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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:"Pharmacy claims file" means a data file composed of service level remittance information including, but not limited to, member demographics, provider information, charge/payment information, and national drug codes from all non-denied adjudicated claims for each prescription filled.
Versionv1.2

File Specification for Pharmacy Claims File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsPC001 Payer This field contains the MHDO submitter code for the payer submitting payments. The first character of the submitter code indicates the type of submitter. This field is primarily used for tracking compliance by Payer. CHAR 6
Multiple versionsPC002 Plan ID CMS National Plan ID CHAR 30
Multiple versionsPC003 Insurance Type/Product Code The insurance type or product code indicates the type of insurance coverage the individual has. CHAR 2
Multiple versionsPC004 Payer Claim Control Number This field contains the claim number used by the payer to internally track the claim. In general the claim number is associated with all service lines of the bill. Therefore, multiple medical records may share the same claim number. CHAR 35
Multiple versionsPC005 Line Counter This field contains the line number for this service. CHAR 5
Multiple versionsPC006 Insured Group Number The group or policy number is associated with the entity thaThas purchased the insurance. For self insured individuals this relates to the purchaser. For the majority of eligibility and claims data the group relates to the employer. CHAR 31
Multiple versionsPC007 Encrypted Subscriber Social Security Number This field contains the Encrypted Social Security Number for the subscriber. If the social security number was not available from the payer this field will be null and the contract field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(MEMBERID). CHAR 32
Multiple versionsPC008 Plan Specific Contract Number This field contains the payer assigned contract number for The subscriber. If the Encrypted Social Security Number is Null, this field forms the core of the unique member number (MEMBERID). CHAR 64
Multiple versionsPC009 Member Suffix or Sequence Number This payer supplied code uniquely identifies the member Within the context of the subscriber Encrypted Social Security Number or the Contract. CHAR 20
Multiple versionsPC010 Member Identification Code This field is used to record the member's social security number when available. If the member is the subscriber, this field should contain the same value as the Encrypted Social Security Number. If the member is not the Subscriber, this field will not equal the Encrypted Social Security Number. CHAR 30
Multiple versionsPC011 Individual Relationship Code This field contains the member's relationship to the subscriber or the insured. CHAR 2
Multiple versionsPC012 Member Gender This field contains the gender of the member. CHAR 1
Multiple versionsPC013 Member Date of Birth This field contains the member's data of birth with a format of CCYYMMDD. This field is used to calculate age as of the from date of service. DATE CCYYMMDD 8
Multiple versionsPC014 Member City Name of Residence This field contains the member's city of residence and was not required reporting until 2004. CHAR 50
Multiple versionsPC015 Member State or Province The Member State or Province contains the 2 character abbreviation code used by the US Postal Service and was not required reporting until 2004. Since this database has been built for Maine residents the code will generally be ME for Maine. CHAR 2
Multiple versionsPC016 Member ZIP Code This field contains ZIP Code of the member. Payers are encouraged to provide a full 9 character zip code. CHAR 11
Multiple versionsPC017 Date Service Approved (AP Date) This field contains the date the record was approved for Payment with a CCYYMMDD format. This is generally referred to as the Paid Date. DATE CCYYMMDD 8
Multiple versionsPC025 Claim Status This field contains the status of the claim as reported by the payer. NUMBER 2
Multiple versionsPC026 Drug Code Each drug product listed under Section 510 of the Federal Food, Drug, and Cosmetic Act is assigned a unique 10-digit, 3-segment number. This number, known as the National Drug Code (NDC), identifies the labeler/vendor, product, and trade package size. The first segment, the labeler code, is assigned by the FDA. A labeler is any firm that manufactures, re-packs or distributes a drug product. The second segment, the product code, identifies a specific strength, dosage form, and formulation for a particular firm. The third segment, the package code, identifies package sizes. Both the product and package codes are assigned by the firm. The NDC will be in one of the following configurations: 4-4-2, 5-3-2, or 5-4-1. CHAR 11
Multiple versionsPC027 Drug Name This field contains the text name of drug as supplied by the payer. CHAR 80
Multiple versionsPC028 New Prescription This field can be used to determine if this is a new prescription. It contains the prescription number. NUMBER 2
Multiple versionsPC029 Generic Drug Indicator This field indicates whether the drug is a branded drug or a generic drug. CHAR 1
Multiple versionsPC030 Dispense as Written Code This field indicates the instructions given to the pharmacist For filling the prescription. For example, a prescription for a brand name drug that also has a generic equivalent may not have the generic equivalent substituted. In this case, the code is 1 - physician requires the script be filled as written. NUMBER 1
Multiple versionsPC031 Compound Drug Indicator This field indicates if this is a compound drug or not. CHAR 1
Multiple versionsPC032 Date Prescription Filled This field contains the date the prescription was filled In a CCYYMMDD format. DATE CCYYMMDD 8
Multiple versionsPC033 Quantity Dispensed This field contains the total unit dosage in metric units. This field may be negative. NUMBER 5
Multiple versionsPC034 Days Supply This field contains the actual days supply for the Prescription based on the metric quantity dispensed. This field may contain a negative value. NUMBER 3
Multiple versionsPC035 Charge Amount This field contains the total charges for the service as Reported by the provider. This is a money field Containing dollars and cents with an implied decimal point. This field may contain a negative value. NUMBER 10
Multiple versionsPC036 Paid Amount This field includes all health plan payments and excludes all member payments. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. NUMBER 10
Multiple versionsPC037 Ingredient Cost/List Price This field contains the cost of the drug that was dispensed as reported by the payer. This is a money field containing Dollars and cents with an implied decimal point. NUMBER 10
Multiple versionsPC038 Postage Amount Claimed This field contains the postage amount included in the charges. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. NUMBER 10
Multiple versionsPC039 Dispensing Fee This field contains the amount charged for dispensing. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. NUMBER 10
Multiple versionsPC040 Copay Amount This field contains the pre-set, fixed dollar amount payable by a member, often on a per visit/service basis. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. NUMBER 10
Multiple versionsPC041 Coinsurance Amount This amount is paid by the member and reflects the Percentage a member must pay toward the cost of a covered service. In many health insurance plans the coinsurance a member is responsible for is capped after a certain dollar amount of eligible expenses have been incurred. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. NUMBER 10
Multiple versionsPC042 Deductible Amount This is an amount that is required to be paid by a member Before health plan benefits will begin to reimburse for Services. It is usually an annual amount of all health care costs that is not covered by the member's insurance plan. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. NUMBER 10
Multiple versionsPC043 Record Type This field indicates the type of record. CHAR 2
Multiple versionsPC901 Member Age This field contains the age of the member in years as of the date the prescription was filled. Children under the age of 1 have an age of zero. If no date of birth is available, this field is null. NUMBER 3
Multiple versionsPC902 Record ID # This field contains a Data Processing Center assigned record number that is unique across all data types. This field is used for tracking purposes. This is the date the record was extracted by the Data Processing Center for inclusion in the MHDO Data Warehouse. The format is CCYYMMDD. NUMBER CCYYMMDD 12
Multiple versionsPC903 MHDO Extract Date This is the date the record was extracted by the Data Processing Center for inclusion in the MHDO Data Warehouse. The format is CCYYMMDD. DATE CCYYMMDD 8
Multiple versionsPC904 Unique Member ID The MEMBERID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Subscriber Social Security Number, the Memberid is comprised of Encrypted Subscriber Social Security Number + Year and Month of Birth + Gender + Individual Relationship Code. If the Encrypted Subscriber Social Security Number is blank, the Memberid is comprised of the Plan Specific Contract Number + Year and Month of Birth + Gender + Individual Relationship Code. CHAR 71
Multiple versionsPC905 Submission ID # This field contains a unique submission number assigned by the Data Processing Center for tracking purposes. Each payer submission receives a submission number that is unique across all data types. NUMBER 12
Multiple versionsPC906 Double Encrypted Payer Control Claim Number This field contains the encrypted version of the Payer Claim Control Number reported in DC004. The claim number used by the payer to internally track the claim. CHAR 100
Multiple versionsPC907 Double Encrypted Subscriber Social Security Number This field contains an encryption of the information Originally submitted by the payer in field DC007 - the Encrypted Social Security Number for the subscriber. If the social security number was not available from the payer this field will be null and the CONTRACT field will be populated. This field has been encrypted using the same algorithm across all payers. If this field is populated, it forms the core of the unique member identification code(MHDO_MEMBERID). CHAR 64
Multiple versionsPC908 Double Encrypted Plan Specific Contract Number This field contains an encryption of the information originally submitted by the payer in field DC008 - the payer assigned contract number for the subscriber. If the Double Encrypted Subscriber Social Security Number is null, this field forms the core of the unique member number (MHDO_MEMBERID). This field has been encrypted using the same algorithm across all payers. CHAR 128
Multiple versionsPC909 Double Encrypted Member Social Security Number The Double Encrypted Member ID is a combination of fields which generally represent a unique individual. For those members with a value in the Double Encrypted Subscriber Social Security Number, the Double Encrypted MemberID is comprised of Double Encrypted Subscriber Social Security Number + Year and Month of Birth + Gender + Individual Relationship Code. If the Double Encrypted Subscriber Social Security Number is blank, the Double Encrypted Memberid is comprised of the Double Encrypted Plan Specific Contract Number + Year and Month of Birth + Gender + Individual Relationship Code. CHAR 128
Multiple versionsPC910 Double Encrypted Member ID The Double Encrypted Member ID is a combination of fields which generally represent a unique individual. For those members with a value in the Encrypted Social Security Number, the Double Encrypted Member ID is comprised of Double Encrypted Subscriber Social Security Number + Year and Month of Birth + Gender + Individual Relationship Code. If the Double Encrypted Social Security Number is blank, the Double Encrypted Memberid is comprised of the Double Encrypted Plan Specific Contract Number + Year and Month of Birth + Gender + Indvidual Relationship Code. CHAR 135
Multiple versionsPC911 Standardized Member Gender This field contains the standardized gender code originally reported in PC012. CHAR 1
Multiple versionsPC912 Standardized Insurance Type/Product Code The insurance type or product code indicates the type of insurance coverage the individual has. CHAR 2
Multiple versionsPC913 Pharmacy ID # This is the provider identification number that links to the Pharmacy Name File file using PCSPC001. INTEGER 12
Multiple versionsPC914 Year Paid This field is derived from Data Service Approved (PC017) and contains the year of payment (YYYY format). Number YYYY 4
Multiple versionsPC915 Month Paid This field is derived from Date Service Approved (PC017) and contains the month of payment (MM format). Number MM 2
Multiple versionsPC916 Year of Service This field is derived from the From Date of Service (PC032) and contains the year the service was performed (YYYY format). Number YYYY 4
Multiple versionsPC917 Month of Service This field is derived from the From Date of Service (PC032) and contains the month the service was performed (MM) format). Number MM 2
Multiple versionsPC918 Payment Quarter This field is derived from Date Service Approved (PC017) and contains the quarter of payment. Number 1
Multiple versionsPC919 Quarter Service Performed This field is derived from the From Date of Service (PC032) and contains the quarter of payment. Number 1
Multiple versionsPC920 Prescribing Physician ID This is the prescribing physician identification number that links to the Medical Service Provider file using MCSP001. INTEGER 12

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Data Element ID Data Element Code Value
PC001 Payer C Commercial carrier
T Third Party Administrator
U Unlicensed entity
PC003 Insurance Type/Product Code 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
AM Automobile Medical
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 (e.g. Black Lung)
TV Title V
VA Veteran Administration Plan
WC Worker's Compensation
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 Employee/Self
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 1 Male
2 Female
PC025 Claim Status 01 Processed as primary
02 Processed as secondary
03 Processed as tertiary
04 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
PC028 New Prescription 00 New prescription
01-99 Refill prescription
PC029 Generic Drug Indicator N No, branded drug
Y Yes, branded drug
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 N Non-compound drug
U Non-specified drug component
Y Compound drug
PC043 Record Type PC Pharmacy Claims
PC911 Standardized Member Gender F Female
M Male
U Unknown
PC912 Standardized Insurance Type/Product Code 11 Other non Federal program
12 Medicare secondary working aged beneficiary or spouse with employer group health plan
13 Medicare secondary end-stage renal disease beneficiary in the 12 month coordination period with an employer's group health plan
14 Medicare secondary, no-fault insurance including auto is primary
15 Medicare secondary worker's compensation
15 Medicare secondary public health service (PHS) or other federal agency
41 Medicare secondary black lung
42 Medicare secondary veteran's administration
43 Medicare secondary disabled beneficiary under age 65 with large group health plan (LGHP)
47 Medicare secondary, other liability insurance is primary
AM Auto insurance policy
CP Medicare conditionally primary
DB Disability benefits
DS Disability
EP Exclusive Provider Organization (EPO)
HM Health Maintenance Organization (HMO)
HN Health Maintenance Organization (HMO) Medicare risk
HS Special low income Medicare beneficiary
IN Indemnity Insurance
LC Long term care
LD Long term policy
LI Life insurance
LM Liability medical
LT Litigation
MA Medicare part A
MB Medicare part B
MC Medicaid
MH Medigap part A
MI Medigap part B
MP Medicare primary
OF Other federal program (e.g. black lung)
OT Other
PE Property Insurance - Personal
PR Preferred Provider Organization (PPO)
PS Point of Service (POS)
QM Qualified Medicare beneficiary
SP Supplemental policy
TV Title V
VA Veteran administration plan
WC Workers' compensation
PC918 Payment Quarter 1 January - March
2 April - June
3 July - September
4 October - December
PC919 Quarter Service Performed 1 January - March
2 April - June
3 July - September
4 October - December
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