ACSMSB1 (90)    BPS NCPDP FORMATS (9002313.92)

Name Value
RECORD FORMAT NAME ACSMSB1
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:   22
    NCPDP FIELD NUMBER:   401
    PROCESSING MODE:   STANDARD
  • TRANSACTION HEADER ORDER:   23
    NCPDP FIELD NUMBER:   110
    PROCESSING MODE:   STANDARD
  • TRANSACTION HEADER ORDER:   9
    NCPDP FIELD NUMBER:   101
    PROCESSING MODE:   STANDARD
PATIENT SEGMENT
  • PATIENT SEGMENT ORDER:   32
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • PATIENT SEGMENT ORDER:   34
    NCPDP FIELD NUMBER:   304
    PROCESSING MODE:   STANDARD
  • PATIENT SEGMENT ORDER:   35
    NCPDP FIELD NUMBER:   335
    PROCESSING MODE:   STANDARD
INSURANCE SEGMENT
  • INSURANCE SEGMENT ORDER:   44
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • INSURANCE SEGMENT ORDER:   46
    NCPDP FIELD NUMBER:   302
    PROCESSING MODE:   STANDARD
  • INSURANCE SEGMENT ORDER:   48
    NCPDP FIELD NUMBER:   301
    PROCESSING MODE:   STANDARD
CLAIM SEGMENT
  • CLAIM SEGMENT ORDER:   56
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   58
    NCPDP FIELD NUMBER:   455
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   61
    NCPDP FIELD NUMBER:   402
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   63
    NCPDP FIELD NUMBER:   436
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   65
    NCPDP FIELD NUMBER:   407
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   67
    NCPDP FIELD NUMBER:   442
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   69
    NCPDP FIELD NUMBER:   403
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   70
    NCPDP FIELD NUMBER:   405
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   71
    NCPDP FIELD NUMBER:   406
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   72
    NCPDP FIELD NUMBER:   408
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   74
    NCPDP FIELD NUMBER:   414
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   77
    NCPDP FIELD NUMBER:   308
    PROCESSING MODE:   STANDARD
  • CLAIM SEGMENT ORDER:   79
    NCPDP FIELD NUMBER:   446
    PROCESSING MODE:   STANDARD
PRESCRIBER SEGMENT
  • PRESCRIBER SEGMENT ORDER:   88
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • PRESCRIBER SEGMENT ORDER:   90
    NCPDP FIELD NUMBER:   466
    PROCESSING MODE:   STANDARD
  • PRESCRIBER SEGMENT ORDER:   92
    NCPDP FIELD NUMBER:   411
    PROCESSING MODE:   STANDARD
COB OTHER PAYMENTS SEGMENT
  • COB OTHER PAYMENTS ORDER:   101
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   103
    NCPDP FIELD NUMBER:   337
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   105
    NCPDP FIELD NUMBER:   338
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   107
    NCPDP FIELD NUMBER:   443
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   109
    NCPDP FIELD NUMBER:   341
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   112
    NCPDP FIELD NUMBER:   342
    PROCESSING MODE:   STANDARD
  • COB OTHER PAYMENTS ORDER:   115
    NCPDP FIELD NUMBER:   431
    PROCESSING MODE:   STANDARD
DUR PPS SEGMENT
  • DUR PPS SEGMENT ORDER:   124
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   126
    NCPDP FIELD NUMBER:   473
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   128
    NCPDP FIELD NUMBER:   439
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   130
    NCPDP FIELD NUMBER:   440
    PROCESSING MODE:   STANDARD
  • DUR PPS SEGMENT ORDER:   132
    NCPDP FIELD NUMBER:   441
    PROCESSING MODE:   STANDARD
PRICING SEGMENT
  • PRICING SEGMENT ORDER:   141
    NCPDP FIELD NUMBER:   111
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   143
    NCPDP FIELD NUMBER:   409
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   145
    NCPDP FIELD NUMBER:   426
    PROCESSING MODE:   STANDARD
  • PRICING SEGMENT ORDER:   148
    NCPDP FIELD NUMBER:   430
    PROCESSING MODE:   STANDARD