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Pharmacy Claims File Submission

Connecticut



Name:Pharmacy Claims File Submission
State:Connecticut
Definition:Not provided
VersionDecember 5, 2013 - v1.2

File Specification for Pharmacy Claims File Submission

Data Element ID Data Element Description Type Format Length
HD001 Record Type Header Record Identifier Text char[2] 2
HD002 Submitter Header Submitter / Carrier ID defined by AHCT Integer varchar[6] 6
HD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Integer int[10] 10
HD004 Type of File Defines the file type and data expected. Text char[2] 2
HD005 Period Beginning Date Header Period Start Date Full Date - Integer int[8] YYYYMMDD 8
HD006 Period Ending Date Header Period Ending Date Full Date - Integer int[8] YYYYMMDD 8
HD007 Record Count Header Record Count Integer varchar[10] 10
HD008 Comments Header Carrier Comments Text varchar[80] 80
HD009 APCD Version Number Submission Guide Version Decimal - Numeric char[3] 3
PC001 Submitter CT APCD defined and maintained unique identifier Integer varchar[6] 6
PC002 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
PC003 Insurance Type Code / Product Type / Product Identification Code Text char[2] 2
PC004 Payer Claim Control Number Payer Claim Control Identification Text varchar[35] 35
PC005 Line Counter Incremental Line Counter Numeric varchar[4] 4
PC005A Version Number Claim Service Line Version Number Numeric varchar[4] 4
PC006 Insured Group or Policy Number Group / Policy Number Text varchar[30] 30
PC007 Subscriber SSN Subscriber's Social Security Number Numeric char[9] 9
PC008 Plan Specific Contract Number Contract Number Text varchar[30] 30
PC009 Member Suffix or Sequence Number Member/Patient's Contract Sequence Number Text varchar[20] 20
PC010 Member SSN Member/Patient's Social Security Number Numeric char[9] 9
PC011 Individual Relationship Code Patient to Subscriber Relationship Code Text varchar[2] 2
PC012 Member Gender Patient's Gender Text char[1] 1
PC013 Member Date of Birth Member/Patient's date of birth Full Date - Integer int[8] YYYYMMDD 8
PC014 Member City Name of Residence City name of the Member/Patient Text varchar[50] 50
PC015 Member State State / Province of the Patient External Code Source - USPS char[2] 2
PC016 Member ZIP Code Zip code of the Member / Patient External Code Source - USPS varchar[9] 9
PC017 Date Service Approved (AP Date) Date Service Approved by Payer Full Date - Integer int[8] YYYYMMDD 8
PC018 Pharmacy Number Pharmacy Number Text varchar[30] 30
PC019 Pharmacy Tax ID Number Pharmacy Tax Identification Number Numeric char[9] 9
PC020 Pharmacy Name Name of Pharmacy Text varchar[100] 100
PC021 National Provider ID - Pharmacy National Provider Identification (NPI) of the Pharmacy External Code Source - NPPES int[10] 10
PC022 Pharmacy Location City City name of the Pharmacy Text varchar[30] 30
PC023 Pharmacy Location State State of the Pharmacy External Code Source - USPS char[2] 2
PC024 Pharmacy ZIP Code Zip code of the Pharmacy External Code Source - USPS varchar[9] 9
PC024A Pharmacy Country Code Country Code of the Pharmacy External Code Source - ANSI char[3] 3
PC025 Claim Status Claim Line Status integer varchar[2] 2
PC026 Drug Code National Drug Code (NDC) External Code Source - FDA char[11] 11
PC027 Drug Name Name of the drug as supplied External Code Source - FDA varchar[80] 80
PC028 New Prescription or Refill Prescription Status Indicator Numeric char[2] 2
PC029 Generic Drug Indicator Generic Drug Indicator Integer int[1] 1
PC030 Dispense as Written Code Prescription Dispensing Activity Code Integer int[1] 1
PC031 Compound Drug Indicator Compound Drug Indicator Integer int[1] 1
PC032 Date Prescription Filled Prescription filled date Full Date - Integer int[8] YYYYMMDD 8
PC033 Quantity Dispensed Claim line units dispensed Quantity - Integer ±varchar[10] 10
PC034 Days' Supply Prescription Supply Days Quantity - Integer ±varchar[3] 3
PC035 Charge Amount Amount of provider charges for the claim line Integer ±varchar[10] 10
PC036 Paid Amount Amount paid by the carrier for the claim line Integer ±varchar[10] 10
PC037 Ingredient Cost/List Price Amount defined as the List Price or Ingredient Cost Integer ±varchar[10] 10
PC038 Postage Amount Claimed Amount of postage claimed on the claim line Integer ±varchar[10] 10
PC039 Dispensing Fee Amount of dispensing fee for the claim line Integer ±varchar[10] 10
PC040 Copay Amount Amount of Copay member/patient is responsible to pay Integer ±varchar[10] 10
PC041 Coinsurance Amount Amount of coinsurance member/patient is responsible to pay Integer ±varchar[10] 10
PC042 Deductible Amount Amount of deductible member/patient is responsible to pay on the claim line Integer ±varchar[10] 10
PC043 Prescribing ProviderID Prescribing Provider Identification Text varchar[30] 30
PC044 Prescribing Physician First Name First name of Prescribing Physician Text varchar[25] 25
PC045 Prescribing Physician Middle Name Middle initial of Prescribing Physician Text varchar[25] 25
PC046 Prescribing Physician Last Name Last name of Prescribing Physician Text varchar[60] 60
PC047 Prescribing Physician DEA Prescriber DEA Text char[9] 9
PC048 National Provider ID - Prescribing National Provider Identification (NPI) of the Prescriber External Code Source - NPPES int[10] 10
PC049 Prescribing Physician Plan Number Carrier-assigned Provider Plan ID Text varchar[30] 30
PC050 Prescribing Physician License Number Prescribing Physician License Number Text varchar[30] 30
PC051 Prescribing Physician Street Address Street address of the Prescribing Physician Text varchar[50] 50
PC052 Prescribing Physician Street Address 2 Secondary street address of the Prescribing Physician Text varchar[50] 50
PC053 Prescribing Physician City City name of the Prescribing Physician Text varchar[30] 30
PC054 Prescribing Physician State State of the Prescribing Physician External Code Source - USPS char[2] 2
PC055 Prescribing Physician Zip Code Zip code of the Prescribing Physician External Code Source - USPS varchar[9] 9
PC056 Filler Filler Filler char[0] 0
PC057 Mail Order pharmacy Indicator - Mail Order Option Integer int[1] 1
PC058 Script number Prescription Number Text varchar[20] 20
PC059 Filler Filler Filler char[0] 0
PC060 Single / Multiple Source Indicator Indicator - Drug Source Integer int[1] 1
PC061 Member Street Address Street address of the Member/Patient Text varchar[50] 50
PC062 Billing Provider Tax ID Number The Billing Provider's Federal Tax Identification Number (FTIN) Numeric char[9] 9
PC063 Paid Date Paid date of the claim line Integer int[8] YYYYMMDD 8
PC064 Date Prescription Written Date prescription was prescribed Full Date - Integer int[8] YYYYMMDD 8
PC065 COB / TPL Amount Amount due from a secondary carrier Integer ±varchar[10] 10
PC066 Other Insurance Paid Amount Amount already paid by primary carrier Integer ±varchar[10] 10
PC067 Medicare Paid Amount Any amount Medicare Paid towards claim line Integer ±varchar[10] 10
PC068 Allowed amount Allowed Amount Integer ±varchar[10] 10
PC069 Member Self Pay Amount Amount member/patient paid out of pocket on the claim line Integer ±varchar[10] 10
PC070 Rebate Indicator Indicator - Rebate Integer int[1] 1
PC071 State Sales Tax Amount of applicable sales tax on the claim line Integer ±varchar[10] 10
PC072 Carve Out Vendor CT APCD ID CT APCD defined and maintained Org ID for linking across submitters Integer varchar[6] 6
PC073 Formulary Code Indicator - Formulary Inclusion Integer int[1] 1
PC074 Route of Administration Route of Administration External Codes Source - NCPDP char[2] 2
PC075 Drug Unit of Measure Units of Measure External Codes Source - NCPDP char[2] 2
PC101 Subscriber Last Name Last name of Subscriber Text varchar[60] 60
PC102 Subscriber First Name First name of Subscriber Text varchar[25] 25
PC103 Subscriber Middle Initial Middle initial of Subscriber Text char[1] 1
PC104 Member Last Name Last name of Member/Patient Text varchar[60] 60
PC105 Member First Name First name of Member/Patient Text varchar[25] 25
PC106 Member Middle Initial Middle initial of the Member/Patient Text char[1] 1
PC107 Carrier Specific Unique Member ID Member's Unique ID Text varchar[50] 50
PC108 Carrier Specific Unique Subscriber ID Subscriber's Unique ID Text varchar[50] 50
PC109 Member Street Address 2 Secondary Street Address of the Member/Patient Text varchar[50] 50
PC110 Claim Line Type Claim Line Activity Type Code Text char[1] 1
PC111 Former Claim Number Previous Claim Number Text varchar[35] 35
PC112 Medicare Indicator Indicator - Medicare Payment Applied Integer int[1] 1
PC113 Pregnancy Indicator Indicator - Pregnancy Integer int[1] 1
PC114 Diagnosis Code ICD Diagnosis Code External Codes Source - ICD varchar[7] 7
PC115 ICD Indicator International Classification of Diseases version Integer int[1] 1
PC116 Denied Flag Indicator - Denied Claim Line Integer int[1] 1
PC117 Denial Reason Denial Reason Code External Code Source - HIPAA -OR- Carrier Lookup Table varchar[30] 30
PC118 Payment Arrangement Type Payment Arrangement Type Value Integer int[1] 1
PC119 Filler Filler Filler char[0] 0
PC120 APCD ID Code Member Enrollment Type Integer int[1] 1
PC899 Record Type File Type Identifier Text char[2] 2
TR001 Record Type Trailer Record Identifier Text char[2] 2
TR002 Submitter Trailer Submitter / Carrier ID defined by AHCT Integer varchar[6] 6
TR003 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
TR004 Type of File Validates the file type defined in HD004. Text char[2] 2
TR005 Period Beginning Date Trailer Period Start Date Full Date - Integer int[8] YYYYMMDD 8
TR006 Period Ending Date Trailer Period Ending Date Full Date - Integer int[8] YYYYMMDD 8
TR007 Date Processed Trailer Processed Date Full Date - Integer int[8] YYYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type HD Header Elements
HD004 Type of File PC PHARMACY CLAIM
HD009 APCD Version Number 1 Current Version; required for reporting periods as of October 2013
PC003 Insurance Type Code / Product 9 Self-pay
11 Other Non-Federal Programs (use of this value requires disclosure to Data Manager prior to submission)
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)
96 Husky Health A
97 Husky Health B
98 Husky Health C
99 Husky Health D
AM Automobile Medical
CH Champus (now TRICARE)
CI Commercial Insurance
DS Disability
HM Health Maintenance Organization
LM Liability Medical
MA Medicare Part A
MB Medicare Part B
MC Medicaid
OF Other Federal Program (use of this value requires disclosure to Data Manager prior to submission)
TV Title V
VA Veterans Affairs Plan
WC Workers' Compensation
ZZ Mutually Defined (use of this value requires disclosure to Data Manager prior to submission)
PC011 Individual Relationship Code 1 Spouse
4 Grandfather or Grandmother
5 Grandson or Granddaughter
7 Nephew or Niece
10 Foster Child
12 Other Adult
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
34 Other Adult
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
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
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 1 Capitation
2 Fee for Service
3 Percent of Charges
4 DRG
5 Pay for Performance
6 Global Payment
7 Other
8 Bundled Payment
PC120 APCD ID Code 0 Unknown / Not Applicable
1 FIG - Fully-Insured Commercial Group Enrollee
2 SIG - Self-Insured Group Enrollee
3 State or Federal Employer Enrollee
4 Individual - Non-Group Enrollee
5 Supplemental Policy Enrollee
6 ICO - Integrated Care Organization
PC899 Record Type PC
TR001 Record Type TR end of the data file
TR004 Type of File PC
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