Element Details

requirement designation element attributes code description mandatory the element must be used per the specification (e g , xml schema validation) business rule if sent, the element must be used per the surescripts business rule note not all business rules reside in this table conditional the element is to be used per the conditions specified optional some fields do not have specific conditions data should be sent if available note this guide only includes data elements where surescripts has specific requirements or further explains the field usage refer to the ncpdp implementation guide for a complete list of elements in addition, comments below where codes are specified are either to call out surescripts notes and/or to show the code recommended by surescripts for a full list of codes, please refer to the ncpdp guide formulary and benefit data load specification the formulary and benefit data load is represented as a flat variable length file the pipe character (hex 7c) will be used to delimit fields and the new line (hex 0a) character will delimit records note mandatory fields cannot be populated with all blank spaces formulary and benefit file header field code comments record type mandatory identifies record type value hdr version/release number mandatory version number of this specification value 60 sender id mandatory id as assigned by surescripts identifying the sending customer (pbm/payer) the sender represents the entity that is providing the data and creating the file sender participant password mandatory password for this customer as assigned by surescripts only populated when pbm/payer is sending file to surescripts receiver id mandatory only populated when pbm/payer is sending file to surescripts value s00000000000001 source name mandatory name of source supplying the formulary pbm/payer transmission control number mandatory unique identifier defined by the sender transmission date mandatory date message was created format ccyymmdd transmission time mandatory time message was created format hhmmssdd transmission file type mandatory identifier telling the type of message value frm = formulary and benefit load transmission action mandatory action for the entire message for pbm/payers, this action tells surescripts if this file replaces all previously loaded files from this source (f = full replace), or if it is an update file, (u = update) contains updated files only, (d = delete), all sub files will be deleted an “f” (full replace) action indicates to the receiver to remove all previously loaded files from this source from the database the new file is then loaded in their place a “u” (update) contains files that need to be updated or added on an individual basis to the formulary database extract date mandatory date the file was extracted from the internal publisher’s system format ccyymmdd file type mandatory test or production values t=test p=production formulary and benefit file trailer reference see formulary and benefit implementation guide version 60 sec 8 1 2 page 39 for element details formulary status file (fs) formulary status header field code comments record type mandatory identifies record type value fhd formulary id mandatory identification for the formulary the id for the drug formulary number id that may have been returned in the x12 eligibility response (271) message (located in loop 2110c, ref02) see f 208 and formulary ids and eligibility fields overview for more information must be unique across all files of this type valid characters are (a z, a z, numeral 0 9, period “ ”, and a dash “ “) non listed prescription single source brand formulary status mandatory tells the receiver how to treat non listed prescription branded medications reference refer to the ncpdp ecl for values values z = zero dollar copay p = on formulary/preferred b = brand preferred (over generic) o = on formulary/non preferred c = carve out n = non formulary x = non reimbursable without authorization y = non reimbursable u = unknown non listed prescription multi source brand formulary status mandatory non listed prescription generic formulary status mandatory tells the receiver how to treat non listed prescription generic medications reference refer to the ncpdp ecl for values values z = zero dollar copay p = on formulary/preferred b = brand preferred (over generic) o = on formulary/non preferred c = carve out n = non formulary x = non reimbursable without authorization y = non reimbursable u = unknown non listed brand over the counter formulary status mandatory tells the receiver how to treat non listed brand over the counter medications reference refer to the ncpdp ecl for values values z = zero dollar copay p = on formulary/preferred b = brand preferred (over generic) o = on formulary/non preferred c = carve out n = non formulary x = non reimbursable without authorization y = non reimbursable u = unknown non listed generic over the counter formulary status mandatory tells the receiver how to treat non listed generic over the counter medications reference refer to the ncpdp ecl for values values z = zero dollar copay p = on formulary/preferred b = brand preferred (over generic) o = on formulary/non preferred c = carve out n = non formulary x = non reimbursable without authorization y = non reimbursable u = unknown non listed medical supplies formulary status mandatory tells the receiver how to treat non listed supplies reference refer to the ncpdp ecl for values values z = zero dollar copay p = on formulary/preferred b = brand preferred (over generic) o = on formulary/non preferred c = carve out n = non formulary x = non reimbursable without authorization y = non reimbursable u = unknown file effective date mandatory ccyymmdd file expiration date mandatory ccyymmdd formulary status detail field code comments record type mandatory identifies record type value fdt product/service id source conditional business rule drug id (ndc) field must be sent mandatory because class id is no longer used note surescripts requires n 11/11 qualified by product/service id qualifier if either product/service id or product/service id qualifier is sent, then both are required product/service id qualifier conditional business rule drug id qualifier field must be sent value 03 = national drug code (ndc) 36 = representative national drug code (ndc) note only ndc is supported by surescripts if either product/service id or product/service id qualifier is sent, then both are required reason for use code optional surescripts recommends using icd 10 diagnosis codes to improve pbm/payer processing accuracy reason for use code qualifier optional value abx = icd 10 reason for use description optional reason for use action conditional reason for use action should be left blank formulary status mandatory status of the medication within the formulary reference refer to the ncpdp ecl for values values z = zero dollar copay p = on formulary/preferred b = brand preferred (over generic) o = on formulary/non preferred c = carve out n = non formulary x = non reimbursable without authorization y = non reimbursable u = unknown preference level optional see appendix a formulary status and preference level for more information values 1 = most preferred 2 98 = ordered preference between least to most 99 = least preferred formulary copay price point conditional formulary copay price point should be left blank drug tier link conditional message link conditional formulary status trailer reference see formulary and benefit implementation guide version 60 sec 8 2 3 page 42 for element details drug tier note surescripts does not support the drug tier file at this time reference see formulary and benefit implementation guide version 60 sec 8 2 4 through 8 2 6 page 42 for header, detail, and trailer element details alternatives products triggers file (at) alternative medications for a specified product alternative products triggers header field code comments record type mandatory identifies record type value ahd alternative product triggers id mandatory the identification number for this alternative file the id for the alternative file that may have been returned in the x12 eligibility response (271) message (located in loop 2110c, msg01 “message text” element) see f 208 and formulary ids and eligibility fields overview for more information must be unique across all files of this type valid characters are (a z, a z, numeral 0 9, period “ ”, and a dash “ “) file effective date mandatory date the file goes into effect format ccyymmdd file expiration date mandatory date the file expires format ccyymmdd alternative products triggers detail field code comments record type mandatory identifies record type value adt product/service id source mandatory business rule drug id (ndc) field must be sent if either product/service id or product/service id qualifier is sent, then both are required product/service id qualifier mandatory business rule drug id qualifier field must be sent values 03 = national drug code (ndc) this can be the representative ndc number note only ndc is supported by surescripts 36 = representative national drug code (ndc) if either product/service id or product/service id qualifier is sent, then both are required alternative product groups link mandatory alternative products triggers trailer reference see formulary and benefit implementation guide version 60 sec 8 3 1 3 page 44 for element details alternative product groups file (ag) alternative medications for a specified product alternative product groups header field code comments record type mandatory identifies record type value agh alternative product groups id mandatory used to link the products links file to the product groups file the id for the alternative file that may have been returned in the x12 eligibility response (271) message (located in loop 2110c, msg01 “message text” element) see f 208 and formulary ids and eligibility fields overview for more information must be unique across all files of this type valid characters are (a z, a z, numeral 0 9, period “ ”, and a dash “ “) file effective date mandatory date the file goes into effect format ccyymmdd file expiration date mandatory date the file expires format ccyymmdd alternative product groups detail field code comments record type mandatory identifies record type value agp alternative product groups link mandatory reason for use code optional reason for use code qualifier optional reason for use description optional formulary status override mandatory this field should be used when indicating medications of higher status reference refer to the ncpdp ecl for values values yes no product/service id alternative conditional business rule drug id (ndc) field must be sent drug id (ndc) mandatory because class id is no longer used if either product/service id or product/service id qualifier is sent, then both are required product/service id qualifier conditional business rule drug id qualifier field must be sent values 03 = national drug code (ndc) this can be the representative ndc number note only ndc is supported by surescripts 36 = representative national drug code (ndc) if either product/service id or product/service id qualifier is sent, then both are required combination drug grouping conditional preference level mandatory if there are multiple alternatives for a given source ndc, this is the pbm/payer’s order of preference (a higher number equals greater preference) 1 99 (lower number indicates more preferred) alternative product groups trailer reference see formulary and benefit implementation guide version 60 sec 8 3 2 3 page 46 for element details copay summary file (cs) note surescripts does not support the copay summary file at this time reference see formulary and benefit implementation guide version 60 sec 8 4 1 page 46 for header, detail, and trailer element details copay product specific file (ps) copay product specific header field code comments record type mandatory identifies record type value cph copay product specific id mandatory must be unique across all files of this type provides the linkage for managing the processing of detail data over time valid characters are (a z, a z, numeral 0 9, period “ ”, and a dash “ “) file effective date mandatory date the file goes into effect ccyymmdd expressed in utc expiration date mandatory date the file expires ccyymmdd copay product specific detail business rule product/service id and product/service id qualifier must be sent note the field reason for use action should be left blank for copay product specific detail reference see formulary and benefit implementation guide version 60 sec 8 4 2 2 page 49 for element details copay product specific trailer reference see formulary and benefit implementation guide version 60 sec 8 4 2 3 page 52 for element details product exclusion file (pe) product exclusion header field code notes record type mandatory value peh product exclusion id mandatory this id will tie the coverage file to a patient or health plan file effective date mandatory format ccyymmdd file expiration date mandatory format ccyymmdd message link optional link value used to match a message trigger product to a text message and/or a web link in the message file product exclusion detail business rule product/service id and product/service id qualifier must be sent reference see formulary and benefit implementation guide version 60 sec 8 5 1 2 page 53 for element details product exclusion trailer reference see formulary and benefit implementation guide version 60 sec 8 5 1 3 page 53 for element details field code comments record type mandatory identifies record type value pet record count mandatory do not include the product exclusion header and trailer records in this count total number of product exclusion detail records age limits (al) business rule product/service id and product/service id qualifier must be sent reference see formulary and benefit implementation guide version 60 sec 8 5 2 page 54 for header, detail, and trailer element details gender limits file (gl) business rule product/service id and product/service id qualifier must be sent reference see formulary and benefit implementation guide version 60 sec 8 5 3 page 55 for header, detail, and trailer element details prior authorization file (pa) business rule product/service id and product/service id qualifier must be sent reference see formulary and benefit implementation guide version 60 sec 8 5 4 page 57 for header, detail, and trailer element details quantity limits file (ql) business rule product/service id and product/service id qualifier must be sent reference see formulary and benefit implementation guide version 60 sec 8 5 5 page 59 for header, detail, and trailer element details specialty products file (sp) business rule product/service id and product/service id qualifier must be sent reference see formulary and benefit implementation guide version 60 sec 8 5 6 page 61 for header, detail, and trailer element details step therapy products file (st) and step therapy products groups (sm) file business rule product/service id and product/service id qualifier must be sent notes surescripts only supports the "step therapy product groups id" in the "step therapy product groups" file header surescripts supports the step therapy product groups link with a length of up to 40 characters reference see formulary and benefit implementation guide version 60 sec 8 5 7 page 62 for step therapy products file and step therapy product groups header, detail, and trailer element details pharmacy network status files reference see formulary and benefit implementation guide version 60 sec 8 6 page 65 for pharmacy chain file and pharmacy network file header, detail, and trailer element details messaging file business rule for general message detail, product/service id and product/service id qualifier must be sent reference see formulary and benefit implementation guide version 60 sec 8 7 page 68 for general message detail and message file and pharmacy network file header, detail, and trailer element details formulary and benefit file validation (for pbm/payers) a formulary and benefit file coming from a pbm/payer goes through a series of validations at surescripts before it is loaded these validations are described in the following sections for more information on the possible error codes returned, refer to the reject code summary formulary and benefit file header and trailer validation the formulary and benefit file header and trailer is the wrapper for the entire file surescripts performs the following validations for the file header and trailer validate the proper physical format of the header (required fields are present and contain valid values as defined in surescripts’ specification) validate the sender (source) participant id and password validate that the file type (usage indicator) is valid for the system the file is sent to (i e t for test, p for production) validate the version number validate the record length and termination of the header and trailer upon failure of the validations performed in steps 1 5, surescripts submits a response file to the pbm/payer with the appropriate error code processing stops when a header level error is encountered formulary and benefit response file a response file is posted for the pbm/payer to retrieve after it has been loaded or attempted to load it contains information related to any errors encountered by the recipient while attempting to load the file for more detailed information on the error codes sent within the response file, refer to the reject code summary formulary and benefit response file header field code notes record type mandatory identifies record type value shd version/release number mandatory version number of this specification 60 sender id mandatory id as assigned by surescripts identifying surescripts receiver id mandatory id assigned by surescripts for the recipient or pbm/payer (original sender of the formulary and benefit data load ) sender participant password mandatory password assigned by surescripts for accessing the pbm/payer system transmission control number mandatory unique identifier defined by the sender transmission date mandatory date message was created ccyymmdd transmission time mandatory time message was created hhmmssdd transmission file type mandatory identifier telling receiver the type of file fre – formulary transaction response transmission number originating mandatory number of the original formulary message transmission date originating mandatory date original incoming file was created (d8 ) ccyymmdd transmission time originating mandatory time original incoming file was created hhmmssdd file type (usage indicator) conditional test or production (t/p) values t=test p=production load status conditional code explaining the status of the load values 01 = file loaded correctly the entire formulary and benefit data load file has loaded without any errors no detail row errors exist 02 = file loaded with errors the file was partially loaded due to row level errors for row error information, refer to the reject codes section 03 = file contains errors file not loaded the entire file was unable to load because of errors this error code is only used for full replace processes or with update processes where all files contain an error and none of the files are loaded 04 = system error – an error has occurred during processing not related to the structure of the file contact surescripts and then resend the same file formulary and benefit response file detail field code notes record type mandatory identifies record type value sdt absolute row number mandatory the absolute row or line number in the file that contains the error if the row number is 1 then the error is for the file header section column in error mandatory column number that contains the error column number of error in row the first field record type is considered column 0, the next field is considered column 1 reject code mandatory describes error for this column note if an error occurred, the entire file that the error was in did not load see reject code summary below additional message information conditional free text description of the error data in error conditional copy of the bad data if the data in error is longer than 100 characters it will be truncated if a pipe character is in the data it will be represented as \[pipe] formulary and benefit response file trailer reference see formulary and benefit implementation guide version 60 sec 9 1 3 page 72 for element details reject code summary for any validation error, an error message is sent including the reject code value and a detailed description when the formulary and benefit file header load status contains “02 – file loaded with errors” or “03 – file contains errors – file not loaded”, the following reject code values may be reported if an overall file header or a file trailer contains an error, the processing of the entire file is stopped and the entire file is rejected response file contains load status “03” if a sub file (list) header or sub file (list) trailer contains an error, that sub file (list) will be rejected, but any other valid sub files (list) will be processed response file has load status “02” if a detail row contains an error, the row containing the error is rejected, but the rest of the sub file will be processed response file has load status “02” example of an error message sdt|22|5|1007|required length 1 35|1782^acetaminophen propoxyphene hydrochloride note the process that surescripts is using to process the formulary files is an enhancement to what is in the standard this enhanced process is needed to provide clearer error details and fewer rejections of the entire file code surescripts detailed error message description 1001 no valid detail 1 0 1002 required list missing 1003 unknown segment there is an extra blank line in the file 1004 unexpected segment header can only be on first line unexpected segment list detail with no list header unexpected segment wrong detail type for header unexpected segment non valid record identifier unexpected segment – missing list trailer unexpected segment list header type does not match list trailer type unexpected segment missing list header 1006 required field missing all fields or no fields must be populated drug reference number drug reference qualifier field \[field name] is required when \[field name] = \[specific value] fields \[list of fields] require \[field name] at least \[number] fields must be populated \[list of fields] field \[field name] is required when \[field name 2] is populated, or \[field name 3] is empty 1007 required length 1 xx not in range \[1 xx] 1009 disallowed characters found not one of allowed values this value must be numeric invalid date format expect yyyymmdd not matching pattern \[a za z0 9 ]+ invalid date yyyymmdd invalid time format expect hhmmssdd invalid transmission action invalid usage indicator invalid extract date format yyyymmdd 1010 extra data found after segment max fields xx 1012 list trailer count xx expected yy 1013 invalid participant id or password invalid receiver id 1014 sender id not certified for processor/payor 9000 duplicate detail record duplicate list header system exception field \[field name 1] is greater than \[field name 2] and should be <= \[value of field name 2] field \[field name] must be empty when \[field name] = \[specific value]