Name: | Pharmacy Claims File Submission |
---|---|
State: | Connecticut |
Definition: | Not provided |
Version | December 5, 2013 - v1.2 |
Data Element ID | Data Element | Description | Type | Format | Length |
---|---|---|---|---|---|
HD001 | Record Type | Header Record Identifier | Text | char[2] | 2 |
HD002 | Submitter | Header Submitter / Carrier ID defined by AHCT | Integer | varchar[6] | 6 |
HD003 | National Plan ID | Header CMS National Plan Identification Number (PlanID) | Integer | int[10] | 10 |
HD004 | Type of File | Defines the file type and data expected. | Text | char[2] | 2 |
HD005 | Period Beginning Date | Header Period Start Date | Full Date - Integer | int[8] YYYYMMDD | 8 |
HD006 | Period Ending Date | Header Period Ending Date | Full Date - Integer | int[8] YYYYMMDD | 8 |
HD007 | Record Count | Header Record Count | Integer | varchar[10] | 10 |
HD008 | Comments | Header Carrier Comments | Text | varchar[80] | 80 |
HD009 | APCD Version Number | Submission Guide Version | Decimal - Numeric | char[3] | 3 |
PC001 | Submitter | CT APCD defined and maintained unique identifier | Integer | varchar[6] | 6 |
PC002 | National Plan ID | CMS National Plan Identification Number (PlanID) | Integer | int[10] | 10 |
PC003 | Insurance Type Code / Product | Type / Product Identification Code | Text | char[2] | 2 |
PC004 | Payer Claim Control Number | Payer Claim Control Identification | Text | varchar[35] | 35 |
PC005 | Line Counter | Incremental Line Counter | Numeric | varchar[4] | 4 |
PC005A | Version Number | Claim Service Line Version Number | Numeric | varchar[4] | 4 |
PC006 | Insured Group or Policy Number | Group / Policy Number | Text | varchar[30] | 30 |
PC007 | Subscriber SSN | Subscriber's Social Security Number | Numeric | char[9] | 9 |
PC008 | Plan Specific Contract Number | Contract Number | Text | varchar[30] | 30 |
PC009 | Member Suffix or Sequence Number | Member/Patient's Contract Sequence Number | Text | varchar[20] | 20 |
PC010 | Member SSN | Member/Patient's Social Security Number | Numeric | char[9] | 9 |
PC011 | Individual Relationship Code | Patient to Subscriber Relationship Code | Text | varchar[2] | 2 |
PC012 | Member Gender | Patient's Gender | Text | char[1] | 1 |
PC013 | Member Date of Birth | Member/Patient's date of birth | Full Date - Integer | int[8] YYYYMMDD | 8 |
PC014 | Member City Name of Residence | City name of the Member/Patient | Text | varchar[50] | 50 |
PC015 | Member State | State / Province of the Patient | External Code Source - USPS | char[2] | 2 |
PC016 | Member ZIP Code | Zip code of the Member / Patient | External Code Source - USPS | varchar[9] | 9 |
PC017 | Date Service Approved (AP Date) | Date Service Approved by Payer | Full Date - Integer | int[8] YYYYMMDD | 8 |
PC018 | Pharmacy Number | Pharmacy Number | Text | varchar[30] | 30 |
PC019 | Pharmacy Tax ID Number | Pharmacy Tax Identification Number | Numeric | char[9] | 9 |
PC020 | Pharmacy Name | Name of Pharmacy | Text | varchar[100] | 100 |
PC021 | National Provider ID - Pharmacy | National Provider Identification (NPI) of the Pharmacy | External Code Source - NPPES | int[10] | 10 |
PC022 | Pharmacy Location City | City name of the Pharmacy | Text | varchar[30] | 30 |
PC023 | Pharmacy Location State | State of the Pharmacy | External Code Source - USPS | char[2] | 2 |
PC024 | Pharmacy ZIP Code | Zip code of the Pharmacy | External Code Source - USPS | varchar[9] | 9 |
PC024A | Pharmacy Country Code | Country Code of the Pharmacy | External Code Source - ANSI | char[3] | 3 |
PC025 | Claim Status | Claim Line Status | integer | varchar[2] | 2 |
PC026 | Drug Code | National Drug Code (NDC) | External Code Source - FDA | char[11] | 11 |
PC027 | Drug Name | Name of the drug as supplied | External Code Source - FDA | varchar[80] | 80 |
PC028 | New Prescription or Refill | Prescription Status Indicator | Numeric | char[2] | 2 |
PC029 | Generic Drug Indicator | Generic Drug Indicator | Integer | int[1] | 1 |
PC030 | Dispense as Written Code | Prescription Dispensing Activity Code | Integer | int[1] | 1 |
PC031 | Compound Drug Indicator | Compound Drug Indicator | Integer | int[1] | 1 |
PC032 | Date Prescription Filled | Prescription filled date | Full Date - Integer | int[8] YYYYMMDD | 8 |
PC033 | Quantity Dispensed | Claim line units dispensed | Quantity - Integer | ±varchar[10] | 10 |
PC034 | Days' Supply | Prescription Supply Days | Quantity - Integer | ±varchar[3] | 3 |
PC035 | Charge Amount | Amount of provider charges for the claim line | Integer | ±varchar[10] | 10 |
PC036 | Paid Amount | Amount paid by the carrier for the claim line | Integer | ±varchar[10] | 10 |
PC037 | Ingredient Cost/List Price | Amount defined as the List Price or Ingredient Cost | Integer | ±varchar[10] | 10 |
PC038 | Postage Amount Claimed | Amount of postage claimed on the claim line | Integer | ±varchar[10] | 10 |
PC039 | Dispensing Fee | Amount of dispensing fee for the claim line | Integer | ±varchar[10] | 10 |
PC040 | Copay Amount | Amount of Copay member/patient is responsible to pay | Integer | ±varchar[10] | 10 |
PC041 | Coinsurance Amount | Amount of coinsurance member/patient is responsible to pay | Integer | ±varchar[10] | 10 |
PC042 | Deductible Amount | Amount of deductible member/patient is responsible to pay on the claim line | Integer | ±varchar[10] | 10 |
PC043 | Prescribing ProviderID | Prescribing Provider Identification | Text | varchar[30] | 30 |
PC044 | Prescribing Physician First Name | First name of Prescribing Physician | Text | varchar[25] | 25 |
PC045 | Prescribing Physician Middle Name | Middle initial of Prescribing Physician | Text | varchar[25] | 25 |
PC046 | Prescribing Physician Last Name | Last name of Prescribing Physician | Text | varchar[60] | 60 |
PC047 | Prescribing Physician DEA | Prescriber DEA | Text | char[9] | 9 |
PC048 | National Provider ID - Prescribing | National Provider Identification (NPI) of the Prescriber | External Code Source - NPPES | int[10] | 10 |
PC049 | Prescribing Physician Plan Number | Carrier-assigned Provider Plan ID | Text | varchar[30] | 30 |
PC050 | Prescribing Physician License Number | Prescribing Physician License Number | Text | varchar[30] | 30 |
PC051 | Prescribing Physician Street Address | Street address of the Prescribing Physician | Text | varchar[50] | 50 |
PC052 | Prescribing Physician Street Address 2 | Secondary street address of the Prescribing Physician | Text | varchar[50] | 50 |
PC053 | Prescribing Physician City | City name of the Prescribing Physician | Text | varchar[30] | 30 |
PC054 | Prescribing Physician State | State of the Prescribing Physician | External Code Source - USPS | char[2] | 2 |
PC055 | Prescribing Physician Zip Code | Zip code of the Prescribing Physician | External Code Source - USPS | varchar[9] | 9 |
PC056 | Filler | Filler | Filler | char[0] | 0 |
PC057 | Mail Order pharmacy | Indicator - Mail Order Option | Integer | int[1] | 1 |
PC058 | Script number | Prescription Number | Text | varchar[20] | 20 |
PC059 | Filler | Filler | Filler | char[0] | 0 |
PC060 | Single / Multiple Source Indicator | Indicator - Drug Source | Integer | int[1] | 1 |
PC061 | Member Street Address | Street address of the Member/Patient | Text | varchar[50] | 50 |
PC062 | Billing Provider Tax ID Number | The Billing Provider's Federal Tax Identification Number (FTIN) | Numeric | char[9] | 9 |
PC063 | Paid Date | Paid date of the claim line | Integer | int[8] YYYYMMDD | 8 |
PC064 | Date Prescription Written | Date prescription was prescribed | Full Date - Integer | int[8] YYYYMMDD | 8 |
PC065 | COB / TPL Amount | Amount due from a secondary carrier | Integer | ±varchar[10] | 10 |
PC066 | Other Insurance Paid Amount | Amount already paid by primary carrier | Integer | ±varchar[10] | 10 |
PC067 | Medicare Paid Amount | Any amount Medicare Paid towards claim line | Integer | ±varchar[10] | 10 |
PC068 | Allowed amount | Allowed Amount | Integer | ±varchar[10] | 10 |
PC069 | Member Self Pay Amount | Amount member/patient paid out of pocket on the claim line | Integer | ±varchar[10] | 10 |
PC070 | Rebate Indicator | Indicator - Rebate | Integer | int[1] | 1 |
PC071 | State Sales Tax | Amount of applicable sales tax on the claim line | Integer | ±varchar[10] | 10 |
PC072 | Carve Out Vendor CT APCD ID | CT APCD defined and maintained Org ID for linking across submitters | Integer | varchar[6] | 6 |
PC073 | Formulary Code | Indicator - Formulary Inclusion | Integer | int[1] | 1 |
PC074 | Route of Administration | Route of Administration | External Codes Source - NCPDP | char[2] | 2 |
PC075 | Drug Unit of Measure | Units of Measure | External Codes Source - NCPDP | char[2] | 2 |
PC101 | Subscriber Last Name | Last name of Subscriber | Text | varchar[60] | 60 |
PC102 | Subscriber First Name | First name of Subscriber | Text | varchar[25] | 25 |
PC103 | Subscriber Middle Initial | Middle initial of Subscriber | Text | char[1] | 1 |
PC104 | Member Last Name | Last name of Member/Patient | Text | varchar[60] | 60 |
PC105 | Member First Name | First name of Member/Patient | Text | varchar[25] | 25 |
PC106 | Member Middle Initial | Middle initial of the Member/Patient | Text | char[1] | 1 |
PC107 | Carrier Specific Unique Member ID | Member's Unique ID | Text | varchar[50] | 50 |
PC108 | Carrier Specific Unique Subscriber ID | Subscriber's Unique ID | Text | varchar[50] | 50 |
PC109 | Member Street Address 2 | Secondary Street Address of the Member/Patient | Text | varchar[50] | 50 |
PC110 | Claim Line Type | Claim Line Activity Type Code | Text | char[1] | 1 |
PC111 | Former Claim Number | Previous Claim Number | Text | varchar[35] | 35 |
PC112 | Medicare Indicator | Indicator - Medicare Payment Applied | Integer | int[1] | 1 |
PC113 | Pregnancy Indicator | Indicator - Pregnancy | Integer | int[1] | 1 |
PC114 | Diagnosis Code | ICD Diagnosis Code | External Codes Source - ICD | varchar[7] | 7 |
PC115 | ICD Indicator | International Classification of Diseases version | Integer | int[1] | 1 |
PC116 | Denied Flag | Indicator - Denied Claim Line | Integer | int[1] | 1 |
PC117 | Denial Reason | Denial Reason Code | External Code Source - HIPAA -OR- Carrier Lookup Table | varchar[30] | 30 |
PC118 | Payment Arrangement Type | Payment Arrangement Type Value | Integer | int[1] | 1 |
PC119 | Filler | Filler | Filler | char[0] | 0 |
PC120 | APCD ID Code | Member Enrollment Type | Integer | int[1] | 1 |
PC899 | Record Type | File Type Identifier | Text | char[2] | 2 |
TR001 | Record Type | Trailer Record Identifier | Text | char[2] | 2 |
TR002 | Submitter | Trailer Submitter / Carrier ID defined by AHCT | Integer | varchar[6] | 6 |
TR003 | National Plan ID | CMS National Plan Identification Number (PlanID) | Integer | int[10] | 10 |
TR004 | Type of File | Validates the file type defined in HD004. | Text | char[2] | 2 |
TR005 | Period Beginning Date | Trailer Period Start Date | Full Date - Integer | int[8] YYYYMMDD | 8 |
TR006 | Period Ending Date | Trailer Period Ending Date | Full Date - Integer | int[8] YYYYMMDD | 8 |
TR007 | Date Processed | Trailer Processed Date | Full Date - Integer | int[8] YYYYMMDD | 8 |
Data Element ID | Data Element | Code | Value |
---|---|---|---|
HD001 | Record Type | HD | Header Elements |
HD004 | Type of File | PC | PHARMACY CLAIM |
HD009 | APCD Version Number | 1 | Current Version; required for reporting periods as of October 2013 |
PC003 | Insurance Type Code / Product | 9 | Self-pay |
11 | Other Non-Federal Programs (use of this value requires disclosure to Data Manager prior to submission) | ||
12 | Preferred Provider Organization (PPO) | ||
13 | Point of Service (POS) | ||
14 | Exclusive Provider Organization (EPO) | ||
15 | Indemnity Insurance | ||
16 | Health Maintenance Organization (HMO) Medicare Risk | ||
17 | Dental Maintenance Organization (DMO) | ||
96 | Husky Health A | ||
97 | Husky Health B | ||
98 | Husky Health C | ||
99 | Husky Health D | ||
AM | Automobile Medical | ||
CH | Champus (now TRICARE) | ||
CI | Commercial Insurance | ||
DS | Disability | ||
HM | Health Maintenance Organization | ||
LM | Liability Medical | ||
MA | Medicare Part A | ||
MB | Medicare Part B | ||
MC | Medicaid | ||
OF | Other Federal Program (use of this value requires disclosure to Data Manager prior to submission) | ||
TV | Title V | ||
VA | Veterans Affairs Plan | ||
WC | Workers' Compensation | ||
ZZ | Mutually Defined (use of this value requires disclosure to Data Manager prior to submission) | ||
PC011 | Individual Relationship Code | 1 | Spouse |
4 | Grandfather or Grandmother | ||
5 | Grandson or Granddaughter | ||
7 | Nephew or Niece | ||
10 | Foster Child | ||
12 | Other Adult | ||
15 | Ward | ||
17 | Stepson or Stepdaughter | ||
19 | Child | ||
20 | Self / Employee | ||
21 | Unknown | ||
22 | Handicapped Dependent | ||
23 | Sponsored Dependent | ||
24 | Dependent of a Minor Dependent | ||
29 | Significant Other | ||
32 | Mother | ||
33 | Father | ||
34 | Other Adult | ||
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 | 1 | Processed as primary |
2 | Processed as secondary | ||
3 | Processed as tertiary | ||
4 | Denied | ||
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 | ||
23 | Not our claim, forwarded to additional payer(s) | ||
25 | Predetermination Pricing Only - no payment | ||
PC029 | Generic Drug Indicator | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
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 | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC057 | Mail Order pharmacy | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC060 | Single / Multiple Source Indicator | 1 | Multi-source brand |
2 | Multi-source brand with generic equivalent | ||
3 | Single source brand | ||
4 | Single source brand with generic equivalent | ||
5 | Unknown | ||
PC070 | Rebate Indicator | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC073 | Formulary Code | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC110 | Claim Line Type | A | Amendment |
B | Back Out | ||
O | Original | ||
R | Replacement | ||
V | Void | ||
PC112 | Medicare Indicator | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC113 | Pregnancy Indicator | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC115 | ICD Indicator | 0 | ICD-10 |
9 | ICD-9 | ||
PC116 | Denied Flag | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC118 | Payment Arrangement Type | 1 | Capitation |
2 | Fee for Service | ||
3 | Percent of Charges | ||
4 | DRG | ||
5 | Pay for Performance | ||
6 | Global Payment | ||
7 | Other | ||
8 | Bundled Payment | ||
PC120 | APCD ID Code | 0 | Unknown / Not Applicable |
1 | FIG - Fully-Insured Commercial Group Enrollee | ||
2 | SIG - Self-Insured Group Enrollee | ||
3 | State or Federal Employer Enrollee | ||
4 | Individual - Non-Group Enrollee | ||
5 | Supplemental Policy Enrollee | ||
6 | ICO - Integrated Care Organization | ||
PC899 | Record Type | PC | |
TR001 | Record Type | TR | end of the data file |
TR004 | Type of File | PC |