512-FC

Accumulated Deductible Amount

Accumulated Deductible Amount

Amount in dollars met by the
patient/family in a deductible
plan.

s9(6)v99 Response Pricing Segment

369-2Q

Additional Documentation
Type ID

Additional Documentation
Type ID

Unique identifier for the data
being submitted.

x(3)

Additional Documentation Segment

526-FQ

Additional Message
Information

Additional Message
Information

Free text message

x(1)-x(4Ø)

Response Status Segment

131-UG

Additional Message Information Continuity

Additional Message Information Continuity

Indicates continuity of the textfound in the current repetition of ‘Additional Message Information’ (526-FQ) with the text found in the next repetition that follows.

Response Status Segment

X(1)

13Ø-UF

Additional Message Information Count

Additional Message Information Count

Count of the ‘Additional Message Information’ (526-FQ) occurrences that follow

9(2)

Response Status Segment

132-UH

Additional Message Information
Qualifier

Additional Message Information
Qualifier

Format qualifier of the ‘Additional Message Information’ (526-FQ) thatfollows. Each value may occur only once per transaction and values must be ordered sequentially (numeric characters precede alpha
characters, i.e., Ø-9, A-Z).

X(2)

33Ø-CW

Alternate ID

Alternate ID

Person identifier to be used for
controlled product reporting.
Identifier may be that of the
patient or the person picking
up the prescription as required
by the governing body.

x(20)

Claim Segment

455-EM

PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER

455-EM

Prescription/

Service Reference

Number Qualifier

Indicates the type of billing submitted

x(1)  Claim Segment

4Ø2-D2

PRESCRIPTION/SERVICE REFERENCE NUMBER

4Ø2-D2

Prescription/Service Reference Number

Reference number assigned

by the provider for the

dispensed drug/product and/or

service provided

9(12) Claim Segment