NCPDP REFERENCE MANUAL - CMS

1 Rev. 2005-4/October 3-1 2002 VIPS, Inc. All Rights Reserved. Use or disclosure of the information contained on this page is subject to the restrictions on the title page of this material. Chapter 3: NCPDP Flat File Format About the Flat File Format (FFF) File Layout The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires that a single standard be used for the electronic submission of retail pharmacy claims NCPDP format. These incoming claims are first passed through an NCPDP translator and stored in a Flat-File-Format (FFF). ViPS programs pass the FFF data through a series of editing programs and produce reports that list the claims included in the transmission and identify any errors in the submitted data. The process then formats the FFF file into the Claims-In-Process (CIP) format used by the VMS subsystems and the Certificate of Medical Necessity (CMN) format used for DME.

2 There are three transmission record types that the ViPS NCPDP recognizes, as described below. Batch Header Record The batch header record is the first record on the NCPDP file. It occurs only once. Field definitions begin on page 3-3. For additional information about the batch header record, refer to the NCPDP Batch Standard Implementation Guide, Version Detail Data Records Record Name Level Required? Max Records Comments ViPS Segment Record Transmission Yes 1 per transmission Generated by ViPS for internal processing; occurs once before each Transaction Header Record. Transmission Header Record Transmission Yes 1 per transmission Occurs once per set of records that constitute a single claim. It must be the first record in the set. Transmission Patient Record Transmission Yes 1 per transmission Transmission Pharmacy Record Transaction No 1 per transaction Transmission Prescriber Record Transaction Yes 1 per transaction Transmission Insurance Record Transmission Yes 1 per transmission NCPDP REFERENCE MANUAL Chapter 3: NCPDP Flat File Format NCPDP REFERENCE MANUAL 3-2 Rev.

3 2005-4/October 2002 VIPS, Inc. All Rights Reserved. Use or disclosure of the information contained on this page is subject to the restrictions on the title page of this material. Record Name Level Required? Max Records Comments Transmission Other COB Record Transaction No 1 per transaction Transmission Work Comp Record Transaction No 1 per transaction Transmission Claim Record Transaction Yes 1 per transaction May have 1 4 occurrences per transmission.

4 Transmission DUR-PPS Record Transaction No 1 per transaction Transmission Coupon Record Transaction No 1 per transaction Transmission Compound Record Transaction No 1 per transaction If this segment is present, there should be only one transaction in the transmission. Transmission Pricing Record Transaction Yes 1 per transaction May have 1 4 occurrences per transmission. Transmission Prior Auth Record Transaction Yes, depending on procedure 1 per transaction Required for procedure codes requiring CMN form , , or to store CMN information; not used otherwise. Transmission Clinical Record Transaction Yes 1 per transaction Field definitions begin on page 3-5.

5 For additional information about the detail data records, refer to the NCPDP Telecommunications Standard Implementation Guide, Version Batch Trailer Record The batch trailer record is the last record on the NCPDP file. It occurs only once. Field definitions begin on page additional information about the batch trailer record, refer to the NCPDP Batch Standard Implementation Guide, Version NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly). 2002 VIPS, * (24)NCPKFLAT124 SegmentIdentifier* (02)00=FileHeaderNCPKFLAT2526 SegmentIdentification* (02)SpacesNCPKFLAT2728 Version*1 (01)ANCPKFLAT2929 BatchNumber* (07)NCPKFLAT3036 TransactionReferenceNumber* (10)SpacesNCPKFLAT3746 GroupIndicator*1 '07'(claimsegment).

6 X(01)NNCPKFLAT4747 NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly). 2002 VIPS, *1 (13) (02) (01)T=TransactionR=ResponseE= (24) (07) (08)Format= (04)Format= (01)T=TestP=ProductionNCPSB00A107107 (02) (24)NCPSB00A110133 NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly). 2002 VIPS, * (24)NCPKFLAT124 SegmentIdentifier* (02)01=ViPSSegmentNCPKFLAT2526 SegmentIdentification* (02)SpacesNCPKFLAT2728 Version*1 (01)ANCPKFLAT2929 BatchNumber* (07)NCPKFLAT3036 TransactionReferenceNumber* (10)NCPKFLAT3746 NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly).

7 2002 VIPS, *1 '07'(claimsegment).X(01)NNCPKFLAT4747 Filler*1 (13)SpacesNCPKFLAT4860 NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly). 2002 VIPS, * (24)NCPKFLAT124 SegmentIdentifier* (02)G1=DataDetailRecordNCPKFLAT2526 SegmentIdentification* (02)00 NCPKFLAT2728 Version*1 (01)ANCPKFLAT2929 BatchNumber* (07)NCPKFLAT3036 TransactionReferenceNumber* (10)NCPKFLAT3746 GroupIndicator*1 '07'(claimsegment).X(01)NNCPKFLAT4747 NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly). 2002 VIPS, *1 (13) (06)NCPST00 BNCPST00A6166 (02)51 NCPST00 BNCPST00A6768 TransactionCode103-A3 IdentifiestypeoftransactionX(02) (10) (01)1,2,3,4 NCPST00 BNCPST00A8181 ServiceProviderIDQualifier202-B2 CodequalifyingtheServiceProviderIDX(02) (15) (08)Format=CCYYMMDDNCPST00 BNCPST00A99106 (10)NCPST00 BNCPST00A107116 ClaimControlNumber1 (14)NCPST00 BNCPST00A117130 NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly).

8 2002 VIPS, (02) (15)NCPST00B133147 NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly). 2002 VIPS, * (24)NCPKFLAT124 SegmentIdentifier* (02)G1=DataDetailRecordNCPKFLAT2526 SegmentIdentification* (02)01 NCPKFLAT2728 Version*1 (01)ANCPKFLAT2929 BatchNumber* (07)NCPKFLAT3036 TransactionReferenceNumber* (10)NCPKFLAT3746 GroupIndicator*1 '07'(claimsegment).X(01)NNCPKFLAT4747 NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly). 2002 VIPS, *1 (13) (02)01 NCPST01A6162 PatientIDQualifier331-CXCodequalifyingth ePatientIDX(02) (20) (08)Format= (01)0=unspecified1=male2=femaleNCPST01A9 393 PatientFirstName310-CAPatient' (12)NCPST01A94105 PatientLastName311-CBPatient' (15) (30) (20)NCPST01A151170 PatientState/ProvinceAddress324- (02)NCPST01A171172 (15)NCPST01A173187 PatientPhoneNumber326-CQPatient's10-digi tphonenumberX(10)NCPST01A188197 NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly).

9 2002 VIPS, (02)00notspecified01home02inter-care03nu rsinghome04 (15)NCPST01A200214 (01)space= (01)space=notspecified1notpregnant2pregn antNCPST01A216216 NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly). 2002 VIPS, * (24)NCPKFLAT124 SegmentIdentifier* (02)G1=DataDetailRecordNCPKFLAT2526 SegmentIdentification* (02)02 NCPKFLAT2728 Version*1 (01)ANCPKFLAT2929 BatchNumber* (07)NCPKFLAT3036 TransactionReferenceNumber* (10)NCPKFLAT3746 GroupIndicator*1 (claimsegment).X(01)NNCPKFLAT4747 Filler*1 (13)SpacesNCPKFLAT4860 NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly). 2002 VIPS, (02)02 NCPST02A6162 ProviderIDQualifier465-EYCodequalifyingt heProviderIDX(02)space=notspecified01=DE A02=statelicense03=SocialSecurityNumber0 4=name05=NPI06=HIN07=stateissued99= (15)NCPST02A6579 NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly).

10 2002 VIPS, * (24)NCPKFLAT124 SegmentIdentifier* (02)G1=DataDetailRecordNCPKFLAT2526 SegmentIdentification* (02)03 NCPKFLAT2728 Version*1 (01)ANCPKFLAT2929 BatchNumber* (07)NCPKFLAT3036 TransactionReferenceNumber* (10)NCPKFLAT3746 GroupIndicator*1 (claimsegment).X(01)NNCPKFLAT4747 Filler*1 (13)SpacesNCPKFLAT4860 NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly). 2002 VIPS, (02)03 NCPST03 ANCPST03B6162 PrescriberIDQualifier466-EZCodequalifyin gthePrescriberIDX(02)06= (15)NCPST03 BNCPST03A6579 PrescriberLocationCode467-1 ELocationaddresscodeassignedtotheprescri berasidentifiedintheNationalProviderSyst em(NPS).X(03) (15)NCPST03 BNCPST03A8397 PrescriberPhoneNumber498-PMPrescribers10 -digitphonenumber9(10)NCPST03 BNCPST03A98107 NCPDPR eferenceManualChapter3:NCPDPFlatFileForm at*Partofthekeyportionoftheportionofthef latfilerecordformat; ; (ViPSSegmentRecordandTransmissionPriorAu thRecordonly).