ACSFLMB1 (79)    BPS NCPDP FORMATS (9002313.92)

Name Value
RECORD FORMAT NAME ACSFLMB1
VERSION Version 5.1
PRODUCTION STATUS PRODUCTION
PAYER SHEET VERSION 2
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
  • PATIENT SEGMENT ORDER:   34
    NCPDP FIELD NUMBER:   335
    PROCESSING MODE:   STANDARD
INSURANCE SEGMENT
  • INSURANCE SEGMENT ORDER:   43
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • INSURANCE SEGMENT ORDER:   45
    NCPDP FIELD NUMBER:   302
    PROCESSING MODE:   STANDARD
  • INSURANCE SEGMENT ORDER:   48
    NCPDP FIELD NUMBER:   309
    PROCESSING MODE:   STANDARD
CLAIM SEGMENT
  • CLAIM SEGMENT ORDER:   101
    NCPDP FIELD NUMBER:   345
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   58
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   60
    NCPDP FIELD NUMBER:   455
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   63
    NCPDP FIELD NUMBER:   402
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   65
    NCPDP FIELD NUMBER:   436
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   67
    NCPDP FIELD NUMBER:   407
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   69
    NCPDP FIELD NUMBER:   456
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   72
    NCPDP FIELD NUMBER:   457
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   75
    NCPDP FIELD NUMBER:   442
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   77
    NCPDP FIELD NUMBER:   403
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   78
    NCPDP FIELD NUMBER:   405
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   79
    NCPDP FIELD NUMBER:   406
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   80
    NCPDP FIELD NUMBER:   408
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   82
    NCPDP FIELD NUMBER:   414
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   85
    NCPDP FIELD NUMBER:   420
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   88
    NCPDP FIELD NUMBER:   308
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   90
    NCPDP FIELD NUMBER:   429
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   92
    NCPDP FIELD NUMBER:   462
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   96
    NCPDP FIELD NUMBER:   343
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   98
    NCPDP FIELD NUMBER:   344
    PROCESSING MODE:   STANDARD
PRESCRIBER SEGMENT
  • PRESCRIBER SEGMENT ORDER:   111
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • PRESCRIBER SEGMENT ORDER:   113
    NCPDP FIELD NUMBER:   466
    PROCESSING MODE:   SPECIAL
    SPECIAL CODE:   
    S BPS("X")="08"
    
  • PRESCRIBER SEGMENT ORDER:   115
    NCPDP FIELD NUMBER:   411
    PROCESSING MODE:   SPECIAL
    SPECIAL CODE:   
    S BPS("X")=$P($G(^VA(200,BPS("RX",BPS(9002313.0201),"Prescriber IEN"),"PS1",1,0)),"^",2)
    
COB OTHER PAYMENTS SEGMENT
  • COB OTHER PAYMENTS ORDER:   124
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   126
    NCPDP FIELD NUMBER:   337
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   128
    NCPDP FIELD NUMBER:   338
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   130
    NCPDP FIELD NUMBER:   339
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   132
    NCPDP FIELD NUMBER:   340
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   134
    NCPDP FIELD NUMBER:   443
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   136
    NCPDP FIELD NUMBER:   342
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   139
    NCPDP FIELD NUMBER:   431
    PROCESSING MODE:   STANDARD
DUR PPS SEGMENT
  • DUR PPS SEGMENT ORDER:   148
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   150
    NCPDP FIELD NUMBER:   473
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   152
    NCPDP FIELD NUMBER:   439
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   154
    NCPDP FIELD NUMBER:   440
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   156
    NCPDP FIELD NUMBER:   441
    PROCESSING MODE:   STANDARD
PRICING SEGMENT
  • PRICING SEGMENT ORDER:   165
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   167
    NCPDP FIELD NUMBER:   409
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   169
    NCPDP FIELD NUMBER:   426
    PROCESSING MODE:   STANDARD
COMPOUND SEGMENT
  • COMPOUND SEGMENT ORDER:   179
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   181
    NCPDP FIELD NUMBER:   450
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   184
    NCPDP FIELD NUMBER:   451
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   186
    NCPDP FIELD NUMBER:   452
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   188
    NCPDP FIELD NUMBER:   447
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   190
    NCPDP FIELD NUMBER:   488
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   192
    NCPDP FIELD NUMBER:   489
    PROCESSING MODE:   STANDARD
  • COMPOUND SEGMENT ORDER:   193
    NCPDP FIELD NUMBER:   448
    PROCESSING MODE:   STANDARD