Element Details

requirement designation \<font color="#000000">element attributes \</font> 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 recommended surescripts recommends sending the element as a best practice optional some fields do not have specific conditions data should be sent if available not used not used by surescripts message header elements note this guide only includes data elements where surescripts has specific requirements or further explains the field usage refer to the ncpdp rtpb xml schema listed in document references for a complete list of fields element code comment to/primary mandatory the identification of the rtpbrequest sender this can be found in the 'from/primary' of the rtpbrequest message to/@qualifier mandatory value d = prescriber from/primary mandatory the identification of the sender of the message this is the surescripts assigned participantid from/@qualifier mandatory value py = payer/processor from/tertiary conditional tertiary field is populated with the surescripts id (s00000000000005) on the rtpbrequest from/@qualifier mandatory value py = payer/processor messageid mandatory a minimum set of standards/algorithms should be used when generating message ids to ensure uniqueness if possible, customers should utilize global unique identifiers (guids) see message linkage docid\ potvndgivkwj0g6cgwrej for more details s 205 the sender shall ensure the combination of the from and messageid elements, for all messages including error, is unique for at least 18 months surescripts recommends an unformatted globally unique identifier (guid) relatestomessageid conditional this element is case sensitive rtpbrequest – populate with value contained in the related interchange control number isa13 field from the 271 eligibility response rtpbresponse – populate with the messageid from the rtpbrequest see message linkage docid\ potvndgivkwj0g6cgwrej for more details s 210 customers shall support the scenarios in the message linkage section of this guide senttime mandatory date/time of initiation refer to utc time format docid 7bl7a3eudop7nx06e4mwi for information on how to properly format the date/time data softwaresendercertificationid conditional business rule softwaresendercertificationid has a max length of 10 characters surescripts requires sending this field identifies the entity responsible for the software that generated the message the developer may be a software vendor or, if the software was developed “in house”, the developer is the entity sending the message (e g , a chain) the value transmitted is determined by the sender software developer consumingapp extension conditional values surescripts = prescriber sender type sshub = hub and life sciences sender type sspharmacy = pharmacy sender type note this is only applicable on the request this is not expected to be returned on the response message linkage s 210 customers shall support the scenarios in the message linkage section of this guide the table below illustrates how the messageids in the eligibility response, rtpbrequest and rtpbresponse, and newrx messages are linked note populate the relatestomessageid in an error message with the messageid sent in the original message field names eligibility response rtpbrequest rtpbresponse newrx messageid elig43211 rtpbreq1 rtpbres1 newrx assigned by responding pbm/payer note this is the interchange control number isa13 field from the 271 eligibility response assigned by provider vendor assigned by pbm/payer assigned by provider vendor relatesto messageid n/a elig43211 rtpbreq1 rtpbres1 if available, populate with the interchange control number isa13 field from the 271 eligibility response populate with the messageid from rtpbrequest if available, populate with the messageid from rtpbresponse note only populate if processedstatus = true rtpbrequest elements notes there may be instances where multiple rtpbrequests are sent in parallel to gather additional information for the provider it is recommended to avoid rate limiting to allow for successful message processing this guide only includes data elements where surescripts has specific requirements or further explains the field usage refer to the real time prescription benefit standard v13 schema listed in document references for a complete list of fields the rtpbrequest for a patient will be tied to the eligibility response received within the last 72 hours for that patient this is accomplished by using the interchange control number isa13 from the 271 eligibility response in the relatestomessageid of the rtpbrequest per acr s 201, customers shall ensure all messages are syntactically correct before transmission to surescripts element code comment patient mandatory name/lastname mandatory patient last name populate with the last name found in the 271 eligibility response in the 2100c loop nm103 recommend using value exactly as it was received in the 271 eligibility response name/firstname mandatory patient first name populate with the first name found in the 271 eligibility response in the 2100c loop nm104 recommend using value exactly as it was received in the 271 eligibility response sexandgender/ administrativegender mandatory patient gender populate with the patient's gender found in the 271 eligibility response in the 2100c loop dmg03 recommend using value exactly as it was received in the 271 eligibility response dateofbirth mandatory date of birth of patient populate with the patient's date of birth found in the 271 eligibility response in the 2100c loop dmg02 that is qualified by the dmg01 code "d8" recommend using value exactly as it was received in the 271 eligibility response stateprovince mandatory patient’s state or province populate with the patient's state or province found in the 271 eligibility response in the 2100c loop n402 recommend using value exactly as it was received in the 271 eligibility response postalcode mandatory patient’s address postal code populate with the patient's postal code found in the 271 eligibility response in the 2100c loop n403 recommend using value exactly as it was received in the 271 eligibility response city extension mandatory patient’s city populate with the patient's city found in the 271 eligibility response in the 2100c loop n401 recommend using value exactly as it was received in the 271 eligibility response customers should use the following url \<extension name="city" url="http //surescripts com/extensions/rtpbrequest/patient/city”> benefitscoordination mandatory pbmmemberid conditional business rule surescripts requires this field to be sent unique pbmmemberid for the patient the id can be found in the 271 eligibility response from the pbm/payer in loop 2100c nm109 requestedproduct mandatory product mandatory drugcoded/ndc mandatory ndc of the requested medication ndc must be an 11 digit numeric in the 5 4 2 format dashes shall not be used and leading zeros shall not be suppressed ndc should be representative do not send repackaged, obsolete, private label or unit dose ndc unless it is the only ndc available to identify the medication concept quantity mandatory value mandatory quantity for the requested medication to ensure successful message processing, dayssupply and quantity should be a numeric value and greater than zero (0) codelistqualifier mandatory quantity codelistqualifier for the requested medication value 38 = original quantity quantityunitof measure/code mandatory the quantityunitcode should reflect the ncit code if the ncit code is not sent, the provider vendor may not be able to translate the quantityunitcode and the response may result in an error example value c48542 = tablet for a list of ncit codes, go to http //evs nci nih gov/ftp1/ncpdp/about html http //evs nci nih gov/ftp1/ncpdp/about html this list should be updated monthly use the ncpdp quantityunitofmeasure terminology rows from the downloaded data pm 200 quantityunitofmeasure code qualifiers shall be correctly associated with medication descriptions dayssupply mandatory business rule dayssupply must be sent for accurate pricing dayssupply is the estimated number of days the prescription will last excluding refills, based upon the prescribed quantity and directions it is the prescribed quantity divided by the daily doses while this is typically system calculated, the prescriber retains responsibility for the value dayssupply and quantity must be a numeric value and greater than zero (0) diagnosis conditional icd 10 diagnosis codes should be included on the rtpbrequest to improve pbm/payer processing accuracy code mandatory @qualifier mandatory value abf = icd10 prescriber mandatory identification/npi mandatory npi for the prescriber npi will be validated against the check digit routine for specific information see https //www cms gov/regulations and guidance/administrative simplification/nationalprovidentstand/downloads/npicheckdigit pdf https //www cms gov/regulations and guidance/administrative simplification/nationalprovidentstand/downloads/npicheckdigit pdf pharmacy mandatory business rule pharmacy must be sent for accurate pricing identification/ncpdpid conditional business rule the ncpdpid for the pharmacy must be sent in the rtpbrequest identification/npi conditional business rule the npi (national provider id) for pharmacy must be sent in the rtpbrequest npi will be validated against the check digit routine for specific information see https //www cms gov/regulations and guidance/administrative simplification/nationalprovidentstand/downloads/npicheckdigit pdf https //www cms gov/regulations and guidance/administrative simplification/nationalprovidentstand/downloads/npicheckdigit pdf businessname mandatory store name primarytelephonenumber mandatory store phone number rtpbresponse elements notes this guide only includes data elements where surescripts has specific requirements or further explains the field usage refer to the ncpdp rtpb xml schema listed in document references for a complete list of fields per acr s 200, customers shall be able to receive syntactically valid maximum and minimum populated messages optional data elements (and values therein) shall not cause message failure element code comment response mandatory processed mandatory processed should only be sent in instances where benefit information is provided please reach out to your surescripts representative for additional information note conditional recommended to send if needed to aid in message processing notprocessed mandatory note conditional additional free text information about the rejectcode strongly recommended to send to further explain why message was rejected responseproduct conditional product mandatory contains the information on the requested medication drugdescription mandatory the drug name, strength, and form associated with the ndc pricingandcoverages mandatory there may be up to 6 pricingandcoverages returned per responseproduct and responsealternativeproduct pm 204 coverage restrictions for all \<pricingandcoverages> elements for medication combinations returned (including alternatives) this concession is allowed an indicator that coverage restriction(s) apply to a specific combination user action on this indicator presents all coverage restrictions in their entirety estimatedcombined planandpatientsavings conditional provides additional patient and/or health plan savings information that may assist with medication selection estimatednetplancost conditional provides additional health plan cost information that may assist with medication selection responsealternative product conditional clinically appropriate alternatives are provided here this would include information for an alternative medication (if provided) similar to what is supplied in the responseproduct element pm 205 all available appropriate alternatives displayed together if all alternatives cannot be shown together, this concession is allowed an indicator that alternative medications are available user interaction on this indicator presents all alternative medications together pricingandcoverages/ pricingandcoverage/ coveragestatusmessage conditional additional free text information about the coverage status may be used to communicate non benefit coverage types as well as coverage restrictions pricingandcoverages/ pricingandcoverage/ drugstatus extension conditional additional free text information about the drug may be used to communicate drug and pricing specifics