United States Health Information Knowledgebase

 

Colorado



At A Glance

Name:Colorado
Abbreviation:CO
Title of SystemColorado All Payer Claims Database
Websitehttp://www.cohealthdata.org Exit Disclaimer [www.cohealthdata.org]
Who Maintains the SystemCenter for Improving Value in Health Care (CIVHC)
Versions:August 2011 - v3
March 2013 - v5
March 2014 - v6

Medical Claims

File Specification for Multiple versionsMedical Claims File Submission - March 2014 - v6

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type Not Provided char 2
Multiple versionsHD002 Payer Code Distributed by CIVHC varchar 8
Multiple versionsHD003 Payer Name Distributed by CIVHC varchar 75
Multiple versionsHD004 Beginning Month Not Provided date CCYYMM 6
Multiple versionsHD005 Ending Month Not Provided date CCYYMM 6
Multiple versionsHD006 Record count Total number of records submitted in the medical claims file, excluding header and trailer records int 10
Multiple versionsMC001 Payer Code Distributed by CIVHC varchar 8
Multiple versionsMC002 Payer Name Distributed by CIVHC varchar 30
Multiple versionsMC003 Insurance Type/Product Code Not Provided char 2
Multiple versionsMC004 Payer Claim Control Number Must apply to the entire claim and be unique within the payer's system. No partial claims. Only paid (or partially paid) claims varchar 35
Multiple versionsMC005 Line Counter Line number for this service. The line counter begins with 1 and is incremented by 1 for each additional service line of a claim. All claims must contain a line 1. int 4
Multiple versionsMC005A Version Number The version number of this claim service line. The original claim will have a version number of 0, with the next version being assigned a 1, and each subsequent version being incremented by 1 for that service line. Plans that cannot increment this column may opt to use YYMM as the version number. int 4
Multiple versionsMC006 Insured Group or Policy Number Group or policy number - not the number that uniquely identifies the subscriber. varchar 30
Multiple versionsMC007 Subscriber Social Security Number Subscriber's social security number; Set as null if unavailable varchar 9
Multiple versionsMC008 Plan Specific Contract Number Plan assigned subscriber's contract number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the subscriber. varchar 128
Multiple versionsMC009 Member Suffix or Sequence Number Unique number of the member within the contract. Must be an identifier that is unique to the member. varchar 20
Multiple versionsMC010 Member Identification Code (patient) Member's social security number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the member. varchar 9
Multiple versionsMC011 Individual Relationship Code Member's relationship to insured char 2
Multiple versionsMC012 Member Gender Not Provided char 1
Multiple versionsMC013 Member Date of Birth Not Provided char YYYYMMDD 8
Multiple versionsMC014 Member City Name City name of member varchar 30
Multiple versionsMC107 Member Street Address Physical street address of the covered member Varchar 50
Multiple versionsMC015 Member State or Province As defined by the US Postal Service char 2
Multiple versionsMC016 Member ZIP Code ZIP Code of member - may include non- US codes. Plus 4 optional but desired. varchar 11
Multiple versionsMC017 Date Service Approved/Accounts Payable Date/Actual Paid Date Not Provided char YYYYMMDD 8
Multiple versionsMC018 Admission Date Required for all inpatient claims. char YYYYMMDD 8
Multiple versionsMC019 Admission Hour Required for all inpatient claims. Time is expressed in military time char HHMM 4
Multiple versionsMC020 Admission Type Required for all inpatient claims (SOURCE: National Uniform Billing Data Element Specifications) int 1
Multiple versionsMC021 Admission Source Required for all inpatient claims (SOURCE: National Uniform Billing Data Element Specifications) char 1
Multiple versionsMC022 Discharge Hour Time expressed in military time int HHMM 4
Multiple versionsMC023 Discharge Status Required for all inpatient claims. char 2
Multiple versionsMC024 Service Provider Number Payer assigned service provider number. Submit facility for institutional claims; physician or healthcare professional for professional claims. varchar 30
Multiple versionsMC025 Service Provider Tax ID Number Federal taxpayer's identification number varchar 10
Multiple versionsMC026 Service National Provider ID National Provider ID. This data element pertains to the entity or individual directly providing the service. varchar 20
Multiple versionsMC027 Service Provider Entity Type Qualifier HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as a "person", and these shall be coded as a person. char 1
Multiple versionsMC028 Service Provider First Name Individual first name. Set to null if provider is a facility or organization. varchar 25
Multiple versionsMC029 Service Provider Middle Name Individual middle name or initial. Set to null if provider is a facility or organization. varchar 25
Multiple versionsMC030 Service Provider Last Name or Organization Name Full name of provider organization or last name of individual provider varchar 60
Multiple versionsMC031 Service Provider Suffix Suffix to individual name. Set to null if provider is a facility or organization. The service provider suffix shall be used to capture the generation of the individual clinician (e.g., Jr., Sr., III), if applicable, rather than the clinician's degree (e.g., MD, LCSW). varchar 10
Multiple versionsMC032 Service Provider Specialty As defined by payer. Dictionary for specialty code values must be supplied during testing. varchar 10
Multiple versionsMC108 Service Provider Street Address Physical practice location street address of the provider administering the services Varchar 50
Multiple versionsMC033 Service Provider City Name City name of provider - preferably practice location varchar 30
Multiple versionsMC034 Service Provider State or Province As defined by the US Postal Service char 2
Multiple versionsMC035 Service Provider ZIP Code ZIP Code of provider - may include non- US codes; do not include dash. Plus 4 optional but desired. varchar 11
Multiple versionsMC036 Type of Bill - Institutional Required for institutional claims; Not to be used for professional claims char 3
Multiple versionsMC037 Place of Service Required for professional claims. Not to be used for institutional claims. Map where you can and default to "99" for all others. char 2
Multiple versionsMC038 Claim Status Not Provided char 2
Multiple versionsMC039 Admitting Diagnosis Required on all inpatient admission claims and encounters. ICD-9-CM or ICD-10-CM. Do not code decimal point. varchar 7
Multiple versionsMC898 ICD-9 / ICD-10 Flag The purpose of this field is to identify which code set is being utilized. char 1
Multiple versionsMC040 E-Code Describes an injury, poisoning or adverse effect. ICD-9-CM or ICD-10-CM. Do not code decimal point. varchar 7
Multiple versionsMC041 Principal Diagnosis ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC042 Other Diagnosis - 1 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC043 Other Diagnosis - 2 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC044 Other Diagnosis - 3 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC045 Other Diagnosis - 4 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC046 Other Diagnosis - 5 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC047 Other Diagnosis - 6 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC048 Other Diagnosis - 7 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC049 Other Diagnosis - 8 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC050 Other Diagnosis - 9 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC051 Other Diagnosis - 10 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC052 Other Diagnosis - 11 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC053 Other Diagnosis - 12 ICD-9-CM or ICD-10_CM. Do not code decimal point. varchar 7
Multiple versionsMC054 Revenue Code National Uniform Billing Committee Codes. Code using leading zeroes, left justified, and four digits. char 10
Multiple versionsMC055 Outpatient Procedure Code Health Care Common Procedural Coding System (HCPCS); this includes the CPT codes of the American Medical Association. Required for Outpatient and Professional claims only. varchar 10
Multiple versionsMC056 Procedure Modifier - 1 Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Required for Outpatient and Professional claims only. char 2
Multiple versionsMC057 Procedure Modifier - 2 Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Required for Outpatient and Professional claims only. char 2
Multiple versionsMC058 ICD-9-CM or ICD-10 Procedure Code Primary procedure code for this line of service. Do not code decimal point. Default to Blank char 7
Multiple versionsMC059 Date of Service - From First date of service for this service line. Date YYYYMMDD 8
Multiple versionsMC060 Date of Service - Thru Last date of service for this service line. Date YYYYMMDD 8
Multiple versionsMC061 Quantity Count of services performed, which shall be set equal to one on all observation bed service lines and should be set equal to zero on all other room and board service lines, regardless of the length of stay. int 3
Multiple versionsMC062 Charge Amount Do not code decimal point or provide any punctuation where $1,000.00 converted to 100000 Same for all financial data that follows. int 10
Multiple versionsMC063 Paid Amount Includes any withhold amounts. Do not code decimal point. For capitated claims set to zero. int 10
Multiple versionsMC064 Prepaid Amount For capitated services, the fee for service equivalent amount. Do not code decimal point. int 10
Multiple versionsMC065 Co-pay Amount The preset, fixed dollar amount for which the individual is responsible. Do not code decimal point. int 10
Multiple versionsMC066 Coinsurance Amount The dollar amount an individual is responsible for - not the percentage. Do not code decimal point. int 10
Multiple versionsMC067 Deductible Amount Do not code decimal point. int 10
Multiple versionsMC068 Patient Account/Control Number Number assigned by hospital varchar 20
Multiple versionsMC069 Discharge Date Date patient discharged. Required for all inpatient claims. Date YYYYMMDD 8
Multiple versionsMC070 Service Provider Country Name Code US for United States. varchar 30
Multiple versionsMC071 DRG Insurers and health care claims processors shall code using the CMS methodology when available. Precedence shall be given to DRGs transmitted from the hospital provider. When the CMS methodology for DRGs is not available, but the DRG system is used, the insurer shall format the DRG and the complexity level within the same field with an "A" prefix, and with a hyphen separating the DRG and the complexity level (e.g. AXXX-XX). varchar 10
Multiple versionsMC072 DRG Version Version number of the grouper used char 2
Multiple versionsMC073 APC Insurers and health care claims processors shall code using the CMS methodology when available. Precedence shall be given to APCs transmitted from the health care provider. char 4
Multiple versionsMC074 APC Version Version number of the grouper used char 2
Multiple versionsMC075 Drug Code An NDC code used only when a medication is paid for as part of a medical claim. varchar 11
Multiple versionsMC076 Billing Provider Number Payer assigned billing provider number. This number should be the identifier used by the payer for internal identification purposes, and does not routinely change. varchar 30
Multiple versionsMC077 National Billing Provider ID National Provider ID varchar 20
Multiple versionsMC078 Billing Provider Last Name or Organization Name Full name of provider billing organization or last name of individual billing provider. varchar 60
Multiple versionsMC101 Subscriber Last Name Subscriber last name varchar 128
Multiple versionsMC102 Subscriber First Name Subscriber first name varchar 128
Multiple versionsMC103 Subscriber Middle Initial Subscriber middle initial char 1
Multiple versionsMC104 Member Last Name Not Provided varchar 128
Multiple versionsMC105 Member First Name Not Provided varchar 128
Multiple versionsMC106 Member Middle Initial Not Provided char 1
Multiple versionsMC201A Present on Admission - PDX Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201B Present on Admission - DX1 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201C Present on Admission - DX2 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201D Present on Admission - DX3 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201E Present on Admission - DX4 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201F Present on Admission - DX5 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201G Present on Admission - DX6 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201H Present on Admission - DX7 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201I Present on Admission - DX8 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201J Present on Admission - DX9 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201K Present on Admission - DX10 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201L Present on Admission - DX11 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC201M Present on Admission - DX12 Code indicating the presence of diagnosis at the time of admission Varchar 1
Multiple versionsMC202 Tooth Number Tooth Number or Letter Identification Char 20
Multiple versionsMC203 Dental Quadrant Dental Quadrant Char 1
Multiple versionsMC204 Tooth Surface Tooth Surface Identification Char 10
Multiple versionsMC205 ICD-9-CM or ICD-10-CM Procedure Date Date MC058 was performed Date 8
Multiple versionsMC058A ICD-9-CM Procedure Code or ICD-10-CM Procedure code Secondary procedure code for this line of service. Do not code decimal point. char 7
Multiple versionsMC205A ICD-9-CM or ICD-10-CM Procedure Date Date MC058A was performed Date 8
Multiple versionsMC058B ICD-9-CM Procedure Code or ICD-10-CM Procedure code Secondary procedure code for this line of service. Do not code decimal point. char 7
Multiple versionsMC205B ICD-9-CM or ICD-10-CM Procedure Date Date MC058B was performed Date 8
Multiple versionsMC058C ICD-9-CM Procedure Code or ICD-10-CM Procedure code Secondary procedure code for this line of service. Do not code decimal point. char 7
Multiple versionsMC205C ICD-9-CM or ICD-10-CM Procedure Date Date MC058C was performed Date 8
Multiple versionsMC058D ICD-9-CM Procedure Code or ICD-10-CM Procedure code Secondary procedure code for this line of service. Do not code decimal point. char 7
Multiple versionsMC205D ICD-9-CM or ICD-10-CM Procedure Date Date MC058E was performed Date 8
Multiple versionsMC058E ICD-9-CM Procedure Code or ICD-10-CM Procedure code Secondary procedure code for this line of service. Do not code decimal point. char 7
Multiple versionsMC205E ICD-9-CM or ICD-10-CM Procedure Date Date MC058E was performed Date 8
Multiple versionsMC206 Capitated Service Indicator Not Provided Char 1
Multiple versionsMC899 Record Type Not Provided char 2
Multiple versionsTR001 Record Type Not Provided char 2
Multiple versionsTR002 Payer Code Distributed by CIVHC varchar 8
Multiple versionsTR003 Payer Name Distributed by CIVHC varchar 75
Multiple versionsTR004 Beginning Month Not Provided date CCYYMM 6
Multiple versionsTR005 Ending Month Not Provided date CCYYMM 6
Multiple versionsTR006 Extraction Date Not Provided date YYYYMMDD 8

Medical Eligibility

File Specification for Multiple versionsMedical Eligibility File Submission - March 2014 - v6

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type Not Provided char 2
Multiple versionsHD002 Payer Code Distributed by CIVHC varchar 8
Multiple versionsHD003 Payer Name Distributed by CIVHC varchar 75
Multiple versionsHD004 Beginning Month Not Provided date CCYYMM 6
Multiple versionsHD005 Ending Month Not Provided date CCYYMM 6
Multiple versionsHD006 Record count Total number of records submitted in the medical eligibility file, excluding header and trailer records int 10
Multiple versionsME001 Payer Code Distributed by CIVHC varchar 8
Multiple versionsME002 Payer Name Distributed by CIVHC varchar 30
Multiple versionsME003 Insurance Type Code/Product changes: Required field; codes added to Lookup Table. char 2
Multiple versionsME004 Year 4 digit Year for which eligibility is reported in this submission int 4
Multiple versionsME005 Month Month for which eligibility is reported in this submission expressed numerical from 01 to 12. char 2
Multiple versionsME006 Insured Group or Policy Number Group or policy number - not the number that uniquely identifies the subscriber varchar 30
Multiple versionsME007 Coverage Level Code Benefit coverage level char 3
Multiple versionsME008 Subscriber Social Security Number Subscriber's social security number; Set as null if unavailable varchar 9
Multiple versionsME009 Plan Specific Contract Number Plan assigned subscriber's contract number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the subscriber. varchar 128
Multiple versionsME010 Member Suffix or Sequence Number Unique number of the member within the contract. Must be an identifier that is unique to the member. This column is the unique identifying column for membership and related medical and pharmacy claims. Only one record per eligibility month. varchar 128
Multiple versionsME011 Member Identification Code Member's social security number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the member. varchar 9
Multiple versionsME012 Individual Relationship Code Member's relationship to insured char 2
Multiple versionsME013 Member Gender Not Provided char 1
Multiple versionsME014 Member Date of Birth Not Provided char YYYYMMDD 8
Multiple versionsME015 Member City Name City location of member varchar 30
Multiple versionsME016 Member State or Province As defined by the US Postal Service char 2
Multiple versionsME017 Member ZIP Code ZIP Code of member - may include non-US codes. Do not include dash. Plus 4 optional but desired. varchar 11
Multiple versionsME018 Medical Coverage Not Provided char 1
Multiple versionsME019 Prescription Drug Coverage Not Provided char 1
Multiple versionsME020 Dental Coverage Not Provided char 1
Multiple versionsME021 Race 1 Not Provided varchar 6
Multiple versionsME022 Race 2 Not Provided varchar 6
Multiple versionsME023 Other Race List race if MC021or MC022 are coded as R9. varchar 15
Multiple versionsME024 Hispanic Indicator Not Provided char 1
Multiple versionsME025 Ethnicity 1 Not Provided varchar 6
Multiple versionsME026 Ethnicity 2 Not Provided varchar 6
Multiple versionsME027 Other Ethnicity List ethnicity if MC025 or MC026 are coded as OTHER. varchar 20
Multiple versionsME028 Primary Insurance Indicator Not Provided char 1
Multiple versionsME029 Coverage Type Insurers using this code shall obtain prior approval. char 3
Multiple versionsME030 Market Category Code Not Provided varchar 4
Multiple versionsME032 Employer Tax ID Employer tax ID varchar 50
Multiple versionsME043 Member Street Address Street address of member varchar 50
Multiple versionsME044 Employer Group Name Employer Group Name or IND for individual Policies varchar 128
Multiple versionsME101 Subscriber Last Name The subscriber last name varchar 128
Multiple versionsME102 Subscriber First Name The subscriber first name varchar 128
Multiple versionsME103 Subscriber Middle Initial The subscriber middle initial char 1
Multiple versionsME104 Member Last Name The member last name varchar 128
Multiple versionsME105 Member First Name The member first name varchar 128
Multiple versionsME897 Plan Effective Date Date eligibility started for this member under this plan type. The purpose of this data element is to maintain eligibility span for each member. char YYYYMMDD 8
Multiple versionsME045 Exchange Offering Identifies whether or not a policy was purchased through the Colorado Health Benefits Exchange (COBHE). char 1
Multiple versionsME106 Group Size Code indicating Group Size consistent with Colorado Insurance Law and Regulation Required only for plans sold in the commercial large, small and non-group markets. The following plan/products do not need to report this value: Student plans Medicare supplemental Medicaid-funded plans Stand-alone behavioral health, dental and vision char 2
Multiple versionsME107 Risk Basis Default to "F" for grandfathered Plans char 1
Multiple versionsME108 High Deductible/ Health Savings Account Plan Default to "N" for grandfathered Plans char 1
Multiple versionsME120 Actuarial Value Report value as calculated in the most recent version of the HHS Actuarial Value Calculator available at http://cciio.cms.gov/resources/regulations/index.html Size includes decimal point. Required as of January 1, 2014 for small group and non-group (individual) plans sold inside or outside the Exchange. Default to "0" for Grandfathered plans decimal 6
Multiple versionsME121 Metallic Value Metal Level (percentage of Actuarial Value) per federal regulations... Required as of January 1, 2014 for small group and non-group (individual) plans sold inside or outside the Exchange. Use values provided in the most recent version of the HHS Actuarial Value Calculator available at : http://cciio.cms.gov/resources/regulations/index.html Default to "0" for Grandfathered plans int 1
Multiple versionsME122 Grandfather Status See definition of "grandfathered plans" in HHS rules CFR 147.140 Required as of January 1, 2014 for small group and non-group (individual) plans sold inside or outside the Exchange. Default to "0" for  Grandfathered plans Char 1
Multiple versionsME899 Record Type Not Provided char 2
Multiple versionsTR001 Record Type Not Provided char 2
Multiple versionsTR002 Payer Code Distributed by CIVHC varchar 8
Multiple versionsTR003 Payer Name Distributed by CIVHC varchar 75
Multiple versionsTR004 Beginning Month Not Provided date CCYYMM 6
Multiple versionsTR005 Ending Month Not Provided date CCYYMM 6
Multiple versionsTR006 Extraction Date Not Provided date YYYYMMDD 8

Medical Provider

File Specification for Multiple versionsMedical Provider File Submission - March 2014 - v6

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type Not Provided char 2
Multiple versionsHD002 Payer Code Distributed by CIVHC varchar 8
Multiple versionsHD003 Payer Name Distributed by CIVHC varchar 75
Multiple versionsHD004 Beginning Month Example: 200801 Date CCYYMM 6
Multiple versionsHD005 Ending Month Example: 200812 Date CCYYMM 6
Multiple versionsHD006 Record count Total number of records submitted in the medical eligibility file, excluding header and trailer records int 10
Multiple versionsMP001 Provider ID Unique identified for the provider as assigned by the reporting entity varchar 30
Multiple versionsMP002 Provider Tax ID Tax ID of the provider. Do not code punctuation. varchar 10
Multiple versionsMP003 Provider Entity Not Provided char 1
Multiple versionsMP004 Provider First Name Individual first name. Set to null if provider is a facility or organization. varchar 25
Multiple versionsMP005 Provider Middle Name or Initial Not Provided varchar 25
MP006 Provider Last Name or Organization Name Full name of provider organization or last name of individual provider varchar 60
Multiple versionsMP007 Provider Suffix Example: Jr; null if provider is an organization. Do not use credentials such as MD or PhD varchar 10
Multiple versionsMP008 Provider Specialty Report the HIPAA-compliant health care provider taxonomy code. Code set is freely available at the National Uniform Claims Committee's web site at http://www.nucc.org/ varchar 50
Multiple versionsMP009 Provider Office Street Address Physical address - address where provider delivers health care services varchar 50
Multiple versionsMP010 Provider Office City Physical address - address where provider delivers health care services varchar 30
Multiple versionsMP011 Provider Office State Physical address - address where provider delivers health care services. Use postal service standard 2 letter abbreviations. char 2
Multiple versionsMP012 Provider Office Zip Physical address - address where provider delivers health care services. Minimum 5 digit code. varchar 11
Multiple versionsMP013 Provider DEA Number Not Provided varchar 12
Multiple versionsMP014 Provider NPI Not Provided varchar 20
Multiple versionsMP015 Provider State License Number Prefix with two-character state of licensure with no punctuation. Example COLL12345 varchar 20
MP016 Provider office Address Physical address - address where provider delivers health care services: Suite number, floor number, Unit number, etc. Varchar 10
MP017 Provider Office number Provider Office number: Telephone number where provider delivers health care services. varchar 10
Multiple versionsMP899 Record Type Not Provided char 2
Multiple versionsTR001 Record Type Not Provided char 2
Multiple versionsTR002 Payer Code Distributed by CIVHC varchar 8
Multiple versionsTR003 Payer Name Distributed by CIVHC varchar 75
Multiple versionsTR004 Beginning Month Example: 200801 Date CCYYMM 6
Multiple versionsTR005 Ending Month Example: 200812 Date CCYYMM 6
Multiple versionsTR006 Extraction Date Not Provided Date YYYYMMDD 8

Pharmacy Claims

File Specification for Multiple versionsPharmacy Claims File Submission - March 2014 - v6

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type Not Provided char 2
Multiple versionsHD002 Payer Code Distributed by CIVHC char 8
Multiple versionsHD003 Payer Name Distributed by CIVHC char 75
Multiple versionsHD004 Beginning Month Not Provided Date CCYYMM 6
Multiple versionsHD005 Ending Month Not Provided Date CCYYMM 6
Multiple versionsHD006 Record count Total number of records submitted in the medical claims file, excluding header and trailer records int 10
Multiple versionsPC001 Payer Code Distributed by CIVHC varchar 8
Multiple versionsPC002 Payer Name Distributed by CIVHC varchar 30
Multiple versionsPC003 Insurance Type/Product Code Not Provided char 2
Multiple versionsPC004 Payer Claim Control Number Must apply to the entire claim and be unique within the payer's system. varchar 35
Multiple versionsPC005 Line Counter Line number for this service. The line counter begins with 1 and is incremented by 1 for each additional service line of a claim. int 4
Multiple versionsPC006 Insured Group Number Group or policy number - not the number that uniquely identifies the subscriber varchar 30
Multiple versionsPC007 Subscriber Social Security Number Subscriber's social security number; Set as null if unavailable varchar 9
Multiple versionsPC008 Plan Specific Contract Number Plan assigned subscriber's contract number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the subscriber. varchar 128
Multiple versionsPC009 Member Suffix or Sequence Number Unique number of the member within the contract. Must be an identifier that is unique to the member. varchar 20
Multiple versionsPC010 Member Identification Code Member's social security number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the member. varchar 128
Multiple versionsPC011 Individual Relationship Code Member's relationship to insured char 2
Multiple versionsPC012 Member Gender Not Provided char 1
Multiple versionsPC013 Member Date of Birth Not Provided Date YYYYMMDD 8
Multiple versionsPC014 Member City Name of Residence City name of member varchar 50
Multiple versionsPC015 Member State or Province As defined by the US Postal Service char 2
Multiple versionsPC016 Member ZIP Code ZIP Code of member - may include non-US codes; Do not include dash. Plus 4 optional but desired. varchar 11
Multiple versionsPC017 Date Service Approved (AP Date) date claim paid if available, otherwise set to Date Prescription Filled Date YYYYMMDD 8
Multiple versionsPC018 Pharmacy Number Payer assigned pharmacy number. AHFS number is acceptable. varchar 30
Multiple versionsPC019 Pharmacy Tax ID Number Federal taxpayer's identification number coded with no punctuation (carriers that contract with outside PBM's will not have this) varchar 10
Multiple versionsPC020 Pharmacy Name Name of pharmacy varchar 50
Multiple versionsPC021 National Provider ID Number National Provider ID. This data element pertains to the entity or individual directly providing the service. varchar 20
Multiple versionsPC048 Pharmacy Location Street Address Street address of pharmacy Varchar 30
Multiple versionsPC022 Pharmacy Location City City name of pharmacy - preferably pharmacy location (if mail order null) varchar 30
Multiple versionsPC023 Pharmacy Location State As defined by the US Postal Service (if mail order null) char 2
Multiple versionsPC024 Pharmacy ZIP Code ZIP Code of pharmacy - may include non-US codes. Do not include dash. Plus 4 optional but desired (if mail order null) varchar 10
Multiple versionsPC024d Pharmacy Country Name Code US for United States varchar 30
Multiple versionsPC025 Claim Status Not Provided char 2
Multiple versionsPC026 Drug Code NDC Code varchar 11
Multiple versionsPC027 Drug Name Text name of drug varchar 80
Multiple versionsPC028 New Prescription or Refill Older systems provide only an "N" for new or an "R" for refill, otherwise provide refill # varchar 2
Multiple versionsPC029 Generic Drug Indicator Not Provided char 2
Multiple versionsPC030 Dispense as Written Code Payers able to map available codes to those below char 1
Multiple versionsPC031 Compound Drug Indicator Not Provided char 1
Multiple versionsPC032 Date Prescription Filled Not Provided Date YYYYMMDD 8
Multiple versionsPC033 Quantity Dispensed Number of metric units of medication dispensed int 5
Multiple versionsPC034 Days Supply Estimated number of days the prescription will last int 3
Multiple versionsPC035 Charge Amount Do not code decimal point or provide any punctuation where $1,000.00 converted to 100000 Same for all financial data that follows. int 10
Multiple versionsPC036 Paid Amount Includes all health plan payments and excludes all member payments. Do not code decimal point. int 10
Multiple versionsPC037 Ingredient Cost/List Price Cost of the drug dispensed. Do not code decimal point. int 10
Multiple versionsPC038 Postage Amount Claimed Do not code decimal point. Not typically captured. int 10
Multiple versionsPC039 Dispensing Fee Do not code decimal point. int 10
Multiple versionsPC040 Co-pay Amount The preset, fixed dollar amount for which the individual is responsible. Do not code decimal point. int 10
Multiple versionsPC041 Coinsurance Amount The dollar amount an individual is responsible for - not the percentage. Do not code decimal point. int 10
Multiple versionsPC042 Deductible Amount Do not code decimal point. int 10
Multiple versionsPC043 Unassigned Reserved for assignment Not Supplied Not Supplied Not Supplied
Multiple versionsPC044 Prescribing Physician First Name Physician first name. varchar 25
Multiple versionsPC045 Prescribing Physician Middle Name Physician middle name or initial. varchar 25
Multiple versionsPC046 Prescribing Physician Last Name Physician last name. varchar 60
Multiple versionsPC047 Prescribing Physician NPI NPI number for prescribing physician varchar 20
Multiple versionsPC049 Member Street Address Street address of member varchar 50
Multiple versionsPC101 Subscriber Last Name Not Provided varchar 128
Multiple versionsPC102 Subscriber First Name Not Provided varchar 128
Multiple versionsPC103 Subscriber Middle Initial Not Provided char 1
Multiple versionsPC104 Member Last Name Not Provided varchar 128
Multiple versionsPC105 Member First Name Not Provided varchar 128
Multiple versionsPC106 Member Middle Initial Not Provided char 1
Multiple versionsPC201 Version Number The version number of this claim service line. The original claim will have a version number of 0, with the next version being assigned a 1, and each subsequent version being incremented by 1 for that service line. Required Default YYMM int 4
Multiple versionsPC202 Prescription Written Date Date Prescription was written Date 8
Multiple versionsPC047a Prescribing Physician Provider ID Provider ID for the prescribing physician varchar 30
Multiple versionsPC047b Prescribing Physician DEA DEA number for prescribing physician varchar 20
Multiple versionsPC899 Record Type Not Provided char 2
Multiple versionsTR001 Record Type Not Provided char 2
Multiple versionsTR002 Payer Code Distributed by CIVHC varchar 8
Multiple versionsTR003 Payer Name Distributed by CIVHC varchar 75
Multiple versionsTR004 Beginning Month Not Provided Date CCYYMM 6
Multiple versionsTR005 Ending Month Not Provided Date CCYYMM 6
Multiple versionsTR006 Extraction Date Not Provided Date YYYYMMDD 8

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