***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