Name: | Pharmacy Claims File Submission |
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State: | Oregon |
Definition: | Medical claims and pharmacy claims files capture plan payments, member financial responsibility (co-pay, co-insurance, deductible), diagnoses, procedures performed, and numerous other data fields. |
Version | 2015.0.1 |
Data Element ID | Data Element | Description | Type | Format | Length |
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Payer type | Not Provided | Text | 1 | |
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Plan-specific contract number | Plan-specific contract number (aka group number) | Text | 30 | |
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Patient ID | Unique identifier for member | Text | 20 | |
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Insurance type/ product code | Not Provided | Text | 6 | |
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Pharmacy NPI | The pharmacy's National Provider Identifier (NPI) | Text | 15 | |
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Pharmacy alternate identifier | The pharmacy's alternate identifier as assigned by the payer; required if NPI is not available | Text | 15 | |
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Pharmacy Name | Not Provided | Text | 35 | |
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Pharmacy city | Not Provided | Text | 30 | |
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Pharmacy state | Not Provided | Text | 2 | |
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Pharmacy ZIP | Not Provided | Text | 15 | |
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Prescribing provider NPI | Identifier for the provider who prescribed the medication as assigned by the reporting entity | Text | 15 | |
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Prescribing provider DEA number | Required if available. DEA number of the provider who prescribed the medication. | Text | 12 | |
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Claim status | Was claim paid, denied, CCO, or encounter only? | Text | 3 | |
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NDC | National Drug Code (NDC) | Text | 11 | |
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Date filled | Date the prescription was filled. example: 20090624 | Text | CCYYMMDD | 8 |
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Payment date | example: 20090624 | Date | CCYYMMDD | 8 |
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Quantity dispensed | Not Provided | Numeric | 10 | |
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Alternate refill number | Required if PC028 (calculated refill number) is not available | Numeric | 2 | |
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Days supply | Days supply of the prescription | Numeric | 3 | |
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Dispense as written code | Not Provided | Text | 1 | |
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Calculated refill number | Processor's calculated refill number. If the processor is not able to calculate, the alternate refill number (PC028A) is to be used. | Numeric | 2 | |
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Compound drug indicator | Indicates if this is a compound drug. | Numeric | 1 | |
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Claim ID | Payer's unique claim control number | Text | 30 | |
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Payment | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Charges | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Ingredient cost/list price | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Dispensing fee paid | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Co-pay | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Coinsurance | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Deductible | Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Patient pay amount | Required if any of PC040, PC041, or PC042 are missing. Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 | Numeric | 12 | |
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Not Provided | For future implementation | Not Supplied | Not Supplied | Not Supplied |
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Data Element ID | Data Element | Code | Value |
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PC001 | Payer type | C | Carrier |
D | Medicaid | ||
G | Other government agency | ||
P | Pharmacy benefits manager | ||
T | Third-party administrator | ||
U | Unlicensed entity | ||
PC003 | Insurance type/ product code | CHP | Special Childrens Health Insurance Program (SCHIP) |
EPO | Commercial EPO | ||
HMO | Commercial HMO | ||
IN | Commercial indemnity | ||
MC | Medicare Cost | ||
MD | Medicaid disabled HMO | ||
MDE | Medicaid dual eligible HMO | ||
MDF | Medicaid fee-for-service | ||
MLI | Medicaid low income HMO | ||
MP | Medicare Advantage PPO | ||
MPD | Medicare Part D only | ||
MR | Medicare Advantage HMO | ||
MRB | Medicaid restricted benefit HMO | ||
PH | Pharmacy benefits only | ||
POS | Commercial POS | ||
PPO | Commercial PPO | ||
SIF | Self insured POS | ||
SIH | Self insured HMO | ||
SIP | Self insured PPO | ||
SL | Commercial stop loss | ||
SN1 | Special needs plan - chronic condition | ||
SN2 | Special needs plan - institutionalized | ||
SN3 | Special needs plan - dual eligible | ||
ZZ | Unknown | ||
PC025 | Claim status | C | CCO encounter |
D | denied | ||
E | other managed care encounter | ||
P | paid | ||
PC030 | Dispense as written code | 0 | No product selection indicated |
1 | Substitution not allowed by provider | ||
2 | Substitution allowed- patient requested product dispensed | ||
3 | Substitution allowed- pharmacist selected product dispensed | ||
4 | Substitution allowed- generic drug not in stock | ||
5 | Substitution allowed- brand drug 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 | 1 | no |
2 | yes |