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Global: ^BPS(9002313.78

Package: E Claims Management Engine

Global: ^BPS(9002313.78


Information

FileMan FileNo FileMan Filename Package
9002313.78 BPS INSURER DATA E Claims Management Engine

Description

Directly Accessed By Routines, Total: 6

Package Total Routines
E Claims Management Engine 4 BPS10P11    BPS10PST    BPSOSRX4    BPSUTIL2    

Accessed By FileMan Db Calls, Total: 4

Package Total Routines
E Claims Management Engine 4 BPS10P11    BPSOSRX2    BPSOSRX4    BPSUSCR2    

Pointed To By FileMan Files, Total: 1

Package Total FileMan Files
E Claims Management Engine 1 BPS REQUESTS(#9002313.77)[#9002313.772(.03)]    

Pointer To FileMan Files, Total: 5

Package Total FileMan Files
E Claims Management Engine 2 BPS CERTIFICATION(#9002313.31)[.06]    BPS NCPDP FORMATS(#9002313.92)[.02.03.04.1]    
Integrated Billing 2 INSURANCE COMPANY(#36)[3.05]    GROUP INSURANCE PLAN(#355.3)[.08]    
Kernel 1 NEW PERSON(#200)[5.01]    

Fields, Total: 40

Field # Name Loc Type Details
.01 TRANSACTION ID 0;1 NUMBER
************************REQUIRED FIELD************************

  • INPUT TRANSFORM:  K:+X'=X!(X>99999999999999)!(X<1)!(X?.E1"."6.N) X
  • LAST EDITED:  OCT 20, 2010
  • HELP-PROMPT:  Enter the numeric identifier for the record (1- 99999999999999, 5 Decimal Digits).
  • DESCRIPTION:  This is a numeric identifier that follows the same format as the IEN of the BPS TRANSACTION (#9002313.59) file. For billing requests and reversals, this is the Prescription IEN, followed by a decimal point, followed by the
    Fill Number left-padded with zeros up to four places and then followed by the COB indicator (1-Primary, 2-Secondary, 3-Tertiary). For a Eligibility Verification request, this is the Patient IEN, followed by a decimal
    point, followed by the Policy Number (with 9000 added to it) and then followed by 1.
  • TECHNICAL DESCR:  At the point that the BPS INSURER DATA record is created, the BPS TRANSACTION record may not be defined so this field uses the same format but cannot be a pointer. The value for this field is created by calling
    IEN^BPSOSRX, which is the same call that is done to determine the IEN of the BPS transaction file. Since the code that creates the value for this field and the code that calculates the IEN of the BPS Transaction field use
    the same API (and parameters), they both will have the same value and thus, the data does not need to be updated when the BPS Transaction record is created (it is already correct).
  • CROSS-REFERENCE:  9002313.78^B
    1)= S ^BPS(9002313.78,"B",$E(X,1,30),DA)=""
    2)= K ^BPS(9002313.78,"B",$E(X,1,30),DA)
.02 B1 PAYER SHEET 0;2 POINTER TO BPS NCPDP FORMATS FILE (#9002313.92) BPS NCPDP FORMATS(#9002313.92)

  • LAST EDITED:  OCT 19, 2010
  • HELP-PROMPT:  Answer with the billing request payer sheet to be used for this payer.
  • DESCRIPTION:  
    This is the payer sheet used to a submit billing request for this particular insurer. Billing request transmissions will be formatted per the specifications in this payer sheet.
.03 B2 PAYER SHEET 0;3 POINTER TO BPS NCPDP FORMATS FILE (#9002313.92) BPS NCPDP FORMATS(#9002313.92)

  • LAST EDITED:  JUL 01, 2008
  • HELP-PROMPT:  Select a payer sheet to be used for reversals.
  • DESCRIPTION:  
    The Reversal payer sheet to be used to send reversals to the Insurer.
.04 B3 PAYER SHEET 0;4 POINTER TO BPS NCPDP FORMATS FILE (#9002313.92) BPS NCPDP FORMATS(#9002313.92)

  • LAST EDITED:  OCT 18, 2010
  • HELP-PROMPT:  Enter the rebill payer sheet used for this payer.
  • DESCRIPTION:  
    This is the payer sheet to be used for a rebill request for this insurer. Rebill transmission will be formatted per the specifications in this payer sheet.
.05 CERTIFY MODE 0;5 SET
  • '0' FOR CERTIFY MODE OFF;
  • '1' FOR CERTFIY MODE ON;

  • LAST EDITED:  JUL 01, 2008
  • HELP-PROMPT:  Switch on/off the certify mode
  • DESCRIPTION:  
    Certify mode is used for certifying software when required by switches and claims end processors.
.06 CERTIFICATION 0;6 POINTER TO BPS CERTIFICATION FILE (#9002313.31) BPS CERTIFICATION(#9002313.31)

  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Enter the Certification record
  • DESCRIPTION:  
    This field is used during certification testing, and points to the entry to use to pull certification data.
.07 INSURANCE NAME 0;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>40!($L(X)<1) X
  • LAST EDITED:  JUL 01, 2008
  • HELP-PROMPT:  Enter the name of the insurance company. Answer must be 1-40 characters.
  • DESCRIPTION:  
    This is the free text name of the Insurance Company as determined by Integrated Billing insurance files.
.08 PLAN ID 0;8 POINTER TO GROUP INSURANCE PLAN FILE (#355.3) GROUP INSURANCE PLAN(#355.3)

  • LAST EDITED:  JUL 01, 2008
  • HELP-PROMPT:  Enter the Group Insurance Plan
  • DESCRIPTION:  
    Group Insurance Plan used for the claim
.09 COB INDICATOR 0;9 SET
  • '1' FOR PRIMARY;
  • '2' FOR SECONDARY;
  • '3' FOR TERTIARY;

  • LAST EDITED:  JUL 01, 2008
  • HELP-PROMPT:  Is the payer a primary, secondary or tertiary insurer?
  • DESCRIPTION:  
    Coordination Of Benefits (COB) indicator for the payer.
.1 E1 PAYER SHEET 0;10 POINTER TO BPS NCPDP FORMATS FILE (#9002313.92) BPS NCPDP FORMATS(#9002313.92)

  • LAST EDITED:  OCT 18, 2010
  • HELP-PROMPT:  Enter the eligibility verification payer sheet for the payer.
  • DESCRIPTION:  
    This is the payer sheet to be used for eligibility verification requests for this insurer. Eligibility verification transmissions will be formatted per the specifications in this payer sheet.
.11 POLICY NUMBER 0;11 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>9999)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  OCT 18, 2010
  • HELP-PROMPT:  Enter the policy number for this insurer (0-9999).
  • DESCRIPTION:  
    This is the policy number assigned for this particular patient and insurer.
1.01 BIN 1;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<1) X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Answer must be 1-10 characters in length.
  • DESCRIPTION:  
    Card Issuer ID or Bank ID Number used for network routing.
1.02 PCN 1;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<1) X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Answer must be 1-10 characters in length.
  • DESCRIPTION:  
    The Processor Control Number for this claim.
1.03 GROUP ID 1;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>17!($L(X)<1) X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Answer must be 1-17 characters in length.
  • DESCRIPTION:  
    ID assigned to the cardholder group or employer group.
1.04 CARDHOLDER ID 1;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>20!($L(X)<1) X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Answer must be 1-20 characters in length.
  • DESCRIPTION:  
    ID number assigned to Cardholder/Subscriber.
1.05 PATIENT RELATIONSHIP CODE 1;5 SET
  • '0' FOR NOT SPECIFIED;
  • '1' FOR CARDHOLDER (SELF);
  • '2' FOR SPOUSE;
  • '3' FOR CHILD;
  • '4' FOR OTHER;

  • LAST EDITED:  APR 22, 2011
  • HELP-PROMPT:  Enter the relationship of the patient to the insured.
  • DESCRIPTION:  
    This stores the relationship of the patient to insurance subscriber and will be used to populate the NCPDP 306-C6 (PATIENT RELATIONSHIP CODE) field.
1.06 CARDHOLDER FIRST NAME 1;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<1) X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Answer must be 1-30 characters in length
  • DESCRIPTION:  
    First name of the Cardholder/Subscriber.
1.07 CARDHOLDER LAST NAME 1;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<1) X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Answer must be 1-15 characters in length
  • DESCRIPTION:  
    Last name of the Cardholder/Subscriber.
1.08 HOME PLAN STATE 1;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<1) X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Answer must be 1-2 characters in length
  • DESCRIPTION:  
    Usually the state where the member lives or purchased their coverage.
1.09 PERSON CODE 1;9 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<1) X
  • LAST EDITED:  JUL 06, 2011
  • HELP-PROMPT:  Enter the person code for the NCPDP request (1-3 characters).
  • DESCRIPTION:  
    This is the Person Code that will be placed in NCPDP field 303-C3 (Person Code). This value is specified by the third-party payer and is found on the patient's insurance card.
2.01 DISPENSING FEE SUBMITTED 2;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<1) X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Type a Dollar amount between 0 and 99999, 2 Decimal Digits
  • DESCRIPTION:  
    Fee amount submitted for the cost associated with dispensing this prescription.
2.02 BASIS OF COST DETERMINATION 2;2 SET
  • '01' FOR AWP;
  • '05' FOR Cost Calculations;
  • '07' FOR Usual & Customary;

  • LAST EDITED:  JUL 01, 2008
  • HELP-PROMPT:  Answer with the basis code for which the cost was determined.
  • DESCRIPTION:  
    Code indicating the method by which 'Ingredient Cost Submitted' was calculated.
2.03 USUAL & CUSTOMARY CHARGE 2;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<1) X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Type a Dollar amount between 0 and 99999, 2 Decimal Digits
  • DESCRIPTION:  
    Amount charged cash customers for the prescription exclusive of sales tax or other amounts claimed.
2.04 GROSS AMOUNT DUE 2;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<1) X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Type a Dollar amount between 0 and 99999, 2 Decimal Digits
  • DESCRIPTION:  Total price claimed from all sources. For prescription claim request, field represents a sum of 'Ingredient Cost Submitted' (49-D9), 'Dispensing Fee Submitted' (412-DC), 'Flat Sales Tax Amount Submitted'(481-HA),
    'Percentage Sales Tax Amount Submitted' (482-GE), 'Incentive Amount Submitted' (438-E3), 'Other Amount Claimed' (48-H9). For service claim request, field represents a sum of 'Professional Services Fee Submitted'
    (477-BE), 'Flat Sales Tax Amount Submitted'(481-HA), 'Percentage Sales Tax Amount Submitted'(482-GE), 'Other Amount Claimed' (48-H9).
2.05 ADMINISTRATIVE FEE 2;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>8!($L(X)<1) X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Type a Dollar amount between 0 and 99999, 2 Decimal Digits
  • DESCRIPTION:  
    Fee charged for any costs related to preparing the prescription.
2.06 SOFTWARE VENDOR CERT ID 2;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<1) X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Answer must be 1-30 characters in length.
  • DESCRIPTION:  
    Certification number assigned by the payer for submission of claims.
2.07 MAXIMUM NCPDP TRANSACTIONS 2;7 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>99999)!(X<1)!(X?.E1"."1.N) X
  • LAST EDITED:  OCT 18, 2010
  • HELP-PROMPT:  Enter the maximum number of transactions allowed in a request (1-9999).
  • DESCRIPTION:  
    This is the maximum number of transactions that can be bundled in a transmission. It is specified by the NCPDP processor.
2.08 INGREDIENT COST 2;8 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>999999)!(X<0)!(X?.E1"."3.N) X
  • LAST EDITED:  JUL 06, 2011
  • HELP-PROMPT:  Type a number between 0 and 999999, 2 decimal digits.
  • DESCRIPTION:  
    This is the INGREDIENT COST that will be placed in the NCPDP field 409-D9 (INGREDIENT COST SUBMITTED) field of the NCPDP submission.
3.01 GROUP NAME 3;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>20!($L(X)<2) X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Answer must be 2-20 characters in length.
  • DESCRIPTION:  
    This is the group name from the Group Insurance File.
3.02 INSURANCE CO PHONE # 3;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>20!($L(X)<7) X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Answer must be 7-20 characters in length.
  • DESCRIPTION:  
    This is the Claim (RX) phone number from the Insurance Company file.
3.03 PHARMACY PLAN ID 3;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<1) X
  • LAST EDITED:  JUL 02, 2008
  • HELP-PROMPT:  Answer must be 1-30 characters in length.
  • DESCRIPTION:  
    This is the ID of the plan file.
3.04 ELIGIBILITY 3;4 SET
  • 'V' FOR VETERAN;
  • 'T' FOR TRICARE;
  • 'C' FOR CHAMPVA;

  • LAST EDITED:  AUG 04, 2011
  • HELP-PROMPT:  Enter eligibility of the claim.
  • DESCRIPTION:  
    The insurance eligibility type of the claim.
3.05 INSURANCE COMPANY 3;5 POINTER TO INSURANCE COMPANY FILE (#36) INSURANCE COMPANY(#36)

  • LAST EDITED:  JAN 16, 2009
  • HELP-PROMPT:  Select the insurance carrier for this claim.
  • DESCRIPTION:  
    This is the INSURANCE COMPANY from file #36.
3.06 PLAN COB 3;6 SET
  • '1' FOR PRIMARY;
  • '2' FOR SECONDARY;
  • '3' FOR TERTIARY;

  • LAST EDITED:  MAR 30, 2009
  • HELP-PROMPT:  Enter Coordination Of Benefits indicator for the insurance plan.
  • DESCRIPTION:  
    The Coordination of Benefits indicator of the patient's insurance plan. This field is a copy of the (#.2) COORDINATION OF BENEFITS field of the (#.3121) INSURANCE TYPE multiple of the PATIENT file (#2).
4.01 B1 PAYER SHEET NAME 4;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<3) X
  • LAST EDITED:  OCT 19, 2010
  • HELP-PROMPT:  Enter the name of the payer sheet that will be used for billing requests (3-30 characters).
  • DESCRIPTION:  
    This is the name of the Billing Request Payer Sheet, which comes from the RECORD FORMAT NAME (#.01) field of the BPS NCPDP FORMATS (#9002313.92) file.
4.02 B2 PAYER SHEET NAME 4;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<3) X
  • LAST EDITED:  NOV 26, 2007
  • HELP-PROMPT:  Answer must be 3-30 characters in length.
  • DESCRIPTION:  
    B2 Payer sheet. The value of the field (#.01) Record Format Name of the file (#9002313.92) BPS NCPDP FORMATS ien Textual description of this record format.
4.03 B3 PAYER SHEET NAME 4;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<3) X
  • LAST EDITED:  OCT 19, 2010
  • HELP-PROMPT:  Enter the name of the payer sheet that will be used for rebill requests (3-30 characters).
  • DESCRIPTION:  
    This is the name of the Rebill Payer Sheet, which comes from the RECORD FORMAT NAME (#.01) field of the BPS NCPDP FORMATS (#9002313.92) file.
4.04 E1 PAYER SHEET NAME 4;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<3) X
  • LAST EDITED:  OCT 19, 2010
  • HELP-PROMPT:  Enter the name of the payer sheet that will be used for eligibility verification requests (3-30 characters).
  • DESCRIPTION:  
    This is the name of the Eligibility Payer Sheet, which comes from the RECORD FORMAT NAME (#.01) field of the BPS NCPDP FORMATS (#9002313.92) file.
5.01 USER 5;1 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • LAST EDITED:  JUL 01, 2008
  • HELP-PROMPT:  Enter the user who made the request
  • DESCRIPTION:  
    ID (IEN of the NEW PERSON file) of the user name who entered this record.
5.02 DATE AND TIME WAS CREATED 5;2 DATE

  • INPUT TRANSFORM:  S %DT="E" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JUN 19, 2008
  • HELP-PROMPT:  Answer with the date/time this record was created
  • DESCRIPTION:  
    Date and time the record was created.
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