United States Health Information Knowledgebase

 

Tennessee



At A Glance

Name:Tennessee
Abbreviation:TN
Title of SystemTennessee All Payer Claims Database
Websitehttp://www.tn.gov/finance/healthplanning/
Who Maintains the SystemDepartment of Finance and Administration, Division of Health Planning
Versions:March 18, 2010
January 31, 2014 - v1.0

Medical Eligibility

File Specification for Medical Eligibility File Submission - March 18, 2010

Data Element ID Data Element Description Type Format Length
HD001 Record Type Must be coded HD to indicate Header record. Text 2
HD002 Payer Payer or submitter code assigned by Onpoint CDM Text 8
HD003 National Plan ID Code according to CMS National Plan ID Text 30
HD004 Type of File Must be coded ME to indicate submission of eligibility data. Text 2
HD005 Period Beginning Date Code the earliest eligibility year/month included in the submission in CCYYMM format. Submissions with records containing an eligibility period (ME004, ME005) before this date will fail. Integer CCYYMM 6
HD006 Period Ending Date Code the latest eligibility year/month included in the submission in CCYYMM format. Submissions with records containing an eligibility period (ME004, ME005) after this date will fail. Integer CCYYMM 6
HD007 Record Count Report the total number of records in the submission, excluding the header and trailer records. If the number of records within the submission does not equal the number reported in this field, the submission will fail. Integer 10
HD008 Comments Submitter comments Text 80
ME001 Payer This field contains the Onpoint CDM-assigned submitter code for the data submitter. The first two characters of the submitter code indicate Tennessee and the third character designates the type of submitter: A single data submitter may have multiple submitter codes because the data submitter is submitting from more than one system or from more than one location. All submitter codes associated with a single data submitter will have the same first 7 characters. A suffix will be used to distinguish the location and/or system variations. This field contains a constant value and is used primarily for tracking compliance by data submitters. Text 8
ME002 National Plan ID Code according to CMS National Plan ID Text 30
ME003 Insurance Type / Product Code This field contains the insurance type or product code that indicates the type of insurance coverage the individual has: Text 6
ME004 Year The year during which the member is eligible for services. This field generally is used in conjunction with the month (ME005) to determine a specific period of eligibility. Integer 4
ME005 Month Month indicates the month during which the member is eligible for services. This field generally is used with the year field (ME004) to determine a specific period of eligibility. Integer 2
ME006 Insured Group Or Policy Number Group number or policy number. If submitting an individual policy, use IND. Text 30
ME007 Coverage Level Code Benefits coverage level: Text 3
ME008 Encrypted Subscriber Index Number Carriers, healthcare claims processors, and pharmacy benefit managers shall input subscriber's Social Security number. During transformation and encryption: All but one digit of the Social Security number shall be combined with a seed value. This modified subscriber index number then is encrypted by an application on the processor's desktop The original input Social Security number is deleted and carriers, healthcare claims processors, and pharmacy benefit managers shall set the input field null if unavailable. This or ME009 must be populated. Text 128
ME009 Encrypted Plan Specific Contract Index Number Carriers and healthcare claims processors shall input a plan-assigned subscriber index number that uniquely identifies members in a contract. This must not be the original contract number, but must be consistent in all fields requiring the plan-specific contract index number and it must be consistent in all file submission types (eligibility, medical, and pharmacy claims) submitted by the submitter. This plan-assigned contract index number shall be combined with a seed value and then encrypted. Carriers and healthcare claims processors shall set as null if unavailable. This or ME008 must be populated. Text 128
ME010 Member Suffix Number Code a number to designate a member within the contract. Integer 20
ME011 Encrypted Member Index Number Carriers, healthcare claims processors, and pharmacy benefit managers shall input member's Social Security number. During transformation and encryption: All but one digit of the Social Security number shall be combined with a seed value This modified member index number then is encrypted by an application on the processor's desktop The original input Social Security number is deleted and replaced with the modified and encrypted output Carriers, healthcare claims processors, and pharmacy benefit managers shall set the input field null if unavailable. Text 128
ME012 Individual Relationship Code This field contains the member's relationship to the subscriber or the insured: Integer 2
ME013 Member Gender Member's gender: Text 1
ME014 Member Year of Birth Carriers, healthcare claims processors and pharmacy benefit managers shall input member's date of birth as CCYYMMDD. During transformation: Age in months will be calculated for member using first day of the month for the eligibility file The age in months value will be added to the end of the record by an application on the processor's desktop The original input date of birth is deleted and replaced with the year of birth only in the output Date CCYYMMDD 8
ME015 Member City Name This field contains the member's city of residence. Text 30
ME016 Member State or Province The member state or province contains the two-character abbreviation code used by the U.S. Postal Service. Text 2
ME017 Member ZIP Code This field contains the ZIP code of the member. Text 5
ME018 Medical Coverage The medical coverage flag indicates whether this member is covered for medical expenses. This is an administrative field required by Onpoint CDM and derived from the eligibility data maintained by the data submitter: Text 1
ME019 Prescription Drug Coverage The prescription drug coverage flag indicates whether this member is covered for prescription drug expenses. This is an administrative field required by Onpoint CDM and derived from the eligibility data maintained by the data submitter: Text 1
ME020 Placeholder Placeholder N/A N/A
ME021 Placeholder Placeholder N/A N/A
ME022 Placeholder Placeholder N/A N/A
ME023 Placeholder Placeholder N/A N/A
ME024 Placeholder Placeholder N/A N/A
ME025 Placeholder Placeholder N/A N/A
ME026 Placeholder Placeholder N/A N/A
ME027 Placeholder Placeholder N/A N/A
ME028 Primary Insurance Indicator Is insurance primary? Text 1
ME029 Coverage Type Type of coverage: Text 3
ME030 Market Category Category of Insurance Policy Text 4
ME031 Special Coverage Form of special coverage: Text 3
ME032 Group Name Name of the group which the member is covered by: Text 128
ME033 Placeholder Placeholder N/A N/A
ME034 Placeholder Placeholder N/A N/A
ME035 Placeholder Placeholder N/A N/A
ME036 Placeholder Placeholder N/A N/A
ME037 Placeholder Placeholder N/A N/A
ME101 Placeholder Placeholder N/A N/A
ME102 Placeholder Placeholder N/A N/A
ME103 Placeholder Placeholder N/A N/A
ME104 Encrypted Index Number, Member Last Name Carriers, healthcare claims processors, and pharmacy benefit managers shall input member's last name. During transformation and encryption: The first character of the last name is combined with a numeric name ID This modified member last name field then is encrypted by an application on the processor's desktop The original input member last name is deleted and replaced with the modified and encrypted output Text 128
ME105 Encrypted Index Number, Member First Name Carriers, healthcare claims processors and pharmacy benefit managers shall input member's first initial. During transformation and encryption: o This first character of the first name is combined with a seed value o This modified member first initial is then encrypted by an application on the processors desktop o The original input member first initial is deleted and replaced with the modified and encrypted output Text 128
ME106 Placeholder Placeholder N/A N/A
ME899 Record Type This field indicates the type of record: This is an administrative field required by Onpoint CDM and populated with a constant value. Text 2
TR001 Record Type Must be coded TR to indicate the Trailer record Text 2
TR002 Payer Payer or submitter code assigned by Onpoint CDM Text 8
TR003 National Plan ID Code according to CMS National Plan ID Text 30
TR004 Type of File Must be coded ME to indicate submission of eligibility data. Text 2
TR005 Period Beginning Date Code the earliest eligibility year/month included in the submission in CCYYMM format. Submissions with records containing an eligibility period (ME004, ME005) before this date will fail. Integer CCYYMM 6
TR006 Period Ending Date Code the latest eligibility year/month included in the submission in CCYYMM format. Submissions with records containing an eligibility period (ME004, ME005) after this date will fail. Integer CCYYMM 6
TR007 Date Processed Date that the file was created in CCYYMMDD format Date CCYYMMDD 8

Medical

File Specification for Multiple versionsMedical File Submission - January 31, 2014 - v1.0

Data Element ID Data Element Description Type Format Length
ADJ_TYP_CD Adjustment Type Code Client-specific code for the type of adjustment for the claim. The corresponding Medstat Advantage Suite standard field is Adjustment Type Code Medstat. Char 1
ADMDX_POA Admitting Diagnosis Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
ADMIT_DATE Admission Date This field contains the date of the inpatient admission as reported by the payer. In ASCII-formatted extracts, this field is presented in a CCYYMMDD format. Date CCYYMMDD 8
ADMIT_DX Admitting Diagnosis This payer-supplied field contains the ICD-9 diagnosis code indicating the reason for the inpatient admission. Char 8
ADMIT_HOUR Admission Hour This payer-supplied field indicates the hour and minutes, using military-time format, of the inpatient's admission to the hospital. Valid codes are 0000 - 2359. Numeric 4
ADMIT_SOURCE Admission Source This payer-supplied field records the source of admission for all inpatient hospital bills. Char 2
ADMIT_TYPE Admission Type This payer-supplied field records the type of admission for all inpatient hospital bills. Numeric 5
APC APC Submitted by Payer This field contains the APC submitted by the payer for this claim. The CMS methodology is preferred for grouping. Text 5
APC_VERSION Version of APC Grouper Used This payer-supplied field contains the version number of the grouper used to assign the APC. Text 2
BILL_TYPE Type of Bill - Institutional This payer-supplied field, which is required for institutional claims and is not to be used for professional claims, contains the Type of Bill code as reported per the National Uniform Billing Committee's official UB-04 specifications manual. Text 4
BILLING_PRVIDN Billing Provider Number This field contains the Billing Provider ID Number. Numeric 20
CHARGE Charge Amount This field contains the total charges for the service as reported by the payer. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
CLAIM Payer Claim Control Number This field contains the Payer Claim Control Number used by the payer to internally track the claim. In general, the claim number is associated with all service lines of the bill. Multiple medical records therefore may share the same claim number. This number must apply to the entire claim and be unique within the payer's system. Text 35
CLAIM_STATUS Claim Status This field contains the status of the claim as reported by the payer. Numeric 2
CLAIM_TYPE Claim Type This is a value-added field that sorts medical claims into type-of-setting or type-of-provider buckets. Numeric 2
COINSURANCE Coinsurance Amount This payer-supplied field contains the dollar amount that a member must pay toward the cost of a covered service (often stipulated as a cost-sharing ratio). In many health insurance plans, the member's coinsurance responsibility is capped after a certain dollar amount of eligible expenses has been incurred. Not all carriers can distinguish between the mutually exclusive fields of Copay Amount (COPAY) and Coinsurance Amount. To determine the total out-of-pocket/member responsibility for this service, you must sum these two fields with the Deductible Amount (DEDUCTIBLE). This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
COPAY Copay Amount This payer-supplied field contains the preset, fixed dollar amount payable by a member, often on a per-visit/-service basis. Not all carriers can distinguish between the mutually exclusive fields of Copay Amount and Coinsurance Amount (COINSURANCE). To determine the total out-of-pocket/member responsibility for this service, you must sum these two fields with the Deductible Amount (DEDUCTIBLE). This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
CPT CPT Procedure Code This payer-supplied field contains the HCPCS or CPT code for the performed procedure. Char 10
CPT_MOD1 Procedure Modifier 1 This payer-supplied field identifies a CPT procedure modifier, which is used to indicate that a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Modifiers may be used to indicate that a service or procedure has both a professional and a technical component, that only part of a service was performed, that a bilateral procedure was performed, or that a service or procedure was provided more than once. A procedure modifier is required when a modifier clarifies or improves the reporting accuracy of the associated procedure code. Char 2
CPT_MOD2 Procedure Modifier 2 This payer-supplied field identifies a CPT procedure modifier, which is used to indicate that a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Modifiers may be used to indicate that a service or procedure has both a professional and a technical component, that only part of a service was performed, that a bilateral procedure was performed, or that a service or procedure was provided more than once. A procedure modifier is required when a modifier clarifies or improves the reporting accuracy of the associated procedure code. Char 2
DEDUCTIBLE Deductible Amount This payer-supplied field contains the dollar amount that a member must pay before health plan benefits will begin to reimburse for services. It is usually an annual amount of all healthcare costs that are not covered by the member's insurance plan. To determine the total out-of-pocket/member responsibility for this service, you must sum this field with both Copay Amount (COPAY) and Coinsurance Amount (COINSURANCE). This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
DISCH_HOUR Discharge Hour This payer-supplied field indicates the hour, using military-time format, of the inpatient's discharge from the hospital. Valid codes are 00 - 23. Numeric 4
DISCH_STATUS Discharge Status This field is required for inpatient hospital admissions. It records the status for the patient discharged from the hospital. This field contains the patient discharge status code as reported by the payer. This field is inconsistently reported across data reporters. It may be underreported on inpatient records and sometimes reported on outpatient records. Numeric 2
DRG DRG Submitted by Payer This field contains the DRG submitted by the payer for this claim. When the preferred CMS methodology is used for grouping, this field contains only the DRG. When the All Payer DRG system is used, this field contains three components and uses the format of ADRG-X, where a constant of A is the prefix, followed by the three-digit DRG, followed by a dash and then the severity level (indicated here by X). Text 10
DRG_VERSION Version of DRG Grouper Used This payer-supplied field contains the version number of the grouper used to assign the DRG. Text 2
DX1 Principal Diagnosis This payer-supplied field contains the ICD-9 diagnosis code for the principal diagnosis. Char 8
DX1_POA Primary Diagnosis Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
DX10 Other Diagnosis 9 This payer-supplied field contains the ICD-9 diagnosis code for the ninth secondary diagnosis. Char 8
DX11 Other Diagnosis 10 This payer-supplied field contains the ICD-9 diagnosis code for the tenth secondary diagnosis. Char 8
DX12 Other Diagnosis 11 This payer-supplied field contains the ICD-9 diagnosis code for the eleventh secondary diagnosis. Char 8
DX13 Other Diagnosis 12 This payer-supplied field contains the ICD-9 diagnosis code for the twelth secondary diagnosis. Char 8
DX2 Other Diagnosis 1 This payer-supplied field contains the ICD-9 diagnosis code for the first secondary diagnosis. Char 8
DX2_POA Other Diagnosis 1 Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
DX3 Other Diagnosis 2 This payer-supplied field contains the ICD-9 diagnosis code for the second secondary diagnosis. Char 8
DX3_POA Other Diagnosis 2 Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
DX4 Other Diagnosis 3 This payer-supplied field contains the ICD-9 diagnosis code for the third secondary diagnosis. Char 8
DX4_POA Other Diagnosis 3 Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
DX5 Other Diagnosis 4 This payer-supplied field contains the ICD-9 diagnosis code for the fourth secondary diagnosis. Char 8
DX5_POA Other Diagnosis 4 Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
DX6 Other Diagnosis 5 This payer-supplied field contains the ICD-9 diagnosis code for the fifth secondary diagnosis. Char 8
DX6_POA Other Diagnosis 5 Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
DX7 Other Diagnosis 6 This payer-supplied field contains the ICD-9 diagnosis code for the sixth secondary diagnosis. Char 8
DX7_POA Other Diagnosis 6 Present on Admission Indicator The Diagnosis Present on Admission Indicator is is tied to a specific diagnosis and indicates that the condition identified by the related diagnosis was present at the time of admission. Char 1
DX8 Other Diagnosis 7 This payer-supplied field contains the ICD-9 diagnosis code for the seventh secondary diagnosis. Char 8
DX9 Other Diagnosis 8 This payer-supplied field contains the ICD-9 diagnosis code for the eigth secondary diagnosis. Char 8
ECODE_DX E-Code This payer-supplied field describes an injury, poisoning, or adverse effect using an ICD-9 E-Code diagnosis. Users should search the Other Diagnosis fields to identify all submitted E-Codes. Note that the same E-Code may be reported in this field and in an Other Diagnosis field, depending upon the data reporter. Char 8
ER_FLAG ER Flag This field is used to identify specific emergency room (ER) REV or procedure codes within a claim. This field is assigned as a value-added field and is set only on the specific claim line where an ER REV or procedure code was found. Char 1
FIRST_SVC_DATE Date of Service - From This payer-supplied field contains the first date of service for this service line. In ASCII-formatted extracts, this field is presented in a CCYYMMDD format. Date CCYYMMDD 8
ICD9_OP ICD-9-CM Procedure Code This field contains an ICD-9 procedure code, which is generally available on inpatient claims. The decimal point is not coded. It is not consistently reported by data reporters. Char 8
ICD9_OP1 ICD-9-CM Procedure Code This field contains an ICD-9 procedure code, which is generally available on inpatient claims. The decimal point is not coded. It is not consistently reported by data reporters. Char 8
ICD9_OP2 ICD-9-CM Procedure Code This field contains an ICD-9 procedure code, which is generally available on inpatient claims. The decimal point is not coded. It is not consistently reported by data reporters. Char 8
ICD9_OP3 ICD-9-CM Procedure Code This field contains an ICD-9 procedure code, which is generally available on inpatient claims. The decimal point is not coded. It is not consistently reported by data reporters. Char 8
ICD9_OP4 ICD-9-CM Procedure Code This field contains an ICD-9 procedure code, which is generally available on inpatient claims. The decimal point is not coded. It is not consistently reported by data reporters. Char 8
ICD9_OP5 ICD-9-CM Procedure Code This field contains an ICD-9 procedure code, which is generally available on inpatient claims. The decimal point is not coded. It is not consistently reported by data reporters. Char 8
INPATIENT_CATEGORY Inpatient Category Code This value-added field is based on BILL_TYPE and is used to differentiate categories of inpatient lines (e.g., skilled nursing facilities (SNF), swing beds, etc.). Numeric 1
IPDISCHARGE Inpatient Discharge Identifier This field is a value-added element that associates all claim lines for a given inpatient stay under one coded value. Numeric 20
LAST_SVC_DATE Date of Service - Thru This payer-supplied field contains the last date of service for this service line. In ASCII-formatted extracts, this field is presented in a CCYYMMDD format. Date CCYYMMDD 8
LINE Line Counter This field contains the line number for this service as reported by the payer. The Line Counter begins with 1 and is incremented by 1 for each additional service line of a claim. Numeric 6
MEMBERIDN Member ID Number This field generally represents a unique combination of member fields unique to the payer. This field should not be used to aggregate all records associated with a member. Numeric 15
NDC National Drug Code This field contains the National Drug Code for this claim as reported by the payer. Each drug product listed under Section 510 of the Federal Food, Drug, and Cosmetic Act is assigned a unique 10-digit, three-segment number. This number, known as the National Drug Code (NDC), identifies the labeler/vendor, product, and trade package size. The first segment, the labeler/vendor code, is assigned by the FDA. A labeler is any firm that manufactures, repacks, or distributes a drug product. The second segment, the product code, identifies a specific strength, dosage form, and formulation for a particular firm. The third segment, the package code, identifies package sizes. Both the product and package codes are assigned by the firm. The NDC will be in one of the following configurations: 4-4-2, 5-3-2, or 5-4-1. Numeric 11
ORIG_CLM_ID Original Claim ID number This field is used with adjustments. If the claim id number changes to a different number due to an adjustment then this field will be populated with the original claim id number. Text 53
PAID_MEDICAL Paid Amount (Medical Paid Amount) This payer-supplied field contains the total dollar amount paid to the provider, including all health plan payments and excluding withhold amounts and all member payments. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
PAYERCODE Payer Code This field contains the data reporter code for the payer or data reporter submitting payments. The first two characters indicate the data collection state and the third character indicates the type of data reporter. A single payer may have multiple data reporter codes because the payer is submitting from more than one system or from more than one location. All data reporter codes associated with a single payer will have the same first seven characters. A suffix in the eighth position may be used to distinguish the location and/or system variations. Char 8
PAYER PAYER This field contains the Payer ID Number. This code is used to identify the data reporter. Its source is the Payer element reported by the payer in the medical claims data. Numeric 8
PID_MED Provider ID Medical Claims This field contains the payer-assigned provider number. Its source is the Service Provider Number element reported by the payer in the medical claims data. Text 40
PLAN_NPI National Plan ID This payer-supplied field contains the National Plan ID for the data reporter. This field is not populated. Text 30
PREPAID Prepaid Amount This payer-supplied field contains the fee for service equivalent that would have been paid by the health care claims processor for a specific service if the service had not been capitated. Capitated services are services rendered by a provider through a contract under which payments are based upon a fixed dollar amount for each member on a monthly basis. Note that the provider did not receive this payment. Any payment for this service was made through capitation, which is not captured in this database. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
PRODUCT Standardized Product Code This field contains the code identifying the member's type of insurance or insurance product. Text 6
QTY Quantity This field contains a count of services performed as reported by the payer. This field may be negative and should be set equal to 1 on all observation bed service lines for this field. This field must be used with caution because the type of units may vary based upon the service performed. For example, one anesthesia unit may equal 10 minutes, while one ambulance transportation unit may equal one mile. Numeric (signed) 14
REV Revenue Code This payer-supplied field contains the revenue code for hospital claims as reported per the National Uniform Billing Committee's official UB-04 specifications manual. Char 4
SVC_PRVIDN Service Provider Number This field contains the service provider ID number. This field cannot be used to aggregate all claims associated with a provider. Numeric 20
PLACE_OF_SERVICE Service Site (Professional) This payer-supplied field, which is required for professional claims and is not be used for institutional claims, records the site where the service was performed. Numeric 2
TYP_OF_SVC Type of Service This field contains the type of service for this claim. Text 2
VERSION_NUM Claim Version This field indicates the claim version number, which is used if the payer adjudicates claims based on a versioning system. Its source is the Version Number element reported by the payer in the medical claims data. See additional documentation on a detailed explanation of versioning. Numeric 4
FILLER FILLER This field is reserved for additional fields that may be added in the future. Char 500

Member

File Specification for Member File Submission - January 31, 2014 - v1.0

Data Element ID Data Element Description Type Format Length
AGE Age This field contains the member's age. Note that: Children under the age of 1 are reported using a value of 0. If no date of birth is available, this value will be -1. Numeric 3
COVERAGE_LEVEL Coverage Level This field indicates the level of coverage. Its source is the Coverage Level Code element reported by the payer in the member eligibility data. Text 3
COVERAGE_TYPE Coverage Type This field indicates the type of coverage and is used to distinguish self-funded plans from commercially insured plans. Its source is the Coverage Type element reported by the payer in the member eligibility data. Text 3
COVG_EFF_DATE Coverage Effective Date Not Available Date 8
COVG_TERM_DATE Coverage Termination Date Not Available Date 8
GENDER Standardized Member Gender This field indicates the member's gender. Its source is the Member Gender element reported by the payer in the pharmacy claims data and medical claims data. Text 1
GROUP_NAME Insured Group Name This field contains the name of the group that covers the member as reported by the payer. If the member is part of a group of one or part of a non-group policy (i.e., when the Market Category Code (MARKET_CATEGORY) is coded as IND, FCH, GCV, or GS1), this field will be null (or display the value BLANK). Its source is the Group Name element in the member eligibility data. Text 128
INS_GROUP Insured Group or Policy Number This payer-supplied field contains the Insured Group or Policy Number associated with the entity that has purchased the insurance. If submitting an individual policy, use IND. For self-insured individuals, this relates to the purchaser. For the majority of eligibility and claims data, the group relates to the employer. The group number does not uniquely identify the subscriber. Text 30
MARKET_CATEGORY Market Category Code This field indicates the type of policy sold by the insurer. Its source is the Market Category Code element reported by the payer in the member eligibility data. Text 4
MEDICAL_COV_FLAG Medical Coverage Flag The medical coverage flag indicates whether this member is covered for medical expenses. Text 1
MEMBER_CITY Member City Name The city of residence for the person, for the most recent month of eligibility. Text 30
MEMBER_COUNTY Member County The county description for the residence of the person. Text 30
MEMBER_STATE Member State The state abbreviation for the residence of the person, for the most recent month of eligibility. Text 2
MEMBERIDN Member ID Number This field generally represents a unique combination of member fields unique to the payer. This field should not be used to aggregate all records associated with a member. Numeric 15
PAT_ZIPCODE Member Zip Code This payer-supplied field contains the member's ZIP code. Text 9
PAYER_NAME Payer Name Not Available Text 12
PAYER PAYER This field contains the Payer ID Number. This code is used to identify the data reporter. Its source is the Payer element reported by the payer in the pharmacy claims data and Payer element reported by the payer in the medical claims data. Text 8
PHARMACY_COV_FLAG Prescription Drug Coverage Flag This field indicates whether or not the member has prescription drug coverage. Text 1
PLAN_CODE Plan Code Not Available Text 8
PLAN_NPI National Plan ID This payer-supplied field contains the National Plan ID for the data reporter. This field is not populated. Char 30
PRIMARY_INS Primary Insurance Indicator This field indicates if the member has primary coverage or secondary/tertiary coverage. Text 1
PRODUCT Standardized Product Code or Insurance Type This field contains the code identifying the member's type of insurance or insurance product. Char 6
REL Individual Relationship to Subscriber This field contains the code indicating the member's relationship to the subscriber or the insured. Text 2
SPECIAL_COVERAGE Special Coverage This field indicates special coverage. Text 3
FILLER FILLER This field is reserved for additional fields that may be added in the future. Char 500

Pharmacy Claims

File Specification for Multiple versionsPharmacy Claims File Submission - January 31, 2014 - v1.0

Data Element ID Data Element Description Type Format Length
ADJ_TYP_CD Adjustment Type Code Client-specific code for the type of adjustment for the claim. The corresponding Medstat Advantage Suite standard field is Adjustment Type Code Medstat. Char 1
CHARGE Gross Amount Due This field contains the gross amount due (total charges) for the service as reported by the provider. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
CLAIM Payer Claim Control Number This field contains the Payer Claim Control Number element reported by the payer. In general, the claim number is associated with all service lines of the bill. Multiple pharmacy records therefore may share the same claim number. This number must apply to the entire claim and be unique within the payer's system. Text 53
CLAIM_STATUS Claim Status This field contains the status of the claim as reported by the payer. Numeric 2
COINSURANCE Coinsurance amount This payer-supplied field contains the dollar amount that a member must pay toward the cost of a covered service. In many health insurance plans, the member's coinsurance responsibility is capped after a certain dollar amount of eligible expenses has been incurred. Not all carriers can distinguish between the mutually exclusive fields of Copay Amount (COPAY) and Coinsurance Amount. To determine the total out-of-pocket/member responsibility for this service, you must sum these two fields with Deductible Amount (DEDUCTIBLE). This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
COMPOUND_DRUG Compound Drug Indicator This payer-supplied field indicates whether or not this is a compound drug. Char 1
COPAY Copay Amount This payer-supplied field contains the preset, fixed dollar amount payable by a member, often on a per-visit/-service basis. Not all carriers can distinguish between the mutually exclusive fields of Copay Amount and Coinsurance Amount (COINSURANCE). To determine the total out-of-pocket/member responsibility for this service, you must sum these two fields with the Deductible Amount (DEDUCTIBLE). This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
DAW Dispense as Written Code This field indicates the instructions given to the pharmacist for filling the prescription. For example, a prescription for a brand-name drug that also has a generic equivalent may not have the generic equivalent substituted. In this case, the code is 1 - physician requires the script to be filled as written. Char 1
DAY_SUPPLY Days Supply This payer-supplied field contains the actual Days Supply for the prescription based on the Quantity Dispensed element (QTY). This field may contain a negative value. Numeric (Signed) 6
DEDUCTIBLE Deductible amount This payer-supplied field contains the dollar amount that a member must pay before health plan benefits will begin to reimburse for services. It is usually an annual amount of all healthcare costs that are not covered by the member's insurance plan. To determine the total out-of-pocket/member responsibility for this service, you must sum this field with both Copay Amount (COPAY) and Coinsurance Amount (COINSURANCE). This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
DISPENSE_FEE Dispensing Fee This field contains the amount charged for dispensing as reported by the payer. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
DRUG_NAME Drug Name This payer-supplied field contains the text name of the drug indicated in the National Drug Code element (NDC). Text 80
FILL_DATE Date Prescription Filled This field contains the date the prescription was filled as reported by the payer. In ASCII-formatted extracts, this field is presented in a CCYYMMDD format. Date CCYYMMDD 8
GENERIC Generic Drug Indicator This payer-supplied field indicates whether the drug is a branded drug or a generic drug. Text 1
INGREDIENT_COST Ingredient Cost/List Price This field contains the cost of the drug that was dispensed as reported by the payer. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
LINE Line Counter This field contains the line number for this service as reported by the payer. The Line Counter begins with 1 and is incremented by 1 for each additional service line of a claim. Numeric 4
MEMBERIDN Member ID Number This field generally represents a unique combination of member fields unique to the payer. This field should not be used to aggregate all records associated with a member. Char 15
ORIG_CLM_ID Original Claim ID number This field is used with adjustments. If the claim id number changes to a different number due to an adjustment then this field will be populated with the original claim id number. Char 11
NDC National Drug Code This field contains the National Drug Code for this claim as reported by the payer. Each drug product listed under Section 510 of the Federal Food, Drug, and Cosmetic Act is assigned a unique 10-digit, three-segment number. This number, known as the National Drug Code (NDC), identifies the labeler/vendor, product, and trade package size. The first segment, the labeler/vendor code, is assigned by the FDA. A labeler is any firm that manufactures, repacks, or distributes a drug product. The second segment, the product code, identifies a specific strength, dosage form, and formulation for a particular firm. The third segment, the package code, identifies package sizes. Both the product and package codes are assigned by the firm. The NDC will be in one of the following configurations: 4-4-2, 5-3-2, or 5-4-1. Numeric 2
NEWPR New Prescription or Refill This payer-supplied field can be used to determine if this is a new prescription. Valid codes include: Note that a value of 01 may have been reported if the specific number of the prescription refill was unavailable. Text 53
PAID_RX Paid Amount (RX Paid Amount) This payer-supplied field contains the total dollar amount paid to the provider, including all health plan payments and excluding withhold amounts and all member payments. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
PAID_DATE First Paid Date and Last Paid Date While multiple paid dates may occur for the same claim as part of the adjudication process, this field contains the Last Paid Date associated with the claim. For claims that were not adjusted, this is the actual paid date. Its source is the Date Service Approved element reported by the payer in the pharmacy claims data. In ASCII-formatted extracts, this field is presented in a CCYYMMDD format. Date CCYYMMDD 8
PAYERCODE Payer Code This field contains the data reporter code for the payer or data reporter submitting payments. The first two characters indicate the data collection state and the third character indicates the type of data reporter. A single payer may have multiple data reporter codes because the payer is submitting from more than one system or from more than one location. All data reporter codes associated with a single payer will have the same first seven characters. A suffix in the eighth position may be used to distinguish the location and/or system variations. Char 8
PAYER PAYER This field contains the Payer ID Number. This code is used to identify the data reporter. Its source is the Payer element reported by the payer in the pharmacy claims data. Text 8
PID_RX Pharmacy ID number Pharmacy Claims This field contains the payer-assigned provider number. Its source is the Service Provider Number element reported by the payer in the pharmacy claims data. Text 40
PLAN_NPI National Plan ID This payer-supplied field contains the National Plan ID for the data reporter. This field is not populated. Text 30
POSTAGE Postage Amount Claimed This field contains the cost of postage included in the Paid Amount field (PAID) as reported by the payer. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
PRODUCT Standardized Product Code This field contains the code identifying the member's type of insurance or insurance product. Its source is the Insurance Type / Product Code element reported by the payer in the pharmacy claims data. Char 6
QTY Quantity Dispensed This field contains the total unit dosage as reported by the payer. This field may contain a negative value. Decimal (signed) 14
RX_PRVIDN Prescribing Physician ID Number This field contains the prescribing physician's ID number. This field cannot be used to aggregate all claims associated with a physician. Numeric 20
SVC_PHARMIDN Servicing Pharmacy ID Number This field contains the servicing pharmacy ID number. This field cannot be used to aggregate all claims associated with a pharmacy. Numeric 20
THIRTY_DAY_EQUIV Thirty Day Equivalency This field is used to indicate the number of thirty day equivalencies associated with this prescription. It is based upon the Days Supply field (DAY_SUPPLY). Numeric 3
VERSION_NUM Claim Version This field indicates the claim version number, which is used if the payer adjudicates claims based on a versioning system. Its source is the Version Number element reported by the payer in the medical claims data. See additional documentation on a detailed explanation of versioning. Numeric 4
FILLER FILLER This field is reserved for additional fields that may be added in the future. Char 500

Provider

File Specification for Provider File Submission - January 31, 2014 - v1.0

Data Element ID Data Element Description Type Format Length
CITY_PROVIDER Provider Location City This field contains the name of the city in which the provider is located as reported by the payer in the medical claims field. Text 30
CITY_PHARMACY Pharmacy City This field contains the name of the city in which the pharmacy is located as reported by the payer in the pharmacy claims field. Char 30
COUNTRY Provider Location Location Country This field contains the country name of the provider's practice location. Its source is the Service Provider Country element reported by the payer in the medical claims data. Char 30
ENTITY_TYPE Service Provider Entity Type Qualifier This field is used to distinguish an individual practitioner from a business entity. Its source is the Service Provider Entity Type Qualifier element reported by the payer in the medical claims data. Char 1
IDN Provider ID Number This field is the primary identification number for each Provider record. Numeric 20
NPI NPI This field contains the National Provider ID. Text 10
NPI_RX National Pharmacy ID Number This field contains the National Pharmacy ID Number. Its source is the National Pharmacy ID Number element reported by the payer in the pharmacy claims data. Char 10
PAYERCODE Payer Code This field contains the data reporter code for the payer or data reporter submitting payments. The first two characters indicate the data collection state and the third character indicates the type of data reporter. A single payer may have multiple data reporter codes because the payer is submitting from more than one system or from more than one location. All data reporter codes associated with a single payer will have the same first seven characters. A suffix in the eighth position may be used to distinguish the location and/or system variations. Text 8
PAYER PAYER This field contains the Payer ID Number. This code is used to identify the data reporter. Its source is the Payer element reported by the payer in the pharmacy claims data and Payer element reported by the payer in the medical claims data. Text 8
PHARMACY_NAME Pharmacy Name This field contains the name of the pharmacy. Its source is the Pharmacy Name element reported by the payer in the pharmacy claims data. Char 100
PID Pharmacy Number This field contains the payer-assigned pharmacy number. Its source is the Pharmacy Number element reported by the payer in the pharmacy claims data. Char 40
PRESCRIBING_PHYSICIAN_NUMBER Prescribing Physician Number This field contains either the NPI number, DEA number or the State License ID for the prescribing physician. Based on NCPDP 466-EZ values, we would expect one of the following values. Use the designated prefix followed by a dash preceding the number. Text 14
PROVIDER_ADDRESS_1 Provider Address Line 1 Not Available Text 30
PROVIDER_ADDRESS_2 Provider Address Line 2 Not Available Text 30
PROVIDER_COUNTY Provider County Not Available Text 30
PROVIDER_ID Provider ID Not Available Numeric 20
PRV_FNAME ProviderFirstName This field contains the first name of the individual provider or prescribing physician. Its source is the payer-supplied Service Provider First Name element in the medical claims data or the Prescribing Physician First Name element in the pharmacy claims data. If the provider is a facility, this field will be blank. Text 25
PRV_LNAME Provider Last Name Organization Name or Provider Last Name. Text 100
PRV_MNAME Provider Middle Name This field contains the middle name or initial of the individual provider or prescribing physician. Its source is the payer-supplied Service Provider Middle Name element in the medical claims data or the Prescribing Physician Middle Name element in the pharmacy claims data. Text 25
PRV_SUFFIX Provider Suffix This field contains the generational suffix of the individual provider. Its source is the Service Provider Suffix element reported by the payer in the medical claims data. Text 10
PRV_TAXID Provider Tax ID This field contains the provider's federal tax ID number. Its source is the Service Provider Tax ID Number element reported by the payer in the medical claims data. For an individual, this code is often the Social Security number. Text 25
PRV_ZIPCODE Provider Zip code This field contains the ZIP code of the provider's practice location. Its source is the Service Provider ZIP Code element reported by the payer in the medical claims data. Text 9
SPECIALTY Payer Supplier Provider Specialty This field identifies the service provider's specialty as reported by the payer. Its source is the Service Provider Specialty element in the medical claims data. Char 50
PRV_STATE Provider Location State This field identifies the state of the provider's practice location using the two-character abbreviation defined by the U.S. Postal Service. Its source is the Service Provider State or Province element reported by the payer in the medical claims data. Text 2
RX_STATE Pharmacy State This field contains the pharmacy location's two-character state abbreviation as defined by the U.S. Postal Service and as reported by the payer in the pharmacy claims field. Char 2
SVC_PHARMIDN Servicing Pharmacy ID Number This field contains the servicing pharmacy ID number. This field cannot be used to aggregate all claims associated with a pharmacy. Numeric 20
TAXID Pharmacy Tax ID Number This field contains the pharmacy's federal tax ID number. Its source is the Pharmacy Tax ID Number element reported by the payer in the pharmacy claims data. If the individual retail pharmacy tax ID number is not available, this field contains the pharmacy chain's tax ID number. Char 100
TAXONOMY Taxonomy Code This field contains the CMS-defined code for the provider's specialty/taxonomy. The American Medical Association (AMA) holds the copyright for the Health Care Provider Taxonomy code set on behalf of the National Uniform Claim Committee, which maintains the coding system. Char 30
ZIPCODE Pharmacy ZIP Code This field contains the ZIP code of the pharmacy location. Its source is the Pharmacy ZIP Code element reported by the payer in the pharmacy claims data. Numeric 9
FILLER FILLER This field is reserved for additional fields that may be added in the future. Char 500

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