***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