The New York State Department of Health (NYSDOH) is pleased to introduce a method for the pharmacy community to submit Medicaid Eligibility Verification System (MEVS) transactions in an on-line, real-time environment. This method includes the mandatory Prospective Drug Utilization Review (ProDUR) program in compliance with OBRA’90 requirements. ProDUR will alert pharmacists to possible medical problems associated with the dispensing of the drug to the recipient. In addition, the new system will allow pharmacies the option of having the claim captured for adjudication by the NYSDOH eMedNY Contractor. The Electronic Claims Capture and Adjudication (ECCA), ProDUR and MEVS submission are all accomplished via the same transaction, with the system providing an immediate response for each program.

The telecommunication standards chosen for the system are the same as those recommended by the National Council for Prescription Drug Program, Inc., (NCPDP) and named under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Only the NCPDP Version 5.1 variable format and the Batch 1.1 format will be supported.

This document was developed to assist pharmacy providers and their system vendors in supporting the telecommunication standards. Format specifications were developed using the September 1999 Official Release of the NCPDP Telecommunication Standard Version 5 Release 1 standard as well as the September 1999 Data Dictionary Official Release provided to support this standard. If you do not have this information, it is available from:

National Council for Prescription Drug Programs Inc.

9240 East Raintree Drive

Scottsdale, AZ 85260

Phone: (480) 477-1000

Fax: (480) 767-1042

This document is divided into sections. The first section contains general background information provided to facilitate the programming necessary to support the telecommunication standard. Subsequent sections contain the NCPDP layouts, NCPDP Reject codes and MEVS codes.

2.0 GENERAL INFORMATION (Rev. 09/03)

2.1 Access Methods (Rev. 11/02)

The MEVS/ProDUR/ECCA system requires the use of the NCPDP transaction formats. The NCPDP formats will only be accepted via a PC-HOST Link (dial-up on the New York MEVS Network) or CPU-CPU link (direct connect to the eMedNY contractor). A provider may also choose to develop a connection through a telecommunication switch or a billing service. Providers using a switching company or billing service will be classified as a CPU-CPU provider, since the switching company or billing service will be connected to the eMedNY contractor as a CPU-CPU connection.

Once a provider has selected an access method, a certification process by the eMedNY contractor must occur. For more information on these access methods or certification process, please contact the Provider Services department at 1-800-343-9000.

Note: Submission via PC-Host or CPU-CPU allows up to four (4) claims per transaction. Submission via a switching company or billing service is limited to what the company allows, up to a maximum of four (4) claims per transaction.

2.2 Communication Protocol (Rev. 11/02)

Pharmacy providers will receive details concerning the correct communication protocol to use after notifying the eMedNY contractor of the access method the provider is selecting. Details will then be provided under a separate document.

2.3 Card Swipe (Rev. 09/03)

The card swipe function will still be available on the OMNI 3750 terminal for pharmacy providers who are designated by NYSDOH Quality Assurance and Audit Office as card swipe providers. Designated pharmacies must swipe the recipient’s card on the OMNI 3750 POS VeriFone Terminal using transaction type 5, prior to entering the on-line DUR transaction. No data should be entered on the POS terminal. The eMedNY contractor will match the transactions to ensure that a swipe was performed. Only transaction type 5 will register the DUR transaction as a swipe. The card swipe only has to be performed once for each recipient per date of service, regardless of the number of prescriptions being filled that day for that recipient.

2.4 Dispensing Validation System (Rev. 02/05)

This function enables suppliers of prescription footwear items, specified drugs, certain medical surgical supplies and durable medical equipment to receive a prior approval number (DVS number) through an automated electronic MEVS system. The DVS transaction can be submitted through the NCPDP variable 5.1 format. The DUR program has been modified to recognize an item or NDC code requiring a DVS number and will process the transaction through all required editing. If approved, and if the item or NDC code is reimbursable under category of service 0441, the DVS number will be returned in response field 526-FQ and the claim will be processed for adjudication (if ECCA is requested). If ECCA is not requested, be sure to record the DVS number for submission on your paper or electronic batch claim. Item codes reimbursable under category of service 0442 cannot be submitted through NCPDP Version 5.1.

2.5 Transaction Format (Rev. 09/03)

The transaction formats in this document are divided into two parts, Request and Response. Each part is displayed in table format. The tables consist of columns. The columns include the NCPDP assigned “Field Number,” “Field Identifier,” “Field Name,” “Format,” “Length” and “Position” and contain strictly NCPDP information. Additional information about these columns can be found in the NCPDP manual. The final two columns include the “Req” (required) and “Value/Comments” columns and are described in the following paragraphs.

For the data in the “Value/Comments” column, a definition of the Values shown in the formats can either be found in the NCPDP Data Dictionary or listed as a comment.

Note: In the POSITION Column, the word “variable” indicates the position of the field in the format can vary depending on the presence or absence of any preceding field.

The “Req” (required) column indicates if the field is required to successfully execute a transaction. The values found in the column include:

R = Completion (or inclusion) of this field is required to successfully complete the transaction. The requirement may be due to the NCPDP format or a MEVS Program (Utilization Threshold, Post & Clear, Electronic Claims Capture and Adjudication, etc.). The entered data in some of the required fields will not be used in the execution of the transactions. These fields are so indicated in the comments column.

O = This field is optional. It is not needed to successfully complete all transactions, but is needed for most transactions.

Request Format (Rev. 09/03)

The NCPDP input format allowed for MEVS/ProDUR/ECCA transactions will consist of the variable “5.1”.

The variable “5.1” format is made up of segments. The segments include the Transaction Header Segment, Patient Segment, Insurance Segment, Claim Segment, Prescriber Segment, COB/Other Payments Segment, DUR/PPS Segment, Pricing Segment, and Prior Authorization Segment. For multiple claims, all segments repeat for each claim up to a maximum of four claims except for the Transaction Header Segment, Patient Segment and Insurance Segment. eMedNY will not process the following segments if they are transmitted: Pharmacy Provider Segment, Workers’ Compensation Segment, Coupon Segment, Compound Segment, and the Clinical Segment. These segments will be ignored if sent.

Response Formats (Rev. 09/03)

Responses will be returned via the same method of input, immediately following the completion of the processing of the transaction. The variable “5.1” format will contain response status codes in the Response Header Segment and for each prescription in the Response Status Segment.

If the header status code indicates the header is acceptable (A), then no errors were detected in the header data. If the header status code indicates the header is unacceptable (R), all prescriptions (claims) submitted are also in error and the response status code for the prescription will be “R”. Reject codes applicable to the header will be present in the first claim reject code list in addition to any reject codes specific to the first claim.

If the header data is acceptable (A) and the prescription (claim) data has passed all edits and is accepted, a “C” will be returned in the prescription (claim) response status code. A “C” will also be returned for acceptable claims for which the Electronic Claims Capture and Adjudication option was selected. Each prescription segment submitted will receive an individual response status code. A single transaction with four (4) claim submissions could have a mixture of prescription (claim) response status codes. The first claim could be “R”, the second claim “C”, etc.

For each transaction, error codes will be returned, if applicable. NCPDP reject codes will be returned in Field 511-FB. MEVS Accepted and Denial Codes listed in Table 1 (page 8.0.1) and Table 2 (page 8.0.2), Rx Denial codes listed in Table 7 (page 8.0.5), UT/PC Codes listed in Table 8 (page 8.0.6), DVS codes listed in Table 9 (page 8.0.7), and the Pend Reason Codes listed in Table 10 (page 8.0.8) will be returned in Field 526-FQ, the additional message field. An NCPDP reject code will always be returned in Field 511-FB and may have a corresponding MEVS code placed in Field 526-FQ to clarify the error. Both Fields should always be reviewed. The valid MEVS and NCPDP codes can be found in Sections 8.0 (page 8.0.1) and 9.0 (page 9.0.1) of this document.

For ProDUR editing, denials will be returned via the rejected response format and can be found in the Response DUR/PPS Segment. DUR warnings will be returned via the approved claim response “C” format. Each submitted claim could have three (3) possible DUR responses. If a claim has three (3) denial responses and also has warnings, only the denials will be returned.

2.6 Electronic Claims Capture and Adjudication (Rev. 12/08)

The Electronic Claims Capture and Adjudication feature is optional. If a pharmacy chooses to have their original or rebill NCPDP claim transaction captured for online adjudication, the Processor Control Number, Field 104-A4, must be completed. Captured claims will be fully edited for completeness and validity of the format of the entered data. There is a possibility that claims captured by the eMedNY contractor for final adjudication may be pended and eventually denied. All claim processing edits are performed during the DUR process. An advantage of ECCA is that it saves the pharmacy from having to file the claims separately.

Proper completion of the Processor Control Number Field requires the provider to certify and attest to the statement made in the Certification Statement. An original signed and notarized Certification Statement must be on file with the eMedNY contractor and renewed annually. The pharmacy must also enter a Personal Identification Number (PIN) and Electronic Transmitter Identification Number (ETIN) in Field 104-A4. The Certification Statement and PIN Selection Form can be found on the eMedNY.org website under Information - Provider Enrollment Forms. To obtain an Electronic Transmitter Identification Number (ETIN), call 800 343-9000. Remittances for claims submitted via ECCA will be returned to the pharmacy via the media the pharmacy selects. Further details on Field 104-A4 can be found in the Unique Treatment of Fields Section.

If a pharmacy chooses ECCA and the claim is approved, the Authorization Number Field 503-F3 in the Response Status segment will be spaces.

Note: If the Processor Control Number Field is not completed, the claim will not be captured for payment but will be processed through all the claim edits. If the claim is approved, the response “NO CLAIM TO FA” will be returned in Field 503-F3.

In any case, the following types of claims cannot be submitted via ECCA:

1.	An Rx billing claim (Transaction Code (B1)) with a date of service more than ninety (90) days old.
2.	A Rebill (Transaction Code B3) for an original ECCA transaction with a date of service more than ninety (90) days old, which contains a PA (Prior Approval) with a PA status date of over ninety (90) days old, will become a non-ECCA claim. You may submit the adjustment on paper or electronic batch.
3.	Adjustments/Rebills with a fill date over two years old.
4.	Voids/Reversals with a fill date over two years old.
5.	Durable Medical Equipment (DME) claims. DME includes any claim identified by specialty code 307 or Category of Service 0442. Note: DME does not include the product supply codes (1 alpha 4 numeric) found in the MMIS Pharmacy Provider Manual in sections 4.2 and 4.3.
6.	A Dispensing Validation System (DVS) transaction for an item that is only reimbursable under Category of Service 0442 (DME). Items reimbursable under Category of Service 0441 (RX) will be processed for ECCA.

2.7 Transaction Overrides (Rev. 09/03)

For a transaction rejected after the first submission, the provider may wish to resubmit the transaction with an override. There are four possible overrides. The first is a UT override, the second is a DUR override, the third is an excess income/spenddown override, and the fourth is a Nursing Home Override.

To submit a UT override, the provider must resubmit the original transaction with an entry in the Submission Clarification Code (420-DK) field. Details concerning the field can be found on page 2.10.8.

For submission of a DUR override, the provider must resubmit the original transaction with the DUR/PPS Segment completed. An entry must be made in Reason for Service Code (439-E4) field and Result of Service Code (441-E6) field. Details concerning these fields can be found on page 2.10.8.

For submission of an excess income/spenddown override, the provider must resubmit the original transaction with an entry in the Eligibility Clarification Code (309-C9) field on the Insurance Segment and the Patient Paid Amount (433-DX) field on the Pricing Segment. Details concerning these fields can be found on page 2.10.6.

For submission of a Nursing Home Override the provider must resubmit the original transaction with an entry in the Eligibility Clarification Code (309-C9) field on the Insurance Segment. The claim will be in a pend status, giving the local district time to update the Client’s file. If the file update is not received in a timely manner, the claim will deny.

2.8 MEVS Program Information (Rev. 11/02)

The following bullets highlight items a provider should be aware of when submitting DUR transactions:

- Service Authorizations (MEVS transaction type 1) are only allowed via PC or CPU access method using the NCPDP format.

- Each claim (prescription) submitted equates to one MEVS service unit.

- If a claim (prescription) is denied for UT and/or Post & Clear, the claim will not be processed through DUR.

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 (Rev. 05/09)

· Prescribing Providers who are in the Post & Clear program are required to “Post” any Pharmacy prescriptions and Supply Items ordered for the Original plus all Refills. The Posted prescriptions/Items (Original plus Refills) must then be “cleared” by the dispensing provider. The Post & Clear Service Authorizations are required for payment to be made.

· Dispensing Providers who are Designated Swipers in the Post & Clear program are required to create a Post & Clear Service Authorization for Pharmacy and Supply Items for the Original plus all Refills. Transactions may be submitted via NCPDP 5.1, EPACES, OMNI or 278 SA/DVS Request.

· Transactions for Supply Items requiring Prior Approval will also require Post & Clear Service Authorization for the Original plus Refills when the ordering or the billing provider is in the Post & Clear program.

· 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 HCFA 1500 Claim Form. 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 HCFA 1500 Claim Form.

Dispensing Validation System Transactions (Rev. 02/05)

- 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 HCFA 1500 Claim Form 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 (Rev. 02/05)

- 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 electronic batch, 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 (Rev. 12/08)

- 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 electronic batch, 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.

- If a rebill is adjusting an ECCA claim which contains a PA (Prior Approval) with a PA Status date of over 90 days old and the date of service is over 90 days old, the claim will become non- ECCA. You may submit the adjustment on paper or electronic batch.

- 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 electronic batch. 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.

2.10 Unique Treatment of Fields (Rev. 06/08)

Important NPI Announcement:

The New York State Department of Health (NYSDOH) will not be ready to implement the NPI system changes by May 23, 2008. As a result, NYS Medicaid provider IDs and license numbers will continue to be required for processing until the NPI system release is installed. This release is currently scheduled for September 1, 2008.

Note: The subsequent field treatments that are affected by the NPI changes are updated with the required NPI formatting following the current description of either the MMIS ID (Medicaid ID) or the state license number. Continue usage of the Medicaid Id or state license number until September 1, 2008, when the transition to NPI usage will begin.

General Edits

The following edits apply to all transactions:

1. The Date of Service (Date Filled) cannot be in the future.

2. The Date of Service (Date Filled) cannot be more than two years old. For an original ECCA transaction, if the date filled is over 90 days old, the transaction will be processed but will not be captured for adjudication. If all other editing is passed, “NO CLAIM TO FA” will be returned in the response. This 90-day rule does not apply to rebills or reversals.

3. The Date of Service cannot be prior to the Date Prescription Written or more than 60 calendar days from the Date Prescription Written.

4. DUR editing will not be performed for NDCs with a Date of Service more than 90 days old.

5. The Fill Number and the Number of Refills Authorized may not exceed five.

6. The Fill Number cannot be greater than the Number of Refills Authorized.

Processor Control Number – (Transaction Header Segment) Field 104-A4 (Rev. 02/05)

This is a ten (10) position field located in positions 11-20 on the Transaction Header segment. If a Pharmacy selects the Electronic Claims Capture and Adjudication option, this field must be completed and will be part of the claim record. It is required by New York State that the Certification Statement must be read prior to entering data in this field. The field entry consists of:

Position 1 Y or N. Y means the provider has read and attests to the facts in the Certification Statement for this claim. N means the provider has not read and is not attesting to the statement. If you have been issued a 4 digit ETIN, you may leave off the “Y” or “N” (read certification statement) in the first position.

Positions 2-3 The pharmacist must enter their first and last initials.

Positions 4-7 The Pharmacy’s PIN must be entered here.

Positions 8-10 The Pharmacy’s ETIN must be entered here.

You must complete the Processor Control Number field in order for a reversal or rebill to appear on your remittance. Reversals and rebills will only appear on a remittance statement if the original transaction resulted in a paid claim. A reversal or rebill of a non-ECCA transaction (Processor Control Number not sent) will not appear on a remittance statement.

Service Provider ID Qualifier – (Transaction Header Segment) Field 202-B2

This is a two (2) position field located in positions 22-23 on the Transaction Header

segment. This field should contain the value 05 to indicate Medicaid ID in field 201-B1 until September 1, 2008.

As of September 1, 2008 and beyond this two (2) position field located in positions 22-23 on the Transaction Header segment should always contain the value 01 to indicate National Provider Identifier.

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

This is a fifteen (15) position field located in positions 24-38 on the Transaction Header

segment. The first eight positions of this field will contain the eight digit assigned MMIS Provider Identification Number when field qualifier 202-B2 reports 05 until September 1, 2008. The remaining seven positions of this field will contain spaces.

As of September 1, 2008 and beyond this fifteen (15) position field located in positions 24-38 on the Transaction Header segment should contain the ten digit NPI assigned to the provider when field qualifier 202-B2 reports 01. The remaining five positions of this field will contain spaces.

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

This is a twenty (20) position field. The only valid field entries are:

a. The eight (8) character ID number assigned by New York State which identifies each individual Medicaid Recipient. This number begins with two (2) alpha characters, followed by five (5) numeric digits and then one (1) alpha character. This is the Client Identification Number found on the recipient’s benefit card.

b. The thirteen (13) digit numeric access number found on the recipient’s benefit card under Access Number. The ISO # should not be entered in this field.

Person Code – (Insurance Segment) Field 303-C3

This field must contain the two (2) character field found on the recipient’s benefit card under SEQ #.

Other Coverage Code – (Claim Segment) Field 308-C8 (Rev. 03/08)

This field will be used in conjunction with Field 431-DV, Other Payor Amount, to allow pharmacies to have their claims electronically captured and adjudicated when the recipient has other third party insurance or is enrolled in a Medicare Managed Care Organization (MCO). The field values are:

0= Not Specified

1= No Other coverage Identified

2= Other Coverage Exists – Payment Collected

3= Other Coverage Exists – This Claim Not Covered

4= Other Coverage Exists – Payment Not Collected (This value is only valid with non-ECCA transactions).

5= Managed Care Plan Denial (This functions the same as Coverage Code 3)

6= Other Coverage Denied – Not a participating provider (This functions the same as Coverage Code 3)

7= No Other coverage Identified (This functions the same as Coverage Code 1)

8= Other Coverage Exists – Payment Collected – Use for claim when billing for a

copay. (This functions the same as Coverage Code 2)

There are several edits in place to ensure that logical entries are made in both field 308-C8 and 431-DV. The following two charts describe what the status of the claim will be based on the field entries. The edits on Chart 1 (page 2.10.4) will occur when the recipient has MEVS Insurance Coverage Codes K, M, O or ALL on file at the eMedNY contractor. Chart 2 (page 2.10.5) will occur when no MEVS Insurance Coverage Codes indicating Pharmacy coverage for the recipient are on file.

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

Rev. (04/05)

Field 308-C8 Value	Field 431-DV Value	NCPDP Format Version	Field 104-A4 Value	Claim Status
0, 1, 4 or 7	431-DV is Not sent	51	Non-ECCA (Processor Control Number not sent)	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.
0, 1 or 7	Not sent	51	ECCA (Processor Control Number sent)	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.
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	Not sent	51	ECCA or 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	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 spaces will be returned in (field 503-F3). 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 spaces will be returned in (field 503-F3).
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 Rev. (04/05)

Field 308-C8 Value	Field 431-DV Value	NCPDP Format Version	Field 104-A4 Value	Claim Status
2 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).
2 or 8	Not sent	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and spaces will be returned in (field 503-F3).
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 spaces will be returned in (field 503-F3).
0, 1 or 7	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, 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, 1 or 7	Zeros	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and spaces will be returned in (field 503-F3).
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 spaces will be returned in (field 503-F3).
3, 5 or 6	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, 3, 5, 6 or 7	Greater than Zero	51	ECCA or Non-ECCA	The transaction will be rejected. NCPDP Reject Code “DV - M/I Other Payor Amount Paid” and Response Code “320 – Other Insurance Information Inconsistent” will be returned.
4	Greater than Zero	51	Non-ECCA
4	Not sent or 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).
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 spaces will be returned in (field 503-F3).
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 4 – 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 Rev. (02/05)

This field is an eleven (11) position numeric field. This field should be filled with an 11 digit prior approval number or an 8 digit prior approval number, followed by three zeros.

If a claim requires prior approval and the recipient is also exempt for co-pay, use a value of zero four (04) 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 zero four (04) in 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 Rev. (10/08)

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 6 – pending an override)

07 = Medically Necessary (use in place of SA Exception Codes 1 & 3 – Immediate Urgent Care & Emergency)

This two (2) position field will also be used to override the “ER” DUR Conflict Code condition in conjunction with reporting the ‘Reason for Service Code’ and the appropriate ‘Result of Service Code’. The Submission Clarification Code to use is as follows:

03 = Vacation Supply – use when early fill is for vacation or travel purposes.

04 = Lost Prescription – should be used when early fill is needed due to enrollee’s

medication being lost, damaged/destroyed, or stolen.

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

Rev. (02/05)

Spaces will be returned in this field if all edits are passed and the provider has elected to have the claim captured and adjudicated. 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, or electronic batch.

Message – (Response Message Segment) Field 504-F4 & Additional Message – (Response Status Segment) Field 526-FQ Rev. (02/05)

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).

· Spaces will be returned in the Authorization Number (Field 503-F3).

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

3.0 Variable “5.1” Transaction (Rev. 12/09)

3.1 Request Segment Usage Matrix (Rev. 12/09)

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
Pharmacy Provider	02	N	O	O	O	O	O	O	O	O	O
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
Clinical	13	N	O	O	O	O	O	O	O	O	O

M = mandatory

O = optional; conditional based on data content

ONY = optional; NYS data content required

N = Not sent

3.2 Variable “5.1” Request Format (Rev. 06/08)

3.2.1 Transaction Header Segment (Rev. 06/08)

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 page 6.0.1. 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 page 6.0.1. P4 = 1-4 PA Requests Only (non-ECCA claims requesting PA)
103	contd	Transaction Code	A/N	2	9-10	R	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 page 6.0.1. 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.
				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 or four character (alpha, numeric or alphanumeric) Electronic Transmitter Identification Number previously assigned to the provider by eMedNY contractor. When reporting a four character ETIN, you may omit the Y (Yes) or N (No) read certification indicator. 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 send until September 1, 2008 Ø1=National Provider ID (NPI) send September 1, 2008 and beyond.
201		Service Provider ID	A/N	15	24-38	R	Field Entry consists of: The eight digit Medicaid Provider Identification Number assigned to the Pharmacy by the Dept. of Health until September 1, 2008. Must left justify, space fill. Field Entry consists of: NPI - the ten digit National Provider Identification Number. Must be sent for September 1, 2008 and beyond. 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.

3.2.2 Insurance Segment (Rev. 09/03)

Required Insurance 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	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 Information

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	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

3.2.3 Patient Segment (Rev. 09/03)

Required Patient Segment Information

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

Optional Patient Segment Information

Any fields entered in the Optional Patient 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	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. 12/09)

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

variable

x’1C’ D7

407

Product/Service ID

A/N

variable

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 Rev. (10/08)

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 or is enrolled in a Medicare Managed Care Organization (MCO).

Acceptable values are:

00	Not Specified –
01/07	No Other Coverage identified
02	Other Coverage Exists – Payment Collected Use for Medicare Part B
03/05/06	Other Coverage Exists – This Claim Not Covered
04	Other Coverage Exists – Payment Not Collected (ECCA not allowed)
08	Other Coverage Exists – Claim is billing for a copay. (Functions same as Coverage Code 2)

Note: For further explanation see page 2.10.3

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.

FS	D6			3	variable	R	x’1C’ D6
406		Compound Code	N	1	variable	R	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)
FS	D8			3	variable	R	x’1C’ D8
408		Dispense As Written (DAW)/Product Selection Code	A/N	1	variable	R	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.
FS	DE			3	variable	R	x’1C’ DE
414		Date Prescription Written	N	8	variable	R	Format = CCYYMMDD
FS	DF			3	variable	R	x’1C’ DF
415		Number of Refills Authorized	N	2	variable	R	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).
FS	DJ			3	variable	O	X’1C’ DJ
419		Prescription Origin Code	N	1	variable	O	Code indicating origin of the prescription. 0 = Not specified 1 = Written 2 = Telephone 3 = Electronic 4 = Facsimile
FS	DK			3	variable	O	x’1C’ DK
420		Submission Clarification Code	N	2	variable	O	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 6 (pending an override) 07 = Medically Necessary – use to replace SA Exception Code 1 & 3 (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. DUR Conflict Override usage. NYSDOH requires reporting the 03 = Vacation Supply or the 04 = Lost Prescription – in conjunction with DUR fields 439-E4 and 441-E6 to override DUR conflict code ER – Drug Overuse.
FS	E7			3	variable	R	x’1C’ E7
442		Quantity Dispensed	D	10	variable	R	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.
FS	D3			3	variable	R	x’1C’ D3
403		Fill Number	N	2	variable	R	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’EK

454

Scheduled Prescription ID Number

variable

NYSDOH requires the Prescription Pad Serial Number of the Official New York State Prescription blank / form in order to process a claim. Some valid Prescriptions can be dispensed when not written on the Official Prescription Forms. For the specific situations, in lieu of the Prescription Serial Number, use the following values:

· Prescriptions on Hospital and their affiliated Clinics Prescription Pads effective until May 19, 2007, use: HHHHHHHH

· Prescriptions written by Out of State prescribers, use: ZZZZZZZZ

· Prescriptions submitted via fax or electronically, use: EEEEEEEE

· Oral Prescriptions, use: 99999999

· Prescriptions for carve-out drugs for nursing home patients, use: NNNNNNNN

FS	EU			3	variable	O	x’1C’ EU
461		Prior Auth Type Code	N	2	variable	O	Acceptable values are: 00 = Not Specified 01 = Prior Authorization (use if no Copay exemption exists) 04 = Exemption from copay
FS	EV			3	variable	O	x’1C’ EV
462		Prior Auth Number Submitted	N	11	variable	O	Use this field to indicate an 11 digit prior approval. Format = NNNNNNNNNNN If reporting an 8 digit prior approval number, format should be as follows: NNNNNNNNZZZ
				8	1-8		NNNNNNNN = Prior Approval Number
				3	9-11		ZZZ = zero fill

3.2.5 Pharmacy Provider Segment (Rev. 12/09)

Required Pharmacy Provider 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	02=Pharmacy Provider

Optional Pharmacy Provider Segment Information Rev. (12/09)

Any fields entered in the Optional Pharmacy Provider 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	EY			3	variable	O	x’1C’ EY
465		Provider ID Qualifier	A/N	2	variable	O	Blank=Not Specified 02=State License 05=NPI 07=State Issued
FS	E9			3	variable	O	x’1C’ E9
444		Provider ID	A/N	15	variable	O	Unique ID assigned to the person responsible for the dispensing of the prescription or provision of service.

3.2.6 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 Rev. (06/08)

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	2E			3	variable	O	x’1C’ 2E
468		Primary Care Provider ID Qualifier	A/N	2	variable	O	Blank=Not Specified Ø5=Medicaid use until September 1, 2008. Ø1=NPI use September 1, 2008 and beyond
FS	DL			3	variable	O	x’1C’ DL
421		Primary Care Provider ID	A/N	10	variable	O	Before September 1, 2008 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. September 1, 2008 and beyond enter the NPI of Referring Provider. If the claim is for a restricted recipient, the primary provider’s NPI number must be entered.
FS	EZ			3	variable	R	x’1C’ EZ
466		Prescriber ID Qualifier	A/N	2	variable	R	Prior to September 1, 2008 use Ø5=Medicaid or Ø8=State License September 1, 2008 and beyond enter: 01=NPI

variable

x’1C’ DB

411

Prescriber ID

A/N

variable

Prior to September 1, 2008 enter the following:

The Ordering Provider who wrote the prescription. Either the Ordering Provider’s MMIS Provider ID number or profession code and license number must be entered. If entering the 8 digit numeric Provider ID number, left justify; space fill. If entering the profession code and number, enter: Profession Code in field positions 1-3. Zeros in position 4 & 5. Six digit license number in position 6-11. If entering an Out of State license number, replace the two zeros in position 4 & 5 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 profession code 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: 0560U000867.

Examples:

MMIS Provider ID

# 01234567

New York license

# 06000987654

Out of State license

# 060NJ345678

Nurse Practitioner

# 0420F421212

Optometrist

# 0560U343434

This is a required field for all NCPDP transactions except eligibility.

On September 1, 2008 & beyond the prescriber NPI must be submitted for all qualified prescribers.

3.2.7 Pricing Segment (Rev. 09/03)

Required Pricing 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	11=Pricing

Optional Pricing Segment Information (Rev. 01/07)

Any fields entered in the Optional Pricing 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	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”.

variable

x’1C’ DN

423

Basis of Cost Determination

A/N

variable

Code indicating the method by which “Ingredient Cost Submitted” was calculated. Use value 09 “Other” when submitting claims for which a drug rebate has been received as a participant of a 340B Drug Purchasing Program.

Valid Values:

· Blank= Not Specified

· 00=Not Specified

· 01=AWP (Average Wholesale Price)

· 02= Local Wholesaler

· 03=Direct

· 04=EAC (Estimated Acquisition Cost)

· 05= Acquisition

· 06= MAC (Maximum Allowable Cost)

· 07= Usual & Customary

· 09= Other

3.2.8 DUR/PPS Segment (Rev. 10/08)

Required DUR/PPS 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	Ø8=DUR/PPS

Optional DUR/PPS Segment Information

This portion of the segment is repeatable up to 9 times. However, only one DUR Conflict and Outcome code is captured and processed. Therefore, only 1 occurrence should be transmitted. Any fields entered in the Optional DUR/PPS 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	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 ER = Drug Overuse 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 1H = Brand-to-Generic Change 1J = Rx-to OTC Change 1K = Filled with Different Dosage Form 2A = Prescription Not Filled 2B = Not Filled, Directions Clarified 3A = Recommendation Accepted 3B = Recommendation Not Accepted 3C = Discontinued Drug 3D = Regimen Changed 3E = Therapy Changed 3F = Therapy Changed – cost increased acknowledged 3G = Drug Therapy Unchanged 3H = Follow-Up/Report 3J = Patient Referral 3K = Instructions Understood 3M = Compliance Aid Provided 3N = Medication Administered

3.2.9 Coordination of Benefits/Other Payments Segment (Rev. 01/07)

Note: Medicare Part D:

· For drugs/OTCs excluded by Medicare Part D but covered by NYS Medicaid, do not send the COB Segment.

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 (Rev. 05/09)

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 qualifying 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) 04 = National Association of Insurance Commissioners (NAIC) 99 = Other
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 or Medicare Managed Care Organization (MCO). For Medicare Part B Claims enter a value of 13 (Medicare Part B)
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
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)

The following two fields can occur up to 9 times with the above segment.

variable

x’1C’ HC

342

Other Payer Amount Paid Qualifier

A/N

variable

Code list qualifying Other Payer Amount Paid for (431-DV), use to itemize paid amounts or use 08 only, for a total amount paid.

01=Delivery

02=Shipping

03=Postage

04=Administrative

05=Incentive

06=Cognitive Service

07=Drug Benefit

08=Sum of All Reimbursement

99=Other

Enter the following value to report Third Party or Medicare Managed Care Organization (MCO) Information.

07= Drug Benefit

To qualify the specific Co-Pay, Coinsurance and Deductible amounts for TPL and Medicare Managed Care Organizations (MCO’s), the following values must be entered:

99=(1st Occurrence) Deductible Amount

99=(2nd Occurrence) Coinsurance Amount

99=(3rd Occurrence) Co-Payment Amount

When reporting Medicare Part B Approved and Paid amounts, the following values must be used:

07=Medicare Approved

08=Medicare Paid

99=(1st Occurrence) Deductible Amount

99=(2nd Occurrence) Coinsurance Amount

99=(3rd Occurrence) Co-Payment Amount

Enter the following field if payment was made by Third Party payer or Medicare Managed Care Organization (MCO).

variable

x’1C’ DV

431

Other Payer Amount Paid

variable

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 or Medicare Managed Care Organization (MCO) 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 or Medicare MCO. 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 or Medicare Managed Care Organization has denied the claim.

Note: When reporting payment from Third Party Insurance or Medicare Managed Care Organization, field 308-C8 must also be populated. Refer to page 2.10.3.

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.

3.2.1 Prior Authorization Segment (Rev. 09/03)

Required Prior Authorization Segment Information

Note: This segment is only required when billing P1 (PA Requests and Rx Billings) and P4 (PA requests Only) Transactions.

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

3.2.2 Clinical Segment (Rev. 12/09)

Required Clinical Segment Information

Note: This segment is only required when reporting drug diagnosis codes for billing.

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	13=Clinical

Optional Clinical Segment Information Rev. (12/09)

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

Fld#	ID	Field Name	Format	Length	Position	Req	Value/Comments
FS	VE			3	variable	O	x’1C’VE
491		Diagnosis Code Count	N	1	variable	O	Count of diagnosis occurrences 1 to 5 Diagnosis Codes may be sent.
FS	WE			3	variable	O	x’1C’WE
492		Diagnosis Code Qualifier	A/N	2	variable	O	Code qualifying the ‘Diagnosis Code’ being sent. ‘01’ = (ICD9).
FS	DO			3	variable	O	x’1C’DO
424		Diagnosis Code	A/N	15	variable	O	Code identifying the diagnosis of the patient.

3.2.3 Second 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:

· Claim Segment

· Pharmacy Provider Segment

· Prescriber Segment

· COB/Other Payments Segment

· DUR/PPS Segment

· Pricing Segment

· Prior Authorization Segment

· Clinical Segment

variable

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

3.2.4 Third Claim Information

Fld#

Field Name

Format

Length

Position

Req

Value/Comments

variable

x’1D’

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

· Claim Segment

· Pharmacy Provider Segment

· Prescriber Segment

· COB/Other Payments Segment

· DUR/PPS Segment

· Pricing Segment

· Prior Authorization Segment

· Clinical Segment

variable

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

3.2.5 Fourth Claim Information

Fld#

Field Name

Format

Length

Position

Req

Value/Comments

variable

x’1D’

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

· Claim Segment

· Pharmacy Provider Segment

· Prescriber Segment

· COB/Other Payments Segment

· DUR/PPS Segment

· Pricing Segment

· Prior Authorization Segment

· Clinical segment

variable

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

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. 06/08)

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. Before September 1, 2008 this will be the Medicaid code. On September 1, 2008 and beyond, either NPI or Medicaid code is returned as submitted.
201		Service Provider ID	A/N	15	9-23	R	Returns the same value that was entered. Before September 1, 2008 this will be the Medicaid ID. On September 1, 2008 and beyond, either NPI or Medicaid number is returned as submitted.
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 (Rev. 02/05)

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, all editing was passed and the claim was captured for adjudication, spaces will be returned. 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	119	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)
				6	50-55		First Insurance Carrier Code
				1	56-56		value = / (Used to separate fields)
				14	57-70		First Insurance Coverage Codes
				1	71-71		value = @ (Used to separate fields)
				6	72-77		Second Insurance Carrier Code
				1	78-78		value = / (Used to separate fields)
				14	79-92		Second Insurance Coverage Codes
				1	93-93		value = + (Used to separate fields)
				2	94-95		Indication of Additional Coverage
				1	96-96		value = * (Used to separate fields)
				11	97-107		Restriction Information - Exception Codes: "xx xx xx xx"
				1	108-108		value = } (Used to separate fields)
				11	109-119		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	F5			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. 06/08)

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. Before September 1, 2008 this will be the Medicaid code. On September 1, 2008 and beyond, either NPI or Medicaid code is returned as submitted.
201		Service Provider ID	A/N	15	9-23	R	Returns the same value that was entered. Before September 1, 2008 this will be the Medicaid ID. On September 1, 2008 and beyond, either NPI or Medicaid number is returned as submitted.
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.

4.0 Eligibility Verification Transaction (Rev. 09/03)

The Eligibility Verification or Inquiry transaction can only be submitted using the variable "5.1" format. The input and response formats are described on the following pages. Any other transaction must use another format. Refer to the other areas within this document for the proper format for the other transactions. An Eligibility Verification transaction does not include any claim or NDC information and therefore only header sections are included in the input and response formats.

Refer to Section 3.1 (page 3.0.1) “Request Segment Usage Matrix” for a quick synopsis of which segments are mandatory, optional, optional but required by NYS, or Not Sent.

4.1 Variable "5.1" Eligibility Verification Request (Rev. 06/08)

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 send until September 1, 2008 Ø1=National Provider ID (NPI) send September 1, 2008 and beyond.
201		Service Provider ID	A/N	15	24-38	R	Field Entry consists of: The eight digit Medicaid Provider Identification Number assigned to the Pharmacy by the Dept. of Health until September 1, 2008. Must left justify, space fill. Field Entry consists of: NPI - the ten digit National Provider Identification Number. Must be sent for September 1, 2008 and beyond. 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. 06/08)

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. Before September 1, 2008 this will be the Medicaid code. On September 1, 2008 and beyond, either NPI or Medicaid code is returned as submitted.
201		Service Provider ID	A/N	15	9-23	R	Returns the same value that was entered. Before September 1, 2008 this will be the Medicaid ID. On September 1, 2008 and beyond, either NPI or Medicaid number is returned as submitted.
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 (Rev. 02/05)

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	104	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)
				6	47-52		First Insurance Carrier Code
				1	53-53		Value = / (Used to separate fields)
				14	54-67		First Insurance Coverage Codes
				1	68-68		Value = @ (Used to separate fields)
				6	69-74		Second Insurance Carrier Code
				1	75-75		Value = / (Used to separate fields)
				14	76-89		Second Insurance Coverage Codes
				1	90-90		Value = + (Used to separate fields)
				2	91-92		Indication of Additional Coverage
				1	93-93		Value = * (Used to separate fields)
				11	94-104		Restriction Information - Exception Codes: "xx xx xx xx"

4.3 Eligibility Verification Rejected Response Format (Rev. 06/08)

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. Before September 1, 2008 this will be the Medicaid code. On September 1, 2008 and beyond, either NPI or Medicaid code is returned as submitted.
201		Service Provider ID	A/N	15	9-23	R	Returns the same value that was entered. Before September 1, 2008 this will be the Medicaid ID. On September 1, 2008 and beyond, either NPI or Medicaid number is returned as submitted.
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. 10/08)

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 field’s 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 ER = Drug Overuse 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.

6.0 Reversal Transaction (Rev. 02/05)

A reversal transaction is needed to cancel or reverse a previously submitted transaction.

Only one claim or service authorization can be reversed at a time.

NCPDP Reversals can be submitted for service dates up to two years old as long as the previous transaction was submitted directly to the eMedNY contractor, or the transaction was submitted to eFunds no longer than 90 days prior to the eMedNY contractor takeover of the MEVS system.

By submitting a reversal via NCPDP format, you can either: reverse a previous NCPDP transaction, or the NCPDP reversal can be used to void a claim sent via paper or electronic batch. If a non-capture transaction (NO CLAIM TO FA) is being reversed, the action taken by the claims processing system is contingent on if the subsequent paper or electronic batch claim was approved during the interim.

If a paper or electronic batch claim was approved for payment during the interim, the paper or electronic batch claim will be voided, and any units used by the claim will be restored to its applicable service authorization or prior approval. The service authorization and prior approval will remain available for future use until the record becomes inactive.

If a subsequent paper or electronic batch claim has not been approved for payment during the interim, the non-capture transaction will be reversed, and any applicable service authorization or DVS prior approval generated as a result of submitting the non-capture transaction will be cancelled. When cancelled, the authorizations and approvals previously generated are no longer useable.

When reversing a previously submitted ECCA transaction that was captured for payment, if approved, the reversal will cancel any service authorization units used and cancel any DVS prior approval generated by the original transaction.

If a reversal transaction for a previously paid claim is approved, the remittance statement will show the reversal transaction, and the information from the original claim that was reversed/voided on the subsequent line of the remittance.

Refer to Section 3.1 (page 3.0.1) “Request Segment Usage Matrix” for a quick synopsis of which segments are mandatory, optional, optional but required by NYS, or Not Sent.

6.1 Reversal Transaction Request Format (Rev. 06/08)

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: B2 = Reversal N2 = DUR Reversal P2 = Prior Authorization Reversal
104		Processor Control Number	A/N	10	11-20	R	Required for a reversal for a paid captured claim. Will be ignored for a non-captured claim.
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 send until September 1, 2008 Ø1=National Provider ID (NPI) send September 1, 2008 and beyond.
201		Service Provider ID	A/N	15	24-38	R	Field Entry consists of: The eight digit Medicaid Provider Identification Number assigned to the Pharmacy by the Dept. of Health until Sept 1st 2008. Must left justify, space fill. Field Entry consists of: NPI - the ten digit National Provider Identification Number. Must be sent for September 1, 2008 and beyond. 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.

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	Ø7=Claim
FS	EM			3	variable	R	X’1C’ EM
455		Prescription/Service Reference Number Qualifier	N	1	variable	R	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

variable

x’1C’ D7

407

Product/Service ID

variable

Use this field to enter either the NDC code or the HCPCS Code.

When entering a National Drug Code identifying the dispensed drug, only an 11 digit numeric entry is acceptable.

6.2 Reversal Response Overview (Rev. 09/03)

Two types of response formats can be expected for a reversal transaction. The first is the accepted response and the second is the rejected response. The transaction response status code is limited to an "A" for "transaction acceptable" or an "R" for "transaction unacceptable" or rejected.

For each transaction, error codes will be returned if applicable. NCPDP format errors will be returned in the reject code fields (511-FB). MEVS denial codes will be part of the message field (504-F4) in the first three bytes. See the layouts that follow for details.

6.3 Reversal Response Accepted Format (Rev. 06/08)

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. Before September 1, 2008 this will be the Medicaid code. On September 1, 2008 and beyond, either NPI or Medicaid code is returned as submitted.
201		Service Provider ID	A/N	15	9-23	R	Returns the same value that was entered. Before September 1, 2008 this will be the Medicaid ID. On September 1, 2008 and beyond, either NPI or Medicaid number is returned as submitted.
401		Date of Service	N	8	24-31	R	Returns the same value that was entered.

Response Status Segment (Rev. 02/05)

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	Spaces 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 8.0.1 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.

6.4 Reversal Response Rejected Format (Rev. 06/08)

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. Before September 1, 2008 this will be the Medicaid code. On September 1, 2008 and beyond, either NPI or Medicaid code is returned as submitted.
201		Service Provider ID	A/N	15	9-23	R	Returns the same value that was entered. Before September 1, 2008 this will be the Medicaid ID. On September 1, 2008 and beyond, either NPI or Medicaid number is returned as submitted.
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.

7.0 INTENTIONALLY LEFT BLANK

8.0 MEVS CODES (Rev. 07/04)

MEVS Accepted Codes – Table 1

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 Nursing Facility Services
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
034	Community Coverage With Community Based Long Term Care
035	Community Coverage without Long Term Care
036	Outpatient Coverage with Community Based Long Term Care
037	Outpatient Coverage without Long Term Care
038	Outpatient Coverage with No Nursing Facility Services

Note: If code is received and not found in tables, call the Provider Services Department at 1-800-343-9000.

MEVS Denial Codes – Table 2 (Rev. 07/09)

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 Profession Code
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
326	Pend For State Review – OHIP/OMIG
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

Note: If code is received and not found in tables, call the Provider Services Department at 1-800-343-9000.

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

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

Note: If code is received and not found in tables, call the Provider Services Department at 1-800-343-9000.

Rx Denial Codes – Table 7 (Rev. 02/10)

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
421	Dispense Brand Drug Instead of Generic Equivalent
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
724	Client Has Medicare Part D
725	Serial Number Missing
726	Serial Number Reported As Missing/Stolen
727	Serial Number Cannot Be Adjusted – Void and Resubmit
728	UR Deny – Conflict With Previous Service

Note: If code is received and not found in tables, call the Provider Services Department at 1-800-343-9000. Pharmacy UT & P & C Codes – Table 8 (Rev. 11/02)

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

Note: If code is received and not found in tables, call the Provider Services Department at 1-800-343-9000.

Dispensing Validation System Reason Codes - Table 9 (Rev. 12/05)

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
723	Client Medicare Part D Denial

Note: If code is received and not found in tables, call the Provider Services Department at 1-800-343-9000.

Pend Reason Codes – Table 10 (Rev. 12/09)

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
321	Pharmacy Service Included in Out-of- State Facility Rate
326	Pend For State Review – OHIP/OMIG
420	UR Deny – Conflict With Previous Service

Note: These codes may appear in the Table 2 response area for non-ECCA and in some eligibility transactions since both transaction types will not be held in a pending status. They will be rejected if the conditions for these reason codes exist.

9.0 NCPDP Reject Codes (Rev. 04/10)

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
33	M/I Prescription Origin Code
34	M/I Submission Clarification Code
35	M/I Primary Care Provider ID
41	Submit Bill To Other Processor Or Primary Payer
50	Non-Matched Pharmacy Number
52	Non-Matched Cardholder ID
53	Non-Matched Person Code
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
78	Cost Exceeds Maximum
80	Drug Diagnosis Code Mismatch
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
EK	M/I Scheduled Prescription ID Number
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
PE	M/I COB/Other Payments Segment

Note: If code is received and not found in tables, call the Provider Services Department at 1-800-343-9000.

10.0 NCPDP 1.1 Batch Transaction Record Structure (Rev. 06/08)

Note: The following pages are only required for providers and vendors that will submit batch transactions via electronic batch. 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 a ten digit National 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.