| Name: | Pharmacy Claims File Submission |
|---|---|
| State: | Tennessee |
| Definition: | "Pharmacy claims file" means a data file containing service level remittance information from all non-denied adjudicated claims for each prescription including, but not limited to: (a) Member demographics; (b) Provider information; (c) Charge/payment information; and (d) National drug codes. |
| Version | March 18, 2010 |
| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| HD001 | Record Type | Must be coded HD to indicate Header record. | Text | 2 | |
| HD002 | Payer | Payer or submitter code assigned by Onpoint CDM | Text | 8 | |
| HD003 | National Plan ID | Code according to CMS National Plan ID | Text | 30 | |
| HD004 | Type of File | Must be coded ME to indicate submission of eligibility data. | Text | 2 | |
| HD005 | Period Beginning Date | Code the earliest date service approved year/month included in the submission in CCYYMM format. Submissions with records containing a service approved date (PC017) before this date will fail. | Integer | CCYYMM | 6 |
| HD006 | Period Ending Date | Code the latest date service approved year/month included in the submission in CCYYMM format. Submissions with records containing a service approved date (PC017) after this date will fail. | Integer | CCYYMM | 6 |
| HD007 | Record Count | 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 | |
| HD008 | Comments | Submitter comments | Text | 80 | |
| PC001 | Payer | This field contains the Onpoint CDM-assigned submitter code for the data submitter. The first two characters of the submitter code indicate Tennessee and the third character designates the type of submitter: 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 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 | |
| PC002 | National Plan ID | Code according to CMS National Plan ID | Text | 30 | |
| 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. | Integer | 4 | |
| PC006 | Insured Group Or Policy Number | Group number or policy number | Text | 30 | |
| PC007 | Encrypted Subscriber Index Number | Carriers, healthcare claims processors, and pharmacy benefit managers shall input subscriber's Social Security number. During transformation and encryption: o All but one digit of the Social Security number shall be combined with a seed value o This modified subscriber index number then is encrypted by an application on the processor's desktop o The original input Social Security number is deleted and replaced with the modified and encrypted output Carriers, healthcare claims processors, and pharmacy benefit managers shall set the input field null if unavailable. This or PC008 must be populated. | Text | 128 | |
| PC008 | Encrypted Plan Specific Contract Index Number | Carriers and healthcare claims processors shall input a plan-assigned subscriber index number that uniquely identifies members in a contract. This must not be the original contract number, but must be consistent in all fields requiring the plan specific contract index number and must be consistent in all file submission types (eligibility, medical, and pharmacy claims) submitted by the submitter. This plan-assigned contract index number shall be combined with a seed value and then encrypted. Carriers and healthcare claims processors shall set as null if unavailable. This or PC007 must be populated. | Text | 128 | |
| PC009 | Member Suffix Number | Code a number to designate a member within the contract. | Integer | 20 | |
| PC010 | Encrypted Member Index Number | Carriers, healthcare claims processors, and pharmacy benefit managers shall input member's Social Security number. During transformation and encryption: o All but one digit of the Social Security number shall be combined with a seed value o This modified member index number then is encrypted by an application on the processor's desktop o The original input Social Security number is deleted and replaced with the modified and encrypted output Carriers, healthcare claims processors, and pharmacy benefit managers shall set the input field 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 Year of Birth | Carriers, healthcare claims processors, and pharmacy benefit managers shall input member's date of birth as CCYYMMDD. During transformation: o Age in months will be calculated for member using first day of the month for the eligibility file o The age in months value will be added to the end of the record by an application on the processor's desktop o The original input date of birth is deleted and replaced with the year of birth only in the output | 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 two-character abbreviation code used by the U.S. Postal Service. | Text | 2 | |
| PC016 | Member ZIP Code | This field contains the ZIP code of the member. Include the first five characters and no suffix. | Text | 5 | |
| PC017 | Date Service Approved (AP Date) | This field contains the date the record was approved for payment. This generally is 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 | |
| PC019 | Pharmacy TaxID | Federal taxpayer's identification number. (Please provide the pharmacy chain's federal tax ID number, if the individual retail pharmacy's tax ID number is not available.) | Text | 10 | |
| 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 | |
| PC022 | Pharmacy Location City | City name of pharmacy - preferably pharmacy location | Text | 30 | |
| PC023 | Pharmacy Location State | State location of the pharmacy - as defined by U.S. postal code | Text | 2 | |
| PC024 | Pharmacy Zip Code | ZIP code of pharmacy (may include non-U.S. codes). Do not include dash. | Text | 11 | |
| PC024A | Pharmacy Country Code | Country of the pharmacy. Code as US for United States. | Text | 30 | |
| 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, repacks, 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. | 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. | Text | 1 | |
| PC032 | Date Prescription Filled | This field contains the date the prescription was filled. Data are 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. Submissions containing 9999999999 will not factor into the calculation of the threshold. | 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. Submissions containing 9999999999 will not factor into the calculation of the threshold. | 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. Submissions containing 9999999999 will not factor into the calculation of the threshold. | Decimal | 10 | |
| PC038 | Postage Amount Claimed | This field contains the claimed cost of postage for 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. Submissions containing 9999999999 will not factor into the calculation of the threshold. | 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. Submissions containing 9999999999 will not factor into the calculation of the threshold. | Decimal | 10 | |
| PC040 | Copay | This field contains the pre-set, fixed dollar amount of copay payable by a member, often on a per visit/service 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. Submissions containing 9999999999 will not factor into the calculation of the threshold. | Decimal | 10 | |
| PC041 | Coinsurance Amount | This field contains the dollar amount of coinsurance payable by a member, often on a per visit/service basis. This is a money field containing dollars and cents with an implied decimal point. This is not a percentage. This field may contain a negative value. 0 is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Submissions containing 9999999999 will not factor into the calculation of the threshold. | 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. Submissions containing 9999999999 will not factor into the calculation of the threshold. | Decimal | 10 | |
| PC043 | Placeholder | Placeholder | N/A | N/A | |
| 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 Tennessee providers encompassing medical service providers, prescribing providers, and medical homes. | 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 Tennessee providers encompassing both medical service providers and prescribing providers. | 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 Tennessee providers encompassing both medical service providers and prescribing providers. | Text | 60 | |
| PC047 | Prescribing Physician Number | This field contains either the DEA number, State License ID, or National Provider Identification (NPI) number for the prescribing physician. This will be used to create a master provider index for Tennessee providers encompassing both medical service providers and prescribing providers. Based on NCPDP 466-EZ values, we would expect one of the following values. Use the designated prefix followed by a dash preceding the number: | Text | 10 | |
| PC101 | Placeholder | Placeholder | N/A | N/A | |
| PC102 | Placeholder | Placeholder | N/A | N/A | |
| PC103 | Placeholder | Placeholder | N/A | N/A | |
| PC104 | Encrypted Index Number, Member Last Name | Carriers, healthcare claims processors, and pharmacy benefit managers shall input member's last name. During transformation and encryption: o The first character of the last name is combined with a numeric name ID o This modified member last name field then is encrypted by an application on the processor's desktop o The original input member last name is deleted and replaced with the modified and encrypted output | Text | 128 | |
| PC105 | Encrypted Index Number, Member First Name | Carriers, healthcare claims processors, and pharmacy benefit managers shall input member's first initial. During transformation and encryption: o This first character of the first name is combined with a seed value o This modified member first initial then is encrypted by an application on the processor's desktop o The original input member first initial is deleted and replaced with the modified and encrypted output | Text | 128 | |
| PC106 | Placeholder | Placeholder | N/A | N/A | |
| PC899 | Record Type | This field indicates the type of record: This is an administrative field required by Onpoint CDM and populated with a constant value. | Text | 2 | |
| TR001 | Record Type | Must be coded TR to indicate the Trailer record | Text | 2 | |
| TR002 | Payer | Payer or submitter code assigned by Onpoint CDM | Text | 8 | |
| TR003 | National Plan ID | Code according to CMS National Plan ID | Text | 30 | |
| TR004 | Type of File | Must be coded PC to indicate submission of pharmacy claims data. | Text | 2 | |
| TR005 | Period Beginning Date | Code the earliest date service approved year/month included in the submission in CCYYMM format. Submissions with records containing a service approved date (PC017) before this date will fail. | Integer | CCYYMM | 6 |
| TR006 | Period Ending Date | Code the latest date service approved year/month included in the submission in CCYYMM format. Submissions with records containing a service approved date (PC017) after this date will fail. | Integer | CCYYMM | 6 |
| TR007 | Date Processed | Date that the file was created in CCYYMMDD format | Date | CCYYMMDD | 8 |
| Data Element ID | Data Element | Code | Value |
|---|---|---|---|
| HD001 | Record Type | HD | Header Record |
| HD004 | Type of File | MC | Medical Claims |
| PC001 | Payer | TNC | Commercial Carrier |
| TNG | Governmental Agency | ||
| TNT | Third-Party Administrator | ||
| TNU | Unlicensed Entity | ||
| PC003 | Insurance Type/Product Code | 12 | Preferred Provider Organization (PPO) |
| 13 | Point of Service (POS) | ||
| 14 | Exclusive Provider Organization (EPO) | ||
| 15 | Indemnity Insurance | ||
| 16 | Health Maintenance Organization (HMO) Medicare Advantage | ||
| DS | Disability | ||
| HM | Health Maintenance Organization | ||
| MA | Medicare Part A | ||
| MB | Medicare Part B | ||
| MCTNCR | Tennessee Medicaid (TennCare) | ||
| MD | Medicare Part D | ||
| OF | Other Federal Program (eg, Black Lung) | ||
| TV | Title V | ||
| VA | Veteran Administration Plan | ||
| WC | Workers' Compensation | ||
| XXTNAC | AccessTN | ||
| XXTNCV | CoverTN | ||
| XXTNKD | CoverKids | ||
| PC011 | Individual Relationship Code | 01 | Covered Individual is Policyholder |
| 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, 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 | No compound |
| U | Not specified | ||
| Y | Compound | ||
| PC047 | Prescribing Physician Number | 01 | National Provider Identifier (NPI) (eg, 01-1234567890) |
| 12 | Drug Enforcement Administration (DEA) (eg, 12-JK523698) | ||
| 13 | State Issued (L&I Provider ID) (eg, 13-L23365) | ||
| PC899 | Record Type | PC | Pharmacy Claims |
| TR001 | Record Type | TR | Trailer Record |
| TR004 | Type of File | PC | Pharmacy Claims |
Agency for Healthcare Research and Quality • 5600 Fishers Lane, Rockville, MD 20857 • Telephone: (301) 427-1364
