Insurance Transmission Fields

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.