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Mississippi Medicaid Provider Billing Handbook Section: Pharmacy Payor Sheet 5.2 Pharmacy Payor Sheet NCPDP VERSION 5.1 PAYER SHEET – B1/B3 Transactions **GENERAL INFORMATION**
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Document Date: 2014-03-05 09:36:25

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File Size: 420,51 KB

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City

Prescriber / Plan / /

Company

M Pharmacy Payor Sheet Page / DOM Mississippi / ACS / GE / /

Event

FDA Phase / /

Facility

C1 Facility / Pharmacy Unit Dose / Pharmacy Payor Sheet / Pharmacy Payor Sheet NCPDP VERSION / Facility 09=Acute Care Facility 10=Outpatient 11=Hospice Blank=Not Specified 1=Not / Pharmacy Payor Sheet Page / /

IndustryTerm

software / /

MedicalTreatment

Enema / /

Organization

Division of Medicaid Date / NS NS / 01=Drug Enforcement Administration / 04=National Association of Insurance Commissioners / Mississippi Division of Medicaid Field NCPDP Field Name / Unit of Measure Dispensing Status Quantity Intended / Mississippi Division of Medicaid Field / 01=Delivery 02=Shipping 03=Postage 04=Administrative 05=Incentive 06=Cognitive Service / Drug Enforcement Administration / Medicare / /

Person

Prescription / Qualifier Blank / /

/

Position

Driver / COB / Qualifier / pharmacist / Physician / B1/B3 Transactions **GENERAL / Local Wholesaler / /

Product

Medicaid / DV / E7 / Medicaid Processor / /

ProgrammingLanguage

R / /

ProvinceOrState

Mississippi / /

RadioStation

AM 409 / AM 473 / AM 485 / AM 337 / /

Technology

Field 1Ø1-A1 1Ø2-A2 NCPDP Field Name BIN Number Version/Release Number 1Ø3-A3 Transaction Code 1Ø4-A4 Processor / /

SocialTag