PRESCRIBER SEGMENT

 

Segment REQUIRED for these transactions: B1 and B3.

       Field

Field Name

VALUES

USED= Y

EDITED=E

PACE VALUES SUPPORTED

COMMENTS

111-AM

SEGMENT IDENTIFICATION

03

E

Prescriber Segment

466-EZ

PRESCRIBER ID QUALIFIER

13

Y

13  =  State Issued

411-DB

PRESCRIBER ID

PA License

E

Pennsylvania license number.  See manual for adjacent state’s format.

427-DR

PRESCRIBER LAST NAME

 

E

 

 

 

     COB SEGMENT

 

Segment REQUIRED for these transactions: B1 and B3 if there is OTHER PAYER information.

       Field

Field Name

VALUES

USED = Y

EDITED=E

PACE VALUES SUPPORTED

COMMENTS

111-AM

SEGMENT IDENTIFICATION

05

E

Coordination of Benefits / Other Payments Segment

337-4C

COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT

 

Y

Maximum of 3 occurrences will be reviewed.

338-5C

OTHER PAYER COVERAGE TYPE

 

Y

 

339-6C

OTHER PAYER ID QUALIFIER

03

Y

03 = BIN#

 

34Ø-7C

OTHER PAYER ID

 

E

BIN #    Edited effective June 20, 2006.

Enter primary payer(s) BIN.

443-E8

OTHER PAYER DATE

 

Y

 

341-HB

OTHER PAYER AMOUNT PAID COUNT

 

Y

Only 1 iteration per grouping supported.

342-HC

OTHER PAYER AMOUNT PAID QUALIFIER

  07*

08

Y

Ø7 = Drug Benefit* (See NOTE below)

Ø8 = Sum of all reimbursement.

 

431-DV

OTHER PAYER AMOUNT PAID

 

E

Multiple iterations per grouping supported. This field must be populated when using Other Coverage Code of “2.” 

471-5E

OTHER PAYER REJECT COUNT

 

Y

 

472-6E

OTHER PAYER REJECT CODE

Y

 

E

Effective June 20, 2006, this field must contain the primary plan’s reject code if billing with an Other Coverage Code of 3, 5, 6 or 7.

 

 

*NOTE: For claims that receive an administrative or incentive fee from the primary payer e.g., the Medicare monthly $54 additional reimbursement, providers are to submit the claim with the drug reimbursement amount paid by the Primary identified with the Other Payer Amount Paid Qualifier of “07.”

 


 

PRICING SEGMENT

 

Segment MANDATORY for these transactions: B1 and B3.

     Field

Field Name

VALUES

USED= Y

EDITED= E

PACE VALUES SUPPORTED

COMMENTS

   111-AM

SEGMENT IDENTIFICATION

11

Y

Pricing Segment

   *4Ø9-D9

INGREDIENT COST SUBMITTED

 Y

                * E

 

*Edited if compound code of 2 is used.

    412-DC

DISPENSING FEE SUBMITTED

 

Y

 

    433-DX

PATIENT PAID AMOUNT SUBMITTED

 

E

Enter amount indicated by payer(s) OTHER THAN PACE/PACENET and CRDP to be paid by cardholder.  DO NOT ENTER PACE/PACENET or CRDP COPAY IN THIS FIELD.

 

     478-H7

OTHER AMOUNT CLAIMED SUBMITTED COUNT

 

Y

 

    479-H8

OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER

.

Y

 

      48Ø-

          H9

OTHER AMOUNT CLAIMED SUBMITTED

 

Y

.

    426-

       DQ

USUAL AND CUSTOMARY CHARGE

 

E

 

       43Ø-

       DU

GROSS AMOUNT DUE

 

Y

May be used at a later date under certain COB circumstances.