Contract ID|Transmision date to the Part D plan|Transaction Reference Number (880-K5)|RHPTran ID|Replay Number|Transaction Code (103-A3)|Service/Provider ID (201-B1)|Service/Provider ID Qualifier (202-B2)|Date of Service (401-D1)|Prescription/Service Reference Number (402-D2)|Fill Number (403-D3)|Product/Service ID (407-D7)|Product/Service ID Qualifier (436-E1)|Reject Code (511-FB) Reason for failure (Error Codes tab)|Reason for failure (Error Codes tab)|Reason for failure (Error Codes tab)|Reason for failure (Error Codes tab)|Reason for failure (Error Codes tab)|HICN|Last Name of Beneficiary (313-CD)|First Name of Beneficiary (312-CC)|Part D Processor (name)|Part D BIN (101-A1)|Part D PCN(104-A4)|Part D Group  (301-C1)|Part D Cardholder ID (302-C2)|Patient Gender Code|Part D DOB Date of Birth|OHI BIN (990-MG)|OHI PCN (991-MH)|OHI Group (992-MJ)|OHI Cardholder ID (356-NU)|OHI Transaction Code (from original claim)|Claim Receive date|Authorization Number (503-F3)|Patient Paid Amount Submitted (433-DX)|Plan Update Date|Transaction Facilitation Update Timestamp|Next Scheduled Re-try|Remaining Retries Available|Current MBI|Effective Date|MBI|Effective Date|Termination Date|MBI|Effective Date|Termination Date|MBI|Effective Date|Termination Date|MBI|Effective Date|Termination Date|MBI|Effective Date|Termination Date
D0001|20170710|14ZDGK47XE|D1170710K47XE|0|N1|0100026|07|20170622|1234506|0|12345678901|03|91|||||123456789HC||||333333|PARTDPCN1|PARTDGRP1|PARTDCARD1|1|19400101|222222|SUPPCN1|SUPGRP1|SUPCARD1|B1|20170710||0.00||||0|MBI00000102|20170101|MBI00000101|20160101|20170101|MBI00000100|20150101|20160101|||||||||
D0001|20170710|14ZDGK47XF|D1170710K47XF|0|N1|0100026|07|20170623|1234506|0|12345678901|03|91|||||123456789HC||||333333|PARTDPCN1|PARTDGRP1|PARTDCARD1|1|19400101|222222|SUPPCN1|SUPGRP1|SUPCARD1|B1|20170710||0.00||||0|MBI00000102|20170101|MBI00000101|20160101|20170101|MBI00000100|20150101|20160101|||||||||