Medicare - Pharmacies - E1: 12/01/06

Note: If a "Value" contains quotation marks around it, then the value are literal characters that must be included in the transaction. If a "Value" is listed but does not contain quotation marks, then the value is an example.

M= Mandatory | O = Optional | R= Required

E1: 12/01/06 Request for Part D

Transaction Header Segment: Mandatory Segment
Field	Field Name	Value	Comments
1Ø1-A1	BIN NUMBER	“011727”	M – Facilitator BIN
1Ø2-A2	VERSION/RELEASE NUMBER	" 51"	M – 5.1 Transaction Format
1Ø3-A3	TRANSACTION CODE	"E1"	M – Eligibility Verification
1Ø4-A4	PROCESSOR CONTROL NUMBER	“2222222222”	M – Must be as indicated for E1:12/01/06
1Ø9-A9	TRANSACTION COUNT	"1"	M – One occurrence
2Ø2-B2	SERVICE PROVIDER ID QUALIFIER	"Ø7"	M – NCPDP Provider ID of Requesting Pharmacy
2Ø1-B1	SERVICE PROVIDER ID	1234567bbbbbbbb	M – Left justified, space filled
4Ø1-D1	DATE OF SERVICE	20060101	M – Must be within 90 days of current date
11Ø-AK	SOFTWARE VENDOR/CERTIFICATION ID	bbbbbbbbbb	M

Patient Segment: Required for Proper Matching

Field

Field Name

Value

Comments

111-AM

SEGMENT IDENTIFICATION

“01”

M – PATIENT SEGMENT

3Ø4-C4

DATE OF BIRTH

19400615

R – Born June 16, 1940

3Ø5-C5

PATIENT GENDER CODE

1

R – Male

31Ø-CA

PATIENT FIRST NAME

JOHN

R

311-CB

PATIENT LAST NAME

DOE

R

325-CP

PATIENT ZIP/POSTAL ZONE

34567

R – Zip Code (5 digit zip)

Note: Other optional fields not shown in these segments are not used.

Insurance Segment: Mandatory Segment

Field

Field Name

Value

Comments

111-AM

SEGMENT IDENTIFICATION

“Ø4”

M – INSURANCE SEGMENT

3Ø2-C2

CARDHOLDER ID

998877665

M – Must include one of the following:
– ID from Medicare Part A card
– ID from Medicare Part B card
– Last 4 digits of the SSN
– Full SSN
– Railroad Board Number

E1: 12/01/06 Response: Accepted for Part D

The Facilitator sends this response when the data provided in the E1 Request enables the Facilitator to find exactly one matching patient who has Part D coverage that is active on the requested Date of Service.

Response Header Segment: Always Returned by Facilitator
Field	Field Name	Value	Comments
1Ø2-A2	VERSION/RELEASE NUMBER	"51"	M – 5.1 Transaction Standard
1Ø3-A3	TRANSACTION CODE	"E1"	M – Eligibility Verification
1Ø9-A9	TRANSACTION COUNT	"1"	M – One occurrence
5Ø1-F1	HEADER RESPONSE STATUS	"A"	M – Accepted
2Ø2-B2	SERVICE PROVIDER ID QUALIFIER	"Ø7"	M – NCPDP Provider ID
2Ø1-B1	SERVICE PROVIDER ID	4563663bbbbbbbb	M – Contains the same value provided in the Request
4Ø1-D1	DATE OF SERVICE	ccyymmdd	M – i.e., 20060101 Contains the same value provided in the Request

Response Message Segment: Always Returned by Facilitator
Field	Field Name	Value	Comments
111-AM	SEGMENT IDENTIFICATION	“20”	M – RESPONSE STATUS SEGMENT
5Ø4-F4	MESSAGE	E1:12/01/06 standardized response	R – Always contains Patient info and Part D info; different content and format than E1:11/15/05. See later “Accepted (Matched) Response Message Information Block Formats” topic for details.

Mandatory Segment
Response Status Segment: Always Returned by Facilitator
Field	Field Name	Value	Comments
111-AM	SEGMENT IDENTIFICATION	“21”	M – RESPONSE STATUS SEGMENT
112-AN	TRANSACTION RESPONSE STATUS	"A"	M – Approved
526-FQ	ADDL MESSAGE INFORMATION		R – Always contains OHI info; different content and format than E1:11/15/05; contains at least Field ID tags even if no OHI coverage See later “Accepted (Matched) Response Message Information Block Formats” topic for details.
549-7F	HELP DESK PHONE NUMBER QUALIFIER	"99"	R – Medicare (CMS) will support these calls.
55Ø-8F	HELP DESK PHONE NUMBER	”8006334227”	R – Medicare (CMS) Help Desk Number
Note: Other optional fields not shown in these segments are not used.

E1: 12/01/06 Response: Rejected for Part D

The Facilitator sends this response when the data provided in the E1 Request does not enable the Facilitator to find one unique patient.

M= Mandatory | O = Optional | R= Required

Response Header Segment: Mandatory Segment
Field	Field Name	Value	Comments
1Ø2-A2	VERSION/RELEASE NUMBER	"51"	M – 5.1 Transaction Standard
1Ø3-A3	TRANSACTION CODE	"E1"	M – Eligibility Verification
1Ø9-A9	TRANSACTION COUNT	"1"	M – One occurrence
5Ø1-F1	HEADER RESPONSE STATUS	"A"	M – Accepted
2Ø2-B2	SERVICE PROVIDER ID QUALIFIER	"Ø7"	M – NCPDP Provider ID
2Ø1-B1	SERVICE PROVIDER ID	4563663bbbbbbbb	M – Contains the same value provided in the Request.
4Ø1-D1	DATE OF SERVICE	ccyymmdd	M – i.e., 20060101 Contains the same value provided in the Request

Response Message Segment: Always Returned by Facilitator
Field	Field Name	Value	Comments
111-AM	SEGMENT IDENTIFICATION	“20”	M – RESPONSE STATUS SEGMENT
5Ø4-F4	MESSAGE	See “Non-Matched Reject Codes and Messages” section	R – Varies; four different types depending on reject reason. See “Reject Codes and Messages” topic for details.

Response Status Segment: Always Returned by Facilitator
Field	Field Name	Value	Comments
111-AM	SEGMENT IDENTIFICATION	“21”	M – Response Status Segment
112-AN	TRANSACTION RESPONSE STATUS	"R"	M – Rejected
51Ø-FA	REJECT COUNT	"1"	R
511-FB	REJECT CODE	See “Non-Matched Reject Codes and Messages” section	R – Varies; three different codes depending on reject reason. See “Reject Codes and Messages” topic for details
526-FQ	ADDL MESSAGE INFORMATION		O – Used for overflow from 5Ø4-F4, if needed (need for overflow not expected)
549-7F	HELP DESK PHONE NUMBER QUALIFIER	"99"	R – Medicare (CMS) is going to support these calls.
55Ø-8F	HELP DESK PHONE NUMBER	”8006334227”	R – Medicare (CMS) Help Desk Number
Note: Other optional fields not shown in these segments are not used.

Accepted (Matched) Response Message Information Block Formats

Accepted (Matched) Message General Structure

An Accepted (Matched) Eligibility Response uses a standardized format to embed parsable data in the Message Information (5Ø4-F4) and Additional Message Information (526-FQ) text blocks. This structured information uses the format described in the next two topics, “Message Information Block 5Ø4-F4 (Patient and Part D Plan Information)” and “Additional Message Information Block 526-FQ (Other Insurance Information).” This format complies with the following rules:

Each data field within the message blocks will be fixed length (as specified in the next two topics).
Each data value will be left-justified within its field and right-padded with blanks (b) as needed to fill out the specified field length.
To aid in readability, each data field will be preceded by a Field ID (such as GP for Group ID). A colon “:” separates the field ID from the actual data value.
There is no truncation. All fields will be sent padded to their full length as appropriate.
Message field (5Ø4-F4) must always begin with Patient Information Section, followed by current Part D processor information, and then the first occurrence of any known Future Part D coverage.
Additional Message Information (526-FQ) contains other coverage information (COB).

Important: Unlike the E1:11/15/05 Response format, which uses delimited variable length formatting and variable segment sequencing, the E1:12/01/06 format uses fixed length fields in a fixed sequence and thus does not use section or field delimiters (& and ; characters respectively in E1:11/15/05).

Message Information Block 5Ø4-F4 (Patient and Part D Plan Information)

This block contains basic patient information, current Part D Plan information, and information about the first instance of any future Part D coverage. The Data Start indicates the physical start of the actual value and the preceding 3 characters indicate the field ID. The Data Length is the actual length of the data exclusive of the data. Key: b=blank

Section or Field Name	Field ID	Data Start	Data Length	Example	Comments
Patient Information	This section always starts the first message block (5Ø4-F4).
Last Name	LN:	4	13	SMITHbbbbbbbb
First Name	FN:	2Ø	1Ø	SAMANTHAbb
Date of Birth	BD:	33	8	194ØØ515	Format: CCYYMMDD
Part D Information	This section is always in the first message block (5Ø4-F4). Any coverage primary and/or secondary to Part D appears in the additional message block (526-FQ).
Level	PD:	44	1	1	Level (i.e. claim sequence), where Ø is primary, 1 is secondary, etc.
BIN	BN:	48	6	123456
PCN	PN:	57	1Ø	987654321Ø
Group	GP:	7Ø	15	ABCDEFGHIJKLMNO
Cardholder ID	ID:	88	2Ø	123456789Ø12345bbbbb
Person Code	PC:	111	3	123
Help Desk #	PH:	117	1Ø	8ØØ5551212	Format=AAAEEENNNN AAA=Area Code EEE=Exchange CodeNNNN=Number
Contract ID	CD:	13Ø	6	123456
PBP (Prescription Benefit Plan)	PB:	139	3	123
Effective Date	ED:	145	8	2ØØ6Ø1Ø1	Format: CCYYMMDD
Termination Date	TD:	156	8	2ØØ7Ø1Ø1	Format: CCYYMMDD
CMS Low-Income Cost Sharing (LICS) Level	LC:	167	1	Y	Values: Y=Yes, N=No
Formulary ID	FI:	171	8	12345678
Future Part D	This section reflects next part D coverage, if any, after current coverage. If no future coverage exists, will contain only the Field IDs followed by 8 blanks each.
Next Medicare Part D Effective Date	FE:	182	8	2ØØ7Ø1Ø1	Format: CCYYMMDD
Next Medicare Part D Termination Date	FT:	193	8	2ØØ71231	Format: CCYYMMDD

Additional Message Information Block 526-FQ (Other Insurance Information)

This block contains information on and up to two additional coverage plans that act in coordination with the Part D Plan. The Data Start indicates the physical start of the actual value and the preceding 3 characters indicate the field ID. The Data Length is the actual length of the data exclusive of the data. Key: b=blank

Section or Field Name	Field ID	Data Start	Data Length	Example	Comments
Other Health Information (first other coverage plan)	If no such plan exists, all Field IDs will still be present but the data fields will be entirely blank.
Level	OH:	4	1	Ø	Level (i.e. claim sequence), where Ø is primary, 1 is secondary, etc.
BIN	BN:	8	6	987654
PCN	PN:	17	1Ø	987654321Ø
Group	GP:	3Ø	15	ONMLKJIHGFEDCBA
Cardholder ID	ID:	48	2Ø	987654321Ø98765bbbbb
Person Code	PC:	71	3	123
Relationship Code	RC:	77	1	1
Help Desk #	PH:	81	1Ø	8ØØ5551212	Format=AAAEEENNNN AAA=Area Code EEE=Exchange CodeNNNN=Number
Other Health Information (second other coverage plan)	If no such plan exists, all Field IDs will still be present but the data fields will be entirely blank.
Level	OH:	94	1	2	Level (i.e. claim sequence), where Ø is primary, 1 is secondary, etc.
BIN	BN:	98	6	765432
PCN	PN:	1Ø7	1Ø	987654321Ø
Group	GP:	12Ø	15	ONMLKJIHGFEDCBA
Cardholder ID	ID:	138	2Ø	987654321Ø98765bbbbb
Person Code	PC:	161	3	123
Relationship Code	RC:	167	1	1
Help Desk #	PH:	171	1Ø	8ØØ5551212	Format=AAAEEENNNN AAA=Area Code EEE=Exchange CodeNNNN=Number

Approved Response Message Text Field Examples

Note: Bolding added below to highlight Field IDs in examples only – not bolded in actual response.

Key: b=blank

Example 1: An Eligibility Accepted With Single PART D Payer

Message (5Ø4-F4)

LN:SMITHbbbbbbbbFN:SAMANTHAbbBD:194ØØ515PD:ØBN:123456PN:987654321ØG
P:ABCDEFGHIJKLMNOID:123456789Ø12345bbbbbPC:123PH:8ØØ5551212CD:12345
6PB:123ED:2ØØ6Ø1Ø1TD:2ØØ7Ø1Ø1LC:YFI:12345678FE:bbbbbbbbFT:bbbbbbbb

Additional Message (526-FQ)

OH:bBN:bbbbbbPN:bbbbbbbbbbGP:bbbbbbbbbbbbbbbID:bbbbbbbbbbbbbbbbbbbb
PC:bbbRC:bPH:bbbbbbbbbbOH:bBN:bbbbbbPN:bbbbbbbbbbGP:bbbbbbbbbbbbbbb
ID:bbbbbbbbbbbbbbbbbbbbPC:bbbRC:bPH:bbbbbbbbbb

Example 2: An Eligibility Accepted With Primary Part D and secondary other

Additional Message (526-FQ)

OH:1BN:987654PN:987654321ØGP:ONMLKJIHGFEDCBAID:987654321Ø98765bbbbb
PC:123RC:1PH:8ØØ5559999OH:bBN:bbbbbbPN:bbbbbbbbbbGP:bbbbbbbbbbbbbbb
bID:bbbbbbbbbbbbbbbbbbbbPC:bbbRC:bPH:bbbbbbbbbb

Example 3: An Eligibility Accepted With Primary Other Health Insurance, Secondary Current Part D, and Future Part D

Message (5Ø4-F4)

LN:SMITHbbbbbbbbFN:SAMANTHAbbBD:194ØØ515PD:1BN:123456PN:987654321ØG
P:ABCDEFGHIJKLMNOID:123456789Ø12345bbbbbPC:123PH:8ØØ5551212CD:12345
6PB:123ED:2ØØ6Ø1Ø1TD:2ØØ7Ø1Ø1LC:NFI:12345678FE:2ØØ7Ø1Ø1FT:2ØØ8Ø1Ø1

Additional Message (526-FQ)

OH:ØBN:987654PN:987654321ØGP:ONMLKJIHGFEDCBAID:987654321Ø98765bbbbb
PC:123RC:1PH:8ØØ5559999OH:bBN:bbbbbbPN:bbbbbbbbbbGP:bbbbbbbbbbbbbbb
ID:bbbbbbbbbbbbbbbbbbbbPC:bbbRC:bPH:bbbbbbbbbb

Example 4: An Eligibility Accepted With Primary Part D, Secondary Other Health Insurance, and Tertiary Other Health Insurance:

Note. The PCN for the Part D does not exist

Message (5Ø4-F4)

LN:SMITHbbbbbbbbFN:SAMANTHAbbBD:194ØØ515PD:ØBN:123456PN:bbbbbbbbbbG
P:ABCDEFGHIJKLMNOID:123456789Ø12345bbbbbPC:123PH:8ØØ5551212CD:12345
6PB:123ED:2ØØ6Ø1Ø1TD:2ØØ7Ø1Ø1LC:YFI:12345678FE:bbbbbbbbFT:bbbbbbbb

Additional Message (526-FQ)

OH:1BN:987654PN:987654321ØGP:ONMLKJIHGFEDCBAID:987654321Ø98765bbbbb
PC:123RC:1PH:8ØØ5559999OH:2BN:876543PN:87654321Ø1GP:NMLKJIHGFEDCBAZ
ID:87654321Ø987654321Ø9PC:231RC:2PH:8ØØ5558888

Reject Codes and Messages

Reject Message General Structure

A Reject (Non-Matched) Eligibility Response complies with the following general rules:

The Reject Code field (511-FB) will contain an appropriate reject code based on the cause of the reject (see table below).
The Message field (5Ø4-F4) will contain appropriate descriptive rejection information; this will be a free text message that does not contain parsable information (see table below).
If needed, overflow rejection information can be placed in Additional Message Information (526-FQ). However, such an overflow is highly unlikely.

Reject Conditions and Associated Codes and Messages

The Facilitator system will return the following reject codes and messages for each condition listed:
Condition	Reject Code	Reject Message	Comments
More than one patient found	"62"	“MORE THAN ONE PATIENT FOUND. THE FOLLOWING FIELDS COULD CAUSE A UNIQUE MATCH: ” + FieldListing	FieldListing is a list of the field names that are not the same across all of the found patients.
Full Cardholder ID matches exactly but first 4 characters of Last Name do not match	"62"	“PATIENT NOT FOUND: CARDHOLDER ID MATCHED BUT LAST NAME DID NOT”
Patient not found	"52":	“NO PATIENT MATCH FOUND”
Patient found but Part D coverage is not active during the submitted Date of Service	"65":	“PATIENT FOUND BUT PART D COVERAGE OUTSIDE SUBMITTED DATE OF SERVICE.”

Rejected Response Message Text Field Examples

Key: b=blank

Example 5: Eligibility Rejected Response resulting from duplicate matches

Reject Code (511-FB) will be “62 “ (Patient/Cardholder ID Name Mismatch)

Message (5Ø4-F4)

MORE THAN ONE PATIENT FOUND. THE FOLLOWING FIELDS COULD CAUSE A UNIQUE MATCH: DATE OF BIRTH, FIRST NAME

Note: This is example only – the actual list after “THE FOLLOWING FIELDS COULD CAUSE A UNIQUE MATCH:” will vary depending on which fields differ across all of the found patients.

Example 6: Eligibility Rejected Response resulting from Cardholder ID matching but first 4 characters of Last Name not matching

Reject Code (511-FB) will be “62 “ (Patient/Cardholder ID Name Mismatch)

Message (5Ø4-F4)

PATIENT NOT FOUND-CARDHOLDER ID MATCHED BUT LAST NAME DID NOT

Example 7: Eligibility Rejected Response resulting from inability to match the supplied request data to the database

Reject Code (511-FB) will be “52 “ (Non-matched Cardholder ID)

Message (5Ø4-F4)

NO PATIENT MATCH FOUND

Example 8: Eligibility Rejected Response resulting from a found patient not having active Part D coverage on the Date of Service submitted but subsequent coverage exists

Reject Code (511-FB) will be “65 “ (Patient Not Covered)

Message (5Ø4-F4)

PATIENT FOUND BUT PART D COVERAGE OUTSIDE SUBMITTED DATE OF SERVICE

Example 9: Eligibility Rejected Response resulting from a found patient not having active Part D coverage on the Date Of Service submitted and no subsequent coverage exists

Reject Code (511-FB) will be “65 “ (Patient Not Covered)

Message (5Ø4-F4)

PATIENT FOUND BUT PART D COVERAGE OUTSIDE SUBMITTED DATE OF SERVICE