Name	Value
RECORD FORMAT NAME	ACSIAB1
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: 304 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 34 NCPDP FIELD NUMBER: 305 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 36 NCPDP FIELD NUMBER: 310 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 38 NCPDP FIELD NUMBER: 311 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 40 NCPDP FIELD NUMBER: 322 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 42 NCPDP FIELD NUMBER: 323 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 44 NCPDP FIELD NUMBER: 324 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 47 NCPDP FIELD NUMBER: 325 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 49 NCPDP FIELD NUMBER: 326 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 51 NCPDP FIELD NUMBER: 307 PROCESSING MODE: STANDARD PATIENT SEGMENT ORDER: 52 NCPDP FIELD NUMBER: 335 PROCESSING MODE: STANDARD
INSURANCE SEGMENT	INSURANCE SEGMENT ORDER: 61 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD INSURANCE SEGMENT ORDER: 65 NCPDP FIELD NUMBER: 312 PROCESSING MODE: STANDARD INSURANCE SEGMENT ORDER: 67 NCPDP FIELD NUMBER: 313 PROCESSING MODE: STANDARD INSURANCE SEGMENT ORDER: 69 NCPDP FIELD NUMBER: 524 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: 306 PROCESSING MODE: STANDARD
CLAIM SEGMENT	CLAIM SEGMENT ORDER: 101 NCPDP FIELD NUMBER: 458 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 104 NCPDP FIELD NUMBER: 459 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 106 NCPDP FIELD NUMBER: 442 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 108 NCPDP FIELD NUMBER: 403 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 109 NCPDP FIELD NUMBER: 405 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 110 NCPDP FIELD NUMBER: 406 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 111 NCPDP FIELD NUMBER: 408 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 113 NCPDP FIELD NUMBER: 414 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 116 NCPDP FIELD NUMBER: 415 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 119 NCPDP FIELD NUMBER: 419 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 121 NCPDP FIELD NUMBER: 420 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 125 NCPDP FIELD NUMBER: 308 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 127 NCPDP FIELD NUMBER: 429 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 129 NCPDP FIELD NUMBER: 418 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 130 NCPDP FIELD NUMBER: 461 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 133 NCPDP FIELD NUMBER: 462 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 137 NCPDP FIELD NUMBER: 463 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 140 NCPDP FIELD NUMBER: 464 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 143 NCPDP FIELD NUMBER: 343 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 145 NCPDP FIELD NUMBER: 344 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 148 NCPDP FIELD NUMBER: 345 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 84 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 86 NCPDP FIELD NUMBER: 455 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 89 NCPDP FIELD NUMBER: 402 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 91 NCPDP FIELD NUMBER: 436 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 93 NCPDP FIELD NUMBER: 407 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 95 NCPDP FIELD NUMBER: 456 PROCESSING MODE: STANDARD CLAIM SEGMENT ORDER: 98 NCPDP FIELD NUMBER: 457 PROCESSING MODE: STANDARD
PHARMACY PROVIDER SEGMENT	PHARMACY PROVIDER ORDER: 158 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD PHARMACY PROVIDER ORDER: 160 NCPDP FIELD NUMBER: 465 PROCESSING MODE: STANDARD PHARMACY PROVIDER ORDER: 162 NCPDP FIELD NUMBER: 444 PROCESSING MODE: STANDARD
PRESCRIBER SEGMENT	PRESCRIBER SEGMENT ORDER: 170 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD PRESCRIBER SEGMENT ORDER: 172 NCPDP FIELD NUMBER: 466 PROCESSING MODE: SPECIAL SPECIAL CODE: S BPS("X")="05" PRESCRIBER SEGMENT ORDER: 174 NCPDP FIELD NUMBER: 411 PROCESSING MODE: SPECIAL SPECIAL CODE: S BPS("X")=$G(BPS("RX",BPS(9002313.0201),"CAID #")) PRESCRIBER SEGMENT ORDER: 177 NCPDP FIELD NUMBER: 427 PROCESSING MODE: STANDARD PRESCRIBER SEGMENT ORDER: 179 NCPDP FIELD NUMBER: 498 PROCESSING MODE: STANDARD PRESCRIBER SEGMENT ORDER: 181 NCPDP FIELD NUMBER: 468 PROCESSING MODE: STANDARD PRESCRIBER SEGMENT ORDER: 184 NCPDP FIELD NUMBER: 421 PROCESSING MODE: STANDARD
COB OTHER PAYMENTS SEGMENT	COB OTHER PAYMENTS ORDER: 193 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 195 NCPDP FIELD NUMBER: 337 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 197 NCPDP FIELD NUMBER: 338 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 199 NCPDP FIELD NUMBER: 339 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 201 NCPDP FIELD NUMBER: 340 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 203 NCPDP FIELD NUMBER: 443 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 206 NCPDP FIELD NUMBER: 341 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 209 NCPDP FIELD NUMBER: 342 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 212 NCPDP FIELD NUMBER: 431 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 214 NCPDP FIELD NUMBER: 471 PROCESSING MODE: STANDARD COB OTHER PAYMENTS ORDER: 216 NCPDP FIELD NUMBER: 472 PROCESSING MODE: STANDARD
WORKERS COMP SEGMENT	WORKERS COMP SEGMENT ORDER: 225 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD WORKERS COMP SEGMENT ORDER: 228 NCPDP FIELD NUMBER: 434 PROCESSING MODE: STANDARD
DUR PPS SEGMENT	DUR PPS SEGMENT ORDER: 236 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD DUR PPS SEGMENT ORDER: 238 NCPDP FIELD NUMBER: 473 PROCESSING MODE: STANDARD DUR PPS SEGMENT ORDER: 240 NCPDP FIELD NUMBER: 439 PROCESSING MODE: STANDARD DUR PPS SEGMENT ORDER: 242 NCPDP FIELD NUMBER: 440 PROCESSING MODE: STANDARD DUR PPS SEGMENT ORDER: 245 NCPDP FIELD NUMBER: 441 PROCESSING MODE: STANDARD DUR PPS SEGMENT ORDER: 247 NCPDP FIELD NUMBER: 474 PROCESSING MODE: STANDARD DUR PPS SEGMENT ORDER: 249 NCPDP FIELD NUMBER: 475 PROCESSING MODE: STANDARD DUR PPS SEGMENT ORDER: 251 NCPDP FIELD NUMBER: 476 PROCESSING MODE: STANDARD
PRICING SEGMENT	PRICING SEGMENT ORDER: 260 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 262 NCPDP FIELD NUMBER: 409 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 264 NCPDP FIELD NUMBER: 412 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 266 NCPDP FIELD NUMBER: 477 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 269 NCPDP FIELD NUMBER: 433 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 272 NCPDP FIELD NUMBER: 481 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 275 NCPDP FIELD NUMBER: 482 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 278 NCPDP FIELD NUMBER: 484 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 281 NCPDP FIELD NUMBER: 426 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 284 NCPDP FIELD NUMBER: 430 PROCESSING MODE: STANDARD PRICING SEGMENT ORDER: 285 NCPDP FIELD NUMBER: 423 PROCESSING MODE: STANDARD
COMPOUND SEGMENT	COMPOUND SEGMENT ORDER: 294 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 296 NCPDP FIELD NUMBER: 450 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 299 NCPDP FIELD NUMBER: 451 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 301 NCPDP FIELD NUMBER: 452 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 303 NCPDP FIELD NUMBER: 447 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 305 NCPDP FIELD NUMBER: 488 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 307 NCPDP FIELD NUMBER: 489 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 308 NCPDP FIELD NUMBER: 448 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 310 NCPDP FIELD NUMBER: 449 PROCESSING MODE: STANDARD COMPOUND SEGMENT ORDER: 312 NCPDP FIELD NUMBER: 490 PROCESSING MODE: STANDARD
PRIOR AUTH SEGMENT	PRIOR AUTH SEGMENT ORDER: 322 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD PRIOR AUTH SEGMENT ORDER: 326 NCPDP FIELD NUMBER: 498.01 PROCESSING MODE: STANDARD PRIOR AUTH SEGMENT ORDER: 327 NCPDP FIELD NUMBER: 498.02 PROCESSING MODE: STANDARD PRIOR AUTH SEGMENT ORDER: 329 NCPDP FIELD NUMBER: 498.03 PROCESSING MODE: STANDARD PRIOR AUTH SEGMENT ORDER: 331 NCPDP FIELD NUMBER: 498.04 PROCESSING MODE: STANDARD PRIOR AUTH SEGMENT ORDER: 332 NCPDP FIELD NUMBER: 498.05 PROCESSING MODE: STANDARD PRIOR AUTH SEGMENT ORDER: 334 NCPDP FIELD NUMBER: 498.06 PROCESSING MODE: STANDARD PRIOR AUTH SEGMENT ORDER: 336 NCPDP FIELD NUMBER: 498.07 PROCESSING MODE: STANDARD PRIOR AUTH SEGMENT ORDER: 338 NCPDP FIELD NUMBER: 498.08 PROCESSING MODE: STANDARD PRIOR AUTH SEGMENT ORDER: 340 NCPDP FIELD NUMBER: 498.09 PROCESSING MODE: STANDARD PRIOR AUTH SEGMENT ORDER: 343 NCPDP FIELD NUMBER: 498.11 PROCESSING MODE: STANDARD PRIOR AUTH SEGMENT ORDER: 345 NCPDP FIELD NUMBER: 498.14 PROCESSING MODE: STANDARD PRIOR AUTH SEGMENT ORDER: 348 NCPDP FIELD NUMBER: 503 PROCESSING MODE: STANDARD PRIOR AUTH SEGMENT ORDER: 350 NCPDP FIELD NUMBER: 498.13 PROCESSING MODE: STANDARD
CLINICAL SEGMENT	CLINICAL SEGMENT ORDER: 359 NCPDP FIELD NUMBER: 111 PROCESSING MODE: STANDARD CLINICAL SEGMENT ORDER: 362 NCPDP FIELD NUMBER: 491 PROCESSING MODE: STANDARD CLINICAL SEGMENT ORDER: 364 NCPDP FIELD NUMBER: 492 PROCESSING MODE: STANDARD CLINICAL SEGMENT ORDER: 366 NCPDP FIELD NUMBER: 424 PROCESSING MODE: STANDARD CLINICAL SEGMENT ORDER: 367 NCPDP FIELD NUMBER: 493 PROCESSING MODE: STANDARD CLINICAL SEGMENT ORDER: 370 NCPDP FIELD NUMBER: 494 PROCESSING MODE: STANDARD CLINICAL SEGMENT ORDER: 371 NCPDP FIELD NUMBER: 495 PROCESSING MODE: STANDARD CLINICAL SEGMENT ORDER: 372 NCPDP FIELD NUMBER: 496 PROCESSING MODE: STANDARD CLINICAL SEGMENT ORDER: 374 NCPDP FIELD NUMBER: 497 PROCESSING MODE: STANDARD CLINICAL SEGMENT ORDER: 375 NCPDP FIELD NUMBER: 499 PROCESSING MODE: STANDARD

ACSIAB1 (82) BPS NCPDP FORMATS (9002313.92)