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NCPDP Re-Billing Service Assignment Section - PM

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Review NCPDP response data and enter 'DUR Overrride' codes and 'Submission Clarification' codes that are filed with the re-bill information. You can also flag response data to be sent to RxConnect to obtain the pharmacist's DUR and/or submission clarification codes.

  1. In the Client ID field, enter the client name, and select.
  2. In the Add/Delete field:
  • Select Add Claim To Re-Bill to assign services that have been claimed to for re-billing.
  • Select Delete Claim From Re-Bill to remove a service from a re-billed claim.
  1. In the Claim Number field, select the claim number.
  2. In the Select Service for Re-Billing field, select the service.
  3. The NCPDP Response button launches a screen that displays the service details.
  4. Click DUR Overrides. The Enter Overrides screen displays.
    Select values for the following fields:
  • Reason for Service Code
  • Professional Service Code
  • Result of Service Code
  • DUR/PPS Level of Effort
  • DUR Co-Agent ID Qualifier
  • DUR Co-Agent ID
  1. In the Submission Clarification field, select the items that clarify the reason for re-billing.
  2. In the Transaction Type field:
  • Select Claim Billing (B1) when a denial has been received with no associated payment for the claim. This is a B1 Transaction form.
  • Select Claim Reversal (B2) when a payment has been received for a claim and needs to be reversed. This is a B2 Transaction form.
  • Select Claim Rebilling (B3) when a claim has been sent but needs to be adjusted. This is a B3 Transaction form.
    Note: The guarantor must be set up for rebilling via the Payors That Support Rebilling (B3) field on the NCPDP System Defaults form.
  1. In the Mark as Resolved upon Filing field:
  • Select Yes to have all of the records marked as Resolved upon submission.
  • Select No to have none of the records marked as Resolved upon submission.
  1. Click File.

► SQL Tables

  • SYSTEM.billing_rebill_ncpdp_dur 
    (To view the 'DUR Override' information) 
  • SYSTEM.billing_rebill_tx_assign
    (The fields 'sub_clarification_code', 'sub_clarification_value', 'transaction_type_code' and 'transaction_type_value' are added to this table)