/I Cardholder ID Number
08	M/I Person Code
09	M/I Birth Date
10	M/I Patient Gender Code
13	M/I Other Coverage Code
14	M/I Eligibility Override Code
15	M/I Date of Service
16	M/I Prescription/Service Reference Number
17	M/I Fill Number
19	M/I Days Supply
20	M/I Compound Code
21	M/I Product/Service ID
22	M/I Dispense as Written (DAW)/Product Selection Code
25	M/I Prescriber Id
28	M/I Date Prescription Written
29	M/I Number Refills Authorized
34	M/I Submission Clarification Code
35	M/I Primary Care Provider ID
50	Non-Matched Pharmacy Number
52	Non-Matched Cardholder Id
61	Product/Service Not Covered for Patient Gender
65	Patient is Not Covered
66	Patient Age Exceeds Maximum Age
70	Product/Service Not Covered
75	Prior Authorization Required
76	Plan Limitations Exceeded
77	Discontinued Product/Service ID Number
81	Claim Too Old
82	Claim Is Post Dated
83	Duplicate Paid/Captured Claim
84	Claim Has Not Paid/Captured
85	Claim Not Processed
87	Reversal Not Processed
88	DUR Reject Error
92	System Unavailable
DQ	M/I Usual and Customary Charge
DV	M/I Other Payor Amount Paid
DX	M/I Patient Paid Amount Submitted
EV	M/I Prior Authorization Number Submitted
E1	M/I Product/Service ID Qualifier
E4	M/I Reason For Service Code
E6	M/I Result of Service Code
E7	M/I Quantity Dispensed
E9	M/I Provider ID
MZ	Error Overflow

1.0 INTRODUCTION (Rev. 09/03)

2.0 GENERAL INFORMATION (Rev. 09/03)

2.1 Access Methods (Rev. 11/02)

2.2 Communication Protocol (Rev. 11/02)

2.3 Card Swipe (Rev. 09/03)

2.4 Dispensing Validation System (Rev. 09/03)

2.5 Transaction Format (Rev. 09/03)

2.6 Electronic Claims Capture and Adjudication (Rev. 09/03)

2.7 Transaction Overrides (Rev. 09/03)

2.8 MEVS Program Information (Rev. 11/02)

2.9 NCPDP/MEVS Transaction Types (Rev. 02/04)

2.10 Unique Treatment of Fields (Rev. 02/04)

Processor Control Number – (Transaction Header Segment) Field 104-A4

Service Provider ID – (Transaction Header Segment) Field 201-B1

Cardholder ID Number – (Insurance Segment) Field 302-C2

Other Coverage Code – (Claim Segment) Field 308-C8

Chart 1 – Recipient with Coverage Codes H, K, M, O or ALL on file

Chart 2 – Recipient without Coverage Codes on file

Eligibility Clarification Code – (Insurance Segment) Field 309-C9

Submission Clarification Code (Claim Segment) Field 420-DK

Reason for Service Code (DUR/PPS Segment) Field 439-E4

Result of Service Code – (DUR/PPS Segment) Field 441-E6

Authorization Number – (Response Status Segment) Field 503-F3

Message – (Response Message Segment) Field 504-F4 & Additional Message – (Response Status Segment) Field 526-FQ

3.0 Variable “5.1” Transaction (Rev. 12/03)

3.1 Request Segment Usage Matrix (Rev. 12/03)

3.2 Variable “5.1” Request Format (Rev. 09/03)

3.3 Variable “5.1” Response Overview (Rev. 09/03)

3.4 Claim Capture Response Format (Rev. 04/04)

3.5 Rejected Response Format (Rev. 12/03)

4.0 Eligibility Verification Transaction (Rev. 09/03)

4.1 Variable "5.1" Eligibility Verification Request (Rev. 09/03)

4.2 Eligibility Verification Accepted Response Format (Rev. 02/04)

4.3 Eligibility Verification Rejected Response Format (Rev. 12/03)

5.0 DUR/PPS Response Segment (Rev. 02/04)

6.0 Reversal Transaction (Rev. 09/03)

6.1 Reversal Transaction Request Format (Rev. 02/04)

6.2 Reversal Response Overview (Rev. 09/03)

6.3 Reversal Response Accepted Format (Rev. 12/03)

6.4 Reversal Response Rejected Format (Rev. 12/03)

7.0 FORMS (Rev. 09/03)

CERTIFICATION STATEMENT FOR PROVIDER UTILIZING ELECTRONIC BILLING

8.0 MEVS CODES (Rev. 09/03)

MEVS Accepted Codes – Table 1

MEVS Denial Codes – Table 2 (Rev. 11/02)

Co-payment Codes – Table 6 (Rev. 11/02)

Rx Denial Codes – Table 7 (Rev. 12/03)

Pharmacy UT & P & C Codes – Table 8 (Rev. 11/02)

Dispensing Validation System Reason Codes - Table 9 (Rev. 12/03)

Pend Reason Codes – Table 10 (Rev. 11/02)

9.0 NCPDP Reject Codes (Rev. 09/03)

10.0 NCPDP 1.1 Batch Transaction Record Structure (Rev. 02/04)