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NCPDP Version D.0 Payer Sheet - EHO Rx

NCPDP Version Payer Sheet Payer name : EHO Date: 9/15/2011 Plan name /Group name : ALL PLANS BIN: 004527 PCN: eho udl Plan name /Group name : ALL PLANS BIN: 003241 PCN: Plan name /Group name : ALL Walgreen s Non-Workers Comp Rxs BIN: 004880 PCN: Plan name /Group name : ALL TEST CLAIMS BIN: 610259 PCN: Processor: EHO Effective as of: 1/01/2012 NCPDP Telecommunication Standard Version /Release #: NCPDP Data Dictionary Version Date: Date of Publication NCPDP External Code List Version Date: Contact/Information Source: Trent Lanham . - (254) 771-6000 Certification Testing Window: 9/15/2011 12/31/2011 Certification Contact Information: Certification Not Required Provider Relations Help Desk Info: (800) 650-1817 Other versions supported: Version will be supported through 6/30/2012 Transaction Header Segment Claim Billing/Claim Rebill Field # NCPDP Field name Value Payer Usage Payer Situation 1 1-A1 BIN NUMBER (see above) M 1 2-A

Patient Segment Segment Identification (111-AM) = “Ø1”Claim Billing/Claim Rebill Field NCPDP Field Name Value Payer Usage Payer Situation 331 -CX PATIENT ID QUALIFIER R

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