844 845 849 C o n t r a c t

845
849
844
Contract & Chargeback Administration
Guidelines for Electronic Data Interchange (EDI)
845
844
849
Contract & Chargeback Administration Guidelines
for Electronic Data Interchange (EDI),
to Support Distributor Service Agreements
Section 1: 845 Price Authorization Acknowledgement/Status
Section 2: 844 Product Transfer Account Adjustment
Section 3: 849 Response to Product Transfer Account Adjustment
Developed by
HDMA eCommerce Task Force
May 2009
Copyright © 2009 by Healthcare Distribution Management Association, United States. All rights reserved. This publication may not be
reproduced, stored in any informational retrieval system or transmitted in whole or in part by any means—electronic, mechanical,
photocopying, recording or otherwise—without the express written permission of the Healthcare Distribution Management Association. This
document is confidential and is intended solely for the use and information of HDMA.
ISBN: 978-0-9824950-0-1
845
849
844
Contract & Chargeback Administration Guidelines
for Electronic Data Interchange (EDI),
to Support Distributor Service Agreements
Section 1: 845 Price Authorization Acknowledgement/Status
Table of Contents
Introduction
4
Transaction Set Detail
5
Data Segments
6
Business Samples
36
Page 4
845 Price Authorization Acknowledgment/
Status
INTRODUCTION
This implementation guideline for the Price Authorization Acknowledgment/Status Electronic Data
Interchange (EDI) transaction set was developed by the Healthcare Distribution Management Association’s
(HDMA) eCommerce Task Force (eCTF). The eCTF provides business and technology expertise to develop
voluntary healthcare industry implementation guidelines for the use of EDI and other technology standards.
HDMA member distributors, manufacturers and technology providers serve on the task force.
The purpose of this HDMA implementation guideline is to present the format and explain the application of
the Accredited Standards Committee (ASC) X12 standards as they pertain to the Price Authorization
Acknowledgment/Status transaction set for use within the context of an EDI environment in healthcare. This
transaction set contains one header, detail and summary area per transaction. The transaction set can be
used by a vendor or manufacturer to transmit specific data relative to the status of or changes to outstanding
price authorizations.
This edition contains the following revisions:
1.) Additional codes have been added to identify third-party pharmacy billing and eligible entities.
2.) Certain usage notes have been added or edited to clarify definitions or use.
Transaction Set Usage:
Price Authorization Acknowledgment/Status (Bid Award/Change Notification)
The purpose of this section is to present the format and explain the application of the ASC X12 standards as
they pertain to the Bid Award/Change Notification transaction set. Once the purchase group or customer
notifies the manufacturer of bid acceptance and awards a contract, the manufacturer should notify the
appropriate distributor(s) through the transmission of a Bid Award/Change Notification. This notification
should include all awarded products, prices and eligible customers for the awarded contract. When the
manufacturer creates a Bid Award/Change Notification for a particular distributor, the manufacturer may elect
to include only those eligible members applicable to that particular distributor. Notification to the appropriate
distributor(s) should occur 45 to 60 days prior to the effective date of the awarded contract. The distributor
needs this time to load the SKUs, product codes and eligible customers; to adjust inventory levels;
and to load any other data necessary to manage the transactions.
The Bid Award/Change Notification should also be used by the manufacturer to notify the appropriate
distributor(s) of any changes to an existing contract –previously sent to the distributor(s) - as these changes
occur during the time the contract is in effect. These changes may include a contract number change, addition
or deletion of a product, contract price change, addition or deletion of an eligible member and/or a change in
the eligible member identification code, to name a few. Notification of changes to an existing contract should
occur not less than 15 days prior to the effective date of the change to allow the distributor time to update
the computer files necessary to manage the transactions.
Use of the Bid Award/Change Notification will assure that the manufacturer, distributor(s) and the purchase
group or customer maintain accurate detail with respect to the price that should be extended to eligible
members for the purchase of awarded products.
For trading partners who elect to use the Price Authorization Acknowledgment/Status, this guideline is
intended to help facilitate trading partners’ use of this transaction set to improve business efficiencies.
Page 5
845
Price Authorization Acknowledgment/Status
PA
Functional Group=
Purpose: This X12 transaction set contains the format and establishes the data content of the Price Authorization
Acknowledgment/Status Transaction Set (845) for use within the context of an Electronic Data Interchange (EDI) environment. The
transaction set can be used by a vendor or manufacturer to transmit specific data relative to the status of or changes to outstanding
price authorizations.
Heading:
Page Pos
6 0100
7 0200
8
9
10
11
12
Id
ST
BPA
0600
DTM
LOOP ID - N1
0700
N1
1100
REF
1200
PER
Segment Name
Transaction Set Header
Beginning Segment for Price
Authorization
Acknowledgment/Status
Date/Time Reference
Name
Reference Identification
Administrative Communications
Contact
Req
M
M
Max Use
1
1
O
10
O
O
O
Repeat
Notes
10000
N1/0700L
Usage
Must use
Must use
Used
1
12
3
Used
Used
Used
Detail:
Page
13
14
15
16
17
18
19
20
21
22
23
Pos
Id
LOOP ID - CON
0100
CON
0200
REF
0400
DTM
LOOP ID - N1
0500
N1
0600
N2
0700
N3
0800
N4
0900
REF
1100
DTM
24
25
26
27
28
29
30
LOOP ID - PAD
1200
PAD
1300
CTB
1600
UIT
2200
DTM
LOOP ID - LIN
2300
LIN
32
33
LOOP ID – CTP
3100
CTP
Segment Name
Req
Max Use
Contract Number Detail
Reference Identification
Date/Time Reference
M
O
O
1
>1
10
Name
Additional Name Information
Address Information
Geographic Location
Reference Identification
Date/Time Reference
O
O
O
O
O
O
1
2
2
1
12
2
Product Adjustment Detail
Restrictions/Conditions
Unit Detail
Date/Time Reference
O
O
O
O
1
10
20
2
Item Identification
O
1
Pricing Information
O
1
Repeat
10000
Notes
Usage
Must use
Optional
Used
>1
N2/0800
Used
Not recommended
Optional
Optional
Used
Used
>1
Used
Used
Used
Used
1
Used
>1
Used
Summary:
Page Pos
34 0100
35 0200
Id
CTT
SE
Segment Name
Transaction Totals
Transaction Set Trailer
Req
M
M
Max Use
1
1
Repeat
Notes
N3/0100
Usage
Must use
Must use
Notes:
1/0700L
2/0800
3/0100
N1*SU**11*DE1111111~
N4*Kansas City*KS*66101~
Number of line items (CTT01) is the accumulation of the number of CON segments. If used, hash total (CTT02) is the sum
of the quantities (QTY02) for each QTY segment.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 6
Pos: 0100
Max: 1
Heading - Mandatory
Loop: N/A
Elements: 2
Transaction Set Header
ST
User Option (Usage): Must use
Purpose: To indicate the start of a transaction set and to assign a control number
Element Summary:
Ref
ST01
Id
143
Element Name
Transaction Set Identifier Code
Req
M
Type
ID
Min/Max
3/3
Usage
Must use
AN
4/9
Must use
Description: Code uniquely identifying a
Transaction Set
Code
845
ST02
329
Name
Price Authorization Acknowledgment/Status
Transaction Set Control Number
M
Description: Identifying control number that must
be unique within the transaction set functional
group assigned by the originator for a transaction
set
Semantics:
1. The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate
transaction set definition (e.g., 810 selects the Invoice Transaction Set).
2. The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the
appropriate implementation convention to match the transaction set definition.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 7
Beginning Segment for Price
Authorization
Acknowledgment/Status
BPA
Pos: 0200
Max: 1
Heading - Mandatory
Loop: N/A
Elements: 4
User Option (Usage): Must use
Purpose: To identify the beginning of a Price Authorization Acknowledgment/Status Transaction Set
Element Summary:
Ref
BPA01
Id
353
Element Name
Transaction Set Purpose Code
Req
M
Type
ID
Min/Max
2/2
Usage
Must use
Description: Code identifying purpose of
transaction set
Code
00
04
45
BPA02
373
Name
Original
Change
Code Usage:
Used to indicate a bid award change only
Follow-up
Description: A second or subsequent transmission of the transaction set when an
expected response has not yet been received
Code Usage:
This code would be used if the manufacturer's system detected a pricing or
eligibility error on an 844 chargeback sent from the distributor.
Date
M
DT
8/8
Must use
X
ID
2/3
Used
X
AN
1/50
Used
Description: Date expressed as CCYYMMDD
where CC represents the first two digits of the
calendar year
BPA03
128
Reference Identification Qualifier
Description: Code qualifying the Reference
Identification
Code
CT
BPA04
127
Name
Contract Number
Reference Identification
Description: Reference information as defined
for a particular Transaction Set or as specified by
the Reference Identification Qualifier
Syntax Rules:
1. P0304 - If either BPA03 or BPA04 is present, then the other is required.
Semantics:
1. BPA02 is the price authorization status date.
2. BPA05 is the price authorization status time.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 8
Pos: 0600
Max: 10
Heading - Optional
Loop: N/A
Elements: 2
Date/Time Reference
DTM
User Option (Usage): Used
Purpose: To specify pertinent dates and times
Element Summary:
Ref
DTM01
Id
374
Element Name
Date/Time Qualifier
Req
M
Type
ID
Min/Max
3/3
Usage
Must use
X
DT
8/8
Used
Description: Code specifying type of date or
time, or both date and time
Code
124
125
126
127
DTM02
373
Name
Group Contract Effective
Group Contract Expiration
Wholesale Contract Effective
Wholesale Contract Expiration
Date
Description: Date expressed as CCYYMMDD
where CC represents the first two digits of the
calendar year
Syntax Rules:
1. R020305 - At least one of DTM02, DTM03 or DTM05 is required.
2. C0403 - If DTM04 is present, then DTM03 is required.
3. P0506 - If either DTM05 or DTM06 is present, then the other is required.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 9
Pos: 0700
Loop Name
Loop: N1
Repeat: 10000
Optional
Elements: N/A
User Option (Usage): Used
Purpose: To identify a party by type of organization, name, and code
Loop Summary:
Pos
0700
1100
1200
Id
N1
REF
PER
Segment Name
Name
Reference Identification
Administrative Communications Contact
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
Req
O
O
O
Max Use
1
12
3
Repeat
ASC X12 Version/Release 004010
Usage
Used
Used
Used
Page 10
Pos: 0700
Max: 1
Heading - Optional
Loop: N1
Elements: 4
Name
N1
User Option (Usage): Used
Purpose: To identify a party by type of organization, name, and code
Usage Note:
This N1 loop at the Header Level is required to identify the manufacturer and the distributor. For group contracts, the
buying group is required to be identified using an N1 loop.
Element Summary:
Ref
N101
Id
98
Element Name
Entity Identifier Code
Req
M
Type
ID
Min/Max
2/3
Usage
Must use
X
AN
1/60
Optional
X
ID
1/2
Used
Description: Code identifying an organizational
entity, a physical location, property or an
individual
Code
BG
DS
SU
N102
93
Name
Buying Group
Distributor
Supplier/Manufacturer
Name
Description: Free-form name
N103
66
Identification Code Qualifier
Description: Code designating the
system/method of code structure used for
Identification Code (67)
Code
11
21
UL
N104
67
Name
Drug Enforcement Administration (DEA)
Health Industry Number (HIN)
UCC/EAN Location Code
Description: A globally unique 13 digit code for the identification of a legal,
functional or physical location within the Uniform Code Council (UCC) and
International Article Number Association (EAN) numbering system
Code Usage:
GS1 – US Global Location Number (GLN)
Identification Code
X
AN
2/80
Used
Description: Code identifying a party or other
code
Syntax Rules:
1. R0203 - At least one of N102 or N103 is required.
2. P0304 - If either N103 or N104 is present, then the other is required.
Comments:
1. This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency
the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
2. N105 and N106 further define the type of entity in N101.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 11
Pos: 1100
Max: 12
Heading - Optional
Loop: N1
Elements: 2
Reference Identification
REF
User Option (Usage): Used
Purpose: To specify identifying information
Usage Note:
Use only when N101 equals BG to communicate the buying group’s contract number.
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Must use
X
AN
1/50
Used
Description: Code qualifying the Reference
Identification
Code
CT
REF02
127
Name
Contract Number
Reference Identification
Description: Reference information as defined
for a particular Transaction Set or as specified by
the Reference Identification Qualifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 12
Administrative Communications
Contact
PER
Pos: 1200
Max: 3
Heading - Optional
Loop: N1
Elements: 4
User Option (Usage): Used
Purpose: To identify a person or office to whom administrative communications should be directed
Usage Note:
Required on original bid award
Element Summary:
Ref
PER01
Id
366
Element Name
Contact Function Code
Req
M
Type
ID
Min/Max
2/2
Usage
Must use
O
AN
1/60
Used
X
ID
2/2
Used
X
AN
1/256
Used
Description: Code identifying the major duty or
responsibility of the person or group named
Code
CD
EA
IC
PER02
93
Name
Contract Contact
EDI Coordinator
Information Contact
Name
Description: Free-form name
PER03
365
Communication Number Qualifier
Description: Code identifying the type of
communication number
Code
EM
FX
TE
PER04
364
Name
Electronic Mail
Facsimile
Telephone
Communication Number
Description: Complete communications number
including country or area code when applicable
Syntax Rules:
1. P0304 - If either PER03 or PER04 is present, then the other is required.
2. P0506 - If either PER05 or PER06 is present, then the other is required.
3. P0708 - If either PER07 or PER08 is present, then the other is required.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 13
Pos: 0100
Repeat: 10000
Mandatory
Loop: CON
Elements: N/A
Loop Contract Number Detail
User Option (Usage): Must use
Purpose: To specify contract or reference number and status
Loop Summary:
Pos
0100
0200
0400
0500
1200
Id
CON
REF
DTM
Segment Name
Contract Number Detail
Reference Identification
Date/Time Reference
Loop N1
Loop PAD
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
Req
M
O
O
O
O
Max Use
1
>1
10
Repeat
>1
>1
ASC X12 Version/Release 004010
Usage
Must use
Optional
Used
Optional
Optional
Page 14
Pos: 0100
Max: 1
Detail - Mandatory
Loop: CON
Elements: 3
Contract Number Detail
CON
User Option (Usage): Must use
Purpose: To specify contract or reference number and status
Element Summary:
Ref
CON01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Must use
M
AN
1/50
Must use
M
ID
2/2
Must use
Description: Code qualifying the Reference
Identification
Code
VC
CON02
127
Name
Vendor Contract Number
Reference Identification
Description: Reference information as defined
for a particular Transaction Set or as specified by
the Reference Identification Qualifier
CON03
846
Contract Status Code
Description: Code designating the current status
of the contract
Code
OC
VA
Name
Original Contract
Valid Open Contract
Code Usage:
Used for Bid Award Change only
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 15
Pos: 0200
Max: >1
Detail - Optional
Loop: CON
Elements: 2
Reference Identification
REF
User Option (Usage): Optional
Purpose: To specify identifying information
Usage Note:
This REF segment at the Detail Level in the CON loop is required when a vendor contract number changes. REF01 and
REF02 must be present to provide the previous vendor contract number. The new vendor contract number appears in the
CON segment at the Detail level.
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Must use
1/50
Used
Description: Code qualifying the Reference
Identification
Code
P1
REF02
127
Name
Previous Contract Number
Code Usage:
Used if this contract supersedes a previous one.
Reference Identification
X
AN
Description: Reference information as defined
for a particular Transaction Set or as specified by
the Reference Identification Qualifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 16
Pos: 0400
Max: 10
Detail - Optional
Loop: CON
Elements: 2
Date/Time Reference
DTM
User Option (Usage): Used
Purpose: To specify pertinent dates and times
Element Summary:
Ref
DTM01
Id
374
Element Name
Date/Time Qualifier
Req
M
Type
ID
Min/Max
3/3
Usage
Must use
X
DT
8/8
Used
Description: Code specifying type of date or
time, or both date and time
Code
092
093
DTM02
373
Name
Contract Effective
Contract Expiration
Date
Description: Date expressed as CCYYMMDD
where CC represents the first two digits of the
calendar year
Syntax Rules:
1. R020305 - At least one of DTM02, DTM03 or DTM05 is required.
2. C0403 - If DTM04 is present, then DTM03 is required.
3. P0506 - If either DTM05 or DTM06 is present, then the other is required.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 17
Pos: 0500
Loop Name
Loop: N1
Repeat: >1
Optional
Elements: N/A
User Option (Usage): Optional
Purpose: To identify a party by type of organization, name, and code
Loop Summary:
Pos
0500
0600
0700
0800
0900
1100
Id
N1
N2
N3
N4
REF
DTM
Segment Name
Name
Additional Name Information
Address Information
Geographic Location
Reference Identification
Date/Time Reference
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
Req
O
O
O
O
O
O
Max Use
1
2
2
1
12
2
Repeat
ASC X12 Version/Release 004010
Usage
Used
Not recommended
Optional
Optional
Used
Used
Page 18
Pos: 0500
Max: 1
Detail - Optional
Loop: N1
Elements: 4
Name
N1
User Option (Usage): Used
Purpose: To identify a party by type of organization, name, and code
Usage Note:
This N1 loop at the Detail Level in the CON loop is required to identify the eligible customers belonging to the buying group
or individual and eligible for the contract.
Element Summary:
Ref
N101
Id
98
Element Name
Entity Identifier Code
Req
M
Type
ID
Min/Max
2/3
Usage
Must use
X
AN
1/60
Recommended
X
ID
1/2
Used
Description: Code identifying an organizational
entity, a physical location, property or an
individual
Code
BT
C9
EB
ST
N102
93
Name
Bill-to-Party
Contract Holder
Code Usage:
Contracted Pharmacies
Eligible Party To The Contract
Code Usage:
Eligible entity
Ship To
Name
Description: Free-form name
N103
66
Identification Code Qualifier
Description: Code designating the
system/method of code structure used for
Identification Code (67)
Code
11
21
PI
UL
N104
67
Name
Drug Enforcement Administration (DEA)
Health Industry Number (HIN)
Payer Identification
Code Usage:
340B Programs
UCC/EAN Location Code
Description: A globally unique 13 digit code for the identification of a legal,
functional or physical location within the Uniform Code Council (UCC) and
International Article Number Association (EAN) numbering system
Code Usage:
GS1 – US Global Location Number (GLN)
Identification Code
X
AN
2/80
Used
Description: Code identifying a party or other
code
Syntax Rules:
1. R0203 - At least one of N102 or N103 is required.
2. P0304 - If either N103 or N104 is present, then the other is required.
Comments:
1. This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency
the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
2. N105 and N106 further define the type of entity in N101.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 19
Pos: 0600
Max: 2
Detail - Optional
Loop: N1
Elements: 2
Additional Name Information
N2
User Option (Usage): Not recommended
Purpose: To specify additional names
Element Summary:
Ref
N201
Id
93
Element Name
Name
Req
M
Type
AN
Min/Max
1/60
Usage
Must use
O
AN
1/60
Used
Description: Free-form name
N202
93
Name
Description: Free-form name
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 20
Pos: 0700
Max: 2
Detail - Optional
Loop: N1
Elements: 2
Address Information
N3
User Option (Usage): Optional
Purpose: To specify the location of the named party
Usage Note:
ThIs segment should only be used in the case where healthcare provider/pharmacy name and address information is not
shared by other means such as the EDI 816, HIBCC HIN Database, GLN Registry for Healthcare, etc.
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Must use
O
AN
1/55
Used
Description: Address information
N302
166
Address Information
Description: Address information
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 21
Pos: 0800
Max: 1
Detail - Optional
Loop: N1
Elements: 3
Geographic Location
N4
User Option (Usage): Optional
Purpose: To specify the geographic place of the named party
Usage Note:
The segment should only be used in the case where healthcare provider/pharmacy name and address information is not
shared by other means such as the EDI 816, HIBCC HIN Database, GLN Registry for Healthcare, etc.
Element Summary:
Ref
N401
Id
19
Element Name
City Name
Req
O
Type
AN
Min/Max
2/30
Usage
Used
X
ID
2/2
Used
O
ID
3/15
Used
Description: Free-form text for city name
N402
156
State or Province Code
Description: Code (Standard State/Province) as
defined by appropriate government agency
N403
116
Postal Code
Description: Code defining international postal
zone code excluding punctuation and blanks (zip
code for United States)
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 is required.
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 22
Pos: 0900
Max: 12
Detail - Optional
Loop: N1
Elements: 2
Reference Identification
REF
User Option (Usage): Used
Purpose: To specify identifying information
Usage Note:
This REF segment at the Detail Level in the CON/N1 loop is required in the Bid Award Change to identify the customers
eligible for the contract. In this case, the current I.D. code appears in the N1 segment of the CON loop and the previous or
secondary I.D. code would appear here. REF01 and REF02 must be present. This REF segment can also be used in a Bid
Award and Bid Award Change to indicate alternate numbers during the transition period as the industry moves toward
widespread adoption of a single identifier.
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Must use
1/50
Used
Description: Code qualifying the Reference
Identification
Code
DH
HI
P2
P3
REF02
127
Name
Drug Enforcement Administration Number
Health Industry Number (HIN)
Previous Drug Enforcement Administration Number
Previous customer reference number
Code Usage:
Previous HIN
Reference Identification
X
AN
Description: Reference information as defined
for a particular Transaction Set or as specified by
the Reference Identification Qualifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 23
Pos: 1100
Max: 2
Detail - Optional
Loop: N1
Elements: 2
Date/Time Reference
DTM
User Option (Usage): Used
Purpose: To specify pertinent dates and times
Usage Note:
This DTM segment at the Detail Level in the CON/N1 loop is used to provide the effective and expiration dates of the
individual customers.
This segment is required only if these dates are different from the dates of the buying group contract indicated at the
Header level. DTM01 and DTM02 must be present. This segment can also be used to provide the effective date of an
identifier being implemented. DTM01 and DTM02 must be present.
Element Summary:
Ref
DTM01
Id
374
Element Name
Date/Time Qualifier
Req
M
Type
ID
Min/Max
3/3
Usage
Must use
X
DT
8/8
Used
Description: Code specifying type of date or
time, or both date and time
Code
129
130
DTM02
373
Name
Customer Contract Effective
Customer Contract Expiration
Date
Description: Date expressed as CCYYMMDD
where CC represents the first two digits of the
calendar year
Syntax Rules:
1. R020305 - At least one of DTM02, DTM03 or DTM05 is required.
2. C0403 - If DTM04 is present, then DTM03 is required.
3. P0506 - If either DTM05 or DTM06 is present, then the other is required.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 24
Pos: 1200
Repeat: >1
Optional
Loop: PAD
Elements: N/A
Loop Product Adjustment Detail
User Option (Usage): Optional
Purpose: To specify the product transfer type, and/or line item number
Loop Summary:
Pos
1200
1300
1600
2200
2300
3100
Id
PAD
CTB
UIT
DTM
Segment Name
Product Adjustment Detail
Restrictions/Conditions
Unit Detail
Date/Time Reference
Loop LIN
Loop CTP
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
Req
O
O
O
O
O
O
Max Use
1
10
20
2
Repeat
1
>1
ASC X12 Version/Release 004010
Usage
Used
Used
Used
Used
Used
Used
Page 25
Pos: 1200
Max: 1
Detail - Optional
Loop: PAD
Elements: 2
Product Adjustment Detail
PAD
User Option (Usage): Used
Purpose: To specify the product transfer type, and/or line item number
Usage Note:
If this PAD segment is used, then an LIN segment must follow.
Element Summary:
Ref
PAD01
Id
350
Element Name
Assigned Identification
Req
X
Type
AN
Min/Max
1/20
Usage
Used
O
ID
2/2
Used
Description: Alphanumeric characters assigned
for differentiation within a transaction set
Usage Note: This is a sequential number
starting with 1 which starts over with each
CON loop.
PAD03
670
Change or Response Type Code
Description: Code specifying the type of change
to the line item
Code
AI
CT
DI
PC
Name
Add Additional Item(s)
Change of Dates
Delete Item(s)
Price Change
Syntax Rules:
1. R0102 - At least one of PAD01 or PAD02 is required.
2. P0405 - If either PAD04 or PAD05 is present, then the other is required.
Semantics:
1. PAD01 is the line item identification.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 26
Pos: 1300
Max: 10
Detail - Optional
Loop: PAD
Elements: 5
Restrictions/Conditions
CTB
User Option (Usage): Used
Purpose: To specify restrictions/conditions (such as shipping, ordering)
Usage Note:
This segment should only be used when the minimum order quantity is greater than 1. Use of this segment is discouraged
because minimum order quantities defeat the purpose of the prime vendor program. Minimum order quantity restrictions
result in excess inventory and are a major cause of returned goods that may not be resold due to Prescription Drug
Marketing Act provisions.
Element Summary:
Ref
CTB01
Id
688
Element Name
Restrictions/Conditions Qualifier
Req
M
Type
ID
Min/Max
2/2
Usage
Must use
X
ID
2/2
Used
X
R
1/15
Used
X
ID
1/3
Used
1/15
Used
Description: Code identifying the type of
restriction/condition
Code
OR
CTB03
673
Name
Ordering
Quantity Qualifier
Description: Code specifying the type of quantity
Code
57
CTB04
380
Name
Minimum Order Quantity
Quantity
Description: Numeric value of quantity
CTB05
522
Amount Qualifier Code
Description: Code to qualify amount
Code
MO
CTB06
610
Name
Minimum Order Value
Description: Minimum value of order allowed
Amount
X
N2
Description: Monetary amount
Syntax Rules:
1.
2.
3.
4.
R020406 - At least one of CTB02, CTB04 or CTB06 is required.
P0304 - If either CTB03 or CTB04 is present, then the other is required.
P0506 - If either CTB05 or CTB06 is present, then the other is required.
C0704 - If CTB07 is present, then CTB04 is required.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 27
Pos: 1600
Max: 20
Detail - Optional
Loop: PAD
Elements: 3
Unit Detail
UIT
User Option (Usage): Used
Purpose: To specify item unit data
Usage Note:
Two occurrences of this UIT segment at the Detail level in the CON/PAD loop are required to add an item in a Bid Award —
one to specify the wholesale price and the other to specify the contract price. This is not necessarily the case in a Bid
Award Change, when specifying a price change, for example. If the contract price changed then only one occurrence of the
UIT segment would be required for the manufacturer to notify the distributor of this change.
Element Summary:
Ref
UIT01
Id
C001
Element Name
Composite Unit of Measure
Req
M
Type
Comp
Min/Max
Usage
Must use
M
ID
2/2
Must use
X
R
1/17
Used
O
ID
2/2
Used
Description: To identify a composite unit of
measure (See Figures Appendix for examples of
use)
UIT01-01
355
Unit or Basis for Measurement Code
Description: Code specifying the units in which a
value is being expressed, or manner in which a
measurement has been taken
Code
UN
UIT02
212
Name
Unit
Unit Price
Description: Price per unit of product, service,
commodity, etc.
UIT03
639
Basis of Unit Price Code
Description: Code identifying the type of unit
price for an item
Code
CT
WH
Name
Contract
Wholesale
Syntax Rules:
1. C0302 - If UIT03 is present, then UIT02 is required.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 28
Pos: 2200
Max: 2
Detail - Optional
Loop: PAD
Elements: 2
Date/Time Reference
DTM
User Option (Usage): Used
Purpose: To specify pertinent dates and times
Usage Note:
This DTM segment at the Detail level in the CON/PAD loop is only used to provide the item contract effective and expiration
dates that are different from the buying group dates indicated at the Header level. When adding an item in a Bid Award
Change, two occurrences of this DTM segment are required — one to specify the item contract effective date and the other
to specify the item contract expiration date. DTM01 and DTM02 must be present.
Element Summary:
Ref
DTM01
Id
374
Element Name
Date/Time Qualifier
Req
M
Type
ID
Min/Max
3/3
Usage
Must use
X
DT
8/8
Used
Description: Code specifying type of date or
time, or both date and time
Code
131
132
DTM02
373
Name
Item Contract Effective
Item Contract Expiration
Date
Description: Date expressed as CCYYMMDD
where CC represents the first two digits of the
calendar year
Syntax Rules:
1. R020305 - At least one of DTM02, DTM03 or DTM05 is required.
2. C0403 - If DTM04 is present, then DTM03 is required.
3. P0506 - If either DTM05 or DTM06 is present, then the other is required.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 29
Pos: 2300
Repeat: 1
Optional
Loop: LIN
Elements: N/A
Loop Item Identification
User Option (Usage): Used
Purpose: To specify basic item identification data
Loop Summary:
Pos
2300
Id
LIN
Segment Name
Item Identification
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
Req
O
Max Use
1
Repeat
ASC X12 Version/Release 004010
Usage
Used
Page 30
Pos: 2300
Max: 1
Detail - Optional
Loop: LIN
Elements: 2
Item Identification
LIN
User Option (Usage): Used
Purpose: To specify basic item identification data
Element Summary:
Ref
LIN02
Id
235
Element Name
Product/Service ID Qualifier
Req
M
Type
ID
Min/Max
2/2
Usage
Must use
Description: Code identifying the type/source of
the descriptive number used in Product/Service
ID (234)
Code
EN
N1
N2
N3
N4
NH
UA
UI
UK
UP
UX
VC
LIN03
234
Name
EAN/UCC - 13
Description: Data structure for the 13 digit EAN.UCC (EAN International.Uniform
Code Council) Global Trade Identification Number (GTIN)
National Drug Code in 4-4-2 Format
Description: 4-digit manufacturer ID, 4-digit product ID, 2-digit trade package size
National Drug Code in 5-3-2 Format
Description: 5-digit manufacturer ID, 3-digit product ID, 2-digit trade package size
National Drug Code in 5-4-1 Format
Description: 5-digit manufacturer ID, 4-digit product ID, 1-digit trade package size
National Drug Code in 5-4-2 Format
Description: 5-digit manufacturer ID, 4-digit product ID, 2-digit trade package size
National Health Related Item Code
U.P.C./EAN Case Code (2-5-5)
U.P.C. Consumer Package Code (1-5-5)
EAN/UCC - 14
Description: Data structure for the 14 digit EAN.UCC (EAN International.Uniform
Code Council) Global Trade Identification Number (GTIN)
UCC - 12
Description: Data structure for the 12 digit EAN.UCC (EAN International.Uniform
Code Council) Global Trade Identification Number (GTIN). Also known as the
Universal Product Code (U.P.C.)
Universal Product Number
Description: A unique identifier of a healthcare product
Vendor's (Seller's) Catalog Number
Product/Service ID
M
AN
1/48
Description: Identifying number for a product or
service
Syntax Rules:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
P0405 - If either LIN04 or LIN05 is present, then the other is required.
P0607 - If either LIN06 or LIN07 is present, then the other is required.
P0809 - If either LIN08 or LIN09 is present, then the other is required.
P1011 - If either LIN10 or LIN11 is present, then the other is required.
P1213 - If either LIN12 or LIN13 is present, then the other is required.
P1415 - If either LIN14 or LIN15 is present, then the other is required.
P1617 - If either LIN16 or LIN17 is present, then the other is required.
P1819 - If either LIN18 or LIN19 is present, then the other is required.
P2021 - If either LIN20 or LIN21 is present, then the other is required.
P2223 - If either LIN22 or LIN23 is present, then the other is required.
P2425 - If either LIN24 or LIN25 is present, then the other is required.
P2627 - If either LIN26 or LIN27 is present, then the other is required.
P2829 - If either LIN28 or LIN29 is present, then the other is required.
P3031 - If either LIN30 or LIN31 is present, then the other is required.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Must use
Page 31
Semantics:
1. LIN01 is the line item identification
Comments:
1. See the Data Dictionary for a complete list of IDs.
2. LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No.,
U.P.C. No., ISBN No., Model No., or SKU.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 32
Pos: 3100
Repeat: >1
Optional
Loop: CTP
Elements: N/A
Loop Pricing Information
User Option (Usage): Used
Purpose: To specify pricing information
Loop Summary:
Pos
3100
Id
CTP
Segment Name
Pricing Information
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
Req
O
Max Use
1
Repeat
ASC X12 Version/Release 004010
Usage
Used
Page 33
Pos: 3100
Max: 1
Detail - Optional
Loop: CTP
Elements: 4
Pricing Information
CTP
User Option (Usage): Used
Purpose: To specify pricing information
Element Summary:
Ref
CTP01
Id
687
Element Name
Class of Trade Code
Req
O
Type
ID
Min/Max
2/2
Usage
Used
X
R
1/17
Used
X
R
1/15
Used
X
Comp
M
ID
Description: Code indicating class of trade
Code
BG
CR
DF
GR
HS
IR
LC
MC
PH
WS
CTP03
212
Name
Buying Group
Chain Store Retail
Doctors' Offices
General Retail
Hospitals
Independent Retail
Long-term Care
Managed Care
Outpatient Pharmacy
User
Unit Price
Description: Price per unit of product, service,
commodity, etc.
CTP04
380
Quantity
Description: Numeric value of quantity
CTP05
C001
Composite Unit of Measure
Used
Description: To identify a composite unit of
measure (See Figures Appendix for examples of
use)
CTP05-01
355
Unit or Basis for Measurement Code
2/2
Must use
Description: Code specifying the units in which a
value is being expressed, or manner in which a
measurement has been taken
Code
UN
Name
Unit
Syntax Rules:
1.
2.
3.
4.
5.
P0405 - If either CTP04 or CTP05 is present, then the other is required.
C0607 - If CTP06 is present, then CTP07 is required.
C0902 - If CTP09 is present, then CTP02 is required.
C1002 - If CTP10 is present, then CTP02 is required.
C1103 - If CTP11 is present, then CTP03 is required.
Semantics:
1. CTP07 is a multiplier factor to arrive at a final discounted price. A multiplier of .90 would be the factor if a 10% discount is given.
2. CTP08 is the rebate amount.
Comments:
1. See Figures Appendix for an example detailing the use of CTP03 and CTP04. See Figures Appendix for an example detailing
the use of CTP03, CTP04 and CTP07.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 34
Pos: 0100
Max: 1
Summary - Mandatory
Loop: N/A
Elements: 1
Transaction Totals
CTT
User Option (Usage): Must use
Purpose: To transmit a hash total for a specific element in the transaction set
Element Summary:
Ref
CTT01
Id
354
Element Name
Number of Line Items
Req
M
Type
N0
Min/Max
1/6
Description: Total number of line items in the
transaction set
Syntax Rules:
1. P0304 - If either CTT03 or CTT04 is present, then the other is required.
2. P0506 - If either CTT05 or CTT06 is present, then the other is required.
Comments:
1. This segment is intended to provide hash totals to validate transaction completeness and correctness.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Usage
Must use
Page 35
Pos: 0200
Max: 1
Summary - Mandatory
Loop: N/A
Elements: 2
Transaction Set Trailer
SE
User Option (Usage): Must use
Purpose: To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST)
and ending (SE) segments)
Element Summary:
Ref
SE01
Id
96
Element Name
Number of Included Segments
Req
M
Type
N0
Min/Max
1/10
Usage
Must use
M
AN
4/9
Must use
Description: Total number of segments included
in a transaction set including ST and SE
segments
SE02
329
Transaction Set Control Number
Description: Identifying control number that must
be unique within the transaction set functional
group assigned by the originator for a transaction
set
Comments:
1. SE is the last segment of each transaction set.
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 36
Business Case Examples
845 Price Authorization Acknowledgment/Status
Example 1: Basic Model of Original Bid Award
The manufacturer, Street Pharmaceuticals, is sending the distributor, Mountain Wholesale Drug, an 845 Price
Authorization Acknowledgment/Status. This example represents an original Bid Award Notification.
This Bid Award Notification should be used by the distributor to determine the contract price to extend to the eligible
customer. An agreement has been reached between the manufacturer, Street Pharmaceuticals, and the purchase group,
Southeastern Buying Group, to extend special pricing to specific customers for specific products. This Bid Award
Notification should list all customers eligible to receive this special pricing for products awarded to the manufacturer by the
purchase group. Note only one contract (CON loop) should be included per transaction set (per ST/SE) in an original bid
award.
This business example shows contract 7676 containing 3 items, which is effective March 1, 2008, being transmitted by the
manufacturer to the distributor on January 15, 2008. This is an original Bid Award Notification. There are two eligible
customers to the contract, Parkview Memorial Hospital and Riverside Community Hospital.
The pertinent information is summarized below:
Contract Number 7676
Contract Effective Date 03/01/2008
Contract Expiration Date 03/30/2010
Manufacturer, Street Pharmaceuticals, GLN: 0123456000001
Distributor, Mountain Wholesale, GLN: 0056789000001
Buying Group, Southeastern Buying Group, GLN: 0054321000001
Customer, Parkview Memorial Hospital, GLN: 0098765000001
Customer, Riverside Community Hospital, 340B ID: 340B657800
Item Number NDC 0333-3333-33
Description Tetracycline
Wholesale Cost $8.95
Contract Cost $7.59
Item Number NDC 0333-4444-44
Description Ampicillin
Wholesale Cost $15.00
Contract Cost $11.00
Item Number NDC 0333-5555-55
Description Codeine Plus
Wholesale Cost $3.98
Contract Cost $2.50
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 37
Sequential Segment Layout
The following is a narrative of each segment. The number on the left corresponds to the segment
number.
Seg. #
Segment Name
Data Values
1
TRANSACTION SET HEADER
ST
ST01
ST02
Transaction Set ID Code
Transaction Set Control Number
845
0020
2
BEGINNING SEGMENT
BAA
BPA01
BPA02
BPA03
BPA04
BPA05
Transaction Set Purpose Code (Original)
Transaction Type Code (Request for Credit)
Date (CCYYMMDD)
Reference Number Qualifier (Contract #)
Reference Number
00
RA
20080215
CT
123456
3
DATE/TIME REFERENCE
DTM
DTM01
DTM02
Date/Time Qualifier (Group Contract Effective)
Date (CCYYMMDD)
124
20080301
4
DATE/TIME REFERENCE
DTM
DTM01
DTM02
Date/Time Qualifier (Group Contract Expiration)
Date (CCYYMMDD)
125
20100331
5
DATE/TIME REFERENCE
DTM
DTM01
DTM02
Date/Time Qualifier (Wholesale Contract Effective)
Date (CCYYMMDD)
126
20080301
6
DATE/TIME REFERENCE
DTM
DTM01
DTM02
Date/Time Qualifier (Wholesale Contract Expiration)
Date (CCYYMMDD)
127
20100331
7
NAME
N1
N101
N103
N104
Entity ID (Supplier/Manufacturer)
ID Code Qualifier (HIN)
ID Code
SU
UL
0123456000001
8
N101
NAME
Entity ID Code (Wholesaler/Distributor)
N1
N103
N104
ID Code Qualifier (HIN)
ID Code
0056789000001
9
NAME
N1
N101
N103
N104
Entity ID Code (Buying Group)
ID Code Qualifier (HIN)
ID Code
BG
UL
0054321000001
10
CON01
CON02
CON03
CONTRACT NUMBER DETAIL
Reference Number Qualifier
Reference Number
Contract Status Code (Valid Open Contract)
CON
VC (Vendor Contract Number)
123456
VA
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
DS
UL
ASC X12 Version/Release 004010
Page 38
11
NAME
N1
N101
N103
N104
Entity ID Code (Eligible Party)
ID Code Qualifier (HIN)
ID Code
EB
UL
00987650000001
12
NAME
N1
N101
N103
N104
Entity ID Code (Eligible Party)
ID Code Qualifier (HIN)
ID Code
EB
PI
340B657800
13
PRODUCT ADJUSTMENT DETAIL
PAD
PAD01
Assigned Identification
1
14
ITEM IDENTIFICATION
LIN
LIN02
LIN03
Product/Service Qualifier (NDC)
Product/Service ID
N1
0333333333
15
UNIT DETAIL
UIT
UIT01
UIT02
UIT03
Unit of Measure Code (Units)
Unit Price
Basis of Unit Price Code (Wholesale)
UN
8.95
WH
16
UNIT DETAIL
UIT
UIT01
UIT02
UIT03
Unit of Measure Code (Units)
Unit Price
Basis of Unit Price Code (Contract)
UN
7.59
CT
17
PRODUCT ADJUSTMENT DETAIL
PAD
PAD01
Assigned Identification
2
18
ITEM IDENTIFICATION
LIN
LIN02
LIN03
Product/Service Qualifier (NDC)
Product/Service ID
N1
0333444444
19
UNIT DETAIL
UIT
UIT01
UIT02
UIT03
Unit of Measure Code (Units)
Unit Price
Basis of Unit Price Code (Wholesale)
UN
15
WH
20
UNIT DETAIL
UIT
UIT01
UIT02
UIT03
Unit of Measure Code (Units)
Unit Price
Basis of Unit Price Code (Contract)
UN
11
CT
21
PRODUCT ADJUSTMENT DETAIL
PAD
PAD01
Assigned Identification
3
22
ITEM IDENTIFICATION
LIN
LIN02
LIN03
Product/Service Qualifier (NDC)
Product/Service ID
N1
0333555555
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 39
23
UNIT DETAIL
UIT
UIT01
UIT02
UIT03
Unit of Measure Code (Units)
Unit Price
Basis of Unit Price Code (Wholesale)
UN
3.98
WH
24
UNIT DETAIL
UIT
UIT01
UIT02
UIT03
Unit of Measure Code (Units)
Unit Price
Basis of Unit Price Code (Contract)
UN
2.5
CT
25
TRANSACTION TOTALS
CTT
CTT01
Number of Line Items (CON Segments)
1
26
TRANSACTION SET TRAILER
SE
SE01
SE02
Number of Included Segments
Transaction Set Control Number
26
0020
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 40
Transmission File
Seg.
No. Segment Data
1 ST*845*0020\
2 BPA*00*20080115\
3 DTM*124*20080301\
4 DTM*125*20100331\
5 DTM*126*20080301\
6 DTM*127*20100331\
7 N1*SU**UL*0123456000001\
8 N1*DS**UL*0056789000001\
9 N1*BG**UL*0054321000001\
10 CON*VC*7676*OC
11 N1*EB**UL*00987650000001\
12 N1*EB**PI*340B657800\
13 PAD*1\
14 LIN**N1*0333333333\
15 UIT*UN*8.95*WH\
16 UIT*UN*7.59*CT\
17 PAD*2\
18 LIN**N1*0333444444\
19 UIT*UN*15*WH\
20 UIT*UN*11*CT\
21 PAD*3\
22 LIN**N1*0333555555\
23 UIT*UN*3.98*WH\
24 UIT*UN*2.5*CT\
25 CTT*1\
26 SE*26*0020\
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 41
845 Price Authorization Acknowledgment/Status (Bid Award/Change Notification)
Example 2: Bid Award Change
The manufacturer, Street Pharmaceuticals, is sending the distributor, Mountain Wholesale Drug, an
845 Price Authorization Acknowledgment/Status. This is a Bid Award Change notification
containing changes that affect an existing contract previously sent to the distributor, Mountain
Wholesale Drug, by the manufacturer, Street Pharmaceuticals.
The distributor should use this transaction set to update the contract information already entered
into their system.
This business example represents a change to the previously transmitted contract number 7676.
The same distributor, manufacturer, and purchase group members are involved. This business
example includes a new GLN number with the previous HIN number, an item expiration date change,
and an item contract cost change.
The pertinent information is summarized below:
Manufacturer, GLN
Street Pharmaceuticals, 0123456000001
Distributor, GLN
Mountain Wholesale, 0056789000001
Buying Group, GLN
Southeastern Buying Group, 0054321000001
Contract Number
7676
Customer
Parkview Memorial Hospital
GLN
0098765000001
Old HIN
HIN786500
Changed Item Number
NDC 0333-3333-33
Contract Effective Date
03/01/2007
Old Expiration Date
03/31/2009
New Expiration Date
03/31/2010
New Price Effective Date
03/01/2008
Product Number NDC
0333-5555-55
Old Contract Cost
$2.50
New Contract Cost
$1.75
Item Effective Date
03/01/2008
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 42
Sequential Segment Layout
The following is a narrative of each segment. The number on the left corresponds to the segment number.
Seg. #
Segment Name
Data Values
1
TRANSACTION SET HEADER
ST
ST01
ST02
Transaction Set ID Code
Transaction Set Control Number
845
0030
2
BEGINNING SEGMENT
BPA
BPA01
BPA02
Transaction Set Purpose Code (Change)
Date (CCYYMMDD)
04
20080215
3
DATE/TIME REFERENCE
DTM
DTM01
DTM02
Date/Time Qualifier (Group Contract Effective)
Date (CCYYMMDD)
124
20070301
4
DATE/TIME REFERENCE
DTM
DTM01
DTM02
Date/Time Qualifier (Group Contract Expiration)
Date (CCYYMMDD)
125
20100331
5
DATE/TIME REFERENCE
DTM
DTM01
DTM02
Date/Time Qualifier (Wholesale Contract Effective)
Date (CCYYMMDD)
126
20070301
6
DATE/TIME REFERENCE
DTM
DTM01
DTM02
Date/Time Qualifier (Wholesale Contract Expiration)
Date (CCYYMMDD)
127
20100331
7
NAME
N1
N101
N103
N104
Entity ID Code (Supplier/Manufacturer)
ID Code Qualifier (HIN)
ID Code
SU
UL
0123456000001
8
NAME
N1
N101
N103
N104
Entity ID Code (Distributor)
ID Code Qualifier (HIN)
ID Code
DS
UL
0056789000001
9
NAME
N1
N101
N103
N104
Entity ID Code (Buying Group)
ID Code Qualifier (HIN)
ID Code
BG
UL
0054321000001
10
CONTRACT NUMBER DETAIL
CON
CON01
CON02
CON03
Reference Number Qualifier
Reference Number
Contract Status Code (Valid Open Contract)
VC (Vendor Contract Number)
7676
VA
11
NAME
N1
N101
N103
N104
Entity ID Code (Eligible Party)
ID Code Qualifier (HIN)
ID Code
EB
UL
0098765000001
12
REFERENCE NUMBERS
REF
REF01
REF02
Reference Number Qualifier
Reference Number (HIN)
P3 (Previous Customer Reference Number)
HIN786500
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 43
13
PRODUCT ADJUSTMENT DETAIL
PAD
PAD01
PAD03
Assigned Identification
Line Item Change or Response Type (Change)
1
CT (Change date)
14
ITEM IDENTIFICATION
LIN
LIN02
LIN03
Product/Service Qualifier (NDC)
Product/Service ID
N1
0333333333
15
DATE/TIME REFERENCE
DTM
DTM01
DTM02
Date/Time Qualifier (Item Contract Expiration)
Date (CCYYMMDD)
132
20100331
16
PRODUCT ADJUSTMENT DETAIL
PAD
PAD01
PAD03
Assigned Identification
Line Item Change or Response Type
2
PC (Price Change)
17
ITEM IDENTIFICATION
LIN
LIN02
LIN03
Product/Service Qualifier (NDC)
Product/Service ID
N1
0333555555
18
UNIT DETAIL
UIT
UIT01
UIT02
UIT03
Unit of Measure Code (Units)
Unit Price
Basis of Unit Price Code (Contract)
UN
1.75
CT
19
DATE/TIME REFERENCE
DTM
DTM01
DTM02
Date/Time Qualifier (Item Contract Effective)
Date (CCYYMMDD)
131
20080301
20
DATE/TIME REFERENCE
DTM
DTM01
DTM02
Date/Time Qualifier (Item Contract Effective)
Date (CCYYMMDD)
132
20100331
21
TRANSACTION TOTALS CTT
CTT01
Number of Line Items (CON Segments)
22
TRANSACTION SET TRAILER
SE
SE01
SE02
Number of Included Segments
Transaction Set Control Number
17
0030
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
1
ASC X12 Version/Release 004010
Page 44
Transmission File
Seg.
No. Segment Data
1 ST*845*0030\
2 BPA*04*20080215\
3 DTM*124*20070301\
4 DTM*125*20100331\
5 DTM*126*20070301\
6 DTM*127*20100331\
7 N1*SU**UL*0123456000001\
8 N1*DS**UL*0056789000001\
9 N1*BG**UL*0054321000001\
10 CON*VC*7676*VA\
11 N1*EB**UL*0098765000001\
12 REF*P3*HIN786500\
13 PAD*1**CT\
14 LIN**N1*0333333333\
15 DTM*132*20000331\
16 PAD*2**PC\
17 LIN**N1*0333555555\
18 UIT*UN*1.75*CT\
19 DTM*131*20080301\
20 DTM*132*20100331\
21 CTT*1\
22 SE*17*0030\
845 Price Authorization Acknowledgment/Status for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
845
849
844
Contract & Chargeback Administration Guidelines
for Electronic Data Interchange (EDI),
to Support Distributor Service Agreements
Section 2: 844 Product Transfer Account Adjustment
Table of Contents
Introduction
4
Transaction Set Detail
5
Data Segments
6
Business Samples
26
Page 4
844 Product Transfer Account Adjustment
INTRODUCTION
This implementation guideline for the 844 Product Transfer Account Adjustment Electronic Data Interchange (EDI)
transaction set was developed by the Healthcare Distribution Management Association’s (HDMA) eCommerce Task Force
(eCTF). The eCTF provides business and technology expertise to develop voluntary healthcare industry implementation
guidelines for the use of EDI and other technology standards. HDMA member distributors, manufacturers and technology
providers serve on the task force.
The purpose of this HDMA implementation guideline is to present the format and explain the application of the Accredited
Standards Committee (ASC) X12 standards as they pertain to the Product Transfer Account Adjustment transaction set
for use within the context of an EDI environment in healthcare. This transaction set contains one header, detail and
summary area per transaction. The transaction set can be used to transmit specific data in the form of a debit, credit or
request for credit relating to pre-authorized product transfer actions.
This edition contains the following revisions (also included in the edition released in 2008):
1.) Additional codes have been added to identify third-party pharmacy billing and eligible entities.
2.) Certain usage notes have been added or edited to clarify definitions or use.
3.) The guideline allows for serialization data to be incorporated.
Additionally, this edition includes additional methods to indicate the transaction type. Indicators for an original submission,
a resubmission, a credit and rebill or a reissue will now be accommodated in two ways, either at the header level when all
lines relate to one transaction type or at the line level when one chargeback may contain various transaction types. A new
qualifier has been added to the header to notify upon receipt if the transaction type is identified at the header or line level.
Transaction Set Usage:
Upon the sale and shipment of products to eligible customers at contract prices, the distributor electronically
transmits a chargeback claim to the manufacturer. This chargeback claim provides the manufacturer with
details of these contract sales. These awarded products and contract prices have been agreed upon by the
manufacturer and the purchase group or customer and the manufacturer has previously notified the
appropriate distributor(s) through the electronic transmission of an 845 Bid Award/Change Notification. The
chargeback claim can be defined as an electronic debit memo sent to the manufacturer by the distributor. The
wholesale cost (the manufacturer price to the distributor on the date of sale to an eligible customer) minus the
contract cost extended to the eligible member yields a “difference.” This difference is “charged back” to the
manufacturer as follows: (Wholesale Cost-Contract Cost) X Quality Sold = Credit Due Distributor.
The 844 Product Transfer Account Adjustment transaction set provides the distributor with an electronic
mechanism to request reimbursement, or a chargeback claim, from the manufacturer. The chargeback
transaction set can also be used by the distributor to send an electronic credit memo (reverse chargeback) to
the manufacturer in cases where a previously “charged back” product has been returned by the eligible
customer to the distributor or manufacturer. As a guideline, distributors should transmit chargeback claims to
the manufacturer no later than 60 days after the sale of the product to the eligible customer. The chargeback
claim should be processed by the manufacturer within 30 days of chargeback transmission. This guideline
also supports chargeback re-submittal(s) using the segments and elements where indicated. The distributor
must provide the chargeback detail line number so the manufacturer can be certain of which line(s) the
distributor is resubmitting. It should also be noted that distributors submit the 844 using different looping
options. For this reason, the chargeback line number is placed in one and only one of two areas. The first
option shows the line number coded immediately after the detail Ship-To N1 loop in a REF segment while the
other option shows the line number in the SII-N9 loop. See the segment and element specifications for further
details.
For trading partners who elect to use the 844 Product Transfer Account Adjustment, this guideline is intended to help
facilitate trading partners’ use of this transaction set to improve business efficiencies.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 5
844
Product Transfer Account Adjustment
Functional Group=CF
Purpose: This X12 Transaction Set contains the format and establishes the data contents of the Product Transfer Account Adjustment
Transaction Set (844) for use within the context of an Electronic Data Interchange (EDI) environment. The transaction set can be used
to transmit specific data in the form of a debit, credit, or request for credit relating to pre-authorized product transfer actions.
Heading:
Page Pos
6
0100
7
0200
8
9
10
Id
ST
BAA
0400
REF
LOOP ID - N1
0700
N1
Segment Name
Transaction Set Header
Beginning Segment for Product
Transfer Account Adjustment
Reference Identification
Req
M
M
Max Use
1
1
O
12
Repeat
Notes
Usage
Optional
50
Name
O
1
Req
Max Use
Contract Number Detail
M
1
Name
Address Information
Geographic Location
Reference Identification
O
O
O
O
1
2
1
12
Sales Item Information
Reference Identification
O
O
1
1
N1/0700
-
Notes
Usage
Detail:
Page
11
12
13
14
15
16
17
18
19
22
Pos
Id
LOOP ID - CON
0100
CON
LOOP ID - N1
0500
N1
0700
N3
0800
N4
0900
REF
LOOP ID - SII
1050
SII
1070
N9
Segment Name
Repeat
10000
>1
Optional
Optional
Optional
>1
Optional
Optional
Summary:
Page
23
24
25
Pos
0100
0200
0300
Id
CTT
AMT
SE
Segment Name
Transaction Totals
Monetary Amount
Transaction Set Trailer
Req
M
O
M
Max Use
1
5
1
Repeat
Notes
N3/0100
Usage
Must Use
-
Notes:
1/0700
3/0100
This N1 Loop at the header level is required to identify the manufacturer and the distributor in an original or resubmitted
chargeback. N101, N103 and N104 must be present.
Number of line items (CTT01) is the accumulation of the number of CON segments. If used, hash total (CTT02) is the sum
of adjustment quantities (QTY02) for each QTY segment.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 6
Pos: 0100
Max: 1
Heading - Mandatory
Loop: N/A
Elements: 2
Transaction Set Header
ST
User Option (Usage): Purpose: To indicate the start of a transaction set and to assign a control number
Example:
ST*844*0004~
Element Summary:
Ref
ST01
Id
143
Element Name
Transaction Set Identifier Code
Req
M
Type
ID
Min/Max
3/3
Usage
-
AN
4/9
-
Description: Code uniquely identifying a
Transaction Set
Code
844
ST02
329
Name
Product Transfer Account Adjustment
Transaction Set Control Number
M
Description: Identifying control number that must
be unique within the transaction set functional
group assigned by the originator for a transaction
set
Semantics:
1. The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate
transaction set definition (e.g., 810 selects the Invoice Transaction Set).
2. The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the
appropriate implementation convention to match the transaction set definition.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 7
Beginning Segment for Product
Transfer Account Adjustment
BAA
Pos: 0200
Max: 1
Heading - Mandatory
Loop: N/A
Elements: 5
User Option (Usage): Purpose: To identify the beginning of a Product Transfer Account Adjustment Transaction Set and further define the type of product
account adjustment transaction set and its reference number and date
Example:
BAA*00*RA*20010903*AM*CB09095P30~
Element Summary:
Ref
BAA01
Id
353
Element Name
Transaction Set Purpose Code
Req
M
Type
ID
Min/Max
2/2
Usage
-
Description: Code identifying purpose of
transaction set
Code
00
15
18
41
45
Name
Original
Re-Submission
Code Usage:
Used to resubmit corrections in response to an 849
Reissue
Code Usage:
Credit and rebill of original chargeback
Corrected and Verified
Code Usage:
Used to indicate a re-issue where original sale was at wholesaler cost/ no original
chargeback
Follow-up
Code Usage:
See detail N9 segment in the SII loop for line level indicator of transaction type
BAA02
640
Transaction Type Code
M
ID
2/2
-
M
DT
8/8
-
X
ID
2/3
-
X
AN
1/50
-
Description: Code specifying the type of
transaction
Code
RA
BAA03
373
Name
Request for Credit
Date
Description: Date expressed as CCYYMMDD
where CC represents the first two digits of the
calendar year
BAA04
128
Reference Identification Qualifier
Description: Code qualifying the Reference
Identification
Code
AM
BAA05
127
Name
Adjustment Memo (Chargeback)
Reference Identification
Description: Reference information as defined
for a particular Transaction Set or as specified by
the Reference Identification Qualifier
Element Usage: Debit Memo Number
Syntax Rules:
1. P0405 - If either BAA04 or BAA05 is present, then the other is required.
Semantics:
1. BAA03 is the account adjustment date.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 8
Pos: 0400
Max: 12
Heading - Optional
Loop: N/A
Elements: 2
Reference Identification
REF
User Option (Usage): Optional
Purpose: To specify identifying information
Segment Usage:
This REF segment at the Header level is required to provide the resubmit number assigned by the manufacturer in a
Chargeback re-submission. REF01 and REF02 must be present.
Example:
REF*RX*123456~
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Optional
Description: Code qualifying the Reference
Identification
Code
RX
REF02
127
Name
Resubmit number
Code Usage:
Number assigned by the manufacturer to identify a previously submitted
chargeback which was rejected due to error. The distributor
provides this number when the chargeback is corrected and resubmitted. Not all
manufacturers assign resubmit numbers.
Reference Identification
X
AN
1/50
Optional
Description: Reference information as defined
for a particular Transaction Set or as specified by
the Reference Identification Qualifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 9
Pos: 0700
Loop Name
Loop: N1
Repeat: 50
Optional
Elements: N/A
User Option (Usage): Purpose: To identify a party by type of organization, name, and code
Example:
N1*SU**11*DE1111111~
Loop Summary:
Pos
0700
Id
N1
Segment Name
Name
Req
O
Max Use
1
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
Repeat
Usage
-
ASC X12 Version/Release 004010
Page 10
Pos: 0700
Max: 1
Heading - Optional
Loop: N1
Elements: 4
Name
N1
User Option (Usage): Purpose: To identify a party by type of organization, name, and code
Example:
N1*SU*21*HIN657800~
Element Summary:
Ref
N101
Id
98
Element Name
Entity Identifier Code
Req
M
Type
ID
Min/Max
2/3
Usage
-
X
AN
1/60
Optional
X
ID
1/2
Optional
Description: Code identifying an organizational
entity, a physical location, property or an
individual
Code
DB
DS
SU
N102
93
Name
Distributor Branch
Distributor
Supplier/Manufacturer
Name
Description: Free-form name
N103
66
Identification Code Qualifier
Description: Code designating the
system/method of code structure used for
Identification Code (67)
Code
11
21
UL
N104
67
Name
Drug Enforcement Administration (DEA)
Health Industry Number (HIN)
UCC/EAN Location Code
Description: A globally unique 13 digit code for the identification of a legal,
functional or physical location within the Uniform Code Council (UCC) and
International Article Number Association (EAN) numbering system
Code Usage:
GS1-US Global Location Number (GLN)
Identification Code
X
AN
2/80
Optional
Description: Code identifying a party or other
code
Syntax Rules:
1. R0203 - At least one of N102 or N103 is required.
2. P0304 - If either N103 or N104 is present, then the other is required.
Comments:
1. This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency
the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
2. N105 and N106 further define the type of entity in N101.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 11
Pos: 0100
Repeat: 10000
Mandatory
Loop: CON
Elements: N/A
Loop Contract Number Detail
User Option (Usage): Purpose: To specify contract or reference number and status
Loop Summary:
Pos
0100
0500
Id
CON
Segment Name
Contract Number Detail
Loop N1
Req
M
O
Max Use
1
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
Repeat
>1
Usage
-
ASC X12 Version/Release 004010
Page 12
Pos: 0100
Max: 1
Detail - Mandatory
Loop: CON
Elements: 3
Contract Number Detail
CON
User Option (Usage): Purpose: To specify contract or reference number and status
Example:
CON*VC*7676*VA~
Element Summary:
Ref
CON01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
-
M
AN
1/50
-
M
ID
2/2
-
Description: Code qualifying the Reference
Identification
Code
VC
CON02
127
Name
Vendor Contract Number
Reference Identification
Description: Reference information as defined
for a particular Transaction Set or as specified by
the Reference Identification Qualifier
CON03
846
Contract Status Code
Description: Code designating the current status
of the contract
Code
VA
Name
Valid Open Contract
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 13
Pos: 0500
Loop Name
Loop: N1
Repeat: >1
Optional
Elements: N/A
User Option (Usage): Purpose: To identify a party by type of organization, name, and code
Loop Summary:
Pos
0500
0700
0800
0900
1050
Id
N1
N3
N4
REF
Segment Name
Name
Address Information
Geographic Location
Reference Identification
Loop SII
Req
O
O
O
O
O
Max Use
1
2
1
12
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
Repeat
>1
Usage
Optional
Optional
Optional
Optional
ASC X12 Version/Release 004010
Page 14
Pos: 0500
Max: 1
Detail - Optional
Loop: N1
Elements: 4
Name
N1
User Option (Usage): Purpose: To identify a party by type of organization, name, and code
Segment Usage:
This N1 loop at the Detail level in the CON loop is required to identify the customer or
ship to location associated with the chargeback. N101, N103, and N104 must be present.
Example:
N1*ST**21*HIN876500~
Element Summary:
Ref
N101
Id
98
Element Name
Entity Identifier Code
Req
M
Type
ID
Min/Max
2/3
Usage
-
X
AN
1/60
Optional
X
ID
1/2
-
Description: Code identifying an organizational
entity, a physical location, property or an
individual
Code
ST
N102
93
Name
Ship To
Name
Description: Free-form name
N103
66
Identification Code Qualifier
Description: Code designating the
system/method of code structure used for
Identification Code (67)
Code
11
21
PI
UL
N104
67
Name
Drug Enforcement Administration (DEA)
Health Industry Number (HIN)
Payer Identification
Code Usage:
340B Programs
UCC/EAN Location Code
Description: A globally unique 13 digit code for the identification of a legal,
functional or physical location within the Uniform Code Council (UCC) and
International Article Number Association (EAN) numbering system
Code Usage:
GS1-US Global Location Number (GLN)
Identification Code
X
AN
2/80
-
Description: Code identifying a party or other
code
Syntax Rules:
1. R0203 - At least one of N102 or N103 is required.
2. P0304 - If either N103 or N104 is present, then the other is required.
Comments:
1. This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency
the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
2. N105 and N106 further define the type of entity in N101.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 15
Pos: 0700
Max: 2
Detail - Optional
Loop: N1
Elements: 2
Address Information
N3
User Option (Usage): Optional
Purpose: To specify the location of the named party
Example:
N3*1300 LENNOX~
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
-
O
AN
1/55
Optional
Description: Address information
N302
166
Address Information
Description: Address information
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 16
Pos: 0800
Max: 1
Detail - Optional
Loop: N1
Elements: 3
Geographic Location
N4
User Option (Usage): Optional
Purpose: To specify the geographic place of the named party
Example:
N4*KANSAS CITY*KS*66101~
Element Summary:
Ref
N401
Id
19
Element Name
City Name
Req
O
Type
AN
Min/Max
2/30
Usage
Optional
X
ID
2/2
Optional
O
ID
3/15
Optional
Description: Free-form text for city name
N402
156
State or Province Code
Description: Code (Standard State/Province) as
defined by appropriate government agency
N403
116
Postal Code
Description: Code defining international postal
zone code excluding punctuation and blanks (zip
code for United States)
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 is required.
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 17
Pos: 0900
Max: 12
Detail - Optional
Loop: N1
Elements: 3
Reference Identification
REF
User Option (Usage): Optional
Purpose: To specify identifying information
Segment Usage:
If used, this segment provides the means to identify another party to the contracted sale. It could designate a centralized
bill-to location ID, a third-party Pharmacy service, or the eligible party to the contract. This segment can also identify the
chargeback line number used for chargeback resubmissions as well as comments.
Example:
REF*HI*HIN876500~
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
-
Description: Code qualifying the Reference
Identification
Code
2U
DH
HI
L1
LU
P7
REF02
127
Name
Payer Identification Number
Code Usage:
340B Programs
Drug Enforcement Administration Number
Health Industry Number (HIN)
Letters or Notes
Code Usage:
This code would qualify any optional notes and comments pertaining to an
original or resubmitted chargeback line. These notes or comments should be
placed in REF03.
Location Number
Code Usage:
GS1-US Global Location Number (GLN)
Product Line Number
Code Usage:
This code qualifies the chargeback line number.
Reference Identification
X
AN
1/50
-
X
AN
1/80
Optional
Description: Reference information as defined
for a particular Transaction Set or as specified by
the Reference Identification Qualifier
REF03
352
Description
Description: A free-form description to clarify the
related data elements and their content
Element Usage: This element can contain any
optional notes or comments pertaining to an
original or resubmitted line on a chargeback.
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 18
Pos: 1050
Loop Sales Item Information
Loop: SII
Repeat: >1
Optional
Elements: N/A
User Option (Usage): Optional
Purpose: To specify line item information related to a sale of an item
Loop Summary:
Pos
1050
1070
Id
SII
N9
Segment Name
Sales Item Information
Reference Identification
Req
O
O
Max Use
1
1
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
Repeat
Usage
Optional
Optional
ASC X12 Version/Release 004010
Page 19
Pos: 1050
Max: 1
Detail - Optional
Loop: SII
Elements: 7
Sales Item Information
SII
User Option (Usage): Optional
Purpose: To specify line item information related to a sale of an item
Segment Usage:
The SII segment will repeat for the number of units of each item sold so that the serial number can be included.
Example:
SII*N1*0333333333*6*UN*8.95*7.5*8.7~
Element Summary:
Ref
SII01
Id
235
Element Name
Product/Service ID Qualifier
Req
M
Type
ID
Min/Max
2/2
Usage
-
Description: Code identifying the type/source of
the descriptive number used in Product/Service
ID (234)
Code
EN
N1
N2
N3
N4
NH
UA
UI
UK
UP
UX
VC
SII02
234
Name
EAN/UCC - 13
Description: Data structure for the 13 digit EAN.UCC (EAN International.Uniform
Code Council) Global Trade Identification Number (GTIN)
National Drug Code in 4-4-2 Format
Description: 4-digit manufacturer ID, 4-digit product ID, 2-digit trade package size
National Drug Code in 5-3-2 Format
Description: 5-digit manufacturer ID, 3-digit product ID, 2-digit trade package size
National Drug Code in 5-4-1 Format
Description: 5-digit manufacturer ID, 4-digit product ID, 1-digit trade package size
National Drug Code in 5-4-2 Format
Description: 5-digit manufacturer ID, 4-digit product ID, 2-digit trade package size
National Health Related Item Code
U.P.C./EAN Case Code (2-5-5)
U.P.C. Consumer Package Code (1-5-5)
EAN/UCC - 14
Description: Data structure for the 14 digit EAN.UCC (EAN International.Uniform
Code Council) Global Trade Identification Number (GTIN)
UCC - 12
Description: Data structure for the 12 digit EAN.UCC (EAN International.Uniform
Code Council) Global Trade Identification Number (GTIN). Also known as the
Universal Product Code (U.P.C.)
Universal Product Number
Description: A unique identifier of a healthcare product
Vendor’s (Seller’s) Catalog Number
Product/Service ID
M
AN
1/48
-
M
R
1/15
-
M
Comp
Description: Identifying number for a product or
service
SII03
380
Quantity
Description: Numeric value of quantity
Element Usage: In the case of a return, the
quantity should be a negative number.
SII04
C001
Composite Unit of Measure
Description: To identify a composite unit of
measure (See Figures Appendix for examples of
use)
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
-
Page 20
SII04-01
355
Unit or Basis for Measurement Code
M
ID
2/2
-
O
R
1/17
Must Use
O
R
1/17
Must Use
O
R
1/18
Must Use
Description: Code specifying the units in which a
value is being expressed, or manner in which a
measurement has been taken
Code
UN
SII05
212
Name
Unit
Unit Price
Description: Price per unit of product, service,
commodity, etc.
Element Usage: Wholesale price
SII06
212
Unit Price
Description: Price per unit of product, service,
commodity, etc.
Element Usage: Contract price
SII07
782
Monetary Amount
Description: Monetary amount
Element Usage: Chargeback claim amount.
This amount should be negative for returns.
Formula: SII03 x (SII05 - SII06).
Semantics:
1.
2.
3.
4.
SII03 is the amount of the product identified in SII01 and SII02.
SII05 is the wholesale acquisition price.
SII06 is the contract price.
SII07 is the extended rebate amount.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 21
Pos: 1070
Max: 1
Detail - Optional
Loop: SII
Elements: 5
Reference Identification
N9
User Option (Usage): Optional
Purpose: To transmit identifying information as specified by the Reference Identification Qualifier
Example:
N9*DI*1030297**20010821*RX*12345*LI*001~
Element Summary:
Ref
N901
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
-
X
AN
1/50
Must Use
X
AN
1/45
Optional
8/8
Must Use
Description: Code qualifying the Reference
Identification
Code
DI
N902
127
Name
Distributor Invoice Number
Reference Identification
Description: Reference information as defined
for a particular Transaction Set or as specified by
the Reference Identification Qualifier
N903
369
Free-form Description
Description: Free-form descriptive text
Element Usage: Order Date
N904
N907
373
Date
O
DT
C040
Description: Date expressed as CCYYMMDD
where CC represents the first two digits of the
calendar year
Element Usage: This date should be the
original date of sale rather than the invoice
date because an 844 can be sent to a
manufacturer more than once.
Reference Identifier
O
Comp
M
ID
Optional
Description: To identify one or more reference
numbers or identification numbers as specified by
the Reference Qualifier
Element Usage: In order to support 844 EDI
chargeback re submittal, this composite
element is required and provides an alternate
means of identifying a chargeback detail line
number, comments, and optionally a resubmission reason code.
Syntax:
1. P0304 - If either C04003 or C04004 is present,
then the other is required.
2. P0506 - If either C04005 or C04006 is present,
then the other is required.
N907-01
128
Reference Identification Qualifier
2/3
-
Description: Code qualifying the Reference
Identification
Code
L1
Name
Letters or Notes
Code Usage:
This code would qualify any optional notes and comments pertaining to an
original or resubmitted chargeback line and should be placed in N907-2.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 22
P7
N907-02
127
Product Line Number
Code Usage:
This code alternatively qualifies the chargeback line number.
Reference Identification
M
AN
1/50
-
X
ID
2/3
Optional
Description: Reference information as defined
for a particular Transaction Set or as specified by
the Reference Identification Qualifier
Element Usage: The chargeback detail line
number must be an integer.
This element can also contain any optional
notes or comments pertaining to an original or
resubmitted line on a chargeback as qualified
in N907-1.
N907-03
128
Reference Identification Qualifier
Description: Code qualifying the Reference
Identification
Element Usage: This optional element can
communicate the reason for resubmission.
Code
8X
ZZ
N907-04
127
Name
Transaction Category or Type
Code Usage:
If 8X is used, it will override BAA01. Designates transaction type in N907-04
Mutually Defined
Code Usage:
Designates Invoice date in N907-04
Reference Identification
X
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
Element Usage: If 8X is used in N907-03, use
‘00’ for original
'15' for resubmission
'18' for credit/rebill with original
'41' for credit/rebill with no original
Element Usage: If ZZ is used in N907-03, include Invoice Date.
N907-05
128
Reference Identification Qualifier
X
Description: Code qualifying the Reference Identification
Code
SE
N907-06
127
Name
Serial Number
Code Usage:
Manufacturer's Item serial number.
Reference Identification
X
AN
1/50
Optional
Description: Reference information as defined
for a particular Transaction Set or as specified by
the Reference Identification Qualifier
Syntax Rules:
1. R0203 - At least one of N902 or N903 is required.
2. C0605 - If N906 is present, then N905 is required.
Semantics:
1. N906 reflects the time zone which the time reflects.
2. N907 contains data relating to the value cited in N902.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 23
Pos: 0100
Max: 1
Summary - Mandatory
Loop: N/A
Elements: 1
Transaction Totals
CTT
User Option (Usage): Purpose: To transmit a hash total for a specific element in the transaction set
Segment Usage:
Total number of CON segments.
Element Summary:
Ref
CTT01
Id
354
Element Name
Number of Line Items
Req
M
Type
N0
Min/Max
1/6
Usage
-
Description: Total number of line items in the
transaction set
Syntax Rules:
1. P0304 - If either CTT03 or CTT04 is present, then the other is required.
2. P0506 - If either CTT05 or CTT06 is present, then the other is required.
Comments:
1. This segment is intended to provide hash totals to validate transaction completeness and correctness.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 24
Pos: 0200
Max: 5
Summary - Optional
Loop: N/A
Elements: 2
Monetary Amount
AMT
User Option (Usage): Must Use
Purpose: To indicate the total monetary amount
Segment Usage:
This AMT segment at the Summary level is required to provide the total chargeback
claim amount for the total SII segments included in the transaction set. The total
chargeback claim amount is defined as the total or sum of the SII07 elements appearing
in the Detail level.
Example:
AMT*CC*14.53~
Element Summary:
Ref
AMT01
Id
522
Element Name
Amount Qualifier Code
Req
M
Type
ID
Min/Max
1/3
Usage
-
M
R
1/18
-
Description: Code to qualify amount
Code
CC
AMT02
782
Name
Chargeback Claim Amount
Monetary Amount
Description: Monetary amount
Element Usage: Total chargeback claim
amount.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 25
Pos: 0300
Max: 1
Summary - Mandatory
Loop: N/A
Elements: 2
Transaction Set Trailer
SE
User Option (Usage): Purpose: To indicate the end of the transaction set and provide the count of the transmitted segments [including the beginning (ST)
and ending (SE) segments]
Element Summary:
Ref
SE01
Id
96
Element Name
Number of Included Segments
Req
M
Type
N0
Min/Max
1/10
Usage
-
M
AN
4/9
-
Description: Total number of segments included
in a transaction set including ST and SE
segments
SE02
329
Transaction Set Control Number
Description: Identifying control number that must
be unique within the transaction set functional
group assigned by the originator for a transaction
set
Comments:
1. SE is the last segment of each transaction set.
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 26
Business Case Examples
844 Product Transfer Account Adjustment (Chargeback)
Example 1: Basic model with general transactions and return transaction
The distributor, Mountain Wholesale Drug, is sending the manufacturer, Street Pharmaceuticals, an 844 Product Transfer Account
Adjustment (Chargeback). This transaction set contains information pertaining to the sale and/or return of product at contract price to
and/or from eligible customers entitling the distributor to a credit and/or debit from the manufacturer. The business example represents
an original chargeback submission. This chargeback transaction contains chargeback claims for contract purchases as well as returns
of contracted product by two hospitals, Parkview Memorial Hospital and Riverside Community Hospital. The product returns require the
distributor to reverse a chargeback amount previously sent to the manufacturer for the initial purchase. Parkview Memorial purchased a
product, Tetracycline and returned a product, Advate 2, at prices specified in contract number 7676. Riverside Community purchased
one product, Tetracycline at a price specified in contract number 9898. The total chargeback claim amount submitted by Mountain
Wholesale Drug to Street Pharmaceuticals equaled $3.37.
Note: Multiple contracts (CON loops) should be included per transaction set (ST/SE). The negative amount is depicted with the minus
sign. The chargeback line numbers are identified in the N1 loop. The EPC numbers appear below listed together but will de-aggregate
when the 844 is generated listing each unit as a separate sale with the same invoice due to constraints from the structure of the ANS
x12 844 transaction set.
The pertinent information is summarized below:
Chargeback/Debit Memo Date
Chargeback/Debit Memo Number
Manufacturer
Manufacturer ID (GLN)
Distributor
Distributor ID (GLN)
Contract
Customer ID (GLN)
Name
Chargeback Line number
Item Number
Description
Quantity
Wholesale Cost
Contract Cost
Chargeback Claim
Invoice Number
Pricing Date
EPCs: (placeholder)
01/05/2008
CB09096P30
Street Pharmaceuticals
0123456000001
Mountain Wholesale Drug
0056789000001
7676
0098765000001
Parkview Memorial Hospital
1
NDC 00333-3333-33
Tetracycline
2
$8.95
$7.50
$2.90
I030297
12/21/2007
12345:678905101112, 12345:678905101113
Contract
Customer ID (GLN)
Name
Chargeback Line number
Item Number
Description
Potency
Quantity Returned
Wholesale Cost
Contract Cost
Chargeback Claim
Invoice Number
Pricing Date
EPCs: (placeholder)
7676
0098765000001
Parkview Memorial Hospital
2
NDC 00333-4444-44
Advate 2
200
-1 (use “-“ for quantity returned)
$3.98
$2.50
$1.48
I030971
11/10/2007
12345:678905101107
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 27
Contract
Customer ID (340B ID)
Customer ID (HIN)
Name
Chargeback Line number
Item Number
Description
Quantity
Wholesale Cost
Contract Cost
Chargeback Claim
Invoice Number
Pricing Date
EPCs: (placeholder)
9898
340B657800
HIN876500
Riverside Community Hospital
3
NDC 00333-3333-33
Tetracycline
1
$8.95
$7.00
$1.95
I117305
12/27/2007
12345:678905101116
Sequential Segment Layout
The following is a narrative of each segment as it appears in the transmission file. The number on
the far left corresponds to the segment number.
Seg. #
Segment Name
Data Values
1
ST01
ST02
TRANSACTION SET HEADER
Transaction Set ID Code
Transaction Set Control Number
ST
844
0003
2
BAA01
BAA02
BAA03
BAA04
BAA05
BEGINNING SEGMENT
Transaction Set Purpose Code (Original)
Transaction Type Code (Request for Credit)
Date (CCYYMMDD)
Reference Number Qualifier (Chargeback)
Reference Number
BAA
00
RA
20080105
AM
CB09096P30
3
N101
N103
N104
NAME
Entity ID (Supplier/Manufacturer)
ID Code Qualifier (GLN)
ID Code
N1
SU
UL
0123456000001
4
N101
N103
N104
NAME N1
Entity ID Code (Wholesaler/Distributor)
ID Code Qualifier (GLN)
ID Code
DS
UL
0056789000001
5
CONTRACT NUMBER DETAIL
CON
CON01
VC
CON02
CON03
Reference Number Qualifier
(Vendor Contract Number)
Reference Number
Contract Status Code (Valid Open Contract)
7676
VA
6
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (GLN)
ID Code
N1
ST
UL
0098765000001
7
REF01
REF02
REFERENCE IDENTFICATION
Reference ID Qualifier
Reference ID
REF
P7
00001 “Chargeback line number”
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 28
8
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity (Quantity Sold)
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
1
UN
8.95
7.5
1.45
9
N901
N902
N904
N907-1
N907-2
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030297
20071221
SE
12345:678905101112
10
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity (Quantity Sold)
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
1
UN
8.95
7.5
1.45
11
N901
N902
N904
N907-1
N907-2
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030297
20071221
SE
12345:678905101113
12
CON01
CON
VC
CON02
CON03
CONTRACT NUMBER DETAIL
Reference Number Qualifier
(Vendor Contract)
Reference Number
Contract Status Code (Valid Open Contract)
7676
VA
13
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (GLN)
ID Code
N1
ST
UL
0098765000001
14
REF01
REF02
REFERENCE IDENTFICATION
Reference ID Qualifier
Reference ID
REF
P7
00002 “Chargeback line number”
15
SII01
SII02
SII03
SII04
SII04-6
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity (Quantity Returned)
Unit of Measure Code (Units)
Multiplier (Potency)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333444444
-1
UN
200
3.98
2.50
-1.48
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 29
16
N901
N902
N904
N907-1
N907-2
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
IO30971
20071110
SE
12345:678905101107
17
CON01
CON
VC
CON02
CON03
CONTRACT NUMBER DETAIL
Reference Number Qualifier
(Vendor Contract)
Reference Number
Contract Status Code (Valid Open Contract)
9898
VA
18
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (340B ID)
ID Code
N1
ST
PI
340B657800
19
REF01-1
REF02-1
REFERENCE IDENTFICATION
Reference ID Qualifier
Reference ID
REF
P7
00003 “Chargeback line number”
20
REF01
REF02
REF03
REFERENCE IDENTIFICATION
Reference ID Qualifier
Reference ID
Description
REF
HI
HIN876500
centralized billing
21
SII01
SII02
SII03
SII04
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity (Quantity Sold)
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
1
UN
8.95
7.00
1.95
22
N901
N902
N904
N907-1
N907-2
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Sale)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I117305
20071227
SE
12345:678905101116
23
CTT01
TRANSACTION TOTALS
Number of Line Items (CON Segments)
CTT
3
24
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Chargeback Claim Amount)
Monetary Amount
AMT
CC
3.37
25
SE01
SE02
TRANSACTION SET TRAILER
Number of Included Segments
Transaction Set Control Number
SE
23
0003
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 30
Transmission File
Seg.#
Segment Data
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
ST*844*0003\
BAA*00*RA*20080105*AM*CB09096P30\
N1*SU**UL*0123456000001\
N1*DS**UL*0056789000001\
CON*VC*7676*VA\
N1*ST**UL*0098765000001\
REF*P7*00001\
SII*N4*00333333333*1*UN*8.95*7.5*1.45\
N9*DI*I030297**20071221*SE: 12345:678905101112\
SII*N4*00333333333*1*UN*8.95*7.5*1.45\
N9*DI*I030297**20071221*SE: 12345:678905101113\
CON*VC*7676*VA\
N1*ST**UL*0098765000001\
REF*P7*000002\
SII*N4*00333444444*-1*UN>>200*3.98*2.5*-1.48\
N9*DI*IO30971**20071110*SE: 12345:678905101107\
CON*VC*9898*VA\
N1*ST**PI*340B657800\
REF*P7*000003\
REF*HI*HIN876500\
SII*N4*00333333333*1*UN*8.95*7*1.95\
N9*DI*I117305**20071227*SE: 12345:678905101116\
CTT*3\
AMT*CC*3.37\
SE*23*0003\
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 31
844 Product Transfer Account Adjustment (Chargeback)
Example 2: Credit/rebill with no original chargeback
The distributor, Mountain Wholesale Drug, is sending the manufacturer, Street Pharmaceuticals, an 844 Product Transfer Account
Adjustment (Chargeback). This transaction set contains information pertaining to a credit/rebill of a sale that originated off contract to or
from eligible customers which was rebilled at a contracted price entitling the distributor to a credit or debit from the manufacturer. The
business example represents only the rebill line to the manufacturer with the contracted price with reference to the original sale. The
customer is Riverside Community Hospital purchasing one product, Codeine Plus.
Note: The transaction is identified as a credit/rebill with no original chargeback transaction in the BAA segment with qualifier ‘41’. The
EPC numbers appear below listed together but will de-aggregate when the 844 is generated listing each unit as a separate sale with
the same invoice due to constraints from the structure of the ANS x12 844 transaction set.
The pertinent information is summarized below:
Chargeback/Debit Memo Date
Chargeback/Debit Memo Number
Manufacturer
Manufacturer ID
Distributor
Distributor ID
Contract
Customer ID
Name
Chargeback Line Number
Item Number
Description
Quantity Rebilled
Wholesale Cost
Contract Cost
Chargeback Claim
Invoice Number
Pricing Date
EPCs: (placeholder)
01/20/2008
CB09098P40
Street Pharmaceuticals
0123456000001
Mountain Drug Wholesale
0056789000001
9898
340B657800
Riverside Community Hospital
1
NDC 00333-5555-55
Codeine Plus
2
$3.98
$3.00
$1.96
I030973
10/15/2007
12345:678905101101, 12345:678905101102
Sequential Segment Layout
The following is a narrative of each segment as it appears in the transmission file. The number on
the far left corresponds to the segment number.
Seg #
Segment Name
Data Values
1
ST01
ST02
TRANSACTION SET HEADER
Transaction Set ID Code
Transaction Set Control Number
ST
844
0006
2
BAA01
BAA02
BAA03
BAA04
BAA05
BEGINNING SEGMENT
Transaction Set Purpose Code (CRRB)
Transaction Set Type Code (Request for Credit)
Date (CCYYMMDD)
Reference Number Qualifier (Chargeback)
Reference Number
BAA
41
RA
20080120
AM
CB09098P40
3
N101
N103
N104
NAME
Entity ID (Supplier/Manufacturer)
ID Code Qualifier (GLN)
ID Code
N1
SU
UL
0123456000001
4
N101
N102
N103
NAME N1
Entity ID Code (Wholesaler/Distributor)
ID Code Qualifier (GLN)
ID Code
DS
UL
0056789000001
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 32
5
CON01
CON02
CON03
CONTRACT NUMBER DETAIL
Reference Number Qualifier
(Vendor Contract)
Reference Number
Contract Status Code (Valid Open Contract)
CON
VC
9898
VA
6
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (GLN)
ID Code
N1
ST
PI
340B657800
7
REF01
REF02
REFERENCE IDENTFICATION
Reference ID Qualifier
Reference ID
REF
P7
00001 “Chargeback line number”
8
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity (Quantity Rebilled)
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333555555
1
UN
3.98
3.00
0.98
9
N901
N902
N904
N907-1
N907-2
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030973
20071015
SE
12345:678905101101
10
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity (Quantity Rebilled)
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333555555
1
UN
3.98
3.00
0.98
11
N901
N902
N904
N907-1
N907-2
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030973
20071015
SE
12345:678905101102
12
CTT01
TRANSACTION TOTALS
Number of Line Items (CON Segments)
CTT
1
13
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Chargeback Claim Amount)
Monetary Amount
AMT
CC
1.96
14
SE01
SE02
TRANSACTION SET TRAILER
Number of Included Segments
Transaction Set Control Number
SE
12
0006
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 33
Transmission File
Seg.
Segment Data
1
2
3
4
5
6
7
8
9
10
11
12
13
14
ST*844*0006\
BAA*41*RA*20080120*AM*CB09098P40\
N1*SU**UL*0123456000001\
N1*DS**UL*0056789000001\
CON*VC*9898*VA\
N1*ST**PI*340B657800\
REF*P7*00001\
SII*N4*00333555555*1*UN*3.98*3*.98\
N9*DI*I030973**20071015*SE: 12345:678905101101\
SII*N4*00333555555*1*UN*3.98*3*.98\
N9*DI*I030973**20071015*SE: 12345:678905101102\
CTT*1\
AMT*CC*1.96\
SE*12*0006\
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 34
844 Product Transfer Account Adjustment (Chargeback)
Example 3: Credit/rebill with original chargeback
The distributor, Mountain Wholesale Drug, is sending the manufacturer, Street Pharmaceuticals, an 844 Product Transfer Account
Adjustment (Chargeback). This transaction set contains information pertaining to a credit/rebill pertaining to the sale of product at
contract price to and/or from eligible customers entitling the distributor to a credit and/or debit from the manufacturer. This chargeback
transaction contains chargeback claims for a contract by Parkview Memorial Hospital. The credit line requires the distributor to reverse
a chargeback amount previously sent to the manufacturer for the initial purchase.
Note: The transaction is identified as a credit/rebill with an original chargeback transaction in the BAA segment with qualifier ‘18’. The
EPC numbers appear below listed together but will de-aggregate when the 844 is generated listing each unit as a separate sale with
the same invoice due to constraints from the structure of the ANS x12 844 transaction set.
The pertinent information is summarized below:
Chargeback/Debit Memo Date
Chargeback/Debit Memo Number
Manufacturer
Manufacturer ID
Distributor
Distributor ID
02/01/2008
CB09097P60
Street Pharmaceuticals
0123456000001
Mountain Wholesale Drug
0056789000001
Contract
Customer ID
Name
Chargeback Line number
Item Number
Description
Quantity Credited
Wholesale Cost
Contract Cost
Chargeback Claim
Invoice Number
Pricing Date
EPCs: (placeholder)
7676
0098765000001
Parkview Memorial Hospital
1
NDC 00333-3333-33
Tetracycline
-2 (use “-“ for quantity credited)
$8.95
$7.50
$-2.90
I030297
12/21/2007
12345:678905101112, 12345:678905101113
Contract
Customer ID
Name
Chargeback Line number
Item Number
Description
Quantity Rebilled
Wholesale Cost
Contract Cost
Chargeback Claim
Invoice Number
Pricing Date
EPCs: (placeholder)
7676
0098765000001
Parkview Memorial Hospital
2
NDC 00333-3333-33
Tetracycline
2
$8.95
$7.10
$3.70
I030297
12/21/2007
12345:678905101112, 12345:678905101113
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 35
Sequential Segment Layout
The following is a narrative of each segment as it appears in the transmission file. The number on
the far left corresponds to the segment number.
Seg #
Segment Name
Data Values
1
ST01
ST02
TRANSACTION SET HEADER
Transaction Set ID Code
Transaction Set Control Number
ST
844
0004
2
BAA01
BAA02
BAA03
BAA04
BAA05
BEGINNING SEGMENT
Transaction Set Purpose Code (CRRB)
Transaction Set Type Code (Request for Credit)
Date (CCYYMMDD)
Reference Number Qualifier (Chargeback)
Reference Number
BAA
18
RA
20080201
AM
CB09097P60
3
N101
N103
N104
NAME
Entity ID (Supplier/Manufacturer)
ID Code Qualifier (GLN)
ID Code
N1
SU
UL
0123456000001
4
N101
N102
N103
NAME N1
Entity ID Code (Wholesaler/Distributor)
ID Code Qualifier (GLN)
ID Code
DS
UL
0056789000001
5
CONTRACT NUMBER DETAIL
CON
CON01
VC
CON02
CON03
Reference Number Qualifier
(Vendor Contract Number)
Reference Number
Contract Status Code (Valid Open Contract)
7676
VA
6
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (GLN)
ID Code
N1
ST
UL
0098765000001
7
REF01
REF02
REFERENCE IDENTFICATION
Reference ID Qualifier
Reference ID
REF
P7
00001 “Chargeback line number”
8
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity (Quantity Credited)
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
-1
UN
8.95
7.5
-1.45
9
N901
N902
N904
N907-1
N907-2
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030297
20071221
SE
12345:678905101112
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 36
10
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity (Quantity Credited)
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
-1
UN
8.95
7.5
-1.45
11
N901
N902
N904
N907-1
N907-2
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030297
20071221
SE
12345:678905101113
12
CONTRACT NUMBER DETAIL
CON
CON01
VC
CON02
CON03
Reference Number Qualifier
(Vendor Contract Number)
Reference Number
Contract Status Code (Valid Open Contract)
7676
VA
13
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (GLN)
ID Code
N1
ST
UL
0098765000001
14
REF01
REF02
REFERENCE IDENTFICATION
Reference ID Qualifier
Reference ID
REF
P7
00002 “Chargeback line number”
15
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity (Quantity Rebilled)
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
1
UN
8.95
7.1
1.85
16
N901
N902
N904
N907-1
N907-2
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030297
20071221
SE
12345:678905101112
17
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity (Quantity Rebilled)
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
1
UN
8.95
7.1
1.85
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 37
18
N901
N902
N904
N907-1
N907-2
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030297
20071221
SE
12345:678905101113
19
CTT01
TRANSACTION TOTALS
Number of Line Items (CON Segments)
CTT
2
20
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Chargeback Claim Amount)
Monetary Amount
AMT
CC
0.80
21
SE01
SE02
TRANSACTION SET TRAILER
Number of Included Segments
Transaction Set Control Number
SE
19
0004
Transmission File
Seg.
Segment Data
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
ST*844*0004\
BAA*18*RA*20080201*AM*CB09097P60\
N1*SU**UL*0123456000001\
N1*DS**UL*0056789000001\
CON*VC*7676*VA\
N1*ST**UL*0098765000001\
REF*P7*00001\
SII*N4*00333333333*-1*UN*8.95*7.5*-1.45\
N9*DI*I030297**20071221*SE: 12345:678905101112\
SII*N4*00333333333*-1*UN*8.95*7.5*-1.45\
N9*DI*I030297**20071221*SE: 12345:678905101113\
CON*VC*7676*VA\
N1*ST**UL*0098765000001\
REF*P7*00002\
SII*N4*00333333333*1*UN*8.95*7.1*1.85\
N9*DI*I030297**20071221*SE: 12345:678905101112\
SII*N4*00333333333*1*UN*8.95*7.1*1.85\
N9*DI*I030297**20071221*SE: 12345:678905101113\
CTT*2\
AMT*CC*.80\
SE*19*0004\
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 38
844 Product Transfer Account Adjustment (Chargeback)
Example 4: Chargeback resubmission
The distributor, Mountain Wholesale Drug, is sending the manufacturer, Street Pharmaceuticals, an 844 Product Transfer Account
Adjustment (Chargeback). This transaction set contains information pertaining to the sale or return of product at contract price to or
from eligible customers entitling the distributor to a credit or debit from the manufacturer. The business example represents a
resubmitted chargeback claim. This chargeback transaction contains resubmission of chargeback claims that were previously submitted
to and rejected by the manufacturer. After researching the rejection, the distributor resubmits the chargeback claim in the 844
(Chargeback) transaction set. This example assumes the chargeback line items submitted by Mountain Drug Wholesale in Example 1
were rejected by Street Pharmaceuticals. The resubmitted line number in this example is line# 3 sent to the manufacturer on original
844 (Chargeback) and provided back to the distributor on 849 (Chargeback Reconciliation).
Note: The line will only be resubmitted for the difference denied on the original by the manufacturer. Upon rejection, if the manufacturer
provided the distributor with a resubmission debit memo number in the 849 transaction set, that number can be sent in the BAA
segment. The chargeback line number is identified in the N1 loop as well as comments from the distributor. The EPC numbers appear
below listed together but will de-aggregate when the 844 is generated listing each unit as a separate sale with the same invoice due to
constraints from the structure of the ANS x12 844 transaction set.
The pertinent information is summarized below:
Chargeback/Debit Memo Date
Chargeback/Debit Memo Number
Manufacturer Resubmission Number
Manufacturer
Manufacturer ID
Distributor
Distributor ID
02/14/2008
CB09096P30
596034549
Street Pharmaceuticals
0123456000001
Mountain Wholesale Drug
0056789000001
Contract
Customer ID
Name
Chargeback Line number
Comments
Item Number
Description
Quantity
Wholesale Cost
Contract Cost
Chargeback Claim
Invoice Number
Pricing Date
EPCs: (placeholder)
9898
340B657800
Riverside Community Hospital
3
submitted price correct at time of sale
NDC 00333-3333-33
Tetracycline
1
$8.95
$7.00
$1.90
I117305
12/27/2007
12345:678905101116
Sequential Segment Layout
The following is a narrative of each segment as it appears in the transmission file. The number on
the far left corresponds to the segment number.
Seg #
Segment Name
Data Values
1
ST01
ST02
TRANSACTION SET HEADER
Transaction Set ID Code
Transaction Set Control Number
ST
844
0002
2
BAA01
BAA02
BAA03
BAA04
BAA05
BEGINNING SEGMENT
Transaction Set Purpose Code (Resubmission)
Transaction Set Type Code (Request for Credit)
Date (CCYYMMDD)
Reference Number Qualifier (Chargeback)
Reference Number
BAA
15
RA
20080214
AM
CB09096P30
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 39
3
REF01
REF02
REFERENCE NUMBERS
Reference Number Qualifier
Reference Number (Resub Only)
REF
RX
596034549
4
N101
N103
N104
NAME
Entity ID (Supplier/Manufacturer)
ID Code Qualifier (GLN)
ID Code
N1
SU
UL
0123456000001
5
N101
N102
N103
NAME
Entity ID Code (Wholesaler/Distributor)
ID Code Qualifier (GLN)
ID Code
N1
DS
UL
0056789000001
6
CONTRACT NUMBER DETAIL
CON
CON01
VC
CON02
CON03
Reference Number Qualifier
(Vendor Contract Number)
Reference Number
Contract Status Code (Valid Open Contract)
9898
VA
7
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (HIN)
ID Code
N1
ST
PI
340B657800
8
REF01
REF02
REFERENCE IDENTFICATION
Reference ID Qualifier
Reference ID
REF
P7
00003 “Chargeback line number”
9
REF01
REF03
REFERENCE IDENTIFICATION
Reference ID Qualifier (notes)
Reference ID
REF
L1
submitted price correct at time of sale
10
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity (Quantity Sold)
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
1
UN
8.95
7.00
1.90
11
N901
N902
N904
N907-1
N907-2
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I117305
20071227
SE
12345:678905101116
12
CTT01
TRANSACTION TOTALS
Number of Line Items (CON Segments)
CTT
1
13
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Chargeback Claim Amount)
Monetary Amount
AMT
CC
1.90
14
SE01
SE02
TRANSACTION SET TRAILER
Number of Included Segments
Transaction Set Control Number
SE
12
0002
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 40
Transmission File
Seg.
Segment Data
1
2
3
4
5
6
7
8
9
10
11
12
13
14
ST*844*0002\
BAA*15*RA*20080214*AM*CB09096P30\
REF*RX*596034549\
N1*UL**UL*0123456000001\
N1*DS**UL*0056789000001\
CON*VC*9898*VA\
N1*ST**PI*340B657800\
REF*P7*00003\
REF*L1**submitted price correct at time of sale\
SII*N4*00333333333*1*UN*8.95*7*1.9\
N9*DI*I117305**20071227*SE: 12345:678905101116\
CTT*1\
AMT*CC*1.9\
SE*12*0002\
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 41
844 Product Transfer Account Adjustment (Chargeback)
Example 5: Basic Alternative Model with all transactions within one Debit Memo
The wholesaler, Mountain Wholesale Drug, is sending the manufacturer, Street Pharmaceuticals, an 844 Product Transfer Account
Adjustment (Chargeback). This transaction set contains information pertaining to all available transaction types as related to product
sold at contract price to eligible customers entitling the wholesaler to a credit and/or debit from the manufacturer. The business example
represents an original sale, a return of product from the customer at contract price, credit/rebill with original chargeback, credit/rebill
with no original chargeback based on off contract sale, and a resubmission of denied chargeback line.
Note: Multiple contracts (CON loops) should be included per transaction set (ST/SE). Header code of ‘45’ in BAA segment used to
direct to line level detail for transaction type identification. The negative amount is depicted with the minus sign. The EPC numbers
appear below listed together but will de-aggregate when the 844 is generated listing each unit as a separate sale with the same invoice
due to constraints from the structure of the ANS x12 844 transaction set. Due to limited ref qualifier/id pairs in SII loop, line number and
comments will be in N1 loop with one CON and ship to for each line.
The pertinent information is summarized below:
Chargeback/Debit Memo Date
Chargeback/Debit Memo Number
Manufacturer
Manufacturer ID (GLN)
Wholesaler
Wholesaler ID (GLN)
02/12/2008
CB09096S60
Street Pharmaceuticals
0123456000001
Mountain Wholesale Drug
0089456870001
Transaction Type
Contract
Customer ID (GLN)
Name
Chargeback Line number
Item Number
Description
Quantity
Wholesale Cost
Contract Cost
Chargeback Claim
Invoice Number
Pricing Date
EPCs: (placeholder)
Original
7676
0098765000001
Parkview Memorial Hospital
1
NDC 00333-3333-33
Tetracycline
2
$8.95
$7.50
$2.90
I030297
12/21/2007
12345:678905101112, 12345:678905101113
Transaction Type
Contract
Customer ID (GLN)
Name
Chargeback Line number
Item Number
Description
Potency
Quantity
Wholesale Cost
Contract Cost
Chargeback Claim
Invoice Number
Pricing Date
EPCs: (placeholder)
Return
7676
0098765000001
Parkview Memorial Hospital
2
NDC 00333-4444-44
Advate 2
200
-1 (use “-“ for negative quantity)
$3.98
$2.50
$-1.48
I030971
11/10/2007
12345:678905101107
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 42
Transaction Type
Contract
Customer ID (GLN)
Name
Chargeback Line number
Item Number
Description
Quantity
Wholesale Cost
Contract Cost
Chargeback Claim
Invoice Number
Pricing Date
EPCs: (placeholder)
Credit/Rebill with original chargeback (contract sale)
7676
0098765000001
Parkview Memorial Hospital
3
NDC 00333-3333-33
Tetracycline
-2 (use “-“ for negative quantity)
$8.95
$7.50
$-2.90
I030297
12/21/2007
12345:678905101112, 12345:678905101113
Transaction Type
Contract
Customer ID (GLN)
Name
Chargeback Line number
Item Number
Description
Quantity
Wholesale Cost
Contract Cost
Chargeback Claim
Invoice Number
Pricing Date
EPCs: (placeholder)
Credit/Rebill with original chargeback (contract sale)
7676
0098765000001
Parkview Memorial Hospital
4
NDC 00333-3333-33
Tetracycline
2
$8.95
$7.10
$3.70
I030297
12/21/2007
12345:678905101112, 12345:678905101113
Transaction Type
Contract
Customer ID (340B ID)
Customer ID (HIN)
Name
Chargeback Line number
Item Number
Description
Quantity
Wholesale Cost
Contract Cost
Chargeback Claim
Invoice Number
Pricing Date
EPCs: (placeholder)
Original
9898
340B657800
HIN876500
Riverside Community Hospital
5
NDC 00333-3333-33
Tetracycline
1
$8.95
$7.00
$1.95
I117305
12/27/2007
12345:678905101116
Transaction Type
Contract
Customer ID (340B ID)
Customer ID (HIN)
Name
Chargeback Line number
Item Number
Description
Quantity
Wholesale Cost
Contract Cost
Chargeback Claim
Invoice Number
Pricing Date
EPCs: (placeholder)
Credit/Rebill with no original chargeback (off contract sale)
9898
340B657800
HIN876500
Riverside Community Hospital
6
NDC 00333-5555-55
Codeine Plus
2
$3.98
$3.00
$1.96
I030973
10/15/2007
12345:678905101101, 12345:678905101102
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 43
Transaction Type
Contract
Customer ID (340B ID)
Customer ID (HIN)
Name
Chargeback Line number
Comments
Item Number
Description
Quantity
Wholesale Cost
Contract Cost
Chargeback Claim
Invoice Number
Pricing Date
EPCs: (placeholder)
Resubmission
9898
340B657800
HIN876500
Riverside Community Hospital
7
submitted price correct at time of sale
NDC 00333-3333-33
Tetracycline
1
$8.95
$7.00
$1.90
I117444
10/31/2007
12345:678905101119
Sequential Segment Layout
The following is a narrative of each segment as it appears in the transmission file. The number on
the far left corresponds to the segment number.
Seg. #
Segment Name
Data Values
1
ST01
ST02
TRANSACTION SET HEADER
Transaction Set ID Code
Transaction Set Control Number
ST
844
0009
2
BAA01
BAA02
BAA03
BAA04
BAA05
BEGINNING SEGMENT
Transaction Set Purpose Code (Follow up)
Transaction Type Code (Request for Credit)
Date (CCYYMMDD)
Reference Number Qualifier (Chargeback)
Reference Number
BAA
45
RA
20080212
AM
CB09096S60
3
N101
N103
N104
NAME
Entity ID (Supplier/Manufacturer)
ID Code Qualifier (GLN)
ID Code
N1
SU
UL
0123456000001
4
N101
N103
N104
NAME
Entity ID Code (Wholesaler/Distributor)
ID Code Qualifier (GLN)
ID Code
N1
DS
UL
0089456870001
5
CONTRACT NUMBER DETAIL
CON
CON01
VC
CON02
CON03
Reference Number Qualifier
(Vendor Contract Number)
Reference Number
Contract Status Code (Valid Open Contract)
7676
VA
6
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (GLN)
ID Code
N1
ST
UL
0098765000001
7
REF01
REF02
REFERENCE INDENTIFICATION
Reference ID Qualifier
Reference ID
(Chargeback Line Number)
REF
P7
00001
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 44
8
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
1
UN
8.95
7.5
1.45
9
N901
N902
N904
N907-3
N907-4
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
(Transaction Type-Original)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030297
20071221
8X
00
10
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
1
UN
8.95
7.5
1.45
11
N901
N902
N904
N907-3
N907-4
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
(Transaction Type-Original)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030297
20071221
8X
00
CON
VC
CON02
CON03
CONTRACT NUMBER DETAIL
Reference Number Qualifier
(Vendor Contract)
Reference Number
Contract Status Code (Valid Open Contract)
7676
VA
13
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (GLN)
ID Code
N1
ST
UL
0098765000001
14
REF01
REF02
REFERENCE INDENTIFICATION
Reference ID Qualifier
Reference ID
REF
P7
00002
15
SII01
SII02
SII03
SII04 - 1
SII04 - 6
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity
Unit of Measure Code (Units)
Multiplier (Potency)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
SII
N4
00333444444
-1
UN
200
3.98
2.50
-1.48
N907-5
N907-6
N907-5
N907-6
12
CON01
SE
12345:678905101112
SE
12345:678905101113
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 45
16
N901
N902
N904
N907-3
N907-4
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
(Transaction Type-Original)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030971
20071110
8X
00
CON
VC
CON02
CON03
CONTRACT NUMBER DETAIL
Reference Number Qualifier
(Vendor Contract)
Reference Number
Contract Status Code (Valid Open Contract)
7676
VA
18
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (GLN)
ID Code
N1
ST
UL
0098765000001
19
REF01
REF02
REFERENCE INDENTIFICATION
Reference ID Qualifier
Reference ID
REF
P7
00003
20
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
-1
UN
8.95
7.50
-1.45
21
N901
N902
N904
N907-3
N907-4
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
(Transaction Type-CRRB w/orig.)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030297
20071221
8X
18
22
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
-1
UN
8.95
7.50
-1.45
23
N901
N902
N904
N907-3
N907-4
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
(Transaction Type-CRRB w/orig.)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030297
20071221
8X
18
N907-5
N907-6
17
CON01
N907-5
N907-6
N907-5
N907-6
SE
12345:678905101107
SE
12345:678905101112
SE
12345:678905101113
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 46
24
CON01
CON02
CON03
CONTRACT NUMBER DETAIL
Reference Number Qualifier
(Vendor Contract)
Reference Number
Contract Status Code (Valid Open Contract)
7676
VA
25
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (GLN)
ID Code
N1
ST
UL
0098765000001
26
REF01
REF02
REFERENCE INDENTIFICATION
Reference ID Qualifier
Reference ID
REF
P7
00004
27
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
1
UN
8.95
7.10
1.85
28
N901
N902
N904
N907-3
N907-4
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
(Transaction Type-CRRB w/orig.)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030297
20071221
8X
18
29
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
1
UN
8.95
7.10
1.85
30
N901
N902
N904
N907-3
N907-4
N9
DI (Distributor Invoice Number)
I030297
20071221
8X
18
N907-5
N907-6
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
(Transaction Type-CRRB w/orig.)
Reference Number Qualifier
Reference Number
31
CONTRACT NUMBER DETAIL
CON
CON01
Reference Number Qualifier
(Vendor Contract Number)
Reference Number
Contract Status Code (Valid Open Contract)
VC
N907-5
N907-6
CON02
CON03
CON
VC
SE
12345:678905101112
SE
12345:678905101113
9898
VA
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 47
32
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (340B ID)
ID Code
N1
ST
PI
340B657800
33
REF01
REF02
REFERENCE IDENTIFICATION
Reference ID Qualifier
Reference ID
(Chargeback Line Number)
REF
P7
5
34
REF01
REF02
REF03
REFERENCE IDENTIFICATION
Reference ID Qualifier (HIN)
Reference ID
Description
REF
HI
HIN876500
centralized billing
35
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333333333
1
UN
8.95
7.00
1.95
36
N901
N902
N904
N907-3
N907-4
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
(Transaction Type-Original)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I117305
20071227
8X
00
N907-5
N907-6
SE
12345:678905101116
37
CONTRACT NUMBER DETAIL
CON
CON01
VC
CON02
CON03
Reference Number Qualifier
(Vendor Contract Number)
Reference Number
Contract Status Code (Valid Open Contract)
9898
VA
38
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (340B ID)
ID Code
N1
ST
PI
340B657800
39
REF01
REF02
REFERENCE IDENTIFICATION
Reference ID Qualifier
Reference ID
(Chargeback Line Number)
REF
P7
6
40
REF01
REF02
REF03
REFERENCE IDENTIFICATION
Reference ID Qualifier (HIN)
Reference ID
Description
REF
HI
HIN876500
centralized billing
41
SII01
SII02
SII03
SII04 - 1
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity
Unit of Measure Code (Units)
SII
N4
00333555555
1
UN
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 48
SII05
SII06
SII07
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
3.98
3.00
0.98
42
N901
N902
N904
N907-3
N907-4
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
(Transaction Type-CRRB w/no orig.)
Reference Number Qualifier
Reference Number
N9
DI (Distributor Invoice Number)
I030973
20071015
8X
41
43
SII01
SII02
SII03
SII04 - 1
SII05
SII06
SII07
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
Quantity
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
SII
N4
00333555555
1
UN
3.98
3.00
0.98
44
N901
N902
N904
N907-3
N907-4
N9
DI (Distributor Invoice Number)
I030973
20071015
8X
41
N907-5
N907-6
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
(Transaction Type-CRRB w/no orig.)
Reference Number Qualifier
Reference Number
45
CONTRACT NUMBER DETAIL
CON
CON01
VC
CON02
CON03
Reference Number Qualifier
(Vendor Contract Number)
Reference Number
Contract Status Code (Valid Open Contract)
9898
VA
46
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (340B ID)
ID Code
N1
ST
PI
340B657800
47
REF01
REF02
REFERENCE IDENTIFICATION
Reference ID Qualifier
Reference ID
REF
P7
7
48
REF01
REF02
REF03
REFERENCE IDENTIFICATION
Reference ID Qualifier (HIN)
Reference ID
Description
REF
HI
HIN876500
centralized billing
49
REF01
REF03
REFERENCE IDENTIFICATION
Reference ID Qualifier
Description
REF
L1
submitted price correct at time of sale
50
SII01
SII02
SALES ITEM INFORMATION
Product/Service ID Qualifier (NDC)
Product/Service ID
SII
N4
00333333333
N907-5
N907-6
SE
12345:678905101101
SE
12345:678905101102
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 49
SII03
SII04 - 1
SII05
SII06
SII07
Quantity
Unit of Measure Code (Units)
Unit Price (Wholesaler)
Unit Price (Contract)
Monetary Amount
(Chargeback Claim Amount)
1
UN
8.95
7.00
1.90
51
N901
N902
N904
N907-3
N907-4
N9
DI (Distributor Invoice Number)
I117444
20071031
8X
15
N907-5
N907-6
REFERENCE IDENTIFICATION
Reference Number Qualifier
Reference Number
Date (Pricing Date)
Reference Number Qualifier
Reference Number
(Transaction Type-Resubmit)
Reference Number Qualifier
Reference Number
52
CTT01
TRANSACTION TOTALS
Number of Line Items (CON Segments)
CTT
7
53
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Chargeback Claim Amount)
Monetary Amount
AMT
CC
8.03
54
SE01
SE02
TRANSACTION SET TRAILER
Number of Included Segments
Transaction Set Control Number
SE
52
0009
SE
12345:678905101119
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 50
Transmission File
Seg.#
Segment Data
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
ST*844*0009\
BAA*45*RA*20080212*AM*CB09096S60\
N1*SU**UL*0123456000001\
N1*DS**UL*0089456870001\
CON*VC*7676*VA\
N1*ST**UL*0098765000001\
REF*P7*00001\
SII*N4*00333333333*1*UN*8.95*7.5*1.45\
N9*DI*I030297**20071221***[8X]00]SE]12345.678905.101112\
SII*N4*00333333333*1*UN*8.95*7.5*1.45\
N9*DI*I030297**20071221***[8X[00[SE[12345.678905.101113\
CON*VC*7676*VA\
N1*ST**UL*0098765000001\
REF*P7*00002\
SII*N4*00333444444*-1*UN>>200*3.98*2.5*-1.48\
N9*DI*IO30971**20071110***[8X[00[SE[12345.678905.101107\
CON*VC*7676*VA\
N1*ST**UL*0098765000001\
REF*P7*00003\
SII*N4*00333333333*-1*UN*8.95*7.50*-1.45\
N9*DI*IO30297**20071221***[8X[18[SE[12345.678905.101112\
SII*N4*00333333333*-1*UN*8.95*7.50*-1.45\
N9*DI*IO30297**20071221***[8X[18[SE[12345.678905.101113\
CON*VC*7676*VA\
N1*ST**UL*0098765000001\
REF*P7*00004\
SII*N4*00333333333*1*UN*8.95*7.10*1.85\
N9*DI*IO30297**20071221***[8X[18[SE[12345.678905.101112\
SII*N4*00333333333*-1*UN*8.95*7.10*1.85\
N9*DI*IO30297**20071221***[8X[18[SE[12345.678905.101113\
CON*VC*9898*VA\
N1*ST**PI*340B657800\
REF*P7*00005\
REF*HI*HIN876500*centralized billing\
SII*N4*00333333333*1*UN*8.95*7.00*1.95\
N9*DI*I117305**20071227[8X[00[SE[12345.678905.101116\
CON*VC*9898*VA\
N1*ST**PI*340B657800\
REF*P7*00006\
REF*HI*HIN876500*centralized billing\
SII*N4*00333555555*1*UN*3.98*3.00*0.98\
N9*DI*I030973**20071015***[8X[41[SE[12345.678905.101101\
SII*N4*00333555555*1*UN*3.98*3.00*0.98\
N9*DI*I030973**20071015***[8X[41[SE[12345.678905.101102\
CON*VC*9898*VA\
N1*ST**PI*340B657800\
REF*P7*00007\
REF*HI*HIN876500*centralized billing\
REF*L1**submitted price correct at time of sale\
SII*N4*00333333333*1*UN*8.95*7.00*1.90\
N9*DI*I117444**20071031***[8X[15[SE[12345.678905.101119\
CTT*7\
AMT*CC*8.03\
SE*52*0009\
844 Product Transfer Account Adjustment Guidelines for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
845
849
844
Contract & Chargeback Administration Guidelines
for Electronic Data Interchange (EDI),
to Support Distributor Service Agreements
Section 3: 849 Response to Product Transfer Account Adjustment
Table of Contents
Introduction
4
Transaction Set Detail
5
Data Segments
7
Business Samples
36
Page 4
849 Response to Product Transfer
Account Adjustment
INTRODUCTION
This implementation guideline for the 849 Response to Product Transfer Account Adjustment Electronic Data
Interchange (EDI) transaction set was developed by the Healthcare Distribution Management Association’s
(HDMA) eCommerce Task Force (eCTF). The eCTF provides business and technology expertise to develop
voluntary healthcare industry implementation guidelines for the use of EDI and other technology standards.
HDMA member distributors, manufacturers and technology providers serve on the task force.
The purpose of this HDMA implementation guideline is to present the format and explain the application of
the Accredited Standards Committee (ASC) X12 standards as they pertain to the Product Transfer Account
Adjustment transaction set for use within the context of an EDI environment in healthcare. This transaction
set contains one header, detail and summary area per transaction. The transaction set can be used to
transmit a detailed or summary response to a party requesting an accounting adjustment relating to a preauthorized product transfer.
This edition contains the following revisions:
1.) Additional codes have been added to identify third-party pharmacy billing and eligible entities.
2.) Certain usage notes have been added or edited to clarify definitions or use.
Additionally, this 2009 edition includes additional methods to indicate the transaction type. Indicators for an
original submission, a resubmission, a credit and rebill or a reissue will now be accommodated in two ways,
either at the header level when all lines relate to one transaction type or at the line level when one
chargeback may contain various transaction types. A new qualifier has been added to the header to notify
upon receipt if the transaction type is identified at the header or line level.
Transaction Set Usage:
Upon the sale and shipment of products to eligible members at contact prices, the appropriate distributor
electronically transmits a chargeback claim via an 844 Product Transfer Account Adjustment transaction set to
the manufacturer. The chargeback claim provides the manufacturer with details of these contract sales and
requests credit due the distributor for these sales. In response to the chargeback claim received from the
distributor, the manufacturer processes the chargeback claim and sends an electronic credit document to the
distributor through the transmission of an 849 Response to Product Transfer Account Adjustment (Chargeback
Reconciliation) transaction set. This is used by the manufacturer to reduce paperwork and expedite the
chargeback payment process. If the chargeback claim submitted by the distributor is found to be without error,
the manufacturer will transmit a chargeback payment process. If the chargeback claim submitted by the
distributor is found to include errors, the manufacturer will transmit a chargeback reconciliation with line item
detail of the item(s) found to be in error in the original chargeback claim. This chargeback reconciliation should
include credit for the undisputed and adjusted credit amounts along with any line item denied for credit. Only
items found in error (adjusted or denied) should be transmitted back to the distributor with an HDMA reject
reason code. If warranted, the distributor can correct the errors and resubmit the chargeback claim for the
item(s) in question. This chargeback reconciliation should be transmitted to the distributor by the manufacturer
within 30 days after receipt of the original chargeback claim. The detail PAD loop LIN segment has been
extended to support chargeback detail line identification which is required to support 844 chargeback
resubmissions.
For trading partners who elect to use the 849 Response to Product Transfer Account Adjustment, this
guideline is intended to help facilitate trading partners’ use of this transaction set to improve business
efficiencies.
Page 5
849
Response to Product Transfer Account
Adjustment
Functional Group=CF
Purpose: This X12 transaction set contains the format and establishes the data contents of the Response to Product Transfer Account
Adjustment Transaction Set (849) for use within the context of an Electronic Data Interchange (EDI) environment. The transaction set
can be used to transmit a detailed or summary response to a party requesting an accounting adjustment relating to a pre-authorized
product transfer.
Heading:
Page Pos
7
0100
8
0200
9
10
11
Id
ST
BRC
0500
REF
LOOP ID - N1
0800
N1
Segment Name
Transaction Set Header
Beginning Segment for Response to
Product Transfer Account
Adjustment
Reference Identification
Req
M
M
Max Use
1
1
O
12
Repeat
Notes
Usage
Must use
Must use
Must use
50
Name
O
1
Must use
Req
Max Use
Contract Number Detail
Request Validation
Reference Identification
O
O
O
1
10
12
Name
Address Information
Geographic Location
Reference Identification
O
O
O
O
1
2
1
12
Product Adjustment Detail
Item Identification
Request Validation
Unit Detail
Quantity
Monetary Amount
Reference Identification
Date/Time Reference
O
O
O
O
O
O
O
O
1
1
10
5
5
2
12
10
Detail:
Page
12
13
14
15
16
17
18
19
20
Pos
Id
LOOP ID - CON
0100
CON
0200
AAA
0300
REF
LOOP ID - N1
0600
N1
0800
N3
0900
N4
1000
REF
21
22
23
25
28
29
30
31
32
LOOP ID - PAD
1200
PAD
1300
LIN
1400
AAA
1700
UIT
1800
QTY
1900
AMT
2100
REF
2200
DTM
Segment Name
Repeat
10000
Notes
Usage
Optional
Optional
Optional
50
Optional
Not recommended
Not recommended
Optional
1000
N2/1400
N2/1700
N2/1800
N2/1900
Optional
Optional
Optional
Optional
Optional
Optional
Optional
Optional
Summary:
Page
33
34
35
Pos
0100
0200
0300
Id
CTT
AMT
SE
Segment Name
Transaction Totals
Monetary Amount
Transaction Set Trailer
Req
M
O
M
Max Use
1
5
1
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
Repeat
Notes
N3/0100
N3/0200
ASC X12 Version/Release 004010
Usage
Must use
Must use
Must use
Page 6
Notes:
2/1400
2/1700
2/1800
2/1900
3/0100
3/0200
AAA*N*DR*DD~
UIT*UN*15*WH~
Two occurrences of this QTY segment at the Detail level in the CON/PAD loop are
required if the quantity sold submitted by the distributor is in error--one to provide the
submitted quantity sold and the other to provide the quantity sold (the valid value
corrected by the manufacturer). The same holds true if the quantity of returns submitted
by the distributor is in error.
The AMT segment is to be used only in cases where the amount cannot be computed from other detail.
Number of line items (CTT01) is the accumulation of the number of CON segments. If used, hash total (CTT02) is the sum
of the quantities (QTY02) for each QTY segment.
The AMT segment is to be used only in cases where the amount cannot be computed from other detail.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 7
Pos: 0100
Max: 1
Heading - Mandatory
Loop: N/A
Elements: 3
Transaction Set Header
ST
User Option (Usage): Must use
Purpose: To indicate the start of a transaction set and to assign a control number
Element Summary:
Ref
ST01
Id
143
Element Name
Transaction Set Identifier Code
Req
M
Type
ID
Min/Max
3/3
Usage
Must use
Rep
1
Description: Code uniquely identifying a
Transaction Set
Code
849
ST02
329
Name
Response to Product Transfer Account Adjustment
Transaction Set Control Number
M
AN
4/9
Must use
1
O
AN
1/35
Optional
1
Description: Identifying control number
that must be unique within the transaction
set functional group assigned by the
originator for a transaction set
ST03
1705
Implementation Convention Reference
Description: Reference assigned to
identify Implementation Convention
Semantics:
1. The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate
transaction set definition (e.g., 810 selects the Invoice Transaction Set).
2. The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the
appropriate implementation convention to match the transaction set definition.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 8
Beginning Segment for
Response to Product Transfer
Account Adjustment
BRC
Pos: 0200
Max: 1
Heading - Mandatory
Loop: N/A
Elements: 4
User Option (Usage): Must use
Purpose: To identify the beginning of a Response to Product Transfer Account Adjustment Transaction Set
Element Summary:
Ref
BRC01
Id
353
Element Name
Transaction Set Purpose Code
Req
M
Type
ID
Min/Max
2/2
Usage
Must use
Rep
1
Description: Code identifying purpose of
transaction set
Code
00
15
18
41
45
BRC02
373
Name
Original
Re-Submission
Code Usage:
Manufacturer response to chargeback resubmission
Reissue
Code Usage:
Manufacturer response to a credit and re-bill of original chargeback
Corrected and Verified
Code Usage:
Manufacturer response to a chargeback request where original sale was at
wholesaler cost/ no original chargeback
Follow-up
Code Usage:
See detail REF segment in the PAD loop for line level indicator of transaction type
Date
M
DT
8/8
Must use
1
X
ID
2/3
Optional
1
AN
1/50
Optional
1
Description: Date expressed as
CCYYMMDD where CC represents the
first two digits of the calendar year
Element Usage: Processing date
BRC03
128
Reference Identification Qualifier
Description: Code qualifying the
Reference Identification
Code
CM
TN
BRC04
127
Name
Buyer's Credit Memo
Transaction Reference Number
Reference Identification
X
Description: Reference information as
defined for a particular Transaction Set or
as specified by the Reference
Identification Qualifier
Syntax Rules:
1. P0304 - If either BRC03 or BRC04 is present, then the other is required.
Semantics:
1. BRC02 is the date of the response to product transfer account adjustment.
2. BRC05 is the time of the response to product transfer account adjustment.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 9
Pos: 0500
Max: 12
Heading - Optional
Loop: N/A
Elements: 2
Reference Identification
REF
User Option (Usage): Must use
Purpose: To specify identifying information
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Must use
Rep
1
Description: Code qualifying the
Reference Identification
Code
AM
RX
REF02
127
Name
Adjustment Memo (Chargeback)
Resubmit number
Code Usage:
Number assigned by the manufacturer to identify a previously submitted
chargeback that was rejected due to error. The distributor provides this number
when the chargeback is corrected and resubmitted. Not all manufacturers assign
resubmit numbers.
Reference Identification
X
AN
1/50
Optional
Description: Reference information as
defined for a particular Transaction Set or
as specified by the Reference
Identification Qualifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
1
Page 10
Pos: 0800
Loop Name
Loop: N1
Repeat: 50
Optional
Elements: N/A
User Option (Usage): Must use
Purpose: To identify a party by type of organization, name, and code
Loop Summary:
Pos
0800
Id
N1
Segment Name
Name
Req
O
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
Max Use
1
Repeat
ASC X12 Version/Release 004010
Usage
Must use
Page 11
Pos: 0800
Max: 1
Heading - Optional
Loop: N1
Elements: 4
Name
N1
User Option (Usage): Must use
Purpose: To identify a party by type of organization, name, and code
Element Summary:
Ref
N101
Id
98
Element Name
Entity Identifier Code
Req
M
Type
ID
Min/Max
2/3
Usage
Must use
Rep
1
X
AN
1/60
Optional
1
X
ID
1/2
Optional
1
Description: Code identifying an
organizational entity, a physical location,
property or an individual
Code
DB
DS
SU
N102
93
Name
Distributor Branch
Distributor
Supplier/Manufacturer
Name
Description: Free-form name
N103
66
Identification Code Qualifier
Description: Code designating the
system/method of code structure used for
Identification Code (67)
Code
11
21
UL
N104
67
Name
Drug Enforcement Administration (DEA)
Health Industry Number (HIN)
UCC/EAN Location Code
Description: A globally unique 13 digit code for the identification of a legal,
functional or physical location within the Uniform Code Council (UCC) and
International Article Number Association (EAN) numbering system
Code Usage:
GS1-US Global Location Number (GLN)
Identification Code
X
AN
2/80
Optional
1
Description: Code identifying a party or
other code
Syntax Rules:
1. R0203 - At least one of N102 or N103 is required.
2. P0304 - If either N103 or N104 is present, then the other is required.
Comments:
1. This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency
the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
2. N105 and N106 further define the type of entity in N101.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 12
Pos: 0100
Repeat: 10000
Optional
Loop: CON
Elements: N/A
Loop Contract Number Detail
User Option (Usage): Optional
Purpose: To specify contract or reference number and status
Loop Summary:
Pos
0100
0200
0300
0600
1200
Id
CON
AAA
REF
Segment Name
Contract Number Detail
Request Validation
Reference Identification
Loop N1
Loop PAD
Req
O
O
O
O
O
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
Max Use
1
10
12
Repeat
50
1000
ASC X12 Version/Release 004010
Usage
Optional
Optional
Optional
Optional
Optional
Page 13
Pos: 0100
Max: 1
Detail - Optional
Loop: CON
Elements: 3
Contract Number Detail
CON
User Option (Usage): Optional
Purpose: To specify contract or reference number and status
Element Summary:
Ref
CON01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Must use
Rep
1
M
AN
1/50
Must use
1
M
ID
2/2
Must use
1
Description: Code qualifying the
Reference Identification
Code
VC
CON02
127
Name
Vendor Contract Number
Reference Identification
Description: Reference information as
defined for a particular Transaction Set or
as specified by the Reference
Identification Qualifier
Element Usage: Contract number that
was submitted by the distributor to the
manufacturer in the chargeback
transmission.
CON03
846
Contract Status Code
Description: Code designating the
current status of the contract
Code
VA
Name
Valid Open Contract
Code Usage:
The contract referenced may not literally be valid. The reject reason code that
appears in the AAA segment which follows identifies the contract-related reason
for rejecting the chargeback. In order to use this mandatory data element, all
contracts are considered valid by using the VA code for valid open contract.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 14
Pos: 0200
Max: 10
Detail - Optional
Loop: CON
Elements: 3
Request Validation
AAA
User Option (Usage): Optional
Purpose: To specify the validity of the request and indicate follow-up action authorized
Element Summary:
Ref
AAA01
Id
1073
Element Name
Yes/No Condition or Response Code
Req
M
Type
ID
Min/Max
1/1
Usage
Must use
Rep
1
O
ID
2/2
Optional
1
2/2
Optional
1
Description: Code indicating a Yes or No
condition or response
Code
N
AAA02
559
Name
No
Agency Qualifier Code
Description: Code identifying the agency
assigning the code values
Code
DR
AAA03
901
Name
National Wholesale Druggists Association
Reject Reason Code
O
ID
Description: Code assigned by issuer to
identify reason for rejection
Code
AA
BB
CC
DD
RI
Name
Rebill Without Offsetting Credit
Contract Number Incorrect
Contract Expired
Contract Not Yet In Force
Invalid Resubmit Number
Code Usage:
Resubmit number does not match any resubmit number assigned or does not
match most recent resubmit number assigned.
Semantics:
1. AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the
code is invalid.
Comments:
1. If AAA02 is used, AAA03 contains a code from an industry code list.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 15
Pos: 0300
Max: 12
Detail - Optional
Loop: CON
Elements: 2
Reference Identification
REF
User Option (Usage): Optional
Purpose: To specify identifying information
Segment Usage:
This REF segment at the Detail Level in the CON loop is used by the manufacturer to correct the contract number
referenced in the chargeback submitted by the distributor. REF01 and REF02 must be present.
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Must use
Rep
1
X
AN
1/50
Optional
1
Description: Code qualifying the
Reference Identification
Code
C8
REF02
127
Name
Corrected Contract Number
Reference Identification
Description: Reference information as
defined for a particular Transaction Set or
as specified by the Reference
Identification Qualifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 16
Pos: 0600
Loop Name
Loop: N1
Repeat: 50
Optional
Elements: N/A
User Option (Usage): Optional
Purpose: To identify a party by type of organization, name, and code
Loop Summary:
Pos
0600
0800
0900
1000
Id
N1
N3
N4
REF
Segment Name
Name
Address Information
Geographic Location
Reference Identification
Req
O
O
O
O
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
Max Use
1
2
1
12
Repeat
ASC X12 Version/Release 004010
Usage
Optional
Not recommended
Not recommended
Optional
Page 17
Pos: 0600
Max: 1
Detail - Optional
Loop: N1
Elements: 4
Name
N1
User Option (Usage): Optional
Purpose: To identify a party by type of organization, name, and code
Segment Usage:
This N1 loop at the Detail Level in the CON loop is required to identify the customers or ship to locations associated with
the chargeback claim. N101 and N104 must be present.
Element Summary:
Ref
N101
Id
98
Element Name
Entity Identifier Code
Req
M
Type
ID
Min/Max
2/3
Usage
Must use
Rep
1
X
AN
1/60
Not recommended
1
X
ID
1/2
Must use
1
Description: Code identifying an
organizational entity, a physical location,
property or an individual
Code
ST
N102
93
Name
Ship To
Name
Description: Free-form name
N103
66
Identification Code Qualifier
Description: Code designating the
system/method of code structure used for
Identification Code (67)
Code
11
21
PI
UL
N104
67
Name
Drug Enforcement Administration (DEA)
Health Industry Number (HIN)
Payer Identification
Code Usage:
This is used to identify 340B Program providers.
UCC/EAN Location Code
Description: A globally unique 13 digit code for the identification of a legal,
functional or physical location within the Uniform Code Council (UCC) and
International Article Number Association (EAN) numbering system
Code Usage:
GS1-US Global Location Number (GLN)
Identification Code
X
AN
2/80
Must use
1
Description: Code identifying a party or
other code
Syntax Rules:
1. R0203 - At least one of N102 or N103 is required.
2. P0304 - If either N103 or N104 is present, then the other is required.
Comments:
1. This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency
the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
2. N105 and N106 further define the type of entity in N101.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 18
Pos: 0800
Max: 2
Detail - Optional
Loop: N1
Elements: 1
Address Information
N3
User Option (Usage): Not recommended
Purpose: To specify the location of the named party
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Must use
Description: Address information
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Rep
1
Page 19
Pos: 0900
Max: 1
Detail - Optional
Loop: N1
Elements: 3
Geographic Location
N4
User Option (Usage): Not recommended
Purpose: To specify the geographic place of the named party
Segment Usage:
Not Recommended by HDMA
Element Summary:
Ref
N401
Id
19
Element Name
City Name
Req
O
Type
AN
Min/Max
2/30
Usage
Optional
Rep
1
X
ID
2/2
Optional
1
O
ID
3/15
Optional
1
Description: Free-form text for city name
N402
156
State or Province Code
Description: Code (Standard
State/Province) as defined by appropriate
government agency
N403
116
Postal Code
Description: Code defining international
postal zone code excluding punctuation
and blanks (zip code for United States)
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 is required.
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 20
Pos: 1000
Max: 12
Detail - Optional
Loop: N1
Elements: 3
Reference Identification
REF
User Option (Usage): Optional
Purpose: To specify identifying information
Segment Usage:
If used, this segment provides the means to identify another party to the contracted sale. It could designate a centralized
bill-to location ID, a third party Pharmacy service, or the eligible party to the contract. This segment can also identify the
chargeback line number used for chargeback resubmissions as well as coments.
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Must use
Rep
1
Description: Code qualifying the
Reference Identification
Code
2U
DH
HI
L1
LU
P7
REF02
127
Name
Payer Identification Number
Code Usage:
340B Programs
Drug Enforcement Administration Number
Health Industry Number (HIN)
Letters or Notes
Code Usage:
This code would qualify any optional notes and comments pertaining to an
original or resubmitted chargeback line. These notes or comments should be
placed in REF03.
Location Number
Code Usage:
GS1-US Global Location Number (GLN)
Product Line Number
Code Usage:
This code qualifies the chargeback line number.
Reference Identification
X
AN
1/50
Optional
1
X
AN
1/80
Optional
1
Description: Reference information as
defined for a particular Transaction Set or
as specified by the Reference
Identification Qualifier
REF03
352
Description
Description: A free-form description to
clarify the related data elements and their
content
Element Usage: This element can
contain any optional notes or
comments pertaining to an original or
resubmitted line on a chargeback.
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 21
Pos: 1200
Repeat: 1000
Optional
Loop: PAD
Elements: N/A
Loop Product Adjustment Detail
User Option (Usage): Optional
Purpose: To specify the product transfer type, and/or line item number
Loop Summary:
Pos
1200
1300
1400
1700
1800
1900
2100
2200
Id
PAD
LIN
AAA
UIT
QTY
AMT
REF
DTM
Segment Name
Product Adjustment Detail
Item Identification
Request Validation
Unit Detail
Quantity
Monetary Amount
Reference Identification
Date/Time Reference
Req
O
O
O
O
O
O
O
O
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
Max Use
1
1
10
5
5
2
12
10
Repeat
ASC X12 Version/Release 004010
Usage
Optional
Optional
Optional
Optional
Optional
Optional
Optional
Optional
Page 22
Product Adjustment Detail
PAD
Pos: 1200
Max: 1
Detail - Optional
Loop: PAD
Elements: 1
User Option (Usage): Optional
Purpose: To specify the product transfer type, and/or line item number
Segment Usage:
If this PAD segment is used, then an LIN segment must follow.
Element Summary:
Ref
PAD01
Id
350
Element Name
Assigned Identification
Req
X
Type
AN
Min/Max
1/20
Usage
Optional
Description: Alphanumeric characters
assigned for differentiation within a
transaction set
Element Usage: This is a sequential
number starting with 1 which starts
over with each CON loop.
Syntax Rules:
1. R0102 - At least one of PAD01 or PAD02 is required.
2. P0405 - If either PAD04 or PAD05 is present, then the other is required.
Semantics:
1. PAD01 is the line item identification.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Rep
1
Page 23
Pos: 1300
Max: 1
Detail - Optional
Loop: PAD
Elements: 3
Item Identification
LIN
User Option (Usage): Optional
Purpose: To specify basic item identification data
Element Summary:
Ref
LIN01
Id
350
Element Name
Assigned Identification
Req
O
Type
AN
Min/Max
1/20
Usage
Optional
Rep
1
M
ID
2/2
Must use
1
Description: Alphanumeric characters
assigned for differentiation within a
transaction set
Element Usage: In order to support
chargeback re-submittals via 844 EDI,
this element is required to identify a
chargeback detail line. This line
number must identify the same exact
chargeback line number submitted on
corresponding 844 chargeback. This
enables both the manufacturer and the
distributor to quickly and easily
identify disputed chargeback lines.
LIN02
235
Product/Service ID Qualifier
Description: Code identifying the
type/source of the descriptive number
used in Product/Service ID (234)
Code
EN
N1
N2
N3
N4
NH
UA
UI
UK
UP
UX
VC
LIN03
234
Name
EAN/UCC - 13
Description: Data structure for the 13 digit EAN.UCC (EAN International.Uniform
Code Council) Global Trade Identification Number (GTIN)
National Drug Code in 4-4-2 Format
Description: 4-digit manufacturer ID, 4-digit product ID, 2-digit trade package size
National Drug Code in 5-3-2 Format
Description: 5-digit manufacturer ID, 3-digit product ID, 2-digit trade package size
National Drug Code in 5-4-1 Format
Description: 5-digit manufacturer ID, 4-digit product ID, 1-digit trade package size
National Drug Code in 5-4-2 Format
Description: 5-digit manufacturer ID, 4-digit product ID, 2-digit trade package size
National Health Related Item Code
U.P.C./EAN Case Code (2-5-5)
U.P.C. Consumer Package Code (1-5-5)
EAN/UCC - 14
Description: Data structure for the 14 digit EAN.UCC (EAN International.Uniform
Code Council) Global Trade Identification Number (GTIN)
UCC - 12
Description: Data structure for the 12 digit EAN.UCC (EAN International.Uniform
Code Council) Global Trade Identification Number (GTIN). Also known as the
Universal Product Code (U.P.C.)
Universal Product Number
Description: A unique identifier of a healthcare product
Vendor's (Seller's) Catalog Number
Product/Service ID
M
AN
1/48
Must use
Description: Identifying number for a
product or service
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
1
Page 24
Syntax Rules:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
P0405 - If either LIN04 or LIN05 is present, then the other is required.
P0607 - If either LIN06 or LIN07 is present, then the other is required.
P0809 - If either LIN08 or LIN09 is present, then the other is required.
P1011 - If either LIN10 or LIN11 is present, then the other is required.
P1213 - If either LIN12 or LIN13 is present, then the other is required.
P1415 - If either LIN14 or LIN15 is present, then the other is required.
P1617 - If either LIN16 or LIN17 is present, then the other is required.
P1819 - If either LIN18 or LIN19 is present, then the other is required.
P2021 - If either LIN20 or LIN21 is present, then the other is required.
P2223 - If either LIN22 or LIN23 is present, then the other is required.
P2425 - If either LIN24 or LIN25 is present, then the other is required.
P2627 - If either LIN26 or LIN27 is present, then the other is required.
P2829 - If either LIN28 or LIN29 is present, then the other is required.
P3031 - If either LIN30 or LIN31 is present, then the other is required.
Semantics:
1. LIN01 is the line item identification
Comments:
1. See the Data Dictionary for a complete list of IDs.
2. LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No.,
U.P.C. No., ISBN No., Model No., or SKU.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 25
Pos: 1400
Max: 10
Detail - Optional
Loop: PAD
Elements: 3
Request Validation
AAA
User Option (Usage): Optional
Purpose: To specify the validity of the request and indicate follow-up action authorized
Element Summary:
Ref
AAA01
Id
1073
Element Name
Yes/No Condition or Response Code
Req
M
Type
ID
Min/Max
1/1
Usage
Must use
Rep
1
O
ID
2/2
Optional
1
2/2
Optional
1
Description: Code indicating a Yes or No
condition or response
Code
N
AAA02
559
Name
No
Agency Qualifier Code
Description: Code identifying the agency
assigning the code values
Code
DR
AAA03
901
Name
National Wholesale Druggists Association
Reject Reason Code
O
ID
Description: Code assigned by issuer to
identify reason for rejection
Code
14
A1
A2
A3
A4
A5
AA
BB
CC
DD
Name
Invalid part number
Code Usage:
Missing or Invalid EPC Serial number.
Insufficient Wholesaler Inventory
Code Usage:
Product quantity in chargeback claim exceeds known quantity in distributor’s
inventory. (Invalid claim - do not resubmit)
Line Item Too Old
Code Usage:
Requested claim on this item is past the allowable chargeback submission
period. (Invalid claim - do not resubmit)
Quantity Invalid - Free Goods
Code Usage:
Chargeback was requested on free goods items. (Corrected by manufacturer - do
not resubmit)
Rebill Without Offsetting Credit
Code Usage:
Chargeback is for re-billed goods for which no offsetting credit has been received
from the distributor. (Correct and resubmit)
Minimum Order Quantity not met
Rebill Without Offsetting Credit
Contract Number Incorrect
Code Usage:
Contract number supplied does not match any valid number in manufacturer file.
Contract Expired
Code Usage:
Invoice date after contract expiration date.
Contract Not Yet In Force
Code Usage:
Invoice date occurred before contract start date.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 26
EE
FF
GG
HH
II
JJ
KK
LL
MM
NN
OO
PP
QQ
RI
RR
SS
TT
Invoice Date Missing or Invalid
Code Usage:
Invoice date for chargeback claim not supplied or invalid.
Customer Not Covered
Code Usage:
Manufacturer has no record of contract with this customer.
Customer Expired
Code Usage:
Customer dropped from contract before invoice date.
Customer Not Yet Eligible
Code Usage:
Invoice date precedes inclusion of customer on contract.
Customer DEA Number, Referenced ID, or Address Missing
Code Usage:
DEA number, customer referenced ID or name/address required to identify
customer is missing.
Customer DEA Number, Referenced ID, or Address Invalid
Code Usage:
Unable to identify customer, DEA number, customer referenced ID, or
name/address invalid.
Drug Not Covered
Code Usage:
Drug for this chargeback not covered on this contract.
Drug Expired
Code Usage:
Drug dropped from contract before invoice date.
Drug Not Yet Eligible
Code Usage:
Invoice date precedes date of inclusion of drug on this contract.
Drug Number Missing or Invalid
Code Usage:
Drug number not submitted or unable to identify.
Wholesaler Not Covered
Code Usage:
Manufacturer has no record of inclusion of this distributor on this contract.
Wholesaler Expired
Code Usage:
Distributor dropped from this contract.
Wholesaler Not Yet Eligible
Code Usage:
Invoice date precedes date of inclusion of this distributor on this contract.
Invalid Resubmit Number
Code Usage:
Resubmit number does not match any resubmit number assigned or does not
match most recent resubmit number assigned.
Quantity Invalid or Not Supplied
Code Usage:
Quantity on invoice invalid or not supplied as required.
Contract Price Missing or Incorrect
Code Usage:
Contract price not supplied or incorrect.
Contract Price Inserted or Corrected
Code Usage:
Contract price was missing or incorrect, but was adjusted to be correct.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 27
UU
VV
WW
XX
YY
Unit Cost Missing or Incorrect
Code Usage:
Unit contract cost missing or incorrect.
Unit Cost Inserted or Corrected
Code Usage:
Unit contract price was missing or incorrect, but was adjusted to be correct.
Extended Amount Incorrect
Code Usage:
Extended chargeback amount incorrect.
Extended Amount Corrected
Code Usage:
Extended chargeback amount was incorrect, but was adjusted to be correct.
Duplicate Chargeback Request
Code Usage:
Manufacturer has record of previous claim on this invoice.
Semantics:
1. AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the
code is invalid.
Comments:
1. If AAA02 is used, AAA03 contains a code from an industry code list.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 28
Pos: 1700
Max: 5
Detail - Optional
Loop: PAD
Elements: 3
Unit Detail
UIT
User Option (Usage): Optional
Purpose: To specify item unit data
Element Summary:
Ref
UIT01
Id
C001
Element Name
Composite Unit of Measure
Req
M
Type
Comp
Min/Max
Usage
Must use
Rep
1
M
ID
2/2
Must use
1
X
R
1/17
Optional
1
O
ID
2/2
Optional
1
Description: To identify a composite unit
of measure (See Figures Appendix for
examples of use)
UIT01-01
355
Unit or Basis for Measurement Code
Description: Code specifying the units in
which a value is being expressed, or
manner in which a measurement has
been taken
Code
UN
UIT02
212
Name
Unit
Unit Price
Description: Price per unit of product,
service, commodity, etc.
UIT03
639
Basis of Unit Price Code
Description: Code identifying the type of
unit price for an item
Code
CT
SC
SW
WH
Name
Contract
Submitted Contract
Submitted Wholesale
Wholesale
Syntax Rules:
1. C0302 - If UIT03 is present, then UIT02 is required.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 29
Pos: 1800
Max: 5
Detail - Optional
Loop: PAD
Elements: 2
Quantity
QTY
User Option (Usage): Optional
Purpose: To specify quantity information
Segment Usage:
Two occurrences of this QTY segment at the Detail level in the CON/PAD loop are required if the quantity sold submitted by
the distributor is in error—one to provide the submitted quantity sold and the other to provide the quantity sold (the valid
value corrected by the manufacturer). The same holds true if the quantity of returns submitted by the distributor is in
error.
Element Summary:
Ref
QTY01
Id
673
Element Name
Quantity Qualifier
Req
M
Type
ID
Min/Max
2/2
Usage
Must use
Rep
1
R
1/15
Optional
1
Description: Code specifying the type of
quantity
Code
32
76
83
84
QTY02
380
Name
Quantity Sold
Returns
Submitted Quantity Sold
Submitted Quantity Returned
Quantity
X
Description: Numeric value of quantity
Syntax Rules:
1. R0204 - At least one of QTY02 or QTY04 is required.
2. E0204 - Only one of QTY02 or QTY04 may be present.
Semantics:
1. QTY04 is used when the quantity is non-numeric.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 30
Pos: 1900
Max: 2
Detail - Optional
Loop: PAD
Elements: 2
Monetary Amount
AMT
User Option (Usage): Optional
Purpose: To indicate the total monetary amount
Segment Usage:
AMT segments for the Adjusted Chargeback Claim Amount and the Submitted Chargeback Claim Amount are required.
Element Summary:
Ref
AMT01
Id
522
Element Name
Amount Qualifier Code
Req
M
Type
ID
Min/Max
1/3
Usage
Must use
Rep
1
1/18
Must use
1
Description: Code to qualify amount
Code
A
S
AMT02
782
Name
Adjusted Chargeback Claim Amount
Submitted Chargeback Claim Amount
Monetary Amount
M
R
Description: Monetary amount
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 31
Pos: 2100
Max: 12
Detail - Optional
Loop: PAD
Elements: 3
Reference Identification
REF
User Option (Usage): Optional
Purpose: To specify identifying information
Segment Usage:
This REF segment at the Detail Level of the CON/PAD loop is required to provide the
distributor invoice number. REF01 and REF02 must be present.
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Must use
Rep
1
Description: Code qualifying the
Reference Identification
Code
DI
L1
8X
REF02
127
Name
Distributor Invoice Number
Letters or Notes
Code Usage:
This code would qualify any optional notes and comments pertaining to an
original or resubmitted chargeback line and should be placed in REF03.
Transaction Category or Type
Code Usage:If 8X is used in REF01, it will override BRC01.
Reference Identification
X
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
Element Usage: If 8X is used in REF01, use
‘00’ for original
'15' for resubmission
'18' for credit/rebill with original
'41' for credit/rebill with no original
REF03
352
Description
X
Description: A free-form description to clarify the related data elements and their content
Element Usage: This element can also contain any optional notes or comments pertaining to an
original or resubmitted line on a chargeback as qualified in REF01.
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 32
Pos: 2200
Max: 10
Detail - Optional
Loop: PAD
Elements: 2
Date/Time Reference
DTM
User Option (Usage): Optional
Purpose: To specify pertinent dates and times
Segment Usage:
This DTM segment at the Detail Level in the CON/PAD loop is required to provide the
distributor invoice date. DTM01 and DTM02 must be present.
Element Summary:
Ref
DTM01
Id
374
Element Name
Date/Time Qualifier
Req
M
Type
ID
Min/Max
3/3
Usage
Must use
Rep
1
X
DT
8/8
Optional
1
Description: Code specifying type of
date or time, or both date and time
Code
003
008
DTM02
373
Name
Invoice
Purchase Order Received
Date
Description: Date expressed as
CCYYMMDD where CC represents the
first two digits of the calendar year
Element Usage: Because an 844 can
be sent to a manufacturer a second
time when a distributor customer is rebilled due to a contract price
discrepancy, it is strongly
recommended that this date be
derived from the original date of sale
rather than the invoice date.
Syntax Rules:
1. R020305 - At least one of DTM02, DTM03 or DTM05 is required.
2. C0403 - If DTM04 is present, then DTM03 is required.
3. P0506 - If either DTM05 or DTM06 is present, then the other is required.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 33
Pos: 0100
Max: 1
Summary - Mandatory
Loop: N/A
Elements: 1
Transaction Totals
CTT
User Option (Usage): Must use
Purpose: To transmit a hash total for a specific element in the transaction set
Element Summary:
Ref
CTT01
Id
354
Element Name
Number of Line Items
Req
M
Type
N0
Min/Max
1/6
Usage
Must use
Description: Total number of line items
in the transaction set
Syntax Rules:
1. P0304 - If either CTT03 or CTT04 is present, then the other is required.
2. P0506 - If either CTT05 or CTT06 is present, then the other is required.
Comments:
1. This segment is intended to provide hash totals to validate transaction completeness and correctness.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Rep
1
Page 34
Pos: 0200
Max: 5
Summary - Optional
Loop: N/A
Elements: 2
Monetary Amount
AMT
User Option (Usage): Must use
Purpose: To indicate the total monetary amount
Segment Usage:
This AMT segment at the Summary Level is required to provide the total amount of the chargeback reconciliation credit
memo. AMT01 and AMT02 must be present. This segment must be sent twice (once for each code in AMT01).
Element Summary:
Ref
AMT01
Id
522
Element Name
Amount Qualifier Code
Req
M
Type
ID
Min/Max
1/3
Usage
Must use
Rep
1
1/18
Must use
1
Description: Code to qualify amount
Element Usage: Submitted
Chargeback Claim Amount is equal to
the value of the chargeback claim
amount at the Summary level in the
844 — which was submitted by the
distributor to the manufacturer.
Adjusted Chargeback Claim Amount is
equal to the value of the credit memo
issued by the manufacturer.
Code
A
S
NA
AMT02
782
Name
Adjusted Chargeback Claim Amount
Submitted Chargeback Claim Amount
Net Adjustment
Monetary Amount
M
R
Description: Monetary amount
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 35
Pos: 0300
Max: 1
Summary - Mandatory
Loop: N/A
Elements: 2
Transaction Set Trailer
SE
User Option (Usage): Must use
Purpose: To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST)
and ending (SE) segments)
Element Summary:
Ref
SE01
Id
96
Element Name
Number of Included Segments
Req
M
Type
N0
Min/Max
1/10
Usage
Must use
Rep
1
M
AN
4/9
Must use
1
Description: Total number of segments
included in a transaction set including ST
and SE segments
SE02
329
Transaction Set Control Number
Description: Identifying control number
that must be unique within the transaction
set functional group assigned by the
originator for a transaction set
Comments:
1. SE is the last segment of each transaction set.
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 36
Business Case Examples
849 Response to Product Transfer Account Adjustment (Chargeback Reconciliation)
Example 1: Reconciliation of Chargeback with pricing error
The manufacturer, Street Pharmaceuticals, is sending to the distributor, Mountain Wholesale Drug, an 849 response to Product
Transfer Account Adjustment (Chargeback Reconciliation). This transaction set is being sent in response to the 844 chargeback
transaction that contains information pertaining to the sale of products to eligible customers at contract prices thereby entitling the
distributor to a credit from the manufacturer. The manufacturer has found that the chargeback submitted by the distributor contains an
error. The chargeback was submitted with 3 line items. Two line items were accepted, therefore no detail was returned. One line item
contained an error and was sent back with the reject reason code. A resubmit number was also included along with the original line
number from the previously received 844 for the line in error. Detail information in this chargeback reconciliation identifies the error.
Note: The chargeback line number is LIN segment. The EPC numbers from the 844 are not required to be sent back on the
corresponding 849. Comments from the manufacturer are identified REF segment prior to the DTM segment.
The pertinent information is summarized below:
Reconciliation Process Date
Chargeback Reconciliation/
Credit Memo Number
Chargeback/Debit Memo Number
Debit Memo Resubmit ID
Manufacturer
Manufacturer ID
Distributor
Distributor ID
Contract
Customer ID
Name
Chargeback Line number
Item Number
Description
Reject Reason Code
Comments
Quantity
Wholesale Cost
Submitted Contract Cost
Adjusted Contract Cost
Submitted Chargeback Claim
Adjusted Chargeback Claim
Invoice Number
Pricing Date
Total Chargeback Claim
Total Adjusted Claim
01/10/2008
PB123
CB09096P30
596034549
Street Pharmaceuticals
0123456000001
Mountain Wholesale Drug
0056789000001
9898
340B657800
Riverside Community Hospital
3
NDC 00333-3333-33
Tetracycline
TT (contract price corrected by manufacturer)
contract price incorrect for this contract
1
$8.95
$7.50
$8.90
$1.95
$0.05
I117305
12/27/2007
$3.37
$1.47
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 37
Sequential Segment Layout
The following is a narrative of each segment as it appears in the transmission file. The number on
the far left corresponds to the segment number.
Seg. #
Segment Name
Data Values
1
ST01
ST02
TRANSACTION SET HEADER
Transaction Set ID Code
Transaction Set Control Number
ST
849
0005
2
BRC01
BRC02
BRC03
BRC04
BEGINNING SEGMENT
Transaction Set Purpose Code (Original)
Date (CCYYMMDD)
Reference Number Qualifier (Credit Memo Number)
Reference Number
BRC
00
20080110
CM
PB123
3
REF01
REF02
REFERENCE NUMBERS
Reference Number Qualifier (Chargeback)
Reference Number
REF
AM
CB09096P30
4
REF01
REF02
REFERENCE NUMBERS
Reference Number Qualifier (Resubmit Number)
Reference Number
REF
RX
596034549
5
N101
N103
N104
NAME
Entity ID (Supplier/Manufacturer)
ID Code Qualifier (HIN)
ID Code
N1
SU
UL
6
N101
N102
N103
NAME
Entity ID Code (Wholesaler/Distributor)
ID Code Qualifier (HIN)
ID Code
N1
DS
UL
7
CON01
CON02
CON03
CONTRACT NUMBER DETAIL
Reference Number Qualifier (Vendor Contract No.)
Reference Number
Contract Status Code (Valid Open Contract)
CON
VC
9898
VA
8
N101
N103
N104
NAME
Entity ID (Ship To)
ID Code Qualifier (340B Id)
ID Code
N1
ST
PI
340B657800
9
PAD01
PRODUCT ADJUSTMENT DETAIL
Assigned Identification
PAD
1
10
LIN01
LIN02
LIN03
ITEM IDENTIFICATION
Assigned Identification Number (chargeback line#)
Product/Service Qualifier (NDC)
Product/Service ID
LIN
00003 “Chargeback line number”
N4
00333333333
11
AAA01
AAA02
AAA03
REQUEST VALIDATION
Validity Code (No)
Item Description Qualifier (HDMA Industry Code)
Reject Reason Code
AAA
N
DR
TT
12
UIT01
UIT02
UIT03
UNIT DETAIL
Unit of Measure Code
Unit Price
Basis of Unit Price Code (Submitted Wholesale)
UIT
UN
8.95
SW
0123456000001
0056789000001
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 38
13
UIT01
UIT02
UIT03
UNIT DETAIL
Unit of Measure Code
Unit Price
Basis of Unit Price Code (Actual Wholesale)
UIT
UN
8.95
WH
14
UIT01
UIT02
UIT03
UNIT DETAIL
Unit of Measure Code
Unit Price
Basis of Unit Price Code (Submitted Contract)
UIT
UN
7.00
SC
15
UIT01
UIT02
UIT03
UNIT DETAIL
Unit of Measure Code
Unit Price
Basis of Unit Price Code (Actual Contract)
UIT
UN
8.90
CT
16
QTY01
QTY02
QUANTITY
Quantity Qualifier (Submitted Quantity Sold)
Quantity
QTY
83
1
17
QTY01
QTY02
QUANTITY
Quantity Qualifier (Actual Quantity Sold)
Quantity
QTY
32
1
18
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Submitted Chargeback Claim)
Monetary Amount
AMT
S
1.95
19
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Adjusted Chargeback Claim)
Monetary Amount
AMT
A
0.05
20
REF01
REF02
REFERENCE NUMBERS
Reference Number Qualifier (Distributor Invoice)
Reference Number
REF
DI
I117305
21
REF01
REF03
REFERENCE NUMBERS
Reference Number Qualifier (notes)
Reference Description
REF
L1
contract price incorrect for this contract
22
DTM01
DTM02
DATE/TIME REFERENCE
Date/Time Qualifier (Pricing Date)
Date (CCYYMMDD)
DTM
003
20071227
23
CTT01
TRANSACTION TOTALS
Number of Line Items (CON Segments)
CTT
1
24
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Submitted Chargeback Claim)
Monetary Amount
AMT
S
3.37
25
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Adjusted Chargeback Claim)
Monetary Amount
AMT
A
1.47
26
SE01
SE02
TRANSACTION SET TRAILER
Number of Included Segments
Transaction Set Control Number
SE
23
0005
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 39
Transmission File
Seg.#
Segment Data
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
ST*849*0005\
BAA*00*20080110*CM*PB123\
REF*AM*CB09096P30\
REF*RX*596034549\
N1*SU**UL*0123456000001\
N1*DS**UL*0056789000001\
CON*VC*9898*VA\
N1*ST**PI21*340B657800\
PAD*1\
LIN*00003*N4*00333333333\
AAA*N*DR*TT\
UIT*UN*8.95*SW\
UIT*UN*8.95*WH\
UIT*UN*7*SC\
UIT*UN*8.9*CT\
QTY*83*1\
QTY*32*1\
AMT*S*1.95\
AMT*A*.05\
REF*DI*I117305\
REF*L1**contract price incorrect for this contract\
DTM*003*20071227\
CTT*1\
AMT*S*3.37\
AMT*A*1.47\
SE*23*0005\
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 40
849 Response to Product Transfer Account Adjustment (Chargeback Reconciliation)
Example 2: Reconciliation of Chargeback without errors
The manufacturer, Street Pharmaceuticals, is sending to the distributor, Mountain Wholesale Drug, an 849 response to Product
Transfer Account Adjustment (Chargeback Reconciliation). This transaction set is being sent in response to the 844 chargeback
transaction that contains information pertaining to the sale of products to eligible customers at contract prices thereby entitling the
distributor to a credit from the manufacturer. This business example shows Chargeback/Debit Memo CB09096P30, resubmission
596034549 to have no errors. The submitted chargeback claim of the resubmission from Mountain Wholesale equals the credit memo
amount paid by Street Pharmaceuticals. Since there are no errors to correct, this 849 transaction does not require detail information
about the individual sales to the eligible customers.
The pertinent information is summarized below:
Reconciliation Process Date
Chargeback Reconciliation/
Credit Memo Number
Chargeback/Debit Memo Number
Debit Memo Resubmit ID
Manufacturer
Manufacturer ID
Distributor
Distributor ID
Total Chargeback Claim
Total Adjusted Claim
02/20/2008
PB135
CB09096P30
596034549
Street Pharmaceuticals
0123456000001
Mountain Wholesale Drug
0056789000001
$1.90
$1.90
Sequential Segment Layout
The following is a narrative of each segment as it appears in the transmission file. The number on
the far left corresponds to the segment number.
Seg. #
Segment Name
Data Values
1
ST01
ST02
TRANSACTION SET HEADER
Transaction Set ID Code
Transaction Set Control Number
ST
849
0009
2
BRC01
BRC02
BRC03
BRC04
BEGINNING SEGMENT
Transaction Set Purpose Code (Original)
Date (CCYYMMDD)
Reference Number Qualifier (Credit Memo Number)
Reference Number
BRC
00
20080220
CM
PB135
3
REF01
REF02
REFERENCE NUMBERS
Reference Number Qualifier (Chargeback)
Reference Number
REF
AM
CB09096P30
4
REF01
REF02
REFERENCE NUMBERS
Reference Number Qualifier (Resubmit Number)
Reference Number
REF
RX
596034549
5
N101
N103
N104
NAME
Entity ID (Supplier/Manufacturer)
ID Code Qualifier (HIN)
ID Code
N1
SU
UL
0123456000001
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 41
6
N101
N102
N103
NAME
Entity ID Code (Wholesaler/Distributor)
ID Code Qualifier (HIN)
ID Code
N1
DS
UL
7
CTT01
TRANSACTION TOTALS
Number of Line Items (CON Segments)
CTT
0
8
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Submitted Chargeback Claim)
Monetary Amount
AMT
S
1.90
9
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Adjusted Chargeback Claim)
Monetary Amount
AMT
A
1.90
10
SE01
SE02
TRANSACTION SET TRAILER
Number of Included Segments
Transaction Set Control Number
SE
7
0009
0056789000001
Transmission File
Seg.#
Segment Data
1
2
3
4
5
6
7
8
9
10
ST*849*0009\
BAA*00*20080110*CM*PB135\
REF*AM*CB09096P30\
REF*RX*596034549\
N1*SU**UL*0123456000001\
N1*DS**UL*0056789000001\
CTT*0\
AMT*S*1.90\
AMT*A*1.90\
SE*7*0009\
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 42
849 Response to Product Transfer Account Adjustment (Chargeback Reconciliation)
Example 3: Basic Alternative Model with all transactions within one Debit Memo with errors
The manufacturer, Street Pharmaceuticals, is sending to the distributor, Mountain Wholesale Drug, an 849 response to Product
Transfer Account Adjustment (Chargeback Reconciliation). This transaction set is being sent in response to the 844 chargeback
transaction that contains information pertaining to the sale of products to eligible customers at contract prices thereby entitling the
distributor to a credit from the manufacturer. The manufacturer has found that the chargeback submitted by the distributor contains
errors.
The chargeback was submitted with 7 line items. Five line items were accepted, therefore no detail was returned. Two line items
contained errors and were sent back with the appropriate reject reason code. A resubmit number was included along with the original
line number from the previously received 844 for the lines in error. Detail information in this chargeback reconciliation identifies the
errors.
Note: The chargeback line number is in the LIN segment. The EPC numbers from the 844 are not required to be sent back on the
corresponding 849. Comments from the manufacturer are identified in the REF segment prior to the DTM segment. Header code ‘45’ in
BRC segment used to direct to line level detail for transaction type identification
The pertinent information is summarized below:
Reconciliation Process Date
Chargeback Reconciliation/Credit Memo Number
Chargeback/Debit Memo Number
Debit Memo Resubmit ID
Manufacturer
Manufacturer ID (GLN)
Wholesaler
Wholesaler ID (GLN)
02/25/2008
PB789
CB09096S60
599124560
Street Pharmaceuticals
0123456000001
Mountain Wholesale Drug
0089456870001
Transaction Type
Contract
Customer ID (340B ID)
Customer ID (HIN)
Name
Chargeback Line number
Item Number
Description
Reject Reason Code
Comments
Quantity
Submitted Wholesale Cost
Submitted Contract Cost
Adjusted Contract Cost
Submitted Chargeback Claim
Adjusted Chargeback Claim
Invoice Number
Pricing Date
Original
9898
340B657800
HIN876500
Riverside Community Hospital
5
NDC 00333-3333-33
Tetracycline
TT (contract price corrected by manufacturer)
contract price incorrect for this contract
1
$8.95
$7.00
$8.90
$1.95
$0.05
I117305
12/27/2007
Transaction Type
Contract
Customer ID (340B ID)
Customer ID (HIN)
Name
Chargeback Line number
Item Number
Description
Reject Reason Code
Comments
Quantity
Submitted Wholesale Cost
Credit/Rebill with no original chargeback (off contract sale)
9898
340B657800
HIN876500
Riverside Community Hospital
6
NDC 00333-5555-55
Codeine Plus
KK (drug not covered)
product never on contract, credit/rebill should not have been done
2
$3.98
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 43
Submitted Contract Cost
Submitted Chargeback Claim
Adjusted Chargeback Claim
Invoice Number
Pricing Date
Total Chargeback Claim
Total Adjusted Claim
$3.00
$1.96
$0.00
I030973
10/15/2007
$8.03
$4.17
Sequential Segment Layout
The following is a narrative of each segment as it appears in the transmission file. The number on
the far left corresponds to the segment number.
Seg. #
Segment Name
Data Values
1
ST01
ST02
TRANSACTION SET HEADER
Transaction Set ID Code
Transaction Set Control Number
ST
849
0011
2
BRC01
BRC02
BRC03
BRC04
BEGINNING SEGMENT
Transaction Set Purpose Code (Follow Up)
Date (CCYYMMDD)
Reference Number Qualifier (Credit Memo Number)
Reference Number
BAA
45
20080225
CM
PB789
3
REF01
REF02
REFERENCE NUMBERS
Reference Number Qualifier (Chargeback)
Reference Number
REF
AM
CB09096S60
4
REF01
REF02
REFERENCE NUMBERS
Reference Number Qualifier (Resubmit number)
Reference Number
REF
RX
599124560
5
N101
N103
N104
NAME
Entity ID (Supplier/Manufacturer)
ID Code Qualifier (GLN)
ID Code
N1
SU
UL
0123456000001
6
N101
N103
N104
NAME
Entity ID Code (Wholesaler/Distributor)
ID Code Qualifier (GLN)
ID Code
N1
DS
UL
0089456870001
7
CON01
CON
VC
CON02
CON03
CONTRACT NUMBER DETAIL
Reference Number Qualifier
(Vendor Contract Number)
Reference Number
Contract Status Code (Valid Open Contract)
9898
VA
8
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (340B ID)
ID Code
N1
ST
PI
340B657800
9
REF01
REF02
REFERENCE INDENTIFICATION
Reference ID Qualifier (Ship to HIN)
Reference ID (HIN number)
REF
HI
HIN876500
10
PAD01
PRODUCT ADJUSTMENT DETAIL
Assigned Identification
PAD
1
11
LIN01
LIN02
LIN03
ITEM IDENTIFICATION
Assigned Identification Number (chargeback line#)
Product/Service Qualifier (NDC)
Product/Service ID
LIN
000005 “Chargeback line number”
N4
00333333333
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 44
12
AAA01
AAA02
AAA03
REQUEST VALIDATION
Validity Code (No)
Item Description Qualifier (HDMA Industry Code)
Reject Reason Code
AAA
N
DR
TT
13
UIT01
UIT02
UIT03
UNIT DETAIL
Unit of Measure Code
Unit Price
Basis of Unit Price Code (Submitted Wholesale)
UIT
UN
8.95
SW
14
UIT01
UIT02
UIT03
UNIT DETAIL
Unit of Measure Code
Unit Price
Basis for Unit Price Code (Adjusted Wholesale)
UIT
UN
8.95
WH
15
UIT01
UIT02
UIT03
UNIT DETAIL
Unit of Measure Code
Unit Price
Basis of Unit Price Code (Submitted Contract)
UIT
UN
7.00
SC
16
UIT01
UIT02
UIT03
UNIT DETAIL
Unit of Measure Code
Unit Price
Basis for Unit Price Code (Adjusted Contract)
UIT
UN
8.90
CT
17
QTY01
QTY02
QUANTITY
Quantity Qualifier (Submitted Quantity Sold)
Quantity
QTY
83
1
18
QTY01
QTY02
QUANTITY
Quantity Qualifier (Adjusted Quantity Sold)
Quantity
QTY
32
1
19
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Submitted Chargeback Claim)
Monetary Amount
AMT
S
1.95
20
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Submitted Chargeback Claim)
Monetary Amount
AMT
A
0.05
21
REF01
REF02
REFERENCE NUMBERS
Reference Number Qualifier (Distributor Invoice)
Reference Description
REF
DI
I117305
22
REF01
REF03
REFERENCE NUMBERS
Reference Number Qualifier (comments)
Reference Description
REF
L1
contract price incorrect for this contract
23
REF01
REF02
REFERENCE NUMBERS
Reference Number Qualifier (transaction type)
Reference Description (original)
REF
8X
00
24
DTM01
DATE/TIME REFERENCE
Date/Time Qualifier (Pricing Date)
DTM
20071227
25
CON01
CON
VC
CON02
CON03
CONTRACT NUMBER DETAIL
Reference Number Qualifier
(Vendor Contract Number)
Reference Number
Contract Status Code (Valid Open Contract)
9898
VA
26
N101
N103
N104
NAME
Entity ID Code (Ship To)
ID Code Qualifier (340B ID)
ID Code
N1
ST
PI
340B657800
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 45
27
REF01
REF02
REFERENCE INDENTIFICATION
Reference ID Qualifier (Ship to HIN)
Reference ID (HIN number)
REF
HI
HIN876500
28
PAD01
PRODUCT ADJUSTMENT DETAIL
Assigned Identification
PAD
1
29
LIN01
LIN02
LIN03
ITEM IDENTIFICATION
Assigned Identification Number (chargeback line#)
Product/Service Qualifier (NDC)
Product/Service ID
LIN
000006 “Chargeback line number”
N4
00333555555
30
AAA01
AAA02
AAA03
REQUEST VALIDATION
Validity Code (No)
Item Description Qualifier (HDMA Industry Code)
Reject Reason Code
AAA
N
DR
KK
31
UIT01
UIT02
UIT03
UNIT DETAIL
Unit of Measure Code
Unit Price
Basis of Unit Price Code (Submitted Wholesale)
UIT
UN
3.98
SW
32
UIT01
UIT02
UIT03
UNIT DETAIL
Unit of Measure Code
Unit Price
Basis for Unit Price Code (Adjusted Wholesale)
UIT
UN
0.00
WH
33
UIT01
UIT02
UIT03
UNIT DETAIL
Unit of Measure Code
Unit Price
Basis of Unit Price Code (Submitted Contract)
UIT
UN
3.00
SC
34
UIT01
UIT02
UIT03
UNIT DETAIL
Unit of Measure Code
Unit Price
Basis for Unit Price Code (Adjusted Contract)
UIT
UN
0.00
CT
35
QTY01
QTY02
QUANTITY
Quantity Qualifier (Submitted Quantity Sold)
Quantity
QTY
83
2
36
QTY01
QTY02
QUANTITY
Quantity Qualifier (Adjusted Quantity Sold)
Quantity
QTY
32
2
37
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Submitted Chargeback Claim)
Monetary Amount
AMT
S
1.96
38
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Submitted Chargeback Claim)
Monetary Amount
AMT
A
0.00
39
REF01
REF02
REFERENCE NUMBERS
Reference Number Qualifier (Distributor Invoice)
Reference Description
REF
DI
I030973
40
REF01
REF03
REFERENCE NUMBERS
Reference Number Qualifier (comments)
Reference Description
REF
L1
product never on contract,
credit/rebill should not have been done
41
REF01
REF02
REFERENCE NUMBERS
Reference Number Qualifier (transaction type)
Reference Description (credit/rebill with no orig.)
REF
8X
41
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 46
42
DTM01
DATE/TIME REFERENCE
Date/Time Qualifier (Pricing Date)
DTM
20071015
43
CTT01
TRANSACTION TOTALS
Number of Line Items (CON segments)
CTT
2
44
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Submitted Chargeback Claim)
Monetary Amount
AMT
S
8.03
45
AMT01
AMT02
MONETARY AMOUNT
Amount Qualifier (Adjusted Chargeback Claim)
Monetary Amount
AMT
A
4.17
46
SE01
SE02
TRANSACTION SET TRAILER
Number of Included Segments
Transaction Set Control Number
SE
43
0011
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Page 47
Transmission File
Seg.#
Segment Data
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
ST*849*0011\
BRC*45*20080225*CM*PB789\
REF*AM*CB09096S60\
REF*RX*599124560\
N1*SU***UL*0123456000001\
N1*DS***UL*0089456870001\
CON*VC*9898*VA\
N1*ST**PI*340B657800\
REF*HI*HIN876500\
PAD*1\
LIN*000005*N4*00333333333\
AAA*N*DR*TT\
UIT*UN*8.95*SW\
UIT*UN*8.95*WH\
UIT*UN*7.00*SC\
UIT*UN*8.90*CT\
QTY*83*1\
QTY*32*1\
AMT*S*1.95\
AMT*A*0.05\
REF*DI*I117305\
REF*L1**contract price incorrect for this contract\
REF*8X*00\
DTM*20071227\
CON*VC*9898*VA\
N1*ST**PI*340B657800\
REF*HI*HIN876500\
PAD*1\
LIN*000006*N4*00333555555\
AAA*N*DR*KK\
UIT*UN*3.98*SW\
UIT*UN*0.00*WH\
UIT*UN*3.00*SC\
UIT*UN*0.00*CT\
QTY*83*2\
QTY*32*2\
AMT*S*1.96\
AMT*A*0.00\
REF*DI*I030973\
REF*L1**product never on contract creditrebill should not have been done
REF*8X*41\
DTM*20071015\
CTT*2\
AMT*S*8.03\
AMT*A*4.17\
SE*43*0011\
849 Response to Product Transfer Account Adjustment for Electronic Data Interchange (EDI)
ASC X12 Version/Release 004010
Healthcare Distribution Management Association (HDMA)
901 North Glebe Road, Suite 1000
Arlington, VA 22203
Phone: 703/787-0000 Fax: 703/935-3200
www.HealthcareDistribution.org
845
849
844