NCPDP PAYER SHEET TEMPLATE
NCPDP PAYER SHEET TEMPLATEIMPLEMENTATION GUIDE FOR VERSION D.0VERSION 17Used as guidance in filling out and creating a NCPDP Telecommunication Standard Implementation-based Version D.0 Payer Sheet, in accordance with theNCPDP Telecommunication Standard Implementation Guide vD.0 (August 2007) and CMS-0055 Final Rule published January 24, 2020.March 2022National Council for Prescription Drug Programs9240 East Raintree DriveScottsdale, AZ 85260Phone:Fax:E-mail:http:(480) 477-1000(480) 767-1042ncpdp@ncpdp.orgwww.ncpdp.org
NCPDP Payer Sheet TemplateVersion 17This work is owned by National Council for Prescription Drug Programs, Inc., 9240 E. Raintree Drive, Scottsdale, AZ 85260, (480) 477-1000,ncpdp@ncpdp.org, and protected by the copyright laws of the United States. 17 U.S.C. §101, et. seq.Permission is given to Council members to copy and use the work or any part thereof in connection with the business purposes of the Council members.The work may not be changed or altered. The work may be shared within the member company but may not be distributed and/or copied for/by othersoutside of the member’s company. The work may not be sold, used or exploited for commercial purposes. This permission may be revoked by NCPDP atany time. NCPDP is not responsible for any errors or damage as a result of the use of the work.All material is provided "as is", without warranty of any kind, expressed or implied, including but not limited to warranties of merchantability, fitness for aparticular purpose, accuracy, completeness and non-infringement of third party rights. In no event shall NCPDP, its members or its contributors be liablefor any claim, or any direct, special, indirect or consequential damages, or any damages whatsoever resulting from loss of use, data or profits, whether inan 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 thefederal, state and local laws, regulations and codes requiring confidentiality of this information and should utilize the standards accordingly.NOTICE: In addition, this NCPDP Standard contains certain data fields and elements that may be completed by users with the proprietary information ofthird parties. The use and distribution of third parties' proprietary information without such third parties' consent, or the execution of a license or otheragreement with such third party, could subject the user to numerous legal claims. All users are encouraged to contact such third parties to determinewhether such information is proprietary and if necessary, to consult with legal counsel to make arrangements for the use and distribution of suchproprietary information.Published by:National Council for Prescription Drug ProgramsCopyright 2022Publication History:Version 1.0 August 2008Version 1.1 April 2010Version 1.2 November 2010Version 1.3 February 2011Version 1.4 August 2011Version 1.5 December 2012Version 16 May 2020Version 17 March 2022Version 17March 2022***OFFICAL RELEASE*** National Council for Prescription Drug Programs, Inc.Use is restricted to rights on copyright page.-2-
NCPDP Payer Sheet TemplateTABLE OF CONTENTS1.GENERAL INFORMATION FOR A PAYER ABOUT THE TEMPLATES . 51.11.22.COPYRIGHT INFORMATION .5EXTERNAL CODE LIST .5GENERAL INSTRUCTIONS TO PAYERS. 62.1HOW TO USE THIS DOCUMENT .62.2TRANSMISSIONS .72.3PLAN DIFFERENTIATION .72.4SEGMENTS .82.4.1Mandatory Segments .82.4.2Situational Segments.82.4.3Optional Segments .92.5FIELDS OR VALUES .92.5.1Situations on Fields .92.5.2Counts and Counters.102.5.3Zero (0) and an “O” .102.6SPECIFIC TOPIC DISCUSSION .102.6.1Partial Fill Transaction Processing .102.6.2Quantity Prescribed (460-ET).102.6.3Coordination of Benefits (COB) Processing .102.6.4Compounds.112.6.5Vaccine Administration .112.7FIELD LEGEND .112.8MANDATORY FIELDS .122.9SITUATIONAL FIELDS - REQUIRED .122.10SITUATIONAL FIELDS – QUALIFIED REQUIREMENT .122.11INFORMATIONAL ONLY FIELDS .122.12OPTIONAL FIELDS .132.13NOT USED FIELDS .133.NCPDP VERSION D CLAIM BILLING/CLAIM REBILL INSTRUCTIONS . 143.13.23.33.44.GENERAL INFORMATION .14REQUEST TEMPLATE INFORMATION .14RESPONSE TEMPLATE INFORMATION .14CERTIFICATION AND/OR TEST DATA .14NCPDP VERSION D CLAIM BILLING/CLAIM REBILL TEMPLATE . 154.1REQUEST CLAIM BILLING/CLAIM REBILL PAYER SHEET TEMPLATE .154.2RESPONSE CLAIM BILLING/CLAIM REBILL PAYER SHEET TEMPLATE .414.2.1Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response .414.2.2Claim Billing/Claim Rebill Accepted/Rejected Response .534.2.3Claim Billing/Claim Rebill Rejected/Rejected Response .605.NCPDP VERSION D CLAIM REVERSAL INSTRUCTIONS . 625.15.25.36.GENERAL INFORMATION .62REQUEST TEMPLATE INFORMATION .62RESPONSE TEMPLATE INFORMATION .62NCPDP VERSION D CLAIM REVERSAL TEMPLATE. 636.1REQUEST CLAIM REVERSAL PAYER SHEET TEMPLATE .636.2RESPONSE CLAIM REVERSAL PAYER SHEET TEMPLATE .666.2.1Claim Reversal Accepted/Approved Response .666.2.2Claim Reversal Accepted/Rejected Response .686.2.3Claim Reversal Rejected/Rejected Response .707.EXAMPLES OF PAYER TEMPLATES . 728.EXAMPLE 1 – HEALTH PLAN OF AMERICA PAYER SHEET – ONE PLAN . 73Version 17March 2022***OFFICAL RELEASE*** National Council for Prescription Drug Programs, Inc.Use is restricted to rights on copyright page.-3-
NCPDP Payer Sheet Template8.1.1Claim Billing/Claim Rebill .738.1.1.1Claim Billing/Claim Rebill Request.738.1.1.2Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response .788.1.1.3Claim Billing/Claim Rebill Accepted/Rejected Response.848.1.1.4Claim Billing/Claim Rebill Rejected/Rejected Response .888.1.2Claim Reversal .898.1.2.1Claim Reversal Request .898.1.2.2Claim Reversal Accepted/Approved Response .918.1.2.3Claim Reversal Accepted/Rejected Response.928.1.2.4Claim Reversal Rejected/Rejected Response .94EXAMPLE 2 – HEALTH SERVICE OF AMERICA PAYER SHEET - SERVICE . 969.9.1.1Service Billing/Service Rebill .969.1.1.1Service Billing/Service Rebill Request.969.1.1.2Service Billing/Service Rebill Accepted/Paid (or Duplicate of Paid) Response . 1019.1.1.3Service Billing/Service Rebill Accepted/Rejected Response . 1049.1.1.4Service Billing/Service Rebill Rejected/Rejected Response . 106EXAMPLE 3 – ABC, INC. PAYER SHEET – TWO PLANS . 10910.10.1.1Workers’ Compensation Claim Billing . 10910.1.1.1 Workers’ Compensation Claim Billing Request . 10910.1.1.2 Workers’ Compensation Claim Billing Accepted/Paid (Or Duplicate of Paid) Response . 11610.1.1.3 Workers’ Compensation Claim Billing Accepted/Rejected Response. 12110.1.1.4 Workers’ Compensation Claim Billing Rejected/Rejected Response. 12610.1.2Workers’ Compensation Claim Reversal . 12710.1.2.1 Workers’ Compensation Claim Reversal Request . 12710.1.2.2 Workers’ Compensation Claim Reversal Accepted/Approved Response . 12910.1.2.3 Workers’ Compensation Claim Reversal Accepted/Rejected Response . 13110.1.2.4 Workers’ Compensation Claim Reversal Rejected/Rejected Response. 13210.1.3Non-Workers’ Compensation Claim . 13310.1.3.1 Non-Workers’ Compensation Claim Request . 13310.1.3.2 Non-Workers’ Compensation Claim Billing Accepted/Paid (Or Duplicate of Paid) Response . 13910.1.3.3 Non-Workers’ Compensation Claim Billing Accepted/Rejected Response . 14510.1.3.4 Non-Workers’ Compensation Claim Billing Rejected/Rejected Response . 14910.1.4Non-Workers’ Compensation Claim Reversal . 15010.1.4.1 Non-Workers’ Compensation Claim Reversal Request . 15010.1.4.2 Non-Workers’ Compensation Claim Reversal Accepted/Approved Response . 15210.1.4.3 Non-Workers’ Compensation Claim Reversal Accepted/Rejected Response . 15410.1.4.4 Non-Workers’ Compensation Claim Reversal Rejected/Rejected Response . 155EXAMPLE 4 – AMERICAN PROCESSOR INC PAYER SHEET - MULTIPLE PLANS. 15811.11.1.1Claim Billing/Claim Rebill . 15811.1.1.1 Claim Billing/Claim Rebill Request . REQUENTLY ASKED QUESTIONS . 159USE OF RED FONT . 159FONT SIZE . 159APPENDIX A. HISTORY OF IMPLEMENTATION GUIDE CHANGES . 160EDITORIAL CORRECTIONS . 160VERSION 1.1 CORRECTIONS. 160VERSION 1.2 . 160VERSION 1.3 . 160VERSION 1.4 . 160VERSION 1.5 . 160VERSION 16 MAY 2020. 160VERSION 17 MONTH 2022 . 161Version 17March 2022***OFFICAL RELEASE*** National Council for Prescription Drug Programs, Inc.Use is restricted to rights on copyright page.-4-
NCPDP Payer Sheet Template1. GENERAL INFORMATION FOR A PAYER ABOUT THE TEMPLATESThis document is to be used as a reference in filling out and creating a Payer Sheet based on NCPDP Telecommunication Standard Implementation GuideVersion D.0. The Payer Sheet must contain request and response information.Payers must read the instructional sections before filling out the templates. Payers may take the request template section and response template section,fill out the template per their usage and send to their trading partners. Payer Sheets may be used in addition to provider manuals or included in providermanuals. Payers must indicate applicable fields to be used in transaction processing, in accordance with the rules established in the NCPDP documentsand the Quantity Prescribed final rule as indicated under CMS-0055 F. Refer to the NCPDP Telecommunication Version D documents, TelecommunicationStandard Implementation Guide Version D.0, Data Dictionary, External Code List and Telecommunication Version D Questions, Answers and rescribed-(460-ET)-Guidance).In this document, the following templates have been created: Claim Billing/Claim RebilloRequestoResponses (Paid and Rejected) Claim ReversaloRequestoResponses (Approved and Rejected)Payers should fill out a template for each request and response transaction supported. If other transactions are supported (Service Billing request andresponses, Service Reversal request and responses, Prior Authorization Inquiry request and responses, etc.), payer templates should be created followingthe guidelines in this document. Payers are reminded to fill out a template for each response type supported including the Rejected transmission andRejected transaction response.If the payer does not support the Claim Rebill (B3) transaction, the Claim Rebill verbiage should be removed from the payer’s template.The Examples sections show how segments and fields on payer sheets might be filled out.1.1 COPYRIGHT INFORMATIONIt is important to adhere to the copyright statement found on page 2 of this document.Permission is hereby granted to any organization to copy from this materialin the creation of a Payer Sheet only as long as the copies are not sold.The data definitions of fields and situations from the Telecommunication Standard Implementation Guidemust not be distributed outside of the intended use of this document.Reference must be given toNational Council for Prescription Drug Programs9240 E. Raintree DriveScottsdale, AZ 85260(480) 477-1000ncpdp@ncpdp.orgAny reproductions of this document and content beyond this are not authorized. The entity publishing a payer sheet that uses this guide must include anacknowledgment in the payer sheet as to the source of the material in the following form:“Materials Reproduced with the Consent of National Council for Prescription Drug Programs, Inc.2022 NCPDP”This may be included in a footer of the document, in an opening section, etc.1.2 EXTERNAL CODE LISTIn the General Information section of the Payer Template, the NCPDP External Code List Publication Date is designated by the payer. If the payer supportsan updated publication date of the NCPDP External Code List, the payer template must be republished with any applicable new information. Refer to theTelecommunication annual and emergency external code list process and dates outlined within the web-enabled ECL.Version 17March 2022***OFFICAL RELEASE*** National Council for Prescription Drug Programs, Inc.Use is restricted to rights on copyright page.-5-
NCPDP Payer Sheet Template2. GENERAL INSTRUCTIONS TO PAYERS2.1 HOW TO USE THIS DOCUMENTHigh-Level Workflow for Completing a Payer TemplatePayer to review theirplan requirements.Determine transactionssupportedDetermine valid andappropriate grouping ofplans per payer sheets.(See section “PlanDifferentiation”.)When applicableDetermine usage ofBIN, PCNs, SoftwareVendor Certification IDsCreate sample payersheet from NCPDPguide. Include NCPDPcopyright statement.Repeat for all plans andtransactions supportedRemove segments notused for plan business.Verify there is noconflict to removingsegments for thesituations defined.Remove fields not usedin given segments.Verify there is noconflict to removingfields for the situationsdefined.On payer sheet, fill inguidance ofinstructions, payersituations (what isshown in red text) forplan businesssegments and fields.Publish payer sheet.Figure 1. High-level workflowVersion 17March 2022***OFFICAL RELEASE*** National Council for Prescription Drug Programs, Inc.Use is restricted to rights on copyright page.-6-
NCPDP Payer Sheet Template2.2 TRANSMISSIONSRefer to the NCPDP Telecommunication Standard Implementation Guide Version D.0 for the structure and syntax of the transaction(s) within thetransmission.In the template, the Segment Identification (112-AM) fields are not shown. Segment, Group and Field Separators are not shown as they are part of thesyntax. These fields are not shown because they are part of the underlying structure of the transaction and are covered in the guide. This template is toshow the business and plan requirements.2.3 PLAN DIFFERENTIATIONIf the payer does not have different plans, this section can be skipped.If the payer supports multiple plans or has different BINs and/or PCNs that cause different segments to be used, different payer sheets must be created foreach unique combination. Coordination of Benefits (COB) is one example where various claims processing rules may apply based on plan or BIN/PCN.NCPDP recommends there only be one COB method used for a single BIN/PCN combination.Examples where multiple payer sheets should be used include: Plans that use different COB methodologyoPlans that are Primary only (i.e., Coordination of Benefits/Other Payments Segment not used) should not be combined with plansthat are supplemental (i.e., COB Segment used)oPlans that use different COB scenarios (OPAP, OPPRA or Government COB) must have different payer sheets as they should havedifferent BIN/PCN combinations. Payers where one or more plans use the Workers’ Compensation Segment while others do not Payers where one or more plans use the Coupon Segment while others do notBecause a payer sheet may be created that represents the “superset” of requirements for multiple plans, the pharmacy will submit based on this“superset”. An individual plan(s) benefit under this “superset” may not require all of the fields in the “superset.” In this instance, the plan will ignore thefields that do not apply to the particular transaction being submitted. For example: One plan or more uses Patient Gender Code while others covered in the same template do not.Examples includeScenario ommentThe payer supports one BINwith multiple PCNs wheresome plans are Primary onlyand others aresupplemental.The payer supports one BINwith multiple PCNs. EachPCN supports the samemethod of coordination ofbenefit processing.The payer supportsWorkers’ Compensationclaims and non-Workers’Compensation claims underthe same BIN.223346PCN XYZ (Primary only)PCN BBC (Supplemental)PCN GAR (Supplemental)223346PCN XYZPCN BBCPCN GARNoSince all plans under this BIN have thesame segments, the same PayerTemplate can be used. (See sectionSpecific Topic Discussion)610041PCN WRK for Workers’Compensation claimsPCN ABC for nonWorkers’ Compensationclaims.YesThe payer supports couponsclaims and non-couponclaims under the same BIN.044356Has no impactYesThe payer supports claimand service billings underthe same BIN.The payer supports a plan112234Has no impactYes662211Has no impactNoTwo Payer Templates must be usedbecause different segments are used.(Workers’ Compensation claims will usethe Workers’ Compensation Segment;non-Workers’ Compensation claims donot use the Workers’ CompensationSegment)Two Payer Templates must be usedbecause different segments are used.(Coupon transactions will use theCoupon Segment; non-Coupontransactions do not use the CouponSegment)Two Payer Templates must be used toavoid confusion in segments used forclaim billing versus service billing.One Payer Template should be usedVersion 17March 2022***OFFICAL RELEASE*** National Council for Prescription Drug Programs, Inc.Use is restricted to rights on copyright page.-7-Since one of the plans is Primary only, itneeds a separate payer sheet.
NCPDP Payer Sheet TemplateScenario ExamplesBINPCNDifferentPayerTemplatesRequired?that may be primary orsupplemental.The processor supportsplans that require their ownBINs.445511887766Has no impactNoThe processor supportsnumerous plans and BINSthat use the three differentCOB Methods112234223346445511887766May impactYesCommentsince all segments used are the same,with the exception of the Coordinationof Benefits/Other Payments Segmentwhich will designate the usage of thesupplemental rules.Since all plans for this processor have thesame segments the same PayerTemplate can be used. (See sectionSpecific Topic Discussion)Three Payer Templates must be used,one for each of the different COBmethods (Scenario 1 – Other PayerAmount Paid (OPAP), Scenario 2 – OtherPayer Patient Responsibility Amount(OPPRA) and Scenario 3 – GovernmentPrograms)2.4 SEGMENTSEach segment is listed as mandatory, situational or optional for a given transaction in the NCPDP Telecommunication Standard Implementation Guide. Ifthe segment is mandatory for a given transaction, that segment must be sent. If the segment is situational, the situations outlined in the guide must befollowed for use. If the segment is optional, please refer to the NCPDP Telecommunication Standard Implementation Guide Version D.0 for moreinformation on optional usage.2.4.1 MANDATORY SEGMENTSSegments which are designed mandatory in the NCPDP Telecommunication Standard Implementation Guide must be included on the Payer Sheet. In themandatory segments, the Payer must fill in the values to be used in the mandatory or situational fields as defined in the NCPDP TelecommunicationStandard Implementation Guide.On the template, each mandatory segment contains an initial question about the use of the segment (This Segment is always sent), with an “X” in theCheck column. The Check “X” is in black and must not be modified by the Payer. An example
NCPDP PAYER SHEET TEMPLATE IMPLEMENTATION GUIDE FOR VERSION D.0 VERSION 17 Used as guidance in filling out and creating a NCPDP Telecommunication Standard Implementation-based Version D.0 Payer Sheet, in accordance with the NCPDP Telecommunication Standard Imp
Segment Identification (111-AM) "Ø4" Claim Billing/Claim Re-bill Field # NCPDP Field Name Value Payer Usage Payer Situation Payer Requirement: Same as Imp Guide 3Ø6-C6 PATIENT RELATIONSHIP CODE RW Imp Guide: Required if needed to uniquely identify the relationship of the Patient to the Cardholder. Payer Requirement: Same as Imp Guide
If your EHR vendor uses NCPDP, it will be helpful for your IT or technical employees to have NCPDP knowledge for troubleshooting and reviewing XML messages. For more information on the NCPDP standard, visit standards.ncpdp.org. If your EHR vendor does not use NCPDP, there is no need to become familiar with this standard
NCPDP VERSION D.0 Claim Billing/Claim Re-bill Template December 1, 2014 ** Start of Request Claim Billing/Claim Re -bill (B1/B3) Payer Sheet Template** General Information Payer Name: Magellan Rx Management Date: December 1, 2014 Plan Name/Group Name: EFFECTIVE 12/01/14 CBA Blue BIN: 017449 PCN: CBG
Pharmacy NCPDP Reject Codes Last Updated 10/2019 NCPDP Reject Code NCPDP Reject Code Description interChange Edit Description 50 Non-Matched Pharmacy Nu
Caremark utilizes the NCPDP reject codes list. This document refers to potential NCPDP Reject Codes a pharmacy may receive for Telecom and FIR Transactions. Although these Reject Codes are available for use, CVS Caremark has not implemented all the NCPDP Reject Codes listed within this document. For additional information on
Express Scripts, Inc. NCPDP Version D.0 Payer Sheet . ØØ2ØØ8Ø229 – GHI Medicare Part D M 1Ø9-A9 Transaction Count 1 One Occurrence 2Ø2 M -B2 Service Provider ID Qualifier Ø1 NPI M. Express Scripts, Inc. N
NCPDP Version D.0 Payer Sheet Commercial . 1. Payer Usage: M Mandatory, O Optional, R Required by ESI to expedite claim process
down your commitment to practice jazz piano, tell it to others, and schedule in specific practice times. MONTH ONE: Jazz Piano 101 A. Chord types (Play each in all keys) 2 B. Quick Fix Voicing C. ETUDE: (Quick fix voicings with inversions for better voice leading) ALL MUSICAL EXAMPLES TAKEN FROM “JAZZ PIANO HANDBOOK” (ALFRED PUBLISHING) AND USED WITH PERMISSION MONTH TWO: Position .
