United States Health Information Knowledgebase

 

File Submission Comparison

Selected Items
Item Name Version State Type Organization
Pharmacy Claims File Submission March 18, 2010 Tennessee File Specification Department of Finance and Administration, Division of Health Planning (DFADHP)
Pharmacy Claims File Submission January 31, 2014 - v1.0 Tennessee File Specification Department of Finance and Administration, Division of Health Planning (DFADHP)

Identifying Attributes

File Specification: Pharmacy Claims File Submission - March 18, 2010 (Tennessee) Pharmacy Claims File Submission - January 31, 2014 - v1.0 (Tennessee)
[Shared] Responsible Organization:
Department of Finance and Administration, Division of Health Planning Department of Finance and Administration, Division of Health Planning
[Unshared] Definition:
"Pharmacy claims file" means a data file containing service level remittance information from all non-denied adjudicated claims for each prescription including, but not limited to: (a) Member demographics; (b) Provider information; (c) Charge/payment information; and (d) National drug codes. Not Provided

Data Elements & Codes

File Specification: Pharmacy Claims File Submission - March 18, 2010 (Tennessee) Pharmacy Claims File Submission - January 31, 2014 - v1.0 (Tennessee)
HD001
[Unshared] Name: Record Type
[Unshared] Type: Text
[Unshared] Length: 2
Codes:
HD
Header Record
Data Element: HD001
not present in this file submission.
HD002
[Unshared] Name: Payer
[Unshared] Type: Text
[Unshared] Length: 8
Data Element: HD002
not present in this file submission.
HD003
[Unshared] Name: National Plan ID
[Unshared] Type: Text
[Unshared] Length: 30
Data Element: HD003
not present in this file submission.
HD004
[Unshared] Name: Type of File
[Unshared] Type: Text
[Unshared] Length: 2
Codes:
MC
Medical Claims
Data Element: HD004
not present in this file submission.
HD005
[Unshared] Name: Period Beginning Date
[Unshared] Type: Integer
[Unshared] Length: 6
Data Element: HD005
not present in this file submission.
HD006
[Unshared] Name: Period Ending Date
[Unshared] Type: Integer
[Unshared] Length: 6
Data Element: HD006
not present in this file submission.
HD007
[Unshared] Name: Record Count
[Unshared] Type: Integer
[Unshared] Length: 10
Data Element: HD007
not present in this file submission.
HD008
[Unshared] Name: Comments
[Unshared] Type: Text
[Unshared] Length: 80
Data Element: HD008
not present in this file submission.
ADJ_TYP_CD
Data Element: ADJ_TYP_CD
not present in this file submission.
[Unshared] Name: Adjustment Type Code
[Unshared] Type: Char
[Unshared] Length: 1
Codes:
O
Original
R
Replacement
V
Void
CHARGE
Data Element: CHARGE
not present in this file submission.
[Unshared] Name: Gross Amount Due
[Unshared] Type: Decimal (signed)
[Unshared] Length: 14
CLAIM
Data Element: CLAIM
not present in this file submission.
[Unshared] Name: Payer Claim Control Number
[Unshared] Type: Text
[Unshared] Length: 53
CLAIM_STATUS
Data Element: CLAIM_STATUS
not present in this file submission.
[Unshared] Name: Claim Status
[Unshared] Type: Numeric
[Unshared] Length: 2
Codes:
1
Processed as primary
2
Processed as secondary
3
Processed as tertiary
4
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
25
none
COINSURANCE
Data Element: COINSURANCE
not present in this file submission.
[Unshared] Name: Coinsurance amount
[Unshared] Type: Decimal (signed)
[Unshared] Length: 14
COMPOUND_DRUG
Data Element: COMPOUND_DRUG
not present in this file submission.
[Unshared] Name: Compound Drug Indicator
[Unshared] Type: Char
[Unshared] Length: 1
Codes:
N
no compound
U
not specified
Y
compound
COPAY
Data Element: COPAY
not present in this file submission.
[Unshared] Name: Copay Amount
[Unshared] Type: Decimal (signed)
[Unshared] Length: 14
DAW
Data Element: DAW
not present in this file submission.
[Unshared] Name: Dispense as Written Code
[Unshared] Type: Char
[Unshared] 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
Subsitution not allowed - brand drug mandated by law
8
Subsitution allowed - generic drug not available in marketplace
9
Other
DAY_SUPPLY
Data Element: DAY_SUPPLY
not present in this file submission.
[Unshared] Name: Days Supply
[Unshared] Type: Numeric (Signed)
[Unshared] Length: 6
DEDUCTIBLE
Data Element: DEDUCTIBLE
not present in this file submission.
[Unshared] Name: Deductible amount
[Unshared] Type: Decimal (signed)
[Unshared] Length: 14
DISPENSE_FEE
Data Element: DISPENSE_FEE
not present in this file submission.
[Unshared] Name: Dispensing Fee
[Unshared] Type: Decimal (signed)
[Unshared] Length: 14
DRUG_NAME
Data Element: DRUG_NAME
not present in this file submission.
[Unshared] Name: Drug Name
[Unshared] Type: Text
[Unshared] Length: 80
FILLER
Data Element: FILLER
not present in this file submission.
[Unshared] Name: FILLER
[Unshared] Type: Char
[Unshared] Length: 500
FILL_DATE
Data Element: FILL_DATE
not present in this file submission.
[Unshared] Name: Date Prescription Filled
[Unshared] Type: Date
[Unshared] Length: 8
GENERIC
Data Element: GENERIC
not present in this file submission.
[Unshared] Name: Generic Drug Indicator
[Unshared] Type: Text
[Unshared] Length: 1
Codes:
N
No, Branded Drug
Y
Yes, Generic Drug
INGREDIENT_COST
Data Element: INGREDIENT_COST
not present in this file submission.
[Unshared] Name: Ingredient Cost/List Price
[Unshared] Type: Decimal (signed)
[Unshared] Length: 14
LINE
Data Element: LINE
not present in this file submission.
[Unshared] Name: Line Counter
[Unshared] Type: Numeric
[Unshared] Length: 4
MEMBERIDN
Data Element: MEMBERIDN
not present in this file submission.
[Unshared] Name: Member ID Number
[Unshared] Type: Char
[Unshared] Length: 15
NDC
Data Element: NDC
not present in this file submission.
[Unshared] Name: National Drug Code
[Unshared] Type: Numeric
[Unshared] Length: 2
NEWPR
Data Element: NEWPR
not present in this file submission.
[Unshared] Name: New Prescription or Refill
[Unshared] Type: Text
[Unshared] Length: 53
Codes:
00
New prescription
01-99
Number of refill(s)
ORIG_CLM_ID
Data Element: ORIG_CLM_ID
not present in this file submission.
[Unshared] Name: Original Claim ID number
[Unshared] Type: Char
[Unshared] Length: 11
PAID_DATE
Data Element: PAID_DATE
not present in this file submission.
[Unshared] Name: First Paid Date and Last Paid Date
[Unshared] Type: Date
[Unshared] Length: 8
PAID_RX
Data Element: PAID_RX
not present in this file submission.
[Unshared] Name: Paid Amount (RX Paid Amount)
[Unshared] Type: Decimal (signed)
[Unshared] Length: 14
PAYER
Data Element: PAYER
not present in this file submission.
[Unshared] Name: PAYER
[Unshared] Type: Text
[Unshared] Length: 8
PAYERCODE
Data Element: PAYERCODE
not present in this file submission.
[Unshared] Name: Payer Code
[Unshared] Type: Char
[Unshared] Length: 8
Codes:
TNC
Commercial data reporter
TNG
Governmental payer
PC001
[Unshared] Name: Payer
[Unshared] Type: Text
[Unshared] Length: 8
Codes:
TNC
Commercial Carrier
TNG
Governmental Agency
TNT
Third-Party Administrator
TNU
Unlicensed Entity
Data Element: PC001
not present in this file submission.
PC002
[Unshared] Name: National Plan ID
[Unshared] Type: Text
[Unshared] Length: 30
Data Element: PC002
not present in this file submission.
PC003
[Unshared] Name: Insurance Type/Product Code
[Unshared] Type: Text
[Unshared] Length: 6
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 Advantage
DS
Disability
HM
Health Maintenance Organization
MA
Medicare Part A
MB
Medicare Part B
MCTNCR
Tennessee Medicaid (TennCare)
MD
Medicare Part D
OF
Other Federal Program (eg, Black Lung)
TV
Title V
VA
Veteran Administration Plan
WC
Workers' Compensation
XXTNAC
AccessTN
XXTNCV
CoverTN
XXTNKD
CoverKids
Data Element: PC003
not present in this file submission.
PC004
[Unshared] Name: Payer Claim Control Number
[Unshared] Type: Text
[Unshared] Length: 35
Data Element: PC004
not present in this file submission.
PC005
[Unshared] Name: Line Counter
[Unshared] Type: Integer
[Unshared] Length: 4
Data Element: PC005
not present in this file submission.
PC006
[Unshared] Name: Insured Group Or Policy Number
[Unshared] Type: Text
[Unshared] Length: 30
Data Element: PC006
not present in this file submission.
PC007
[Unshared] Name: Encrypted Subscriber Index Number
[Unshared] Type: Text
[Unshared] Length: 128
Data Element: PC007
not present in this file submission.
PC008
[Unshared] Name: Encrypted Plan Specific Contract Index Number
[Unshared] Type: Text
[Unshared] Length: 128
Data Element: PC008
not present in this file submission.
PC009
[Unshared] Name: Member Suffix Number
[Unshared] Type: Integer
[Unshared] Length: 20
Data Element: PC009
not present in this file submission.
PC010
[Unshared] Name: Encrypted Member Index Number
[Unshared] Type: Text
[Unshared] Length: 128
Data Element: PC010
not present in this file submission.
PC011
[Unshared] Name: Individual Relationship Code
[Unshared] Type: Integer
[Unshared] Length: 2
Codes:
01
Covered Individual is Policyholder
02
Spouse
03
Child
04
Other
Data Element: PC011
not present in this file submission.
PC012
[Unshared] Name: Member Gender
[Unshared] Type: Integer
[Unshared] Length: 1
Codes:
1
Male
2
Female
3
Unknown
Data Element: PC012
not present in this file submission.
PC013
[Unshared] Name: Member Year of Birth
[Unshared] Type: Date
[Unshared] Length: 8
Data Element: PC013
not present in this file submission.
PC014
[Unshared] Name: Member City Name of Residence
[Unshared] Type: Text
[Unshared] Length: 30
Data Element: PC014
not present in this file submission.
PC015
[Unshared] Name: Member State or Province
[Unshared] Type: Text
[Unshared] Length: 2
Data Element: PC015
not present in this file submission.
PC016
[Unshared] Name: Member ZIP Code
[Unshared] Type: Text
[Unshared] Length: 5
Data Element: PC016
not present in this file submission.
PC017
[Unshared] Name: Date Service Approved (AP Date)
[Unshared] Type: Date
[Unshared] Length: 8
Data Element: PC017
not present in this file submission.
PC018
[Unshared] Name: Pharmacy Number
[Unshared] Type: Text
[Unshared] Length: 30
Data Element: PC018
not present in this file submission.
PC019
[Unshared] Name: Pharmacy TaxID
[Unshared] Type: Text
[Unshared] Length: 10
Data Element: PC019
not present in this file submission.
PC020
[Unshared] Name: Pharmacy Name
[Unshared] Type: Text
[Unshared] Length: 30
Data Element: PC020
not present in this file submission.
PC021
[Unshared] Name: National Pharmacy ID Number
[Unshared] Type: Text
[Unshared] Length: 20
Data Element: PC021
not present in this file submission.
PC022
[Unshared] Name: Pharmacy Location City
[Unshared] Type: Text
[Unshared] Length: 30
Data Element: PC022
not present in this file submission.
PC023
[Unshared] Name: Pharmacy Location State
[Unshared] Type: Text
[Unshared] Length: 2
Data Element: PC023
not present in this file submission.
PC024
[Unshared] Name: Pharmacy Zip Code
[Unshared] Type: Text
[Unshared] Length: 11
Data Element: PC024
not present in this file submission.
PC024A
[Unshared] Name: Pharmacy Country Code
[Unshared] Type: Text
[Unshared] Length: 30
Data Element: PC024A
not present in this file submission.
PC025
[Unshared] Name: Claim Status
[Unshared] Type: Text
[Unshared] Length: 2
Codes:
1
Processed as primary
2
Processed as secondary
3
Processed as tertiary
4
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
25
Predetermination pricing only - no payment
Data Element: PC025
not present in this file submission.
PC026
[Unshared] Name: Drug Code
[Unshared] Type: Text
[Unshared] Length: 11
Data Element: PC026
not present in this file submission.
PC027
[Unshared] Name: Drug Name
[Unshared] Type: Text
[Unshared] Length: 80
Data Element: PC027
not present in this file submission.
PC028
[Unshared] Name: New Prescription or Refill
[Unshared] Type: Integer
[Unshared] Length: 2
Codes:
00
New prescription
01-99
Refill prescription
Data Element: PC028
not present in this file submission.
PC029
[Unshared] Name: Generic Drug Indicator
[Unshared] Type: Text
[Unshared] Length: 1
Codes:
N
No, branded drug
Y
Yes, generic drug
Data Element: PC029
not present in this file submission.
PC030
[Unshared] Name: Dispense as Written Code
[Unshared] Type: Integer
[Unshared] 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
Data Element: PC030
not present in this file submission.
PC031
[Unshared] Name: Compound Drug Indicator
[Unshared] Type: Text
[Unshared] Length: 1
Codes:
N
No compound
U
Not specified
Y
Compound
Data Element: PC031
not present in this file submission.
PC032
[Unshared] Name: Date Prescription Filled
[Unshared] Type: Text
[Unshared] Length: 8
Data Element: PC032
not present in this file submission.
PC033
[Unshared] Name: Quantity Dispensed
[Unshared] Type: Integer
[Unshared] Length: 5
Data Element: PC033
not present in this file submission.
PC034
[Unshared] Name: Days Supply
[Unshared] Type: Integer
[Unshared] Length: 3
Data Element: PC034
not present in this file submission.
PC035
[Unshared] Name: Gross Amount Due
[Unshared] Type: Decimal
[Unshared] Length: 10
Data Element: PC035
not present in this file submission.
PC036
[Unshared] Name: Total Amount Paid
[Unshared] Type: Decimal
[Unshared] Length: 10
Data Element: PC036
not present in this file submission.
PC037
[Unshared] Name: Ingredient Cost/List Price
[Unshared] Type: Decimal
[Unshared] Length: 10
Data Element: PC037
not present in this file submission.
PC038
[Unshared] Name: Postage Amount Claimed
[Unshared] Type: Decimal
[Unshared] Length: 10
Data Element: PC038
not present in this file submission.
PC039
[Unshared] Name: Dispensing Fee Paid
[Unshared] Type: Decimal
[Unshared] Length: 10
Data Element: PC039
not present in this file submission.
PC040
[Unshared] Name: Copay
[Unshared] Type: Decimal
[Unshared] Length: 10
Data Element: PC040
not present in this file submission.
PC041
[Unshared] Name: Coinsurance Amount
[Unshared] Type: Decimal
[Unshared] Length: 10
Data Element: PC041
not present in this file submission.
PC042
[Unshared] Name: Deductible Amount
[Unshared] Type: Decimal
[Unshared] Length: 10
Data Element: PC042
not present in this file submission.
PC043
[Unshared] Name: Placeholder
[Unshared] Type: N/A
[Unshared] Length: N/A
Data Element: PC043
not present in this file submission.
PC044
[Unshared] Name: Prescribing Physician First Name
[Unshared] Type: Text
[Unshared] Length: 25
Data Element: PC044
not present in this file submission.
PC045
[Unshared] Name: Prescribing Physician Middle Name
[Unshared] Type: Text
[Unshared] Length: 25
Data Element: PC045
not present in this file submission.
PC046
[Unshared] Name: Prescribing Physician Last Name
[Unshared] Type: Text
[Unshared] Length: 60
Data Element: PC046
not present in this file submission.
PC047
[Unshared] Name: Prescribing Physician Number
[Unshared] Type: Text
[Unshared] Length: 10
Codes:
01
National Provider Identifier (NPI) (eg, 01-1234567890)
12
Drug Enforcement Administration (DEA) (eg, 12-JK523698)
13
State Issued (L&I Provider ID) (eg, 13-L23365)
Data Element: PC047
not present in this file submission.
PC101
[Unshared] Name: Placeholder
[Unshared] Type: N/A
[Unshared] Length: N/A
Data Element: PC101
not present in this file submission.
PC102
[Unshared] Name: Placeholder
[Unshared] Type: N/A
[Unshared] Length: N/A
Data Element: PC102
not present in this file submission.
PC103
[Unshared] Name: Placeholder
[Unshared] Type: N/A
[Unshared] Length: N/A
Data Element: PC103
not present in this file submission.
PC104
[Unshared] Name: Encrypted Index Number, Member Last Name
[Unshared] Type: Text
[Unshared] Length: 128
Data Element: PC104
not present in this file submission.
PC105
[Unshared] Name: Encrypted Index Number, Member First Name
[Unshared] Type: Text
[Unshared] Length: 128
Data Element: PC105
not present in this file submission.
PC106
[Unshared] Name: Placeholder
[Unshared] Type: N/A
[Unshared] Length: N/A
Data Element: PC106
not present in this file submission.
PC899
[Unshared] Name: Record Type
[Unshared] Type: Text
[Unshared] Length: 2
Codes:
PC
Pharmacy Claims
Data Element: PC899
not present in this file submission.
PID_RX
Data Element: PID_RX
not present in this file submission.
[Unshared] Name: Pharmacy ID number Pharmacy Claims
[Unshared] Type: Text
[Unshared] Length: 40
PLAN_NPI
Data Element: PLAN_NPI
not present in this file submission.
[Unshared] Name: National Plan ID
[Unshared] Type: Text
[Unshared] Length: 30
POSTAGE
Data Element: POSTAGE
not present in this file submission.
[Unshared] Name: Postage Amount Claimed
[Unshared] Type: Decimal (signed)
[Unshared] Length: 14
PRODUCT
Data Element: PRODUCT
not present in this file submission.
[Unshared] Name: Standardized Product Code
[Unshared] Type: Char
[Unshared] Length: 6
Codes:
12
Medicare Secondary Working Aged Beneficiary or Spouse with an Employer's 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 Workers Compensation
16
Medicare Secondary Public Health Service or Other Federal Agency
41
Medicare Secondary Black Lung
42
Medicare Secondary Veterans Administration
43
Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health
47
Medicare Secondary, Other Liability Insurance is Primary
ACA
Affordable Care Act
CP
Medicare Conditionally Primary
D
Disability
DB
Disability Benefits
EP
Exclusive Provider Organization
HM
Health Maintenance Organization (HMO)
HN
Health Maintenance Organization (HMO) Medicare Risk / Medicare Part C
HS
Special Low Income Medicare Beneficiary
IN
Indemnity
MA
Medicare Part A
MB
Medicare Part B
MCTNCR
Tennessee Medicaid (TennCare)
MD
Medicare Part D
MH
Medigap Part A
MI
Medigap Part B
MP
Medicare Primary
PR
Preferred Provider Organization (PPO)
PS
Point of Service (POS)
QM
Qualified Medicare Beneficiary
SP
Supplemental Policy
WC
Worker's Compensation
XXTNAC
AccessTN
XXTNCV
CoverTN
XXTNKD
CoverKids
QTY
Data Element: QTY
not present in this file submission.
[Unshared] Name: Quantity Dispensed
[Unshared] Type: Decimal (signed)
[Unshared] Length: 14
RX_PRVIDN
Data Element: RX_PRVIDN
not present in this file submission.
[Unshared] Name: Prescribing Physician ID Number
[Unshared] Type: Numeric
[Unshared] Length: 20
SVC_PHARMIDN
Data Element: SVC_PHARMIDN
not present in this file submission.
[Unshared] Name: Servicing Pharmacy ID Number
[Unshared] Type: Numeric
[Unshared] Length: 20
THIRTY_DAY_EQUIV
Data Element: THIRTY_DAY_EQUIV
not present in this file submission.
[Unshared] Name: Thirty Day Equivalency
[Unshared] Type: Numeric
[Unshared] Length: 3
TR001
[Unshared] Name: Record Type
[Unshared] Type: Text
[Unshared] Length: 2
Codes:
TR
Trailer Record
Data Element: TR001
not present in this file submission.
TR002
[Unshared] Name: Payer
[Unshared] Type: Text
[Unshared] Length: 8
Data Element: TR002
not present in this file submission.
TR003
[Unshared] Name: National Plan ID
[Unshared] Type: Text
[Unshared] Length: 30
Data Element: TR003
not present in this file submission.
TR004
[Unshared] Name: Type of File
[Unshared] Type: Text
[Unshared] Length: 2
Codes:
PC
Pharmacy Claims
Data Element: TR004
not present in this file submission.
TR005
[Unshared] Name: Period Beginning Date
[Unshared] Type: Integer
[Unshared] Length: 6
Data Element: TR005
not present in this file submission.
TR006
[Unshared] Name: Period Ending Date
[Unshared] Type: Integer
[Unshared] Length: 6
Data Element: TR006
not present in this file submission.
TR007
[Unshared] Name: Date Processed
[Unshared] Type: Date
[Unshared] Length: 8
Data Element: TR007
not present in this file submission.
VERSION_NUM
Data Element: VERSION_NUM
not present in this file submission.
[Unshared] Name: Claim Version
[Unshared] Type: Numeric
[Unshared] Length: 4
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