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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)
File Specification: Pharmacy Claims File Submission - 2010-03-16 (Maine) Pharmacy Claims File Submission - v1.2 (Maine)
[Shared] Responsible Organization:
Maine Health Data Organization Maine Health Data Organization
[Unshared] 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.
File Specification: Pharmacy Claims File Submission - 2010-03-16 (Maine) Pharmacy Claims File Submission - v1.2 (Maine)
PC001
[Shared] Name: Payer
[Unshared] Type: varchar
[Unshared] Length: 8
Codes:
 
 
 
 
 
 
[Shared] Name: Payer
[Unshared] Type: CHAR
[Unshared] Length: 6
Codes:
C
Commercial carrier
T
Third Party Administrator
U
Unlicensed entity
PC002
[Shared] Name: Plan ID
[Unshared] Type: varchar
[Shared] Length: 30
[Shared] Name: Plan ID
[Unshared] Type: CHAR
[Shared] Length: 30
PC003
[Shared] Name: Insurance Type/Product Code
[Unshared] Type: varchar
[Shared] Length: 2
Codes:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[Shared] Name: Insurance Type/Product Code
[Unshared] Type: CHAR
[Shared] 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
[Shared] Name: Payer Claim Control Number
[Unshared] Type: varchar
[Shared] Length: 35
[Shared] Name: Payer Claim Control Number
[Unshared] Type: CHAR
[Shared] Length: 35
PC005
[Shared] Name: Line Counter
[Unshared] Type: integer
[Unshared] Length: 4
[Shared] Name: Line Counter
[Unshared] Type: CHAR
[Unshared] Length: 5
PC006
[Shared] Name: Insured Group Number
[Unshared] Type: varchar
[Unshared] Length: 30
[Shared] Name: Insured Group Number
[Unshared] Type: CHAR
[Unshared] Length: 31
PC007
[Unshared] Name: Month
[Unshared] Type: varchar
[Unshared] Length: 128
[Unshared] Name: Encrypted Subscriber Social Security Number
[Unshared] Type: CHAR
[Unshared] Length: 32
PC008
[Shared] Name: Plan Specific Contract Number
[Unshared] Type: varchar
[Unshared] Length: 128
[Shared] Name: Plan Specific Contract Number
[Unshared] Type: CHAR
[Unshared] Length: 64
PC009
[Shared] Name: Member Suffix or Sequence Number
[Unshared] Type: integer
[Shared] Length: 20
[Shared] Name: Member Suffix or Sequence Number
[Unshared] Type: CHAR
[Shared] Length: 20
PC010
[Shared] Name: Member Identification Code
[Unshared] Type: varchar
[Unshared] Length: 128
[Shared] Name: Member Identification Code
[Unshared] Type: CHAR
[Unshared] Length: 30
PC011
[Shared] Name: Individual Relationship Code
[Unshared] Type: integer
[Shared] Length: 2
Codes:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[Shared] Name: Individual Relationship Code
[Unshared] Type: CHAR
[Shared] 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
[Shared] Name: Member Gender
[Unshared] Type: integer
[Shared] Length: 1
Codes:
 
 
 
 
[Shared] Name: Member Gender
[Unshared] Type: CHAR
[Shared] Length: 1
Codes:
1
Male
2
Female
PC013
[Shared] Name: Member Date of Birth
[Unshared] Type: date
[Unshared] Length: Not Provided
[Shared] Name: Member Date of Birth
[Unshared] Type: DATE
[Unshared] Length: 8
PC014
[Shared] Name: Member City Name of Residence
[Unshared] Type: varchar
[Shared] Length: 50
[Shared] Name: Member City Name of Residence
[Unshared] Type: CHAR
[Shared] Length: 50
PC015
[Shared] Name: Member State or Province
[Unshared] Type: varchar
[Shared] Length: 2
[Shared] Name: Member State or Province
[Unshared] Type: CHAR
[Shared] Length: 2
PC016
[Shared] Name: Member ZIP Code
[Unshared] Type: varchar
[Shared] Length: 11
[Shared] Name: Member ZIP Code
[Unshared] Type: CHAR
[Shared] Length: 11
PC017
[Shared] Name: Date Service Approved (AP Date)
[Unshared] Type: date
[Unshared] Length: Not Provided
[Shared] Name: Date Service Approved (AP Date)
[Unshared] Type: DATE
[Unshared] Length: 8
PC025
[Shared] Name: Claim Status
[Unshared] Type: integer
[Shared] Length: 2
Codes:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[Shared] Name: Claim Status
[Unshared] Type: NUMBER
[Shared] 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
[Shared] Name: Drug Code
[Unshared] Type: varchar
[Shared] Length: 11
[Shared] Name: Drug Code
[Unshared] Type: CHAR
[Shared] Length: 11
PC027
[Shared] Name: Drug Name
[Unshared] Type: varchar
[Shared] Length: 80
[Shared] Name: Drug Name
[Unshared] Type: CHAR
[Shared] Length: 80
PC028
[Shared] Name: New Prescription
[Unshared] Type: integer
[Shared] Length: 2
Codes:
00
New prescription
01-99
Number of refill
[Shared] Name: New Prescription
[Unshared] Type: NUMBER
[Shared] Length: 2
Codes:
00
New prescription
01-99
Refill prescription
PC029
[Shared] Name: Generic Drug Indicator
[Unshared] Type: varchar
[Shared] Length: 1
Codes:
 
 
 
 
[Shared] Name: Generic Drug Indicator
[Unshared] Type: CHAR
[Shared] Length: 1
Codes:
N
No, branded drug
Y
Yes, branded drug
PC030
[Shared] Name: Dispense as Written Code
[Unshared] Type: integer
[Shared] Length: 1
Codes:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[Shared] Name: Dispense as Written Code
[Unshared] Type: NUMBER
[Shared] 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
[Shared] Name: Compound Drug Indicator
[Unshared] Type: varchar
[Shared] Length: 1
Codes:
 
 
 
 
 
 
[Shared] Name: Compound Drug Indicator
[Unshared] Type: CHAR
[Shared] Length: 1
Codes:
N
Non-compound drug
U
Non-specified drug component
Y
Compound drug
PC032
[Shared] Name: Date Prescription Filled
[Unshared] Type: date
[Unshared] Length: Not Provided
[Shared] Name: Date Prescription Filled
[Unshared] Type: DATE
[Unshared] Length: 8
PC033
[Shared] Name: Quantity Dispensed
[Unshared] Type: integer
[Shared] Length: 5
[Shared] Name: Quantity Dispensed
[Unshared] Type: NUMBER
[Shared] Length: 5
PC034
[Shared] Name: Days Supply
[Unshared] Type: integer
[Shared] Length: 3
[Shared] Name: Days Supply
[Unshared] Type: NUMBER
[Shared] Length: 3
PC035
[Shared] Name: Charge Amount
[Unshared] Type: decimal
[Shared] Length: 10
[Shared] Name: Charge Amount
[Unshared] Type: NUMBER
[Shared] Length: 10
PC036
[Shared] Name: Paid Amount
[Unshared] Type: decimal
[Shared] Length: 10
[Shared] Name: Paid Amount
[Unshared] Type: NUMBER
[Shared] Length: 10
PC037
[Shared] Name: Ingredient Cost/List Price
[Unshared] Type: decimal
[Shared] Length: 10
[Shared] Name: Ingredient Cost/List Price
[Unshared] Type: NUMBER
[Shared] Length: 10
PC038
[Shared] Name: Postage Amount Claimed
[Unshared] Type: decimal
[Shared] Length: 10
[Shared] Name: Postage Amount Claimed
[Unshared] Type: NUMBER
[Shared] Length: 10
PC039
[Shared] Name: Dispensing Fee
[Unshared] Type: decimal
[Shared] Length: 10
[Shared] Name: Dispensing Fee
[Unshared] Type: NUMBER
[Shared] Length: 10
PC040
[Shared] Name: Copay Amount
[Unshared] Type: decimal
[Shared] Length: 10
[Shared] Name: Copay Amount
[Unshared] Type: NUMBER
[Shared] Length: 10
PC041
[Shared] Name: Coinsurance Amount
[Unshared] Type: decimal
[Shared] Length: 10
[Shared] Name: Coinsurance Amount
[Unshared] Type: NUMBER
[Shared] Length: 10
PC042
[Shared] Name: Deductible Amount
[Unshared] Type: decimal
[Shared] Length: 10
[Shared] Name: Deductible Amount
[Unshared] Type: NUMBER
[Shared] Length: 10
PC043
[Unshared] Name: Unassigned
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
Codes:
 
 
[Unshared] Name: Record Type
[Unshared] Type: CHAR
[Unshared] Length: 2
Codes:
PC
Pharmacy Claims
PC101
[Unshared] Name: Encryped Subscriber Last Name
[Unshared] Type: varchar
[Unshared] Length: 128
Data Element: PC101
not present in this file submission.
PC102
[Unshared] Name: Encryped Subscriber First Name
[Unshared] Type: varchar
[Unshared] Length: 128
Data Element: PC102
not present in this file submission.
PC103
[Unshared] Name: Encryped Subscriber Middle Initial
[Unshared] Type: varchar
[Unshared] Length: 1
Data Element: PC103
not present in this file submission.
PC104
[Unshared] Name: Encryped Member Last Name
[Unshared] Type: varchar
[Unshared] Length: 128
Data Element: PC104
not present in this file submission.
PC105
[Unshared] Name: Encryped Member First Name
[Unshared] Type: varchar
[Unshared] Length: 128
Data Element: PC105
not present in this file submission.
PC106
[Unshared] Name: Encryped Member Middle Initial
[Unshared] Type: varchar
[Unshared] Length: 1
Data Element: PC106
not present in this file submission.
PC899
[Unshared] Name: Record Type
[Unshared] Type: varchar
[Unshared] Length: 2
Codes:
PC
 
Data Element: PC899
not present in this file submission.
PC901
[Shared] Name: Member Age
[Unshared] Type: integer
[Shared] Length: 3
[Shared] Name: Member Age
[Unshared] Type: NUMBER
[Shared] Length: 3
PC902
[Unshared] Name: Record ID#
[Unshared] Type: integer
[Unshared] Length: Not Provided
[Unshared] Name: Record ID #
[Unshared] Type: NUMBER
[Unshared] Length: 12
PC903
[Unshared] Name: Date of Transfer to MHDO
[Unshared] Type: date
[Unshared] Length: Not Provided
[Unshared] Name: MHDO Extract Date
[Unshared] Type: DATE
[Unshared] Length: 8
PC904
[Unshared] Name: Encrypted Member ID# (longer of ESSN or Contract) + DOB
[Unshared] Type: varchar
[Shared] Length: 71
[Unshared] Name: Unique Member ID
[Unshared] Type: CHAR
[Shared] Length: 71
PC905
[Unshared] Name: Submission ID#
[Unshared] Type: integer
[Unshared] Length: Not Provided
[Unshared] Name: Submission ID #
[Unshared] Type: NUMBER
[Unshared] Length: 12
PC906
[Unshared] Name: Double Encrypted Payer Claim Control Number
[Unshared] Type: varchar
[Shared] Length: 100
[Unshared] Name: Double Encrypted Payer Control Claim Number
[Unshared] Type: CHAR
[Shared] Length: 100
PC907
[Shared] Name: Double Encrypted Subscriber Social Security Number
[Unshared] Type: varchar
[Shared] Length: 64
[Shared] Name: Double Encrypted Subscriber Social Security Number
[Unshared] Type: CHAR
[Shared] Length: 64
PC908
[Shared] Name: Double Encrypted Plan Specific Contract Number
[Unshared] Type: varchar
[Shared] Length: 128
[Shared] Name: Double Encrypted Plan Specific Contract Number
[Unshared] Type: CHAR
[Shared] Length: 128
PC909
[Unshared] Name: Double Encrypted Member Identification Code
[Unshared] Type: varchar
[Shared] Length: 128
[Unshared] Name: Double Encrypted Member Social Security Number
[Unshared] Type: CHAR
[Shared] Length: 128
PC910
[Unshared] Name: Double Encrypted Member ID# (longer of MHDO_ESSN or
[Unshared] Type: varchar
[Shared] Length: 135
[Unshared] Name: Double Encrypted Member ID
[Unshared] Type: CHAR
[Shared] Length: 135
PC911
[Shared] Name: Standardized Member Gender
[Unshared] Type: varchar
[Shared] Length: 1
Codes:
 
 
 
 
 
 
[Shared] Name: Standardized Member Gender
[Unshared] Type: CHAR
[Shared] Length: 1
Codes:
F
Female
M
Male
U
Unknown
PC912
[Shared] Name: Standardized Insurance Type/Product Code
[Unshared] Type: varchar
[Shared] Length: 2
Codes:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[Shared] Name: Standardized Insurance Type/Product Code
[Unshared] Type: CHAR
[Shared] 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
[Unshared] Name: Key to Pharmacy Detail table
[Unshared] Type: integer
[Unshared] Length: Not Provided
[Unshared] Name: Pharmacy ID #
[Unshared] Type: INTEGER
[Unshared] Length: 12
PC914
[Unshared] Name: PAID_YR
[Unshared] Type: integer
[Unshared] Length: Not Provided
[Unshared] Name: Year Paid
[Unshared] Type: Number
[Unshared] Length: 4
PC915
[Unshared] Name: PAID_MON
[Unshared] Type: integer
[Unshared] Length: Not Provided
[Unshared] Name: Month Paid
[Unshared] Type: Number
[Unshared] Length: 2
PC916
[Unshared] Name: INCURRED_YR
[Unshared] Type: integer
[Unshared] Length: Not Provided
[Unshared] Name: Year of Service
[Unshared] Type: Number
[Unshared] Length: 4
PC917
[Unshared] Name: INCURRED_MON
[Unshared] Type: integer
[Unshared] Length: Not Provided
[Unshared] Name: Month of Service
[Unshared] Type: Number
[Unshared] Length: 2
PC918
[Unshared] Name: Quarter
[Unshared] Type: integer
[Unshared] Length: Not Provided
Codes:
 
 
 
 
 
 
 
 
[Unshared] Name: Payment Quarter
[Unshared] Type: Number
[Unshared] Length: 1
Codes:
1
January - March
2
April - June
3
July - September
4
October - December
PC919
[Unshared] Name: Quarter
[Unshared] Type: integer
[Unshared] Length: Not Provided
Codes:
 
 
 
 
 
 
 
 
[Unshared] Name: Quarter Service Performed
[Unshared] Type: Number
[Unshared] Length: 1
Codes:
1
January - March
2
April - June
3
July - September
4
October - December
PC920
[Unshared] Name: Prescribing Physician ID#
[Unshared] Type: integer
[Shared] Length: 12
[Unshared] Name: Prescribing Physician ID
[Unshared] Type: INTEGER
[Shared] Length: 12
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