CVS CAREMARK PAYER SHEET

CVS CAREMARK PAYER SHEET Supplemental to Medicare Part D Other PAYER Amount Paid (OPAP) 02/11/2021 Page 2 of 29 Table of Contents HIGHLIGHTS Updates, Changes & Reminders PART 1: GENERAL INFORMATION Pharmacy Help Desk Information PART 2: BILLING TRANSACTION / SEGMENTS AND FIELDS PART 3: REVERSAL TRANSACTION PART 4: PAID (OR DUPLICATE OF PAID) RESPONSE PART 5: REJECT RESPONSE APPENDIX A: BIN / PCN COMBINATIONS Primary BIN and PCN Values APPENDIX B: MEDICARE PART D Medicare Part D Patient Residence Medicare Part D Prescriber NPI Requirements Medicare Part D Use of Prescription Origin Code Medicare Part D Vaccine Processing APPENDIX C: COORDINATION OF BENEFITS (COB) Submission Requirements for COB Single Transaction COB (STCOB) APPENDIX D: COMPOUND BILLING Route of Administration Transition 02/11/2021 Page 3 of 29 HIGHLIGHTS Updates, Changes & Reminders This PAYER SHEET refers to Medicare Part D Other PAYER Amount Paid (OPAP) Billing.

338-5C Other Payer Coverage Type M 339-6C Other Payer ID Qualifier RW Required when Other Payer ID (34Ø-7C) is used 34Ø-7C Other Payer ID RW Required when identification of the Other Payer is necessary for claim/encounter adjudication 443-E8 Other Payer Date RW Required when identification of the

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