Name: | Pharmacy Claims File Submission |
---|---|
State: | Massachusetts |
Definition: | A MA APCD File Type for reporting all Paid Pharmacy Claim Lines of a given time period. File accommodates Replacement and Void lines. |
Version | October 1, 2014 - v4.0 |
Data Element ID | Data Element | Description | Type | Format | Length |
---|---|---|---|---|---|
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Record Type | Header Record Identifier | Text | char[2] | 2 |
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Submitter | Header Submitter / Carrier ID defined by CHIA | Integer | varchar[6] | 6 |
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National Plan ID | Header CMS National Plan Identification Number (PlanID) | Integer | int[10] | 10 |
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Type of File | Defines the file type and data expected. | Text | char[2] | 2 |
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Period Beginning Date | Header Period Start Date | Date Period - Integer | int[6] CCYYMM | 6 |
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Period Ending Date | Header Period Ending Date | Date Period - Integer | int[6] CCYYMM | 6 |
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Record Count | Header Record Count | Integer | varchar[10] | 10 |
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Comments | Header Carrier Comments | Text | varchar[80] | 80 |
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APCD Version Number | Submission Guide Version | Decimal - Numeric | char[3] | 3 |
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Submitter | CHIA defined and maintained unique identifier | Integer | varchar[6] | 6 |
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National Plan ID | CMS National Plan Identification Number (PlanID) | Integer | int[10] | 10 |
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Insurance Type Code/Product | Type / Product Identification Code | Lookup Table - Text | char[2] | 2 |
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Payer Claim Control Number | Payer Claim Control Identification | Text | varchar[35] | 35 |
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Line Counter | Incremental Line Counter | Integer | varchar[4] | 4 |
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Version Number | Claim Service Line Version Number | Integer | varchar[4] | 4 |
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Insured Group or Policy Number | Group / Policy Number | Text | varchar[30] | 30 |
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Subscriber SSN | Subscriber's Social Security Number | Numeric | char[9] | 9 |
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Plan Specific Contract Number | Contract Number | Text | varchar[30] | 30 |
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Member Suffix or Sequence Number | Member/Patient's Contract Sequence Number | Text | varchar[20] | 20 |
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Member SSN | Member/Patient's Social Security Number | Numeric | char[9] | 9 |
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Individual Relationship Code | Patient to Subscriber Relationship Code | Lookup Table - Text | char[2] | 2 |
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Member Gender | Patient's Gender | Lookup Table - Text | char[1] | 1 |
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Member Date of Birth | Member/Patient's date of birth | Full Date - Integer | int[8] CCYYMMDD | 8 |
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Member City Name of Residence | City name of the Member/Patient | Text | varchar[50] | 50 |
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Member State | State / Province of the Patient | External Code Source 2 - Text | char[2] | 2 |
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Member ZIP Code | Zip code of the Member / Patient | External Code Source 2 - Text | varchar[9] | 9 |
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Date Service Approved (AP Date) | Date Service Approved by Payer | Full Date - Integer | int[8] CCYYMMDD | 8 |
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Pharmacy Number | Pharmacy Number | Text | varchar[30] | 30 |
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Pharmacy Tax ID Number | Pharmacy Tax Identification Number | Numeric | char[9] | 9 |
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Pharmacy Name | Name of Pharmacy | Text | varchar[100] | 100 |
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National Provider ID - Pharmacy | National Provider Identification (NPI) of the Pharmacy | External Code Source 3 - Integer | int[10] | 10 |
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Pharmacy Location City | City name of the Pharmacy | Text | varchar[30] | 30 |
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Pharmacy Location State | State of the Pharmacy | External Code Source 2 - Text | char[2] | 2 |
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Pharmacy ZIP Code | Zip code of the Pharmacy | External Code Source 2 - Text | varchar[9] | 9 |
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Pharmacy Country Code | Country Code of the Pharmacy | External Code Source 1 - Text | char[3] | 3 |
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Claim Status | Claim Line Status | Lookup Table - Numeric | varchar[2] | 2 |
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Drug Code | National Drug Code (NDC) | External Code Source 12 - Text | char[11] | 11 |
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Drug Name | Name of the drug as supplied | External Code Source 12 - Text | varchar[80] | 80 |
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New Prescription or Refill | Prescription Status Indicator | Numeric | char[2] | 2 |
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Generic Drug Indicator | Generic Drug Indicator | Lookup Table - Integer | int[1] | 1 |
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Dispense as Written Code | Prescription Dispensing Activity Code | Lookup Table - Integer | int[1] | 1 |
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Compound Drug Indicator | Compound Drug Indicator | Lookup Table - Integer | int[1] | 1 |
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Date Prescription Filled | Prescription filled date | Full Date - Integer | int[8] CCYYMMDD | 8 |
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Quantity Dispensed | Claim line units dispensed | Quantity - Integer | ±varchar[10] | 10 |
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Day's Supply | Prescription Supply Days | Quantity - Integer | ±varchar[4] | 4 |
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Charge Amount | Amount of provider charges for the claim line | Integer | ±varchar[10] | 10 |
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Paid Amount | Amount paid by the carrier for the claim line | Integer | ±varchar[10] | 10 |
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Ingredient Cost/List Price | Amount defined as the List Price or Ingredient Cost | Integer | ±varchar[10] | 10 |
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Postage Amount Claimed | Amount of postage claimed on the claim line | Integer | ±varchar[10] | 10 |
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Dispensing Fee | Amount of dispensing fee for the claim line | Integer | ±varchar[10] | 10 |
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Copay Amount | Amount of Copay member/patient is responsible to pay | Integer | ±varchar[10] | 10 |
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Coinsurance Amount | Amount of coinsurance member/patient is responsible to pay | Integer | ±varchar[10] | 10 |
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Deductible Amount | Amount of deductible member/patient is responsible to pay on the claim line | Integer | ±varchar[10] | 10 |
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Prescribing ProviderID | Prescribing Provider Number | Text | varchar[30] | 30 |
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Prescribing Physician First Name | First name of Prescribing Physician | Text | varchar[25] | 25 |
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Prescribing Physician Middle Name | Middle initial of Prescribing Physician | Text | varchar[25] | 25 |
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Prescribing Physician Last Name | Last name of Prescribing Physician | Text | varchar[60] | 60 |
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Prescribing Physician DEA Number | Prescribing DEA | Text | char[9] | 9 |
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National Provider ID - Prescribing | National Provider Identification (NPI) of the Prescribing Provider | External Code Source 3 - Integer | int[10] | 10 |
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Prescribing Physician Plan Number | Carrier-assigned Provider Plan ID | Text | varchar[30] | 30 |
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Prescribing Physician License Number | Prescribing Physician License Number | Text | varchar[30] | 30 |
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Prescribing Physician Street Address | Street address of the Prescribing Physician | Text | varchar[50] | 50 |
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Prescribing Physician Street Address 2 | Secondary Street Address of the Prescribing Physician | Text | varchar[50] | 50 |
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Prescribing Physician City | City name of the Prescribing Physician | Text | varchar[30] | 30 |
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Prescribing Physician State | State of the Physician | External Code Source 2 - Text | char[2] | 2 |
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Prescribing Physician Zip | Zip code of the Prescribing Physician | External Code Source 2 - Text | varchar[9] | 9 |
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Product ID Number | Product Identification | Text | varchar[30] | 30 |
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Mail Order pharmacy | Indicator - Mail Order Option | Lookup Table - Integer | int[1] | 1 |
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Script number | Prescription Number | Text | varchar[20] | 20 |
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Recipient PCP ID | Patient's PCP ID Number | Text | varchar[30] | 30 |
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Single/Multiple Source Indicator | Drug Source Indicator | Lookup Table - Integer | int[1] | 1 |
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Member Street Address | Street address of the Member/Patient | Text | varchar[50] | 50 |
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Billing Provider Tax ID Number | The Billing Provider's Federal Tax Identification Number (FTIN) | Numeric | char[9] | 9 |
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Paid Date | Paid date of the claim line | Full Date - Integer | int[8] | 8 |
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Date Prescription Written | Date prescription was prescribed | Full Date - Integer | int[8] | 8 |
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Coordination of Benefits/TPL Liability Amount | Amount due from a Secondary Carrier when known | Integer | ±varchar[10] | 10 |
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Other Insurance Paid Amount | Amount paid by a Primary / Prior Carrier | Integer | ±varchar[10] | 10 |
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Medicare Paid Amount | Amount Medicare paid on claim | Integer | ±varchar[10] | 10 |
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Allowed amount | Allowed Amount | Integer | ±varchar[10] | 10 |
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Member Self Pay Amount | Amount member/patient paid out of pocket on the claim line | Integer | ±varchar[10] | 10 |
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Rebate Indicator | Drug Rebate Eligibility Indicator | Lookup Table - Integer | int[1] | 1 |
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State Sales Tax | Amount of applicable sales tax on the claim line | Integer | ±varchar[10] | 10 |
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Delegated Benefit Administrator Organization ID | CHIA defined and maintained Org ID for linking across submitters | Integer | varchar[6] | 6 |
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Formulary Code | Formulary inclusion identifier | Lookup Table - Integer | int[1] | 1 |
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Route of Administration | Route of Administration | Lookup Table - Numeric | char[2] | 2 |
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Drug Unit of Measure | Units of Measure | Lookup Table - Text | char[3] | 3 |
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Subscriber Last Name | Last name of Subscriber | Text | varchar[60] | 60 |
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Subscriber First Name | First name of Subscriber | Text | varchar[25] | 25 |
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Subscriber Middle Initial | Middle initial of Subscriber | Text | char[1] | 1 |
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Member Last Name | Last name of Member/Patient | Text | varchar[60] | 60 |
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Member First Name | First name of Member/Patient | Text | varchar[25] | 25 |
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Member Middle Initial | Middle initial of the Member/Patient | Text | char[1] | 1 |
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Carrier Specific Unique Member ID | Member's Unique ID | Text | varchar[50] | 50 |
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Carrier Specific Unique Subscriber ID | Subscriber's Unique ID | Text | varchar[50] | 50 |
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Member Street Address 2 | Secondary Street Address of the Member/Patient | Text | varchar[50] | 50 |
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Claim Line Type | Claim Line Activity Type Code | Lookup Table - Text | char[1] | 1 |
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Former Claim Number | Previous Claim Number | Text | varchar[35] | 35 |
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Medicare Indicator | Indicator - Medicare Payment Applied | Lookup Table - Integer | int[1] | 1 |
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Pregnancy Indicator | Indicator - Pregnancy | Lookup Table - Integer | int[1] | 1 |
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Diagnosis Code | ICD Diagnosis Code | External Code Source 8 - Text | varchar[7] | 7 |
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ICD Indicator | International Classification of Diseases version | Lookup Table - Integer | int[1] | 1 |
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Denied Flag | Denied Claim Line Indicator | Lookup Table - Integer | int[1] | 1 |
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Denial Reason | Denial Reason Code | Carrier Defined Table - OR - External Code Source 16 | Varchar[30] | 30 |
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Payment Arrangement Type | Payment Arrangement Type Value | Lookup Table - Numeric | char[2] | 2 |
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GIC ID | GIC Member ID | Text | varchar[9] | 9 |
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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 |
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Record Type | File Type Identifier | Text | char[2] | 2 |
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Record Type | Trailer Record Identifier | Text | char[2] | 2 |
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Submitter | Trailer Submitter / Carrier ID defined by CHIA | Integer | varchar[6] | 6 |
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National Plan ID | CMS National Plan Identification Number (PlanID) | Integer | int[10] | 10 |
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Type of File | Validates the file type defined in HD004. | Text | char[2] | 2 |
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Period Beginning Date | Trailer Period Start Date | Date Period - Integer | int[6] CCYYMM | 6 |
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Period Ending Date | Trailer Period Ending Date | Date Period - Integer | int[6] CCYYMM | 6 |
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Date Processed | Trailer Processed Date | Full Date - Integer | int[8] CCYYMMDD | 8 |
Data Element ID | Data Element | Code | Value |
---|---|---|---|
HD001 | Record Type | HD | Header Elements |
HD004 | Type of File | PC | PHARMACY CLAIM |
HD009 | APCD Version Number | 2.1 | Prior Version; valid only for reporting periods prior to October 2013 |
3.0 | Version 3.0; required for reporting periods as of October 2013 No longer valid as of May 2015 | ||
4.0 | Version 4.0; required for reporting periods October 2013 onward as of May 2015 | ||
PC003 | Insurance Type Code/Product | 09 | Self-pay |
10 | Central Certification | ||
11 | Other Non-Federal Programs | ||
12 | Preferred Provider Organization (PPO) | ||
13 | Point of Service (POS) | ||
14 | Exclusive Provider Organization (EPO) | ||
15 | Indemnity Insurance | ||
16 | Health Maintenance Organization (HMO) Medicare Risk | ||
17 | Dental Maintenance Organization (DMO) | ||
AM | Automobile Medical | ||
BL | Blue Cross / Blue Shield | ||
CC | Commonwealth Care | ||
CE | Commonwealth Choice | ||
CH | Champus | ||
CI | Commercial Insurance Co. | ||
DS | Disability | ||
HM | Health Maintenance Organization | ||
LI | Liability | ||
LM | Liability Medical | ||
MA | Medicare Part A | ||
MB | Medicare Part B | ||
MC | Medicaid | ||
OF | Other Federal Program | ||
TF | HSN Trust Fund | ||
TV | Title V | ||
VA | Veterans Administration Plan | ||
WC | Workers' Compensation | ||
ZZ | Other | ||
PC011 | Individual Relationship Code | 01 | Spouse |
04 | Grandfather or Grandmother | ||
05 | Grandson or Granddaughter | ||
07 | Nephew or Niece | ||
10 | Foster Child | ||
15 | Ward | ||
17 | Stepson or Stepdaughter | ||
19 | Child | ||
20 | Self/Employee | ||
21 | Unknown | ||
22 | Handicapped Dependent | ||
23 | Sponsored Dependent | ||
24 | Dependent of a Minor Dependent | ||
29 | Significant Other | ||
32 | Mother | ||
33 | Father | ||
36 | Emancipated Minor | ||
39 | Organ Donor | ||
40 | Cadaver Donor | ||
41 | Injured Plaintiff | ||
43 | Child Where Insured Has No Financial Responsibility | ||
53 | Life Partner | ||
76 | Dependent | ||
PC012 | Member Gender | F | Female |
M | Male | ||
O | Other | ||
U | 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 | ||
23 | Not our claim, forwarded to additional payer(s) | ||
25 | Predetermination Pricing Only - no payment | ||
PC029 | Generic Drug Indicator | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
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 | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC057 | Mail Order pharmacy | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC060 | Single/Multiple Source Indicator | 1 | Multi-source brand |
2 | Multi-source brand with generic equivalent | ||
3 | Single source brand | ||
4 | Single source brand with generic equivalent | ||
5 | Unknown | ||
PC070 | Rebate Indicator | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC073 | Formulary Code | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC074 | Route of Administration | 00 | Not Specified |
01 | Buccal | ||
02 | Dental | ||
03 | Inhalation | ||
04 | Injection | ||
05 | Intraperitoneal | ||
06 | Irrigation | ||
07 | Mouth / Throat | ||
08 | Mucous Membrane | ||
09 | Nasal | ||
10 | Ophthalmic | ||
11 | Oral | ||
12 | Other / Misc | ||
13 | Otic | ||
14 | Perfusion | ||
15 | Rectal | ||
16 | Sublingual | ||
17 | Topical | ||
18 | Transdermal | ||
19 | Translingual | ||
20 | Urethral | ||
21 | Vaginal | ||
22 | Enteral | ||
PC075 | Drug Unit of Measure | EA | Each |
F2 | International Units | ||
GM | Grams | ||
MEQ | Milliequivalent | ||
MG | Milligram | ||
ML | Milliliters | ||
MM | Millimeter | ||
UG | Microgram | ||
UU | Unit | ||
PC110 | Claim Line Type | A | Amendment |
B | Back Out | ||
O | Original | ||
R | Replacement | ||
V | Void | ||
PC112 | Medicare Indicator | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC113 | Pregnancy Indicator | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC115 | ICD Indicator | 0 | ICD-10 |
9 | ICD-9 | ||
PC116 | Denied Flag | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC118 | Payment Arrangement Type | 01 | Capitation |
02 | Fee for Service | ||
03 | Percent of Charges | ||
04 | DRG | ||
05 | Pay for Performance | ||
06 | Global Payment | ||
07 | Other | ||
08 | Bundled Payment | ||
09 | Payment Amount Per Episode (PAPE) (MassHealth) | ||
PC120 | APCD ID Code | 0 | Unknown / Not Applicable |
1 | FIG - Fully-Insured Commercial Group Enrollee | ||
2 | SIG - Self-Insured Group Enrollee | ||
3 | GIC - Group Insurance Commission Enrollee | ||
4 | MCO - MassHealth Managed Care Organization Enrollee | ||
5 | Supplemental Policy Enrollee | ||
6 | ICO - Integrated Care Organization or SCO - Senior Care Option | ||
PC121 | Claim Line Paid Flag | 1 | Yes |
2 | No | ||
3 | Unknown | ||
4 | Other | ||
5 | Not Applicable | ||
PC899 | Record Type | PC | |
TR001 | Record Type | TR | |
TR004 | Type of File | PC |