GENERAL INFORMATION

PRESCRIBER ROUTING V10.6 CERTIFICATION TEST SCENARIOS

BASED ON PRESCRIPTION ROUTING 10.6 IG 2013-05-01 AND APPLICATION CERTIFICATION REQUIREMENTS 2013-05-01
Copyright 2013 Surescripts, LLC. All rights reserved.
Information in this document is subject to change without notice. This document is the property of Surescripts, LLC, and contains information that
is proprietary and confidential. Surescripts is a registered trademark of Surescripts, LLC. The Surescripts logo is a trademark of Surescripts, LLC.
All other trademarks are the property of their respective owners.
This document and all other documents, materials, or other information of any kind transmitted or orally communicated by Surescripts (or its
members) in the course of the parties dealings constitute and are hereby designated as confidential and proprietary information of Surescripts for
purposes of the Confidentiality Agreement entered into by Surescripts and the recipient and are intended by Surescripts to be, and shall be
deemed to be, Proprietary Information under such Confidentiality Agreement.
Disclaimer:
These test cases include negative tests, which are for the testing purpose only. Participants are advised not make any changes to their
application based on these negative test scenarios. On each test case, the fields used for negative testing are marked in RED. For example, one
of the test cases instructs you to not send the patient's Date of Birth in a NEWRX message (DOB is a required field). This is only to ensure that
the application will prevent any message from being sent without DOB.
Participant applications are required to meet with all the requirements in the Implementation Guide.
Special characters: XML escapes certain special characters while sent in a message. Vendors shall test their application's ability to handle
these escaped characters and all other special characters while being sent and received in the message.
All patient Dates of Birth are provided in the following format: MM-DD-YYYY.
NDC's provided are for example purposes only. Participants may chose any valid NDC for the given drug during testing.
Surescripts test cases do not cover all possible scenarios in production. Certification participants are responsible for QA and testing all
scenarios specific to their production environment.
Participants must successfully compete certification testing for New and Renewal messages before beginning CancelRx certification testing.

Participants must prepare the following before beginning certification testing:

1) Please register the following prescribers:
A. Test prescriber with NPI
B. Test prescriber with NPI and DEA (with controlled substance service level, if supported).
2) Create the free text long drug name as described in Test case 4. If free text medications are not supported in your application, please find the
longest drug name from your database, preferably including some special characters.
PARTICIPANT CERTIFICATION TEST SCENARIOS. SURESCRIPTS CONFIDENTIAL AND PROPRIETARY. NOT TO BE COPIED OR
DISTRIBUTED.

Please only use the following Surescripts 10.6 Test Pharmacies:

Pharmacy Name
CA Pharmacy 10.6MU

NCPDP
ID
9911557

Mail Order Pharmacy 10.6MU

2323239

Mail Order Pharmacy 10.6MU NOCS

1629900

1356606818 New, Refill, Change, Cancel

1629-90 Supply Ln

Saint Louis

MO

63105

(314) 555-3142

NYC Pharmacy 10.6MU

TX Pharmacy 10.6MU

1120188
1367084

1013988328 New, Refill, Change, Cancel

1366629743 New, Refill, Change, Cancel,
ControlledSubstance

88 Park Street
W136 N7084 Texans Way

Brooklyn
Houston

NY
TX

11201
77001

(718) 555-7181
(832) 555-8232

VA Pharmacy 10.6MU

7723703

1083879860 New, Refill, Change, Cancel,

ControlledSubstance

7723 Jefferson Davis Hwy

Arlington

VA

22202

(703) 555-7034

10Dot6 Pharmacy Store1 MU Long

Name

3105551

1700134780 New, Refill, Change, Cancel,

ControlledSubstance

56789 Long Pharmacy Name

for 10.6MU

ReallyLongCityName
ForPharmacy
106MU

CA

Arlington

VA

Test 000 Pharmacy 10.6MU

0001060

NPI

Service Level

Address

City

1801849179 New, Refill, Change, Cancel,

ControlledSubstance
1538460530 New, Refill, Change, Cancel,
ControlledSubstance

65432 Cabernet Turn

1356609333 New, Refill, Change, Cancel,

ControlledSubstance

State

Zip

Sonoma

CA

95476

(707) 555-7071

9292 Langley Rd

Phoenix

AZ

85001

(623) 555-2323

1234 Long Address Line 2 for

10.6MU
000 Pending Response Way

Phone #

90009-8989 (310) 5553105x123456789

22201

(703) 555-1234

Purpose: To test the ability of the Prescriber vendor to:

1. Create and send a cancel request message for a new prescription;
2. Receive a Cancel response message and process.

INSTRUCTIONS TO PARTICIPANT:
Please create a NEWRX using the following profile. Create a Cancel request message following the NewRx.

NEW RX 1 & CANCEL REQUEST 1.1

Patient Demographics:
First Name: Ci
Last Name: Li
Prefix: Mr
Gender: Male
Date Of Birth: 10-18-1923
Medication:
Drug Description: ZIOPTAN .0015% Ophthalmic Solution
NDC: 00006393130
Medication Quantity: 1
Potency Unit Code: Carton
Substitutions: Allowed
Refill Quantity: 0
Directions: D
Pharmacy: VA Pharmacy 10.6MU (NCPDP 7723703)

CANCEL RESPONSE 2.1 - PHARMACY WILL SEND AN APPROVED CANCEL RESPONSE MESSAGE INDICATING NO
DISPENSES HAVE BEEN MADE
1) Receive the Cancel response message and process;
2) Display Notes received in Cancel response message (if supported);
3) Update patient's medication chart (if supported).

Purpose: To test the ability of the Prescriber vendor to:

1. Create and send a cancel request message for an existing prescription;
2. Receive a Cancel response message and process.

INSTRUCTIONS TO PARTICIPANT:
Please create a NEWRX using the following profile. Create a Cancel request message following the NewRx.

NEW RX 2 & CANCEL REQUEST 1.2

Patient Demographics:
File ID: 6532865
Prefix: Ms
First Name: Debra
Last Name: Tucker
Gender: Female
Date Of Birth: 01-11-1970
Address Line 1: 8331 Everwood Dr.
Address Line 2: Apt 342
City: Cleveland
State: OH
Zip Code: 44103
Day Time Phone: 4408450398
Medication:
Drug Description: Accuneb 1.25MG/3ML Inhalant Solution
NDC: 49502069303
Medication Quantity: 75.555
Potency Unit Code: Milliliter
Substitutions: Allowed
Refill Qualifier: 5
Directions: Inhale one unit every 4-6 hours via nebulizer or as necessary for wheezing
Notes: Patient has discontinued use of other inhalers.
Written Date: Today's date
Pharmacy: TX Pharmacy 10.6MU (NCPDP 1367084)

CANCEL RESPONSE 2.2 - PHARMACY WILL SEND AN APPROVED CANCEL RESPONSE MESSAGE INDICATING HOW MANY
DISPENSES HAVE BEEN MADE
1) Receive the Cancel response message and process;
2) Display Notes received in Cancel response message (if supported);
3) Update patient's medication chart (if supported).

Purpose: To test the ability of the Prescriber vendor to:

1. Create and send a cancel request message for an existing prescription;
2. Receive a Cancel response message and process.

INSTRUCTIONS TO PARTICIPANT:
Please create a NEWRX using the following profile. Create a Cancel request message following the NewRx.

NEW RX 3 & CANCEL REQUEST 1.3

Patient Demographics:
Prefix: Ms
First Name: Felicia
Middle Name: Ann
Last Name: Flounders
Gender: Female
Date of Birth: 11-01-1980
Address Line 1: 6715 Swanson Ave
Address Line 2: Apt 102
City: Bethesda
State: MD
Zip Code: 20187
Day Time Phone: 3018620035x2345
Night Time Phone: 3019289283
Medication:
Drug Description: Pataday 0.2% Ophthalmic Solution
NDC: 00065027225
Medication Quantity: 1
Potency Unit Code: Bottle
Substitutions: Not allowed
Days Supply: 3
Refill Quantity: 1
Directions: 1 drop in both eyes once a day for 4 weeks, wait 10-15 minutes before contact lens insertion. Shake well.
Notes: This medicine is for topical ophthalmic use only.
Pharmacy: TX Pharmacy 10.6MU (NCPDP 1367084)

CANCEL RESPONSE 2.3 - PHARMACY WILL SEND AN APPROVED CANCEL RESPONSE MESSAGE INDICATING ALL
DISPENSES HAVE BEEN MADE
1) Receive the Cancel response message and process;
2) Display Notes received in Cancel response message (if supported);
3) Update patient's medication chart (if supported).

Purpose: To test the ability of the Prescriber vendor to:

1. Create and send a cancel request message for a new prescription;
2. Receive a Cancel response message and process.

INSTRUCTIONS TO PARTICIPANT:
Please create a NEWRX using the following profile. Create a Cancel request message following the NewRx.

NEWRX 4 and CANCEL REQUEST 1.4

Patient Demographics:
Patient ID - Send two patient qualifiers, one of them can be Mutually defined (ZZ) qualifier and value (if supported)
Last Name : !"#$%'()*+,-/:;=?@[\]^_`{|}~0000&<>
First Name: !"#$%'()*+,-/:;=?@[\]^_`{|}~0000&<>
Middle Name: !"#$%'()*+,-/:;=?@[\]^_`{|}~0000&<>
Suffix : Junior iii
Prefix : Patient II
Gender: Male
Date Of Birth: 01-01-1948
AddressLine1: !"#$%'()*+,-/:;=?@[\]^_`{|}~0000&<>
AddressLine2: !"#$%'()*+,-/:;=?@[\]^_`{|}~0000&<>
City : !"#$%'()*+,-/:;=?@[\]^_`{|}~0000&<> City
State : CO
Zip Code : 803615977
Email: !"#$%'()*+,-/:;=?@[\]^_`{|}~0000&<>@Globaltemec.com
Night Phone: 57192121221234567890x4444
Home Phone: 7034445522x4472
Night Phone: 7034445523x4473
Night Phone: 7034445524x4474
Beeper Number: 7034445525x4475
Cell Phone: 7034445526x4476
Telephone: 7034445527x4477
Fax Number: 7034445528x4478
Patient relationship: if supported
Medication:
DrugDescription: KENALOG-40 40 MG/ML VIAL (Drug Description Field !"#$%'()*+,-/:;=?@[\]^_`{|}~0000&<> Drug Description Field)
(If your application does not allow free text field, please select the longest drug name from your database, preferably including some special characters.)

NDC: NDC appropriate to drug description

Strength: DRU Strength3456789012345678901234567890123456789013245678901234567890
Drug DB Code: Appropriate to Drug database used for application
Drug DB Code Qualifier: Appropriate to Drug database used for application
FormSourceCode: Pharmaceutical Dosage Form
FormCode: Injectable
Strength Source Code: Units of Presentation
StrengthCode: Microgram per Milliliter
Quantity: 12345.12345
Unit Source Code: Potency Unit
Potency Unit code: Vial
Directions: !"#$%'()*+,-/:;=?@[\]^_`{|}~0000&<> Inject 0.5 ML of Kenalog-40 injection intramuscular, daily for 1 wk, then every alternate day 2
weeks
Note: !"#$%'()*+,-/:;=?@[\]^_`{|}~0000&<> THIS IS A TEST MESSAGE PLEASE DISREGARD, THIS IS A TEST MESSAGE PLEASE
DISREGARD. THIS IS A TEST MESSAGE PLEASE DISREGARD **********(10) TESTING MAX LENGTH. PLEASE DISREGARD.
Refills: 99
Days Supply: 999
Substitution: Allowed
Written Date: Todays date
Effective Date: Today's Date
Last Fill Date: 4-1-2011 (repeat as many loops of Date field as supported).
Drug Status Coverage Code: Send as many values as allowed by the application (Can send up to 5 codes)
Drug use evaluation code: repeat as many times as possible.(Can send upto 5 codes)
Diagnosis:
Diagnosis (Primary) : Send Primary diagnosis code if possible
Qualifier: ICD-9
Diagnosis (Secondary) : Send Secondary diagnosis code if possible
Qualifier: ICD-9
Prior Authorization: Send prior authorization code if possible
Qualifier: G1
Please include any other field supported as per the implementation guide (if not already included here).
Pharmacy: 10Dot6 Pharmacy Store1 MU Long Name (NCPDP 3105551)

CANCEL RESPONSE 2.4 - PHARMACY WILL SEND A DENIED CANCEL RESPONSE

1) Receive the Cancel response message and process;
2) Display Notes received in Cancel response message (if supported);
3) Update patient's medication chart (if supported).

THIS TEST CASE IS ONLY APPLICABLE TO PARTICIPANTS CERTIFIED FOR EPCS SERVICE.
Purpose: To test the ability of the Prescriber vendor to:
1. Create and send a cancel request message for a new prescription;
2. Receive a Cancel response message (partial dispenses made by the pharmacy) and process.

INSTRUCTIONS TO PARTICIPANT:
Please create a NEWRX using the following profile. Create a Cancel request message following the NewRx.

NEW RX 5 & CANCEL REQUEST 1.5

Patient Demographics:
First Name: Kara
Last Name: Whiteside
Gender: Female
DOB: 10-11-1952
Address Line 1: 23230 Seaport
City: Akron
State: OH
Zip Code: 44306
Day Time Phone: 3305547754
If certifying on EPCS Services, please use the following medication. Please use PlanX to write the NEWRX.
Drug Description: VICODIN ES 7.5-300 MG TABLET
NDC: 00074304313
Medication Quantity: 10
Potency Unit Code: "Unspecified"
Substitutions: Allowed
Refill Quantity: 2
Directions: Take one tablet three times a day after every meal. Do not take on empty stomach.
Notes: This is a schedule III medication.
Written date: Today's Date
Pharmacy: Mail Order Pharmacy 10.6MU (NCPDP 2323239)

CANCEL RESPONSE 2.5 - PHARMACY WILL SEND AN APPROVED CANCEL RESPONSE MESSAGE INDICATING HOW MANY
DISPENSES HAVE BEEN MADE
1) Receive the Cancel response message and process;
2) Display Notes received in Cancel response message (if supported);
3) Update patient's medication chart (if supported).

Surescripts reserves the right to modify its test cases (PRESCRIBER CancelRx v10.6 Certification Test Scenarios) as needed to
ensure that software offerings can send and receive electronic messages in accordance with the industry standards, safely and
accurately. Surescripts shall notify Participants of any such changes within an adequate timeframe to enable the Participant to
comply with any changes. All notifications shall be sent to the Participants designated point of contact.