GLOBAL MAP DATA DICTIONARY #9002313.02 -- BPS CLAIMS FILE 3/24/25 PAGE 1
STORED IN ^BPSC( *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 1.0)
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Intermediate form of transmissions. Fields are stored in formatted form. Raw packet is also stored.
Most fields are in Free Text format to accommodate NCPDP Standard formatting criteria and required field lengths. Fields other
than those with decimals in the number correlate directly to the field numbers supplied in the NCPDP Data Dictionary.
While many of the fields in this file indicate coded values, they are NCPDP coded values preceded by the NCPDP field identifier to
be used in the NCPDP transmission. Example: Compound Code is either a 1 or 0. The NCPDP field identifier for 'Compound Code' is
'D6'. The field length is 3 thereby allowing the identifier for that field to be included in the data stored in that field. So,
'D61' is stored for that field.
Per VHA Directive 2004-038, this file definition should not be modified.
CROSS
REFERENCED BY: TRANSMIT FLAG(AD), TRANSMITTED ON(AE), DATE OF SERVICE(AF), DATE CLOSED(AG), CLAIM ID(B), PATIENT NAME(C)
INDEXED BY: CLOSED (AC)
^BPSC(D0,0)= (#.01) CLAIM ID [1F] ^ (#.02) ELECTRONIC PAYER [2P:9002313.92] ^ ^ (#.04) TRANSMIT FLAG [4S] ^ (#.05) TRANSMITTED
==>ON [5D] ^ (#.06) CREATED ON [6D] ^ (#.07) AUTO REVERSE FLAG [7S] ^ (#.08) TRANSACTION [8P:9002313.59] ^
^BPSC(D0,1)= (#1.01) PATIENT NAME [1F] ^ ^ ^ (#1.04) GROUP INSURANCE PLAN [4P:355.3] ^
^BPSC(D0,100)= (#101) IIN NUMBER [1F] ^ (#102) VERSION/RELEASE NUMBER [2F] ^ (#103) TRANSACTION CODE [3F] ^ (#104) PROCESSOR
==>CONTROL NUMBER [4F] ^ ^ ^ ^ ^ (#109) TRANSACTION COUNT [9F] ^ (#110) SOFTWARE VENDOR/CERT ID [10F] ^
^BPSC(D0,110)= ^ ^ ^ (#114) MEDICAID SUBROGATION ICN/TCN [4F] ^ (#115) MEDICAID ID NUMBER [5F] ^ (#116) MEDICAID AGENCY NUMBER
==>[6F] ^
^BPSC(D0,200)= (#201) SERVICE PROVIDER ID [1F] ^ (#202) SERV PROVIDER ID QUALIFIER [2F] ^
^BPSC(D0,300)= (#301) GROUP ID [1F] ^ (#302) CARDHOLDER ID [2F] ^ (#303) PERSON CODE [3F] ^ (#304) DATE OF BIRTH [4F] ^ (#305)
==>PATIENT GENDER CODE [5S] ^ (#306) PATIENT RELATIONSHIP CODE [6F] ^ (#307) PLACE OF SERVICE [7F] ^ ^ (#309)
==>ELIGIBILITY CLARIFICATION CODE [9F] ^ (#310) PATIENT FIRST NAME [10F] ^ (#311) PATIENT LAST NAME [11F] ^ (#312)
==>CARDHOLDER FIRST NAME [12F] ^ (#313) CARDHOLDER LAST NAME [13F] ^ (#314) HOME PLAN [14F] ^
^BPSC(D0,321)= ^ (#322) PATIENT STREET ADDRESS [2F] ^ (#323) PATIENT CITY ADDRESS [3F] ^ (#324) PATIENT STATE/PROVINCE ADDRESS
==>[4F] ^ (#325) PATIENT ZIP/POSTAL ZONE [5F] ^ (#326) PATIENT TELEPHONE NUMBER [6F] ^
^BPSC(D0,330)= (#331) PATIENT ID QUALIFIER [1F] ^ (#332) PATIENT ID [2F] ^ (#333) EMPLOYER ID [3F] ^ (#334) SMOKER/NONSMOKER [4F]
==>^ (#335) PREGNANCY INDICATOR [5F] ^ (#336) FACILITY ID [6F] ^
^BPSC(D0,340)= ^ ^ ^ ^ ^ ^ ^ ^ ^ (#350) PATIENT E-MAIL ADDRESS [10F] ^
^BPSC(D0,350)= ^ ^ ^ ^ ^ (#356) OTHER PAYER CARDHOLDER ID [6F] ^ ^ ^ (#359) MEDIGAP ID [9F] ^ (#360) MEDICAID INDICATOR
==>[10F] ^
^BPSC(D0,360)= (#361) PROVIDER ACCEPT ASSGNMT INDCTR [1F] ^
^BPSC(D0,380)= ^ ^ ^ (#384) PATIENT RESIDENCE [4F] ^
^BPSC(D0,400,0)=^9002313.0201A^^ (#400) TRANSACTIONS
^BPSC(D0,400,D1,0)= (#.01) TRANSACTION ORDER [1N] ^ ^ ^ (#.04) MEDICATION NAME [4F] ^ (#.05) PRESCRIPTION NUMBER [5P:52] ^
^BPSC(D0,400,D1,110)= ^ ^ (#113) MEDICAID PAID AMOUNT [3F] ^ ^ ^ ^ (#117) BILLING ENTITY TYPE INDICATOR [7F] ^ (#118) PAY TO
==>QUALIFIER [8F] ^ (#119) PAY TO ID [9F] ^ (#120) PAY TO NAME [10F] ^
^BPSC(D0,400,D1,120)= (#121) PAY TO STREET ADDRESS [1F] ^ (#122) PAY TO CITY ADDRESS [2F] ^ (#123) PAY TO STATE/PROVINCE ADDRESS
==>[3F] ^ (#124) PAY TO ZIP/POSTAL ZONE [4F] ^ (#125) GENERIC EQUIV PROD ID QLFR [5F] ^ (#126) GENERIC
==>EQUIVALENT PRODUCT ID [6F] ^
^BPSC(D0,400,D1,140)= ^ ^ ^ ^ ^ ^ (#147) PHARMACY SERVICE TYPE [7F] ^
^BPSC(D0,400,D1,300)= ^ ^ ^ ^ ^ ^ ^ (#308) OTHER COVERAGE CODE [8F] ^
^BPSC(D0,400,D1,310)= ^ ^ ^ ^ (#315) EMPLOYER NAME [5F] ^ (#316) EMPLOYER STREET ADDRESS [6F] ^ (#317) EMPLOYER CITY ADDRESS
==>[7F] ^ (#318) EMPLOYER STATE/PROV ADDRESS [8F] ^ (#319) EMPLOYER ZIP/POSTAL ZONE [9F] ^ (#320) EMPLOYER
==>TELEPHONE NUMBER [10F] ^
^BPSC(D0,400,D1,320)= (#321) EMPLOYER CONTACT NAME [1F] ^ ^ ^ ^ ^ ^ (#327) CARRIER ID [7F] ^ ^ ^ (#330) ALTERNATE ID [10F]
==>^
^BPSC(D0,400,D1,330)= ^ ^ ^ ^ ^ ^ (#337) COB/OTHER PAYMENTS COUNT [7F] ^
^BPSC(D0,400,D1,337,0)=^9002313.0401A^^ (#337.01) COB OTHER PAYMENTS
^BPSC(D0,400,D1,337,D2,0)= (#.01) COB OTHER PAYMENT COUNTER [1F] ^ (#338) OTHER PAYER COVERAGE TYPE [2F] ^ (#339) OTHER PAYER ID
==>QUALIFIER [3F] ^ (#340) OTHER PAYER ID [4F] ^ (#443) OTHER PAYER DATE [5F] ^ (#341) OTHER PAYER AMOUNT
==>PAID COUNT [6F] ^ (#471) OTHER PAYER REJECT COUNT [7F] ^ (#353) OTHER PAYER-PAT RESP AMT CNT [8F] ^
==>(#392) BENEFIT STAGE COUNT [9F] ^ (#993) INTERNAL CONTROL NUMBER [10F] ^ (#2149) OTHER PAYER
==>RECONCILIATION ID [11F] ^
^BPSC(D0,400,D1,337,D2,1,0)=^9002313.401342A^^ (#342) OTHER PAYER AMT PAID QUALIFIER
^BPSC(D0,400,D1,337,D2,1,D3,0)= (#.01) OTHER PAYER AMT PAID QUALIFIER [1F] ^ (#431) OTHER PAYER AMOUNT PAID [2F] ^
^BPSC(D0,400,D1,337,D2,2,0)=^9002313.401472A^^ (#472) OTHER PAYER REJECT CODE
^BPSC(D0,400,D1,337,D2,2,D3,0)= (#.01) OTHER PAYER REJECT CODE [1F] ^
^BPSC(D0,400,D1,337,D2,3,0)=^9002313.401353^^ (#353.01) OTHER PAYER-PATIENT RESP MLTPL
^BPSC(D0,400,D1,337,D2,3,D3,0)= (#.01) OTHER PAYER-PATIENT COUNTER [1N] ^ (#351) OTHER PAYER-PAT RESP AMT QLFR [2F] ^ (#352)
==>OTHER PAYER-PAT RESP AMOUNT [3F] ^
^BPSC(D0,400,D1,337,D2,4,0)=^9002313.401392^^ (#392.01) BENEFIT STAGE MLTPL
^BPSC(D0,400,D1,337,D2,4,D3,0)= (#.01) BENEFIT STAGE COUNTER [1N] ^ (#393) BENEFIT STAGE QUALIFIER [2F] ^ (#394) BENEFIT STAGE
==>AMOUNT [3F] ^
^BPSC(D0,400,D1,340)= ^ ^ (#343) DISPENSING STATUS [3F] ^ (#344) QTY INTENDED TO BE DISPENSED [4F] ^ (#345) DAYS SUPPLY INTEND
==>TO BE DISP [5F] ^
^BPSC(D0,400,D1,350)= ^ ^ ^ (#354) SUBMISSION CLARIF CODE COUNT [4F] ^ ^ ^ (#357) DELAY REASON CODE [7F] ^
^BPSC(D0,400,D1,354.01,0)=^9002313.02354^^ (#354.01) SUBMISSION CLARIFICATION MLTPL
^BPSC(D0,400,D1,354.01,D2,0)= (#.01) SUBMISSION CLRFCTN CODE CNTR [1N] ^
^BPSC(D0,400,D1,354.01,D2,1)= (#420) SUBMISSION CLARIFICATION CODE [1F] ^
^BPSC(D0,400,D1,360)= ^ ^ ^ (#364) PRESCRIBER FIRST NAME [4F] ^ (#365) PRESCRIBER STREET ADDRESS [5F] ^ (#366) PRESCRIBER CITY
==>ADDRESS [6F] ^ (#367) PRESCRIBER STATE/PROV ADDRESS [7F] ^ (#368) PRESCRIBER ZIP/POSTAL ZONE [8F] ^ (#369)
==>ADDITIONAL DCMNTN TYPE ID [9F] ^ (#370) LENGTH OF NEED [10F] ^
^BPSC(D0,400,D1,370)= (#371) LENGTH OF NEED QUALIFIER [1F] ^ (#372) PRESCRIBER/SUPPLIER DT SIGNED [2F] ^ (#373) REQUEST STATUS
==>[3F] ^ (#374) REQUEST PERIOD BEGIN DATE [4F] ^ (#375) REQ PERIOD RECERT/REVISED DT [5F] ^ (#376) SUPPORTING
==>DOCUMENTATION [6F] ^ (#377) QUESTION NUMBER/LETTER COUNT [7F] ^
^BPSC(D0,400,D1,377.01,0)=^9002313.023771^^ (#377.01) QUESTION NUMBER/LETTER MLTPL
^BPSC(D0,400,D1,377.01,D2,0)= (#.01) QUESTION NUMBER/LETTER COUNTER [1N] ^ (#378) QUESTION NUMBER/LETTER [2F] ^ (#379) QUESTION
==>PERCENT RESPONSE [3F] ^ (#380) QUESTION DATE RESPONSE [4F] ^ (#381) QUESTION DOLLAR AMT RESPONSE
==>[5F] ^ (#382) QUESTION NUMERIC RESPONSE [6F] ^ (#383) QUESTION ALPHANUMERIC RESPONSE [7F] ^
^BPSC(D0,400,D1,380)= ^ ^ ^ ^ (#385) FACILITY NAME [5F] ^ (#386) FACILITY STREET ADDRESS [6F] ^ (#387) FACILITY STATE/PROV
==>ADDRESS [7F] ^ (#388) FACILITY CITY ADDRESS [8F] ^ (#389) FACILITY ZIP/POSTAL ZONE [9F] ^
^BPSC(D0,400,D1,389)= ^ (#390) NARRATIVE MESSAGE [2F] ^
^BPSC(D0,400,D1,390)= (#391) PATIENT ASSIGNMENT INDICATOR [1F] ^
^BPSC(D0,400,D1,400)= ^ (#402) PRESCRIPTION/SERVICE REF NO [2F] ^ (#403) FILL NUMBER [3F] ^ ^ (#405) DAYS SUPPLY [5F] ^ (#406)
==>COMPOUND CODE [6F] ^ (#407) PRODUCT/SERVICE ID [7F] ^ (#408) DAW PRODUCT SELECTION CODE [8F] ^ (#409)
==>INGREDIENT COST SUBMITTED [9F] ^ ^ (#411) PRESCRIBER ID [11F] ^ (#412) DISPENSING FEE SUBMITTED [12F] ^ ^
==>(#414) DATE PRESCRIPTION WRITTEN [14F] ^ (#415) NUMBER OF REFILLS AUTHORIZED [15F] ^ ^ ^ (#418) LEVEL OF
==>SERVICE [18F] ^ (#419) PRESCRIPTION ORIGIN CODE [19F] ^ ^ (#421) PRIMARY CARE PROVIDER ID [21F] ^ ^
==>(#423) BASIS OF COST DETERMINATION [23F] ^ (#424) DIAGNOSIS CODE [24F] ^ ^ (#426) USUAL AND CUSTOMARY
==>CHARGE [26F] ^ ^ ^ (#429) SPECIAL PACKAGING INDICATOR [29F] ^ (#430) GROSS AMOUNT DUE [30F] ^
^BPSC(D0,400,D1,420)= ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ (#427) PRESCRIBER LAST NAME
==>[27F] ^
^BPSC(D0,400,D1,430)= (#431) OTHER PAYER AMOUNT PAID [1F] ^ ^ (#433) PATIENT PAID AMOUNT REPORTED [3F] ^ (#434) DATE OF INJURY
==>[4F] ^ (#435) CLAIM/REFERENCE ID [5F] ^ (#436) PRODUCT/SERVICE ID QUALIFIER [6F] ^ ^ (#438) INCENTIVE
==>AMOUNT SUBMITTED [8F] ^
^BPSC(D0,400,D1,440)= ^ (#442) QUANTITY DISPENSED [2F] ^ (#443) OTHER PAYER DATE [3F] ^ (#444) PROVIDER ID [4F] ^ (#445) ORIG
==>PRESCRIBED PROD/SERV CODE [5F] ^ (#446) ORIGINALLY PRESCRIBED QUANTITY [6F] ^ (#447) COMPOUND INGREDIENT
==>COMP COUNT [7F] ^ ^ ^ (#450) COMPOUND DOSAGE FORM DESC CODE [10F] ^
^BPSC(D0,400,D1,447,0)=^9002313.0501A^^ (#447.01) COMPOUND REPEATING FIELDS
^BPSC(D0,400,D1,447,D2,0)= (#.01) COMPOUND REPEATING COUNT [1F] ^ (#488) COMPOUND PRODUCT ID QUALIFIER [2F] ^ (#489) COMPOUND
==>PRODUCT ID [3F] ^ (#448) COMPOUND INGREDIENT QUANTITY [4F] ^ (#449) COMPOUND INGREDIENT DRUG COST [5F]
==>^ (#490) COMP INGRED BASIS COST DETERM [6F] ^ (#362) COMPOUND INGRED MOD CODE CNT [7F] ^
^BPSC(D0,400,D1,447,D2,1,0)=^9002313.05011^^ (#362.01) COMPND INGRED MDFR MLTPL
^BPSC(D0,400,D1,447,D2,1,D3,0)= (#.01) COMPND INGRED MDFR COUNTER [1N] ^ (#363) COMPOUND INGRED MODIFIER CODE [2F] ^
^BPSC(D0,400,D1,450)= (#451) COMPOUND DISP UNIT FORM INDCTR [1F] ^ (#452) COMPOUND ROUTE OF ADMIN [2F] ^ (#453) ORIG PRESCR
==>PROD/SERV ID QUAL [3F] ^ (#454) SCHEDULED PRESCRIPTION ID NUM [4F] ^ (#455) PRESCRIPTION/SERV REF NO QLFR
==>[5F] ^ (#456) ASSOC PRESCRIPTION/SERV REF NO [6F] ^ (#457) ASSOC PRESCRIPTION/SERV DATE [7F] ^ (#458)
==>PROCEDURE MODIFIER CODE COUNT [8F] ^ ^ (#460) QUANTITY PRESCRIBED [10F] ^
^BPSC(D0,400,D1,459,0)=^9002313.201459A^^ (#459) PROCEDURE MODIFIER CODE
^BPSC(D0,400,D1,459,D2,0)= (#.01) PROCEDURE MODIFIER CODE [1F] ^
^BPSC(D0,400,D1,460)= (#461) PRIOR AUTHORIZATION TYPE CODE [1F] ^ (#462) PRIOR AUTH NUMBER SUBMITTED [2F] ^ (#463) INTERMEDIARY
==>AUTH TYPE ID [3F] ^ (#464) INTERMEDIARY AUTHORIZATION ID [4F] ^ (#465) PROVIDER ID QUALIFIER [5F] ^ (#466)
==>PRESCRIBER ID QUALIFIER [6F] ^ (#467) PRESCRIBER LOCATION CODE [7F] ^ (#468) PRIMARY CARE PROVIDER ID QLFR
==>[8F] ^ (#469) PRIM CARE PROV LOCATION CODE [9F] ^ (#470) PRIM CARE PROVIDER LAST NAME [10F] ^
^BPSC(D0,400,D1,470)= (#471) OTHER PAYER REJECT COUNT [1F] ^ ^ ^ ^ ^ ^ (#477) PROF SERVICE FEE SUBMITTED [7F] ^ (#478) OTHER
==>AMT CLAIMED SBMTTD COUNT [8F] ^
^BPSC(D0,400,D1,473.01,0)=^9002313.1001A^^ (#473.01) DUR PPS REPEATING FIELDS
^BPSC(D0,400,D1,473.01,D2,0)= (#.01) DUR PPS CODE COUNT [1F] ^ (#439) REASON FOR SERVICE CODE [2F] ^ (#440) PROFESSIONAL SERVICE
==>CODE [3F] ^ (#441) RESULT OF SERVICE CODE [4F] ^ (#474) DUR/PPS LEVEL OF EFFORT [5F] ^ (#475)
==>DUR/DUE CO-AGENT ID QUALIFIER [6F] ^ (#476) DUR/DUE CO-AGENT ID [7F] ^
^BPSC(D0,400,D1,478.01,0)=^9002313.0601A^^ (#478.01) OTHER AMT CLAIMED MULTIPLE
^BPSC(D0,400,D1,478.01,D2,0)= (#.01) OTHER AMT CLAIMED COUNTER [1F] ^ (#479) OTHER AMT CLAIMED SUBM QLFR [2F] ^ (#480) OTHER AMT
==>CLAIMED SUBMITTED [3F] ^
^BPSC(D0,400,D1,480)= (#481) REGULATORY FEE AMT SUBMITTED [1F] ^ (#482) PERCENT TAX AMT SUBMITTED [2F] ^ (#483) PERCENT TAX RATE
==>SUBMITTED [3F] ^ (#484) PERCENTAGE TAX BASIS SBMTTD [4F] ^ (#485) COUPON TYPE [5F] ^ (#486) COUPON NUMBER
==>[6F] ^ (#487) COUPON VALUE AMOUNT [7F] ^
^BPSC(D0,400,D1,490)= (#491) DIAGNOSIS CODE COUNT [1F] ^
^BPSC(D0,400,D1,491.01,0)=^9002313.0701A^^ (#491.01) CLINICAL DIAGNOSIS
^BPSC(D0,400,D1,491.01,D2,0)= (#.01) DIAGNOSIS COUNTER [1F] ^ (#492) DIAGNOSIS CODE QUALIFIER [2F] ^ (#424) DIAGNOSIS CODE [3F] ^
^BPSC(D0,400,D1,493)= (#493) CLINICAL INFORMATION COUNTER [1F] ^
^BPSC(D0,400,D1,493.01,0)=^9002313.0801A^^ (#493.01) CLINICAL INFORMATION
^BPSC(D0,400,D1,493.01,D2,0)= (#.01) CLINICAL INFORMATION COUNT [1F] ^ (#494) MEASUREMENT DATE [2F] ^ (#495) MEASUREMENT TIME
==>[3F] ^ (#496) MEASUREMENT DIMENSION [4F] ^ (#497) MEASUREMENT UNIT [5F] ^ (#499) MEASUREMENT VALUE
==>[6F] ^
^BPSC(D0,400,D1,498)= (#498.01) REQUEST TYPE [1F] ^ (#498.02) REQUEST PERIOD DATE-BEGIN [2F] ^ (#498.03) REQUEST PERIOD DATE-END
==>[3F] ^ (#498.04) BASIS OF REQUEST [4F] ^ (#498.05) AUTHORIZED REP FIRST NAME [5F] ^ (#498.06) AUTHORIZED
==>REP LAST NAME [6F] ^ (#498.07) AUTHORIZED REP STREET ADDRESS [7F] ^ (#498.08) AUTH REP CITY ADDRESS [8F] ^
==>(#498.09) AUTHORIZED REP STATE/PROV ADDR [9F] ^ ^ (#498.11) AUTHORIZED REP ZIP/POSTAL ZONE [11F] ^
==>(#498.12) PRESCRIBER TELEPHONE NUMBER [12F] ^ ^ (#498.14) PRIOR AUTH NUMBER-ASSIGNED [14F] ^
^BPSC(D0,400,D1,498.13,0)=^9002313.0901^^ (#498.13) PRIOR AUTH SUPPORTING DOCUMENT
^BPSC(D0,400,D1,498.13,D2,0)= (#.01) PRIOR AUTH SUPPORTING DOCUMENT [1W] ^
^BPSC(D0,400,D1,500)= ^ ^ (#503) AUTHORIZATION NUMBER [3F] ^
^BPSC(D0,400,D1,570)= ^ ^ ^ ^ ^ ^ ^ ^ (#579) ASSOC RX/SERVICE PROV ID QUAL [9F] ^ (#580) ASSOC RX/SERVICE PROVIDER ID
==>[10F] ^
^BPSC(D0,400,D1,580)= (#581) ASSOC RX/SERVICE REF NUM QUAL [1F] ^ (#582) ASSOC RX/SERVICE FILL NUMBER [2F] ^ (#583) SERVICE
==>PROVIDER NAME [3F] ^ (#584) SERVICE PROVIDER STREET [4F] ^ (#585) SERVICE PROVIDER CITY [5F] ^ (#586)
==>SERVICE PROVIDE STATE/PROVINCE [6F] ^ (#587) SERVICE PROVIDER ZIP/POST CODE [7F] ^ ^ ^ (#590) SELLER
==>INITIALS [10F] ^
^BPSC(D0,400,D1,590)= (#591) PURCHASER ID QUALIFIER [1F] ^ (#592) PURCHASER ID [2F] ^ (#593) PURCHASER ID STATE/PROVINCE [3F] ^
==>(#594) PURCHASER DATE OF BIRTH [4F] ^ (#595) PURCHASER GENDER CODE [5F] ^ (#596) PURCHASER FIRST NAME [6F]
==>^ (#597) PURCHASER LAST NAME [7F] ^ (#598) PURCHASER STREET ADDRESS [8F] ^ (#599) PURCHASER CITY ADDRESS
==>[9F] ^
^BPSC(D0,400,D1,600)= (#600) UNIT OF MEASURE [1F] ^
^BPSC(D0,400,D1,670)= ^ ^ ^ ^ (#675) PURCHASER STATE/PROVINCE CODE [5F] ^ (#676) PURCHASER ZIP/POSTAL CODE [6F] ^ (#677)
==>PURCHASER COUNTRY CODE [7F] ^ (#678) TIME OF SERVICE [8F] ^ (#679) SELLER ID [9F] ^ (#680) SELLER ID
==>QUALIFIER [10F] ^
^BPSC(D0,400,D1,680)= (#681) SALES TRANSACTION ID [1F] ^
^BPSC(D0,400,D1,870)= ^ ^ ^ ^ ^ ^ ^ ^ ^ (#880) TRANSACTION REFERENCE NUMBER [10F] ^
^BPSC(D0,400,D1,990)= ^ ^ ^ ^ (#995) ROUTE OF ADMINISTRATION [5F] ^ (#996) COMPOUND TYPE [6F] ^
^BPSC(D0,400,D1,A20)= ^ ^ (#1023) PURCHASER RELATIONSHIP CODE [3F] ^ (#1024) PRESCRIBER ID STATE/PROVINCE [4F] ^ (#1025)
==>PRESCRIBER ALTERNATE ID QUAL [5F] ^ (#1026) PRESCRIBER ALTERNATE ID [6F] ^ (#1027) PRESCRIBER ALTERNATE
==>STATE [7F] ^ ^ (#1029) REPORTED ADJUDICATED PROG TYPE [9F] ^ (#1030) RELEASED DATE [10F] ^
^BPSC(D0,400,D1,A30)= (#1031) RELEASED TIME [1F] ^ (#1032) COMPOUND PREPARATION TIME [2F] ^
^BPSC(D0,400,D1,A90)= ^ ^ (#1093) SERVICE PROVIDER COUNTRY CODE [3F] ^
^BPSC(D0,400,D1,B10)= ^ ^ ^ ^ (#2015) EMPLOYER STREET ADDRESS LINE 1 [5F] ^ (#2016) EMPLOYER STREET ADDRESS LINE 2 [6F] ^
==>(#2017) EMPLOYER CONTACT FIRST NAME [7F] ^ (#2018) EMPLOYER CONTACT LAST NAME [8F] ^ (#2019) EMPLOYER PHONE
==>NUMBER EXT [9F] ^
^BPSC(D0,400,D1,B11)= ^ ^ (#2013) AUTH REP STREET ADDRESS LINE 1 [3F] ^ (#2014) AUTH REP STREET ADDRESS LINE 2 [4F] ^ ^ ^ ^
==>^ ^ (#2020) FACILITY STREET ADDRESS LINE 1 [10F] ^
^BPSC(D0,400,D1,B20)= (#2021) FACILITY STREET ADDRESS LINE 2 [1F] ^ ^ ^ (#2024) PAY TO STREET ADDRESS LINE 1 [4F] ^ (#2025) PAY
==>TO STREET ADDRESS LINE 2 [5F] ^ (#2026) PRESCRIBER PHONE NUMBER EXT [6F] ^ (#2027) PRESCRIBER STREET ADDR
==>LINE 1 [7F] ^ (#2028) PRESCRIBER STREET ADDR LINE 2 [8F] ^
^BPSC(D0,400,D1,B21)= ^ ^ ^ ^ ^ ^ ^ ^ (#2029) PURCHASER STREET ADDRESS LINE1 [9F] ^ (#2030) PURCHASER STREET ADDRESS
==>LINE2 [10F] ^
^BPSC(D0,400,D1,B30)= (#2031) SERVICE PROV STREET ADD LINE 1 [1F] ^ (#2032) SERVICE PROV STREET ADD LINE 2 [2F] ^ ^ (#2034) AUTH
==>REP COUNTRY CODE [4F] ^ (#2035) EMPLOYER COUNTRY CODE [5F] ^ ^ (#2037) FACILITY COUNTRY CODE [7F] ^ ^
==>(#2039) PAY TO COUNTRY CODE [9F] ^ (#2040) PRES ALT ID ASSOC COUNTRY CODE [10F] ^
^BPSC(D0,400,D1,B40)= (#2041) PRES ID ASSOC COUNTRY CODE [1F] ^ (#2042) PRESCRIBER COUNTRY CODE [2F] ^ (#2043) PURCHASER ID ASSOC
==>COUNTRY CD [3F] ^ (#2044) INTERMEDIARY ID COUNT [4F] ^
^BPSC(D0,400,D1,B44,0)=^9002313.022044^^ (#2044.01) INTERMEDIARY ID MULTIPLE
^BPSC(D0,400,D1,B44,D2,0)= (#.01) INTERMEDIARY ID COUNTER [1N] ^ (#2045) INTERMEDIARY ID TYPE CODE [2F] ^ (#2046) INTERMEDIARY ID
==>TYPE ENTITY [3F] ^ (#2047) INTERMEDIARY ID QUALIFIER [4F] ^ (#2048) INTERMEDIARY ID [5F] ^ (#2049)
==>INTERMEDIARY ID STATE/PROV ADD [6F] ^ (#2055) INTERMEDIARY ID COUNTRY CODE [7F] ^ (#2050) INTERMEDIARY
==>ID RELATION CODE [8F] ^
^BPSC(D0,400,D1,B50)= ^ ^ ^ ^ ^ (#2056) LAST KNOWN IIN NUMBER [6F] ^ (#2057) LAST KNOWN PROCESSOR CNTRL NUM [7F] ^ (#2058)
==>LAST KNOWN GROUP ID [8F] ^ (#2059) LAST KNOWN CARDHOLDER ID [9F] ^ (#2060) YEAR OF LAST PAID CLAIM [10F] ^
^BPSC(D0,400,D1,B60)= (#2061) MONTH OF LAST PAID CLAIM [1F] ^
^BPSC(D0,400,D1,B90)= ^ ^ ^ ^ (#2095) FACILITY ID QUALIFIER [5F] ^ (#2096) PROVIDER FIRST NAME [6F] ^ (#2097) PROVIDER LAST
==>NAME [7F] ^
^BPSC(D0,400,D1,C00)= (#2101) ORIG MANUFACTURER PRODUCT ID [1F] ^ (#2102) ORIG MANUFACTURER PROD ID QUAL [2S] ^
^BPSC(D0,400,D1,C40)= ^ ^ ^ ^ ^ ^ (#2147) OTHER PAYER PROGRAM TYPE [7P:9002313.38] ^ ^ (#2149) OTHER PAYER RECONCILIATION
==>ID [9F] ^ (#2150) BENEFIT STAGE INDICATOR COUNT [10N] ^
^BPSC(D0,400,D1,C50)= (#2151) BENEFIT STAGE INDICATOR [1P:9002313.35] ^ ^ ^ ^ ^ ^ ^ ^ ^ (#2160) COMPOUND LEVEL OF
==>COMPLEXITY [10S] ^
^BPSC(D0,400,D1,C80)= ^ ^ ^ ^ ^ ^ ^ ^ ^ (#2190) LTPAC BILLING METHODOLOGY [10S] ^
^BPSC(D0,400,D1,C90)= (#2191) LTPAC DISPENSE FREQUENCY [1P:9002313.36] ^ (#2192) NUMBER LTPAC DISPENSING EVENTS [2N] ^ ^ ^ ^
==>^ ^ (#2198) PREPARATION ENVIRONMENT CODE [8S] ^ (#2199) PREPARATION ENVIRONMENT TYPE [9S] ^
^BPSC(D0,400,D1,D00)= (#2201) PRESCRIBER DEA NUMBER [1F] ^ (#2202) TOTAL PRESCRIBED QTY REMAINING [2N] ^
^BPSC(D0,400,D1,D10)= ^ ^ ^ (#2214) SUBROGATION AMOUNT REQUESTED [4N] ^ ^ (#2216) SUBMISSION TYPE CODE COUNT [6N] ^ (#2217)
==>SUBMISSION TYPE CODE [7S] ^ (#2218) DO NOT DISPENSE BEFORE DATE [8D] ^
^BPSC(D0,400,D1,D20)= (#2221) MULTIPLE RX/SVC GROUP ID [1F] ^ (#2222) MULT RX/SVC GROUP REASON CODE [2S] ^
^BPSC(D0,400,D1,D50)= (#2251) OTHER PAYR TAX EXEMPT INDICATR [1S] ^ (#2252) OTHER PAYR FEE EXMPT INDICATR [2S] ^ (#2253) OTHER
==>PAYR FEE TYPE COUNT [3N] ^ ^ ^ ^ (#2257) PRESCRIBER PLACE OF SERVICE [7P:9002313.34] ^ ^ ^ (#2260)
==>REGULATORY FEE COUNT [10N] ^
^BPSC(D0,400,D1,D60)= (#2261) REGULATORY FEE TYPE CODE [1S] ^ ^ (#2263) OTHER PAYER FEE TYPE CODE [3S] ^
^BPSC(D0,400,D1,E10)= ^ (#2312) PRESCRIBER MIDDLE NAME [2F] ^
^BPSC(D0,400,D1,F30)= ^ (#2432) SEX ASSIGNED AT BIRTH [2S] ^
^BPSC(D0,401)= (#401) DATE OF SERVICE [1F] ^
^BPSC(D0,520)= ^ ^ ^ (#524) PLAN ID [4F] ^
^BPSC(D0,610)= ^ ^ ^ ^ ^ ^ ^ (#618) PATIENT ID COUNT [8N] ^
^BPSC(D0,900)= (#901) CLOSED [1S] ^ (#902) DATE CLOSED [2D] ^ (#903) CLOSED BY [3P:200] ^ (#904) CLOSED REASON [4P:356.8] ^
==>(#905) DROP TO PAPER [5S] ^ (#906) DATE REOPENED [6D] ^ (#907) REOPENED BY [7P:200] ^ (#908) REOPENED COMMENT [8F]
==>^
^BPSC(D0,980)= ^ ^ ^ ^ ^ ^ ^ ^ ^ (#990) OTHER PAYER BIN NUMBER [10F] ^
^BPSC(D0,990)= (#991) OTHER PAYER PROC CONTROL NUM [1F] ^ (#992) OTHER PAYER GROUP ID [2F] ^ ^ ^ ^ ^ (#997) CMS PART D DEFND
==>QLFD FACILITY [7F] ^
^BPSC(D0,A20)= ^ (#1022) PATIENT ID STATE/PROVINCE [2F] ^
^BPSC(D0,A40)= ^ ^ (#1043) PATIENT COUNTRY CODE [3F] ^ ^ (#1045) VETERINARY USE INDICATOR [5F] ^
^BPSC(D0,B00)= ^ ^ ^ ^ ^ ^ ^ (#2008) PATIENT STREET ADDRESS LINE 1 [8F] ^ (#2009) PATIENT STREET ADDRESS LINE 2 [9F] ^
^BPSC(D0,B30)= ^ ^ ^ ^ ^ ^ ^ (#2038) PATIENT ID ASSOC COUNTRY CODE [8F] ^
^BPSC(D0,E00)= ^ ^ ^ ^ ^ (#2306) SPECIES [6F] ^ ^ ^ (#2309) PATIENT MIDDLE NAME [9F] ^ (#2310) PATIENT NAME PREFIX [10F] ^
^BPSC(D0,E10)= (#2311) PATIENT NAME SUFFIX [1F] ^
^BPSC(D0,M,0)=^9002313.29999^^ (#9999) RAW DATA SENT
^BPSC(D0,M,D1,0)= (#.01) RAW DATA SENT [1W] ^
INPUT TEMPLATE(S):
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):