NCPDP Payer Sheet Guidelines
Posted: 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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