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New Prescription or Refill

PC028, Massachusetts

Versions: December 1, 2010 - v2.1 • June 7, 2013 - v3.1• October 1, 2014 - v4.0Compare Versions


Name:New Prescription or Refill
Data Element ID:PC028
Description:Prescription Status Indicator
State:Massachusetts
Data Type:Numeric
Data Type Description:ID Count
Format:char[2]
Length:2
Column:30
Threshold:1
File:PC
Element Submission Guideline:Report the status of prescription by numeric value. EXAMPLE: 00 = new prescription; First Refill = 01, etc.
Condition:All
Cat:A0
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File Specification for Multiple versionsPharmacy Claims File Submission - October 1, 2014 - v4.0

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type Header Record Identifier Text char[2] 2
Multiple versionsHD002 Submitter Header Submitter / Carrier ID defined by CHIA Integer varchar[6] 6
Multiple versionsHD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Integer int[10] 10
Multiple versionsHD004 Type of File Defines the file type and data expected. Text char[2] 2
Multiple versionsHD005 Period Beginning Date Header Period Start Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsHD006 Period Ending Date Header Period Ending Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsHD007 Record Count Header Record Count Integer varchar[10] 10
Multiple versionsHD008 Comments Header Carrier Comments Text varchar[80] 80
Multiple versionsHD009 APCD Version Number Submission Guide Version Decimal - Numeric char[3] 3
Multiple versionsPC001 Submitter CHIA defined and maintained unique identifier Integer varchar[6] 6
Multiple versionsPC002 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
Multiple versionsPC003 Insurance Type Code/Product Type / Product Identification Code Lookup Table - Text char[2] 2
Multiple versionsPC004 Payer Claim Control Number Payer Claim Control Identification Text varchar[35] 35
Multiple versionsPC005 Line Counter Incremental Line Counter Integer varchar[4] 4
Multiple versionsPC005A Version Number Claim Service Line Version Number Integer varchar[4] 4
Multiple versionsPC006 Insured Group or Policy Number Group / Policy Number Text varchar[30] 30
Multiple versionsPC007 Subscriber SSN Subscriber's Social Security Number Numeric char[9] 9
Multiple versionsPC008 Plan Specific Contract Number Contract Number Text varchar[30] 30
Multiple versionsPC009 Member Suffix or Sequence Number Member/Patient's Contract Sequence Number Text varchar[20] 20
Multiple versionsPC010 Member SSN Member/Patient's Social Security Number Numeric char[9] 9
Multiple versionsPC011 Individual Relationship Code Patient to Subscriber Relationship Code Lookup Table - Text char[2] 2
Multiple versionsPC012 Member Gender Patient's Gender Lookup Table - Text char[1] 1
Multiple versionsPC013 Member Date of Birth Member/Patient's date of birth Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsPC014 Member City Name of Residence City name of the Member/Patient Text varchar[50] 50
Multiple versionsPC015 Member State State / Province of the Patient External Code Source 2 - Text char[2] 2
Multiple versionsPC016 Member ZIP Code Zip code of the Member / Patient External Code Source 2 - Text varchar[9] 9
Multiple versionsPC017 Date Service Approved (AP Date) Date Service Approved by Payer Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsPC018 Pharmacy Number Pharmacy Number Text varchar[30] 30
Multiple versionsPC019 Pharmacy Tax ID Number Pharmacy Tax Identification Number Numeric char[9] 9
Multiple versionsPC020 Pharmacy Name Name of Pharmacy Text varchar[100] 100
Multiple versionsPC021 National Provider ID - Pharmacy National Provider Identification (NPI) of the Pharmacy External Code Source 3 - Integer int[10] 10
Multiple versionsPC022 Pharmacy Location City City name of the Pharmacy Text varchar[30] 30
Multiple versionsPC023 Pharmacy Location State State of the Pharmacy External Code Source 2 - Text char[2] 2
Multiple versionsPC024 Pharmacy ZIP Code Zip code of the Pharmacy External Code Source 2 - Text varchar[9] 9
Multiple versionsPC024A Pharmacy Country Code Country Code of the Pharmacy External Code Source 1 - Text char[3] 3
Multiple versionsPC025 Claim Status Claim Line Status Lookup Table - Numeric varchar[2] 2
Multiple versionsPC026 Drug Code National Drug Code (NDC) External Code Source 12 - Text char[11] 11
Multiple versionsPC027 Drug Name Name of the drug as supplied External Code Source 12 - Text varchar[80] 80
Multiple versionsPC028 New Prescription or Refill Prescription Status Indicator Numeric char[2] 2
Multiple versionsPC029 Generic Drug Indicator Generic Drug Indicator Lookup Table - Integer int[1] 1
Multiple versionsPC030 Dispense as Written Code Prescription Dispensing Activity Code Lookup Table - Integer int[1] 1
Multiple versionsPC031 Compound Drug Indicator Compound Drug Indicator Lookup Table - Integer int[1] 1
Multiple versionsPC032 Date Prescription Filled Prescription filled date Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsPC033 Quantity Dispensed Claim line units dispensed Quantity - Integer ±varchar[10] 10
Multiple versionsPC034 Day's Supply Prescription Supply Days Quantity - Integer ±varchar[4] 4
Multiple versionsPC035 Charge Amount Amount of provider charges for the claim line Integer ±varchar[10] 10
Multiple versionsPC036 Paid Amount Amount paid by the carrier for the claim line Integer ±varchar[10] 10
Multiple versionsPC037 Ingredient Cost/List Price Amount defined as the List Price or Ingredient Cost Integer ±varchar[10] 10
Multiple versionsPC038 Postage Amount Claimed Amount of postage claimed on the claim line Integer ±varchar[10] 10
Multiple versionsPC039 Dispensing Fee Amount of dispensing fee for the claim line Integer ±varchar[10] 10
Multiple versionsPC040 Copay Amount Amount of Copay member/patient is responsible to pay Integer ±varchar[10] 10
Multiple versionsPC041 Coinsurance Amount Amount of coinsurance member/patient is responsible to pay Integer ±varchar[10] 10
Multiple versionsPC042 Deductible Amount Amount of deductible member/patient is responsible to pay on the claim line Integer ±varchar[10] 10
Multiple versionsPC043 Prescribing ProviderID Prescribing Provider Number Text varchar[30] 30
Multiple versionsPC044 Prescribing Physician First Name First name of Prescribing Physician Text varchar[25] 25
Multiple versionsPC045 Prescribing Physician Middle Name Middle initial of Prescribing Physician Text varchar[25] 25
Multiple versionsPC046 Prescribing Physician Last Name Last name of Prescribing Physician Text varchar[60] 60
Multiple versionsPC047 Prescribing Physician DEA Number Prescribing DEA Text char[9] 9
Multiple versionsPC048 National Provider ID - Prescribing National Provider Identification (NPI) of the Prescribing Provider External Code Source 3 - Integer int[10] 10
Multiple versionsPC049 Prescribing Physician Plan Number Carrier-assigned Provider Plan ID Text varchar[30] 30
Multiple versionsPC050 Prescribing Physician License Number Prescribing Physician License Number Text varchar[30] 30
Multiple versionsPC051 Prescribing Physician Street Address Street address of the Prescribing Physician Text varchar[50] 50
Multiple versionsPC052 Prescribing Physician Street Address 2 Secondary Street Address of the Prescribing Physician Text varchar[50] 50
Multiple versionsPC053 Prescribing Physician City City name of the Prescribing Physician Text varchar[30] 30
Multiple versionsPC054 Prescribing Physician State State of the Physician External Code Source 2 - Text char[2] 2
Multiple versionsPC055 Prescribing Physician Zip Zip code of the Prescribing Physician External Code Source 2 - Text varchar[9] 9
Multiple versionsPC056 Product ID Number Product Identification Text varchar[30] 30
Multiple versionsPC057 Mail Order pharmacy Indicator - Mail Order Option Lookup Table - Integer int[1] 1
Multiple versionsPC058 Script number Prescription Number Text varchar[20] 20
Multiple versionsPC059 Recipient PCP ID Patient's PCP ID Number Text varchar[30] 30
Multiple versionsPC060 Single/Multiple Source Indicator Drug Source Indicator Lookup Table - Integer int[1] 1
Multiple versionsPC061 Member Street Address Street address of the Member/Patient Text varchar[50] 50
Multiple versionsPC062 Billing Provider Tax ID Number The Billing Provider's Federal Tax Identification Number (FTIN) Numeric char[9] 9
Multiple versionsPC063 Paid Date Paid date of the claim line Full Date - Integer int[8] 8
Multiple versionsPC064 Date Prescription Written Date prescription was prescribed Full Date - Integer int[8] 8
Multiple versionsPC065 Coordination of Benefits/TPL Liability Amount Amount due from a Secondary Carrier when known Integer ±varchar[10] 10
Multiple versionsPC066 Other Insurance Paid Amount Amount paid by a Primary / Prior Carrier Integer ±varchar[10] 10
Multiple versionsPC067 Medicare Paid Amount Amount Medicare paid on claim Integer ±varchar[10] 10
Multiple versionsPC068 Allowed amount Allowed Amount Integer ±varchar[10] 10
Multiple versionsPC069 Member Self Pay Amount Amount member/patient paid out of pocket on the claim line Integer ±varchar[10] 10
Multiple versionsPC070 Rebate Indicator Drug Rebate Eligibility Indicator Lookup Table - Integer int[1] 1
Multiple versionsPC071 State Sales Tax Amount of applicable sales tax on the claim line Integer ±varchar[10] 10
Multiple versionsPC072 Delegated Benefit Administrator Organization ID CHIA defined and maintained Org ID for linking across submitters Integer varchar[6] 6
Multiple versionsPC073 Formulary Code Formulary inclusion identifier Lookup Table - Integer int[1] 1
Multiple versionsPC074 Route of Administration Route of Administration Lookup Table - Numeric char[2] 2
Multiple versionsPC075 Drug Unit of Measure Units of Measure Lookup Table - Text char[3] 3
Multiple versionsPC101 Subscriber Last Name Last name of Subscriber Text varchar[60] 60
Multiple versionsPC102 Subscriber First Name First name of Subscriber Text varchar[25] 25
Multiple versionsPC103 Subscriber Middle Initial Middle initial of Subscriber Text char[1] 1
Multiple versionsPC104 Member Last Name Last name of Member/Patient Text varchar[60] 60
Multiple versionsPC105 Member First Name First name of Member/Patient Text varchar[25] 25
Multiple versionsPC106 Member Middle Initial Middle initial of the Member/Patient Text char[1] 1
Multiple versionsPC107 Carrier Specific Unique Member ID Member's Unique ID Text varchar[50] 50
Multiple versionsPC108 Carrier Specific Unique Subscriber ID Subscriber's Unique ID Text varchar[50] 50
Multiple versionsPC109 Member Street Address 2 Secondary Street Address of the Member/Patient Text varchar[50] 50
Multiple versionsPC110 Claim Line Type Claim Line Activity Type Code Lookup Table - Text char[1] 1
Multiple versionsPC111 Former Claim Number Previous Claim Number Text varchar[35] 35
Multiple versionsPC112 Medicare Indicator Indicator - Medicare Payment Applied Lookup Table - Integer int[1] 1
Multiple versionsPC113 Pregnancy Indicator Indicator - Pregnancy Lookup Table - Integer int[1] 1
Multiple versionsPC114 Diagnosis Code ICD Diagnosis Code External Code Source 8 - Text varchar[7] 7
Multiple versionsPC115 ICD Indicator International Classification of Diseases version Lookup Table - Integer int[1] 1
Multiple versionsPC116 Denied Flag Denied Claim Line Indicator Lookup Table - Integer int[1] 1
Multiple versionsPC117 Denial Reason Denial Reason Code Carrier Defined Table - OR - External Code Source 16 Varchar[30] 30
Multiple versionsPC118 Payment Arrangement Type Payment Arrangement Type Value Lookup Table - Numeric char[2] 2
Multiple versionsPC119 GIC ID GIC Member ID Text varchar[9] 9
Multiple versionsPC120 APCD ID Code Member Enrollment Type Lookup Table - Integer int[1] 1
PC121 Claim Line Paid Flag Claim Line Paid Indicator Lookup Table - Integer int[1] 1
Multiple versionsPC899 Record Type File Type Identifier Text char[2] 2
Multiple versionsTR001 Record Type Trailer Record Identifier Text char[2] 2
Multiple versionsTR002 Submitter Trailer Submitter / Carrier ID defined by CHIA Integer varchar[6] 6
Multiple versionsTR003 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
Multiple versionsTR004 Type of File Validates the file type defined in HD004. Text char[2] 2
Multiple versionsTR005 Period Beginning Date Trailer Period Start Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsTR006 Period Ending Date Trailer Period Ending Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsTR007 Date Processed Trailer Processed Date Full Date - Integer int[8] CCYYMMDD 8

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