Submit an NCPDP Telecom standard B1 claim transaction and process a B2 reversal for a pharmacy billing workflow

Steps

1. Build the NCPDP Telecom D.0 (or current version) B1 claim request: fixed-width or variable-length segments grouped into Transaction Header (Segment ID 'AM'), Insurance (Segment ID 'AM' group B1), Patient (Segment ID 'CA'), Claim (Segment ID '07'), Pricing (Segment ID '11'), and Prescriber (Segment ID '03') segments
2. Populate mandatory claim fields: NCPDP Provider ID (Field 201-B1), Date of Service (401-D1 CCYYMMDD), RxNumber (402-D2), Drug NDC (407-D7 in 11-digit format), Quantity Dispensed (442-E7), Days Supply (405-D5), Compound Code (406-D6), DAW Code (408-D8), and the primary payer BIN/PCN/Group from the insurance card
3. Submit the request to the PBM or payer switch via HTTPS or VPN-secured TCP; the response returns a header with Response Status (Field 501-F1): 'P' for paid, 'R' for rejected, 'D' for duplicate
4. On a 'P' response, parse the Pricing segment response fields: Ingredient Cost Paid (506-F6), Dispensing Fee Paid (507-F7), Patient Pay Amount (505-F5), and Other Payer Amount Recognized (565-J4) for copay calculation and patient receipt
5. For a B2 reversal, build a new transaction with Transaction Code 'B2': reuse the original claim's BIN/PCN, Service Provider ID, Date of Service, Rx Number, and Fill Number exactly; submit within the payer's reversal window (typically up to 30 days, but varies)
6. Confirm reversal with response status 'P' on the B2 transaction; a 'R' reversal rejection with reject code '88' (DUR reject) or '14' (M/I Date of Service) indicates a field mismatch with the original claim