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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 |
337-4C | Other Payer Count | Indicates how many other payers are being submitted; automatically generated based on COB segment |
338-5C | OP Coverage Type 1 | Code identifying the type of other payer; blank - not specified, 01 - Primary, 02 - Secondary, and so forth. Located in the COB tab of the main processing screen |
339-6C | OP ID Qualifier 1 | Code indicating the Other Payer ID qualifier; located in the COB tab of the main processing screen |
340-7C | OP ID 1 | Other Payer ID number, must correctly correspond to the ID selected above; located in the COB tab of the main processing screen |
443-E8 | OP Date 1 | Payment or rejection date of the claim submitted to other payer, generated automatically based on that claim |
993-A7 | Internal Control Number 1 | Number assigned by processor to identify an adjudicated claim when supplied in payer to payer COB only; located in the COB tab of the main processing screen |
341-HB | OPAP Count 1 | Total of OP amounts paid; this field automatically adds the populated lines in the COB segment, located in the COB tab of the main processing screen |
342-HC | OPAP Qualifier 1.1 | The OP amount paid qualifier indicating type of payment taken; located in the COB tab of the main processing screen |
431-DV | OPAP Amount 1.1 | The OP amount paid itself based on qualifier above; located in the COB tab of the main processing screen |
353-NR | OPPRA Count 1 | Total of OP patient responsibility amounts paid; this field automatically adds the populated lines in the COB segment, located in the COB tab of the main processing screen |
351-NP | OPPRA Qualifier 1.1 | The OP patient responsibility amount paid qualifier indicating type of payment requested; located in the COB tab of the main processing screen |
352-NQ | OPPRA Amount 1.1 | The OP patient responsibility amount paid itself based on qualifier above; located in the COB tab of the main processing screen |
392-MU | Benefit Stage Count 1 | Total of the number of benefit stage occurrences; this field automatically adds the populated lines in the COB segment, located in the COB tab of the main processing screen |
393-MV | Benefit Stage Qualifier 1.1 | Blank, 01- Deductible, 02- Initial Benefit, 03- Coverage Gap, 04-Catastrophic Coverage, 50-Not paid under Part D but paid under Part C, 60- Not paid under Part D but paid as or under supplemental benefit only, 61- Part D drug not paid by Part D plan benefit, paid as or under a co-administered insured benefit only, 62- Non-Part D/non-qualified drug not paid by Part D plan benefit. Paid as or under a co-administered benefit only, 70- Part D drug not paid by Part D plan benefit, paid by the beneficiary under plan-sponsored negotiated pricing, 80- Non-Part D/non-qualified drug not paid by Part D plan benefit, hospice benefit, or any other component of Medicare; paid by the beneficiary under plan-sponsored negotiated pricing, 90- Enhance or OTC drug (PDE value of E/O) not applicable to the Part D drug spend, but is covered by the Part D plan; located in the COB tab of the main processing screen |
394-MW | Benefit Stage Amount 1.1 | The actual benefit stage amount as indicated by the qualifier above; located in the COB tab of the main processing screen |
471-5E | OP Reject Count 1 | The total of the number of other payer rejections; this field automatically adds the populated lines in the COB segment, located in the COB tab of the main processing screen |
472-6E | OP Reject Codes 1.1 | The other payer rejection code itself, based on the qualifier above; located in the COB tab of the main processing screen |