USHIK: APCD File Submission Comparison

File Submission Comparison

Selected Items

Item Name	Version	State	Type	Organization
Pharmacy Claims File Submission	2010-03-16	Maine	File Specification	Maine Health Data Organization (MHDO)
Pharmacy Claims File Submission	v1.2	Maine	File Specification	Maine Health Data Organization (MHDO)

Identifying Attributes

File Specification:	Pharmacy Claims File Submission - 2010-03-16 (Maine)	Pharmacy Claims File Submission - v1.2 (Maine)
Responsible Organization:	Maine Health Data Organization	Maine Health Data Organization
Definition:	Not Provided	"Pharmacy claims file" means a data file composed of service level remittance information including, but not limited to, member demographics, provider information, charge/payment information, and national drug codes from all non-denied adjudicated claims for each prescription filled.

Data Elements & Codes

File Specification:

Pharmacy Claims File Submission - 2010-03-16 (Maine)

Pharmacy Claims File Submission - v1.2 (Maine)

PC001

Name:	Payer
Type:	varchar
Length:	8
Codes:

Name:	Payer
Type:	CHAR
Length:	6
Codes:
C	Commercial carrier
T	Third Party Administrator
U	Unlicensed entity

PC002

Name:	Plan ID
Type:	varchar
Length:	30

Name:	Plan ID
Type:	CHAR
Length:	30

PC003

Name:	Insurance Type/Product Code
Type:	varchar
Length:	2
Codes:

Name:	Insurance Type/Product Code
Type:	CHAR
Length:	2
Codes:
12	Preferred Provider Organization (PPO)
13	Point of Service (POS)
14	Exclusive Provider Organization (EPO)
15	Indemnity Insurance
16	Health Maintenance Organization (HMO) Medicare Risk
AM	Automobile Medical
DS	Disability
HM	Health Maintenance Organization
LI	Liability
LM	Liability Medical
MA	Medicare Part A
MB	Medicare Part B
MC	Medicaid
OF	Other Federal Program (e.g. Black Lung)
TV	Title V
VA	Veteran Administration Plan
WC	Worker's Compensation

PC004

Name:	Payer Claim Control Number
Type:	varchar
Length:	35

Name:	Payer Claim Control Number
Type:	CHAR
Length:	35

PC005

Name:	Line Counter
Type:	integer
Length:	4

Name:	Line Counter
Type:	CHAR
Length:	5

PC006

Name:	Insured Group Number
Type:	varchar
Length:	30

Name:	Insured Group Number
Type:	CHAR
Length:	31

PC007

Name:	Month
Type:	varchar
Length:	128

Name:	Encrypted Subscriber Social Security Number
Type:	CHAR
Length:	32

PC008

Name:	Plan Specific Contract Number
Type:	varchar
Length:	128

Name:	Plan Specific Contract Number
Type:	CHAR
Length:	64

PC009

Name:	Member Suffix or Sequence Number
Type:	integer
Length:	20

Name:	Member Suffix or Sequence Number
Type:	CHAR
Length:	20

PC010

Name:	Member Identification Code
Type:	varchar
Length:	128

Name:	Member Identification Code
Type:	CHAR
Length:	30

PC011

Name:	Individual Relationship Code
Type:	integer
Length:	2
Codes:

Name:	Individual Relationship Code
Type:	CHAR
Length:	2
Codes:
01	Spouse
04	Grandfather or Grandmother
05	Grandson or Granddaughter
07	Nephew or Niece
10	Foster Child
15	Ward
17	Stepson or Stepdaughter
19	Child
20	Employee/Self
21	Unknown
22	Handicapped Dependent
23	Sponsored Dependent
24	Dependent of a Minor Dependent
29	Significant Other
32	Mother
33	Father
36	Emancipated Minor
39	Organ Donor
40	Cadaver Donor
41	Injured Plaintiff
43	Child Where Insured Has No Financial Responsibility
53	Life Partner
76	Dependent

PC012

Name:	Member Gender
Type:	integer
Length:	1
Codes:

Name:	Member Gender
Type:	CHAR
Length:	1
Codes:
1	Male
2	Female

PC013

Name:	Member Date of Birth
Type:	date
Length:	Not Provided

Name:	Member Date of Birth
Type:	DATE
Length:	8

PC014

Name:	Member City Name of Residence
Type:	varchar
Length:	50

Name:	Member City Name of Residence
Type:	CHAR
Length:	50

PC015

Name:	Member State or Province
Type:	varchar
Length:	2

Name:	Member State or Province
Type:	CHAR
Length:	2

PC016

Name:	Member ZIP Code
Type:	varchar
Length:	11

Name:	Member ZIP Code
Type:	CHAR
Length:	11

PC017

Name:	Date Service Approved (AP Date)
Type:	date
Length:	Not Provided

Name:	Date Service Approved (AP Date)
Type:	DATE
Length:	8

PC025

Name:	Claim Status
Type:	integer
Length:	2
Codes:

Name:	Claim Status
Type:	NUMBER
Length:	2
Codes:
01	Processed as primary
02	Processed as secondary
03	Processed as tertiary
04	Denied
19	Processed as primary, forwarded to additional payer(s)
20	Processed as secondary, forwarded to additional payer(s)
21	Processed as tertiary, forwarded to additional payer(s)
22	Reversal of previous payment

PC026

Name:	Drug Code
Type:	varchar
Length:	11

Name:	Drug Code
Type:	CHAR
Length:	11

PC027

Name:	Drug Name
Type:	varchar
Length:	80

Name:	Drug Name
Type:	CHAR
Length:	80

PC028

Name:	New Prescription
Type:	integer
Length:	2
Codes:
00	New prescription
01-99	Number of refill

Name:	New Prescription
Type:	NUMBER
Length:	2
Codes:
00	New prescription
01-99	Refill prescription

PC029

Name:	Generic Drug Indicator
Type:	varchar
Length:	1
Codes:

Name:	Generic Drug Indicator
Type:	CHAR
Length:	1
Codes:
N	No, branded drug
Y	Yes, branded drug

PC030

Name:	Dispense as Written Code
Type:	integer
Length:	1
Codes:

Name:	Dispense as Written Code
Type:	NUMBER
Length:	1
Codes:
0	Not dispensed as written
1	Physician dispense as written
2	Member dispense as written
3	Pharmacy dispense as written
4	No generic available
5	Brand dispensed as generic
6	Override
7	Substitution not allowed - brand drug mandated by law
8	Substitution allowed - generic drug not available in marketplace
9	Other

PC031

Name:	Compound Drug Indicator
Type:	varchar
Length:	1
Codes:

Name:	Compound Drug Indicator
Type:	CHAR
Length:	1
Codes:
N	Non-compound drug
U	Non-specified drug component
Y	Compound drug

PC032

Name:	Date Prescription Filled
Type:	date
Length:	Not Provided

Name:	Date Prescription Filled
Type:	DATE
Length:	8

PC033

Name:	Quantity Dispensed
Type:	integer
Length:	5

Name:	Quantity Dispensed
Type:	NUMBER
Length:	5

PC034

Name:	Days Supply
Type:	integer
Length:	3

Name:	Days Supply
Type:	NUMBER
Length:	3

PC035

Name:	Charge Amount
Type:	decimal
Length:	10

Name:	Charge Amount
Type:	NUMBER
Length:	10

PC036

Name:	Paid Amount
Type:	decimal
Length:	10

Name:	Paid Amount
Type:	NUMBER
Length:	10

PC037

Name:	Ingredient Cost/List Price
Type:	decimal
Length:	10

Name:	Ingredient Cost/List Price
Type:	NUMBER
Length:	10

PC038

Name:	Postage Amount Claimed
Type:	decimal
Length:	10

Name:	Postage Amount Claimed
Type:	NUMBER
Length:	10

PC039

Name:	Dispensing Fee
Type:	decimal
Length:	10

Name:	Dispensing Fee
Type:	NUMBER
Length:	10

PC040

Name:	Copay Amount
Type:	decimal
Length:	10

Name:	Copay Amount
Type:	NUMBER
Length:	10

PC041

Name:	Coinsurance Amount
Type:	decimal
Length:	10

Name:	Coinsurance Amount
Type:	NUMBER
Length:	10

PC042

Name:	Deductible Amount
Type:	decimal
Length:	10

Name:	Deductible Amount
Type:	NUMBER
Length:	10

PC043

Name:	Unassigned
Type:	Not Provided
Length:	Not Provided
Codes:

Name:	Record Type
Type:	CHAR
Length:	2
Codes:
PC	Pharmacy Claims

PC101

Name:	Encryped Subscriber Last Name
Type:	varchar
Length:	128

Data Element: PC101
not present in this file submission.

PC102

Name:	Encryped Subscriber First Name
Type:	varchar
Length:	128

Data Element: PC102
not present in this file submission.

PC103

Name:	Encryped Subscriber Middle Initial
Type:	varchar
Length:	1

Data Element: PC103
not present in this file submission.

PC104

Name:	Encryped Member Last Name
Type:	varchar
Length:	128

Data Element: PC104
not present in this file submission.

PC105

Name:	Encryped Member First Name
Type:	varchar
Length:	128

Data Element: PC105
not present in this file submission.

PC106

Name:	Encryped Member Middle Initial
Type:	varchar
Length:	1

Data Element: PC106
not present in this file submission.

PC899

Name:	Record Type
Type:	varchar
Length:	2
Codes:
PC

Data Element: PC899
not present in this file submission.

PC901

Name:	Member Age
Type:	integer
Length:	3

Name:	Member Age
Type:	NUMBER
Length:	3

PC902

Name:	Record ID#
Type:	integer
Length:	Not Provided

Name:	Record ID #
Type:	NUMBER
Length:	12

PC903

Name:	Date of Transfer to MHDO
Type:	date
Length:	Not Provided

Name:	MHDO Extract Date
Type:	DATE
Length:	8

PC904

Name:	Encrypted Member ID# (longer of ESSN or Contract) + DOB
Type:	varchar
Length:	71

Name:	Unique Member ID
Type:	CHAR
Length:	71

PC905

Name:	Submission ID#
Type:	integer
Length:	Not Provided

Name:	Submission ID #
Type:	NUMBER
Length:	12

PC906

Name:	Double Encrypted Payer Claim Control Number
Type:	varchar
Length:	100

Name:	Double Encrypted Payer Control Claim Number
Type:	CHAR
Length:	100

PC907

Name:	Double Encrypted Subscriber Social Security Number
Type:	varchar
Length:	64

Name:	Double Encrypted Subscriber Social Security Number
Type:	CHAR
Length:	64

PC908

Name:	Double Encrypted Plan Specific Contract Number
Type:	varchar
Length:	128

Name:	Double Encrypted Plan Specific Contract Number
Type:	CHAR
Length:	128

PC909

Name:	Double Encrypted Member Identification Code
Type:	varchar
Length:	128

Name:	Double Encrypted Member Social Security Number
Type:	CHAR
Length:	128

PC910

Name:	Double Encrypted Member ID# (longer of MHDO_ESSN or
Type:	varchar
Length:	135

Name:	Double Encrypted Member ID
Type:	CHAR
Length:	135

PC911

Name:	Standardized Member Gender
Type:	varchar
Length:	1
Codes:

Name:	Standardized Member Gender
Type:	CHAR
Length:	1
Codes:
F	Female
M	Male
U	Unknown

PC912

Name:	Standardized Insurance Type/Product Code
Type:	varchar
Length:	2
Codes:

Name:	Standardized Insurance Type/Product Code
Type:	CHAR
Length:	2
Codes:
11	Other non Federal program
12	Medicare secondary working aged beneficiary or spouse with employer group health plan
13	Medicare secondary end-stage renal disease beneficiary in the 12 month coordination period with an employer's group health plan
14	Medicare secondary, no-fault insurance including auto is primary
15	Medicare secondary public health service (PHS) or other federal agency
41	Medicare secondary black lung
42	Medicare secondary veteran's administration
43	Medicare secondary disabled beneficiary under age 65 with large group health plan (LGHP)
47	Medicare secondary, other liability insurance is primary
AM	Auto insurance policy
CP	Medicare conditionally primary
DB	Disability benefits
DS	Disability
EP	Exclusive Provider Organization (EPO)
HM	Health Maintenance Organization (HMO)
HN	Health Maintenance Organization (HMO) Medicare risk
HS	Special low income Medicare beneficiary
IN	Indemnity Insurance
LC	Long term care
LD	Long term policy
LI	Life insurance
LM	Liability medical
LT	Litigation
MA	Medicare part A
MB	Medicare part B
MC	Medicaid
MH	Medigap part A
MI	Medigap part B
MP	Medicare primary
OF	Other federal program (e.g. black lung)
OT	Other
PE	Property Insurance - Personal
PR	Preferred Provider Organization (PPO)
PS	Point of Service (POS)
QM	Qualified Medicare beneficiary
SP	Supplemental policy
TV	Title V
VA	Veteran administration plan
WC	Workers' compensation

PC913

Name:	Key to Pharmacy Detail table
Type:	integer
Length:	Not Provided

Name:	Pharmacy ID #
Type:	INTEGER
Length:	12

PC914

Name:	PAID_YR
Type:	integer
Length:	Not Provided

Name:	Year Paid
Type:	Number
Length:	4

PC915

Name:	PAID_MON
Type:	integer
Length:	Not Provided

Name:	Month Paid
Type:	Number
Length:	2

PC916

Name:	INCURRED_YR
Type:	integer
Length:	Not Provided

Name:	Year of Service
Type:	Number
Length:	4

PC917

Name:	INCURRED_MON
Type:	integer
Length:	Not Provided

Name:	Month of Service
Type:	Number
Length:	2

PC918

Name:	Quarter
Type:	integer
Length:	Not Provided
Codes:

Name:	Payment Quarter
Type:	Number
Length:	1
Codes:
1	January - March
2	April - June
3	July - September
4	October - December

PC919

Name:	Quarter
Type:	integer
Length:	Not Provided
Codes:

Name:	Quarter Service Performed
Type:	Number
Length:	1
Codes:
1	January - March
2	April - June
3	July - September
4	October - December

PC920

Name:	Prescribing Physician ID#
Type:	integer
Length:	12

Name:	Prescribing Physician ID
Type:	INTEGER
Length:	12

United States Health Information Knowledgebase

File Submission Comparison

Identifying Attributes

Data Elements & Codes