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.
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.