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NCPDP Payer Sheet Guidelines

April 7, 2011

Pharmacies must follow these guidelines when submitting claims with multiple payers that require coordination of benefits from more than one health plan/payer. Retain other payer denial reasons documentation to support your MHCP billing.

Complete the following fields to report Other Coverage Code 02 (other coverage exists & payment was collected)

Field

Field Name

Definition/Instruction

308-C8

Other Coverage Code

Enter code 02: payment was made by other payer

337-4C

Coordination of Benefits payment counts

Enter number of payments made on this claim.

338-5C

Other payer coverage type

Code identifying the payer as, Primary, Secondary or Tertiary

339-6C

Other payer ID Qualifier

Qualifier used to describe the other payer ID. DHS requires you to use the code (99) for “Other” or (03) for “BIN”

340-7C

Other Payer ID

Use any number you want to identify the other payer until standard payer IDs are issued.

341-HB

Other payer amount paid count

Number of payments made on this claim.

342-HC

Other payer amount paid qualifier

Enter code 07 or 08 to identify the TPL payment.

431-DV

Other payer amount paid

Amount of payment made on this claim

Complete the following fields to report Other Coverage Code 04 (other coverage exists, no payment was made and you are billing for more than copay only)

Field

Field Name

Definition/Instruction

308-C8

Other Coverage Code

Enter code 04: other coverage paid $0.00; billing for more than copay

337-4C

Coordination of Benefits payment counts

Enter number of paid occurrences even if paid $0.00

338-5C

Other payer coverage type

Code identifying the payer as, Primary, Secondary or Tertiary

339-6C

Other payer ID Qualifier

Qualifier used to describe the other payer ID. DHS requires you to use the code (99) for “Other” or (03) for “BIN”

340-7C

Other Payer ID

Use any number you want to identify the other payer until standard payer IDs are issued.

341-HB

Other payer amount paid count

Number of payments made on this claim

342-HC

Other payer amount paid qualifier

Code 07 or 08 qualifying other payer amount paid

431-DV

Other payer amount paid

Enter 0 (zero dollar amount)

Complete the following fields to report Other Coverage Code 08 (billing for copay only)

Field

Field Name

Definition/Instruction

308-C8

Other Coverage Code

Enter code 08: billing for copay only

337-4C

Coordination of Benefits payment counts

Enter number of payments made on this claim if a payment is made by the other payer

338-5C

Other payer coverage type

Code identifying the payer as, Primary, Secondary or Tertiary

339-6C

Other payer ID Qualifier

Qualifier used to describe the other payer ID. DHS requires you to use the code (99) for “Other” or (03) for “BIN”

340-7C

Other Payer ID

Use any number you want to identify the other payer until standard payer IDs are issued.

341-HB

Other payer amount paid count

Number of payments made on this claim.

342-HC

Other payer amount paid qualifier

Code (99) qualifying other payer amount paid

431-DV

Other payer amount paid

Amount of payment made on this claim

430-DU

Gross Amount Due

Enter copay amount

478-H7

Other Amount Claimed Submitted Count

Number of copays made on claim

479-H8

Other Amount Claimed Submitted Qualifier

Qualifier (99) used to describe the Other Amount Claimed Submitted

480-H9

Other Amount Claimed Submitted

Enter Copay Amount

Other Coverage Denial Codes

03: Other coverage exists-this claim not covered

05: Managed Care denial

06: Other coverage denied-not a participating provider

07: Other coverage exists-not in effect at time of service

Complete the following fields to report the denial:

Field

Field Name

Definition/Instruction

308-C8

Other Coverage Code

Code indicating if other coverage exist and if the other payer denied this claim

337-4C

Coordination of Benefits/Other Payments Counts

Number of denied occurrences made on this claim

338-5C

Other payer coverage type

Code identifying the payer as, Primary, Secondary or Tertiary

339-6C

Other payer ID Qualifier

Qualifier used to describe the other payer ID DHS requires you to use the code (99) for “Other” or (03) for “BIN”

341-HB

Other payer amount paid count

Leave blank when no payment is made

342-HC

Other payer amount paid qualifier

Code 07 or 08, qualifying other payer amount paid

431-DV

Other payer amount paid

Amount of payment made on this claim

471-5E

Other payer reject count

Number of reject codes provided by the Other payer

472-6E

Other payer reject code. Up to 3 codes allowed

NCPDP reject codes supplied by the other payer

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