| Document Date: 2014-03-27 18:19:41
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City Cardholder / / Company Xerox / ACS / / Currency USD / / Facility pharmacy Amount / pharmacy Complete / pharmacy Pass / Lovelace Molina Presbyterian University of New Mexico Value Options AmeriGroup Evercare BCBS New Mexico Optum Health / Servicing Pharmacy / pharmacy Required / / IndustryTerm pharmacy claim processor / prescribed product / secure web site / / Organization European Union / Lovelace Molina Presbyterian University of New Mexico Value Options AmeriGroup Evercare BCBS New Mexico Optum Health / / Person COB CLAIMS / / / Position IDENTIFICATION PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUMBER PRODUCT/SERVICE ID QUALIFIER / COB / Occurrence 2Ø2-B2 2Ø1-B1 4Ø1-D1 11Ø-AK SERVICE PROVIDER ID QUALIFIER SERVICE / MEDICAID MCO ENCOUNTER CLAIM SUBMISSION GUIDE GENERAL INFORMATION Payer Name / PAYER AMOUNT PAID QUALIFIER / qualifier / pharmacist / PayerPatient Responsibility Amount Qualifier / PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER / COMPOUND PRODUCT ID QUALIFIER / ORIGINALLY PRESCRIBED PRODUCT/SERVICE ID QUALIFIER / QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUMBER PRODUCT/SERVICE ID QUALIFIER / AMOUNT CLAIMED SUBMITTED QUALIFIER / SEGMENT IDENTIFICATION PRESCRIBER ID QUALIFIER / / ProgrammingLanguage R / C / / ProvinceOrState New Mexico / / RadioStation AM 466 / AM 337 / AM 455 / / Technology NCPDP Field Name Value 1Ø1-A1 1Ø2-A2 1Ø3-A3 1Ø4-A4 BIN NUMBER VERSION/RELEASE NUMBER TRANSACTION CODE PROCESSOR / pharmacy claim processor / / URL http /
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NEW MEXICO MEDICAID MCO ENCOUNTER CLAIM SUBMISSION GUIDE GENERAL INFORMATION Payer Name: New Mexico Medicaid Plan Name/Group Name: NM Medicaid BIN: [removed]Managed Care