E1: 11/15/05 - Payer Sheet for Part D

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This section includes the following programmer details:

E1 Specifications

• Request
• Response: Accepted
• Response: Rejected

E1 Message Text Format

• Message Structure
• Records
• Fields
• Examples

E1 Batch Specifications

E1 Specifications for Part D

Request for Part D

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

Response: Accepted for Part D

The Facilitator sends this response when the data provided in the E1 Request enables the Facilitator to find one unique patient.

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.

E1 Message Text Format for Part D

This section defines the structure and meaning of the text included in fields 5Ø4-F4 and 526-FQ when the Facilitator finds a match for data contained in the Eligibility Request from the pharmacy.

Message Structure

The message returned by the Facilitator contains Records and Fields. A Record represents information about one of the patient’s insurance coverage. The Fields represent the details of that coverage.

Records

• A Record represents information about one of the patient’s insurance coverage.
• The last character of every Record is always the ampersand.
• Records repeat if the patient has more than one insurance plan.
• A record cannot be split so that part of it appears in 5Ø4-F4 and the remaining part appears in
  526-FQ.
• Records contain fields that describe the details of the insurance coverage.
  

Fields

• The Field Delimiter always appears before the value of the field.
• The Field Delimiter is always followed by a colon.
• A Field Value is always followed by a semicolon.
  

Examples

Primary Coverage Only

PRIMARY;BN:123456;PN:1234567890;GP:123456789012345;ID:12345678901234567890;
PC:001;PH:8001234567;&

Primary and Secondary Coverage

PRIMARY;BN:123456;PN:1234567890;GP:123456789012345;ID:12345678901234567890;
PC:001;PH:8001234567;&
ADDINS:1;BN:123456;PN:1234567890;GP:123456789012345;ID:12345678901234567890;
PC:001;PH:8001234567;&

Primary, Secondary, and Tertiary Coverage

In this example, Field 5Ø4-F4 contains the first two records and Field 526-FQ contains the last record.

PRIMARY;BN:123456;PN:1234567890;GP:123456789012345;ID:12345678901234567890;
PC:001;PH:8001234567;&
ADDINS:1;BN:123456;PN:1234567890;GP:123456789012345;ID:12345678901234567890;
PC:001;PH:8001234567;&
ADDINS:2;BN:123456;PN:1234567890;GP:123456789012345;ID:12345678901234567890;
PC:001;PH:8001234567;&

E1 Batch Specifications for Part D

View Batch File Specifications in PDF.

Each transaction batch file sent to RelayHealth from a customer computer and each response file sent from RelayHealth to a customer computer contains the following three sections:

• File Header Record. Starts each file.
  
• File Data Record(s). One or more claim or response data records in the appropriate format for the transaction type. See the applicable NCPDP technical specifications manual for details.
  
• File Trailer Record. Ends each file.

The file header and file trailer record must be present in every transmission. The formats for the file header, file data, and file trailer records are fully described in the NCPDP Batch Standard Format documents. As a convenience, the information is summarized in the next three subtopics.

File Header Record

The file header record is the first record in each file. There is only one header record per file. The table below summarizes the fields included in the file header record.

A/N = Alphanumeric field (left justify, blank fill)
N = Numeric field (right justify, zero fill)

File Header Notes

• Only one header record exists per file.
  
• Transmission type “T” is required when the pharmacy is submitting a batch. Transmission type “E” is required when the entire batch has been rejected by the processor or switch. Transmission type “R” is returned to the pharmacy to denote that the file contains responses to claims.
  
• The processor or switch receiving the file assigns the Sender ID. This ID reflects valid enrollment between trading partners for batch file submission.
  
• The Batch number is assigned by the sender and must match the trailer Batch Number field.
  
• The Batch number on the response file should be the same Batch number from the claim file originally sent from the pharmacy. This will link the claim batch file to the response batch file.
  
• The Version/Release number refers to the actual Version/Release of NCPDP Batch Standard being used. In this guide, Version/Release 11 is being used.
  

File Data Records

Each file contains one or more data records. There is no limit to the number of data records that can be included per file. Any transaction format that is acceptable to the real-time switch may be delivered via batch.

A/N = Alphanumeric field (left justify, blank fill)
N = Numeric field (right justify, zero fill)

Transaction Detail Notes

• The Transaction Reference number is assigned by the pharmacy. When the processor receives the file and begins processing the claims, the Transaction Reference number must be returned with the response. The Transaction Reference number is used to link a response to the original claim.
  
• Data Record - see the applicable NCPDP Standard Format document for the definition of the record layouts for the NCPDP Data Record.
  

File Trailer Record

The file trailer record is the last record in the file and contains information about the file, such as the number of data records, the date and time the file was created, and the batch number.

A/N = Alphanumeric field (left justify, blank fill)
N = Numeric field (right justify, zero fill)

Transaction Detail Notes

• Only one Trailer Record exists per file.
  
• The Batch number must match the Batch Number field in the header record.
  
• The record count field includes the total number of records in the batch, including the header and trailer records.
  
• The message field can be used to further explain the reasons why the entire batch is in error, include information about testing, or any other data that needs to be sent with the batch. This field should contain informational data only. Do not include required data.
  
• The maximum number of records in a file is 9,999,999,999, including one (1) Transaction Header and one (1) Transaction Trailer.