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Pharmacy Claims File Submission

Tennessee

Versions: March 18, 2010• January 31, 2014 - v1.0Compare Versions


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.
VersionMarch 18, 2010

File Specification for Pharmacy Claims File Submission

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

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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
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