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NCPDP PAYER SHEET TEMPLATE
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Document Date: 2013-12-24 12:48:46

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File Size: 308,80 KB

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Company

ACS / Submission / First DataBank / Xerox / /

Currency

USD / /

Event

FDA Phase / /

/

IndustryTerm

prescribed product / law instructions / /

Organization

NCPDP Field Name Claim Billing/Claim Rebill Value Payer Usage Payer Situation Service / NM Medicaid Fee For Service / European Union / 1Ø2-A2 1Ø3-A3 1Ø9-A9 5Ø1-F1 2Ø2-B2 2Ø1-B1 4Ø1-D1 NCPDP Field Name Value VERSION/RELEASE NUMBER TRANSACTION CODE TRANSACTION COUNT HEADER RESPONSE STATUS SERVICE PROVIDER ID QUALIFIER SERVICE PROVIDER ID DATE OF SERVICE / Medicare / /

Person

HEADER RESPONSE / /

/

Position

DUR CO-AGENT ID QUALIFIER / physician / PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER / ORIGINALLY PRESCRIBED PRODUCT/SERVICE ID QUALIFIER / GENERAL INFORMATION Date / COB / 4Ø3-D3 PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUMBER PRODUCT/SERVICE ID QUALIFIER / AMOUNT CLAIMED SUBMITTED QUALIFIER / 2Ø1-B1 4Ø1-D1 11Ø-AK SERVICE PROVIDER ID QUALIFIER SERVICE / ADDITIONAL MESSAGE INFORMATION QUALIFIER / Payer Amount Paid Qualifier / qualifier / pharmacist / PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER / Payer Sheet GENERAL INFORMATION Date / prompting pharmacist / COMPOUND PRODUCT ID QUALIFIER / AMOUNT PAID QUALIFIER / /

Product

C8 / /

ProgrammingLanguage

R / C / /

ProvinceOrState

New Mexico / /

Technology

Transaction Header Segment NCPDP Field Name 1Ø1-A1 1Ø2-A2 1Ø3-A3 1Ø4-A4 BIN NUMBER VERSION/RELEASE NUMBER TRANSACTION CODE PROCESSOR / /

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