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	Version Number
A3-103	Transaction Code
A4-104	Processor Control Number
A9-109	Transaction Count
B2-202	Service Provider ID
D1-401	Date of Service
AK110	Software Vendor Certification #

Insurance Info

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 Clerification 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

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

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

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

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

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

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

Workers comp fields are generated when a Date of Injury has been set on a claim.

Field Name	Description
Placeholder	Placeholder

DUR Information

Field Name	Description
Placeholder	Placeholder

Coupon Information

Field Name	Description
Placeholder	Placeholder

Compound Drug Information

Field Name	Description
Placeholder	Placeholder

P/A Request Information

Field Name	Description
Placeholder	Placeholder

Clinical Information

Field Name	Description
Placeholder	Placeholder

Additional Documantation Segment

Field Name	Description
Placeholder	Placeholder

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.