STANDARD DATA DICTIONARY #9002313.78 -- BPS INSURER DATA FILE 3/24/25 PAGE 1
STORED IN ^BPS(9002313.78, *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 1.0)
DATA NAME GLOBAL DATA
ELEMENT TITLE LOCATION TYPE
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This file is used to store insurers' details data returned by Integrated Billing package to be used by ECME engine to build claim
requests and reversals and send them to insurers (payers). Generally there should be few or no entries in this file unless there
are stranded claims, reversal or requests that need to be un-stranded by the user.
Per VHA Directive 2004-038, this file definition should not be modified.
DD ACCESS: @
RD ACCESS: Pp
WR ACCESS: @
DEL ACCESS: @
LAYGO ACCESS: @
AUDIT ACCESS: @
POINTED TO BY: INSURER DATA field (#.03) of the INSURER DATA sub-field (#9002313.772) of the BPS REQUESTS File (#9002313.77)
CROSS
REFERENCED BY: TRANSACTION ID(B)
9002313.78,.01TRANSACTION ID 0;1 NUMBER (Required)
INPUT TRANSFORM: K:+X'=X!(X>99999999999999)!(X<1)!(X?.E1"."6.N) X
LAST EDITED: OCT 20, 2010
HELP-PROMPT: Enter the numeric identifier for the record (1- 99999999999999, 5 Decimal Digits).
DESCRIPTION: This is a numeric identifier that follows the same format as the IEN of the BPS TRANSACTION
(#9002313.59) file. For billing requests and reversals, this is the Prescription IEN, followed by a
decimal point, followed by the Fill Number left-padded with zeros up to four places and then
followed by the COB indicator (1-Primary, 2-Secondary, 3-Tertiary). For a Eligibility Verification
request, this is the Patient IEN, followed by a decimal point, followed by the Policy Number (with
9000 added to it) and then followed by 1.
TECHNICAL DESCR: At the point that the BPS INSURER DATA record is created, the BPS TRANSACTION record may not be
defined so this field uses the same format but cannot be a pointer. The value for this field is
created by calling IEN^BPSOSRX, which is the same call that is done to determine the IEN of the BPS
transaction file. Since the code that creates the value for this field and the code that
calculates the IEN of the BPS Transaction field use the same API (and parameters), they both will
have the same value and thus, the data does not need to be updated when the BPS Transaction record
is created (it is already correct).
CROSS-REFERENCE: 9002313.78^B
1)= S ^BPS(9002313.78,"B",$E(X,1,30),DA)=""
2)= K ^BPS(9002313.78,"B",$E(X,1,30),DA)
9002313.78,.02B1 PAYER SHEET 0;2 POINTER TO BPS NCPDP FORMATS FILE (#9002313.92)
LAST EDITED: OCT 19, 2010
HELP-PROMPT: Answer with the billing request payer sheet to be used for this payer.
DESCRIPTION: This is the payer sheet used to a submit billing request for this particular insurer. Billing
request transmissions will be formatted per the specifications in this payer sheet.
9002313.78,.03B2 PAYER SHEET 0;3 POINTER TO BPS NCPDP FORMATS FILE (#9002313.92)
LAST EDITED: JUL 01, 2008
HELP-PROMPT: Select a payer sheet to be used for reversals.
DESCRIPTION:
The Reversal payer sheet to be used to send reversals to the Insurer.
9002313.78,.04B3 PAYER SHEET 0;4 POINTER TO BPS NCPDP FORMATS FILE (#9002313.92)
LAST EDITED: OCT 18, 2010
HELP-PROMPT: Enter the rebill payer sheet used for this payer.
DESCRIPTION: This is the payer sheet to be used for a rebill request for this insurer. Rebill transmission will
be formatted per the specifications in this payer sheet.
9002313.78,.05CERTIFY MODE 0;5 SET
'0' FOR CERTIFY MODE OFF;
'1' FOR CERTFIY MODE ON;
LAST EDITED: JUL 01, 2008
HELP-PROMPT: Switch on/off the certify mode
DESCRIPTION:
Certify mode is used for certifying software when required by switches and claims end processors.
9002313.78,.06CERTIFICATION 0;6 POINTER TO BPS CERTIFICATION FILE (#9002313.31)
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter the Certification record
DESCRIPTION: This field is used during certification testing, and points to the entry to use to pull
certification data.
9002313.78,.07INSURANCE NAME 0;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: JUL 01, 2008
HELP-PROMPT: Enter the name of the insurance company. Answer must be 1-40 characters.
DESCRIPTION: This is the free text name of the Insurance Company as determined by Integrated Billing insurance
files.
9002313.78,.08PLAN ID 0;8 POINTER TO GROUP INSURANCE PLAN FILE (#355.3)
LAST EDITED: JUL 01, 2008
HELP-PROMPT: Enter the Group Insurance Plan
DESCRIPTION:
Group Insurance Plan used for the claim
9002313.78,.09COB INDICATOR 0;9 SET
'1' FOR PRIMARY;
'2' FOR SECONDARY;
'3' FOR TERTIARY;
LAST EDITED: JUL 01, 2008
HELP-PROMPT: Is the payer a primary, secondary or tertiary insurer?
DESCRIPTION:
Coordination Of Benefits (COB) indicator for the payer.
9002313.78,.1 E1 PAYER SHEET 0;10 POINTER TO BPS NCPDP FORMATS FILE (#9002313.92)
LAST EDITED: OCT 18, 2010
HELP-PROMPT: Enter the eligibility verification payer sheet for the payer.
DESCRIPTION: This is the payer sheet to be used for eligibility verification requests for this insurer.
Eligibility verification transmissions will be formatted per the specifications in this payer
sheet.
9002313.78,.11POLICY NUMBER 0;11 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: OCT 18, 2010
HELP-PROMPT: Enter the policy number for this insurer (0-9999).
DESCRIPTION:
This is the policy number assigned for this particular patient and insurer.
9002313.78,1.01BIN 1;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION:
Card Issuer ID or Bank ID Number used for network routing.
9002313.78,1.02PCN 1;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Answer must be 1-10 characters in length.
DESCRIPTION:
The Processor Control Number for this claim.
9002313.78,1.03GROUP ID 1;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>17!($L(X)<1) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Answer must be 1-17 characters in length.
DESCRIPTION:
ID assigned to the cardholder group or employer group.
9002313.78,1.04CARDHOLDER ID 1;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION:
ID number assigned to Cardholder/Subscriber.
9002313.78,1.05PATIENT RELATIONSHIP CODE 1;5 SET
'0' FOR NOT SPECIFIED;
'1' FOR CARDHOLDER (SELF);
'2' FOR SPOUSE;
'3' FOR CHILD;
'4' FOR OTHER;
LAST EDITED: APR 22, 2011
HELP-PROMPT: Enter the relationship of the patient to the insured.
DESCRIPTION: This stores the relationship of the patient to insurance subscriber and will be used to populate
the NCPDP 306-C6 (PATIENT RELATIONSHIP CODE) field.
9002313.78,1.06CARDHOLDER FIRST NAME 1;6 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Answer must be 1-30 characters in length
DESCRIPTION:
First name of the Cardholder/Subscriber.
9002313.78,1.07CARDHOLDER LAST NAME 1;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>15!($L(X)<1) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Answer must be 1-15 characters in length
DESCRIPTION:
Last name of the Cardholder/Subscriber.
9002313.78,1.08HOME PLAN STATE 1;8 FREE TEXT
INPUT TRANSFORM: K:$L(X)>2!($L(X)<1) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Answer must be 1-2 characters in length
DESCRIPTION:
Usually the state where the member lives or purchased their coverage.
9002313.78,1.09PERSON CODE 1;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: JUL 06, 2011
HELP-PROMPT: Enter the person code for the NCPDP request (1-3 characters).
DESCRIPTION: This is the Person Code that will be placed in NCPDP field 303-C3 (Person Code). This value is
specified by the third-party payer and is found on the patient's insurance card.
9002313.78,2.01DISPENSING FEE SUBMITTED 2;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>8!($L(X)<1) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Type a Dollar amount between 0 and 99999, 2 Decimal Digits
DESCRIPTION:
Fee amount submitted for the cost associated with dispensing this prescription.
9002313.78,2.02BASIS OF COST DETERMINATION 2;2 SET
'01' FOR AWP;
'05' FOR Cost Calculations;
'07' FOR Usual & Customary;
LAST EDITED: JUL 01, 2008
HELP-PROMPT: Answer with the basis code for which the cost was determined.
DESCRIPTION:
Code indicating the method by which 'Ingredient Cost Submitted' was calculated.
9002313.78,2.03USUAL & CUSTOMARY CHARGE 2;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>8!($L(X)<1) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Type a Dollar amount between 0 and 99999, 2 Decimal Digits
DESCRIPTION:
Amount charged cash customers for the prescription exclusive of sales tax or other amounts claimed.
9002313.78,2.04GROSS AMOUNT DUE 2;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>8!($L(X)<1) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Type a Dollar amount between 0 and 99999, 2 Decimal Digits
DESCRIPTION: Total price claimed from all sources. For prescription claim request, field represents a sum of
'Ingredient Cost Submitted' (4�9-D9), 'Dispensing Fee Submitted' (412-DC), 'Flat Sales Tax Amount
Submitted'(481-HA), 'Percentage Sales Tax Amount Submitted' (482-GE), 'Incentive Amount Submitted'
(438-E3), 'Other Amount Claimed' (48�-H9). For service claim request, field represents a sum of
'Professional Services Fee Submitted' (477-BE), 'Flat Sales Tax Amount Submitted'(481-HA),
'Percentage Sales Tax Amount Submitted'(482-GE), 'Other Amount Claimed' (48�-H9).
9002313.78,2.05ADMINISTRATIVE FEE 2;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>8!($L(X)<1) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Type a Dollar amount between 0 and 99999, 2 Decimal Digits
DESCRIPTION:
Fee charged for any costs related to preparing the prescription.
9002313.78,2.06SOFTWARE VENDOR CERT ID 2;6 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION:
Certification number assigned by the payer for submission of claims.
9002313.78,2.07MAXIMUM NCPDP TRANSACTIONS 2;7 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>99999)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: OCT 18, 2010
HELP-PROMPT: Enter the maximum number of transactions allowed in a request (1-9999).
DESCRIPTION: This is the maximum number of transactions that can be bundled in a transmission. It is specified
by the NCPDP processor.
9002313.78,2.08INGREDIENT COST 2;8 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999999)!(X<0)!(X?.E1"."3.N) X
LAST EDITED: JUL 06, 2011
HELP-PROMPT: Type a number between 0 and 999999, 2 decimal digits.
DESCRIPTION: This is the INGREDIENT COST that will be placed in the NCPDP field 409-D9 (INGREDIENT COST
SUBMITTED) field of the NCPDP submission.
9002313.78,3.01GROUP NAME 3;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<2) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Answer must be 2-20 characters in length.
DESCRIPTION:
This is the group name from the Group Insurance File.
9002313.78,3.02INSURANCE CO PHONE # 3;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<7) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Answer must be 7-20 characters in length.
DESCRIPTION:
This is the Claim (RX) phone number from the Insurance Company file.
9002313.78,3.03PHARMACY PLAN ID 3;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: JUL 02, 2008
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION:
This is the ID of the plan file.
9002313.78,3.04ELIGIBILITY 3;4 SET
'V' FOR VETERAN;
'T' FOR TRICARE;
'C' FOR CHAMPVA;
LAST EDITED: AUG 04, 2011
HELP-PROMPT: Enter eligibility of the claim.
DESCRIPTION:
The insurance eligibility type of the claim.
9002313.78,3.05INSURANCE COMPANY 3;5 POINTER TO INSURANCE COMPANY FILE (#36)
LAST EDITED: JAN 16, 2009
HELP-PROMPT: Select the insurance carrier for this claim.
DESCRIPTION:
This is the INSURANCE COMPANY from file #36.
9002313.78,3.06PLAN COB 3;6 SET
'1' FOR PRIMARY;
'2' FOR SECONDARY;
'3' FOR TERTIARY;
LAST EDITED: MAR 30, 2009
HELP-PROMPT: Enter Coordination Of Benefits indicator for the insurance plan.
DESCRIPTION: The Coordination of Benefits indicator of the patient's insurance plan. This field is a copy of
the (#.2) COORDINATION OF BENEFITS field of the (#.3121) INSURANCE TYPE multiple of the PATIENT
file (#2).
9002313.78,4.01B1 PAYER SHEET NAME 4;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<3) X
LAST EDITED: OCT 19, 2010
HELP-PROMPT: Enter the name of the payer sheet that will be used for billing requests (3-30 characters).
DESCRIPTION: This is the name of the Billing Request Payer Sheet, which comes from the RECORD FORMAT NAME (#.01)
field of the BPS NCPDP FORMATS (#9002313.92) file.
9002313.78,4.02B2 PAYER SHEET NAME 4;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<3) X
LAST EDITED: NOV 26, 2007
HELP-PROMPT: Answer must be 3-30 characters in length.
DESCRIPTION: B2 Payer sheet. The value of the field (#.01) Record Format Name of the file (#9002313.92) BPS
NCPDP FORMATS ien Textual description of this record format.
9002313.78,4.03B3 PAYER SHEET NAME 4;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<3) X
LAST EDITED: OCT 19, 2010
HELP-PROMPT: Enter the name of the payer sheet that will be used for rebill requests (3-30 characters).
DESCRIPTION: This is the name of the Rebill Payer Sheet, which comes from the RECORD FORMAT NAME (#.01) field of
the BPS NCPDP FORMATS (#9002313.92) file.
9002313.78,4.04E1 PAYER SHEET NAME 4;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<3) X
LAST EDITED: OCT 19, 2010
HELP-PROMPT: Enter the name of the payer sheet that will be used for eligibility verification requests (3-30
characters).
DESCRIPTION: This is the name of the Eligibility Payer Sheet, which comes from the RECORD FORMAT NAME (#.01)
field of the BPS NCPDP FORMATS (#9002313.92) file.
9002313.78,5.01USER 5;1 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: JUL 01, 2008
HELP-PROMPT: Enter the user who made the request
DESCRIPTION:
ID (IEN of the NEW PERSON file) of the user name who entered this record.
9002313.78,5.02DATE AND TIME WAS CREATED 5;2 DATE
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Answer with the date/time this record was created
DESCRIPTION:
Date and time the record was created.
FILES POINTED TO FIELDS
BPS CERTIFICATION (#9002313.31) CERTIFICATION (#.06)
BPS NCPDP FORMATS (#9002313.92) B1 PAYER SHEET (#.02)
B2 PAYER SHEET (#.03)
B3 PAYER SHEET (#.04)
E1 PAYER SHEET (#.1)
GROUP INSURANCE PLAN (#355.3) PLAN ID (#.08)
INSURANCE COMPANY (#36) INSURANCE COMPANY (#3.05)
NEW PERSON (#200) USER (#5.01)
INPUT TEMPLATE(S):
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):