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

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