Table 1: SDMCD Incoming NCPDP Medicaid Claim Format

Table 1: SDMCD Incoming NCPDP Medicaid Claim Format
Data Element	Format	Required/Conditional/Optional
Required transaction header section
Bin #	NCPDP	Required ‘601574’
Version #	NCPDP	Required
Transaction code	NCPDP	Required
Processor control #	NCPDP	Optional
Pharmacy ID	10 N	Required National Provider ID (NPI)
*Cardholder ID#	9 A/N	Required SDMCD Medicaid ID #
Date of Birth	NCPDP	Required
Sex code	NCPDP	Required
Date filled	NCPDP	Required
Optional header information section
Patient first name	NCPDP	Required
Patient last name	NCPDP	Required
Required claim information section, the fields listed below are repeated per transaction submitted, for the same client same date filled.
RX#	NCPDP	Required
New/Refill #	NCPDP	Required
Metric quantity	NCPDP	Required
Days Supply	NCPDP	Required
Compound Code	NCPDP	Conditional
NDC#	NCPDP	Required
DAW	NCPDP	Conditional
Prescriber ID	9 A/N	Required DEA Number
Date prescription written	NCPDP	Optional
Usual & customary charge	NCPDP	Required
Optional claim information section
PA/MC code & number	NCPDP	Conditional Used for prior approval number, if one is applicable to the prescription. If prior approval is not applicable, then this field is used for primary care codes: R = REFERRAL - Prescription is written by a physician other than the PCP, but the PCP has provided the referral to the prescribing physician. Documentation must be available to verify the referral. When the PCP is an IHS, RHC, or FQHC, an R must be used. E = EXEMPT - Exempt prescriptions include: true emergency services, denoted as such on the prescription; or mental health prescriptions for individuals diagnosed with Severely and Persistently Mentally Ill (SPMI) or with Severely Emotionally Disturbed (SED), denoted as such on the prescription. D = DENTAL - Prescription is written by dental or orthodontic provider that does not have a South Dakota Medicaid provider number.
Level of service	NCPDP	SDMCD Conditional A value of 03 means emergency service.
Diagnosis code	NCPDP	Optional
Unit dose indicator	NCPDP	Conditional Code ‘3’ = pharmacy unit dosed
Gross amt due	NCPDP	Optional
Other payor amt	NCPDP	Conditional
Patient paid amt	NCPDP	Optional
DUR conflict code	NCPDP	Conditional [see Table 10]
DUR intervention	NCPDP	Conditional [see Table 10]
DUR outcome code	NCPDP	Conditional [see Table 10]
Other payor date/ primary payor denial date	NCPDP	Conditional