United States Health Information Knowledgebase

 

File Submission Comparison

Selected Items
Action Item Name Version State Type Organization
Pharmacy Claims File Submission September 27, 2011 - v2011.1.1 Oregon File Specification Office for Oregon Health Policy and Research (OHPR)
Pharmacy Claims File Submission June 25, 2012 - v2013.0.0 Oregon File Specification Office for Oregon Health Policy and Research (OHPR)
Pharmacy Claims File Submission June 27, 2013 - v2014.0.0 Oregon File Specification Office for Oregon Health Policy and Research (OHPR)
Pharmacy Claims File Submission 2015.0.1 Oregon File Specification Office for Oregon Health Policy and Research (OHPR)
File Specification: Pharmacy Claims File Submission - September 27, 2011 - v2011.1.1 (Oregon) Pharmacy Claims File Submission - June 25, 2012 - v2013.0.0 (Oregon) Pharmacy Claims File Submission - June 27, 2013 - v2014.0.0 (Oregon) Pharmacy Claims File Submission - 2015.0.1 (Oregon)
[Shared] Responsible Organization:
Office for Oregon Health Policy and Research Office for Oregon Health Policy and Research Office for Oregon Health Policy and Research Office for Oregon Health Policy and Research
[Unshared] Definition:
Not Provided Medical claims and pharmacy claims files capture plan payments, member financial responsibility (co-pay, co-insurance, deductible), diagnoses, procedures performed, and numerous other data fields. Medical claims and pharmacy claims files capture plan payments, member financial responsibility (co-pay, co-insurance, deductible), diagnoses, procedures performed, and numerous other data fields. Medical claims and pharmacy claims files capture plan payments, member financial responsibility (co-pay, co-insurance, deductible), diagnoses, procedures performed, and numerous other data fields.
File Specification: Pharmacy Claims File Submission - September 27, 2011 - v2011.1.1 (Oregon) Pharmacy Claims File Submission - June 25, 2012 - v2013.0.0 (Oregon) Pharmacy Claims File Submission - June 27, 2013 - v2014.0.0 (Oregon) Pharmacy Claims File Submission - 2015.0.1 (Oregon)
PC001
[Shared] Name: Payer type
[Shared] Type: Text
[Shared] Length: 1
Codes:
C
Carrier
D
Medicaid
G
Other government agency
P
Pharmacy benefits manager
T
Third-party administrator
U
Unlicensed entity
[Shared] Name: Payer type
[Shared] Type: Text
[Shared] Length: 1
Codes:
C
Carrier
D
Medicaid
G
Other government agency
P
Pharmacy benefits manager
T
Third-party administrator
U
Unlicensed entity
[Shared] Name: Payer type
[Shared] Type: Text
[Shared] Length: 1
Codes:
C
Carrier
D
Medicaid
G
Other government agency
P
Pharmacy benefits manager
T
Third-party administrator
U
Unlicensed entity
[Shared] Name: Payer type
[Shared] Type: Text
[Shared] Length: 1
Codes:
C
Carrier
D
Medicaid
G
Other government agency
P
Pharmacy benefits manager
T
Third-party administrator
U
Unlicensed entity
PC003
[Shared] Name: Insurance type/ product code
[Shared] Type: Text
[Shared] Length: 6
Codes:
CHP
Special Childrens Health Insurance Program (SCHIP)
EPO
Commercial EPO
HMO
Commercial HMO
IN
Commercial indemnity
MC
Medicare Cost
MD
Medicaid disabled HMO
MDE
Medicaid dual eligible HMO
MDF
Medicaid fee-for-service
MLI
Medicaid low income HMO
MP
Medicare Advantage PPO
 
 
MR
Medicare Advantage HMO
MRB
Medicaid restricted benefit HMO
PH
Pharmacy benefits only
POS
Commercial POS
PPO
Commercial PPO
SIF
Self insured POS
SIH
Self insured HMO
SIP
Self insured PPO
SL
Commercial stop loss
SN1
Special needs plan - chronic condition
SN2
Special needs plan - institutionalized
SN3
Special needs plan - dual eligible
ZZ
Unknown
[Shared] Name: Insurance type/ product code
[Shared] Type: Text
[Shared] Length: 6
Codes:
CHP
Special Childrens Health Insurance Program (SCHIP)
EPO
Commercial EPO
HMO
Commercial HMO
IN
Commercial indemnity
MC
Medicare Cost
MD
Medicaid disabled HMO
MDE
Medicaid dual eligible HMO
MDF
Medicaid fee-for-service
MLI
Medicaid low income HMO
MP
Medicare Advantage PPO
 
 
MR
Medicare Advantage HMO
MRB
Medicaid restricted benefit HMO
PH
Pharmacy benefits only
POS
Commercial POS
PPO
Commercial PPO
SIF
Self insured POS
SIH
Self insured HMO
SIP
Self insured PPO
SL
Commercial stop loss
SN1
Special needs plan - chronic condition
SN2
Special needs plan - institutionalized
SN3
Special needs plan - dual eligible
ZZ
Unknown
[Shared] Name: Insurance type/ product code
[Shared] Type: Text
[Shared] Length: 6
Codes:
CHP
Special Childrens Health Insurance Program (SCHIP)
EPO
Commercial EPO
HMO
Commercial HMO
IN
Commercial indemnity
MC
Medicare Cost
MD
Medicaid disabled HMO
MDE
Medicaid dual eligible HMO
MDF
Medicaid fee-for-service
MLI
Medicaid low income HMO
MP
Medicare Advantage PPO
 
 
MR
Medicare Advantage HMO
MRB
Medicaid restricted benefit HMO
PH
Pharmacy benefits only
POS
Commercial POS
PPO
Commercial PPO
SIF
Self insured POS
SIH
Self insured HMO
SIP
Self insured PPO
SL
Commercial stop loss
SN1
Special needs plan - chronic condition
SN2
Special needs plan - institutionalized
SN3
Special needs plan - dual eligible
ZZ
Unknown
[Shared] Name: Insurance type/ product code
[Shared] Type: Text
[Shared] Length: 6
Codes:
CHP
Special Childrens Health Insurance Program (SCHIP)
EPO
Commercial EPO
HMO
Commercial HMO
IN
Commercial indemnity
MC
Medicare Cost
MD
Medicaid disabled HMO
MDE
Medicaid dual eligible HMO
MDF
Medicaid fee-for-service
MLI
Medicaid low income HMO
MP
Medicare Advantage PPO
MPD
Medicare Part D only
MR
Medicare Advantage HMO
MRB
Medicaid restricted benefit HMO
PH
Pharmacy benefits only
POS
Commercial POS
PPO
Commercial PPO
SIF
Self insured POS
SIH
Self insured HMO
SIP
Self insured PPO
SL
Commercial stop loss
SN1
Special needs plan - chronic condition
SN2
Special needs plan - institutionalized
SN3
Special needs plan - dual eligible
ZZ
Unknown
PC004
[Shared] Name: Claim ID
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Claim ID
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Claim ID
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Claim ID
[Shared] Type: Text
[Shared] Length: 30
PC008
[Shared] Name: Plan-specific contract number
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Plan-specific contract number
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Plan-specific contract number
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Plan-specific contract number
[Shared] Type: Text
[Shared] Length: 30
PC010
[Shared] Name: Patient ID
[Shared] Type: Text
[Shared] Length: 20
[Shared] Name: Patient ID
[Shared] Type: Text
[Shared] Length: 20
[Shared] Name: Patient ID
[Shared] Type: Text
[Shared] Length: 20
[Shared] Name: Patient ID
[Shared] Type: Text
[Shared] Length: 20
PC017
[Shared] Name: Payment date
[Shared] Type: Date
[Shared] Length: 8
[Shared] Name: Payment date
[Shared] Type: Date
[Shared] Length: 8
[Shared] Name: Payment date
[Shared] Type: Date
[Shared] Length: 8
[Shared] Name: Payment date
[Shared] Type: Date
[Shared] Length: 8
PC020
[Shared] Name: Pharmacy Name
[Shared] Type: Text
[Shared] Length: 35
[Shared] Name: Pharmacy Name
[Shared] Type: Text
[Shared] Length: 35
[Shared] Name: Pharmacy Name
[Shared] Type: Text
[Shared] Length: 35
[Shared] Name: Pharmacy Name
[Shared] Type: Text
[Shared] Length: 35
PC021
[Shared] Name: Pharmacy NPI
[Shared] Type: Text
[Shared] Length: 15
[Shared] Name: Pharmacy NPI
[Shared] Type: Text
[Shared] Length: 15
[Shared] Name: Pharmacy NPI
[Shared] Type: Text
[Shared] Length: 15
[Shared] Name: Pharmacy NPI
[Shared] Type: Text
[Shared] Length: 15
PC021A
[Shared] Name: Pharmacy alternate identifier
[Shared] Type: Text
[Shared] Length: 15
[Shared] Name: Pharmacy alternate identifier
[Shared] Type: Text
[Shared] Length: 15
[Shared] Name: Pharmacy alternate identifier
[Shared] Type: Text
[Shared] Length: 15
[Shared] Name: Pharmacy alternate identifier
[Shared] Type: Text
[Shared] Length: 15
PC022
[Shared] Name: Pharmacy city
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Pharmacy city
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Pharmacy city
[Shared] Type: Text
[Shared] Length: 30
[Shared] Name: Pharmacy city
[Shared] Type: Text
[Shared] Length: 30
PC023
[Shared] Name: Pharmacy state
[Shared] Type: Text
[Shared] Length: 2
[Shared] Name: Pharmacy state
[Shared] Type: Text
[Shared] Length: 2
[Shared] Name: Pharmacy state
[Shared] Type: Text
[Shared] Length: 2
[Shared] Name: Pharmacy state
[Shared] Type: Text
[Shared] Length: 2
PC024
[Shared] Name: Pharmacy ZIP
[Shared] Type: Text
[Shared] Length: 15
[Shared] Name: Pharmacy ZIP
[Shared] Type: Text
[Shared] Length: 15
[Shared] Name: Pharmacy ZIP
[Shared] Type: Text
[Shared] Length: 15
[Shared] Name: Pharmacy ZIP
[Shared] Type: Text
[Shared] Length: 15
PC025
[Shared] Name: Claim status
[Shared] Type: Text
[Shared] Length: 3
Codes:
 
 
D
denied
E
encounter only
P
paid
[Shared] Name: Claim status
[Shared] Type: Text
[Shared] Length: 3
Codes:
C
CCO encounter
D
denied
E
other managed care encounter
P
paid
[Shared] Name: Claim status
[Shared] Type: Text
[Shared] Length: 3
Codes:
C
CCO encounter
D
denied
E
other managed care encounter
P
paid
[Shared] Name: Claim status
[Shared] Type: Text
[Shared] Length: 3
Codes:
C
CCO encounter
D
denied
E
other managed care encounter
P
paid
PC026
[Shared] Name: NDC
[Shared] Type: Text
[Shared] Length: 11
[Shared] Name: NDC
[Shared] Type: Text
[Shared] Length: 11
[Shared] Name: NDC
[Shared] Type: Text
[Shared] Length: 11
[Shared] Name: NDC
[Shared] Type: Text
[Shared] Length: 11
PC028
[Shared] Name: Calculated refill number
[Shared] Type: Numeric
[Shared] Length: 2
[Shared] Name: Calculated refill number
[Shared] Type: Numeric
[Shared] Length: 2
[Shared] Name: Calculated refill number
[Shared] Type: Numeric
[Shared] Length: 2
[Shared] Name: Calculated refill number
[Shared] Type: Numeric
[Shared] Length: 2
PC028A
[Shared] Name: Alternate refill number
[Shared] Type: Numeric
[Shared] Length: 2
[Shared] Name: Alternate refill number
[Shared] Type: Numeric
[Shared] Length: 2
[Shared] Name: Alternate refill number
[Shared] Type: Numeric
[Shared] Length: 2
[Shared] Name: Alternate refill number
[Shared] Type: Numeric
[Shared] Length: 2
PC030
[Shared] Name: Dispense as written code
[Shared] Type: Text
[Shared] Length: 1
Codes:
0
No product selection indicated
1
Substitution not allowed by provider
2
Substitution allowed- patient requested product dispensed
3
Substitution allowed- pharmacist selected product dispensed
4
Substitution allowed- generic drug not in stock
5
Substitution allowed- brand drug 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
[Shared] Name: Dispense as written code
[Shared] Type: Text
[Shared] Length: 1
Codes:
0
No product selection indicated
1
Substitution not allowed by provider
2
Substitution allowed- patient requested product dispensed
3
Substitution allowed- pharmacist selected product dispensed
4
Substitution allowed- generic drug not in stock
5
Substitution allowed- brand drug 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
[Shared] Name: Dispense as written code
[Shared] Type: Text
[Shared] Length: 1
Codes:
0
No product selection indicated
1
Substitution not allowed by provider
2
Substitution allowed- patient requested product dispensed
3
Substitution allowed- pharmacist selected product dispensed
4
Substitution allowed- generic drug not in stock
5
Substitution allowed- brand drug 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
[Shared] Name: Dispense as written code
[Shared] Type: Text
[Shared] Length: 1
Codes:
0
No product selection indicated
1
Substitution not allowed by provider
2
Substitution allowed- patient requested product dispensed
3
Substitution allowed- pharmacist selected product dispensed
4
Substitution allowed- generic drug not in stock
5
Substitution allowed- brand drug 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
[Shared] Type: Numeric
[Shared] Length: 1
Codes:
1
no
2
yes
[Shared] Name: Compound drug indicator
[Shared] Type: Numeric
[Shared] Length: 1
Codes:
1
no
2
yes
[Shared] Name: Compound drug indicator
[Shared] Type: Numeric
[Shared] Length: 1
Codes:
1
no
2
yes
[Shared] Name: Compound drug indicator
[Shared] Type: Numeric
[Shared] Length: 1
Codes:
1
no
2
yes
PC032
[Shared] Name: Date filled
[Shared] Type: Text
[Shared] Length: 8
[Shared] Name: Date filled
[Shared] Type: Text
[Shared] Length: 8
[Shared] Name: Date filled
[Shared] Type: Text
[Shared] Length: 8
[Shared] Name: Date filled
[Shared] Type: Text
[Shared] Length: 8
PC033
[Shared] Name: Quantity dispensed
[Shared] Type: Numeric
[Shared] Length: 10
[Shared] Name: Quantity dispensed
[Shared] Type: Numeric
[Shared] Length: 10
[Shared] Name: Quantity dispensed
[Shared] Type: Numeric
[Shared] Length: 10
[Shared] Name: Quantity dispensed
[Shared] Type: Numeric
[Shared] Length: 10
PC034
[Shared] Name: Days supply
[Shared] Type: Numeric
[Shared] Length: 3
[Shared] Name: Days supply
[Shared] Type: Numeric
[Shared] Length: 3
[Shared] Name: Days supply
[Shared] Type: Numeric
[Shared] Length: 3
[Shared] Name: Days supply
[Shared] Type: Numeric
[Shared] Length: 3
PC035
[Shared] Name: Charges
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Charges
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Charges
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Charges
[Shared] Type: Numeric
[Shared] Length: 12
PC036
[Shared] Name: Payment
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Payment
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Payment
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Payment
[Shared] Type: Numeric
[Shared] Length: 12
PC037
[Shared] Name: Ingredient cost/list price
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Ingredient cost/list price
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Ingredient cost/list price
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Ingredient cost/list price
[Shared] Type: Numeric
[Shared] Length: 12
PC039
[Shared] Name: Dispensing fee paid
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Dispensing fee paid
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Dispensing fee paid
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Dispensing fee paid
[Shared] Type: Numeric
[Shared] Length: 12
PC040
[Shared] Name: Co-pay
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Co-pay
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Co-pay
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Co-pay
[Shared] Type: Numeric
[Shared] Length: 12
PC041
[Shared] Name: Coinsurance
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Coinsurance
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Coinsurance
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Coinsurance
[Shared] Type: Numeric
[Shared] Length: 12
PC042
[Shared] Name: Deductible
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Deductible
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Deductible
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Deductible
[Shared] Type: Numeric
[Shared] Length: 12
PC043
[Shared] Name: Patient pay amount
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Patient pay amount
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Patient pay amount
[Shared] Type: Numeric
[Shared] Length: 12
[Shared] Name: Patient pay amount
[Shared] Type: Numeric
[Shared] Length: 12
PC047
[Shared] Name: Prescribing provider DEA number
[Shared] Type: Text
[Shared] Length: 12
[Shared] Name: Prescribing provider DEA number
[Shared] Type: Text
[Shared] Length: 12
[Shared] Name: Prescribing provider DEA number
[Shared] Type: Text
[Shared] Length: 12
[Shared] Name: Prescribing provider DEA number
[Shared] Type: Text
[Shared] Length: 12
PC048
[Shared] Name: Prescribing provider NPI
[Shared] Type: Text
[Shared] Length: 15
[Shared] Name: Prescribing provider NPI
[Shared] Type: Text
[Shared] Length: 15
[Shared] Name: Prescribing provider NPI
[Shared] Type: Text
[Shared] Length: 15
[Shared] Name: Prescribing provider NPI
[Shared] Type: Text
[Shared] Length: 15
PC201
Data Element: PC201
not present in this file submission.
Data Element: PC201
not present in this file submission.
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
PC202
Data Element: PC202
not present in this file submission.
Data Element: PC202
not present in this file submission.
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
PC203
Data Element: PC203
not present in this file submission.
Data Element: PC203
not present in this file submission.
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
PC204
Data Element: PC204
not present in this file submission.
Data Element: PC204
not present in this file submission.
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
PC205
Data Element: PC205
not present in this file submission.
Data Element: PC205
not present in this file submission.
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
PC206
Data Element: PC206
not present in this file submission.
Data Element: PC206
not present in this file submission.
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
PC207
Data Element: PC207
not present in this file submission.
Data Element: PC207
not present in this file submission.
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
PC208
Data Element: PC208
not present in this file submission.
Data Element: PC208
not present in this file submission.
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
PC209
Data Element: PC209
not present in this file submission.
Data Element: PC209
not present in this file submission.
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
PC210
Data Element: PC210
not present in this file submission.
Data Element: PC210
not present in this file submission.
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
[Unshared] Name: Not Provided
[Unshared] Type: Not Provided
[Unshared] Length: Not Provided
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