Name	Value
RECORD FORMAT NAME	FHVAB1V5
VERSION	Version 5.1
PRODUCTION STATUS	PRODUCTION
PAYER SHEET VERSION	1
TRANSACTION HEADER SEGMENT	TRANSACTION HEADER ORDER: 10 NCPDP FIELD NUMBER: 102 PROCESSING MODE: STANDARD TRANSACTION HEADER ORDER: 12 NCPDP FIELD NUMBER: 103 PROCESSING MODE: STANDARD TRANSACTION HEADER ORDER: 13 NCPDP FIELD NUMBER: 104 PROCESSING MODE: STANDARD TRANSACTION HEADER ORDER: 15 NCPDP FIELD NUMBER: 109 PROCESSING MODE: STANDARD TRANSACTION HEADER ORDER: 17 NCPDP FIELD NUMBER: 202 PROCESSING MODE: SPECIAL SPECIAL CODE: S BPS("X")="05" TRANSACTION HEADER ORDER: 19 NCPDP FIELD NUMBER: 201 PROCESSING MODE: SPECIAL SPECIAL CODE: S BPS("X")=BPS("Site","Medicaid Pharmacy #") TRANSACTION HEADER ORDER: 21 NCPDP FIELD NUMBER: 401 PROCESSING MODE: STANDARD TRANSACTION HEADER ORDER: 22 NCPDP FIELD NUMBER: 110 PROCESSING MODE: STANDARD TRANSACTION HEADER ORDER: 9 NCPDP FIELD NUMBER: 101 PROCESSING MODE: STANDARD
PATIENT SEGMENT	PATIENT SEGMENT ORDER: 31 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 33 NCPDP FIELD NUMBER: 331 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 35 NCPDP FIELD NUMBER: 332 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 36 NCPDP FIELD NUMBER: 304 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 37 NCPDP FIELD NUMBER: 305 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 39 NCPDP FIELD NUMBER: 310 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 41 NCPDP FIELD NUMBER: 311 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 43 NCPDP FIELD NUMBER: 322 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 45 NCPDP FIELD NUMBER: 323 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 47 NCPDP FIELD NUMBER: 324 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 50 NCPDP FIELD NUMBER: 325 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 52 NCPDP FIELD NUMBER: 326 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 54 NCPDP FIELD NUMBER: 307 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 55 NCPDP FIELD NUMBER: 333 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 56 NCPDP FIELD NUMBER: 334 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 58 NCPDP FIELD NUMBER: 335 PROCESSING MODE: STANDARD
INSURANCE SEGMENT	INSURANCE SEGMENT ORDER: 69 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD INSURANCE SEGMENT ORDER: 71 NCPDP FIELD NUMBER: 302 PROCESSING MODE: STANDARD INSURANCE SEGMENT ORDER: 72 NCPDP FIELD NUMBER: 312 PROCESSING MODE: STANDARD INSURANCE SEGMENT ORDER: 74 NCPDP FIELD NUMBER: 313 PROCESSING MODE: STANDARD INSURANCE SEGMENT ORDER: 76 NCPDP FIELD NUMBER: 314 PROCESSING MODE: STANDARD INSURANCE SEGMENT ORDER: 77 NCPDP FIELD NUMBER: 524 PROCESSING MODE: STANDARD INSURANCE SEGMENT ORDER: 78 NCPDP FIELD NUMBER: 309 PROCESSING MODE: STANDARD INSURANCE SEGMENT ORDER: 81 NCPDP FIELD NUMBER: 336 PROCESSING MODE: STANDARD INSURANCE SEGMENT ORDER: 82 NCPDP FIELD NUMBER: 301 PROCESSING MODE: STANDARD INSURANCE SEGMENT ORDER: 83 NCPDP FIELD NUMBER: 303 PROCESSING MODE: STANDARD INSURANCE SEGMENT ORDER: 84 NCPDP FIELD NUMBER: 306 PROCESSING MODE: STANDARD
CLAIM SEGMENT	CLAIM SEGMENT ORDER: 101 NCPDP FIELD NUMBER: 436 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 103 NCPDP FIELD NUMBER: 407 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 105 NCPDP FIELD NUMBER: 456 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 108 NCPDP FIELD NUMBER: 457 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 111 NCPDP FIELD NUMBER: 458 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 114 NCPDP FIELD NUMBER: 459 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 116 NCPDP FIELD NUMBER: 442 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 118 NCPDP FIELD NUMBER: 403 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 119 NCPDP FIELD NUMBER: 405 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 120 NCPDP FIELD NUMBER: 406 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 121 NCPDP FIELD NUMBER: 408 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 123 NCPDP FIELD NUMBER: 414 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 126 NCPDP FIELD NUMBER: 415 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 129 NCPDP FIELD NUMBER: 419 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 131 NCPDP FIELD NUMBER: 420 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 134 NCPDP FIELD NUMBER: 460 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 136 NCPDP FIELD NUMBER: 308 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 138 NCPDP FIELD NUMBER: 429 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 142 NCPDP FIELD NUMBER: 453 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 145 NCPDP FIELD NUMBER: 445 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 148 NCPDP FIELD NUMBER: 446 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 150 NCPDP FIELD NUMBER: 330 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 151 NCPDP FIELD NUMBER: 454 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 154 NCPDP FIELD NUMBER: 600 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 155 NCPDP FIELD NUMBER: 418 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 159 NCPDP FIELD NUMBER: 461 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 163 NCPDP FIELD NUMBER: 462 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 167 NCPDP FIELD NUMBER: 463 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 170 NCPDP FIELD NUMBER: 464 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 173 NCPDP FIELD NUMBER: 343 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 176 NCPDP FIELD NUMBER: 344 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 179 NCPDP FIELD NUMBER: 345 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 94 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 96 NCPDP FIELD NUMBER: 455 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 99 NCPDP FIELD NUMBER: 402 PROCESSING MODE: STANDARD
PRESCRIBER SEGMENT	PRESCRIBER SEGMENT ORDER: 189 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD PRESCRIBER SEGMENT ORDER: 191 NCPDP FIELD NUMBER: 466 PROCESSING MODE: SPECIAL SPECIAL CODE: S BPS("X")="05" PRESCRIBER SEGMENT ORDER: 193 NCPDP FIELD NUMBER: 411 PROCESSING MODE: SPECIAL SPECIAL CODE: S BPS("X")=$G(BPS("RX",BPS(9002313.0201),"CAID #")) PRESCRIBER SEGMENT ORDER: 194 NCPDP FIELD NUMBER: 467 PROCESSING MODE: STANDARD PRESCRIBER SEGMENT ORDER: 196 NCPDP FIELD NUMBER: 427 PROCESSING MODE: STANDARD PRESCRIBER SEGMENT ORDER: 198 NCPDP FIELD NUMBER: 498 PROCESSING MODE: STANDARD PRESCRIBER SEGMENT ORDER: 200 NCPDP FIELD NUMBER: 468 PROCESSING MODE: STANDARD PRESCRIBER SEGMENT ORDER: 203 NCPDP FIELD NUMBER: 421 PROCESSING MODE: STANDARD PRESCRIBER SEGMENT ORDER: 205 NCPDP FIELD NUMBER: 469 PROCESSING MODE: STANDARD PRESCRIBER SEGMENT ORDER: 208 NCPDP FIELD NUMBER: 470 PROCESSING MODE: STANDARD
COB OTHER PAYMENTS SEGMENT	COB OTHER PAYMENTS ORDER: 218 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 220 NCPDP FIELD NUMBER: 337 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 223 NCPDP FIELD NUMBER: 338 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 225 NCPDP FIELD NUMBER: 339 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 228 NCPDP FIELD NUMBER: 340 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 231 NCPDP FIELD NUMBER: 443 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 234 NCPDP FIELD NUMBER: 341 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 237 NCPDP FIELD NUMBER: 342 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 240 NCPDP FIELD NUMBER: 431 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 243 NCPDP FIELD NUMBER: 471 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 245 NCPDP FIELD NUMBER: 472 PROCESSING MODE: STANDARD
DUR PPS SEGMENT	DUR PPS SEGMENT ORDER: 254 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD DUR PPS SEGMENT ORDER: 256 NCPDP FIELD NUMBER: 473 PROCESSING MODE: STANDARD DUR PPS SEGMENT ORDER: 260 NCPDP FIELD NUMBER: 439 PROCESSING MODE: STANDARD DUR PPS SEGMENT ORDER: 264 NCPDP FIELD NUMBER: 440 PROCESSING MODE: STANDARD DUR PPS SEGMENT ORDER: 266 NCPDP FIELD NUMBER: 441 PROCESSING MODE: STANDARD DUR PPS SEGMENT ORDER: 268 NCPDP FIELD NUMBER: 474 PROCESSING MODE: STANDARD DUR PPS SEGMENT ORDER: 270 NCPDP FIELD NUMBER: 475 PROCESSING MODE: STANDARD DUR PPS SEGMENT ORDER: 272 NCPDP FIELD NUMBER: 476 PROCESSING MODE: STANDARD
PRICING SEGMENT	PRICING SEGMENT ORDER: 280 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 282 NCPDP FIELD NUMBER: 409 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 284 NCPDP FIELD NUMBER: 412 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 286 NCPDP FIELD NUMBER: 477 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 289 NCPDP FIELD NUMBER: 433 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 292 NCPDP FIELD NUMBER: 438 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 294 NCPDP FIELD NUMBER: 478 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 297 NCPDP FIELD NUMBER: 479 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 301 NCPDP FIELD NUMBER: 480 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 304 NCPDP FIELD NUMBER: 481 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 307 NCPDP FIELD NUMBER: 482 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 310 NCPDP FIELD NUMBER: 483 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 313 NCPDP FIELD NUMBER: 484 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 316 NCPDP FIELD NUMBER: 426 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 319 NCPDP FIELD NUMBER: 430 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 320 NCPDP FIELD NUMBER: 423 PROCESSING MODE: STANDARD
COMPOUND SEGMENT	COMPOUND SEGMENT ORDER: 329 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 331 NCPDP FIELD NUMBER: 450 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 334 NCPDP FIELD NUMBER: 451 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 336 NCPDP FIELD NUMBER: 452 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 338 NCPDP FIELD NUMBER: 447 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 340 NCPDP FIELD NUMBER: 488 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 343 NCPDP FIELD NUMBER: 489 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 346 NCPDP FIELD NUMBER: 448 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 349 NCPDP FIELD NUMBER: 449 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 351 NCPDP FIELD NUMBER: 490 PROCESSING MODE: STANDARD

FHVAB1V5 (103) BPS NCPDP FORMATS (9002313.92)