Claim Segment

Field #

Field Name

Possible Value or Explanation of Field

455-EM

Reference Number Qualifier

1 - Rx Billing, 2- Service Billing. Located in the Drug File (F4)

402-D2

RX Number

Prescription number; currently max length of seven (7) digits

436-E1

Product ID Qualifier

Product ID qualifier corresponding to the qualifier used in the Drug File (F4) for selected product.

407-D7

Product ID

Product ID number corresponding to the number used in the Drug File (F4) for selected product.

442-E7

Quantity Filled

The quantity filled for the current prescription; it is converted to a value plus three decimal points- 30.000 = 30000. Located on the main processing screen.

460-ET

Quantity Prescribed

The quantity prescribed by the doctor; it is converted to a value plus three decimal points- 30.000 = 30000. Located on the main processing screen.

403-D3

Refill Code

Refill code determining the prescription number in the chain. Ø - original fill, 1 - first refill, 2 - second refill, and so forth

415-DF

Refills Authorized

Indicates how many refills were authorized; value taken from the main processing screen

405-D5

Days Supply

Indicates the day supply for the prescription; value taken from the main processing screen

406-D6

Compound Code

Ø- Not Specified, 1- Not a Compound, 2- Compound; this value is pulled from the compound indicator in the Drug File (F4)

408-D8

DAW Code

Ø- No product Selection Indicated, 01- Substitution Not Allowed by Prescriber, 2- Substitution allowed- patient requested product dispensed, 3- Substitution allowed- pharmacist selected product dispensed, 4- Substitution allowed- generic drug not in stock, 5- Substitution allowed- brand drug dispensed as generic, 6- Override, 7- Substitution not allowed- brand drug mandated by law, 8- Substitution allowed- generic drug not available in marketplace, 9- Substitution allowed by Prescriber but plan requests brand; this field is located on the main processing screen

414-DE

Written Date

The written date for the prescription; converts into YYYYMMDD format, located on the main processing screen

429-DT

Special Packaging Indicator

Indicates type of dispensing dose if required; nested in the "More" button on the main processing screen

600-28

Unit of Measure

The unit of measure for the dispensed medication; located in the Drug File (F4)

308-C8

Other Coverage Code

Used in Coordination of Benefit claims with secondary/tertiary/quaternary billing; indicates to those payers what the primary payer status is. Current accepted values are02 - Primary exists, claim covered and paid, 03 - Primary exists, claim not covered, 04 - Primary exists, claim not paid, 08 - Billing for Copay

354-NX

Submission Clarification (RX Override) Count

Indicates how many submission clarification codes are sent in the claim

420-DK

Submission Clarification (RX Override) Code

Indicates the submission clarification code(s) attached to the claim; field located on the main processing screen

461-EU

Prior Authorization Type

Indicates the type of Prior Authorization sent; located on the main processing screen

462-EV

Prior Authorization Number

This field will contain the actual prior authorization number for the above corresponding qualifier; also located on the main processing screen below the qualifier field

463-EW

Intermediary Auth Type

Field will most likely be phased out in next NCPDP version. Located under "More" on the main processing screen.

464-EX

Intermediary Auth Number

Field will most likely be phased out in next NCPDP version. Located under "More" on the main processing screen.

458-SE

Procedure Modifier Count

Indicates how many of the below codes are being sent with this claim

459-ER

Procedure Modifier Codes

Identifies special circumstances related to the performance of service; needs to be attached to the product ID numbers such as NDC/Medicaid/Medicare IDs in the Drug File (F4) in the format of ID-Code, ie. 12345678912-KX. These codes can be found in the HCPCS Codes Article

419-DJ

Origin Code

Indicates the prescription origin; located on the main processing screen

454-EK

Control Triplicate Number

Indicates the control triplicate / serial number most commonly used for control medication; located above the RX Status on the main processing screen

418-DI

Level of Service

Indicates the level of service; nested in the "More" button on the main processing screen

147-U7

Pharmacy Service Type

Indicates the pharmacy's service type; this field is located on the Pharmacy Info tab of the Pharmacy Setup section under File > Pharmacy Setup

995-E2

Route of Administration

Indicates how the medication is administered; nested in the "More" button on the main processing screen

996-G1

Compound Type

01- Anti-Infective, 02- Ionotropic, 03- Chemotherapy, 04- Pain management, 05- TPN/PPN, 06- Hydration, 07- Ophthalmic, 99- Other

453-EJ

Originally Prescribed ID Qual

Indicates the originally prescribed product ID qualifier; nested in the "More" button on the main processing screen

445-EA

Originally Prescribed Product ID

Indicates the originally prescribed product ID number; nested in the "More" button on the main processing screen

446-EB

Originally Prescribed Quantity

Indicates the originally prescribed quantity; nested in the "More" button on the main processing screen

391-MT

Patient Assignment Indicator

Indicates the patient's choice on assignment of benefits; nested in the "More" button on the main processing screen

357-NV

Delay Reason Code

1- Proof of eligibility unknown or unavailable, 2- Litigation, 3- Authorization delays, 4- Delay in certifying provider, 5- Delay in supplying billing forms, 6- Delay in delivery of custom made appliances, 7- This party processing delay, 8- Delay in eligibility determination, 9- Original claims rejected or denied due to a reason unrelated to the billing limitation issue, 10- Administration delay in the prior approval process, 11- Other, 12- Received late with no exceptions, 13- Substantial damage by fire, etc to provider records, 14- Theft, sabotage or other willful acts by employee; nested in the "More" button on the main processing screen