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Pharmacy Claims File Submission

Colorado

Versions: August 2011 - v3• March 2013 - v5• March 2014 - v6Compare Versions


At A Glance

Name:Pharmacy Claims File Submission
State:Colorado
Definition:Not Provided
VersionMarch 2014 - v6

File Specification for Pharmacy Claims File Submission

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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Codes and Values

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
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