Insurance Transmission Fields

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Quickscrip transmits electronic prescriptions in the new D.0 transmission format as of 2011.

To see what fields of data are being transmitted, enter T/B at the time of transmission (in RXFILL and Dual Billing EDIT) or Y/B (in the EDIT Screen).

Note: When searching this document by field number, be aware that insurance companies often reverse the numeric code (Thus, field A1-101, may be called 101-A1 by an insurance customer support representative)

Segment ID Field

The Field AM-111 is the Segment identifier field. This field will apper multiple times in a transmission, and is used to seperate transmitted data into relevant groupings.

Transmission Header

The transmission header contains routing information that your switch uses to determine where the claim is sent to.

Field Name Description
A1-101 Insurance Bin Number
A2-102 Transmission Format Version Number
A3-103 Transaction Code
A4-104 Processor Control Number
A9-109 Transaction Count
B2-202 Service Provider ID Type
B1-201 Service Provider ID
D1-401 Date of Service
AK110 Software Vendor Certification #

Insurance Info (AM-111 04)

Field Name Description
C2-302 Cardhoder ID Number
CC-312 Cardholder First Name
CD-313 Cardholder Last Name
CE-314 Home Plan
FO-524 Plan ID
C9-309 Eligibility Clarification Code
C1-301 Group ID
C3-303 Person Code
C6-306 Relationship Code
2D-361 Provider Accept Assignment
G2-997 Long Term Care Claim Submission
2B-360 Medicaid Indicator
N5-115 Medicaid ID Number

Patient Info (AM-111 01)

Field Name Description
CX-331 Patient ID Type
CY-332 Patient ID
C4-304 Date of Birth
C5-305 Gender Code
C7-307 Place of Service
CA-310 Patient First name
CB-311 Patient Last name
CM-322 Patient Street Address
CN-323 Patient City
CO-324 Patient State
CP-325 Patient Zip code
CQ-326 Patient Phone
CZ-333 Patient Employer ID
1C-334 Patient Smoker?
2C-335 Patient Pregnant?
4X-384 Patient Residence
HN-350 Patient Email Address

Pharmacy Information (AM-111 02)

This information is rarely sent, as it is almost never required.

Field Name Description
EY-465 RPh ID type
E9-444 RPh ID

Group Separator

The Group Separator marks the beginning of the info for 1 claim. If multiple claims are batched together, then each claim will be preceded by a new Group Separator.

Field Name Description
GS-029 Group Separator

Prescription Information (AM-111 07)

Field Name Description
EM-455 Rx number type
D2-402 Rx#
E1-436 Prod/Service ID type
D7-407 NDC# (Prod/Service ID)
E7-442 Quantity dispensed
D3-403 Refill#
D5-405 Days Supply
D6-406 Compound Code
D8-408 DAW code
DE-414 Date Rx written
DF-415 # of Refills authorized
U7-147 Pharmacy Service Type
DJ-419 Rx Origin Code
NX-354 Submission Clarify count
DK-420 Submission Clarify code
DI-418 Level of Service
C8-308 Other coverage code
EN-456 Associated Rx/service ref #
EP-457 Associated Rx/service date
SE-458 Procedure modifier count MAX
ER-459 Procedure modifier code
ET-460 Quantity prescribed
DT-429 Special Packaging Indicator
EJ-453 Orig Rxd item ID type
EA-445 Orig Rxd item ID
EB-446 Orig Rxd quantity
CW-330 Alternate ID
EK-454 Scheduled Rx ID number
28-600 Unit of Measure
EU-461 P/A type code
EV-462 P/A AUTH #
EW-463 Intermediary Auth type
EX-464 Intermediary Auth ID
HD-343 Dispensing status
HF-344 Qty intended to dispense
HG-345 Days Supply intended
NV-357 Delay Reason Code
MT-391 Patient Assignment Indicator
E2-995 Route of Administration
G1-996 Compound Type

Doctor Information (AM-111 03)

Field Name Description
EZ-466 Prescriber ID type
DB-411 Prescriber ID
DR-427 Prescriber Last Name
PM-498 Prescriber Phone #
2E-468 Primary care doc ID type
DL-421 Primary care doc ID
4E-470 Primary care doc last name
2J-364 Prescriber First Name
2K-365 Prescriber street address
2M-366 Prescriber city
2N-367 Prescriber State
2P-368 Prescriber Zip Code

Pricing Informaction (AM-111 11)

In Quickscrip claim transmissions, numberical values end with a letter of the alphabhet and do not include a decimal.
Thus 7462E would corrispond to $746.25.

Field Name Description
D9-409 Ingredient Cost submitted
DC-412 Dispensing Fee submitted
BE-477 Professional Fee submitted
DX-433 Patient paid amt submitted
E3-438 Incentive amt submitted
H7-478 OtherAmtSubmitted count MAX
H8-479 Other amt submitted type
H9-480 Other amt submitted
HA-481 Flat sales tax submitted
GE-482  % sales tax amt submitted
HE-483  % sales tax rate submitted
JE-484  % sales tax basis submited
DQ-426 Usual & Customary
DU-430 Gross Amount Due
DN-423 Basis of Cost determination

Coordination of Benefits (AM-111 05)

This section typically appears on secondary billing claims.

Field Name Description
4C-337 Other Payor count
5C-338 Other Payor coverage type
6C-339 Other Payor ID type
7C-340 Other Payor ID
E8-443 Other Payor date
A7-993 Internal Control Number
HB-341 Other Payor AmtPaid count
HC-342 Other Payor amt paid type
DV-431 Other Payor amt paid
5E-471 Other Payor reject count
6E-472 Other Payor reject code
NR-353 OP Patient Resp Amt Count
NP-351 OP Patient Resp Amt Qualifier
NQ-352 OP Patient Resp Amt
MU-392 Benefit Stage Count
MV-393 Benefit Stage Qualifier
MW-394 Benefit Stage Amount

Workers Comp Information (AM-111 06)

Workers comp fields are generated when a Date of Injury (/IY) has been attached to a claim.

Field Name Description
DY-434 Date of injury
CF-315 Employer Name
CG-316 Employer street address
CH-317 Employer City
CI-318 Employer State
CJ-319 Employer Zip
CK-320 Employer Phone
CL-321 Employer Contact Name
CR-327 Carrier ID
DZ-435 Claim reference #
TR-117 WC Billing Entity Type
TS-118 WC Pay To Qualifier
TT-119 WC Pay To ID
TU-120 WC Pay To Name
TV-121 WC Pay To Address
TW-122 WC Pay to City
TX-123 WC Pay to State
TY-124 WC Pay to Zip
TZ-125 Gx Equiv Prod ID Qual
UA-126 Gx Equiv Prod ID

DUR Information (AM-111 08)

These fields are transmitted when a DUR code has been entered into the SIG lines.
See the DUR Codes page for additional information.

Field Name Description
0Z-035 DUR count
7E-473 DUR/PPS code count
E4-439 Reason for service code
E5-440 Professional service code
E6-441 Result of service code
8E-474 DUR/PPS level of effort
J9-475 DUR Co-agent ID type
H6-476 DUR co-agent ID

Coupon Information (AM-111 09)

Field Name Description
KE-485 Coupon type
ME-486 Coupon number
NE-487 Coupon value/amount

Compound Drug Information (AM-111 10)

Field Name Description
EF-450 Dosage form descrip code
EG-451 Dispensing unit form indicator
EC-447 Ingred Component count MAX 25
2G-362 Cmpnd Ingredient Modifier Code Count
2H-363 Cmpnd Ingredient Modifier Code
RE-488 Product ID type
TE-489 Product ID
ED-448 Ingredient quantity
EE-449 Ingredient drug cost
UE-490 Ingredient basis of cost

P/A Request Information (AM-111 12)

Field Name Description
PA-498 Request type
PB-498 P/A start date
PC-498 P/A end date
PD-498 Basis of request
PE-498 auth rep first name
PF-498 auth rep last name
PG-498 auth rep street address
PH-498 auth rep city
PJ-498 auth rep state
PK-498 auth rep zip
PY-498 P/A number assigned
F3-503 P/A number
PP-498 P/A number supporting docs

Clinical Information (AM-111 13)

Field Name Description
VE-491 Diagnosis code count
WE-492 Diagnosis code type
DO-424 Diagnosis code
XE-493 Clinical Info counter
ZE-494 Measurement date
H1-495 Measurement time
ZE-496 Measurement dimension
ZE-497 Measurement unit
ZE-499 Measurement value

Additional Documantation Segment (AM-111 14)

Field Name Description
2Q-369 Addl Doc Type ID
2V-374 Req Period Begin Date
2W-375 Req Period Revised Date
2U-373 Request Status
2S-371 Length of Need Qual
2R-370 Length of Need
2T-372 Prescriber Date Signed
2X-376 Supporting Documentation
2Z-377 Question # / letter cnt
4B-378 Question # / letter
4D-379 Question % response
4G-380 Question Date Response
4H-381 Question $ amt Response
4J-382 Question Numeric Resp
4K-383 Question Alpha Response

Older Versions

On rare occasions, an insurance may require a claim be send on an older transmission standard (RXOL51 or RXO3PI). Please contact Cost Effective Computers for these claims.