Medicaid Fee For Service / European Union / For Service / DRNMPROD For Service / /
Person
Christine Marshall / / /
Position
physician / SERVICE PROVIDER ID QUALIFIER SERVICE / ORIGINALLY PRESCRIBED PRODUCT/SERVICE ID QUALIFIER / Payer Sheet GENERAL INFORMATION Payer Name / Amount Claimed Submitted Qualifier / Revision History Version Number Date Description Author / qualifier / CE REFERENCE NUMBER QUALIFIER PRESCRIPTION/SERVI CE REFERENCE NUMBER PRODUCT/SERVICE ID QUALIFIER / pharmacist / /
Product
Process CLARIFICATION CODE compound / /
ProgrammingLanguage
R / C / /
ProvinceOrState
New Mexico / /
Technology
1Ø1-A1 1Ø2-A2 1Ø3-A3 1Ø4-A4 Transaction Header Segment NCPDP Field Name BIN NUMBER VERSION/RELEASE NUMBER TRANSACTION CODE PROCESSOR / /