Electronic Billing Services Inc & Signetic LLC – BIN 026480

Payer Sheet

Payer Name: Electronic Billing Services Inc & Signetic LLC	Date: 08/13/2025
Plan Name/Group Name:
Processor:	Switch: RelayHealth
Effective as of: 08/13/2025	Version: D.0
Certification Testing Window:
Provider Relations Help Desk Info: Electronic Billing Services, Inc. (573) 472-3613 Signetic LLC support@signetic.com
BIN: 026480 Carrier Group:	PCN: List provided by Signetic

“M” fields are ‘Mandatory’ for the Segment in the designated Transaction.

“O” fields are ‘Optional’- conditional based on data content- but may be made Mandatory by the Payer.

“R” fields are ‘Required’ for the Segment in the designated Transaction.

“RW” fields are ‘Required When’. The situations designated have qualifications for usage.

“Q” Qualified Requirement. The situations designated have qualifications for usage ("Required if x", "Not required if y").

CLAIM BILLING TRANSACTION

Transaction Header Segment (Mandatory)

Field#	NCPDP Field Name	Submit	Value	Comments
101-A1	BIN Number	M	026480	Signetic’s BIN number
102-A2	Version/Release Number	M	D0
103-A3	Transaction Code	M	B1 = Claim Billing
104-A4	Processor Control Number	M		Contains the Signetic specific PCN for the payer that is being billed. This list of possible codes are provided by Signetic and should be used. All other values will result in an exception.
109-A9	Transaction Count	M	1
202-B2	Service Provider ID Qualifier	M	01 = NPI
201-B1	Service Provider ID	M	10-digit NPI	Pharmacy NPI
401-D1	Date Of Service	M
110-AK	Software Vendor/Certification ID	M	Blank Fill

Insurance Segment (Mandatory)

Field#	NCPDP Field Name	Submit	Value	Comments
111-AM	Segment ID	M	04
302-C2	Cardholder ID	M
312-CC	Cardholder First Name	Rw
313-CD	Cardholder Last Name	Rw
306-C6	Patient Relationship Code	M
314-CE	Home Plan	O
524-F0	Plan ID	O
301-C1	Group ID	O
303-C3	Person Code	O	99 = Secondary Insurance

Patient Segment (Mandatory)

Field#	NCPDP Field Name	Submit	Value	Comments
111- AM	Segment ID	M	01
310-CA	Patient First Name	M
311-CB	Patient Last Name	M
332-CY	Patient ID	0
322- CM	Patient Street Address	M
323-CN	Patient City Address	M
324-CO	Patient State/Province Address	M
325-CP	Patient Postal Code	M
305-C5	Patient Gender Code	M	1 = Male 2 = Female
304-C4	Patient Date of Birth	M
331-CX	Patient ID Qualifier	O
326-CQ	Patient Phone Number	O
397-C7	Place of Service	M	Examples: 01 = pharmacy 11 = office 12 = home 13 = assisted living 14 = Group Hm 31 = SNF 32 = Nursing Facility 60 = Mass Immunize center 81 = Indep. Lab	Uses the standard CMS coding of 2 characters: https://www.cms.gov/medicare/coding-billing/place-of-service-codes/code-sets SEE NOTE BELOW

Service Facility Segment (Optional)

When the service is provided to the patient at a location OTHER THAN the provider’s address, you MUST use the Service Facility Segment below to transmit the address and NPI (if there is one) for that location.

Field#	NCPDP Field Name	Submit	Value	Comments
111-AM	Segment ID	M	15
336-8C	Facility ID	Q	NPI of the facility	Required if the facility has a NPI
385-3Q	Facility Name	Q
386-3U	Facility Street Address	Q
388-5J	FACILITY CITY ADDRESS	Q
387-3V	FACILITY STATE/PROVINCE ADDRESS	Q
389-6D	FACILITY ZIP/POSTAL ZONE	Q

Claim Segment (Mandatory)

Field#	NCPDP Field Name	Submit	Value	Comments
111-AM	Segment ID	M	07
455-EM	Rx/Service Reference Number Qualifier	M	1= Billing
402-D2	Rx/Service Reference Number	M
436-E1	Product/Service ID Qualifier	M	03 = NDC 09 = HCPCS or CPT	NDC for immunizations and Part B drugs; HCPCS for other services.
407-D7	Product/Service ID	M		11-digit NDC HCPCS or CPT code
442-E7	Quantity Dispensed	M
600-28	Unit of Measure	M	EA = Each GM = Grams ML = Milliliters
414-DE	Date Prescription Written	M
456-EN	Associated Prescription/Service Reference Number	O
457-EP	Associated Prescription/Service Date	O
458-SE	Procedure Modifier Code Count	O
459-ER	Procedure Modifier Code	O		Submit RR modifier for any rental, NU, KX, or any applicable other modifiers. Rentals will be automatically billed monthly.
403-D3	Fill Number	O
405-D5	Days Supply	O
415-DF	Number of Refills Authorized	O
354-NX	Submission Clarification Code Count	RW	Maximum count of 3	Submission clarification code (420-DK) is used
420-DK	Submission Clarification Code	RW	For Hep B and Monoclonal vaccines: 02 = first dose 03 = 2 dose series 04 = 3 dose series 05 = 4 dose series
420-DK	Submission Clarification Code	RW	For vaccines: 06 = indicates vaccine was administered inside a patient’s home, add M0201 for additional payment 07 = do not add administration billing code/fee to the claim	M0201 is allowed for certain POS codes per CMS. Be sure to follow the rules and limitations.
420-DK	Submission Clarification Code	RW	For Part B drugs: 11 = respiratory drug first in the lifetime dispensing 12 = immunosuppressive first time dispensing post-transplant 13 = respiratory, immunosuppressive, oral anti-cancer or oral antiemetic first of multiple drugs dispensed in a 30-day period 14 =respiratory, immunosuppressive, oral anti-cancer or oral antiemetic subsequent drug of multiple dispensed in a 30-day period
420-DK	Submission Clarification Code	RW	90 or 51 = 100% insurance paid, 0% patient pay 80 or 50 = 80% insurance paid, 20% patient pay	Use when you want to bypass the Eligibility Check and determine financial responsibility based on the SCC code.
419-DJ	Prescription Origin Code	O
461-EU	Prior authorization type code	O
462-EV	Prior authorization number submitted	O
391-MT	Patient Assignment Indicator (Direct Member Reimbursement Indicator)	O	Y = Patient Assigns Benefits N = Patient does not assign benefits. If not sent, it will assume “Y”	Required when the claim adjudicator does not assume the patient assigned his/her benefits to the provider.

Pricing Segment (Mandatory)

Field#	NCPDP Field Name	Submit	Value	Comments
111-AM	Segment ID	M	11
430-DU	Gross Amount Due	M
477-BE	Professional service fee submitted	O
433-DX	Patient paid amount submitted	O
481-HA	Flat sales tax amount submitted	O
482-GE	Percentage sales tax amount submitted	O
483-HE	Percentage sales tax rate submitted	O
484-JE	Percentage sales tax basis submitted	O
426-DQ	Usual and customary charge	O

Pharmacy Provider Segment (Mandatory) Rendering Provider info

Field#	NCPDP Field Name	Submit	Value	Comments
111-AM	Segment ID	M	02
465-EY	Provider ID Qualifier	M	05=NPI
444-E9	Provider ID	M

Prescriber Segment (Mandatory) referring provider or ordering provider

Field#	NCPDP Field Name	Submit	Value	Comments
111-AM	Segment ID	M	03
466-EZ	Prescriber ID Qualifier	M	01=NPI
411-DB	Prescriber ID	M		NPI
427-2J	Prescriber First Name	0
364-DR	Prescriber Last Name	0
498-PM	Prescriber Phone Number	0
467-1E	Prescriber location code	O
468-2E	Primary care provider ID qualifier	O
421-DL	Primary care provider ID	O
469-H5	Primary care provider location code	O
470-4E	Primary care provider last name	O

Clinical Segment (Mandatory)

Field#	NCPDP Field Name	Submit	Value	Comments
111-AM	Segment ID	M	13
491-VE	Diagnosis Code Count	M	Max count of 4	Required if Diagnosis Code Qualifier is used.
492-WE	Diagnosis Code Qualifier	M	02 = ICD10	Required if Diagnosis Code is provided.
424-DO	Diagnosis Code	M

Narrative Segment (Optional)

Always include a narrative when submitting claims for nebulizer drugs.

Field#	NCPDP Field Name	Submit	Value	Comments
111 -AM	Segment ID	RW	16
390 - BM	Narrative Message	O	Max size 80	Free format comment

CLAIM REVERSAL TRANSACTION

Transaction Header Segment (Mandatory)

Field#	NCPDP Field Name	Submit	Value	Comments
101-A1	BIN Number	M	026480	Signetic’s BIN number
102-A2	Version/Release Number	M	D0
103-A3	Transaction Code	M	B2 = Reversal
104-A4	Processor Control Number	M		Contains the Signetic specific PCN for the payer that is being billed. This list of possible codes are provided by Signetic and should be used. All other values will result in an exception.
109-A9	Transaction Count	M	1
202-B2	Service Provider ID Qualifier	M	01 = NPI
201-B1	Service Provider ID	M	10-digit NPI
401-D1	Date Of Service	M
110-AK	Software Vendor/Certification ID	M	Blank Fill

Insurance Segment – Required

Field#	NCPDP Field Name	Submit	Value	Comments
111-AM	Segment ID	M	04
302-C2	Cardholder ID	M		Required only if the insurance segment is sent.

Claim Segment (Mandatory)

Field#	NCPDP Field Name	Submit	Value	Comments
111-AM	Segment ID	M	07
455-EM	Rx/Service Reference Number Qualifier	M	1= Billing
402-D2	Rx/Service Reference Number	M
436-E1	Product/Service ID Qualifier	M	03 = NDC 09 = HCPCS or CPT	NDC for immunizations and Part B drugs; HCPCS for other services.
407-D7	Product/Service ID	M		Use the 11-digit NDC of the dispensed product or HCPCS/CPT code
415-DF	Number of Refills Authorized	O

Additional Comments

All Provider NPIs must be registered and configured with Electronic Billing Services (EBS) before they can successfully transmit NCPDP claims using this BIN.

If the NCPDP transmission is accepted, a “paid” response will be provided in all cases.

Any problems with the information provided will be “rejected”

End of document