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DATA ELEMENT REQUEST FORM (DERF)/EXTERNAL CODE LIST (ECL) DERF #: FINAL DERF RESOLUTION ECL #: DERF ECL Emergency ECL RECEIPT DATE: Approved – No Modifications WG MTG REVIEW DATE(S): Approved – With Modifications Denied Pended 1 2 3 (No further action) Withdrawn DERF/ECL INSTRUCTIONS Please refer to the following instructions when completing this DERF/ECL form. Use additional attachments when necessary to provide complete information. Incomplete forms will be returned for additional information prior to processing. This form is used for multiple purposes: 1) To add/modify a data element to the Data Dictionary, 2) To add/modify a data element value to the External Code List (ECL), 3) To add/modify information in a standard or implementation guide, 4) To bring forward a new standard or implementation guide. REFERENCES OTHER SDO DATA DICTIONARY (LIST SDO, STANDARD AND VERSION): NCPDP STANDARDS/IMPLEMENTATION GUIDES: INDICATE WHICH STANDARDS(S) ARE IMPACTED BY THIS REQUEST Audit Financial Information Reporting Post Adjudication Specialized Batch Formulary & Benefit Prescription File Transfer Subrogation Benefit Integration Manufacturer Rebates Prior Authorization Transfer Telecommunication Billing Unit Medicaid Subrogation Product Identifiers UCF/ WC UCF Data Dictionary Medical Rebates Retiree Drug Subsidy Uniform Healthcare Payer Data External Code List Pharmacy/Combo ID Card SCRIPT XML Standard DESCRIBE THE BUSINESS NEED OR PURPOSE ADDRESSED BY THIS DERF/ECL SUBMISSION (REQUIRED): This section should explain, in detail, what the requester would like changed, added, or deleted and the reasons why the modifications are necessary. The written explanation should give the readers an understanding as to what the requester is attempting to accomplish.

NEW DATA ELEMENT - Use this section to indicate the proposed field name, the size (length, including decimals, if applicable), and the format (e.g. numeric, alpha/numeric, dollar). Include a definition of the field. If applicable, every value/code requested must contain a definition. Specify the situation in which this new field would be used. Fill out Transaction Usage section next. Proposed Name or XML tag (required): Size (required): Format (required): Segment for the New Data Element (required for Telecom or XML-based standard): Definition (required): Codes/Values – every code/value must include a definition (Use attachments if necessary): (Staff will determine actual code or value) Value Suggested Value Description (required) Value Description Definition (as needed for Value Limitations (not clarity) required)

Number of Repetitions for New Data Element (required if repeating data element):

Reject Codes – Add new reject codes associated with the new data element. (Staff assigns all values and creates standard reject codes for new fields.) Value Suggested Value Description (required) Value Limitation or Explanation (not required)

CHANGE EXISTING DATA ELEMENT (ALL INFORMATION IS REQUIRED FOR CHANGES) To change a data element, complete this section, indicating the current Data Dictionary/ECL element information. For applicable standards, list the Field Number and ID from the Data Dictionary. Check what information is changing (e.g. field size (length), format (numeric, alpha/numeric, dollar), adding or changing a value, field name or definition). Summarize all changes that are being requested. Fill out Transaction Usage section next. Field Number : ID: Name or XML tag: Requested change to (choose at least one): Size Format Values Definition Name

Revised: August 2017 Page: 1 Limitations to change: (i.e. “Used in Versions XX and above.”) Summarize Proposed Changes (Use attachments if necessary): Codes/Values – every code/value change must include a definition (Use attachments if necessary): Value Suggested Value Description (required) Value Description Definition (as needed for Value Limitations (not clarity) required)

TELECOMMUNICATION STANDARD ONLY Reason for Emergency Change / Reference to REQUESTING EMERGENCY ECL CHANGE associated to Regulation or Legislation: Regulatory/Legislative Compliance EMERGENCY ECL REQUESTS PERTAIN ONLY TO THE TELECOMMUNICATION STANDARD. Used for regulatory and legislative changes which require the addition of a value(s) to be implemented prior to Date Needed By: the scheduled annual implementation date of the next ECL Publication. If (no earlier than 180 days from the ECL Publication) approved, the request will appear in the next ECL publication. There will be a minimum of 180 days required before the implementation of an emergency ECL change. Please refer to the Publication Release/ Implementation Dates Chart in the Emergency Telecommunication External Code List Value Addendum. TRANSACTION USAGE- Which transaction(s) is the field used in? (Use attachments if necessary): (required for Telecom or Batch Standard)

Standard Indicate Transaction(s)/File Used If Used, Situation must be provided. Audit Batch Financial Information Reporting Formulary and Benefit Manufacturer Rebates Medicaid Subrogation Medical Rebates Data Submission Post Adjudication Prescription File Transfer Retiree Drug Subsidy Prior Authorization Transfer SCRIPT NewRx RxRenewalRequest/Response RxFill RxFillIndicatorChange CancelRx CancelRxResponse GetMessage RxChangeRequest/Response RxHistory Request/ Response CancelRx and NewRx Resupply DrugAdministration NewRxRequest NewRxResponseDenied PAInitiationRequest/Response PARequest/Response PAAppealRequest/Response PACancelRequest/Response RxTransferRequest/Response RxTransferConfirm

Specialized Census MTMServiceRequest/Response

Revised: August 2017 Page: 2 MTMService Documentation ClinicalInfoRequest/Response CFInventoryList CFProductInquiry/Response CFRxOrderRequest CFRxOrderCompletion CFRxOrderCancel CFManifest

Telecommunication Eligibility Verification Claim Billing/Rebill/Encounter Service Billing/Rebill Predetermination of Benefits Claim Reversal Service Reversal Prior Authorization Request and Billing (Claim) Prior Authorization Request and Billing (Service) Prior Authorization Reversal (Claim) Prior Authorization Reversal (Service) Prior Authorization Inquiry Prior Authorization Request Only (Claim) Information Reporting/Rebill (Claim) Information Reporting/Rebill (Service) Information Reporting Reversal (Claim) Information Reporting Reversal (Service) Controlled Substance Reporting/ Rebill (specify non-prescription or general) Controlled Substance Reporting Reversal (specify non-prescription or general)

Uniform Healthcare Payer Data XML Standard (Required) Transport Transactions Error Status Verify Get Message Password Change (THIS SECTION MUST BE COMPLETED) SUBMITTER Name: Task Group submitting DERF (if applicable): Title: Fax: Company: email: Address: City/State/Zip: Phone: Signature: Date:

FOR MC MAINTENANCE AND CONTROL USE ONLY Work Groups that may be impacted (check all appropriate boxes): WG1 Telecommunication WG11 ePrescribing & Related Transactions WG2 Product Identification WG14 Long Term Post Acute Care WG3 Standard Identifiers WG16 Property and Casualty/Workers’ Compensation WG7 Manufacturer & Associated Trading Partner WG45 External Standards Assessment, Harmonization, and Implementation Guidance Transaction Standards WG9 Government Programs MC Maintenance and Control WG10 Professional Pharmacy Services Other Return completed form by email, mail or fax: NCPDP, 9240 E. Raintree Drive, Scottsdale, Arizona 85260-7519 Revised: August 2017 Page: 3 email [email protected]  fax (480) 767-1042  phone (480) 477-1000

This section is used by NCPDP Staff Only DERF MODIFICATIONS (Actions Taken by WG(s) Review) WG

DERF/ ECL STATUS:

Approved/Reviewed with no modifications Approved/Reviewed with modifications (complete modifications below) Pended by work group Reason: Denied by Work Group Withdrawn by submitter

Changed ECL to DERF (also check appropriate DERF status) Reason:

Vote Pink Yellow Green Total Approved Opposed

Modifications:

DERF/ ECL STATUS:

Approved/Reviewed with no further modifications Approved/Reviewed with further modifications (complete modifications below) Pended by work group Reason: Denied by Work Group Withdrawn by submitter Changed ECL to DERF (also check appropriate DERF status)

Vote Pink Yellow Green Total Approved Opposed

Modifications:

Revised: August 2017 Page: 4