| RECORD FORMAT NAME |
ACSINMB1 |
| 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: 310
- PROCESSING MODE: STANDARD
-
- PATIENT SEGMENT ORDER: 35
- NCPDP FIELD NUMBER: 311
- PROCESSING MODE: STANDARD
-
- PATIENT SEGMENT ORDER: 37
- NCPDP FIELD NUMBER: 307
- PROCESSING MODE: STANDARD
-
- PATIENT SEGMENT ORDER: 38
- NCPDP FIELD NUMBER: 335
- PROCESSING MODE: STANDARD
|
| INSURANCE SEGMENT |
-
- INSURANCE SEGMENT ORDER: 49
- NCPDP FIELD NUMBER: 111
- PROCESSING MODE: STANDARD
-
- INSURANCE SEGMENT ORDER: 51
- NCPDP FIELD NUMBER: 302
- PROCESSING MODE: STANDARD
-
- INSURANCE SEGMENT ORDER: 52
- NCPDP FIELD NUMBER: 301
- PROCESSING MODE: STANDARD
|
| CLAIM SEGMENT |
-
- CLAIM SEGMENT ORDER: 60
- NCPDP FIELD NUMBER: 111
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 62
- NCPDP FIELD NUMBER: 455
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 65
- NCPDP FIELD NUMBER: 402
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 67
- NCPDP FIELD NUMBER: 436
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 69
- NCPDP FIELD NUMBER: 407
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 71
- NCPDP FIELD NUMBER: 442
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 73
- NCPDP FIELD NUMBER: 403
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 74
- NCPDP FIELD NUMBER: 405
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 75
- NCPDP FIELD NUMBER: 406
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 76
- NCPDP FIELD NUMBER: 408
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 78
- NCPDP FIELD NUMBER: 414
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 81
- NCPDP FIELD NUMBER: 420
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 84
- NCPDP FIELD NUMBER: 308
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 86
- NCPDP FIELD NUMBER: 461
- PROCESSING MODE: STANDARD
-
- CLAIM SEGMENT ORDER: 89
- NCPDP FIELD NUMBER: 462
- PROCESSING MODE: STANDARD
|
| PRESCRIBER SEGMENT |
-
- PRESCRIBER SEGMENT ORDER: 100
- NCPDP FIELD NUMBER: 111
- PROCESSING MODE: STANDARD
-
- PRESCRIBER SEGMENT ORDER: 102
- NCPDP FIELD NUMBER: 466
- PROCESSING MODE: SPECIAL
- SPECIAL CODE:
S BPS("X")="08"
-
- PRESCRIBER SEGMENT ORDER: 104
- 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)
|
| DUR PPS SEGMENT |
-
- DUR PPS SEGMENT ORDER: 112
- NCPDP FIELD NUMBER: 111
- PROCESSING MODE: STANDARD
-
- DUR PPS SEGMENT ORDER: 114
- NCPDP FIELD NUMBER: 439
- PROCESSING MODE: STANDARD
-
- DUR PPS SEGMENT ORDER: 116
- NCPDP FIELD NUMBER: 440
- PROCESSING MODE: STANDARD
-
- DUR PPS SEGMENT ORDER: 118
- NCPDP FIELD NUMBER: 441
- PROCESSING MODE: STANDARD
|
| PRICING SEGMENT |
-
- PRICING SEGMENT ORDER: 127
- NCPDP FIELD NUMBER: 111
- PROCESSING MODE: STANDARD
-
- PRICING SEGMENT ORDER: 129
- NCPDP FIELD NUMBER: 426
- PROCESSING MODE: STANDARD
|
| COMPOUND SEGMENT |
-
- COMPOUND SEGMENT ORDER: 139
- NCPDP FIELD NUMBER: 111
- PROCESSING MODE: STANDARD
-
- COMPOUND SEGMENT ORDER: 141
- NCPDP FIELD NUMBER: 450
- PROCESSING MODE: STANDARD
-
- COMPOUND SEGMENT ORDER: 144
- NCPDP FIELD NUMBER: 451
- PROCESSING MODE: STANDARD
-
- COMPOUND SEGMENT ORDER: 146
- NCPDP FIELD NUMBER: 452
- PROCESSING MODE: STANDARD
-
- COMPOUND SEGMENT ORDER: 148
- NCPDP FIELD NUMBER: 447
- PROCESSING MODE: STANDARD
-
- COMPOUND SEGMENT ORDER: 150
- NCPDP FIELD NUMBER: 488
- PROCESSING MODE: STANDARD
-
- COMPOUND SEGMENT ORDER: 152
- NCPDP FIELD NUMBER: 489
- PROCESSING MODE: STANDARD
-
- COMPOUND SEGMENT ORDER: 153
- NCPDP FIELD NUMBER: 448
- PROCESSING MODE: STANDARD
-
- COMPOUND SEGMENT ORDER: 155
- NCPDP FIELD NUMBER: 449
- PROCESSING MODE: STANDARD
|
