Name: | Pharmacy Claims File Submission |
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State: | Colorado |
Definition: | Not Provided |
Version | March 2014 - v6 |
Data Element ID | Data Element | Description | Type | Format | Length |
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Record Type | Not Provided | char | 2 | |
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Payer Code | Distributed by CIVHC | char | 8 | |
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Payer Name | Distributed by CIVHC | char | 75 | |
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Beginning Month | Not Provided | Date | CCYYMM | 6 |
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Ending Month | Not Provided | Date | CCYYMM | 6 |
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Record count | Total number of records submitted in the medical claims file, excluding header and trailer records | int | 10 | |
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Payer Code | Distributed by CIVHC | varchar | 8 | |
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Payer Name | Distributed by CIVHC | varchar | 30 | |
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Insurance Type/Product Code | Not Provided | char | 2 | |
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Payer Claim Control Number | Must apply to the entire claim and be unique within the payer's system. | varchar | 35 | |
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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 | |
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Insured Group Number | Group or policy number - not the number that uniquely identifies the subscriber | varchar | 30 | |
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Subscriber Social Security Number | Subscriber's social security number; Set as null if unavailable | varchar | 9 | |
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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 | |
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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 | |
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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 | |
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Individual Relationship Code | Member's relationship to insured | char | 2 | |
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Member Gender | Not Provided | char | 1 | |
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Member Date of Birth | Not Provided | Date | YYYYMMDD | 8 |
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Member City Name of Residence | City name of member | varchar | 50 | |
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Member State or Province | As defined by the US Postal Service | char | 2 | |
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Member ZIP Code | ZIP Code of member - may include non-US codes; Do not include dash. Plus 4 optional but desired. | varchar | 11 | |
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Date Service Approved (AP Date) | date claim paid if available, otherwise set to Date Prescription Filled | Date | YYYYMMDD | 8 |
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Pharmacy Number | Payer assigned pharmacy number. AHFS number is acceptable. | varchar | 30 | |
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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 | |
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Pharmacy Name | Name of pharmacy | varchar | 50 | |
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National Provider ID Number | National Provider ID. This data element pertains to the entity or individual directly providing the service. | varchar | 20 | |
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Pharmacy Location Street Address | Street address of pharmacy | Varchar | 30 | |
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Pharmacy Location City | City name of pharmacy - preferably pharmacy location (if mail order null) | varchar | 30 | |
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Pharmacy Location State | As defined by the US Postal Service (if mail order null) | char | 2 | |
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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 | |
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Pharmacy Country Name | Code US for United States | varchar | 30 | |
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Claim Status | Not Provided | char | 2 | |
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Drug Code | NDC Code | varchar | 11 | |
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Drug Name | Text name of drug | varchar | 80 | |
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New Prescription or Refill | Older systems provide only an "N" for new or an "R" for refill, otherwise provide refill # | varchar | 2 | |
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Generic Drug Indicator | Not Provided | char | 2 | |
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Dispense as Written Code | Payers able to map available codes to those below | char | 1 | |
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Compound Drug Indicator | Not Provided | char | 1 | |
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Date Prescription Filled | Not Provided | Date | YYYYMMDD | 8 |
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Quantity Dispensed | Number of metric units of medication dispensed | int | 5 | |
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Days Supply | Estimated number of days the prescription will last | int | 3 | |
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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 | |
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Paid Amount | Includes all health plan payments and excludes all member payments. Do not code decimal point. | int | 10 | |
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Ingredient Cost/List Price | Cost of the drug dispensed. Do not code decimal point. | int | 10 | |
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Postage Amount Claimed | Do not code decimal point. Not typically captured. | int | 10 | |
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Dispensing Fee | Do not code decimal point. | int | 10 | |
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Co-pay Amount | The preset, fixed dollar amount for which the individual is responsible. Do not code decimal point. | int | 10 | |
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Coinsurance Amount | The dollar amount an individual is responsible for - not the percentage. Do not code decimal point. | int | 10 | |
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Deductible Amount | Do not code decimal point. | int | 10 | |
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Unassigned | Reserved for assignment | Not Supplied | Not Supplied | Not Supplied |
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Prescribing Physician First Name | Physician first name. | varchar | 25 | |
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Prescribing Physician Middle Name | Physician middle name or initial. | varchar | 25 | |
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Prescribing Physician Last Name | Physician last name. | varchar | 60 | |
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Prescribing Physician NPI | NPI number for prescribing physician | varchar | 20 | |
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Member Street Address | Street address of member | varchar | 50 | |
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Subscriber Last Name | Not Provided | varchar | 128 | |
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Subscriber First Name | Not Provided | varchar | 128 | |
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Subscriber Middle Initial | Not Provided | char | 1 | |
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Member Last Name | Not Provided | varchar | 128 | |
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Member First Name | Not Provided | varchar | 128 | |
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Member Middle Initial | Not Provided | char | 1 | |
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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 | |
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Prescription Written Date | Date Prescription was written | Date | 8 | |
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Prescribing Physician Provider ID | Provider ID for the prescribing physician | varchar | 30 | |
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Prescribing Physician DEA | DEA number for prescribing physician | varchar | 20 | |
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Record Type | Not Provided | char | 2 | |
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Record Type | Not Provided | char | 2 | |
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Payer Code | Distributed by CIVHC | varchar | 8 | |
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Payer Name | Distributed by CIVHC | varchar | 75 | |
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Beginning Month | Not Provided | Date | CCYYMM | 6 |
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Ending Month | Not Provided | Date | CCYYMM | 6 |
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Extraction Date | Not Provided | Date | YYYYMMDD | 8 |
Data Element ID | Data Element | Code | Value |
---|---|---|---|
HD001 | Record Type | PC | |
PC003 | Insurance Type/Product Code | 12 | Preferred Provider Organization (PPO) |
13 | Point of Service (POS) | ||
15 | Indemnity Insurance | ||
16 | Health Maintenance Organization (HMO) Medicare Advantage | ||
17 | Dental Maintenance Organization (DMO) | ||
99 | Other | ||
CI | Commercial Insurance Company | ||
DN | Dental | ||
HM | Health Maintenance Organization | ||
HN | HMO Medicare Risk/ Medicare Part C | ||
MA | Medicare Part A | ||
MB | Medicare Part B | ||
MC | Medicaid | ||
MD | Medicare Part D | ||
MP | Medicare Primary | ||
QM | Qualified Medicare Beneficiary | ||
SP | Supplemental Policy | ||
SP | Medicare Supplemental (Medi-gap) plan | ||
TV | Title V | ||
PC011 | Individual Relationship Code | 01 | Spouse |
04 | Grandfather or Grandmother | ||
05 | Grandson or Granddaughter | ||
07 | Nephew or Niece | ||
10 | Foster Child | ||
15 | Ward | ||
17 | Stepson or Stepdaughter | ||
19 | Child | ||
20 | Employee/Self | ||
21 | Unknown | ||
22 | Handicapped Dependent | ||
23 | Sponsored Dependent | ||
24 | Dependent of a Minor Dependent | ||
29 | Significant Other | ||
32 | Mother | ||
33 | Father | ||
36 | Emancipated Minor | ||
39 | Organ Donor | ||
40 | Cadaver Donor | ||
41 | Injured Plaintiff | ||
43 | Child Where Insured Has No Financial Responsibility | ||
53 | Life Partner | ||
76 | Dependent | ||
PC012 | Member Gender | F | Female |
M | Male | ||
U | UNKNOWN | ||
PC025 | Claim Status | 01 | Processed as primary |
02 | Processed as secondary | ||
03 | Processed as tertiary | ||
19 | Processed as primary, forwarded to additional payer(s) | ||
20 | Processed as secondary, forwarded to additional payer(s) | ||
21 | Processed as tertiary, forwarded to additional payer(s) | ||
22 | Reversal of previous payment | ||
PC028 | New Prescription or Refill | 01 | New prescription |
02 | Refill | ||
PC029 | Generic Drug Indicator | 01 | branded drug |
02 | generic drug | ||
PC030 | Dispense as Written Code | 0 | Not dispensed as written |
1 | Physician dispense as written | ||
2 | Member dispense as written | ||
3 | Pharmacy dispense as written | ||
4 | No generic available | ||
5 | Brand dispensed as generic | ||
6 | Override | ||
7 | Substitution not allowed - brand drug mandated by law | ||
8 | Substitution allowed - generic drug not available in marketplace | ||
9 | Other | ||
PC031 | Compound Drug Indicator | N | Non-compound drug |
U | Non-specified drug compound | ||
Y | Compound drug | ||
PC899 | Record Type | PC | |
TR001 | Record Type | PC |