Hawaii Medicaid Payer Sheet
B1-B3 Transactions
NCPDP VERSION 5 PAYER SHEET – B1/B3 Transactions
**GENERAL INFORMATION**
Payer Name: Hawaii Medicaid Fee for Service
Date: January 1, 2006
Plan Name/Group Name: Hawaii Medicaid
Processor: ACS State Healthcare
Switch: NDCHealth, WebMD or QS1/Powerline
Effective as of: To be determined
Version/Release #: 5.1
Certification: Certification is not required, however, testing will be offered to software vendors
ACS POS Help Desk: 1-877-439-0803
Other versions supported: 3C until a date TBD
** OTHER TRANSACTIONS SUPPORTED **
Transaction Code
B1
B3
Transaction Name
Billing
ReBill
BILLING TRANSACTION:
Transaction Header Segment: Mandatory in all cases
Field #
1Ø1-A1
1Ø2-A2
1Ø3-A3
NCPDP Field Name/length
BIN Number
Version/Release Number
Transaction Code
1Ø4-A4
Processor Control Number
1Ø9-A9
Transaction Count
2Ø2-B2
2Ø1-B1
4Ø1-D1
11Ø-AK
Service Provider ID Qualifier
Service Provider ID
Date of Service
Software Vendor/Certification ID
Value
61ØØ84
51
B1 = Billing
B2 = Reversals
B3 = Rebill
DRHIPROD = Production
DRHIACCP = Test
1 = One Occurrence
2 = Two Occurrences
3 = Three Occurrences
4 = Four Occurrences
Ø7 – NCPDP Provider number
NCPDP Provider number
CCYYMMDD
ØØØØØØØØØØ
M/R/RW
M
M
M
Comment
M
M
M
M
M
M
Populate with zeros
M/R/RW
M
NA
Comment
Patient Segment
Not used by Hawaii
NA
R
R
Not used by Hawaii
NA
NA
NA
NA
NA
Not used by Hawaii
Not used by Hawaii
Not used by Hawaii
Not used by Hawaii
Not used by Hawaii
Patient Segment: Optional
Field
111-AM
331-CX
NCPDP Field Name
Segment Identification
Patient ID Qualifier
332-CY
3Ø4-C4
3Ø5-C5
Patient ID
Date of Birth
Patient Gender Code
31Ø –CA
311 – CB
322-CM
323-CN
324-CO
Value
Ø1
Blank = Not Specified
Ø1=Social Security Number
Ø2=Driver’s License Number
Ø3=U.S. Military ID
99=Other
CCYYMMDD
Ø=Not specified
1=Male
2=Female
Patient First Name
Patient Last Name
Patient Street Address
Patient City Address
Patient State/Province Address
Page: 1
Hawaii Medicaid Payer Sheet
Field
325-CP
326-CQ
3Ø7-C7
NCPDP Field Name
Patient Zip/POSTAL Zone
Patient Phone Number
Patient Location
333-CZ
334-1C
335-2C
Employer ID
Smoker/Non-Smoker Code
Pregnancy Indicator
B1-B3 Transactions
Value
Ø=Not specified
1=Home
2=Inter-Care
3=Nursing Home
4=Long Term/Extended Care
5=Rest Home
6=Boarding Home
7=Skilled Care Facility
8=Sub-Acute care Facility
9=Acute Care Facility
1Ø=Outpatient
11=Hospice
Blank=Not Specified
1=Not pregnant
2=Pregnant
M/R/RW
NA
NA
NA
Comment
Not used by Hawaii
Not used by Hawaii
Not used by Hawaii
NS
NS
NA
Not Supported
Not Supported
Not used by Hawaii
Insurance Segment: Mandatory
Field #
111-AM
3Ø2-C2
NCPDP Field Name
Segment Identification
Cardholder ID
312-CC
313-CD
314-CE
524-FO
3Ø9-C9
Cardholder First Name
Cardholder Last Name
Home Plan
Plan ID
Eligibility Clarification Code
Value
Ø4
1Ø digit Hawaii Medicaid ID
number
Ø=Not specified
M/R/RW
M
M
Comment
Insurance Segment
NA
NA
NS
NA
NA
Not used by Hawaii
Not used by Hawaii
Not Supported
Not used by Hawaii
Not used by Hawaii
NS
R
Not Supported
RW
Default to “1”
1=No Override
2=Override
3=Full Time Student
4=Disabled Dependent
5=Dependent Parent
6=Significant Other
336-8C
3Ø1-C1
Facility ID
Group ID
3Ø6-C6
Patient Relationship Code
HAWAII1ØØØ
OYS members use – HAWAII2ØØØ
1 = Cardholder
2 = Spouse
3=Child
4=Other
Page: 2
Hawaii Medicaid Payer Sheet
B1-B3 Transactions
Claim Segment: Mandatory
Field #
111-AM
455-EM
4Ø2-D2
436-E1
4Ø7-D7
456-EN
NCPDP Field Name
Segment Identification
Prescription/Service Reference Number
Qualifier
Prescription/Service Reference Number
457-EP
458-SE
459-ER
442-E7
4Ø3-D3
Product/Service ID Qualifier
Product/Service ID
Associated Prescription/Service
Reference #
Associated Prescription/Service Date
Procedure Modifier Count
Procedure Modifier Code Count
Quantity Dispensed
Fill Number
4Ø5-D5
4Ø6-D6
Days Supply
Compound Code
Value
Ø7
1 = Rx Billing
Number assigned by the
pharmacy
Ø3 = National Drug Code
NDC Number
Metric Decimal Quantity
Ø = Original Dispensing
1-99 = Number of refills
Ø= Not specified
M/R/RW
M
M
Comment
Claim Segment
M
M
M
NA
NA
NA
NA
R
R
R
NA
1= Not a compound
2 = Compound
Not used by Hawaii
Not used by Hawaii
Not used by Hawaii
Not used by Hawaii
Not used by Hawaii.
Compounds have to
be submitted on paper.
Required when it is
necessary to submit a
claim.
4Ø8-D8
Dispense as Written (DAW)
Ø=Default, no product
selection indicated
1=Physician request
5=brand used as generic
7=brand mandated by law
RW
414-DE
415-DF
Date Prescription Written
Number of Refills Authorized
CCYYMMDD
R
NA
Not used by Hawaii
419-DJ
Prescription Origin Code
NA
Not used by Hawaii
42Ø-DK
Submission Clarification Code
NA
Not used by Hawaii.
Compounds have to
be submitted on paper.
46Ø-ET
Quantity Prescribed
NS
3Ø8-C8
Other Coverage Code
Not Supported, use
442-E7
Valid Value ‘8’ is the
only value accepted by
HI Medicaid. This
value is only accepted
when submitting an
SPAP claim requesting
copay reimbursement
only.
Ø=Not Specified
1-99=number of refill
Ø=Not specified
1=Written
2=Telephone
3=Electronic
4=Facsimile
Ø=Not specified, default
1=No override
2=Other override
3=Vacation Supply
4=Lost Prescription
5=Therapy Change
6=Starter Dose
7=Medically Necessary
8=Process compound for
Approved Ingredients
9=Encounters
99=Other
Ø=Not Specified
1=No other Coverage
Identified
2=Other coverage existspayment collected
3=Other coverage exists-this
claim not covered
4=Other coverage existspayment not collected
5=Managed care plan denial
6=Other coverage exists, not a
participating provider
7=Other Coverage exists-not
in effect at time of service
8=Claim is a billing for a copay
Page: 3
RW
Hawaii Medicaid Payer Sheet
Field #
429-DT
B1-B3 Transactions
NCPDP Field Name
Unit Dose Indicator
Value
Ø=Not specified
453-EJ
Orig Prescribed Product/Service ID Qual
445-EA
446-EB
330-CW
454-EK
418-DI
461-EU
Originally Prescribed Product/Service
Code
Originally Prescribed Quantity
Alternate ID
Scheduled prescription ID Number
Level of Service
Prior Authorization Type Code
462-EV
463-EW
464-EX
343-HD
Prior Authorization Number Submitted
Intermediary Authorization Type ID
Intermediary Authorization ID
Dispensing Status
344-HF
345-HG
6ØØ-28
Quantity Intended to be Dispensed
Days Supply Intended to be Dispensed
Unit of Measure
1=Not Unit Dose
2=Manufacturer Unit Does
3=Pharmacy Unit Does
Ø1=Universal Product
Code (UPC)
Ø3=National Drug Code
(NDC)
Ø=Not Specified
1=Prior Authorization
2=Medical Certification
3=EPSDT (Early Periodic
Screening Diagnosis
Treatment)
4=Exemption from Copay
5=Exemption from RX
6=Family Plan. Indic.
7=AFDC (Aid to Families with
Dependent Children)
8=Payer Defined Exemption
P = initial Fill
C = Completion
Page: 4
M/R/RW
NA
Comment
Not used by Hawaii
NA
Not used by Hawaii
NA
Not used by Hawaii
NA
NS
NS
NA
R
Not used by Hawaii
Not supported
Not Supported
Not used by Hawaii
Enter 1 for prior
authorization number
obtained through ACS
R
NA
NA
NA
Enter PA number
Not used by Hawaii
Not used by Hawaii
Not used by Hawaii
NA
NA
NS
Not used by Hawaii
Not used by Hawaii
Not Supported
Hawaii Medicaid Payer Sheet
B1-B3 Transactions
Pharmacy Provider Segment: Optional – this segment is not used by Hawaii Medicaid
Field #
111-AM
NCPDP Field Name
Segment Identification
465-EY
Provider ID Qualifier
444-E9
Provider ID
Value
Ø2
M/R/RW
NA
Blank=Not specified
Ø1=Drug Enforcement
Administration (DEA)
Ø2=State License
Ø3=Social Security Number
(SSN)
Ø4=Name
Ø5=National Provider Identifier
(NPI)
Ø6=Health Industry Number
(HIN)
Ø7=State Issued
99=Other
NA
Comment
Pharmacy Provider
Segment
Not used by Hawaii
NA
Not used by Hawaii
M/R/RW
M
R
Comment
Prescriber Segment
Prescriber Segment: Optional
Field #
111-AM
466-EZ
NCPDP Field Name
Segment Identification
Prescriber ID Qualifier
411-DB
Prescriber ID
467-1E
427-DR
498-PM
468-2E
Prescriber Location Code
Prescriber Last Name
Prescriber Phone Number
Primary Care Provider ID Qualifier
421-DL
469-H5
47Ø-4E
Primary Care Provider ID
Primary care Provider Location Code
Primary Care Provider Last Name
Value
Ø3
12 = Drug Enforcement
Administration (DEA) or
Ø5 = Medicaid ID number
DEA Number or HPMMIS
Medicaid provider ID
Blank=Not Specified
Ø1=National Provider ID (NPI)
Ø2=Blue Cross
Ø3=Blue Shield
Ø4=Medicare
Ø5=Medicaid
Ø6=UPIN
Ø7=NCPDP Provider ID
Ø8=State License
Ø9=Champus
1Ø=Health Industry Number
(HIN)
11=Federal Tax ID
12=Drug Enforcement
Administration (DEA)
13=State Issued
14=Plan Specific
99=Other
1
Page: 5
R
NS
NA
NA
NA
Not Supported
Not used by Hawaii
Not used by Hawaii
Not used by Hawaii
NA
NS
NS
Not used by Hawaii
Not Supported
Not Supported
Hawaii Medicaid Payer Sheet
B1-B3 Transactions
COB/Other Payments Segment: Optional – Not used by Hawaii POS
Field #
111-AM
NCPDP Field Name
Segment Identification
337-4C
Coordination of Benefits/Other Payments
Count
Other Payer Coverage Type
338-5C
Value
Ø5
M/R/RW
NA
Comment
COB/Other
Payments Segment
NA
NA
(Repeating)
339-6C
Other Payer Id Qualifier
34Ø-7C
443-E8
Other Payer ID
Other Payer Date
341-HB
342-HC
Other Payer Amount Paid Count
Other Payer Amount Paid Qualifier
431-DV
471-5E
472-6E
Other Payer Amount Paid
Other Payer Reject Count
Other Payer Reject Code
Blank=Not Specified
Ø1=National Payer ID
Ø2=Health Industry Number
Ø3=Bank Information Number
(BIN)
Ø4=National Association of
Insurance Commissioners
(NAIC)
Ø9=Coupon
99-Other
10 characters
CCYYMMDD
Blank=Not specified
Ø1=Delivery
Ø2=Shipping
Ø3=Postage
Ø4=Administrative
Ø5=Incentive
Ø6=Cognitive Service
Ø7=Drug Benefit
Ø8=Sum of all Reimbursement
98=Coupon
99=Other
S$$$$$$cc
2 Characters
NA
NA
NA
NA
NA
(Repeating)
NA
NA
NA
Workers’ Compensation Segment: Not used by Hawaii Medicaid
Field #
111-AM
NCPDP Field Name
Segment Identification
434-DY
315-CF
316-CG
317-CH
318-CI
319-CJ
320-CK
321-CL
327-CR
435-DZ
Date of Injury
Employer Name
Employer Street Address
Employer City Address
Employer State/Province ID
Employer Zip/Postal Zone
Employer Phone Number
Employer Contact Name
Carrier ID
Claim/Reference ID
Value
Ø6
M/R/RW
NA
NA
NS
NS
NS
NS
NS
NS
NS
NS
NS
Page: 6
Comment
Workers’
Compensation
Segment
Not Supported
Not Supported
Not Supported
Not Supported
Not Supported
Not Supported
Not Supported
Not Supported
Not Supported
Hawaii Medicaid Payer Sheet
B1-B3 Transactions
DUR/PPS Segment: Optional
Field #
111-AM
473-7E
NCPDP Field Name
Segment Identification
DUR/PPS Code counter
439-E4
Reason For Service Code
Value
Ø8
See Attached list of valid
values
M/R/RW
M
M
RW
(Repeating)
44Ø-E5
Professional Service Code
See Attached list of valid
values
RW
441-E6
Result of Service Code
See attached list of valid
values
RW
478-8E
475-J9
476-H6
DUR/PPS Level of Effort
DUR Co-Agent ID Qualifier
DUR Co-Agent ID
NA
NA
NA
Comment
DUR/PPS Segment
Required when
submitting this
segment
Required when there
is a conflict to resolve
or reason for service
to be explained
Required when there
is a professional
service to be
identified
Required when There
is a result of service
to be submitted
Not used by Hawaii
Not used by Hawaii
Not used by Hawaii
Pricing Segment: Mandatory
Field #
111-AM
409-D9
412-DC
477-BE
433-DX
478-H7
NCPDP Field Name
Segment Identification
Ingredient Cost Submitted
Dispensing Fee Submitted
Professional Service Fee Submitted
Patient Paid Amount
Other Amount Claims Submitted Count
479-H8
Value
11
Value must be greater than 0
M/R/RW
M
R
NA
NA
NA
RW
Other Amount Claimed Submitted
Qualifier
Valid value = 99
RW
480-H9
Other Amount Claimed Submitted
Value must be $1 or $3
RW
481-HA
482-GE
484-JE
Flat Sales Tax Amount Submitted
Percentage Sales Tax Amount
Submitted
Percentage Sales Tax Basis Submitted
426-DQ
430–DU
Usual and Customary Charge
Gross Amount Due
423-DN
Basis of Cost Determination
Blank=Not specified
01=Gross Amount Due
02=Ingredient Cost
03=Ingredient Cost +
Dispensing Fee
s9(6)v99
Blank=Not specified
ØØ=Not specified
Ø1=AWP (Average Wholesale
Price)
Ø2=Local Wholesaler
Page: 7
Comment
Pricing Segment
NA
NA
Not used by Hawaii
Not used by Hawaii
Not used by Hawaii
Required when
submitting an SPAP
claim for copay only
Required when
submitting an SPAP
claim for copay only
Required when
submitting an SPAP
claim for copay only.
The amount in this
field must match the
amount in the Gross
Amount Due field.
Not used by Hawaii
Not used by Hawaii
NA
Not used by Hawaii
R
RW
NA
The amount in this
field must match the
amount in Other
Amount Claimed
Submitted.
Not used by Hawaii
Hawaii Medicaid Payer Sheet
B1-B3 Transactions
Ø3=Direct
Ø4=EAC (Estimated
Acquisition Cost)
Ø5=Acquisition
Ø6=MAC (Maximum Allowable
Cost)
Ø7=Usual & customary
Ø9=Other
Coupon Segment: Segment is not supported
Field #
111-AM
485-KE
486-ME
487-NE
NCPDP Field Name
Segment Identification
Coupon Type
Coupon Number
Coupon Value Amount
Compound Segment: Optional
Value
Ø9
Comment
Coupon Segment
M/R/RW
N/A
NA
Comment
Compound Segment
- Segment not used by Hawaii
Field #
111-AM
45Ø-EF
NCPDP Field Name
Segment Identification
Compound Dosage Form Description
Code
451-EG
Compound Dispensing Unit Form
Indicator
452-EH
Compound Route of Administration
447-EC
Compound Ingredient Component
Value
1Ø
Ø1=Capsule
Ø2=Ointment
Ø3=Cream
Ø4=Suppository
Ø5=Powder
Ø6=Emulsion
Ø7=Liquid
1Ø=Tablet
11=Solution
12=Suspension
13=Lotion
14=Shampoo
15=Elixir
16=Syrup
17=Lozenge
18=Enema
1=Each
2=Grams
3=Milliliters
1=Buccal
2=Dental
3=Inhalation
4=Injection
5=Intraperitoneal
6=Irrigation
7=Mouth/Throat
8=Mucous Membrane
9=Nasal
1Ø=Ophthalmic
11=Oral
12=Other/Miscellaneous
13=Otic
14=Perfusion
15=Rectal
16=Sublingual
17=Topical
18=Transdermal
19=Translingual
2Ø=Urethral
21=Vaginal
22=Enteral
Compound Product ID Qualifier
NA
NA
NA
(Repeating)
(Count)
488-RE
M/R/RW
NS
NS
NS
NS
Ø1=Universal Product Code
(UPC)
Ø3=National Drug Code (NDC)
Page: 8
NA
(Repeating)
Hawaii Medicaid Payer Sheet
489-TE
B1-B3 Transactions
Compound Product ID
NA
(Repeating)
448-ED
9(7)v999
Compound Ingredient Quantity
NA
(Repeating)
449-EE
490-UE
Compound Ingredient Drug Cost
Compound ingredient basis of Cost
Determination
Blank=Not specified
Ø1=AWP
Ø2=Local Wholesaler
Ø3=Direct
Ø4=EAC
Ø5=Acquisition
Ø6=MAC
Ø7=Usual & customary
Ø9=Other
Page: 9
NA
NA
Hawaii Medicaid Payer Sheet
B1-B3 Transactions
Prior Authorization Segment: Not Used by Hawaii
Field #
111-AM
NCPDP Field Name
Segment Identification
498-PA
498-PB
498-PC
498-PD
498-PE
498-PF
498-PG
Request Type
Request Period Date –Begin
Request Period Date- End
Basis of Request
Authorized Representative First Name
Authorized Representative Last Name
Authorized Representative Street
Address
Authorized Representative City Address
Authorized Representative
State/Province Address
Authorized Representative Zip/Postal
Code
Prior Authorization Number Assigned
Authorization Number
Prior Authorization Supporting
Documentation
498-PH
498-PJ
498-PK
498-PY
503-F3
498-PP
Value
12
M/R/RW
NA
Comment
Prior Authorization
Segment
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Clinical Segment: Required When
Field #
111-AM
491-VE
492-WE
NCPDP Field Name
Segment Identification
Diagnosis Code Count
Diagnosis Code Qualifier
Value
13
424-DO
Diagnosis Code
RW
493-XE
Clinical Information Counter
NA
494-ZE
Measurement Date
NA
495-H1
496-H2
497-H3
499-H4
Measurement Time
Measurement Dimension
Measurement Unit
Measurement Value
NA
NA
NA
NA
Page: 10
M/R/RW
NA
RW
RW
Comment
Clinical Segment
Always a “1”
Ø1=International
Classification of
Diseases (ICD9)
Used when known to
bypass prior
authorization
rejections.
Drug Utilization Review Coding
Reason for Service Codes (DUR Conflict Codes)
Code
Meaning
Code
Meaning
AT
CH
DA
DC
DD
DF
DI
DL
DS
ER
HD
IC
ID
Additive Toxicity
Call Help Desk
Drug Allergy Alert
Inferred Drug Disease Precaution
Drug-Drug Interaction
Drug Food Interactions
Drug Incompatibility
Drug Lab conflict
Tobacco use precaution
Over Use precaution
High Dose alert
Iatrogenic condition alert
Ingredient Duplication
LD
LR
MC
MN
MX
OH
PA
PG
PR
SE
SX
TD
Low Dose alert
Under Use Precaution
Drug Disease Precaution
Insufficient Duration Alert
Excessive Duration Alert
Alcohol Precaution
Drug Age Precaution
Drug Pregnancy alert
Prior Adverse drug reaction
Side effect alert
Drug gender alert
Therapeutic Duplication
Professional Service Codes (Intervention Codes)
Code
Meaning
Code
M0
P0
MD Interface
Patient Interaction
R0
Meaning
Pharmacist reviewed
Result of Service Codes (DUR Outcome Codes)
Code
Meaning
Code
Meaning
1A
1B
1C
1D
Filled – False Positive
Filled as is
Filled with different dose
Filled with different directions
1F
1G
2A
2B
Filled – Different quantity
Filled after prescriber approval
Not Filled
Not Filled – Directions Clarified


DUR Information, if applicable, will appear in the text message of the response
Mail paper drug claims to:
ACS State Healthcare
Attn: Hawaii Medicaid
Northridge Center One, Ste 400
365 Northridge Road
Atlanta, GA 30350
Page: 11