Insurance Transmission Fields: Difference between revisions
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|width="300pt"|'''Description''' | |width="300pt"|'''Description''' | ||
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|A1-101|| Insurance | |A1-101|| [http://www.quickrx.net/wiki/Insurance_Bin Insurance Bin Number] | ||
|- | |- | ||
|A2-102|| Version Number | |A2-102|| [http://www.quickrx.net/wiki/Version_Number Transmission Format Version Number] | ||
|- | |- | ||
|A3-103|| Transaction Code | |A3-103|| [http://www.quickrx.net/wiki/Transaction_Count Transaction Code] | ||
|- | |- | ||
|A4-104|| Processor Control Number | |A4-104|| [http://www.quickrx.net/wiki/Processor_Control_Number Processor Control Number] | ||
|- | |- | ||
|A9-109|| Transaction Count | |A9-109|| [http://www.quickrx.net/wiki/Transaction_Count Transaction Count] | ||
|- | |- | ||
|B2-202|| Service Provider ID | |B2-202|| [http://www.quickrx.net/wiki/Service_Provider_ID Service Provider ID Type] | ||
|- | |- | ||
| | |B1-201|| [http://www.quickrx.net/wiki/Service_Provider_ID Service Provider ID] | ||
|- | |- | ||
|AK110|| Software Vendor Certification # | |D1-401|| [http://www.quickrx.net/wiki/Date_of_Service Date of Service] | ||
|- | |||
|AK110|| [http://www.quickrx.net/wiki/Software_Vendor_Certification Software Vendor Certification #] | |||
|} | |} | ||
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|width="300pt"|'''Description''' | |width="300pt"|'''Description''' | ||
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|C2-302|| Cardhoder ID Number | |C2-302|| [http://www.quickrx.net/wiki/Cardholder_ID Cardhoder ID Number] | ||
|- | |- | ||
|CC-312|| Cardholder First Name | |CC-312|| [http://www.quickrx.net/wiki/Cardholder_Name Cardholder First Name] | ||
|- | |- | ||
|CD-313|| Cardholder Last Name | |CD-313|| [http://www.quickrx.net/wiki/Cardholder_Name Cardholder Last Name] | ||
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|CE-314|| Home Plan | |CE-314|| Home Plan | ||
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|FO-524|| Plan ID | |FO-524|| Plan ID | ||
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|C9-309|| Eligibility | |C9-309|| Eligibility Clarification Code | ||
|- | |- | ||
|C1-301|| Group ID | |C1-301|| Group ID | ||
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|CB-311 || Patient Last name | |CB-311 || Patient Last name | ||
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|CM-322 || Patient Street Address | |CM-322 || [http://quickrx.net/wiki/Workers_Comp_Claims Patient Street Address] | ||
|- | |- | ||
|CN-323 || Patient City | |CN-323 || [http://quickrx.net/wiki/Workers_Comp_Claims Patient City] | ||
|- | |- | ||
|CO-324 || Patient State | |CO-324 || [http://quickrx.net/wiki/Workers_Comp_Claims Patient State] | ||
|- | |- | ||
|CP-325 || Patient Zip code | |CP-325 || [http://quickrx.net/wiki/Workers_Comp_Claims Patient Zip code] | ||
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|CQ-326 || Patient Phone | |CQ-326 || Patient Phone | ||
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|2C-335 || Patient Pregnant? | |2C-335 || Patient Pregnant? | ||
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|4X-384 || Patient Residence | |4X-384 || [http://www.quickrx.net/wiki/PRS_PSC_Codes Patient Residence] | ||
|- | |- | ||
|HN-350 || Patient Email Address | |HN-350 || Patient Email Address | ||
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|width="300pt"|'''Description''' | |width="300pt"|'''Description''' | ||
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|GS-029|| Group Separator | |GS-029|| [http://www.quickrx.net/wiki/Transaction_Count Group Separator] | ||
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|} | |} | ||
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|DF-415|| # of Refills authorized | |DF-415|| # of Refills authorized | ||
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|U7-147|| Pharmacy Service Type | |U7-147|| [http://www.quickrx.net/wiki/PRS_PSC_Codes Pharmacy Service Type] | ||
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|DJ-419|| Rx | |DJ-419|| [http://www.quickrx.net/wiki/Origin_Code Rx Origin Code] | ||
|- | |- | ||
|NX-354|| Submission Clarify count | |NX-354|| Submission Clarify count | ||
|- | |- | ||
|DK-420|| Submission | |DK-420|| [http://quickrx.net/wiki/Submission_Clarification_Codes Submission Clarify code] | ||
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|DI-418|| Level of Service | |DI-418|| Level of Service | ||
|- | |- | ||
|C8-308|| Other coverage code | |C8-308|| [http://www.quickrx.net/wiki/Other_Coverage_Codes Other coverage code] | ||
|- | |- | ||
|EN-456|| Associated Rx/service ref # | |EN-456|| Associated Rx/service ref # | ||
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|HG-345|| Days Supply intended | |HG-345|| Days Supply intended | ||
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|NV-357|| Delay Reason Code | |NV-357|| [http://www.quickrx.net/wiki/Delay_Reason_Code Delay Reason Code] | ||
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|MT-391|| Patient Assignment Indicator | |MT-391|| Patient Assignment Indicator | ||
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|width="300pt"|'''Description''' | |width="300pt"|'''Description''' | ||
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|EZ-466|| Prescriber ID type | |EZ-466|| [https://www.quickscrip.net/wiki/PrescriberID Prescriber ID type] | ||
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|DB-411|| Prescriber ID | |DB-411|| [https://www.quickscrip.net/wiki/PrescriberID Prescriber ID] | ||
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|DR-427|| Prescriber Last Name | |DR-427|| Prescriber Last Name | ||
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|} | |} | ||
==Workers Comp Information== | ==Workers Comp Information (AM-111 06)== | ||
Workers comp fields are generated when a '''Date of Injury''' has been | Workers comp fields are generated when a '''Date of Injury''' (/IY) has been attached to a claim. | ||
{| border="1" cellpadding="2" | {| border="1" cellpadding="2" | ||
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|width="300pt"|'''Description''' | |width="300pt"|'''Description''' | ||
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|DY-434|| Date of injury | |DY-434|| [http://quickrx.net/wiki/Workers_Comp_Claims Date of injury] | ||
|- | |- | ||
|CF-315|| Employer Name | |CF-315|| [http://quickrx.net/wiki/Workers_Comp_Claims Employer Name] | ||
|- | |- | ||
|CG-316|| Employer street address | |CG-316|| [http://quickrx.net/wiki/Workers_Comp_Claims Employer street address] | ||
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|CH-317|| Employer City | |CH-317|| [http://quickrx.net/wiki/Workers_Comp_Claims Employer City] | ||
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|CI-318|| Employer State | |CI-318|| [http://quickrx.net/wiki/Workers_Comp_Claims Employer State] | ||
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|CJ-319|| Employer Zip | |CJ-319|| [http://quickrx.net/wiki/Workers_Comp_Claims Employer Zip] | ||
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|CK-320|| Employer Phone | |CK-320|| [http://quickrx.net/wiki/Workers_Comp_Claims Employer Phone] | ||
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|CL-321|| Employer Contact Name | |CL-321|| [http://quickrx.net/wiki/Workers_Comp_Claims Employer Contact Name] | ||
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|CR-327|| Carrier ID | |CR-327|| Carrier ID | ||
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|} | |} | ||
==DUR Information== | ==DUR Information (AM-111 08)== | ||
These fields are transmitted when a DUR code has been entered into the SIG lines. <br/> | These fields are transmitted when a DUR code has been entered into the SIG lines. <br/> | ||
See the [http://www.quickrx.net/wiki/DUR_Codes DUR Codes] page for additional information. | See the [http://www.quickrx.net/wiki/DUR_Codes DUR Codes] page for additional information. | ||
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|} | |} | ||
==Coupon Information== | ==Coupon Information (AM-111 09)== | ||
{| border="1" cellpadding="2" | {| border="1" cellpadding="2" | ||
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|} | |} | ||
==Compound Drug Information== | ==Compound Drug Information (AM-111 10)== | ||
{| border="1" cellpadding="2" | {| border="1" cellpadding="2" | ||
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|} | |} | ||
==P/A Request Information== | ==P/A Request Information (AM-111 12)== | ||
{| border="1" cellpadding="2" | {| border="1" cellpadding="2" | ||
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|} | |} | ||
==Clinical Information== | ==Clinical Information (AM-111 13)== | ||
{| border="1" cellpadding="2" | {| border="1" cellpadding="2" | ||
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|} | |} | ||
==Additional Documantation Segment== | ==Additional Documantation Segment (AM-111 14)== | ||
{| border="1" cellpadding="2" | {| border="1" cellpadding="2" | ||
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Latest revision as of 19:25, 4 May 2021
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.