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