Name: | Virginia |
---|---|
Abbreviation: | VA |
Title of System | The Virginia All-Payer Claims Database |
Website | http://vhi.org/APCD ![]() |
Who Maintains the System | Virginia Health Information under the authority of the Virginia Department of Health |
Versions: | August 2013 - v1.2 |
Data Element ID | Data Element | Description | Type | Format | Length |
---|---|---|---|---|---|
HD001 | Record Type | Not Provided | char | 2 | |
HD002 | Payer Code | NAIC code (example: 12345); leave blank if not applicable | varchar | 8 | |
HD003 | Payer Name | Not Provided | varchar | 75 | |
HD004 | Beginning Month | Not Provided | date | CCYYMM | 6 |
HD005 | Ending Month | Not Provided | date | CCYYMM | 6 |
HD006 | Record count | Total number of records submitted in the medical claims file, excluding header and trailer records | int | 10 | |
MC001 | Payer | Payer submitting payments | varchar | 8 | |
MC002 | National Plan ID | CMS National Plan ID | varchar | 30 | |
MC003 | Insurance Type/Product Code | Not Provided | char | 2 | |
MC004 | Payer Claim Control Number | Must apply to the entire claim and be unique within the payer's system. | varchar | 35 | |
MC005 | 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. | tinyint | 4 | |
MC005A | 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. | tinyint | 4 | |
MC006 | Insured Group or Policy Number | Group or policy number - not the number that uniquely identifies the subscriber. | varchar | 30 | |
MC007 | Subscriber Social Security Number | Subscriber's social security number; Set as null if unavailable | varchar | 9 | |
MC008 | 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 | |
MC009 | 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 | |
MC010 | 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 | |
MC011 | Individual Relationship Code | Member's relationship to insured | char | 2 | |
MC012 | Member Gender | Not Provided | char | 1 | |
MC013 | Member Date of Birth | Not Provided | char | CCYYMMDD | 8 |
MC014 | Member City Name | City name of member | varchar | 30 | |
MC015 | Member State or Province | As defined by the US Postal Service | char | 2 | |
MC016 | Member ZIP Code | ZIP Code of member - may include non-US codes. Plus 4 optional but desired. | varchar | 11 | |
MC017 | Date Service Approved/Accounts Payable Date/Actual Paid Date | Not Provided | char | CCYYMMDD | 8 |
MC018 | Admission Date | Required for all inpatient claims. | char | CCYYMMDD | 8 |
MC019 | Admission Hour | Required for all inpatient claims. Time is expressed in military time | char | HHMM | 4 |
MC020 | Admission Type | Required for all inpatient claims (SOURCE: National Uniform Billing Data Element Specifications) | tinyint | 1 | |
MC021 | Admission Source | Required for all inpatient claims (SOURCE: National Uniform Billing Data Element Specifications) | char | 1 | |
MC022 | Discharge Hour | Time expressed in military time | tinyint | HHMM | 4 |
MC023 | Discharge Status | Required for all inpatient claims. See Lookup Table B-1.E for codes. | char | 2 | |
MC024 | Service Provider Number | Payer assigned service provider number, preferably for the individual provider but alternately for the clinic where the service occurred. | varchar | 30 | |
MC025 | Service Provider Tax ID Number | Federal taxpayer's identification number | varchar | 10 | |
MC026 | Service National Provider ID | National Provider ID. This data element pertains to the entity or individual directly providing the service. | varchar | 20 | |
MC027 | 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. Health care claims processors shall code according to: | char | 1 | |
MC028 | Service Provider First Name | Individual first name. Set to null if provider is a facility or organization. | varchar | 25 | |
MC029 | Service Provider Middle Name | Individual middle name or initial. Set to null if provider is a facility or organization. | varchar | 25 | |
MC030 | Service Provider Last Name or Organization Name | Full name of provider organization or last name of individual provider | varchar | 60 | |
MC031 | 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 | |
MC032 | Service Provider Specialty | As defined by payer. Dictionary for specialty code values must be supplied during testing. | varchar | 10 | |
MC033 | Service Provider City Name | City name of provider - preferably practice location | varchar | 30 | |
MC034 | Service Provider State or Province | As defined by the US Postal Service | char | 2 | |
MC035 | Service Provider ZIP Code | ZIP Code of provider - may include non-US codes; do not include dash. Plus 4 optional but desired. | varchar | 11 | |
MC036 | Type of Bill - Institutional | Required for institutional claims; Not to be used for professional claims. | char | 3 | |
MC037 | Place of Service - Professional | Required for professional claims. Not to be used for institutional claims. Map where you can and default to "99" for all others. | char | 2 | |
MC038 | Claim Status | Not Provided | char | 2 | |
MC039 | Admitting Diagnosis | Required on all inpatient admission claims and encounters. ICD-9-CM or ICD-10-CM. Do not code decimal point. | varchar | 7 | |
MC040 | E-Code | Describes an injury, poisoning or adverse effect. ICD-9-CM or ICD-10-CM. Do not code decimal point. | varchar | 7 | |
MC041 | Principal Diagnosis | ICD-9-CM or ICD-10_CM. Do not code decimal point. | varchar | 7 | |
MC042 | Other Diagnosis - 1 | ICD-9-CM or ICD-10_CM. Do not code decimal point. | varchar | 7 | |
MC043 | Other Diagnosis - 2 | ICD-9-CM or ICD-10_CM. Do not code decimal point. | varchar | 7 | |
MC044 | Other Diagnosis - 3 | ICD-9-CM or ICD-10_CM. Do not code decimal point. | varchar | 7 | |
MC045 | Other Diagnosis - 4 | ICD-9-CM or ICD-10_CM. Do not code decimal point. | varchar | 7 | |
MC046 | Other Diagnosis - 5 | ICD-9-CM or ICD-10_CM. Do not code decimal point. | varchar | 7 | |
MC047 | Other Diagnosis - 6 | ICD-9-CM or ICD-10_CM. Do not code decimal point. | varchar | 7 | |
MC048 | Other Diagnosis - 7 | ICD-9-CM or ICD-10_CM. Do not code decimal point. | varchar | 7 | |
MC049 | Other Diagnosis - 8 | ICD-9-CM or ICD-10_CM. Do not code decimal point. | varchar | 7 | |
MC050 | Other Diagnosis - 9 | ICD-9-CM or ICD-10_CM. Do not code decimal point. | varchar | 7 | |
MC051 | Other Diagnosis - 10 | ICD-9-CM or ICD-10_CM. Do not code decimal point. | varchar | 7 | |
MC052 | Other Diagnosis - 11 | ICD-9-CM or ICD-10_CM. Do not code decimal point. | varchar | 7 | |
MC053 | Other Diagnosis - 12 | ICD-9-CM or ICD-10_CM. Do not code decimal point. | varchar | 7 | |
MC054 | Revenue Code | National Uniform Billing Committee Codes. Code using leading zeroes, left justified, and four digits. | char | 10 | |
MC055 | Procedure Code | Health Care Common Procedural Coding System (HCPCS); This includes the CPT codes of the American Medical Association. | varchar | 10 | |
MC056 | Procedure Modifier - 1 | Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. | char | 2 | |
MC057 | Procedure Modifier - 2 | Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. | char | 2 | |
MC058 | ICD-9/10-CM Principal Procedure Code | Primary procedure code for this line of service. Do not code decimal point. | char | 7 | |
MC059 | Date of Service - From | First date of service for this service line. | date | CCYYMMDD | 8 |
MC060 | Date of Service - Thru | Last date of service for this service line. | date | CCYYMMDD | 8 |
MC061 | 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 | |
MC062 | 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 | |
MC063 | Paid Amount | Includes any withhold amounts. Do not code decimal point. For capitated claims set to zero. | int | 10 | |
MC064 | Prepaid Amount | For capitated services, the fee for service equivalent amount. Do not code decimal point. | int | 10 | |
MC065 | Co-pay Amount | The preset, fixed dollar amount for which the individual is responsible. Do not code decimal point. | int | 10 | |
MC066 | Coinsurance Amount | The dollar amount an individual is responsible for - not the percentage. Do not code decimal point. | int | 10 | |
MC067 | Deductible Amount | Do not code decimal point. | int | 10 | |
MC068 | Patient Account/Control Number | Number assigned by hospital | varchar | 20 | |
MC069 | Discharge Date | Date patient discharged. Required for all inpatient claims. | date | CCYYMMDD | 8 |
MC070 | Service Provider Country Name | Code US for United States. | varchar | 30 | |
MC071 | 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 | |
MC072 | DRG Version | Version number of the grouper used | char | 2 | |
MC073 | 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 | |
MC074 | APC Version | Version number of the grouper used | char | 2 | |
MC075 | Drug Code | An NDC code used only when a medication is paid for as part of a medical claim. | varchar | 11 | |
MC076 | 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 | |
MC077 | National Billing Provider ID | National Provider ID | varchar | 20 | |
MC078 | Billing Provider LastName or Organization Name | Full name of provider billing organization or last name of individual billing provider. | varchar | 60 | |
MC101 | Subscriber Last Name | Subscriber last name | varchar | 128 | |
MC102 | Subscriber First Name | Subscriber first name | varchar | 128 | |
MC103 | Subscriber Middle Initial | Subscriber middle initial | char | 1 | |
MC104 | Member Last Name | Member last name | varchar | 128 | |
MC105 | Member First Name | Member first name | varchar | 128 | |
MC106 | Member Middle Initial | Member middle intial | char | 1 | |
MC107 | Member Street Address | Physical street address of the covered member | varchar | 50 | |
MC108 | Service Provider Street Address | Physical practice location street address of the provider administering the services | varchar | 50 | |
MC200 | ICD-9 / ICD-10 Flag | The purpose of this field is to identify which code set is being utilized. | char | 1 | |
MC201 | ICD-9/10-CM Other Procedure Code - 1 | Secondary procedure code for this line of service. Do not code decimal point. | varchar | 7 | |
MC202 | ICD-9/10-CM Other Procedure Code - 2 | Secondary procedure code for this line of service. Do not code decimal point. | varchar | 7 | |
MC203 | ICD-9/10-CM Other Procedure Code - 3 | Secondary procedure code for this line of service. Do not code decimal point. | varchar | 7 | |
MC204 | ICD-9/10-CM Other Procedure Code - 4 | Secondary procedure code for this line of service. Do not code decimal point. | varchar | 7 | |
MC205 | ICD-9/10-CM Other Procedure Code - 5 | Secondary procedure code for this line of service. Do not code decimal point. | varchar | 7 | |
MC206 | ICD-9/10-CM Other Procedure Code - 6 | Secondary procedure code for this line of service. Do not code decimal point. | varchar | 7 | |
MC207 | Carrier Associated with Claim | For each claim, the NAIC code of the carrier when a TPA processes claims on behalf of the carrier. Optional if all medical claims processed by data submitters acting as Third Party Administrators (TPAs) under contract to a data submitter for carved-out services are submitted by the data submitter with unified member IDs in all files. | varchar | 8 | |
MC208 | Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number | For each claim, the carrier specific contract number or subscriber/member social security number when a TPA processes claims on behalf of the carrier. Optional if all medical claims processed by data submitters acting as Third Party Administrators (TPAs) under contract to a data submitter for carved-out services are submitted by the data submitter with unified member IDs in all files. | varchar | 128 | |
MC209 | Practitioner Group Practice | Name of group practice to which a practitioner is affiliated if different from MC078 | varchar | 60 | |
MC899 | Record Type | Not Provided | char | 2 | |
TR001 | Record Type | Not Provided | char | 2 | |
TR002 | Payer Code | NAIC code (example: 12345); leave blank if not applicable | varchar | 8 | |
TR003 | Payer Name | Not Provided | varchar | 75 | |
TR004 | Beginning Month | Not Provided | date | CCYYMM | 6 |
TR005 | Ending Month | Not Provided | date | CCYYMM | 6 |
TR006 | Extraction Date | Not Provided | date | CCYYMMDD | 8 |
Data Element ID | Data Element | Description | Type | Format | Length |
---|---|---|---|---|---|
HD001 | Record Type | Not Provided | char | 2 | |
HD002 | Payer Code | NAIC code (example: 12345); leave blank if not applicable | varchar | 8 | |
HD003 | Payer Name | Not Provided | varchar | 75 | |
HD004 | Beginning Month | Not Provided | date | CCYYMM | 6 |
HD005 | Ending Month | Not Provided | date | CCYYMM | 6 |
HD006 | Record count | Total number of records submitted in the medical eligibility file, excluding header and trailer records | int | 10 | |
ME001 | Payer Name/Code | Payer submitting payments-assigned by VHI (may be multiple to support different platforms, or as required) | varchar | 8 | |
ME002 | National Plan ID | CMS National Plan ID or NAIC | varchar | 30 | |
ME003 | Insurance Type Code/Product | Not Provided | char | 2 | |
ME004 | Year | 4 digit Year for which eligibility is reported in this submission | int | 4 | |
ME005 | Month | Month for which eligibility is reported in this submission expressed numerical from 01 to 12. | char | 2 | |
ME006 | Insured Group or Policy Number | Group or policy number - not the number that uniquely identifies the subscriber | varchar | 30 | |
ME007 | Coverage Level Code | Benefit coverage level | char | 3 | |
ME008 | Subscriber Social Security Number | Subscriber's social security number; Set as null if unavailable | varchar | 9 | |
ME009 | 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 | |
ME010 | Member Suffix or Sequence Number | Unique number of the member within the contract. Must be an identifier that is unique to the member. | varchar | 128 | |
ME011 | 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 | |
ME012 | Individual Relationship Code | Member's relationship to insured. | char | 2 | |
ME013 | Member Gender | Not Provided | char | 1 | |
ME014 | Member Date of Birth | Not Provided | char | CCYYMMDD | 8 |
ME015 | Member City Name | City location of member | varchar | 30 | |
ME016 | Member State or Province | As defined by the US Postal Service | char | 2 | |
ME017 | Member ZIP Code | ZIP Code of member - may include non-US codes. Do not include dash. Plus 4 optional but desired. | varchar | 11 | |
ME018 | Medical Coverage | Not Provided | char | 1 | |
ME019 | Prescription Drug Coverage | Not Provided | char | 1 | |
ME020 | Dental Coverage | Not Provided | char | 1 | |
ME021 | Race 1 | Not Provided | varchar | 6 | |
ME022 | Race 2 | Not Provided | varchar | 6 | |
ME023 | Other Race | List race if MC021or MC022 are coded as R9. | varchar | 15 | |
ME024 | Hispanic Indicator | Not Provided | char | 1 | |
ME025 | Ethnicity 1 | Not Provided | varchar | 6 | |
ME026 | Ethnicity 2 | Not Provided | varchar | 6 | |
ME027 | Other Ethnicity | List ethnicity if MC025 or MC026 are coded as OTHER. | varchar | 20 | |
ME028 | Primary Insurance Indicator | Not Provided | char | 1 | |
ME029 | Coverage Type | Not Provided | char | 3 | |
ME030 | Market Category Code | Not Provided | varchar | 4 | |
ME031 | Special Coverage | Not Provided | varchar | 3 | |
ME032 | Group Name | Group name or IND for individual policies | varchar | 128 | |
ME101 | Subscriber Last Name | The subscriber last name | varchar | 128 | |
ME102 | Subscriber First Name | The subscriber first name | varchar | 128 | |
ME103 | Subscriber Middle Initial | The subscriber middle initial | char | 1 | |
ME104 | Member Last Name | The member last name | varchar | 128 | |
ME105 | Member First Name | The member first name | varchar | 128 | |
ME201 | Member Street Address | Street address of member | varchar | 50 | |
ME202 | Employer Name | Name of the Employer, or if same as Group Name, null | varchar | 50 | |
ME897 | 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 | CCYYMMDD | 8 |
ME899 | Record Type | Not Provided | char | 2 | |
TR001 | Record Type | Not Provided | char | 2 | |
TR002 | Payer Code | NAIC code (example: 12345); leave blank if not applicable | varchar | 8 | |
TR003 | Payer Name | Not Provided | varchar | 75 | |
TR004 | Beginning Month | Not Provided | date | CCYYMM | 6 |
TR005 | Ending Month | Not Provided | date | CCYYMM | 6 |
TR006 | Extraction Date | Not Provided | date | CCYYMMDD | 8 |
Data Element ID | Data Element | Description | Type | Format | Length |
---|---|---|---|---|---|
HD001 | Record Type | Not Provided | char | 2 | |
HD002 | Payer Code | NAIC code (example: 12345); leave blank if not applicable | char | 8 | |
HD003 | Payer Name | Example: | char | 75 | |
HD004 | Beginning Month | Not Provided | Date | CCYYMM | 6 |
HD005 | Ending Month | Not Provided | Date | CCYYMM | 6 |
HD006 | Record count | Total number of records submitted in the medical claims file, excluding header and trailer records | int | 10 | |
PC001 | Payer | Payer submitting payments MHDO Submitter Code; MN has its own codes too | varchar | 8 | |
PC002 | Plan ID | CMS National Plan ID or NAIC | varchar | 30 | |
PC003 | Insurance Type/Product Code | Not Provided | char | 2 | |
PC004 | Payer Claim Control Number | Must apply to the entire claim and be unique within the payer's system. | varchar | 35 | |
PC005 | 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. | tinyint | 4 | |
PC006 | Insured Group Number | Group or policy number - not the number that uniquely identifies the subscriber | varchar | 30 | |
PC007 | Subscriber Social Security Number | Subscriber's social security number; Set as null if unavailable | varchar | 9 | |
PC008 | 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 | |
PC009 | 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 | |
PC010 | 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 | |
PC011 | Individual Relationship Code | Member's relationship to insured | char | 2 | |
PC012 | Member Gender | Not Provided | char | 1 | |
PC013 | Member Date of Birth | Not Provided | date | CCYYMMDD | 8 |
PC014 | Member City Name of Residence | City name of member | varchar | 50 | |
PC015 | Member State or Province | As defined by the US Postal Service | char | 2 | |
PC016 | Member ZIP Code | ZIP Code of member - may include non-US codes; Do not include dash. Plus 4 optional but desired. | varchar | 11 | |
PC017 | Date Service Approved (AP Date) | date claim paid if available, otherwise set to Date Prescription Filled | date | CCYYMMDD | 8 |
PC018 | Pharmacy Number | Payer assigned pharmacy number. AHFS number is acceptable. | varchar | 30 | |
PC019 | Pharmacy Tax ID Number | Federal taxpayer's identification number coded with no punctuation (carriers that contract with outside PBMs will not have this) | varchar | 10 | |
PC020 | Pharmacy Name | Name of pharmacy | varchar | 50 | |
PC021 | National Provider ID Number | National Provider ID. This data element pertains to the entity or individual directly providing the service. | varchar | 20 | |
PC022 | Pharmacy Location City | City name of pharmacy - preferably pharmacy location (if mail order null) | varchar | 30 | |
PC023 | Pharmacy Location State | As defined by the US Postal Service (if mail order null) | char | 2 | |
PC024 | 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 | |
PC024A | Pharmacy Country Name | Code US for United States | varchar | 30 | |
PC025 | Claim Status | Not Provided | char | 2 | |
PC026 | Drug Code | NDC Code | varchar | 11 | |
PC027 | Drug Name | Text name of drug | varchar | 80 | |
PC028 | New Prescription or Refill | Provide '01' for new prescriptions; for refills, provide the refill number | varchar | 2 | |
PC029 | Generic Drug Indicator | Not Provided | char | 2 | |
PC030 | Dispensed as Written Code | Payers able to map available codes to those listed below | char | 1 | |
PC031 | Compound Drug Indicator | Not Provided | char | 1 | |
PC032 | Date Prescription Filled | Not Provided | date | CCYYMMDD | 8 |
PC033 | Quantity Dispensed | Number of metric units of medication dispensed | int | 5 | |
PC034 | Days Supply | Estimated number of days the prescription will last | int | 3 | |
PC035 | 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 | |
PC036 | Paid Amount | Includes all health planpayments and excludes all member payments. Do not code decimal point. | int | 10 | |
PC037 | Ingredient Cost/List Price | Cost of the drug dispensed. Do not code decimal point. | int | 10 | |
PC038 | Postage Amount Claimed | Do not code decimal point. Not typically captured. | int | 10 | |
PC039 | Dispensing Fee | Do not code decimal point. | int | 10 | |
PC040 | Co-pay Amount | The preset, fixed dollar amount for which the individual is responsible. Do not code decimal point. | int | 10 | |
PC041 | Coinsurance Amount | The dollar amount an individual is responsible for - not the percentage. Do not code decimal point. | int | 10 | |
PC042 | Deductible Amount | Do not code decimal point. | int | 10 | |
PC043 | Unassigned | Reserved for assignment | Not Supplied | Not Supplied | Not Supplied |
PC044 | Prescribing Physician First Name | Physician first name. | varchar | 25 | |
PC045 | Prescribing Physician Middle Name | Physician middle name or initial. | varchar | 25 | |
PC046 | Prescribing Physician Last Name | Physician last name. | varchar | 60 | |
PC047 | Prescribing Physician Number | DEA or NPI number for prescribing physician | varchar | 20 | |
PC101 | Subscriber Last Name | Not Provided | varchar | 128 | |
PC102 | Subscriber First Name | Not Provided | varchar | 128 | |
PC103 | Subscriber Middle Initial | Not Provided | char | 1 | |
PC104 | Member Last Name | Not Provided | varchar | 128 | |
PC105 | Member First Name | Not Provided | varchar | 128 | |
PC106 | Member Middle Initial | Not Provided | char | 1 | |
PC201 | Pharmacy Location Street Address | Street address of pharmacy | varchar | 30 | |
PC202 | Member Street Address | Street address of member | varchar | 50 | |
PC203 | Carrier Associated with Claim | For each claim, the NAIC code of the carrier when a PBM processes claims on behalf of the carrier. Optional if all pharmacy claims processed by data submitters acting as Pharmacy Benefits Managers (PBMs) under contract to a data submitter for carved-out services are submitted by the data submitter with unified member IDs in all files. | varchar | 8 | |
PC204 | Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number | For each claim, the carrier specific contract number or subscriber/member social security number when a PBM processes claims on behalf of the carrier. Optional if all pharmacy claims processed by data submitters acting as Pharmacy Benefits Managers (PBMs) under contract to a data submitter for carved-out services are submitted by the data submitter with unified member IDs in all files. | varchar | 128 | |
PC899 | Record Type | Not Provided | char | 2 | |
TR001 | Record Type | Not Provided | char | 2 | |
TR002 | Payer Code | NAIC code (example: 12345); leave blank if not applicable | varchar | 8 | |
TR003 | Payer Name | Not Provided | varchar | 75 | |
TR004 | Beginning Month | Not Provided | Date | CCYYMM | 6 |
TR005 | Ending Month | Not Provided | Date | CCYYMM | 6 |
TR006 | Extraction Date | Not Provided | Date | CCYYMMDD | 8 |
Data Element ID | Data Element | Description | Type | Format | Length |
---|---|---|---|---|---|
HD001 | Record Type | Not Provided | char | 2 | |
HD002 | Payer Code | NAIC code (example: 12345); leave blank if not applicable | varchar | 8 | |
HD003 | Payer Name | Not Provided | varchar | 75 | |
HD004 | Beginning Month | Example: 200801 | Date | CCYYMM | 6 |
HD005 | Ending Month | Example: 200812 | Date | CCYYMM | 6 |
HD006 | Record count | Total number of records submitted in the medical eligibility file, excluding header and trailer records | int | 10 | |
MP001 | Provider ID | Unique identified for the provider as assigned by the reporting entity | varchar | 30 | |
MP002 | Provider Tax ID | Tax ID of the provider. Do not code punctuation. | varchar | 10 | |
MP003 | Provider Entity | Not Provided | char | 1 | |
MP004 | Provider First Name | Individual first name. Set to null if provider is a facility or organization. | varchar | 25 | |
MP005 | 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 | |
MP007 | Provider Suffix | Example: Jr;null if provider is an organization. Do not use credentials such as MD or PhD | varchar | 10 | |
MP008 | 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 http://www.nucc.org/ | varchar | 50 | |
MP009 | Provider Office Street Address | Physical address - address where provider delivers health care services | varchar | 50 | |
MP010 | Provider Office City | Physical address - address where provider delivers health care services | varchar | 30 | |
MP011 | Provider Office State | Physical address - address where provider delivers health care services. Use postal service standard 2 letter abbreviations. | char | 2 | |
MP012 | Provider Office Zip | Physical address - address where provider delivers health care services. Minimum 5 digit code. | varchar | 11 | |
MP013 | Provider DEA Number | Not Provided | varchar | 12 | |
MP014 | Provider NPI | Not Provided | varchar | 20 | |
MP015 | Provider State License Number | Prefix with two-character state of licensure with no punctuation. Example COLL12345 | varchar | 15 | |
MP899 | Record Type | Not Provided | char | 2 | |
TR001 | Record Type | Not Provided | char | 2 | |
TR002 | Payer Code | NAIC code (example: 12345); leave blank if not applicable | varchar | 8 | |
TR003 | Payer Name | Not Provided | varchar | 75 | |
TR004 | Beginning Month | Example: 200801 | Date | CCYYMM | 6 |
TR005 | Ending Month | Example: 200812 | Date | CCYYMM | 6 |
TR006 | Extraction Date | Not Provided | Date | CCYYMMDD | 8 |