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BLUE CROSS BLUE SHIELD OF ARIZONA

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BCBS AZ Payer Sheet
September 24, 1998

Blue Cross Blue Sheild Arizonia

Bin #: 603017
States: National
Destination: ComCoTec
Accepting: Claim Adjudication, Reversals
Format: NCPDP Version 3A or 32V


1. NCPDP Data Elements Version
Fld #Data ElementFormatDescription
Required Header Information
101-A1Bin # NCPDPRequired, “603017”
102-A2Version # NCPDPRequired, “32” or “3A”
103-A3Transaction Code NCPDPRequired
104-A4Processor Control # 10 A/NRequired, NDC Definition:
POS 1-5: Plan ID
POS 6-8: NDC System ID, 3A/N
POS 9-10: Blank
201-B1Pharmacy # NCPDP Required
301-C1Group # NCPDPOptional
302-C2Cardholder ID # NCPDPRequired
303-C3Person Code NCPDPOptional
304-C4Date of Birth NCPDPRequired
305-C5Sex Code NCPDPRequired
306-C6Relationship Code NCPDPRequired
308-C8Other Coverage Code NCPDPOptional
401-D1Date Filled NCPDPRequired
Optional Header Information
307-C7Customer Location NCPDPOptional
309-C9Elig Clarif. Code NCPDPOptional
310-CAPatient First Name NCPDPRequired
311-CBPatient Last Name NCPDPRequired
Required Claim Information
402-D2RX # NCPDPRequired
403-D3New/Refill Code NCPDPRequired
404-D4Metric Quantity NCPDPRequired
405-D5Days Supply NCPDPRequired
406-D6Compound Code NCPDPRequired
407-D7NDC # NCPDPRequired
408-D8Disp. as Written NCPDPRequired
409-D9Ingredient Cost NCPDPRequired
411-DBPrescriber ID NCPDPRequired
414-DEDate Written NCPDPRequired
415-DF# Refills Auth. NCPDPRequired
419-DJPrescr.Origin Code NCPDPOptional
420-DKPrescr. Denial Clar. NCPDPOptional
Optional Claim Information
410-DASales Tax NCPDPOptional
412-DCDisp. Fee Submitted NCPDPRequired
416-DGPA/MC Code & Number NCPDPOptional
418-DILevel of Service NCPDPOptional
421-DLPrimary Prescriber NCPDPOptional
422-DMClinic ID NCPDPOptional
423-DNBasis of Cost Deter. NCPDPOptional
424-DODiagnosis Code NCPDPOptional
430-DUGross Amount Due NCPDPRequired
433-DXPatient Paid Amount NCPDPRequired
439-E4DUR Conflict Code NCPDPRequired
440-E5DUR Intervention Code NCPDPRequired
441-E6DUR Outcome Code NCPDPRequired
442-E7Metric Decimal Qty. NCPDPRequired
An "optional" data element means the plan does not currently use the field for claim adjudication, but reserves the possiblity of use in the future.



2. GENERAL INFORMATION

Live Date: 10/1/98

Maximum prescriptions per transactions: 4

Plan specific information/customer service: 800-232-2345 x4273
602-864-4273

Pharmacy Help Desk: 1-800-325-1810

Vendor certification required: No

Switch Support: 1-800-388-2316

Technical assistance\Help Desk: 1-630-268-3600
ask for: RxCLAIM tech support

3. TEST DATA

Pharmacy ID = 0000240
Call Plan Customer Service help desk for testing specific plans





4. OTHER INFORMATION
Prescriber ID—DEA# is the required entry for Prescriber ID.

ComCoTec provides on-line prospective DUR edits for all of their plans. Please contact their help desk for further information.





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