SDMDBIL5 (138)    BPS NCPDP FORMATS (9002313.92)

Name Value
RECORD FORMAT NAME SDMDBIL5
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:   STANDARD
  • TRANSACTION HEADER ORDER:   19
    NCPDP FIELD NUMBER:   201
    PROCESSING MODE:   STANDARD
  • 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:   334
    PROCESSING MODE:   STANDARD
  • PATIENT SEGMENT ORDER:   45
    NCPDP FIELD NUMBER:   335
    PROCESSING MODE:   STANDARD
INSURANCE SEGMENT
  • INSURANCE SEGMENT ORDER:   54
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • INSURANCE SEGMENT ORDER:   56
    NCPDP FIELD NUMBER:   302
    PROCESSING MODE:   STANDARD
  • INSURANCE SEGMENT ORDER:   59
    NCPDP FIELD NUMBER:   312
    PROCESSING MODE:   STANDARD
  • INSURANCE SEGMENT ORDER:   62
    NCPDP FIELD NUMBER:   313
    PROCESSING MODE:   STANDARD
CLAIM SEGMENT
  • CLAIM SEGMENT ORDER:   102
    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:   419
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   110
    NCPDP FIELD NUMBER:   420
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   113
    NCPDP FIELD NUMBER:   460
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   115
    NCPDP FIELD NUMBER:   308
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   117
    NCPDP FIELD NUMBER:   429
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   119
    NCPDP FIELD NUMBER:   453
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   122
    NCPDP FIELD NUMBER:   445
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   125
    NCPDP FIELD NUMBER:   446
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   127
    NCPDP FIELD NUMBER:   600
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   128
    NCPDP FIELD NUMBER:   418
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   129
    NCPDP FIELD NUMBER:   461
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   132
    NCPDP FIELD NUMBER:   462
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   136
    NCPDP FIELD NUMBER:   343
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   139
    NCPDP FIELD NUMBER:   344
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   142
    NCPDP FIELD NUMBER:   345
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   72
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   74
    NCPDP FIELD NUMBER:   455
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   77
    NCPDP FIELD NUMBER:   402
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   79
    NCPDP FIELD NUMBER:   436
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   81
    NCPDP FIELD NUMBER:   407
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   84
    NCPDP FIELD NUMBER:   456
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   87
    NCPDP FIELD NUMBER:   457
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   90
    NCPDP FIELD NUMBER:   458
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   93
    NCPDP FIELD NUMBER:   459
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   95
    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
PHARMACY PROVIDER SEGMENT
  • PHARMACY PROVIDER ORDER:   152
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • PHARMACY PROVIDER ORDER:   154
    NCPDP FIELD NUMBER:   465
    PROCESSING MODE:   STANDARD
  • PHARMACY PROVIDER ORDER:   156
    NCPDP FIELD NUMBER:   444
    PROCESSING MODE:   STANDARD
PRESCRIBER SEGMENT
  • PRESCRIBER SEGMENT ORDER:   164
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • PRESCRIBER SEGMENT ORDER:   166
    NCPDP FIELD NUMBER:   466
    PROCESSING MODE:   STANDARD
  • PRESCRIBER SEGMENT ORDER:   168
    NCPDP FIELD NUMBER:   411
    PROCESSING MODE:   STANDARD
  • PRESCRIBER SEGMENT ORDER:   171
    NCPDP FIELD NUMBER:   427
    PROCESSING MODE:   STANDARD
  • PRESCRIBER SEGMENT ORDER:   174
    NCPDP FIELD NUMBER:   498
    PROCESSING MODE:   STANDARD
  • PRESCRIBER SEGMENT ORDER:   176
    NCPDP FIELD NUMBER:   468
    PROCESSING MODE:   STANDARD
  • PRESCRIBER SEGMENT ORDER:   179
    NCPDP FIELD NUMBER:   421
    PROCESSING MODE:   STANDARD
COB OTHER PAYMENTS SEGMENT
  • COB OTHER PAYMENTS ORDER:   188
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   190
    NCPDP FIELD NUMBER:   337
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   192
    NCPDP FIELD NUMBER:   338
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   194
    NCPDP FIELD NUMBER:   339
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   196
    NCPDP FIELD NUMBER:   340
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   197
    NCPDP FIELD NUMBER:   443
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   198
    NCPDP FIELD NUMBER:   341
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   201
    NCPDP FIELD NUMBER:   342
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   204
    NCPDP FIELD NUMBER:   431
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   207
    NCPDP FIELD NUMBER:   471
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   209
    NCPDP FIELD NUMBER:   472
    PROCESSING MODE:   STANDARD
WORKERS COMP SEGMENT
  • WORKERS COMP SEGMENT ORDER:   218
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • WORKERS COMP SEGMENT ORDER:   221
    NCPDP FIELD NUMBER:   434
    PROCESSING MODE:   STANDARD
  • WORKERS COMP SEGMENT ORDER:   223
    NCPDP FIELD NUMBER:   327
    PROCESSING MODE:   STANDARD
  • WORKERS COMP SEGMENT ORDER:   224
    NCPDP FIELD NUMBER:   435
    PROCESSING MODE:   STANDARD
DUR PPS SEGMENT
  • DUR PPS SEGMENT ORDER:   233
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   235
    NCPDP FIELD NUMBER:   473
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   237
    NCPDP FIELD NUMBER:   439
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   239
    NCPDP FIELD NUMBER:   440
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   241
    NCPDP FIELD NUMBER:   441
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   243
    NCPDP FIELD NUMBER:   474
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   245
    NCPDP FIELD NUMBER:   475
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   247
    NCPDP FIELD NUMBER:   476
    PROCESSING MODE:   STANDARD
PRICING SEGMENT
  • PRICING SEGMENT ORDER:   255
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   257
    NCPDP FIELD NUMBER:   409
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   259
    NCPDP FIELD NUMBER:   412
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   261
    NCPDP FIELD NUMBER:   477
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   264
    NCPDP FIELD NUMBER:   433
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   267
    NCPDP FIELD NUMBER:   438
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   269
    NCPDP FIELD NUMBER:   478
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   272
    NCPDP FIELD NUMBER:   479
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   276
    NCPDP FIELD NUMBER:   480
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   279
    NCPDP FIELD NUMBER:   426
    PROCESSING MODE:   STANDARD
COUPON SEGMENT
  • COUPON SEGMENT ORDER:   289
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • COUPON SEGMENT ORDER:   291
    NCPDP FIELD NUMBER:   485
    PROCESSING MODE:   STANDARD
  • COUPON SEGMENT ORDER:   293
    NCPDP FIELD NUMBER:   487
    PROCESSING MODE:   STANDARD
COMPOUND SEGMENT
  • COMPOUND SEGMENT ORDER:   302
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   304
    NCPDP FIELD NUMBER:   450
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   307
    NCPDP FIELD NUMBER:   451
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   309
    NCPDP FIELD NUMBER:   452
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   311
    NCPDP FIELD NUMBER:   447
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   313
    NCPDP FIELD NUMBER:   488
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   315
    NCPDP FIELD NUMBER:   489
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   316
    NCPDP FIELD NUMBER:   448
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   318
    NCPDP FIELD NUMBER:   449
    PROCESSING MODE:   STANDARD
PRIOR AUTH SEGMENT
  • PRIOR AUTH SEGMENT ORDER:   327
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • PRIOR AUTH SEGMENT ORDER:   330
    NCPDP FIELD NUMBER:   498.14
    PROCESSING MODE:   STANDARD
CLINICAL SEGMENT
  • CLINICAL SEGMENT ORDER:   340
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • CLINICAL SEGMENT ORDER:   342
    NCPDP FIELD NUMBER:   491
    PROCESSING MODE:   STANDARD
  • CLINICAL SEGMENT ORDER:   344
    NCPDP FIELD NUMBER:   492
    PROCESSING MODE:   STANDARD
  • CLINICAL SEGMENT ORDER:   346
    NCPDP FIELD NUMBER:   424
    PROCESSING MODE:   STANDARD
  • CLINICAL SEGMENT ORDER:   347
    NCPDP FIELD NUMBER:   493
    PROCESSING MODE:   STANDARD
  • CLINICAL SEGMENT ORDER:   350
    NCPDP FIELD NUMBER:   494
    PROCESSING MODE:   STANDARD
  • CLINICAL SEGMENT ORDER:   351
    NCPDP FIELD NUMBER:   495
    PROCESSING MODE:   STANDARD
  • CLINICAL SEGMENT ORDER:   352
    NCPDP FIELD NUMBER:   496
    PROCESSING MODE:   STANDARD
  • CLINICAL SEGMENT ORDER:   354
    NCPDP FIELD NUMBER:   497
    PROCESSING MODE:   STANDARD
  • CLINICAL SEGMENT ORDER:   355
    NCPDP FIELD NUMBER:   499
    PROCESSING MODE:   STANDARD