NCPDP Eligibility Requests

NCPDP Eligibility Verification (E1) Request

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Create an E1 request file to be processed by DayTech. The E1 transaction set is used to check a client's eligibility within the Medicare Part D program. Eligibility Verification (E1) Requests are only supported for Medicare Part D guarantors.

Said requests are identified by Transaction Facilitator (e.g. RelayHealth) specific BIN (011727) and PCN (2222222222) values that are included with each request. For a Medicare Part D request, the Cardholder ID is the SSN of the beneficiary. As part of the response, CMS will return up to 3 coverage plans including the PDP (prescription drug plan) as well as any supplemental plans.

Financial Eligibility forms

The Financial Eligibility forms include:

myAvatar PM > Client Management > Account Management

• Financial Eligibility

• Cross Episode Financial Eligibility

• Family Financial Eligibility

The following fields are added to the Guarantor Selection section of the above forms. This information is necessary for electronic billing:

• Subscriber's Policy # Suffix - Enter the patient's relationship code (00 if cardholder).

• NCPDP Eligibility Verification (E1) Request Status - Select the status of the inquiry. Request Inquiry will initiate the E1 Request for the client. This E1 transaction will be created when the E1 file is generated based on Financial Eligibility flag. After the initial request, this prompt will automatically show the most current status of the E1 Request.

• NCPDP Eligibility Verification (E1) Reject Reason Code - Displays the reason code if a rejection is received in the E1 Response.