NCPDP D.0

West Virginia Medicaid
Health PAS-Rx
Pharmacy Point-of-Sale (POS)

NCPDP Version D.0
Vendor Specification
January 2012
Version 1.3
The printed version of this document may not be current.
Please verify the latest version of this document on the web at
http://www.dhhr.wv.gov/bms/ and http://www.wvmmis.com.
Vendor Specification Document NCPDP D.0 January 2012
TABLE OF CONTENTS
1
OVERVIEW ................................................................................................................ 3
1.1
INTENDED AUDIENCE ................................................................................................ 3
1.2
CLARIFICATION OF TERMS ......................................................................................... 4
System Description ................................................................................................... 4
RESTRICTIONS AND QUALIFICATIONS ........................................................................ 5
POLICIES AFFECTING SUBMISSIONS ........................................................................... 6
HEALTH PAS-RX ENROLLMENT PROCEDURES ............................................................. 7
5.1
SYSTEM SOFTWARE VENDOR ENROLLMENT .............................................................. 7
5.2
PROVIDER ENROLLMENT ........................................................................................... 7
HELP INFORMATION ................................................................................................. 8
6.1
POS Technical support help desk ............................................................................... 8
6.2
POS Claims and PA Help Desk .................................................................................... 8
TRANSACTION FORMATS .......................................................................................... 8
APPENDIX A PROVIDER TRADING PARTNER AGREEMENT .................................................. A1

APPENDIX B NCPDP D.0 TRANSACTION SET INFORMATION ............................................... B1
B1
NCPDP VERSION D.0 PAYER SHEET B1/B2 TRANSACTIONS .................................... B2
B1.1
BILLING TRANSACTION B1 .................................................................................... B2
B1.2
PAID (or Duplicate of Paid) Response ..................................................................... B8
B1.3
Claim Reject Response Transmission Rejected/Transaction Rejected ................. B11
B1.4
Claim Reject Response Transmission Accepted/Transaction Rejected................. B12
B1.5
CLAIM REVERSAL TRANSACTION B2 ................................................................... B14
B1.6
Claim Reversal Response Accepted OR Duplicate of Reversed ............................ B15
B1.7
Claim Reversal Response - Rejected...................................................................... B17
B2
NCPDP VERSION D.0 PAYER SHEET E1 TRANSACTIONS ........................................ B19
B2.1
ELIGIBILITY VERIFICATION REQUEST ...................................................................... B19
B2.2
ELIGIBILITY VERIFICATION RESPONSE - Accepted .................................................. B20
B2.3
ELIGIBILITY VERIFICATION - Rejected ..................................................................... B20
APPENDIX C EDITS AND MESSAGES ................................................................................... C1

APPENDIX D VALID ROUTE OF ADMINISTRATION VALUES ................................................. D1
APPENDIX E PLACE OF SERVICE VALUES .............................................................................E1
Page 1

REVISION HISTORY
CONTROLLED COPIES ISSUED BY:
Health PAS-Rx Support Group
Revision Revision Description
Approval
Date
1.0
Initial Release
M. Luettel
08/2011
1.1
Added Appendix E
M. Luettel
10/2011
1.2
Changed Route of Administration to be an

optional field
No longer use 433-DX Patient Paid Amount
Submitted
M. Luettel
12/2011
M. Luettel
01/2012
1.3
Page 2
OVERVIEW
The purpose of this manual is to provide information necessary to electronically submit

Pharmacy Point of Sale (POS) claims to Molina Medicaid Solutions, the West Virginia (WV)
Medicaid fiscal agent.
The WV Health PAS-Rx Pharmacy POS Vendor Specification Document (VSD) provides a detailed
description of the requirements needed for telecommunication switch vendors to send NCPDP
D.0 formatted transactions to the pharmacy claims adjudication system. The WV Health PAS-Rx
Pharmacy POS only supports processing of transactions submitted in NCPDP D.0 format. There
will be an interim period of support for NCPDP 5.1 as defined by the existing NCPDP Version 5.1
Vendor Specification for West Virginia.
Currently, the following transaction types are supported for West Virginia:
Eligibility (E1)
Billing (B1)
Reversal (B2)
Pharmacy claims submitted electronically to WV Medicaid must adhere to the Health Insurance
Portability and Accountability Act (HIPAA)-compliant NCPDP transaction and code set standards
as described in this manual.
All comments, suggestions and/or questions regarding this Vendor Specification should be
directed to Molina Medicaid Solutions Provider Services during the hours of 8:00 am and 5:00
pm Monday through Friday:
Provider Services
In-state and border (KY, VA, MD, OH, PA): 888-483-0801
Out of State: 304-348-3360
Fax: 304-348-3380
http://www.wvmmis.com
1.1 INTENDED AUDIENCE
This document is intended for use by telecommunication switch vendors routing pharmacy POS
transactions to and from the West Virginia Medicaid Program. Switch vendors provide the
telecommunication link between the pharmacy provider and WV Health PAS-Rx Pharmacy POS
system.
Some information contained in this document may also be of use to pharmacy providers and
system software vendors in ensuring their products will work effectively with the switches and
the WV Health PAS-Rx Pharmacy POS system.
Page 3

1.2 CLARIFICATION OF TERMS
Within the context of this document, the following definitions are used:
Pharmacy provider a pharmacy (retail, hospital, etc.) that provides prescription
medications to Medicaid members.
Switch vendor a company that provides a data telecommunications network from
pharmacy providers to the Health PAS-Rx Pharmacy POS computer system.
System vendor a company which sells software to pharmacy providers that
enables them to input claim data which is subsequently formatted to conform to a
National Council for Prescription Drug Programs (NCPDP) D.0 standard.
POS Technical Support Help Desk a service provided to answer questions and help
resolve problems submitted by switch vendors that relate to claim transmission
to/from the switch vendor. This includes issues related to the NCPDP D.0 formats
described in Appendix B. Molina Medicaid Solutions-WV will provide the POS
Technical Help Desk.
POS Claims and Prior Authorization Help Desk - a service provided to answer
questions and help resolve problems related to pharmacy claim adjudication. This
support includes prior authorization, DUR and claim processing associated with
policy requirements, not transmission of the transaction. Rational Drug Therapy
Program (RDTP) associated with the University of West Virginia located in
Morgantown, West Virginia will provide POS Claims and Prior Authorization Help
Desk support.
2
SYSTEM DESCRIPTION
The Health PAS-Rx Pharmacy POS claims adjudication system is available through authorized
telecommunication switch vendors. It is to be used in conjunction with pharmacy computer
systems using the NCPDP telecommunications standards D.0. The copyrighted NCPDP
standards can be obtained by contacting NCPDP via:
The National Council for Prescription Drug Programs
9240 East Raintree Dr., Scottsdale, AZ 85260
(480) 477-1000 voice; (480) 767-1042 fax
ncpdp@ncpdp.org email
www.ncpdp.org web browser
A pharmacy processes a prescription through the pharmacys in-house computer system to
generate a standard transaction. The transaction is transmitted via a switch vendor network to
the West Virginia Medicaid Health PAS-Rx Pharmacy POS adjudication system for processing. A
paid, accepted, duplicate or rejected response in the NCPDP D.0 format version of the original
claim is returned to the pharmacy via the switch.
The Health PAS-Rx Pharmacy POS system returns information to the pharmacist that can be
used in the correction of claim errors.
Page 4

The system fully supports real-time claim reversal transactions. This enables the pharmacist to
back out or credit any return to stock or other prescription transaction adjudicated in error.
The system supports real-time eligibility verification transactions. This enables the pharmacist
to inquire via NCPDP D.0 to verify Medicaid pharmacy service eligibility of an individual prior to
submitting the claim. This same verification is performed when a claim is submitted for
pharmacy adjudication processing.
The Health PAS-Rx Pharmacy POS system also supports batch billing of Pharmacy claims via the
NCPDP 1.2 standard. Claims contained within the NCPDP 1.2 batch must comply with the
NCPDP D.0 format as described in this document.
3
RESTRICTIONS AND QUALIFICATIONS
The following restrictions or qualifications apply:

1. Pharmacies using the WV Health PAS-Rx Pharmacy POS system are required to transmit
their NCPDP D.0 formatted pharmacy claims through a telecommunication switch vendor
authorized by the West Virginia Bureau for Medical Services (BMS).
2. Pharmacies and switch vendors must have an approved trading partner agreement with
Molina Medicaid Solutions prior to transmitting their NCPDP D.0 formatted pharmacy
claims.
3. The Health PAS-Rx Pharmacy POS system does not support direct dial-up from an individual
pharmacy.
4. New, duplicate paid, resubmitted denied, reversal claims and member pharmacy eligibility
can be submitted via the WV Health PAS-Rx Pharmacy POS system.
5. An NCPDP transmission may contain from one to four transactions for single drug
prescriptions for the same recipient/member and the same DOS. For a compound drug
prescription, the transmission must contain only one transaction.
6. All claim records must be completed according to the record specifications in this
document. All appropriate data validity is to be performed by the switch vendor before a
transaction is generated.
7. Claims requiring supportive documentation or attachments cannot be submitted through
the real-time Health PAS-Rx Pharmacy POS system.
8. Previously submitted claims can be reversed and re-submitted via the real-time WV Health
PAS-Rx Pharmacy POS system for corrective action so long as the date of service (DOS) is
within one year of data of submission. Claims with DOS greater than one year cannot be
processed via WV Health PAS-Rx Pharmacy POS. Contact Provider Services for procedures
on submitting pharmacy claims not transmitted via NCPDP D.0 format.
9. Pharmacy Providers can verify eligibility and download Remittance Advice documents via
the web portal. For assistance contact Provider Services or see information available via
http://www.wvmmis.com.
Page 5

4
POLICIES AFFECTING SUBMISSIONS
The following policies are in addition to those outlined in the WV Medicaid Provider Manual
and in no way supersede this publication.
1. The required edits, submission standards, and data specifications, as outlined in this
document, must be fulfilled and maintained by all pharmacy providers submitting claims
through the WV Health PAS-Rx Pharmacy POS system.
2. At any time, an authorized representative of the following organizations, their agents or
assignees can request supportive documentation to ensure that all requirements are met:
West Virginia Medicaid Program
West Virginia Attorney General
US Attorney General
US Department of Health and Human Services
General Accounting Office.
At any time, the regulatory agents listed above can request actual information used to bill
West Virginia Medicaid claims through the WV Health PAS-Rx Pharmacy POS system (e.g.,
provider data, member data, reference data, pricing data). This is independent of
considerations of whether the data are maintained on physical media, such as computer
printout, or stored on machine-readable media, such as magnetic tape and disk storage
devices. All information obtained by these regulatory agents will be held in strictest
confidence.
3. The individual pharmacy provider is ultimately responsible for accuracy and valid
reporting of all Medicaid claims submitted for payment. A provider using the services of a
telecommunication switch vendor must ensure through legal contract that it is the
responsibility of a vendor to report claim information as directed by the provider in
compliance with all policies stated by West Virginia Medicaid. The individual provider is
required to maintain a record of all Medicaid claims submitted for payment, as are the
telecommunication vendors.
4. All information supplied by BMS or Molina Medicaid Solutions within the computing and
accounting systems of a provider (e.g., provider data, member data, reference data and
statistical data) can be used only in the accurate accounting of claims containing or
referencing that information. Any redistribution or dissemination of that information for
any purpose other than the accurate accounting of Medicaid claims is considered an illegal
use of confidential information.
Page 6

5
HEALTH PAS-RX ENROLLMENT PROCEDURES
The following sections describe the Health PAS-Rx Pharmacy POS vendor enrollment
procedures.
5.1 SYSTEM SOFTWARE VENDOR ENROLLMENT
System software vendors should contact one of the BMS authorized telecommunication switch
vendors to obtain a payer sheet or discuss the technical specifications for implementing the WV
Health PAS-Rx Pharmacy POS system. Refer to B1 for Payer Sheet information. A list of
authorized telecommunication switch vendors is available upon request from Molina Medicaid
Solutions-WV Provider Services.
The telecommunication switch vendor will instruct the system software vendor on the
necessary system modifications for upgrading to NCPDP Version D.0 implementation
requirements as defined for submitting a West Virginia Medicaid pharmacy claim. After
completing the modifications, the system vendor will go through a certification process
conducted by the telecommunication switch vendor that includes a thorough test of the
transactions passing through the telecommunication switch to ensure that they are formatted
properly to meet NCPDP D.0 requirements as defined for processing a West Virginia Medicaid
pharmacy claim.
Once the telecommunication switch vendor has certified the system software vendor, the
switch vendor should pursue the following steps:
1. Contact Molina Medicaid Solutions Technical Support Help Desk via Provider Services to
obtain test claims to be used only for switch vendor test purposes.
2. When ready to test, the switch vendor must contact Molina Medicaid Solutions-Technology
Solutions Center to schedule the submission of the WV Health PAS-Rx Pharmacy POS test
transactions. All test transactions must be uniquely identified. Molina Medicaid Solutions
will identify the appropriate processor control number and network connection (IP address)
to be used by the switch vendor for testing purposes. The switch vendor must supply
Molina Medicaid Solutions the IP of their computer system to be used for submission of test
claims. Once approved, Molina Medicaid Solutions will supply the IP of the Production
computer and request the IP from which the switch vendor will be submitting validate
pharmacy claims. Test claims submitted to the Production system IP will be rejected.
3. The switch vendor should supply Molina Medicaid Solutions-West Virginia with at least one
hard copy and an electronic copy of the vendor user documentation so that the POS
Technical Support Help Desk can use it to respond to switch vendor requests for assistance.
5.2 PROVIDER ENROLLMENT
Before a provider can submit WV Health PAS-Rx Pharmacy POS claims, they must be properly
enrolled in the West Virginia Medicaid system. Once enrolled, the steps for approval are as
follows:
1. Enter into a trading partner agreement with Molina Medicaid Solutions and complete the
appropriate applications required by the State of West Virginia to be a pharmacy provider.
Page 7

Appendix A, Provider Trading Partner Agreement, provides information regarding this form.
The agreement form can be obtained from http://www.wvmmis.com or by contacting
Molina Medicaid Solutions-WV Provider Enrollment at 1-888-483-0793, Option 3.
2. Select and contract with an authorized telecommunications switch vendor. A list of the
authorized telecommunication switch vendors is available upon request from Molina
Medicaid Solutions-WV Provider Enrollment 1-888-483-0793, Option 3.
6
HELP INFORMATION
Pharmacy providers should contact the appropriate Help Desk when there are questions or
problems relating to real time pharmacy claims adjudication. When the Help Desk is not
available, providers should contact their system software vendors Help Desk, which will
contact Molina Medicaid Solutions if necessary.
6.1 POS TECHNICAL SUPPORT HELP DESK
The POS Technical Support Help Desk provides information on system status if the provider is
having difficulty connecting electronically with the WV Health PAS-Rx Pharmacy POS system. If
having difficulties, please call (800) 642-4230.
6.2 POS CLAIMS AND PA HELP DESK
Rational Drug Therapy Program (RDTP), Morgantown, WV has been designated by BMS as the
West Virginia POS Claims Help Desk. RDTP will provide pharmacy adjudication, DUR and
pharmacy prior authorization assistance and can be contacted at (800) 847-3859. Help Desk
hours are Eastern Time. Hours are 8:30 a.m. to 9 p.m., Monday through Saturday and Sunday
Noon to 6 p.m.
The POS Claims Help Desk assists providers in pharmacy claims adjudication. The PA Help Desk
assists providers in obtaining a prior authorization if required to process the prescription.
7
TRANSACTION FORMATS
Appendix B, NCPDP D.0 Transaction Set Information, defines the data elements required for
Health PAS-Rx Pharmacy POS claims processing. Appendix C provides information regarding
Code Messages. Code Messages define the NCPDP reject codes that can be output from WV
Health PAS-Rx Pharmacy POS system.
West Virginia Health PAS-Rx Pharmacy POS will support the NCPDP Version D.0 standard but
does not currently support any higher format (e.g., NCPDP Version D.1 and D.2). WV Health
PAS-Rx Pharmacy POS does not support any lower format (e.g., NCPDP 5.3). There will be an
interim period of support for NCPDP 5.1 as defined by the existing NCPDP Version 5.1 Vendor
Specification for West Virginia.
All input transactions submitted by telecommunications network switches to the West Virginia
Health PAS-Rx Pharmacy POS system must be in the following envelope. A 16-byte header
Page 8

must be prefixed to each Health PAS-Rx Pharmacy POS transaction submitted to the Health
PAS-Rx Pharmacy POS system by any network switch. The format of the header is as follows:
Bytes 1-3. Must be a network switch identifier. Contact Molina Medicaid Solutions Computing and Network Services at (800) 642-4230 to obtain a network switch
identifier. If an ID was previously assigned to a network switch, it is not necessary to
obtain an additional identifier for the Health PAS-Rx Pharmacy POS project.
Bytes 4-9. Should contain an identifier containing any combination of the characters
0-9, A-Z or all zeroes. The switch uses this to match up the response with the original
request. This is necessary since many claims are processed in parallel, and the
response to a later claim may be returned before the response to an earlier claim. If
a switch does not use this identifier, it will have to single thread the claims sent to
Molina Medicaid Solutions; i.e., send one claim and wait for the response before
sending another.
Bytes 10-16. Must be spaces.
Each real-time pharmacy transaction submitted to the WV Health PAS-Rx Pharmacy POS system
by any network must be terminated by an End of Transaction (EOT) flag consisting of a single
(1) byte containing the binary value 00000100, which is equal to 04 in Octal, Decimal, or
Hexadecimal.
Response transactions returned to the network by the WV Health PAS-Rx Pharmacy POS system
will be in the following envelope:
The same header that was prefixed to the input transaction by the
telecommunications network switch will be prefixed to the response transaction
returned to the network switch (with some variations depending on the
requirements of the switch).
The response transaction will be terminated with an EOT in the same way as the
input transaction.
Page 9
APPENDIX A PROVIDER TRADING PARTNER AGREEMENT

Pharmacy Switch Vendors must enter into a provider trading partner agreement prior to
transmitting pharmacy claim transactions in support of the West Virginia Medicaid program.
The completed agreement form is to be returned to Molina Medicaid Solutions. Once
authorized, the pharmacy switch vendor will be approved to submit claims.
The standard Provider Trading Partner Agreement can be found at
http://www.dhhr.wv.gov/bms/ or by contacting Provider Enrollment at 1-888-483-0793,
Option 3.
Page A1
APPENDIX B NCPDP D.0 TRANSACTION SET INFORMATION

The following NCPDP D.0 transaction types are accepted: Billing (B1), Reversal (B2) and
Eligibility Verification (E1). For these transaction types, only Claim Billing is supported.
Encounter and Medicaid Subrogation are not supported.
The following NCPDP D.0 transaction types are not accepted: Rebill (B3), Prior Authorization
(P1-P4), Information Reporting (N1-N3), Service (S1-S3), Predetermination of Benefits (D1),
Financial Information Reporting (F1-F5) and Controlled Substance (C1-C3).
Please note that the West Virginia Health PAS-Rx Pharmacy POS will not be accepting partial
fills. The West Virginia Health PAS-Rx Pharmacy POS will accept a controlled substance
submitted via a B1 transaction. Health PAS-Rx Pharmacy POS uses the controlled substance
indicator as set by First Data Bank.
The West Virginia Health PAS-Rx Pharmacy POS will not accept Workers Compensation
segments as part of the B1 transaction. The West Virginia Health PAS-Rx Pharmacy POS will
accept compound prescriptions.
The following sections contain details of our Payer Sheet/Record Layout submission
requirements.
Page B1
B1 NCPDP VERSION D.0 PAYER SHEET B1/B2 TRANSACTIONS

Fields designed as Mandatory (M) are in accordance with the NCPDP Telecommunication
Implementation Guide Version D.0 and are the only fields designated mandatory. Fields
designated as Required (R) will always be sent, as required by West Virginia or NCPDP. Fields
designated as Required When (RW), will be sent under circumstances that are explained in
the Comment column. Fields designated as Optional (O) by the system are designated with
an (O).
B1.1 BILLING TRANSACTION B1
Transaction Header Segment: Mandatory
Field #
101-A1
102-A2
103-A3
104-A4
109-A9
NCPDP Field Name

BIN Number
Version/Release Number
Transaction Code
Processor Control Number
Transaction Count
Value
610164
D0
B1
DRWVPROD
1-4
202-B2
201-B1
401-D1
Service Provider ID Qualifier

Service Provider ID
Date of Service
01 NPI
Pharmacy NPI
Date Filled
110-AK
Software Vendor/Certification ID
M/O/R/RW
M
M
M
M
M
M
M
M
Comment
WV Medicaid
Version D.0
Billing
Production
One to four occurrences.
One occurrence for
Compounds.
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Identifies the software
source.
Insurance Segment: Mandatory

Field #
111-AM
302-C2
NCPDP Field Name

Segment Identification
Cardholder ID
Value
04
Members Medicaid
Cardholder number
M/O/R/RW
M
M
Comment
Insurance Segment
Max length 20
NCPDP Field Name

Date of Birth
Value
01
M/O/R/RW
M
R
Comment
Patient Segment
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
305-C5
Patient Gender Code
0=Not Specified
1=Male
2=Female
310-CA
311-CB
Patient First Name

Patient Last Name
Patient Segment: Required

Field #
111-AM
304-C4
O
R
Page B2
Max length 12
Max length 15

Field #
307-C7
335-2C
NCPDP Field Name

Place of Service
Value
See Appendix E
Pregnancy Indicator
Blank=Not Specified
1=Not Pregnant
2=Pregnant
M/O/R/RW
RW
RW
Comment
Required if this field
could result in different
coverage, pricing, or
patient financial
responsibility
Required when the
member is pregnant
Claim Segment: Mandatory

NOTE: Partial fills are not supported in WV
Field #
111-AM
455-EM
Value
07
1
402-D2
NCPDP Field Name

Prescription/Service Reference Number
Qualifier
M/O/R/RW
M
M
436-E1
Product/Service ID Qualifier
407-D7
Product/Service ID
00
03
06
NDC (Drug Code)
442-E7
403-D3
405-D5
406-D6
Quantity Dispensed
Fill Number
Days Supply
Compound Code
R
R
R
R
408-D8
Dispense As Written (DAW)/Product

Selection Code
9(7)V999
9(2)
9(3)
1=Not a Compound
2=Compound
0 No DAW
1 Physician DAW
4 No Generic
Available
5 Brand Dispensed as
Generic
6-Override
414-DE
Date Prescription Written
354-NX
Submission Clarification Code Count
13
420-DK
Submission Clarification Code
4=Lost Prescription
Supply
99=3 Day Emergency
Supply
Prescription Number 12
digits
Compound
NDC & DUR/PPS
DUR/PPS
West Virginia: 11
characters; or 0, if
Compound
IF qualifier = 06
(DUR/PPS),
Product/Service ID =
zeroes
Days Supply
Page B3
Comment
Claim Segment
Rx Billing
RW
RW
(Repeating)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Required when 420-DK is
submitted
Up to 3 entries are
allowed, but for Editing
only the first one
submitted will be used.

Field #
308-C8
NCPDP Field Name

Other Coverage Code
Value
2=Other coverage exists
payment collected
this claim not
covered
payment not
collected
03=NDC
453-EJ
Originally Prescribed Product/Service ID

Qualifier
445-EA
Originally Prescribed Product/Service ID
NDC (Drug Code)
600-28
Unit of Measure
461-EU
Prior Authorization Type Code
EA=Each
GM=Grams
ML=Milliliters
5=Exemption from Rx
462-EV
Prior Authorization Number Submitted
995-E2
Route of Administration
Prior Authorization
Number
See Appendix D
M/O/R/RW
RW
Comment
Use 3 when no payment
made and provide valid
reject code. Use 4 when
no payment made due to
meeting deductible. Use
2 when payment(s) have
been received.
RW
Required When
Product/Service ID
Qualifier = 06 (DUR/PPS
Segment submitted)
Required When
Product/Service ID
Qualifier = 06 (DUR/PPS
Segment submitted)
RW
RW
Use 5 for pharmacist

edit override
O
O
For a compound claim, it

is the route of the
complete mixture.
Pricing Segment: Mandatory

Field #
111-AM
409-D9
426-DQ
430-DU
NCPDP Field Name

Ingredient Cost Submitted
Usual and Customary Charge
Gross Amount Due
11
s9(6)V99
s9(6)V99
s9(6)V99
Value
M/O/R/RW
M
R
R
R
Comment
Pricing Segment
Value
03
01=NPI
Prescriber NPI
M/O/R/RW
M
R
R
Comment
Prescriber Segment
M/O/R/RW
M
Comment
COB/Other Payments
Segment
Prescriber Segment: Required for WV

Field #
111-AM
466-EZ
411-DB
NCPDP Field Name

Prescriber ID Qualifier
Prescriber ID
COB/Other Payments Segment: Situational

Field #
111-AM
NCPDP Field Name

Value
05
Page B4

Field #
337-4C
338-5C
339-6C
340-7C
NCPDP Field Name

Coordination of Benefits/Other
Payments Count
Value
1-3
Other Payer Coverage Type
Blank=Not Specified
01=Primary
02=Secondary
03=Tertiary
01=National Payer ID
1C=Medicare Number
1D=Medicaid Number
02=Health Industry
Number (HIN)
03=Bank Information
Number (BIN)
04=National Association of
Insurance
Commissioners (NAIC)
05=Medicare Carrier
Number
Other Payer ID Qualifier
Other Payer ID
M/O/R/RW
M
Comment
Maximum number of
repetitions supported by
West Virginia is three (3).
M
(Repeating)
R
(Repeating)
Must not be Blank.
(Repeating)
443-E8
Other Payer Date
R
(Repeating)
341-HB
Other Payer Amount Paid Count
1-9
342-HC
Other Payer Amount Paid Qualifier
01=Delivery Cost
02=Shipping Cost
03=Postage Cost
04=Administrative Cost
05=Incentive
06=Cognitive Service
07=Drug Benefit
09=Compound Preparation
Cost Submitted
10=Sales Tax
s9(6)V99
431-DV
Other Payer Amount Paid
RW
RW
(Repeating)
07 is the only qualifier

recognized.
RW
(Repeating)
471-5E
472-6E
Other Payer Reject Count

Other Payer Reject Code
1-5
3 character reject code
353-NR
Other Payer-Patient Responsibility

Amount Count
1-3
351-NP

Amount Qualifier
06=Patient Pay Amount as

reported by previous payer
RW
RW
(Repeating)
RW
Page B5
Payment or denial date

of other payer
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Maximum of nine (9).
Required When Other
Coverage Code (308-C8)
= 2.
Required When Other
Coverage Code (308-C8)
= 2.
RW
(Repeating)
Required When Other

Coverage Code is
specified. Must be >
$0.00 if Other Coverage
Code = 2.
Maximum of 5
Up to five (5) Reject
Codes Allowed
Required and non-zero
when Other Coverage
(308-C8) = 2 or 4.
Required if Other PayerPatient Responsibility
Amount
(352-NQ) is used.

Field #
352-NQ
NCPDP Field Name

Amount
Value
s9(8)V99
M/O/R/RW
RW
(Repeating)
Comment
Required if Other PayerPatient Responsibility
Amount
(353-NR) is used.
M/O/R/RW
M
R
Comment
DUR/PPS Segment
Maximum number of
West Virginia is three (3).
DUR/PPS Segment: Situational

Field #
111-AM
473-7E
NCPDP Field Name

DUR/PPS Code Counter
Value
08
1-3
(Repeating)
439-E4
440-E5
441-E6
Reason for Service Code
Professional Service Code
Result of Service Code
West Virginia:
DD=Drug-Drug Interaction
ER=Early Refill
HD=High Dose
ID=Ingredient Duplication
LD=Low Dose
LR=Late Refill
MX=Excessive Duration
PG=Drug-Pregnancy
SX=Drug Gender
TD=Therapeutic
00=No Intervention
AS=Patient Assessment
CC=Coordination of Care
DE= Dosing Evaluation/
Determination
DP=Dosage Evaluated
FE=Formulary Enforcement
GP=Generic Product
Selection
M0=Prescriber Consulted
MA= Medication
Administration
MB=Overriding Benefit
MP=Patient will be
Monitored
MR=Medication Review
PA=Previous Patient
Tolerance
00=Not Specified
1A= Filled As Is, False
Positive
1B= Filled Prescription As Is
1C=Filled, With Different
Dose
1D=Filled, With Different
Directions
1E=Filled, With Different
Drug
1F=Filled, With Different
Quantity
1G=Filled, with Prescriber
Approval
Page B6
R
(Repeating)
R
(Repeating)
R
(Repeating)

Field #
NCPDP Field Name
Value
M/O/R/RW
Comment
M/O/R/RW
M
Comment
Compound Segment
West Virginia supports
repeating fields in this
segment.
West Virginia supports
claim submissions with
up to 25 ingredients and
only supports the billing
of compounds for those
ingredients with an NDC
number.
1H=Brand-to-Generic
Change
1J=Rx-to-OTC Change
Compound Segment: Situational

Field #
111-AM
NCPDP Field Name

Value
450-EF
Compound Dosage Form Description Code
451-EG
Compound Dispensing Unit Form Indicator
447-EC
Compound Ingredient Component (Count)
01=Capsule
02=Ointment
03=Cream
04=Suppository
05=Powder
06=Emulsion
07=Liquid
10=Tablet
11=Solution
12=Suspension
13=Lotion
14=Shampoo
15=Elixir
16=Syrup
17=Lozenge
18=Enema
1=Each
2=Grams
3=Milliliters
2 - 25
488-RE
Compound Product ID Qualifier
03
10
M
M
(Repeating)
489-TE
Compound Product ID
NDC (Drug Code)
M
(Repeating)
448-ED
Compound Ingredient Quantity
9(7)V999
M
(Repeating)
449-EE
Compound Ingredient Drug Cost
s9(6)V99
R
(Repeating)
Page B7
West Virginia: accepts

from 2 to 25
Indicates NDC qualifier is
used
List primary ingredient as
first repeating entry.

Field #
490-UE
B1.2
NCPDP Field Name

Compound Ingredient Basis of Cost
Determination
Value
01=AWP (Average
Wholesale Price)
02=Local Wholesaler
03=Direct
04=EAC (Estimated
Acquisition Cost)
05=Acquisition
06=MAC (Maximum
Allowable Cost)
07=Usual & Customary
09=Other
M/O/R/RW
RW
Comment
(Repeating)
PAID (OR DUPLICATE OF PAID) RESPONSE
Response Header Segment: Mandatory

Field #
102-A2
NCPDP Field Name

D0
Value
M/O/R/RW
M
103-A3
Transaction Code
B1
109-A9
Transaction Count
1-4
501-F1
202-B2
Header Response Status

A
01 - NPI
M
M
201-B1
Service Provider ID
Pharmacy NPI
401-D1
Date of Service
Date Filled
Comment
Same value as in billing
request
request
request
Accepted
request
request
request
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Response Message Segment: Situational

Field #
111-AM
NCPDP Field Name

504-F4
Message
Value
20
M/O/R/RW
M
RW
Comment
Response Message
Segment
Max length 200
Response Status Segment: Mandatory

Field #
111-AM
NCPDP Field Name

112-AN
Transaction Response Status
Value
21
P=Paid
D=Duplicate of Paid
Page B8
M/O/R/RW
M
M
Comment
Response Status
Segment

Field #
503-F3
NCPDP Field Name

Authorization Number
130-UF
132-UH
Additional Message Information Count

Additional Message Information Qualifier
526-FQ
Additional Message Information
Value
Transaction Control
Number (TCN)
M/O/R/RW
R
RW
RW
(Repeating)
RW
Comment
Format:
YYJJJPBBDDDDDLL
YY: 2 digit year (e.g.
11=2011)
JJJ: Julian Day (e.g. 213 =
August 1, 2011)
P = Pharmacy
BB = Batch #; real time =
01
DDDDD = document #
LL = line #
Maximum count of 25
01 09 until further
defined by NCPDP
Max length 40
(Repeating)
131-UG
Additional Message Information Continuity
+ = current text
continues
(Repeating)
RW
Value
22
1 Rx Billing
M/O/R/RW
M
M
Response Claim Segment: Mandatory

Field #
111-AM
455-EM
402-D2
NCPDP Field Name

Qualifier
Prescription Number
Comment
Response Claim Segment
Response Pricing Segment: Mandatory

Field #
111-AM
NCPDP Field Name

23
Value
M/O/R/RW
M
505-F5
Patient Pay Amount
s9(6)V99
506-F6
Ingredient Cost Paid
s9(6)V99
RW
507-F7
Dispensing Fee Paid
s9(6)V99
RW
566-J5
Other Payer Amount Recognized
s9(6)V99
RW
509-F9
Total Amount Paid
s9(6)V99
Comment
Response Pricing
Segment
Amount to be paid by
the patient to the
pharmacist
Drug ingredient cost paid
included in the Total
Amount Paid (59-F9).
Dispensing fee paid
included in the Total
Amount Paid (59-F9).
Total dollar amount of
any payment from
another source.
Response DUR/PPS Segment: Situational

Field #
111-AM
NCPDP Field Name

Value
24
Page B9
M/O/R/RW
M
Comment
Response DUR/PPS
Segment

Field #
567-J6
NCPDP Field Name

DUR/PPS Response Code Counter
439-E4
528-FS
529-FT
530-FU
Clinical Significance Code
Other Pharmacy Indicator
Value
1-9
West Virginia:
DD=Drug-Drug
Interaction
ER=Early Refill
HD=High Dose
ID=Ingredient
Duplication
LD=Low Dose
LR=Late Refill
PG=Pregnancy
Precaution
SX=Breastfeeding
Precaution
TD=Therapeutic
Duplication
Blank=Not Specified
1=Major
2=Moderate
3=Minor
9=Undetermined
0=Not Specified
1=Your Pharmacy
2=Other Pharmacy in
Same Chain
3=Other Pharmacy
Previous Date of Fill
M/O/R/RW
RW
RW
(Repeating)
RW
(Repeating)
RW
(Repeating)
RW
(Repeating)
531-FV
Quantity of Previous Fill
9(7)V999
Comment
Maximum number of
West Virginia is three (3)
for non-compound
claim; nine (9) for
compound claim.
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
RW
(Repeating)
532-FW
Database Indicator
1=First DataBank
RW
(Repeating)
533-FX
544-FY
Other Prescriber Indicator
0=Not Specified
1=Same Prescriber
2=Other Prescriber
DUR Free Text Message
RW
(Repeating)
RW
Max length 30
(Repeating)
570-NS
DUR Additional Text
RW
(Repeating)
Page B10
Max length 100

B1.3
CLAIM REJECT RESPONSE TRANSMISSION REJECTED/TRANSACTION REJECTED

Field #
102-A2
NCPDP Field Name

Value
D.0 Version D.0
M/O/R/RW
M
103-A3
Transaction Code
B1- Billing
109-A9
Transaction Count
1-4
501-F1
202-B2

R
01 - NPI
M
M
201-B1
Service Provider ID
Pharmacy NPI
401-D1
Date of Service
Date Filled
Comment
request
request
request
Rejected
request
request
request
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day

Field #
111-AM
NCPDP Field Name

504-F4
Message
Value
20
M/O/R/RW
M
RW
Comment
Response Message
Segment
Max length 200.

Field #
111-AM
NCPDP Field Name

21
Value
M/O/R/RW
M
112-AN
503-F3
Transaction Control
Number (TCN)
RW
510-FA
511-FB
Reject Count
Reject Codes
1-5
NCPDP Reject Code
M
R
546-4F
Rejected Field Occurrence Indicator
9(2)
(Repeating)
RW
(Repeating)
Page B11
Comment
Response Status
Segment
Rejected
Format:
YYJJJPBBDDDDDLL
11=2011)
August 1, 2011)
P = Pharmacy
01
DDDDD = document #
LL = line #
From 1 up to 5
Repeating Reject Count
times

Field #
130-UF
132-UH
NCPDP Field Name

526-FQ
Value
M/O/R/RW
RW
RW
(Repeating)
RW
Comment
Maximum count of 25
01 09 until further
defined by NCPDP
Max length 40
(Repeating)
131-UG
B1.4
+ = current text
continues
RW
(Repeating)
CLAIM REJECT RESPONSE TRANSMISSION ACCEPTED/TRANSACTION REJECTED

Field #
102-A2
NCPDP Field Name

Value
D0 Version D.0
M/O/R/RW
M
103-A3
Transaction Code
B1- Billing
109-A9
Transaction Count
1-4
501-F1
202-B2

A
01 - NPI
M
M
201-B1
Service Provider ID
Pharmacy NPI
401-D1
Date of Service
Date Filled
Comment
request
request
request
Accepted
request
request
request
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day

Field #
111-AM
NCPDP Field Name

504-F4
Message
Value
20
M/O/R/RW
M
RW
Comment
Response Message
Segment
Max length 200.

Field #
111-AM
NCPDP Field Name

21
Value
M/O/R/RW
M
112-AN
Page B12
Comment
Response Status
Segment
Rejected

Field #
503-F3
NCPDP Field Name

Value
Transaction Control
Number (TCN)
M/O/R/RW
RW
510-FA
511-FB
Reject Count
Reject Code
1-5
NCPDP Reject Code
R
R
546-4F
9(2)
Comment
Format:
YJJJPBBDDDDDLL
11=2011)
August 1, 2011)
P = Pharmacy
01
DDDDD = document #
LL = line #
From 1 to 5
(Repeating)
RW
(Repeating)
130-UF
132-UH

526-FQ
RW
RW
(Repeating)
RW
Max count of 25
01 09 until further
defined by NCPDP
Max length 40
(Repeating)
131-UG
+ = current text
continues
RW
(Repeating)

Field #
111-AM
455-EM
42-D2
NCPDP Field Name

Qualifier
Value
22
1 Rx Billing
Prescription Number
M/O/R/RW
M
M
Comment
Response DUR/PPS Segment: Situational

Field #
111-AM
567-J6
NCPDP Field Name

24
Value
DUR/PPS Response Code Counter
1-9
M/O/R/RW
M
RW
(Repeating)
Page B13
Comment
Response DUR/PPS
Segment
Maximum number of
West Virginia for noncompound claim is three
(3).
Maximum number of
West Virginia for
compound claim is nine
(9).

Field #
439-E4
528-FS
529-FT
530-FU
NCPDP Field Name

Value
West Virginia:
DD=Drug-Drug
Interaction
ER=Early Refill
HD=High Dose
ID=Ingredient
Duplication
LD=Low Dose
LR=Late Refill
PG=Pregnancy
Precaution
SX=-Breastfeeding
Precaution
TD=Therapeutic
Duplication
Blank=Not Specified
1=Major
2=Moderate
3=Minor
9=Undetermined
0=Not Specified
1=Your Pharmacy
2=Other Pharmacy in
Same Chain
3=Other Pharmacy
Clinical Significance Code
Other Pharmacy Indicator
Previous Date of Fill
M/O/R/RW
RW
(Repeating)
RW
(Repeating)
RW
(Repeating)
RW
(Repeating)
531-FV
Quantity of Previous Fill
9(7)V999
Comment
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
RW
(Repeating)
532-FW
Database Indicator
1=First DataBank
RW
(Repeating)
533-FX
544-FY
Other Prescriber Indicator
0=Not Specified
1=Same Prescriber
2=Other Prescriber
DUR Free Text Message
RW
(Repeating)
RW
Max length 30
(Repeating)
570-NS
DUR Additional Text
RW
Max length 100
(Repeating)
B1.5
CLAIM REVERSAL TRANSACTION B2

Field #
101-A1
102-A2
103-A3
104-A4
109-A9
NCPDP Field Name

BIN Number
Transaction Code
Transaction Count
Value
610164
D0
B2
DRWVPROD
1-4
Page B14
M/O/R/RW
M
M
M
M
M
Comment
WV Medicaid
Version D.0
Reversal
Production
1 to 4 occurrences

Field #
202-B2
201-B1
NCPDP Field Name

Service Provider ID
Value
01 NPI
Pharmacy NPI
401-D1
Date of Service
Date Filled
110-AK
M/O/R/RW
M
M
M
Comment
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
source.
Claim Segment: Mandatory

Field #
111-AM
455-EM
402-D2
NCPDP Field Name

Qualifier
436-E1
Product/Service ID Qualifier
407-D7
Product/Service ID
Value
07
1
M/O/R/RW
M
M
M
03
00
06
NDC (Drug Code)
Comment
Claim Segment
Rx Billing
Prescription Number
12 digits
NDC
Compound
DUR/PPS
Drug Code
If DUR/PPS use original
claim Prescribed
Product/Service Code
(NDC) or if Qualifier = 06,
then use zeroes.
Compound reversal.
If Qualifier =03
Use NDC of 1st repeating
segment in original claim
submission.
If Qualifier =00
Use NDC of zeros.
B1.6
CLAIM REVERSAL RESPONSE ACCEPTED OR DUPLICATE OF REVERSED

Field #
102-A2
NCPDP Field Name

D.0
Value
M/O/R/RW
M
103-A3
Transaction Code
B2
109-A9
Transaction Count
1-4
501-F1
202-B2

A
01 - NPI
M
M
Page B15
Comment
Same value as in reversal
request
request
request
Accepted
request

Field #
201-B1
NCPDP Field Name

Service Provider ID
Value
Pharmacy NPI
401-D1
Date of Service
Date Filled
M/O/R/RW
M
M
Comment
request
request
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day

Field #
111-AM
NCPDP Field Name

504-F4
Message
Value
20
M/O/R/RW
M
RW
Comment
Response Message
Segment
Transmission level Edit
Number(s) /message(s)

Field #
111-AM
NCPDP Field Name

112-AN
503-F3
130-UF
132-UH
Value
21
A
S
Transaction Control
Number (TCN)
M/O/R/RW
M
Segment
M
RW
RW
RW
(Repeating)
526-FQ
RW
Comment
Response Status
Approved
Duplicate of Approved
Format: YYJJJRDDDDDD
11=2011)
August 1, 2011)
R = Reversal
DDDDD D= document #
Maximum count of 25
01 09 until further
defined by NCPDP
Max length 40
(Repeating)
131-UG
+ = current text
continues
(Repeating)
RW
Value
22
1 Rx Billing
M/O/R/RW
M
M

Field #
111-AM
455-EM
402-D2
NCPDP Field Name

Qualifier
Prescription Number
Page B16
Comment
12 digits

B1.7
CLAIM REVERSAL RESPONSE - REJECTED

Field #
102-A2
NCPDP Field Name

D.0
Value
M/O/R/RW
M
103-A3
Transaction Code
B2
109-A9
Transaction Count
1-4
501-F1
202-B2
A
R
01 - NPI
201-B1
Service Provider ID
Pharmacy NPI
401-D1
Date of Service
Date Filled
Comment
request
request
request
Accepted
Rejected
request
request
request
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day

Field #
111-AM
NCPDP Field Name

504-F4
Message
Value
20
M/O/R/RW
M
RW
Comment
Response Message
Segment
Transmission level Edit
Number(s) /message(s)
*Header Segment

Field #
111-AM
NCPDP Field Name

21
Value
112-AN
510-FA
511-FB

Reject Count
Reject Code
R
1-5
NCPDP Reject Code
546-4F
9(2)
M/O/R/RW
M
Segment
M
R
R
Comment
Response Status
Rejected
From 1 to 5
(Repeating)
RW
(Repeating)
130-UF
132-UH

526-FQ
RW
RW
(Repeating)
RW
(Repeating)
131-UG
+ = current text
continues
Page B17
RW
(Repeating)
Maximum count of 25
01 09 until further
defined by NCPDP
Max length 40

Field #
111-AM
455-EM
402-D2
NCPDP Field Name

Qualifier
Value
22
1 Rx Billing
Prescription Number
Page B18
M/O/R/RW
M
M
M
Comment
12 digits
B2 NCPDP VERSION D.0 PAYER SHEET E1 TRANSACTIONS

B2.1 ELIGIBILITY VERIFICATION REQUEST

Field #
101-A1
NCPDP Field Name

BIN Number
Value
610164
M/O/R/RW
M
102-A2
103-A3
104-A4
109-A9
202-B2
201-B1
401-D1
Transaction Code
Transaction Count
Service Provider ID
Date of Service
D0
E1
DRWVPROD
1
01 NPI
Pharmacy NPI
110-AK
M
M
M
M
M
M
M
Comment
WV Medicaid
Version D.0
Eligibility Verification
Production
One occurrence
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
source
Insurance Segment: Mandatory

Field #
111-AM
302-C2
NCPDP Field Name

Cardholder ID
Value
04
Members Medicaid
Cardholder number
M/O/R/RW
M
M
Comment
Insurance Segment
Max length 20
M/O/R/RW
M
R
Comment
Patient Segment
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Max length 12
Max length 15
Patient Segment: Required for WV

Field #
111-AM
304-C4
310-CA
311-CB
305-C5
NCPDP Field Name

Date of Birth
Patient First Name

Patient Last Name
Patient Gender Code
Value
01
0=Not Specified
1=Male
2=Female
Page B19
O
RW
R

B2.2
ELIGIBILITY VERIFICATION RESPONSE - ACCEPTED

Field #
102-A2
NCPDP Field Name

Value
D0
M/O/R/RW
M
103-A3
Transaction Code
E1
109-A9
Transaction Count
501-F1
202-B2

A
01 - NPI
M
M
201-B1
Service Provider ID
Pharmacy NPI
401-D1
Date of Service
Comment
Same value as in
eligibility request
Same value as in
eligibility request
Same value as in
eligibility request
Accepted
Same value as in
eligibility request
Same value as in
eligibility request
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day

Field #
111-AM
NCPDP Field Name

504-F4
Message
Value
20
M/O/R/RW
M
RW
Comment
Response Message
Segment
Max length 200.

Field
111-AM
112-AN
B2.3
NCPDP Field Name

Value
21
M/O/R/RW
M
Segment
M
Comment
Response Status
M/O/R/RW
M
Comment
Same value as in
eligibility request
Same value as in
eligibility request
Same value as in
eligibility request
Rejected
Accepted
Same value as in
eligibility request
Approved
ELIGIBILITY VERIFICATION - REJECTED

Field #
102-A2
NCPDP Field Name

Value
D0
103-A3
Transaction Code
E1
109-A9
Transaction Count
501-F1
202-B2
R
A
01 NPI
Page B20

Field #
201-B1
401-D1
NCPDP Field Name

Service Provider ID
Value
Pharmacy NPI
Date of Service
Date Filled
M/O/R/RW
M
M
Comment
Same value as in
eligibility request
Same value as in
eligibility request
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day

Field #
111-AM
504-F4
NCPDP Field Name

Value
20
Message
M/O/R/RW
M
RW
Comment
Response Message
Segment
Max length 200.

Field
111-AM
NCPDP Field Name

Value
21
112-AN
510-FA
Reject Count
1-5
511-FB
Reject Code
NCPDP Reject Code
M/O/R/RW
M
Segment
M
Comment
Response Status
From one up to 5
Rejected
R
(Repeating)
546-4F
130-UF
132-UH
9(2)
RW
RW
Maximum count of 25
RW
01 09 until further
defined by NCPDP
Max length 40
(Repeating)
526-FQ
RW
(Repeating)
131-UG

continues
+ = current text
RW
(Repeating)
Page B21
APPENDIX C EDITS AND MESSAGES

Messages are returned as a method of keeping the provider informed of problems and
situations that occurred while attempting to process the claim and as the result of claim
processing. Depending upon the point in Health PAS-Rx processing, an NCPDP Reject Code may
or may not be returned. Health PAS-Rx returns an edit number and text message as deemed
appropriate. A message may be returned without an edit number. Edit numbers are followed
by either a D or a W. Denied claims are not paid. Warnings are informational messages on
claims that are payable.
The edit numbers and messages reflect the WV POS configuration as of the date indicated on
published document. The execution of an edit and the display of messages are subject to
change. Based upon changes to business requirements as determined by BMS, edits may no
longer be applicable, new edits may be included, and new edits and messages may be added.
Because edits are subject to change, edits and messages are provided as a separate document.
The Pharmacy Master Edit Matrix document can be found at http://www.dhhr.wv.gov/bms/
and http://www.wvmmis.com.
Specific edits can be overridden. As business requirements change, BMS may direct that an edit
can no longer be overridden, the override level changed, and other edits be allowed override
capability. The edit override is identified by the entry in the PA Type Code field on the NCPDP
D.0 transaction. Contact the POS Help Desk for more information if needed.
If a Prior Authorization (PA) is required, an edit number, D and text message indicating that a
PA is required, will be returned. Claims requiring a PA will be denied until a PA has been
granted. Contact the PA Help Desk to obtain a PA before resubmitting the claim. Once a PA is
obtained, resubmit the claim for processing.
POS claims are electronically transferred from the pharmacy desktops software system
application to a switch vendor that forwards the claim transmission to Molina Medicaid
Solutions for processing. During the transfer and receipt of data, problems may occur that
prevents the Health PAS-Rx application from properly processing the claim. For example, if the
electronic transmission cannot be translated from XML format into an NCPDP response, the
message SERIALIZATION ERROR will be returned, in which case you would need to call Molina
at (800) 642-4230. The following are other messages that may be returned and require
resubmission:
ESN generator is down - Call Molina at (800) 642-4230.
Host application timeout Resubmit claim.
Parser timeout - Call Molina at (800) 642-4230.
Request invalidly formatted Call your desktop software vendor.
Parser is down - Call Molina at (800) 642-4230.
Host Application Error - Call Molina at (800) 642-4230.
Page C1
APPENDIX D VALID ROUTE OF ADMINISTRATION VALUES

420254004
54471007
112239003
47056001
417070009
418162004
372449004
372450004
372451000
372452007
417985001
404820008
420163009
17751009
372453002
31638007
418743005
372454008
418136008
127490009
372457001
432087007
421503006
419954003
424494006
424109004
429817007
419396008
372458006
58100008
12130007
404819002
419778001
372459003
418821007
372460008
418331006
372461007
420719007
372462000
Body cavity route

Buccal route
By inhalation
By irrigation
Caudal route
Colostomy route
Dental route
Endocervical route
Endosinusial route
Endotracheopulmonary route
Enteral route
Epidural route
Esophagostomy route
External route
Extra-amniotic route
Extraluminal route
Fistula route
Gastroenteral route
Gastro-intestinal stoma route
Gastrostomy route
Gingival route
Hemodiafiltration route
Hemodialysis route
Ileostomy route
Infusion route
Injection route
Interstitial route
Intraabdominal route
Intraamniotic route
Intra-arterial route
Intra-articular route
Intrabiliary route
Intrabronchial route
Intrabursal route
Intracameral route
Intracardiac route
Intracartilaginous route
Intracavernous route
Intracerebroventricular route
Intracervical route
Page D1

418892005
418608002
418287000
372463005
418987007
372464004
372465003
417989007
418887008
89947002
372466002
37737002
372467006
60213007
78421000
418133000
372468001
417255000
419631009
38239002
372469009
419810008
420201002
419231003
418418000
372470005
418877009
418586008
418947002
72607000
417950001
404818005
418091004
62226000
418114005
419993007
404817000
404816009
47625008
420287000
372471009
418401004
419464001
Intracisternal route
Intracorneal route
Intracoronal route
Intracoronary route
Intracranial route
Intradermal route
Intradiscal route
Intraductal route
Intraduodenal route
Intraepithelial route
Intralesional route
Intraluminal route
Intralymphatic route
Intramedullary route
Intramuscular route
Intramyometrial route
Intraocular route
Intraosseous route
Intraovarian route
Intraperitoneal route
Intrapleural route
Intraprostatic route
Intrapulmonary route
Intrasinal route
Intraspinal route
Intrasternal route
Intrasynovial route
Intratendinous route
Intratesticular route
Intrathecal route
Intrathoracic route
Intratracheal route
Intratympanic route
Intrauterine route
Intravenous central route
Intravenous peripheral route
Intravenous piggyback route
Intravenous push route
Intravenous route
Intraventricular route - cardiac
Intravesical route
Intravitreal route
Iontophoresis route
Page D2

127491008
420185003
420204005
46713006
420218003
127492001
418730005
54485002
26643006
419643005
418441008
372473007
418664002
10547007
418851001
419165009
37161004
16857009
127493006
428191002
372474001
418722009
417946008
372475000
420047004
419762003
421032001
418204005
418321004
372476004
34206005
419601003
37839007
419874009
416174007
419320008
419894000
418813001
6064005
419243002
45890007
9942002
404815008
Jejunostomy route
Laryngeal route
Mucous fistula route
Nasal route
Nasoduodenal route
Nasogastric route
Nasojejunal route
Ophthalmic route
Oral route
Orbital floor route
Orogastric route
Oromucosal route
Oropharyngeal route
Otic route
Paracervical route
Paravertebral route
Per rectum (route)
Per vagina
Percutaneous gastrostomy (button) route
Percutaneous route
Periarticular route
Peribulbar route
Pericardial route
Perineural route
Periosteal route
Peritendinous route
Peritoneal dialysis route
Periurethral route
Retrobulbar route
Subconjunctival route
Subcutaneous route
Subgingival route
Sublingual route
Submucosal route
Suborbital route
Subtendinous route
Surgical cavity route
Surgical drain route
Topical route
Transcervical route
Transdermal route
Transluminal route
Transmucosal route
Page D3

418511008
419021003
419684008
90028008
420168000
Transurethral route
Tumor cavity route
Ureteral route
Urethral route
Urostomy route
Page D4
APPENDIX E PLACE OF SERVICE VALUES
Place of
Service
Code(s)
Place of Service
Name
Place of Service Description
01
Pharmacy**
A facility or location where drugs and other medically

related items and services are sold, dispensed, or
otherwise provided directly to patients.
02
Unassigned
N/A
03
School
A facility whose primary purpose is education.
Homeless Shelter
A facility or location whose primary purpose is to provide

temporary housing to homeless individuals (e.g.,
emergency shelters, individual or family shelters).
04
Indian Health
Service
05
Free-standing
Facility
Indian Health
Service
06
Provider-based
Facility
Tribal 638
07
Free-standing
Facility
A facility or location, owned and operated by the Indian

Health Service, which provides diagnostic, therapeutic
(surgical and non-surgical), and rehabilitation services to
American Indians and Alaska Natives who do not require
hospitalization.
A facility or location, owned and operated by the Indian
Health Service, which provides diagnostic, therapeutic
(surgical and non-surgical), and rehabilitation services
rendered by, or under the supervision of, physicians to
American Indians and Alaska Natives admitted as
inpatients or outpatients.
A facility or location owned and operated by a federally
recognized American Indian or Alaska Native tribe or
tribal organization under a 638 agreement, which
provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members
who do not require hospitalization.
Page E1

Place of
Service
Code(s)
Place of Service
Name
Tribal 638
08
Provider-based
Facility
Prison/
09
10
Correctional
Facility

A facility or location owned and operated by a federally
recognized American Indian or Alaska Native tribe or
tribal organization under a 638 agreement, which
provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members
admitted as inpatients or outpatients.
A prison, jail, reformatory, work farm, detention center,

or any other similar facility maintained by either Federal,
State or local authorities for the purpose of confinement
or rehabilitation of adult or juvenile criminal offenders.
Unassigned
11
Office
Location, other than a hospital, skilled nursing facility

(SNF), military treatment facility, community health
center, State or local public health clinic, or intermediate
care facility (ICF), where the health professional routinely
provides health examinations, diagnosis, and treatment
of illness or injury on an ambulatory basis.
12
Home
Location, other than a hospital or other facility, where

the patient receives care in a private residence.
Assisted Living
Facility
Congregate residential facility with self-contained living

units providing assessment of each resident's needs and
on-site support 24 hours a day, 7 days a week, with the
capacity to deliver or arrange for services including some
health care and other services.
Group Home *
A residence, with shared living areas, where clients

receive supervision and other services such as social
and/or behavioral services, custodial service, and
minimal services (e.g., medication administration).
Mobile Unit
A facility/unit that moves from place-to-place equipped

to provide preventive, screening, diagnostic, and/or
treatment services.
13
14
15
Page E2

Place of
Service
Code(s)
16
17
18-19
20
Place of Service
Name
Temporary
Lodging
A short term accommodation such as a hotel, camp

ground, hostel, cruise ship or resort where the patient
receives care, and which is not identified by any other
POS code.
Walk-in Retail
Health Clinic
A walk-in health clinic, other than an office, urgent care

facility, pharmacy or independent clinic and not
described by any other Place of Service code, that is
located within a retail operation and provides, on an
ambulatory basis, preventive and primary care services.
(This code is available for use immediately with a final
effective date of May 1, 2010)
Unassigned
N/A
Urgent Care
Facility
Location, distinct from a hospital emergency room, an

office, or a clinic, whose purpose is to diagnose and treat
illness or injury for unscheduled, ambulatory patients
seeking immediate medical attention.
Inpatient Hospital
A facility, other than psychiatric, which primarily

provides diagnostic, therapeutic (both surgical and
nonsurgical), and rehabilitation services by, or under, the
supervision of physicians to patients admitted for a
variety of medical conditions.
22
Outpatient
Hospital
A portion of a hospital which provides diagnostic,

therapeutic (both surgical and nonsurgical), and
rehabilitation services to sick or injured persons who do
not require hospitalization or institutionalization.
23
Emergency Room
Hospital
A portion of a hospital where emergency diagnosis and

treatment of illness or injury is provided.
24
Ambulatory
Surgical Center
A freestanding facility, other than a physician's office,

where surgical and diagnostic services are provided on
an ambulatory basis.
Birthing Center
A facility, other than a hospital's maternity facilities or a

physician's office, which provides a setting for labor,
delivery, and immediate post-partum care as well as
immediate care of new born infants.
21
25
Page E3

Place of
Service
Code(s)
26
27-30
Place of Service
Name
A medical facility operated by one or more of the

Uniformed Services. Military Treatment Facility (MTF)
Military
also refers to certain former U.S. Public Health Service
Treatment Facility
(USPHS) facilities now designated as Uniformed Service
Treatment Facilities (USTF).
Unassigned
N/A
Skilled Nursing
Facility
A facility which primarily provides inpatient skilled

nursing care and related services to patients who require
medical, nursing, or rehabilitative services but does not
provide the level of care or treatment available in a
hospital.
32
Nursing Facility
A facility which primarily provides to residents skilled

nursing care and related services for the rehabilitation of
injured, disabled, or sick persons, or, on a regular basis,
health-related care services above the level of custodial
care to other than mentally retarded individuals.
33
Custodial Care
Facility
A facility which provides room, board and other personal

assistance services, generally on a long-term basis, and
which does not include a medical component.
34
Hospice
A facility, other than a patient's home, in which palliative

and supportive care for terminally ill patients and their
families are provided.
Unassigned
N/A
41
Ambulance - Land
A land vehicle specifically designed, equipped and

staffed for lifesaving and transporting the sick or injured.
42
Ambulance Air
or Water
An air or water vehicle specifically designed, equipped

and staffed for lifesaving and transporting the sick or
injured.
Unassigned
N/A
31
35-40
43-48
Page E4

Place of
Service
Code(s)
Place of Service
Name
49
Independent
Clinic
A location, not part of a hospital and not described by

any other Place of Service code, that is organized and
operated to provide preventive, diagnostic, therapeutic,
rehabilitative, or palliative services to outpatients only.
(effective 10/1/03)
50
Federally
Qualified Health
Center
A facility located in a medically underserved area that

provides Medicare beneficiaries preventive primary
medical care under the general direction of a physician.
51
A facility that provides inpatient psychiatric services for

Inpatient
the diagnosis and treatment of mental illness on a 24Psychiatric Facility
hour basis, by or under the supervision of a physician.
Psychiatric
Facility-Partial
Hospitalization
A facility for the diagnosis and treatment of mental

illness that provides a planned therapeutic program for
patients who do not require full time hospitalization, but
who need broader programs than are possible from
outpatient visits to a hospital-based or hospital-affiliated
facility.
53
Community
Mental Health
Center
A facility that provides the following services: outpatient

services, including specialized outpatient services for
children, the elderly, individuals who are chronically ill,
and residents of the CMHC's mental health services area
who have been discharged from inpatient treatment at a
mental health facility; 24 hour a day emergency care
services; day treatment, other partial hospitalization
services, or psychosocial rehabilitation services;
screening for patients being considered for admission to
State mental health facilities to determine the
appropriateness of such admission; and consultation and
education services.
54
A facility which primarily provides health-related care

Intermediate Care
and services above the level of custodial care to mentally
Facility/Mentally
retarded individuals but does not provide the level of
Retarded
care or treatment available in a hospital or SNF.
52
Page E5

Place of
Service
Code(s)
Place of Service
Name
55
A facility which provides treatment for substance

(alcohol and drug) abuse to live-in residents who do not
Residential
require acute medical care. Services include individual
Substance Abuse
and group therapy and counseling, family counseling,
Treatment Facility
laboratory tests, drugs and supplies, psychological
testing, and room and board.
56
Psychiatric
Residential
Treatment Center
57
A location which provides treatment for substance

Non-residential
(alcohol and drug) abuse on an ambulatory basis.
Substance Abuse Services include individual and group therapy and
Treatment Facility counseling, family counseling, laboratory tests, drugs and
supplies, and psychological testing.
58-59
A facility or distinct part of a facility for psychiatric care

which provides a total 24-hour therapeutically planned
and professionally staffed group living and learning
environment.
Unassigned
N/A
Mass
Immunization
Center
A location where providers administer pneumococcal

pneumonia and influenza virus vaccinations and submit
these services as electronic media claims, paper claims,
or using the roster billing method. This generally takes
place in a mass immunization setting, such as, a public
health center, pharmacy, or mall but may include a
physician office setting.
61
Comprehensive
Inpatient
Rehabilitation
Facility
A facility that provides comprehensive rehabilitation

services under the supervision of a physician to
inpatients with physical disabilities. Services include
physical therapy, occupational therapy, speech
pathology, social or psychological services, and orthotics
and prosthetics services.
62
Comprehensive
Outpatient
Rehabilitation
Facility
A facility that provides comprehensive rehabilitation

services under the supervision of a physician to
outpatients with physical disabilities. Services include
physical therapy, occupational therapy, and speech
pathology services.
Unassigned
N/A
60
63-64
Page E6

Place of
Service
Code(s)
65
66-70
Place of Service
Name
End-Stage Renal
A facility other than a hospital, which provides dialysis
Disease
treatment, maintenance, and/or training to patients or
Treatment Facility caregivers on an ambulatory or home-care basis.
Unassigned
N/A
71
Public Health
Clinic
A facility maintained by either State or local health

departments that provides ambulatory primary medical
care under the general direction of a physician.
72
A certified facility which is located in a rural medically

Rural Health Clinic underserved area that provides ambulatory primary
medical care under the general direction of a physician.
73-80
Unassigned
N/A
81
Independent
Laboratory
A laboratory certified to perform diagnostic and/or

clinical tests independent of an institution or a
physician's office.
82-98
Unassigned
N/A
Other Place of
Service
Other place of service not identified above.
99
Page E7

NCPDP D.0

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

NCPDP D.0

Caricato da

Copyright:

Formati disponibili

West Virginia Medicaid

Pharmacy Point-of-Sale (POS)

Vendor Specification Document NCPDP D.0 January 2012

INTENDED AUDIENCE ................................................................................................ 3

CLARIFICATION OF TERMS ......................................................................................... 4

System Description ................................................................................................... 4

RESTRICTIONS AND QUALIFICATIONS ........................................................................ 5

POLICIES AFFECTING SUBMISSIONS ........................................................................... 6

HEALTH PAS-RX ENROLLMENT PROCEDURES ............................................................. 7

SYSTEM SOFTWARE VENDOR ENROLLMENT .............................................................. 7

PROVIDER ENROLLMENT ........................................................................................... 7

HELP INFORMATION ................................................................................................. 8

POS Technical support help desk ............................................................................... 8

POS Claims and PA Help Desk .................................................................................... 8

TRANSACTION FORMATS .......................................................................................... 8

APPENDIX A PROVIDER TRADING PARTNER AGREEMENT .................................................. A1

NCPDP VERSION D.0 PAYER SHEET B1/B2 TRANSACTIONS .................................... B2

BILLING TRANSACTION B1 .................................................................................... B2

PAID (or Duplicate of Paid) Response ..................................................................... B8

Claim Reject Response Transmission Rejected/Transaction Rejected ................. B11

Claim Reject Response Transmission Accepted/Transaction Rejected................. B12

CLAIM REVERSAL TRANSACTION B2 ................................................................... B14

Claim Reversal Response Accepted OR Duplicate of Reversed ............................ B15

Claim Reversal Response - Rejected...................................................................... B17

NCPDP VERSION D.0 PAYER SHEET E1 TRANSACTIONS ........................................ B19

ELIGIBILITY VERIFICATION REQUEST ...................................................................... B19

ELIGIBILITY VERIFICATION RESPONSE - Accepted .................................................. B20

ELIGIBILITY VERIFICATION - Rejected ..................................................................... B20

APPENDIX C EDITS AND MESSAGES ................................................................................... C1

Vendor Specification Document NCPDP D.0 January 2012

Health PAS-Rx Support Group

Revision Revision Description

Changed Route of Administration to be an

Vendor Specification Document NCPDP D.0 January 2012

The purpose of this manual is to provide information necessary to electronically submit

Vendor Specification Document NCPDP D.0 January 2012

Vendor Specification Document NCPDP D.0 January 2012

RESTRICTIONS AND QUALIFICATIONS

The following restrictions or qualifications apply:

Vendor Specification Document NCPDP D.0 January 2012

POLICIES AFFECTING SUBMISSIONS

Vendor Specification Document NCPDP D.0 January 2012

HEALTH PAS-RX ENROLLMENT PROCEDURES

Vendor Specification Document NCPDP D.0 January 2012

Vendor Specification Document NCPDP D.0 January 2012

Vendor Specification Document NCPDP D.0 January 2012

APPENDIX A PROVIDER TRADING PARTNER AGREEMENT

Vendor Specification Document NCPDP D.0 January 2012

APPENDIX B NCPDP D.0 TRANSACTION SET INFORMATION

Vendor Specification Document NCPDP D.0 January 2012

B1 NCPDP VERSION D.0 PAYER SHEET B1/B2 TRANSACTIONS

NCPDP Field Name

Service Provider ID Qualifier

Insurance Segment: Mandatory

NCPDP Field Name

NCPDP Field Name

Patient Gender Code

Patient First Name

Patient Segment: Required

Vendor Specification Document NCPDP D.0 January 2012

NCPDP Field Name

Claim Segment: Mandatory

NCPDP Field Name

Dispense As Written (DAW)/Product