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Pharmacy Claims File Submission

Rhode Island

Versions: February 2014 - v1.1• June 2014 - v1.3Compare Versions


At A Glance

Name:Pharmacy Claims File Submission
State:Rhode Island
Definition:Not provided
VersionJune 2014 - v1.3

File Specification for Pharmacy Claims File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type This field must be coded HD to indicate the start of the header record. Text 2
Multiple versionsHD002 Submitter Code This field must contain the submitter code assigned to you by Onpoint Health Data. Text 8
Multiple versionsHD003 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
Multiple versionsHD004 Type of File This field must be coded PC to indicate submission of pharmacy claims data. Text 2
Multiple versionsHD005 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
Multiple versionsHD006 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
Multiple versionsHD007 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
Multiple versionsHD008 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
Multiple versionsPC001 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
Multiple versionsPC002 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
Multiple versionsPC003 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
Multiple versionsPC004 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
Multiple versionsPC004A 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
Multiple versionsPC005 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
Multiple versionsPC005A 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
Multiple versionsPC006 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
Multiple versionsPC007 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
Multiple versionsPC008 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
Multiple versionsPC009 Member Suffix or Sequence Number Use this field to report the unique number of the member within the contract. Text 20
Multiple versionsPC010 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
Multiple versionsPC010A 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
Multiple versionsPC011 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
Multiple versionsPC012 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
Multiple versionsPC013 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
Multiple versionsPC014 Member City Use this field to report the name of the member's city of residence. Text 30
Multiple versionsPC015 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
Multiple versionsPC016 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
Multiple versionsPC017 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
Multiple versionsPC018 Pharmacy Number Use this field to report the payer-assigned pharmacy number. Text 30
Multiple versionsPC019 Pharmacy Tax ID Number Use this field to report the pharmacy's federal taxpayer's identification number. Text 9
Multiple versionsPC020 Pharmacy Name Use this field to report the name of the pharmacy. Text 30
Multiple versionsPC020A Mail-Order Pharmacy Use this field to report whether or not this pharmacy is a mail-order pharmacy. Text 1
Multiple versionsPC020B 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
Multiple versionsPC021 National Pharmacy ID Number Use this field to report the National Provider Identification (NPI) of the pharmacy. Text 10
Multiple versionsPC022 Pharmacy Location City Use this field to report the city where the prescription was filled. Text 30
Multiple versionsPC023 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
Multiple versionsPC024 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
Multiple versionsPC024A 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
Multiple versionsPC025 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
Multiple versionsPC026 National Drug Code Use this field to report the National Drug Code assigned by the U.S. Food and Drug Administration (FDA). Text 11
Multiple versionsPC027 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
Multiple versionsPC028 New Prescription or Refill Use this field to report whether this is a new prescription or refill. Integer 2
Multiple versionsPC029 Generic Drug Indicator Use this field to report whether the drug is a branded drug or a generic drug. Text 1
Multiple versionsPC030 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
Multiple versionsPC031 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
Multiple versionsPC032 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
Multiple versionsPC033 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
Multiple versionsPC034 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
Multiple versionsPC035 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
Multiple versionsPC036 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
Multiple versionsPC037 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
Multiple versionsPC038 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
Multiple versionsPC039 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
Multiple versionsPC040 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
Multiple versionsPC041 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
Multiple versionsPC042 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
Multiple versionsPC044 Prescribing Provider First Name Use this field to report the first name of the prescribing provider. Text 35
Multiple versionsPC045 Prescribing Provider Middle Initial Use this field to report the middle initial of the prescribing provider. Text 1
Multiple versionsPC046 Prescribing Provider Last Name Use this field to report the last name of the prescribing provider. Text 60
Multiple versionsPC047 Prescribing Provider DEA Number Use this field to report the prescribing provider's Drug Enforcement Agency (DEA) number. Text 9
Multiple versionsPC047A Prescribing Provider State License Number Use this field to report the prescribing provider's state license number. Text 20
Multiple versionsPC047B Prescribing Provider Street Address Use this field to report the prescribing provider's street address. Text 55
Multiple versionsPC047C Prescribing Provider City Use this field to report the prescribing provider's city. Text 30
Multiple versionsPC047D 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
Multiple versionsPC047E 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
Multiple versionsPC048 Prescribing Provider NPI Use this field to report the prescribing provider's National Provider Identifier (NPI). Text 10
Multiple versionsPC048A 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
Multiple versionsPC080 Placeholder N/A N/A N/A
Multiple versionsPC081 Placeholder N/A N/A N/A
Multiple versionsPC082 Placeholder N/A N/A N/A
Multiple versionsPC083 Placeholder N/A N/A N/A
Multiple versionsPC084 Placeholder N/A N/A N/A
Multiple versionsPC101 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
Multiple versionsPC102 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
Multiple versionsPC103 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
Multiple versionsPC104 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
Multiple versionsPC105 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
Multiple versionsPC106 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
Multiple versionsPC899 Record Type Use this field to report the constant value of "PC" to denote a pharmacy claims record. Text 2
Multiple versionsTR001 Record Type This field must be coded TR to indicate the start of the trailer record. Text 2
Multiple versionsTR002 Submitter Code This field must contain the submitter code assigned to you by Onpoint Health Data. Text 8
Multiple versionsTR003 Placeholder This field must be coded as null; it is reserved for trailer consistency across all clients using Onpoint CDM. Text 30
Multiple versionsTR004 Type of File This field must be coded PC to indicate submission of pharmacy claims data. Text 2
Multiple versionsTR005 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
Multiple versionsTR006 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
Multiple versionsTR007 Date Processed Use this field to report the date on which the file was created in CCYYMMDD format. Date CCYYMMDD 8

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Codes and Values

Data Element ID Data Element Code Value
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
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