| Name: | Pharmacy Claims File Submission |
|---|---|
| State: | Minnesota |
| Definition: | "Health care claims data" means information included in an institutional, professional, or pharmacy drug claim or equivalent encounter information transaction for a covered individual that is required under Minnesota Statutes, section 62J.536. |
| Version | May 2009 |
| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| HD001 | Record Type | Not Provided | Text | 2 | |
| HD002 | Payer | Payer Code | Text | 8 | |
| HD004 | Type of File | Not Provided | Text | 2 | |
| HD005 | Period Beginning Date | Not Provided | Integer | CCYYMM | 6 |
| HD006 | Period Ending Date | Not Provided | Integer | CCYYMM | 6 |
| HD007 | Record Count | Total number of records submitted in the file | Integer | 10 | |
| HD008 | Comments | Payer comments | Text | 80 | |
| PC001 | Payer | This field contains the NCDMS assigned submitter code for the data submitter. The first two characters of the submitter code indicate Minnesota and the third character designates the type of submitter. MNC Commercial carrier MNG Governmental agency MNT Third Party Administrator MNU Unlicensed entity 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 6 characters. A suffix will be used to distinguish the location and/or system variations. This field contains a constant value and is primarily used for tracking compliance by data submitter. | Text | 8 | |
| PC003 | 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 | |
| PC004 | Payer Claim Control Number | This field contains the claim number used by the data submitter to internally track the claim. In general the claim number is associated with all service lines of the bill. It must apply to the entire claim and be unique within the data submitter's system. | Text | 35 | |
| PC005 | Line Counter | This field contains the line number for this service. The line counter begins with 1 and is incremented by 1 for each additional service line of a claim. This field is used in algorithms to determine the final payment for the service. If the data submitter's processing system assigns an internal line counter for the adjudication process, that number may be submitted in place of the line number submitted by the provider. This should be discussed with NCDMS staff. | Integer | 4 | |
| PC008 | Plan Specific Contract Number | This field contains the data submitter assigned contract number for the subscriber. This field is encrypted using the same algorithm across all data submitters and is not available in the analytical data warehouse. When this field is populated, it forms the core of the unique member identification code. Set as null if unavailable. | Text | 128 | |
| PC011 | Individual Relationship Code | This field contains the member's relationship to the subscriber or the insured. | Integer | 2 | |
| PC012 | Member Gender | This field contains the gender of the member. | Integer | 1 | |
| PC013 | Member Date of Birth | This field contains the member's date of birth with a format of CCYYMMDD. During the encryption process, this field is used to calculate age as of the date the prescription was filled. The field is then encrypted. This data element will not be transmitted in unencrypted form.. | Date | CCYYMMDD | 8 |
| PC014 | Member City Name of Residence | This field contains the member's city of residence. | Text | 30 | |
| PC015 | Member State or Province | The member state or province contains the 2 character abbreviation code used by the US Postal Service. | Text | 2 | |
| PC016 | Member ZIP Code | This field contains ZIP Code of the member. | Text | 5 | |
| PC017 | Date Service Approved (AP Date) | This field contains the date the record was approved for payment. This is generally referred to as the paid date and reported with a CCYYMMDD format. May submit batch date. | Date | CCYYMMDD | 8 |
| PC018 | Pharmacy Number | Payer assigned pharmacy number. Required if PC021 is not filled. | Text | 30 | |
| PC020 | Pharmacy Name | This field contains the name of the pharmacy. | Text | 30 | |
| PC021 | National Pharmacy ID Number | The field contains the National Provider Identification (NPI) number and pertains to the entity or individual directly providing the service. Required if PC018 is not filled. | Text | 20 | |
| PC025 | Claim Status | This field contains the status of the claim as reported by the data submitter. It will be used in the algorithms to determine the final payment for this service. | Text | 2 | |
| PC026 | Drug Code | Each drug product listed under Section 510 of the Federal Food, Drug, and Cosmetic Act is assigned a unique 10-digit, 3-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 code, is assigned by the FDA. A labeler is any firm that manufactures, re-packs 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. | Text | 11 | |
| PC027 | Drug Name | This field contains the text name of drug as supplied by the data submitter. Voluntary - not required | Text | 80 | |
| PC028 | New Prescription or Refill | This field can be used to determine if this is a new prescription. It contains the prescription number. | Integer | 2 | |
| PC029 | Generic Drug Indicator | This field indicates whether the drug is a branded drug or a generic drug. | Text | 1 | |
| PC030 | 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 be filled as written. | Integer | 1 | |
| PC031 | Compound Drug Indicator | This field indicates if this is a compound drug or not. 0 Not specified 1 No Compound 2 Compound | Text | 1 | |
| PC032 | Date Prescription Filled | This field contains the date the prescription was filled. Data is reported in a CCYYMMDD format. | Text | CCYYMMDD | 8 |
| PC033 | Quantity Dispensed | This field contains the total unit dosage in metric units. This field may be negative. | Integer | 5 | |
| PC034 | Days Supply | This field contains the actual days supply for the prescription based on the metric quantity dispensed. This field may contain a negative value. | Integer | 3 | |
| PC035 | Gross Amount Due | This field contains the total charges for the service as reported by the provider. This is a money field containing dollars and cents with an implied decimal point and may contain a negative value. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. | Decimal | 10 | |
| PC036 | Total Amount Paid | This field includes all health plan payments and excludes all member payments. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. | Decimal | 10 | |
| PC036A | Other Amount Paid | This field contains the amount paid for additional costs claimed in "Other Amount Claimed Submitted (480-H9)." This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. | Decimal | 10 | |
| PC036B | Other Payer Amount Recognized | This field contains the total dollar amount of any payment from another source, including coupons. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. | Decimal | 10 | |
| PC037 | Ingredient Cost/List Price | This field contains the cost of the drug that was dispensed as reported by the data submitter. This is a money field containing dollars and cents with an implied decimal point. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. | Decimal | 10 | |
| PC039 | Dispensing Fee Paid | This field contains the amount charged for dispensing. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. | Decimal | 10 | |
| PC040 | Copay / Co- insurance Amount | This field contains the pre-set, fixed dollar amount payable by a member, often on a per script basis. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. | Decimal | 10 | |
| PC042 | Deductible Amount | Do not code decimal point. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. | Decimal | 10 | |
| PC043 | Patient Pay Amount | Amount that is calculated by the payer and returned to the pharmacy as the total amount to be paid by the patient to the pharmacy. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. | Decimal | 10 | |
| PC044 | Prescribing Physician First Name | This is the first name of the prescribing physician. This will be used to create a master provider index for Minnesota providers encompassing medical service providers, prescribing providers and medical homes. Since there is currently no HIPAA equivalent field for prescribing physician first name, this is a voluntary field. | Text | 25 | |
| PC045 | Prescribing Physician Middle Name | This is the middle name or initial of the prescribing physician. This will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Since there is currently no HIPAA equivalent field for prescribing physician middle initial, this is a voluntary field. | Text | 25 | |
| PC046 | Prescribing Physician Last Name | This is the last name of the prescribing physician. This will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. | Text | 60 | |
| PC047 | Prescribing Physician DEA / Legacy Number | This field contains either the DEA number, the data submitter's legacy, pre-NPI number, or the Minnesota Health Care Program ID for the prescribing physician. This will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Required if PC048 is not filled. D DEA ID number L Legacy ID number M MHCP O Other | Text | 9 | |
| PC048 | Prescribing Physician National Provider Identification Number | This field contains the National Provider Identification (NPI) number for the prescribing physician. This will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Required if PC047 is not filled. | Text | 20 | |
| PC101 | Subscriber Last Name | Subscriber last name, used to create a unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. | Text | 128 | |
| PC102 | Subscriber First Name | Subscriber first name, used to create unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. | Text | 128 | |
| PC103 | Subscriber Middle Initial | Subscriber middle initial, used to create unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. | Text | 1 | |
| PC104 | Member Last Name | Member last name, used to create a unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. | Text | 128 | |
| PC105 | Member First Name | Member first name, used to create a unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. | Text | 128 | |
| PC106 | Member Middle Initial | Member middle initial, used to create unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. | Text | 1 | |
| PC899 | Record Type | This field indicates the type of record. PC Pharmacy Claims This is an administrative field required by NCDMS and populated with a constant value. | Text | 2 | |
| TR001 | Record Type | Value TR | Text | 2 | |
| TR002 | Payer | Payer Code | Text | 8 | |
| TR004 | Type of File | PC = Pharmacy Drug Claims | Text | 2 | |
| TR005 | Period Beginning Date | Not Provided | Integer | YYYYMM | 6 |
| TR006 | Period Ending Date | Not Provided | Integer | YYYYMM | 6 |
| TR007 | Date Processed | Date file was created | Date | CCYYMMDD | 8 |
| Data Element ID | Data Element | Code | Value |
|---|---|---|---|
| HD001 | Record Type | HD | Header Record |
| HD004 | Type of File | PC | Pharmacy Drug Claims |
| PC001 | Payer | MNC | Commercial carrier |
| MNG | Governmental agency | ||
| MNT | Third Party Administrator | ||
| MNU | Unlicensed entity | ||
| PC003 | Insurance Type/ Product Code | 12 | Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan |
| 13 | Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month Coordination Period with an Employer's Group Health Plan | ||
| 14 | Medicare Secondary, No-fault Insurance Including Auto is Primary | ||
| 15 | Medicare Secondary Worker's Compensation | ||
| 16 | Medicare Secondary Public Health Service or Other Federal Agency | ||
| 41 | Medicare Secondary Black Lung | ||
| 42 | Medicare Secondary Veteran's Administration | ||
| 43 | Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health | ||
| 47 | Medicare Secondary, Other Liability Insurance is Primary | ||
| CP | Medicare Conditionally Primary | ||
| D | Disability | ||
| DB | Disability Benefits | ||
| EP | Exclusive Provider Organization | ||
| HM | Health Maintenance Organization (HMO) | ||
| HN | Health Maintenance Organization (HMO) Medicare Risk | ||
| HS | Special Low Income Medicare Beneficiary | ||
| IN | Indemnity | ||
| MA | Medicare Part A | ||
| MB | Medicare Part B | ||
| MCFFSM | Medical Assistance - Fee-for-service Medical Assistance | ||
| MCMDHO | Medical Assistance - MN Disability Health Options | ||
| MCMISC | Medical Assistance - Other managed care program within Medical Assistance | ||
| MCMSHO | Medical Assistance - MN Senior Health Options | ||
| MCPMAP | Medical Assistance - Prepaid Medical Assistance Program | ||
| MCSNBC | Medical Assistance - Special Needs Basic Care | ||
| MD | Medicare Part D | ||
| MH | Medigap Part A | ||
| MI | Medigap Part B | ||
| MP | Medicare Primary | ||
| PR | Preferred Provider Organization (PPO) | ||
| PS | Point of Service (POS) | ||
| QM | Qualified Medicare Beneficiary | ||
| SP | Supplemental Policy | ||
| XXCDEP | Non-Medical-Assistance Public Program - Chemical Dependency | ||
| XXGAMC | Non-Medical-Assistance Public Program - General Assistance Medical Care | ||
| XXHIVA | Non-Medical-Assistance Public Program - HIV/AIDS | ||
| XXMCHA | Non-Medical-Assistance Public Program - Minnesota Comprehensive Health Association | ||
| XXMISC | Non-Medical-Assistance Public Program - Other non-Medical Assitance public program | ||
| XXMNCR | Non-Medical-Assistance Public Program - MinnesotaCare | ||
| PC011 | Individual Relationship Code | 01 | Covered Individual is Policy holder |
| 02 | Spouse | ||
| 03 | Child | ||
| 04 | Other | ||
| PC012 | Member Gender | 1 | Male |
| 2 | Female | ||
| 3 | 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 | ||
| 25 | Predetermination pricing only - no payment | ||
| PC028 | New Prescription or Refill | 00 | New prescription |
| 01-99 | Refill prescription | ||
| PC029 | Generic Drug Indicator | N | No, branded drug |
| Y | Yes, branded 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 | 0 | Not specified |
| 1 | No Compound | ||
| 2 | Compound | ||
| PC047 | Prescribing Physician DEA / Legacy Number | D | DEA ID number |
| L | Legacy ID number | ||
| M | MHCP | ||
| O | Other | ||
| PC899 | Record Type | PC | Pharmacy Claims |
| TR001 | Record Type | TR | Trailer Record |
| TR004 | Type of File | PC | Pharmacy Drug Claims |
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