ESIB1V5 (10)    BPS NCPDP FORMATS (9002313.92)

Name Value
RECORD FORMAT NAME ESIB1V5
VERSION Version 5.1
PRODUCTION STATUS PRODUCTION
PAYER SHEET VERSION 1
TRANSACTION HEADER SEGMENT
  • TRANSACTION HEADER ORDER:   12
    NCPDP FIELD NUMBER:   102
    PROCESSING MODE:   STANDARD
  • TRANSACTION HEADER ORDER:   14
    NCPDP FIELD NUMBER:   103
    PROCESSING MODE:   STANDARD
  • TRANSACTION HEADER ORDER:   15
    NCPDP FIELD NUMBER:   104
    PROCESSING MODE:   STANDARD
  • TRANSACTION HEADER ORDER:   17
    NCPDP FIELD NUMBER:   109
    PROCESSING MODE:   STANDARD
  • TRANSACTION HEADER ORDER:   19
    NCPDP FIELD NUMBER:   202
    PROCESSING MODE:   STANDARD
  • TRANSACTION HEADER ORDER:   21
    NCPDP FIELD NUMBER:   201
    PROCESSING MODE:   STANDARD
  • TRANSACTION HEADER ORDER:   23
    NCPDP FIELD NUMBER:   401
    PROCESSING MODE:   STANDARD
  • TRANSACTION HEADER ORDER:   24
    NCPDP FIELD NUMBER:   110
    PROCESSING MODE:   STANDARD
  • TRANSACTION HEADER ORDER:   9
    NCPDP FIELD NUMBER:   101
    PROCESSING MODE:   STANDARD
PATIENT SEGMENT
  • PATIENT SEGMENT ORDER:   33
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • PATIENT SEGMENT ORDER:   35
    NCPDP FIELD NUMBER:   304
    PROCESSING MODE:   STANDARD
  • PATIENT SEGMENT ORDER:   36
    NCPDP FIELD NUMBER:   305
    PROCESSING MODE:   STANDARD
  • PATIENT SEGMENT ORDER:   38
    NCPDP FIELD NUMBER:   310
    PROCESSING MODE:   STANDARD
  • PATIENT SEGMENT ORDER:   40
    NCPDP FIELD NUMBER:   311
    PROCESSING MODE:   STANDARD
  • PATIENT SEGMENT ORDER:   42
    NCPDP FIELD NUMBER:   322
    PROCESSING MODE:   STANDARD
  • PATIENT SEGMENT ORDER:   45
    NCPDP FIELD NUMBER:   323
    PROCESSING MODE:   STANDARD
  • PATIENT SEGMENT ORDER:   48
    NCPDP FIELD NUMBER:   324
    PROCESSING MODE:   STANDARD
  • PATIENT SEGMENT ORDER:   51
    NCPDP FIELD NUMBER:   325
    PROCESSING MODE:   STANDARD
INSURANCE SEGMENT
  • INSURANCE SEGMENT ORDER:   61
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • INSURANCE SEGMENT ORDER:   63
    NCPDP FIELD NUMBER:   302
    PROCESSING MODE:   STANDARD
  • INSURANCE SEGMENT ORDER:   64
    NCPDP FIELD NUMBER:   312
    PROCESSING MODE:   STANDARD
  • INSURANCE SEGMENT ORDER:   67
    NCPDP FIELD NUMBER:   313
    PROCESSING MODE:   STANDARD
  • INSURANCE SEGMENT ORDER:   70
    NCPDP FIELD NUMBER:   309
    PROCESSING MODE:   STANDARD
  • INSURANCE SEGMENT ORDER:   73
    NCPDP FIELD NUMBER:   301
    PROCESSING MODE:   STANDARD
  • INSURANCE SEGMENT ORDER:   74
    NCPDP FIELD NUMBER:   303
    PROCESSING MODE:   STANDARD
  • INSURANCE SEGMENT ORDER:   75
    NCPDP FIELD NUMBER:   306
    PROCESSING MODE:   STANDARD
CLAIM SEGMENT
  • CLAIM SEGMENT ORDER:   100
    NCPDP FIELD NUMBER:   406
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   103
    NCPDP FIELD NUMBER:   408
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   105
    NCPDP FIELD NUMBER:   415
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   108
    NCPDP FIELD NUMBER:   308
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   112
    NCPDP FIELD NUMBER:   418
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   113
    NCPDP FIELD NUMBER:   462
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   85
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   87
    NCPDP FIELD NUMBER:   455
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   90
    NCPDP FIELD NUMBER:   402
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   92
    NCPDP FIELD NUMBER:   436
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   94
    NCPDP FIELD NUMBER:   407
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   96
    NCPDP FIELD NUMBER:   442
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   98
    NCPDP FIELD NUMBER:   403
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   99
    NCPDP FIELD NUMBER:   405
    PROCESSING MODE:   STANDARD
PRESCRIBER SEGMENT
  • PRESCRIBER SEGMENT ORDER:   124
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • PRESCRIBER SEGMENT ORDER:   126
    NCPDP FIELD NUMBER:   466
    PROCESSING MODE:   STANDARD
  • PRESCRIBER SEGMENT ORDER:   128
    NCPDP FIELD NUMBER:   411
    PROCESSING MODE:   STANDARD
COB OTHER PAYMENTS SEGMENT
  • COB OTHER PAYMENTS ORDER:   136
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   138
    NCPDP FIELD NUMBER:   337
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   140
    NCPDP FIELD NUMBER:   338
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   142
    NCPDP FIELD NUMBER:   341
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   145
    NCPDP FIELD NUMBER:   342
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   148
    NCPDP FIELD NUMBER:   431
    PROCESSING MODE:   STANDARD
WORKERS COMP SEGMENT
  • WORKERS COMP SEGMENT ORDER:   157
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • WORKERS COMP SEGMENT ORDER:   160
    NCPDP FIELD NUMBER:   434
    PROCESSING MODE:   STANDARD
  • WORKERS COMP SEGMENT ORDER:   163
    NCPDP FIELD NUMBER:   315
    PROCESSING MODE:   STANDARD
  • WORKERS COMP SEGMENT ORDER:   166
    NCPDP FIELD NUMBER:   316
    PROCESSING MODE:   STANDARD
  • WORKERS COMP SEGMENT ORDER:   169
    NCPDP FIELD NUMBER:   317
    PROCESSING MODE:   STANDARD
  • WORKERS COMP SEGMENT ORDER:   172
    NCPDP FIELD NUMBER:   318
    PROCESSING MODE:   STANDARD
  • WORKERS COMP SEGMENT ORDER:   175
    NCPDP FIELD NUMBER:   319
    PROCESSING MODE:   STANDARD
  • WORKERS COMP SEGMENT ORDER:   178
    NCPDP FIELD NUMBER:   435
    PROCESSING MODE:   STANDARD
DUR PPS SEGMENT
  • DUR PPS SEGMENT ORDER:   188
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   190
    NCPDP FIELD NUMBER:   473
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   192
    NCPDP FIELD NUMBER:   439
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   194
    NCPDP FIELD NUMBER:   440
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   196
    NCPDP FIELD NUMBER:   441
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   198
    NCPDP FIELD NUMBER:   474
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   200
    NCPDP FIELD NUMBER:   476
    PROCESSING MODE:   STANDARD
PRICING SEGMENT
  • PRICING SEGMENT ORDER:   208
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   210
    NCPDP FIELD NUMBER:   409
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   212
    NCPDP FIELD NUMBER:   426
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   215
    NCPDP FIELD NUMBER:   430
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   216
    NCPDP FIELD NUMBER:   423
    PROCESSING MODE:   STANDARD