Name: | Pharmacy Claims File Submission |
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State: | Rhode Island |
Definition: | Not provided |
Version | June 2014 - v1.3 |
Data Element ID | Data Element | Description | Type | Format | Length |
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Record Type | This field must be coded HD to indicate the start of the header record. | Text | 2 | |
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Submitter Code | This field must contain the submitter code assigned to you by Onpoint Health Data. | Text | 8 | |
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Placeholder | This field must be coded as null; it is reserved for header consistency across all clients using Onpoint Health Data's APCD services. | Text | 30 | |
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Type of File | This field must be coded PC to indicate submission of pharmacy claims data. | Text | 2 | |
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Period Beginning Date | Use this field to report the earliest date service approved year/month included in the submission in CCYYMM format. Submissions with records containing a Payment Date / Settlement Date value (PC017) outside of the date range indicated in this file's header and trailer records will fail. | Integer | CCYYMM | 6 |
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Period Ending Date | Use this field to report the latest date service approved year/month included in the submission in CCYYMM format. Submissions with records containing a Payment Date / Settlement Date value (PC017) outside of the date range indicated in this file's header and trailer records will fail. | Integer | CCYYMM | 6 |
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Record Count | Use this field to report the total number of records in the submission, excluding the header and trailer records. If the number of records within the submission does not equal the number reported in this field, the submission will fail. | Integer | 10 | |
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Comments | This field may be used by the submitter to document a file name, system source, or other administrative device to assist with their internal tracking of the submission. | Text | 80 | |
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Submitter Code | Use this field to report your Onpoint-assigned submitter code for the data submitter. Note that the first two characters of the submitter code are used to indicate the reporting state and the third character designates the type of submitter. For Rhode Island's APCD collection, valid prefixes include: Notes: A single data submitter may have multiple submitter codes if they are 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 six 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 | |
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NAIC | Use this field to report, at a record level, the code as assigned by the NAIC that uniquely identifies the applicable insurance plan. If no NAIC number has been assigned, report as "0". | Text | 5 | |
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Insurance Type / Product Code | Use this field to report the member's type of insurance or insurance product. Notes: The value reported for this field should be consistent with the value reported in ME003 ("Insurance Type / Product Code") in the eligibility file. To ensure reporting consistency between submitters, all Medicare Advantage plans should use the code "HN" to denote a Health Maintenance Organization (HMO) - Medicare Risk. Valid codes are maintained by the Accredited Standards Committee (ASC) and are available in the ASC X12 transaction set. | Text | 2 | |
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Payer Claim Control Number | Use this field to report the claim number used by the data submitter to internally track the claim. Notes: In general, the claim number is associated with all service lines of the claim. It must apply to the entire claim and be unique within the data submitter's system. The value reported in this field should remain consistent over time. If reporting multiple versions of the same claim, this number should remain the same; use PC005A (Version Number) to report multiple versions of the same claim subject to subsequent changes/adjustments. | Text | 50 | |
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Claim Submitter's Identifier | Use this field to report the claim number used by the pharmacy to track a claim from creation through payment. | Text | 38 | |
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Line Counter | Use this field to report the line number for this service. Notes: The line counter should begin with 1 and be incremented by 1 for each additional service line of a claim. | Integer | 4 | |
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Version Number | Use this field to report the version number of the claim service record. Notes: The version number should begin with 0 and be incremented by 1 for each subsequent version of that service line. If versioning is not used to report adjusted claims, report claims with a Version Number of zero (0). | Integer | 4 | |
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Insured Group or Policy Number | Use this field to report the group or policy number. Notes: This is not the number that uniquely identifies the subscriber. The value reported for this field should be consistent with the value reported in the Insured Group or Policy Number fields across all file types (ME006, MC006, PC006). If a policy is sold to an individual as a non-group policy, then this field should be reported with a value of "IND". This principle pertains to all claim types: commercial, Medicaid, and Medicare. | Text | 50 | |
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Subscriber Social Security Number | Use this field to report the subscriber's 9-digit Social Security number. Notes: The value reported for this field should be consistent with the value reported in ME008 ("Subscriber Social Security Number") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. | Text | 9 | |
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Plan-Specific Contract Number | Use this field to report the submitter-assigned contract number for the subscriber. Notes: The value reported for this field should be consistent with the value reported in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. | Text | 80 | |
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Member Suffix or Sequence Number | Use this field to report the unique number of the member within the contract. | Text | 20 | |
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Member Social Security Number | Use this field to report the member's 9-digit Social Security number. Notes: The value reported for this field should be consistent with the value reported in ME011 ("Member Social Security Number") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. | Text | 9 | |
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Unique Member Identifier | Use this field to report the Unique Member Identifier assigned by the Lockbox Vendor in the Response File's field RF017. Notes: The value reported for this field should be reported identically to the "Unique Member Identifier" field in the eligibility file (ME010A). | String | 32 | |
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Member Relationship | Use this field to report the member's relationship to the subscriber or the insured. Notes: The value reported for this field should be consistent with the value reported in ME012 ("Member Relationship") in the eligibility file. Valid codes are maintained by the National Council for Prescription Drug Programs (NCPDP) and are available in the NCPDP standards set. | Text | 2 | |
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Member Gender | Use this field to report the member's gender. Notes: The value reported for this field should be consistent with the value reported in ME013 ("Member Gender") in the eligibility file. Valid codes are maintained by the National Council for Prescription Drug Programs (NCPDP) and are available in the NCPDP standards set. Please note that an additional gender code has been added for this field to accommodate a non-NCPDP value of O (Other). | Text | 1 | |
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Member Date of Birth | Use this field to report the member's date of birth using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Notes: The value reported for this field should be consistent with the value reported in ME014 ("Member Date of Birth") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Immediately prior to hashing this field, Onpoint's hashing application calculates a member's age in months based on the Member Date of Birth field (ME014, MC013, PC013). The Member Date of Birth field is then hashed and both the hashed value and the value- added Age in Months element are submitted to the APCD - the hashed value to allow for quality assurance review, the de-identified Age in Months to enable analytic use of the APCD. | Date | CCYYMMDD | 8 |
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Member City | Use this field to report the name of the member's city of residence. | Text | 30 | |
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Member State or Province | Use this field to report the member's state or province using the two-character abbreviation code defined by the U.S. Postal Service(for U.S. states) and Canada Post (for Canadian provinces). | Text | 2 | |
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Member ZIP/Postal Code | Use this field to report the ZIP/postal code associated with the member's residence. Notes: For U.S. ZIP codes, include the ZIP+4 (also referred to as the "plus-four" or "add-on" code). Do not code dashes or spaces within ZIP/postal codes. | Text | 9 | |
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Payment Date / Settlement Date | Use this field to report the date on which the record was approved for payment using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). Notes: This is generally referred to as the paid date and reported with a CCYYMMDD format. When BPR04 is "NON" for nonpayment, include remittance date. | Date | CCYYMMDD | 8 |
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Pharmacy Number | Use this field to report the payer-assigned pharmacy number. | Text | 30 | |
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Pharmacy Tax ID Number | Use this field to report the pharmacy's federal taxpayer's identification number. | Text | 9 | |
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Pharmacy Name | Use this field to report the name of the pharmacy. | Text | 30 | |
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Mail-Order Pharmacy | Use this field to report whether or not this pharmacy is a mail-order pharmacy. | Text | 1 | |
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Out-of-Network Indicator | Use this field to report whether or not the pharmacy at which the prescription was filled was out of network. | Text | 1 | |
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National Pharmacy ID Number | Use this field to report the National Provider Identification (NPI) of the pharmacy. | Text | 10 | |
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Pharmacy Location City | Use this field to report the city where the prescription was filled. | Text | 30 | |
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Pharmacy Location State or Province | Use this field to report the state or province where the prescription was filled using the two- character abbreviation defined by the U.S. Postal Service (for U.S. states) and Canada Post (for Canadian provinces). | Text | 2 | |
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Pharmacy ZIP/Postal Code | Use this field to report the ZIP/postal code where the prescription was filled. Notes: For U.S. ZIP codes, include the ZIP+4 (also referred to as the "plus-four" or "add-on" code). Do not code dashes or spaces within ZIP/postal codes. | Text | 9 | |
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Pharmacy Country | Use this field to report the name of the country where the prescription was filled. Notes: Please code only a two-digit response - "US" - to indicate the United States. | Text | 30 | |
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Claim Status | Use this field to report the status of the claim - whether paid as primary, paid as secondary, denied, etc. Notes: Valid codes are maintained by the Accredited Standards Committee (ASC) and are available in the ASC X12 transaction set. | Text | 2 | |
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National Drug Code | Use this field to report the National Drug Code assigned by the U.S. Food and Drug Administration (FDA). | Text | 11 | |
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Drug Name | Use this field to report the text name of the drug. Notes: Valid codes are maintained by the National Council for Prescription Drug Programs (NCPDP) and are available in the NCPDP standards set. | Text | 80 | |
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New Prescription or Refill | Use this field to report whether this is a new prescription or refill. | Integer | 2 | |
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Generic Drug Indicator | Use this field to report whether the drug is a branded drug or a generic drug. | Text | 1 | |
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Dispense as Written Code | Use this field to report the instructions given to the pharmacist for filling the prescription. Notes: Valid codes are maintained by the National Council for Prescription Drug Programs (NCPDP) and are available in the NCPDP standards set. | Integer | 1 | |
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Compound Drug Indicator | Use this field to indicate whether or not the drug is a compound drug. Notes: Valid codes are maintained by the National Council for Prescription Drug Programs (NCPDP) and are available in the NCPDP standards set. | Text | 1 | |
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Date Prescription Filled | Use this field to report the date on which the prescription was filled using an 8-digit format of CCYYMMDD (e.g., January 18, 1972, would be coded as "19720118"). | Date | CCYYMMDD | 8 |
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Quantity Dispensed | Use this field to report the total unit dosage in metric units. Notes: This field may contain a negative value. When coding this field, always report with two decimal places. If the actual value included three decimal place, round to two. Do not include the decimal point when coding this field. | Decimal | 10,2 | |
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Days' Supply | Use this field to report the days' supply for the prescription based on the metric quantity dispensed. Notes: This field may contain a negative value. | Integer | 3 | |
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Charge Amount | Use this field to report total charges for the prescription as reported by the pharmacy. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. | Decimal | 10,2 | |
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Paid Amount | Use this field to report the total dollar amount paid to the provider, including all health plan payments and excluding all member payments and withholds from providers. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. | Decimal | 10,2 | |
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Ingredient Cost / List Price | Use this field to report the cost of the drug that was dispensed. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. | Decimal | 10,2 | |
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Postage Amount Claimed | Use this field to report the cost of postage included in the Paid Amount field (PC036). Notes: Do not include the decimal point when coding this field. | Decimal | 10,2 | |
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Dispensing Fee | Use this field to report the amount charged for dispensing the prescription. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. | Decimal | 10,2 | |
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Copay Amount | Use this field to report the preset, fixed dollar amount payable by a member, often on a per visit/service basis. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. | Decimal | 10,2 | |
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Coinsurance Amount | Use this field to report the dollar amount that a member must pay toward the cost of a covered service. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. | Decimal | 10,2 | |
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Deductible Amount | Use this field to report the dollar amount that a member must pay before the health plan benefits will begin to reimburse for services. Notes: This is a money field containing dollars and cents with an implied decimal point. Do not include the decimal point when coding this field. This field may contain a negative value. A reported value of 0 is acceptable. | Decimal | 10,2 | |
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Prescribing Provider First Name | Use this field to report the first name of the prescribing provider. | Text | 35 | |
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Prescribing Provider Middle Initial | Use this field to report the middle initial of the prescribing provider. | Text | 1 | |
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Prescribing Provider Last Name | Use this field to report the last name of the prescribing provider. | Text | 60 | |
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Prescribing Provider DEA Number | Use this field to report the prescribing provider's Drug Enforcement Agency (DEA) number. | Text | 9 | |
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Prescribing Provider State License Number | Use this field to report the prescribing provider's state license number. | Text | 20 | |
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Prescribing Provider Street Address | Use this field to report the prescribing provider's street address. | Text | 55 | |
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Prescribing Provider City | Use this field to report the prescribing provider's city. | Text | 30 | |
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Prescribing Provider State or Province | Use this field to report the prescribing provider's state using the two-character abbreviation defined by the U.S. Postal Service (for U.S. states) and Canada Post (for Canadian provinces). | Text | 2 | |
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Prescribing Provider ZIP/Postal Code | Use this field to report the prescribing provider's ZIP/postal code associated with the prescribing provider's location. Notes: For U.S. ZIP codes, include the ZIP+4 (also referred to as the "plus-four" or "add-on" code). Do not code dashes or spaces within ZIP/postal codes. | Text | 9 | |
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Prescribing Provider NPI | Use this field to report the prescribing provider's National Provider Identifier (NPI). | Text | 10 | |
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Prescribing Provider Plan ID | Use this field to report the payer-supplied ID for the prescribing provider. Note: The provider data reported in the eligibility, claims, and provider files are used to create a Provider Master Index that is used to match the data across all file types. It is expected that a provider's identifiers (e.g., plan-assigned ID, NPI, etc.) will be reported consistently by a submitter across file types as this is the payer-assigned provider ID (ME051, MC024, PC048A, PV006). | Text | 15 | |
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Placeholder | N/A | N/A | N/A | |
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Placeholder | N/A | N/A | N/A | |
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Placeholder | N/A | N/A | N/A | |
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Placeholder | N/A | N/A | N/A | |
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Placeholder | N/A | N/A | N/A | |
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Subscriber Last Name | Use this field to report the subscriber's last name. Notes: The value reported for this field should be consistent with the value reported in ME101 ("Subscriber Last Name") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. | Text | 60 | |
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Subscriber First Name | Use this field to report the subscriber's first name. Notes: The value reported for this field should be consistent with the value reported in ME102 ("Subscriber First Name") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. | Text | 35 | |
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Subscriber Middle Initial | Use this field to report the subscriber's middle initial. Notes: The value reported for this field should be consistent with the value reported in ME103 ("Subscriber Middle Initial") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. | Text | 1 | |
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Member Last Name | Use this field to report the member's last name. Notes: If the member is the subscriber, report the subscriber's last name again in this field. The value reported for this field should be consistent with the value reported in ME104 ("Member Last Name") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. | Text | 60 | |
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Member First Name | Use this field to report the member's first name. Notes: If the member is the subscriber, report the subscriber's first name again in this field. The value reported for this field should be consistent with the value reported in ME105 ("Member First Name") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. | Text | 35 | |
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Member Middle Initial | Use this field to report the member's middle initial. Notes: If the member is the subscriber, report the subscriber's middle initial again in this field. The value reported for this field should be consistent with the value reported in ME106 ("Member Middle Initial") in the eligibility file. This field will be rendered non-recoverable through the use of a one-way hashing algorithm prior to transmission to Onpoint. Upon receipt by Onpoint, this field will be a text field with a length of 128. | Text | 1 | |
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Record Type | Use this field to report the constant value of "PC" to denote a pharmacy claims record. | Text | 2 | |
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Record Type | This field must be coded TR to indicate the start of the trailer record. | Text | 2 | |
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Submitter Code | This field must contain the submitter code assigned to you by Onpoint Health Data. | Text | 8 | |
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Placeholder | This field must be coded as null; it is reserved for trailer consistency across all clients using Onpoint CDM. | Text | 30 | |
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Type of File | This field must be coded PC to indicate submission of pharmacy claims data. | Text | 2 | |
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Period Beginning Date | Use this field to report the earliest date service approved year/month included in the submission in CCYYMM format. Submissions with records containing a Payment Date / Settlement Date value (PC017) outside of the date range indicated in this file's header and trailer records will fail. | Integer | CCYYMM | 6 |
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Period Ending Date | Use this field to report the latest date service approved year/month included in the submission in CCYYMM format. Submissions with records containing a Payment Date / Settlement Date value (PC017) outside of the date range indicated in this file's header and trailer records will fail. | Integer | CCYYMM | 6 |
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Date Processed | Use this field to report the date on which the file was created in CCYYMMDD format. | Date | CCYYMMDD | 8 |
Data Element ID | Data Element | Code | Value |
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HD001 | Record Type | HD | header record |
HD003 | Placeholder | Null | |
HD004 | Type of File | PC | pharmacy claims data |
PC001 | Submitter Code | RIC | Commercial carrier |
RIG | Governmental agency | ||
RIT | Third-party administrator | ||
PC012 | Member Gender | F | Female |
M | Male | ||
U | Unknown | ||
PC020A | Mail-Order Pharmacy | N | No |
U | Unknown | ||
Y | Yes | ||
PC020B | Out-of-Network Indicator | I | In network |
N | Not applicable | ||
O | Out of network | ||
U | Unknown | ||
PC028 | New Prescription or Refill | 00 | New prescription |
01-99 | Number of refill(s) | ||
PC029 | Generic Drug Indicator | N | No, branded drug |
Y | Yes, generic drug | ||
PC899 | Record Type | PC | pharmacy claims record |
TR001 | Record Type | TR | trailer record |
TR003 | Placeholder | Null | |
TR004 | Type of File | PC | pharmacy claims data |