Magellan Complete Care (MCC) of Arizona NCPDP Version D.0 ...

1 Magellan Complete Care (MCC) of Arizona NCPDP Version Claim Billing / Re-Bill Payer Specifications October 1, 2018. General Information Payer Name: Magellan Complete Care Date: October 1, 2018. Plan Name/Group Name: Magellan Complete Care of Arizona BIN: 016523 PCN: 6222979 NEW! Processor: Magellan Rx Management Effective as of: 10/01/2018 NCPDP Telecommunication Standard Version /Release #: D.. NCPDP Data Dictionary Version Date: October 2016 NCPDP External Code List Version Date: October 2016. Contact Information Source: 800-424-5891.

2 Certification Testing Window: September 5, 2018 through September 19, 2018. Certification Contact Information: 800-424-5891. Provider Relations Help Desk Info: 800-424-5891. Other versions supported: No Other Transactions Supported Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Transaction Code Transaction Name B1 Claim Billing B2 Reversal B3 Re-bill Proprietary & Confidential 2018 Magellan Health, Inc. All rights reserved. Field Legend for Columns Payer Situation Payer Usage Column Value Explanation Column The Field is mandatory for the Segment in the MANDATORY M No designated Transaction.

3 The Field has been designated with the situation of REQUIRED R Required for the Segment in the designated No Transaction. Required when. The situations designated have QUALIFIED. RW qualifications for usage ( Required if x, Not Yes REQUIREMENT. required if y"). Fields that are not used in the Claim Billing/Claim Re-bill transactions and those that do not have qualified requirements ( , not used) for this payer are excluded from the template. NCPDP . Claim Billing/Claim Re-bill Transaction The following lists the segments and fields in a Claim Billing or Claim Re-bill Transaction for the NCPDP .

4 Telecommunication Standard Implementation Guide Version D.. Claim Billing/Claim Re-bill If Situational, Transaction Header Segment Questions Check Payer Situation This segment is always sent X. Source of certification IDs required in Software X. Vendor/Certification ID (11 -AK) is Payer Issued Transaction Header Segment Claim Billing/Claim Re-bill Field # NCPDP Field Name Value Payer Usage Payer Situation 1 1-A1 BIN NUMBER 016523 M NEW! 1 2-A2 Version /RELEASE NUMBER D M. 1 3-A3 TRANSACTION CODE B1, B3 M. 1 4-A4 PROCESSOR CONTROL NUMBER 6222979 M NEW!

5 1 9-A9 TRANSACTION COUNT One transaction for B2 or M compound claim; Four allowed for B1 or B3. 2 2-B2 SERVICE PROVIDER ID QUALIFIER M. 2 1-B1 SERVICE PROVIDER ID M. 4 1-D1 DATE OF SERVICE M. Page 2 | MCC of AZ Payer Specifications Transaction Header Segment Claim Billing/Claim Re-bill Field # NCPDP Field Name Value Payer Usage Payer Situation 11 -AK SOFTWARE VENDOR/ The provider's software M Required when vendor is CERTIFICATION ID vendor will provide this certified with Magellan Rx Management otherwise submit all zeroes Claim Billing/Claim Re-bill If Insurance Segment Questions Check Situational, Payer Situation This segment is always sent X.

6 Insurance Segment Claim Billing/Claim Re-bill Segment Identification (111-AM) = 4 . Payer Field # NCPDP Field Name Value Payer Situation Usage 3 2-C2 CARDHOLDER ID M. 312-CC CARDHOLDER FIRST NAME R. 313-CD CARDHOLDER LAST NAME R. 3 1-C1 GROUP ID AHCCCSRX R NEW! Claim Billing/Claim Re-bill If Patient Segment Questions Check Situational, Payer Situation This segment is always sent Patient Segment Claim Billing/Claim Re-bill Segment Identification (111-AM) = 1 . Field NCPDP Field Name Value Payer Usage Payer Situation 331-CX PATIENT ID QUALIFIER RW Required if Patient ID (332-CY) is used.

7 332-CY PATIENT ID RW Required if necessary for state/federal/regulatory agency programs to validate dual eligibility. 3 4-C4 DATE OF BIRTH R. 3 5-C5 PATIENT GENDER CODE R. 31 -CA PATIENT FIRST NAME R. 311-CB PATIENT LAST NAME R. MCC of AZ Payer Specifications | Page 3. Patient Segment Claim Billing/Claim Re-bill Segment Identification (111-AM) = 1 . Field NCPDP Field Name Value Payer Usage Payer Situation 307-C7 PLACE OF SERVICE RW Required if this field could result in different coverage, pricing, or patient financial responsibility.

8 335-2C PREGNANCY INDICATOR Blank = Not Specified RW Required if this field could result 1 = Not Pregnant in different coverage, pricing, or 2 = Pregnant patient financial responsibility. 384-4X PATIENT RESIDENCE RW Required if this field could result in different coverage, pricing, or patient financial responsibility. Claim Billing/Claim Re-bill If Claim Segment Questions Check Situational, Payer Situation This segment is always sent X. Claim Segment Claim Billing/Claim Re-bill Segment Identification (111-AM) = 7 . Field # NCPDP Field Name Value Payer Usage Payer Situation 455-EM PRESCRIPTION/SERVICE 1 = Rx Billing M.

9 REFERENCE NUMBER. QUALIFIER. 4 2-D2 PRESCRIPTION/SERVICE M. REFERENCE NUMBER. 436-E1 PRODUCT/SERVICE ID 03' = National Drug M. QUALIFIER Code (NDC). 00' = Not Specified (Use for Compounds). 4 7-D7 PRODUCT/SERVICE ID M 0' for Compounds 456-EN ASSOCIATED RW Required if the completion . PRESCRIPTION/SERVICE transaction in a partial fill REFERENCE NUMBER (Dispensing Status (343-HD) =. C (Completed)). Required if the Dispensing Status (343-HD) = P (Partial Fill) and there are multiple occurrences of partial fills for this prescription.

10 Page 4 | MCC of AZ Payer Specifications Claim Segment Claim Billing/Claim Re-bill Segment Identification (111-AM) = 7 . Field # NCPDP Field Name Value Payer Usage Payer Situation 457-EP ASSOCIATED RW Required if the completion . PRESCRIPTION/SERVICE DATE transaction in a partial fill (Dispensing Status (343-HD) =. C (Completed)). Required if Associated Prescription/Service Reference Number (456-EN) is used. Required if the Dispensing Status (343-HD) = P (Partial Fill) and there are multiple occurrences of partial fills for this prescription.