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| Table of Contents |
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| Info |
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For fields with the number one (1) appended, the segment will display additional fields for sequential fields (ingredient 2, 3, etc). |
Field # | Field Name | Possible Value or Explanation of Field |
409-D9 | Ingredient Cost | Refers to the cost field on the main Processing Screen |
412-DC | Dispensing Fee | Refers to the fee field on the main Processing Screen |
433-DX | Patient Paid Amount | Refers to the copay fee field on the main Processing Screen |
438-E3 | Incentive Fee | Refers to the incentive fee field (expand other with + button) on the main Processing Screen |
482-GE | Percentage Sales Tax Amount | Sales tax amount as calculated based on the percentage rate below |
483-HE | Percentage Sales Tax Rate | Sales tax rate as indicated on the pricing segment of the Insurance Plan File (F5) |
484-JE | Percentage Sales Tax Basis | Code indicating the basis for the percentage cost; blank - not specified, 02 - ingredient cost, 03 - Ingredient cost plus dispensing fee, 04 - professional service fee |
481-HA | Flat Sales Tax Amount | Sales tax amount based on the flat fee as indicated on the pricing segment of the Insurance Plan File (F5) |
477-BE | Professional Service Fee | This professional service fee gets transmitted when the Drug is switched to Service Billing from RX Billing in the Drug file. |
426-DQ | Usual & Customary Charge | Refers to the U&C charges field on the main Processing Screen |
430-DU | Gross Amount Due | This refers to the total field on the main processing screen |
423-DN | Basis of Cost | Refers to the Basis of Cost field on the main Processing Screen |
478-H7 | Other Amount Submitted Count | Indicates how many other amounts were submitted; this is calculated by adding the lines of the "Other" pricing segment accessed by the "+" sign on the main processing screen |
479-H8 | Other Amount Submitted Qualifier 1 | Indicates the qualifier for the other amount specified; located in the "Other" pricing segment accessed by the "+" sign on the main processing screen |
480-H9 | Other Amount Submitted 1 | Indicates the total amount for the other amount specified based on the qualifier above; located in the "Other" pricing segment accessed by the "+" sign on the main processing screen |