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Medi-Cal Rx NCPDP Payer Specification Sheet

2022 California Department of Health Care Services. All rights reserved. California Department of Health Care Services Medi-Cal Rx NCPDP Payer Specification Sheet Version April 1, 2022 Instructions Related to Transactions Based on NCPDP Version (B1) Claim Billing (B2) Claim Reversal (B3) Claim Rebill (P2) Prior Authorization Reversal (P3) Prior Authorization Inquiry (P4) Prior Authorization Request (B1) SB393 Drug Price Inquiry (E1) Eligibility Verification DHCS Medi-Cal Rx NCPDP Payer Specification Sheet 2 04/01/2022 Revision History Document Version Date Comments 10/22/2020 Initial Version 09/23/2021 Added detailed sections for: B1 Drug Price Inquiry (Section ) E1 Eligibility Verification (Section ) Updated the following fields: 307-C7 (Section , Section , Section ) 420-DK (Section ) 461-EU (Section ) 423-DN (Section ) 436-E1 (Section , Section , Section , Section ) 10/01/2021 Finalized upon DHCS Approval.

Payer Situation 202-B2 Service Provider ID Qualifier 01 = National Provider Identifier (NPI) M 201-B1 Service Provider ID M 401-D1 Date of Service M 110-AK Software Vendor/ Certification ID This will be provided by the provider’s software vendor. ... Reference Number Qualifier 1= Rx Billing M 402-D2 Prescription/Service Reference Number

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medi-calrx.dhcs.ca.gov

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