D A T A E LE M E N T R E Q U E S T F O R M (DERF)/E X TE R N A L C O D E L IS T (ECL)
DERF/ECL INSTRUCTIONS
Please refer to the following instructions when completing this DERF/ECL form. Use additional attachments when necessary to provide complete information. Incomplete forms will be returned for additional information prior to processing. This form is used for multiple purposes: 1) To add/modify a data element to the Data Dictionary, 2) To add/modify a data element value to the
External Code List (ECL), 3) To add/modify information in a standard or implementation guide, 4) To bring forward a new standard or implementation guide.
R EFERENCES OTHER SDO D ATA D ICTIONARY ( LIST SDO, STANDARD AND VERSION ):
NCPDP S TANDARDS /I MPLEMENTATION G UIDES : I NDICATE WHICH STANDARDS ( S ) ARE IMPACTED BY THIS REQUEST
Audit Formulary & Benefit Prescription File Transfer Telecommunication
Batch
Billing Unit
Data Dictionary
External Code List
Manufacturer Rebates
Medicaid Subrogation
Medical Rebates
Pharmacy/Combo ID Card
Prior Authorization Transfer
Product Identifiers
Retiree Drug Subsidy
SCRIPT
UCF/ WC UCF
Uniform Healthcare Payer Data
XML Standard
Financial Information
Reporting
Post Adjudication Specialized
DESCRIBE THE BUSINESS NEED OR PURPOSE ADDRESSED BY THIS DERF/ECL SUBMISSION (REQUIRED): This section should explain, in detail, what the requester would like changed, added, or deleted and the reasons why the modifications are necessary.
The written explanation should give the readers an understanding as to what the requester is attempting to accomplish.
NEW DATA ELEMENT - Use this section to indicate the proposed field name, the size (length, including decimals, if applicable), and the format (e.g. numeric, alpha/numeric, dollar). Include a definition of the field. If applicable, every value/code requested must contain a definition. Specify the situation in which this new field would be used. Fill out Transaction Usage section next.
Proposed Name or XML tag (required):
Size (required): Format (required):
Segment for the New Data Element (required for Telecom or XML-based standard):
Definition (required):
Codes/Values – every code/value must include a definition (Use attachments if necessary): (Staff will determine actual code or value)
Value Suggested Value Description (required) Value Description Definition (as needed for
clarity)
Value Limitations (not
required)
Number of Repetitions for New Data Element (required if repeating data element):
Reject Codes – Add new reject codes associated with the new data element. (Staff assigns all values and creates standard reject codes for new fields.)
Value Suggested Value Description (required) Value Limitation or Explanation (not required)
CHANGE EXISTING DATA ELEMENT (ALL INFORMATION IS REQUIRED FOR CHANGES) To change a data element, complete this section, indicating the current Data Dictionary/ECL element information. For applicable standards, list the Field Number and ID from the Data Dictionary. Check what information is changing (e.g. field size (length), format (numeric, alpha/numeric, dollar), adding or changing a value, field name or definition). Summarize all changes that are being requested. Fill out Transaction Usage section next.
Field Number : ID: Name or XML tag:
Revised: February 2015 Page: 1

Requested change to (choose at least one): Size
Limitations to change: (i.e. “Used in Versions XX and above.”)
Summarize Proposed Changes (Use attachments if necessary):
Format Values
Codes/Values – every code/value change must include a definition (Use attachments if necessary):
Value Suggested Value Description (required)
Definition
Value Description Definition (as needed for
clarity)
Name
Value Limitations (not
required)
TELECOMMUNICATION STANDARD ONLY
REQUESTING EMERGENCY ECL CHANGE associated to
Regulatory/Legislative Compliance
Reason for Emergency Change / Reference to
Regulation or Legislation:
EMERGENCY ECL REQUESTS PERTAIN ONLY TO THE
TELECOMMUNICATION STANDARD. Used for regulatory and legislative changes which require the addition of a value(s) to be implemented prior to the scheduled annual implementation date of the next ECL Publication. If approved, the request will appear in the next ECL publication. There will be a minimum of 180 days required before the implementation of an
Date Needed By:
(no earlier than 180 days from the ECL Publication) emergency ECL change. Please refer to the Publication Release/
Implementation Dates Chart in the Emergency Telecommunication External
Code List Value Addendum.
TRANSACTION USAGE- Which transaction(s) is the field used in? (Use attachments if necessary): (required for Telecom or Batch Standard)
Standard
Audit
Batch
Financial Information Reporting
Formulary and Benefit
Manufacturer Rebates
Medicaid Subrogation
Medical Rebates Data Submission
Post Adjudication
Prescription File Transfer
Retiree Drug Subsidy
Prior Authorization Transfer
SCRIPT
Specialized
Revised: February 2015
Indicate Transaction(s)/File Used
NewRx
RxRenewalRequest/Response
RxFill
RxFillIndicatorChange
CancelRx
CancelRxResponse
GetMessage
RxChangeRequest/Response
RxHistory Request/ Response
CancelRx and NewRx
Resupply
DrugAdministration
NewRxRequest
NewRxResponseDenied
PAInitiationRequest/Response
PARequest/Response
PAAppealRequest/Response
PACancelRequest/Response
RxTransferRequest/Response
RxTransferConfirm
Census
MTMServiceRequest/Response
MTMService Documentation
ClinicalInfoRequest/Response
Page: 2
If Used, Situation must be provided.

Telecommunication
Uniform Healthcare Payer Data
XML Standard (Required)
CFInventoryList
CFProductInquiry/Response
CFRxOrderRequest
CFRxOrderCompletion
CFRxOrderCancel
CFManifest
Eligibility Verification
Claim Billing/Rebill/Encounter
Service Billing/Rebill
Predetermination of Benefits
Claim Reversal
Service Reversal
Prior Authorization Request and Billing
(Claim)
Prior Authorization Request and Billing
(Service)
Prior Authorization Reversal (Claim)
Prior Authorization Reversal (Service)
Prior Authorization Inquiry
Prior Authorization Request Only (Claim)
Information Reporting/Rebill (Claim)
Information Reporting/Rebill (Service)
Information Reporting Reversal (Claim)
Information Reporting Reversal (Service)
Controlled Substance Reporting/ Rebill
(specify non-prescription or general)
Controlled Substance Reporting Reversal
(specify non-prescription or general)
Transport Transactions
Error
Status
Verify
Get Message
Password Change
(T HIS S ECTION M UST B E C OMPLETED )
S UBMITTER
Name:
Title:
Company:
Address:
Task Group submitting DERF (if applicable):
Fax:
email:
City/State/Zip: Phone:
Signature: Date:
OR
AINTENANCE AND
ONTROL
SE
NLY
Work Groups that may be impacted (check all appropriate boxes):
WG1 Telecommunication
WG2 Product Identification
WG3 Standard Identifiers
WG7 Manufacturer & Associated Trading Partner
Transaction Standards
WG9 Government Programs
WG10 Professional Pharmacy Services
WG11 ePrescribing & Related Transactions
WG14 Long Term Post Acute Care
WG16 Property and Casualty/Workers’ Compensation
WG45 External Standards Assessment, Harmonization, and Implementation
Guidance
MC Maintenance and Control
Other
Return completed form by email, mail or fax:
NCPDP, 9240 E. Raintree Drive, Scottsdale, Arizona 85260-7519 email DERF@NCPDP.org  fax (480) 767-1042  phone (480) 477-1000
Revised: February 2015 Page: 3

This section is used by NCPDP Staff Only
DERF MODIFICATIONS (Actions Taken by WG(s) Review)
WG
DERF/ ECL STATUS:
Approved/Reviewed with no modifications
Approved/Reviewed with modifications (complete modifications below)
Pended by work group
Reason:
Denied by Work Group
Withdrawn by submitter
Changed ECL to DERF (also check appropriate DERF status)
Reason:
Vote
Approved
Opposed
Pink Yellow Green Total
Modifications:
MC
DERF/ ECL STATUS:
Approved/Reviewed with no further modifications
Approved/Reviewed with further modifications (complete modifications below)
Pended by work group
Reason:
Denied by Work Group
Withdrawn by submitter
Changed ECL to DERF (also check appropriate DERF status)
Vote
Approved
Opposed
Pink Yellow Green Total
Modifications:
Revised: February 2015 Page: 4