Name: | Pharmacy Claims File Submission |
---|---|
State: | Vermont |
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: member demographics; provider information; charge/payment information; and national drug codes. |
Version | October 2008 |
Data Element ID | Data Element | Description | Type | Format | Length |
---|---|---|---|---|---|
HD001 | Record Type | Not provided | Text | 2 | |
HD002 | Payer | Payer submitting payments; | Text | 8 | |
HD003 | National Plan Id | CMS National Plan ID; This is not yet available. Code as null | Text | 30 | |
HD004 | Type of File | Not provided | Text | 2 | |
HD005 | Period Beginning Date | Beginning of paid period for Claims Beginning of month covered for Eligibility | Integer | CCYYMM | 6 |
HD006 | Period Ending Date | End of paid period for Claims End of month covered for Eligibility | Integer | CCYYMM | 6 |
HD007 | Record Count | Total number of records submitted in the file | Integer | 10 | |
HD008 | Comments | Payer comments | Text | 80 | |
PC001 | Payer | Payer submitting payments; | Text | 8 | |
PC002 | National | CMS National Plan ID; This is not yet available. Code as null | Text | 30 | |
PC003 | Insurance Type/Produ ct Code | Type of Insurance Product | Text | 2 | |
PC004 | Payer Claim Control Number | Unique claim identifier | Text | 35 | |
PC005 | Line Counter | Claim line number for service rendered | Integer | 4 | |
PC006 | Insured Group Number | Group number or Policy Number | Text | 30 | |
PC007 | Encrypted Subscriber Unique Identificatio n Number | Subscriber's social security number; used to create unique member ID | Text | 128 | |
PC008 | Plan Specific Contract Number | Do not include values in this field that will distinguish one member of the family from another. If submitted, this should be the contract or certificate number for the subscriber and all of his/her dependents | Text | 128 | |
PC009 | Member Suffix or Sequence Number | The unique number of the member within the contract. | Integer | 20 | |
PC010 | Member Identification Code | Member's social security number; used to create unique member ID | Text | 128 | |
PC011 | Individual Relationship Code | Member's relationship to insured | Integer | 2 | |
PC012 | Member Gender | Member's gender | Integer | 1 | |
PC013 | Member Date of Birth | Not provided | Date | CCYYMMDD | 8 |
PC014 | Member City Name of Residence | The city location of the member. | Text | 30 | |
PC015 | Member State or Province | As defined by the US Postal Service | Text | 2 | |
PC016 | Member ZIP Code | ZIP Code of member - may include non-US codes. | Text | 9 | |
PC017 | Date Service Approved (AP Date) | Not provided | Date | CCYYMMDD | 8 |
PC018 | Pharmacy Number | Payer assigned pharmacy number | Text | 30 | |
PC019 | Pharmacy Tax ID Number | Federal taxpayer's identification number | Text | 10 | |
PC020 | Pharmacy Name | Name of pharmacy | Text | 30 | |
PC021 | National Pharmacy ID Number | Required if National Provider ID is mandated for use under HIPAA | Text | 20 | |
PC022 | Pharmacy Location City | Pharmacy City | Text | 30 | |
PC023 | Pharmacy Location State | Location of pharmacy state | Text | 2 | |
PC024 | Pharmacy ZIP Code | ZIP Code of pharmacy- may include non-US codes Do not include dash | Text | 10 | |
PC024A | Pharmacy Country Name | Code US for United States | Text | 30 | |
PC025 | Claim Status | Status of claim | Integer | 2 | |
PC026 | Drug Code | NDC Code | Text | 11 | |
PC027 | Drug Name | Name of drug | Text | 80 | |
PC028 | New Prescription or Refill | New prescription or refill number | Integer | 2 | |
PC029 | Generic Drug Indicator | Generic indicator | Text | 1 | |
PC030 | Dispense as Written Code | Dispense as written | Integer | 1 | |
PC031 | Compound Drug Indicator | Compound drug ID | Text | 1 | |
PC032 | Date Prescription Filled | Not provided | Text | CCYYMMDD | 8 |
PC033 | Quantity Dispensed | Quantity of drug dispensed | Integer | 5 | |
PC034 | Days Supply | Days of supply for drug | Integer | 3 | |
PC035 | Charge Amount | Do not code decimal point | Decimal | 10 | |
PC036 | Paid Amount | Do not code decimal point | Decimal | 10 | |
PC037 | Ingredient Cost/List Price | Do not code decimal point | Decimal | 10 | |
PC038 | Postage Amount Claimed | Do not code decimal point | Decimal | 10 | |
PC039 | Dispensing Fee | Do not code decimal point | Decimal | 10 | |
PC040 | Copay Amount | Do not code decimal point | Decimal | 10 | |
PC041 | Coinsurance Amount | Do not code decimal point | Decimal | 10 | |
PC042 | Deductible Amount | Do not code decimal point | Decimal | 10 | |
PC044 | Prescribing Physician First Name | Physician first name. Required if PC047 is not filled | Text | 25 | |
PC045 | Prescribing Physician Middle Name | Physician middle name or initial. Required if PC047 is not filled | Text | 25 | |
PC046 | Prescribing Physician Last Name | Physician last name. Required if PC047 is not filled | Text | 60 | |
PC047 | Prescribing Physician Number | DEA number for prescribing physician | Text | 9 | |
PC101 | Encrypted Subscriber Last Name | Encrypted subscriber last name, used to create unique member ID | Text | 128 | |
PC102 | Encrypted Subscriber First Name | Encrypted subscriber first name, used to create unique member ID | Text | 128 | |
PC103 | Encrypted Subscriber Middle Initial | Encrypted subscriber middle initial, used to create unique member ID | Text | 1 | |
PC104 | Encrypted Member Last Name | Encrypted member last name, used to create unique member ID | Text | 128 | |
PC105 | Encrypted Member First Name | Encrypted member first name, used to create unique member ID | Text | 128 | |
PC106 | Encrypted Member Middle Initial | Encrypted member middle initial, used to create unique member ID | Text | 1 | |
PC899 | Record Type | Not provided | Text | 2 | |
TR001 | Record Type | Not provided | Text | 2 | |
TR002 | Payer | Payer Code | Text | 8 | |
TR003 | National Plan ID | CMS National Plan ID; This is not yet available. Code as null | Text | 30 | |
TR004 | Type of File | Not provided | Text | 2 | |
TR005 | Period Beginning Date | Beginning of paid period for Claims Beginning of month covered for Eligibility | Integer | YYYYMM | 6 |
TR006 | Period Ending Date | End of paid period for Claims End of month covered for Eligibility | Integer | YYYYMM | 6 |
TR007 | Date Processed | Date file was created | Date | CCYYMMDD | 8 |
Data Element ID | Data Element | Code | Value |
---|---|---|---|
HD001 | Record Type | HD | |
HD004 | Type of File | PC | Pharmacy Claims |
PC899 | Record Type | PC | |
TR001 | Record Type | TR | |
TR004 | Type of File | PC | Pharmacy Claims |