NCPDP Telecommunication VD.0 Claim Examples …

1 NCPDP Telecommunication Claim Examples Paid on X12/005010X221A1 Health Care Claim Payment/Advice (835) Billing and Payment Scenarios Version All material is provided "as is", without warranty of any kind, expressed or implied, including but not limited to warranties of merchantability, fitness for a particular purpose, accuracy, completeness and non-infringement of third party rights. In no event shall NCPDP , its members or its contributors be liable for any Claim , or any direct, special, indirect or consequential damages, or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use or performance of the material. NCPDP recognizes the confidentiality of certain information exchanged electronically through the use of its standards. Users should be familiar with the federal, state, and local laws, regulations and codes requiring confidentiality of this information and should utilize the standards accordingly.

2 NOTICE: In addition, this NCPDP Standard contains certain data fields and elements that may be completed by users with the proprietary information of third parties. The use and distribution of third parties' proprietary information without such third parties' consent, or the execution of a license or other agreement with such third party, could subject the user to numerous legal claims. All users are encouraged to contact such third parties to determine whether such information is proprietary and if necessary, to consult with legal counsel to make arrangements for the use and distribution of such proprietary information. Published by: National Council for Prescription drug Programs Publication History: Version January 2013 Version March 2017 All rights reserved. National Council for Prescription drug Programs 9240 E. Raintree Drive Scottsdale, AZ 85260 (480) 477-1000 NCPDP Telecommunication Claim Examples Paid on X12/005010X221A1 Health Care Claim Payment/Advice (835) Billing and Payment Scenarios Page 2 of 58 March 2017 Contents 1.

3 Document Scope .. 4 2. Purpose .. 6 3. NCPDP Telecommunication Standard Billing and Response and X12/005010X221A1 Health Care Claim Payment/Advice (835) Remittance Examples .. 7 NCPDP Telecommunication Standard General Assumptions: .. 7 X12/005010X221A1 835 General Assumptions: .. 7 4. Examples .. 8 Typical Claim .. 8 1A Billing Transaction .. 8 1B Billing Response Transaction .. 9 835 for Billing Response 1B .. 9 1C Reversal Transaction .. 10 1D Reversal Response Transaction .. 10 835 for Reversal Response 1D (Out of Cycle) .. 11 Retroactive Billing ..12 2A Billing Transaction .. 12 2B Billing Response Transaction .. 13 835 for Billing Response 2B .. 13 Claim Submitted DUR/PPS Reject Claim Submitted With DUR Paid ..15 3A Billing Transaction .. 15 3B Billing Response Transaction .. 15 3C Billing Transaction with DUR .. 16 3D Billing Response Transaction .. 17 835 for Billing Response 3D.

4 17 COB Claim Submission to Secondary Insurance ..19 4A Billing Transaction .. 19 4B Billing Response Transaction .. 20 835 for Billing Response 4D .. 20 COB Claim Submission with Other Coverage Code of 8 and Patient Pay Amount Reported as Returned from Primary Payer ..22 5A Billing Transaction .. 22 5B Billing Response Transaction .. 23 835 for Billing Response 5B .. 23 Billed With Tax Paid Patient Is Responsible For Part of Tax Causing Patient Pay to Increase by Amount of Tax ..25 6A Billing Transaction .. 25 6B Billing Response Transaction .. 26 835 for Billing Response 6B .. 26 Billed With Tax Paid ..28 7A Billing Transaction .. 28 7B Billing Response Transaction .. 29 835 for Billing Response 7B .. 29 NCPDP Telecommunication Claim Examples Paid on X12/005010X221A1 Health Care Claim Payment/Advice (835) Billing and Payment Scenarios Page 3 of 58 March 2017 Multi-Ingredient Compound - Payable.

5 31 8A Billing Transaction .. 31 8B Billing Response Transaction .. 32 835 for Billing Response 8B .. 33 Patient is not Cardholder ..34 9A Billing Transaction .. 34 9B Billing Response Transaction .. 35 835 for Billing Response 9B .. 35 Paid Claim with Patient Pay Components ..37 10A Billing Transaction .. 37 10B Billing Response Transaction .. 38 835 for Response 10B .. 38 Discount Card with Membership Fee ..40 11A Billing Transaction .. 40 11B Billing Response Transaction .. 41 835 for Response 11B .. 41 Prior Authorization ..43 12A Claim Submission .. 43 12B Rejection Requires Prior Authorization .. 44 12C Submission with Prior Authorization .. 44 12D Paid Lower Amount with an Incentive .. 45 835 for Response 12D: .. 46 Worker s Compensation Claim Submission ..48 13A Workers Compensation Billing .. 48 13B Workers Compensation Billing Accepted Response Paid.

6 49 835 for Response 13B: .. 49 Health Savings Account (HSA) Claim Submission ..51 14A Claim Submission .. 51 14B Claim Paid .. 52 835 Response for Response 14B: .. 52 Other Payment Information for the 835 (Paper Claims) ..54 Paper Claim A .. 54 Paper Claim B .. 55 5. Discussion ..57 6. Revision History ..58 NCPDP Telecommunication Claim Examples Paid on X12/005010X221A1 Health Care Claim Payment/Advice (835) Billing and Payment Scenarios Page 4 of 58 March 2017 1. Document Scope Users of this document should consult the NCPDP documents listed below for further information and clarification. DATA DICTIONARY Full reference to all data elements with definition, sizes, and values used in NCPDP documents. EXTERNAL CODE LIST Full reference to values used in the NCPDP standard. STANDARDS MATRIX This document contains charts that list the Standards and Implementation Guides versions approved or under consideration by NCPDP , with reference to the Data Dictionary and External Code List documents appropriate for use.

7 Telecommunication STANDARD AND Telecommunication STANDARD IMPLEMENTATION GUIDE The NCPDP Telecommunication Standard and NCPDP Telecommunication Standard Implementation Guide Version D. 0 define the record layout for real-time prescription Claim transactions between providers and adjudicators. Since the communication between these parties is two-way, the record layout for both the transmitted Claim and the response to the Claim are defined by the Version D. 0 guide. The NCPDP Batch Standard Implementation Guide uses the NCPDP Telecommunication Standard format for the Detail Record of the file. PHARMACY REFERENCE GUIDE TO THE X12/005010X221A1 HEALTH CARE Claim PAYMENT/ADVICE (835) This document provides rules to support the use of the X12 835 005010X221A1 between business partners. This document must be used in conjunction with the X12/005010X221A1 Health Care Claim Payment/Advice (835).

8 This document does not supersede 005010X221A1. There are other fields that must be populated that are not included in this document.. This only addresses claims using the NCPDP transactions or pharmacy paper Claim forms. This document provides the pharmacy industry specific field information as it relates to the NCPDP Telecommunication Standard Information found in this document has met the X12 intellectual property and fair use policy requirements. Claim ADJUSTMENT REASON CODE/ NCPDP REJECT CODE MAPPING SPREADSHEET This document provides information on the use of Claim Adjustment Reason Code (CARC) and NCPDP Reject Codes in the X12/005010X221A1 Health Care Claim Payment/Advice (835) for the pharmacy industry. This mapping document provides specific situations for the use of appropriate Claim Adjustment Reason Code (CARC), Claim Adjustment Group Code and NCPDP Reject Codes for the pharmacy industry when using the NCPDP Telecommunication Standard and pharmacy paper claims.

9 NCPDP Telecommunication Claim Examples Paid on X12/005010X221A1 Health Care Claim Payment/Advice (835) Billing and Payment Scenarios Page 5 of 58 March 2017 NCPDP IMPLEMENTATION GUIDANCE FOR THE X12/005010X221A1 HEALTH CARE Claim PAYMENT/ADVICE (835) This document contains guidance to the pharmacy industry to prepare for the implementation of the X12 835. Other documents cited in this document: X12 INFORMATION The X12 Technical Report 3 documents (TR3) are available at NCPDP Telecommunication Claim Examples Paid on X12/005010X221A1 Health Care Claim Payment/Advice (835) Billing and Payment Scenarios Page 6 of 58 March 2017 2. Purpose The Purpose of this document is to provide a round-trip picture of the prescription drug Claim utilizing the HIPAA named NCPDP Telecommunication Standard Version through the use of hypothetical scenarios initiated by a pharmacy provider, including submissions, reversal, and resubmissions.

10 Each scenario is paired with the pharmacy initiated transaction and the processor response, including paid and rejected. A companion document details HIPAA X12/005010X221A1 Health Care Claim Payment/Advice (835) payment and remittance files (corresponding to the pharmacy initiated transactions within this document) that would be received by the pharmacy provider. Authors This document is the result of an ongoing effort the NCPDP Work Group 45 External Standards Assessment, Harmonization and Implementation Guidance. NCPDP Telecommunication Claim Examples Paid on X12/005010X221A1 Health Care Claim Payment/Advice (835) Billing and Payment Scenarios Page 7 of 58 March 2017 3. NCPDP Telecommunication Standard Billing and Response and X12/005010X221A1 Health Care Claim Payment/Advice (835) Remittance Examples NCPDP Telecommunication Standard General Assumptions: Scenarios may exist to show both of the following situations: o within one payment cycle and o Out of ( crossing ) payment cycle so these can be detailed on the 835 (or NOT included as the case may be).