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Pharmacy Claims File Submission

Oregon

Versions: September 27, 2011 - v2011.1.1• June 25, 2012 - v2013.0.0• June 27, 2013 - v2014.0.0• 2015.0.1Compare Versions


At A Glance

Name:Pharmacy Claims File Submission
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.
Version2015.0.1

File Specification for Pharmacy Claims File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsPC001 Payer type Not Provided Text 1
Multiple versionsPC008 Plan-specific contract number Plan-specific contract number (aka group number) Text 30
Multiple versionsPC010 Patient ID Unique identifier for member Text 20
Multiple versionsPC003 Insurance type/ product code Not Provided Text 6
Multiple versionsPC021 Pharmacy NPI The pharmacy's National Provider Identifier (NPI) Text 15
Multiple versionsPC021A Pharmacy alternate identifier The pharmacy's alternate identifier as assigned by the payer; required if NPI is not available Text 15
Multiple versionsPC020 Pharmacy Name Not Provided Text 35
Multiple versionsPC022 Pharmacy city Not Provided Text 30
Multiple versionsPC023 Pharmacy state Not Provided Text 2
Multiple versionsPC024 Pharmacy ZIP Not Provided Text 15
Multiple versionsPC048 Prescribing provider NPI Identifier for the provider who prescribed the medication as assigned by the reporting entity Text 15
Multiple versionsPC047 Prescribing provider DEA number Required if available. DEA number of the provider who prescribed the medication. Text 12
Multiple versionsPC025 Claim status Was claim paid, denied, CCO, or encounter only? Text 3
Multiple versionsPC026 NDC National Drug Code (NDC) Text 11
Multiple versionsPC032 Date filled Date the prescription was filled. example: 20090624 Text CCYYMMDD 8
Multiple versionsPC017 Payment date example: 20090624 Date CCYYMMDD 8
Multiple versionsPC033 Quantity dispensed Not Provided Numeric 10
Multiple versionsPC028A Alternate refill number Required if PC028 (calculated refill number) is not available Numeric 2
Multiple versionsPC034 Days supply Days supply of the prescription Numeric 3
Multiple versionsPC030 Dispense as written code Not Provided Text 1
Multiple versionsPC028 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
Multiple versionsPC031 Compound drug indicator Indicates if this is a compound drug. Numeric 1
Multiple versionsPC004 Claim ID Payer's unique claim control number Text 30
Multiple versionsPC036 Payment Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 Numeric 12
Multiple versionsPC035 Charges Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 Numeric 12
Multiple versionsPC037 Ingredient cost/list price Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 Numeric 12
Multiple versionsPC039 Dispensing fee paid Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 Numeric 12
Multiple versionsPC040 Co-pay Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 Numeric 12
Multiple versionsPC041 Coinsurance Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 Numeric 12
Multiple versionsPC042 Deductible Two explicit decimal places. Enter 0 if amount equals zero. Leave blank if missing. Example: 15102.00 Numeric 12
Multiple versionsPC043 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
Multiple versionsPC201 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsPC202 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsPC203 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsPC204 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsPC205 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsPC206 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsPC207 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsPC208 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsPC209 Not Provided For future implementation Not Supplied Not Supplied Not Supplied
Multiple versionsPC210 Not Provided For future implementation Not Supplied Not Supplied Not Supplied

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Codes and Values

Data Element ID Data Element Code Value
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
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