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Pharmacy Claims File Submission

Maine

Versions: Pharmacy Claims File Submission• Pharmacy Claims File SubmissionCompare Versions


Name:Pharmacy Claims File Submission
State:Maine
Definition:Not Provided
Version2010-03-16

File Specification for Pharmacy Claims File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsPC001 Payer Payer submitting payments, MHDO Submitter Code varchar 8
Multiple versionsPC002 Plan ID CMS National Plan ID varchar 30
Multiple versionsPC003 Insurance Type/Product Code Not Provided varchar 2
Multiple versionsPC004 Payer Claim Control Number Must apply to the entire claim and be unique within the payer's varchar 35
Multiple versionsPC005 Line Counter Line number for this service integer 4
Multiple versionsPC006 Insured Group Number Group or policy number - not the number that uniquely identifies varchar 30
Multiple versionsPC007 Month Encrypted subscriber's social security number varchar 128
Multiple versionsPC008 Plan Specific Contract Number Encrypted plan assigned contract number varchar 128
Multiple versionsPC009 Member Suffix or Sequence Number Uniquely numbers the member within the contract integer 20
Multiple versionsPC010 Member Identification Code Encrypted member's social security number varchar 128
Multiple versionsPC011 Individual Relationship Code Member's relationship to insured integer 2
Multiple versionsPC012 Member Gender Not Provided integer 1
Multiple versionsPC013 Member Date of Birth Not Provided date CCYYMMDD
Multiple versionsPC014 Member City Name of Residence City name of member varchar 50
Multiple versionsPC015 Member State or Province As defined by the US Postal Service varchar 2
Multiple versionsPC016 Member ZIP Code ZIP Code of member - may include non-US codes. Do not include varchar 11
Multiple versionsPC017 Date Service Approved (AP Date) Not Provided date CCYYMMDD
Multiple versionsPC025 Claim Status Not Provided integer 2
Multiple versionsPC026 Drug Code NDC Code varchar 11
Multiple versionsPC027 Drug Name Text name of drug varchar 80
Multiple versionsPC028 New Prescription 00 New prescription, 01-99 Number of refill integer 2
Multiple versionsPC029 Generic Drug Indicator Not Provided varchar 1
Multiple versionsPC030 Dispense as Written Code Not Provided integer 1
Multiple versionsPC031 Compound Drug Indicator Not Provided varchar 1
Multiple versionsPC032 Date Prescription Filled Not Provided date CCYYMMDD
Multiple versionsPC033 Quantity Dispensed Number of metric units of medication dispensed integer 5
Multiple versionsPC034 Days Supply Estimated number of days the prescription will last integer 3
Multiple versionsPC035 Charge Amount Not Provided decimal 10
Multiple versionsPC036 Paid Amount Includes all health plan payments and excludes all member decimal 10
Multiple versionsPC037 Ingredient Cost/List Price Cost of the drug dispensed decimal 10
Multiple versionsPC038 Postage Amount Claimed Not Provided decimal 10
Multiple versionsPC039 Dispensing Fee Not Provided decimal 10
Multiple versionsPC040 Copay Amount The preset, fixed dollar amount for which the individual is decimal 10
Multiple versionsPC041 Coinsurance Amount Not Provided decimal 10
Multiple versionsPC042 Deductible Amount Not Provided decimal 10
Multiple versionsPC043 Unassigned Reserved for assignment Not Supplied Not Supplied Not Supplied
PC101 Encryped Subscriber Last Name The encrypted subscriber last name varchar 128
PC102 Encryped Subscriber First Name The encrypted subscriber first name varchar 128
PC103 Encryped Subscriber Middle Initial The encrypted subscriber middle initial varchar 1
PC104 Encryped Member Last Name The encrypted member last name varchar 128
PC105 Encryped Member First Name The encrypted member first name varchar 128
PC106 Encryped Member Middle Initial The encrypted member middle initial varchar 1
PC899 Record Type Not Provided varchar 2
Multiple versionsPC901 Member Age Not Provided integer 3
Multiple versionsPC902 Record ID# Not Provided integer
Multiple versionsPC903 Date of Transfer to MHDO Not Provided date CCYYMMDD
Multiple versionsPC904 Encrypted Member ID# (longer of ESSN or Contract) + DOB Not Provided varchar 71
Multiple versionsPC905 Submission ID# Not Provided integer
Multiple versionsPC906 Double Encrypted Payer Claim Control Number Not Provided varchar 100
Multiple versionsPC907 Double Encrypted Subscriber Social Security Number Not Provided varchar 64
Multiple versionsPC908 Double Encrypted Plan Specific Contract Number Not Provided varchar 128
Multiple versionsPC909 Double Encrypted Member Identification Code Not Provided varchar 128
Multiple versionsPC910 Double Encrypted Member ID# (longer of MHDO_ESSN or Not Provided varchar 135
Multiple versionsPC911 Standardized Member Gender Not Provided varchar 1
Multiple versionsPC912 Standardized Insurance Type/Product Code Not Provided varchar 2
Multiple versionsPC913 Key to Pharmacy Detail table Not Provided integer
Multiple versionsPC914 PAID_YR Not Provided integer
Multiple versionsPC915 PAID_MON Not Provided integer
Multiple versionsPC916 INCURRED_YR Not Provided integer
Multiple versionsPC917 INCURRED_MON Not Provided integer
Multiple versionsPC918 Quarter calculated from PC915 integer
Multiple versionsPC919 Quarter calculated from PC917 integer
Multiple versionsPC920 Prescribing Physician ID# Not Provided integer 12

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Data Element ID Data Element Code Value
PC028 New Prescription 00 New prescription
01-99 Number of refill
PC899 Record Type PC
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