ØØ
Ø1
Ø2
Ø3
Ø4
Ø5
Ø6
Ø7
Ø8
Ø9
1C
1E
1Ø
11
12
13
14
15
16
17
19
2C
2E
2Ø
21
22
23
25
26
28
29
3A
3B
3C
3D
3E
3F
3G
3H
3J
3K
3M
3N
3P
3R
3S
3T
3W
3X
3Y
32
33
34
35
38
39
4C
4E
4Ø
41
5C
5E
5Ø
51
52
53
54
55
56
58
6C
6E
6Ø
61
62
63
64
65
66
67
68
69
7C
7E
7Ø
71
72
73
74
75
76
77
78
79
8C
8E
8Ø
81
82
83
84
85
86
87
88
89
9Ø
91
92
*95
*96
*97
*98
99
AA
AB
AC
AD
AE
AF
AG
AH
AJ
AK
AM
A9
BE
B2
CA
CB
CC
CD
CE
CF
CG
CH
CI
CJ
CK
CL
CM
CN
CO
CP
CQ
CR
CW
CX
CY
CZ
DC
DN
DQ
DR
DT
DU
DV
DX
DY
DZ
EA
EB
EC
ED
EE
EF
EG
EH
EJ
EK
EM
EN
EP
ER
ET
EU
EV
EW
EX
EY
EZ
E1
E3
E4
E5
E6
E7
E8
E9
FO
GE
HA
HB
HC
HD
HE
HF
HG
H1
H2
H3
H4
H5
H6
H7
H8
H9
JE
J9
KE
M1
M2
M3
M4
M5
M6
M7
M8
ME
MZ
NE
NN
PA
PB
PC
PD
PE
PF
PG
PH
PJ
PK
PM
PN
PP
PR
PS
PT
PV
PW
PX
PY
PZ
P1
P2
P3
P4
P5
P6
P7
P8
P9
RA
RB
RC
RD
RE
RF
RG
RH
RJ
RK
RM
RN
RP
RS
RT
RU
R1
R2
R3
R4
R5
R6
R7
R8
R9
SE
TE
UE
VE
WE
XE
ZE
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("M/I" Means Missing/Invalid)
M/I Bin
M/I Version Number
M/I Transaction Code
M/I Processor Control Number
M/I Pharmacy Number
M/I Group Number
M/I Cardholder ID Number
M/I Person Code
M/I Birth Date
M/I Smoker/Non-Smoker Code
M/I Prescriber Location Code
M/I Patient Gender Code
M/I Patient Relationship Code
M/I Patient Location
M/I Other Coverage Cod
M/I Eligibility Clarification Code
M/I Date of Service
M/I Prescription/Service Reference Number
M/I Fill Number
M/I Days Supply
M/I Pregnancy Indicator
M/I Primary Care Provider ID Qualifier
M/I Compound Code
M/I Product/Service ID
M/I Dispense As Written (DAW)/Product Selection Code
M/I Ingredient Cost Submitted
M/I Prescriber ID
M/I Unit Of Measure
M/I Date Prescription Written
M/I Number Refills Authorized
M/I Request Type
M/I Request Period Date-Begin
M/I Request Period Date-End
M/I Basis Of Request
M/I Authorized Representative First Name
M/I Authorized Representative Last Name
M/I Authorized Representative Street Address
M/I Authorized Representative City Address
M/I Authorized Representative State/Province Address
M/I Authorized Representative Zip/Postal Zone
M/I Prescriber Phone Number
M/I Prior Authorized Number Assigned
M/I Authorization Number
Prior Authorization Not Required
M/I Prior Authorization Supporting Documentation
Active Prior Authorization Exists Resubmit At Expiration Of Prior Authorization
Prior Authorization In Process
Authorization Number Not Found
Prior Authorization Denied
M/I Level Of Service
M/I Prescription Origin Code
M/I Submission Clarification Code
M/I Primary Care Provider ID
M/I Basis Of Cost
M/I Diagnosis Code
M/I Coordination Of Benefits/Other Payments Count
M/I Primary Care Provider Last Name
Pharmacy Not Contracted With Plan On Date Of Service
Submit Bill To Other Processor Or Primary Payer
M/I Other Payer Coverage Type
M/I Other Payer Reject Count
Non-Matched Pharmacy Number
Non-Matched Group ID
Non-Matched Cardholder ID
Non-Matched Person Code
Non-Matched Product/Service ID Number
Non-Matched Product Package Size
Non-Matched Prescriber ID
Non-Matched Primary Prescriber
M/I Other Payer ID Qualifier
M/I Other Payer Reject Code
Product/Service Not Covered For Patient Age
Product/Service Not Covered For Patient Gender
Patient/Card Holder ID Name Mismatch
Institutionalized Patient Product/Service ID Not Covered
Claim Submitted Does Not Match Prior Authorization
Patient Is Not Covered
Patient Age Exceeds Maximum Age
Filled Before Coverage Effective
Filled After Coverage Expired
Filled After Coverage Terminated
M/I Other Payer ID
M/I DUR/PPS Code Counter
Product/Service Not Covered
Prescriber Is Not Covered
Primary Prescriber Is Not Covered
Refills Are Not Covered
Other Carrier Payment Meets Or Exceeds Payable
Prior Authorization Required
Plan Limitations Exceeded
Discontinued Product/Service ID Number
Cost Exceeds Maximum
Refill Too Soon
M/I Facility ID
M/I DUR/PPS Level Of Effort
Drug-Diagnosis Mismatch
Claim Too Old
Claim Is Post-Dated
Duplicate Paid/Captured Claim
Claim Has Not Been Paid/Captured
Claim Not Processed
Submit Manual Reversal
Reversal Not Processed
DUR Reject Error
Rejected Claim Fees Paid
Host Hung Up
Host Response Error
System Unavailable/Host Unavailable
Time Out
Scheduled Downtime
Payer Unavailable
Connection To Payer Is Down
Host Processing Error
Patient Spenddown Not Met
Date Written Is After Date Filled
Product Not Covered Non-Participating Manufacturer
Billing Provider Not Eligible To Bill This Claim Type
QMB (Qualified Medicare Beneficiary)-Bill Medicare
Patient Enrolled Under Managed Care
Days Supply Limitation For Product/Service
Unit Dose Packaging Only Payable For Nursing Home Recipients
Generic Drug Required
M/I Software Vendor/Certification ID
M/I Segment Identification
M/I Transaction Count
M/I Professional Service Fee Submitted
M/I Service Provider ID Qualifier
M/I Patient First Name
M/I Patient Last Name
M/I Cardholder First Name
M/I Cardholder Last Name
M/I Home Plan
M/I Employer Name
M/I Employer Street Address
M/I Employer City Address
M/I Employer State/Province Address
M/I Employer Zip Postal Zone
M/I Employer Phone Number
M/I Employer Contact Name
M/I Patient Street Address
M/I Patient City Address
M/I Patient State/Province Address
M/I Patient Zip/Postal Zone
M/I Patient Phone Number
M/I Carrier ID
M/I Alternate ID
M/I Patient ID Qualifier
M/I Patient ID
M/I Employer ID
M/I Dispensing Fee Submitted
M/I Basis Of Cost Determination
M/I Usual And Customary Charge
M/I Prescriber Last Name
M/I Unit Dose Indicator
M/I Gross Amount Due
M/I Other Payer Amount Paid
M/I Patient Paid Amount Submitted
M/I Date Of Injury
M/I Claim/Reference ID
M/I Originally Prescribed Product/Service Code
M/I Originally Prescribed Quantity
M/I Compound Ingredient Component Count
M/I Compound Ingredient Quantity
M/I Compound Ingredient Drug Cost
M/I Compound Dosage Form Descriptin Code
M/I Compound Dispensing Unit Form Indicator
M/I Compound Route Of Administration
M/I Originally Prescribed Product/Service ID Qualifier
M/I Scheduled Prescription ID Number
M/I Prescription/Service Reference Number Qualifier
M/I Associated Prescription/Service Reference Number
M/I Associated Prescription/Service Date
M/I Procedure Modifier Code
M/I Quantity Prescribed
M/I Prior Authorization Type Code
M/I Prior Authorization Number Submitted
M/I Intermediary Authorization Type ID
M/I Intermediary Authorization ID
M/I Provider ID Qualifier
M/I Prescriber ID Qualifier
M/I Product/Service ID Qualifier
M/I Incentive Amount Submitted
M/I Reason For Service Code
M/I Professional Service Code
M/I Result Of Service Code
M/I Quantity Dispensed
M/I Other Payer Date
M/I Provider ID
M/I Plan ID
M/I Percentage Sales Tax Amount Submitted
M/I Flat Sales Tax Amount Submitted
M/I Other Payer Amount Paid Count
M/I Other Payer Amount Paid Qualifier
M/I Dispensing Status
M/I Percentage Sales Tax Rate Submitted
M/I Quantity Intended To Be Dispensed
M/I Days Supply Intended To Be Dispensed
M/I Measurement Time
M/I Measurement Dimension
M/I Measurement Unit
M/I Measurement Value
M/I Primary Care Provider Location Code
M/I DUR Co-Agent ID
M/I Other Amount Claimed Submitted Count
M/I Other Amount Claimed Submitted Qualifier
M/I Other Amount Claimed Submitted
M/I Percentage Sales Tax Basis Submitted
M/I DUR Co-Agent ID Qualifier
M/I Coupon Type
Patient Not Covered In This Aid Category
Recipient Locked In
Host PA/MC Error
Prescription/Service Reference Number/Time Limit Exceeded
Requires Manual Claim
Host Eligibility Error
Host Drug File Error
Host Provider File Error
M/I Coupon Number
Error Overflow
M/I Coupon Value Amount
Transaction Rejected At Switch Or Intermediary
PA Exhausted/Not Renewable
Invalid Transaction Count For This Transaction Code
M/I Claim Segment
M/I Clinical Segment
M/I COB/Other Payments Segment
M/I Compound Segment
M/I Coupon Segment
M/I DUR/PPS Segment
M/I Insurance Segment
M/I Patient Segment
M/I Pharmacy Provider Segment
M/I Prescriber Segment
M/I Pricing Segment
M/I Prior Authorization Segment
M/I Transaction Header Segment
M/I Workers’ Compensation Segment
Non-Matched Associated Prescription/Service Date
Non-Matched Employer ID
Non-Matched Other Payer ID
Non-Matched Unit Form/Route of Administration
Non-Matched Unit Of Measure To Product/Service ID
Associated Prescription/Service Reference Number Not Found
Clinical Information Counter Out Of Sequence
Compound Ingredient Component Count Does Not Match Number Of Repetitions
Coordination Of Benefits/Other Payments Count Does Not Match Number Of Repetitions
Coupon Expired
Date Of Service Prior To Date Of Birth
Diagnosis Code Count Does Not Match Number Of Repetitions
DUR/PPS Code Counter Out Of Sequence
Field Is Non-Repeatable
PA Reversal Out Of Order
Multiple Partials Not Allowed
Different Drug Entity Between Partial & Completion
Mismatched Cardholder/Group ID-Partial To Completion
M/I Compound Product ID Qualifier
Improper Order Of ‘Dispensing Status’ Code On Partial Fill Transaction
M/I Associated Prescription/service Reference Number On Completion Transaction
M/I Associated Prescription/Service Date On Completion Transaction
Associated Partial Fill Transaction Not On File
Partial Fill Transaction Not Supported
Completion Transaction Not Permitted With Same ‘Date Of Service’ As Partial Transaction
Plan Limits Exceeded On Intended Partial Fill Values
Out Of Sequence ‘P’ Reversal On Partial Fill Transaction
M/I Associated Prescription/Service Date On Partial Transaction
M/I Associated Prescription/Service Reference Number On Partial Transaction
Mandatory Data Elements Must Occur Before Optional Data Elements In A Segment
Other Amount Claimed Submitted Count Does Not Match Number Of Repetitions
Other Payer Reject Count Does Not Match Number Of Repetitions
Procedure Modifier Code Count Does Not Match Number Of Repetitions
Procedure Modifier Code Invalid For Product/Service ID
Product/Service ID Must Be Zero When Product/Service ID Qualifier Equals Ø6
Product/Service Not Appropriate For This Location
Repeating Segment Not Allowed In Same Transaction
Syntax Error
Value In Gross Amount Due Does Not Follow Pricing Formulae
M/I Procedure Modifier Code Count
M/I Compound Product ID
M/I Compound Ingredient Basis Of Cost Determination
M/I Diagnosis Code Count
M/I Diagnosis Code Qualifier
M/I Clinical Information Counter
M/I Measurement Date
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