Ø1 M/I Bin
Ø2 M/I Version Number
Ø3 M/I Transaction Code
Ø4 M/I Processor Control Number
Ø5 M/I Pharmacy Number
Ø6 M/I Group Number
Ø7 M/I Cardholder ID Number
Ø8 M/I Person Code
Ø9 M/I Birth Date
1C M/I Smoker/Non-Smoker Code
1E M/I Prescriber Location Code
M/I Patient Gender Code
11 M/I Patient Relationship Code
12 M/I Patient Location
13 M/I Other Coverage Code
14 M/I Eligibility Clarification Code
15 M/I Date of Service
16 M/I Prescription/Service Reference Number
17 M/I Fill Number
19 M/I Days Supply
2C M/I Pregnancy Indicator
2E M/I Primary Care Provider ID Qualifier
M/I Compound Code
21 M/I Product/Service ID
22 M/I Dispense As Written (DAW)/Product Selection Code
23 M/I Ingredient Cost Submitted
25 M/I Prescriber ID
26 M/I Unit Of Measure
28 M/I Date Prescription Written
29 M/I Number Refills Authorized
3A M/I Request Type
3B M/I Request Period Date-Begin
3C M/I Request Period Date-End
3D M/I Basis Of Request
3E M/I Authorized Representative First Name
3F M/I Authorized Representative Last Name
3G M/I Authorized Representative Street Address
3H M/I Authorized Representative City Address
3J M/I Authorized Representative State/Province Address
3K M/I Authorized Representative Zip/Postal Zone
3M M/I Prescriber Phone Number
3N M/I Prior Authorized Number Assigned
3P M/I Authorization Number
3R Prior Authorization Not Required
3S M/I Prior Authorization Supporting Documentation
3T Active Prior Authorization Exists Resubmit At Expiration Of Prior Authorization
3W Prior Authorization In Process
3X Authorization Number Not Found
3Y Prior Authorization Denied
32 M/I Level Of Service
33 M/I Prescription Origin Code
34 M/I Submission Clarification Code
35 M/I Primary Care Provider ID
38 M/I Basis Of Cost
39 M/I Diagnosis Code
4C M/I Coordination Of Benefits/Other Payments Count
4E M/I Primary Care Provider Last Name
Pharmacy Not Contracted With Plan On Date Of Service
41 Submit Bill To Other Processor Or Primary Payer
5C M/I Other Payer Coverage Type
5E M/I Other Payer Reject Count
Non-Matched Pharmacy Number
51 Non-Matched Group ID
52 Non-Matched Cardholder ID
53 Non-Matched Person Code
54 Non-Matched Product/Service ID Number
55 Non-Matched Product Package Size
56 Non-Matched Prescriber ID
58 Non-Matched Primary Prescriber
6C M/I Other Payer ID Qualifier
6E M/I Other Payer Reject Code
Product/Service Not Covered For Patient Age
61 Product/Service Not Covered For Patient Gender
62 Patient/Card Holder ID Name Mismatch
63 Institutionalized Patient Product/Service ID Not Covered
64 Claim Submitted Does Not Match Prior Authorization
65 Patient Is Not Covered
66 Patient Age Exceeds Maximum Age
67 Filled Before Coverage Effective
68 Filled After Coverage Expired
69 Filled After Coverage Terminated
7C M/I Other Payer ID
7E M/I DUR/PPS Code Counter
Product/Service Not Covered
71 Prescriber Is Not Covered
72 Primary Prescriber Is Not Covered
73 Refills Are Not Covered
74 Other Carrier Payment Meets Or Exceeds Payable
75 Prior Authorization Required
76 Plan Limitations Exceeded
77 Discontinued Product/Service ID Number
78 Cost Exceeds Maximum
79 Refill Too Soon
8C M/I Facility ID
8E M/I DUR/PPS Level Of Effort
Drug-Diagnosis Mismatch
81 Claim Too Old
82 Claim Is Post-Dated
83 Duplicate Paid/Captured Claim
84 Claim Has Not Been Paid/Captured
85 Claim Not Processed
86 Submit Manual Reversal
87 Reversal Not Processed
88 DUR Reject Error
89 Rejected Claim Fees Paid
Host Hung Up Host Disconnected Before Session Completed
91 Host Response Error Response Not In Appropriate Format To Be Displayed
92 System Unavailable/Host Unavailable Processing Host Did Not Accept
Transaction/Did Not Respond Within Time Out Period
*95 Time Out
*96 Scheduled Downtime
*97 Payer Unavailable
*98 Connection To Payer Is Down
99 Host Processing Error Do Not Retransmit Claims