| RECORD FORMAT NAME |
FHVAB2V5 |
| 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: 304
- PROCESSING MODE: STANDARD
|
| INSURANCE SEGMENT |
-
- INSURANCE SEGMENT ORDER: 41
- NCPDP FIELD NUMBER: 111
- PROCESSING MODE: STANDARD
-
- INSURANCE SEGMENT ORDER: 43
- NCPDP FIELD NUMBER: 302
- PROCESSING MODE: STANDARD
|
| CLAIM SEGMENT |
-
- CLAIM SEGMENT ORDER: 51
- NCPDP FIELD NUMBER: 111
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 53
- NCPDP FIELD NUMBER: 455
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 56
- NCPDP FIELD NUMBER: 402
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 58
- NCPDP FIELD NUMBER: 436
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 60
- NCPDP FIELD NUMBER: 407
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 62
- NCPDP FIELD NUMBER: 442
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 64
- NCPDP FIELD NUMBER: 403
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 65
- NCPDP FIELD NUMBER: 405
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 66
- NCPDP FIELD NUMBER: 406
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 67
- NCPDP FIELD NUMBER: 408
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 69
- NCPDP FIELD NUMBER: 414
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 72
- NCPDP FIELD NUMBER: 308
- PROCESSING MODE: STANDARD
|
