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Pharmacy Fixed Format File Submission

Maryland

Versions: Pharmacy Fixed Format File Submission• Pharmacy Fixed Format File Submission• Pharmacy Fixed Format File SubmissionCompare Versions


Name:Pharmacy Fixed Format File Submission
State:Maryland
Definition:Not provided
VersionFebruary 20, 2013

File Specification for Pharmacy Fixed Format File Submission

Data Element ID Data Element Description Type Format Length
Multiple versions1 Record Identifier The value is 2 numeric 1
Multiple versions2 Patient IdentifierP (payer encrypted) Patient's unique identification number assigned by payer and encrypted. alphanumeric 12
Multiple versions3 Patient IdentifierU (UUID encrypted) Patient's universally unique identification (UUID) number generated using an encryption algorithm provided by MHCC. alphanumeric 12
Multiple versions4 Patient Sex Sex of Patient. numeric 1
Multiple versions5 Patient Zip Code Zip code of patient's residence. numeric 5
Multiple versions6 Patient Year and Month of Birth Date of patient's birth using 00 instead of day. numeric CCYYMM00 8
Multiple versions7 Pharmacy NCPDP Number Unique 7 digit number assigned by the National Council for Prescription Drug Program (NCPDP). numeric 7
Multiple versions8 Pharmacy Zip Code Zip code of pharmacy where prescription was filled and dispensed. numeric 5
Multiple versions9 Practitioner DEA # Drug Enforcement Agency number assigned to an individual registered under the Controlled Substance Act. alphanumeric 11
Multiple versions10 Fill Number The code used to indicate if the prescription is an original prescription or a refill. Use '01' for all refills if the specific number of the prescription refill is not available. numeric 2
Multiple versions11 NDC Number National Drug Code 11 digit number. numeric 11
Multiple versions12 Drug Compound Indicates a mix of drugs to form a compound medication. numeric 1
Multiple versions13 Drug Quantity Number of units of medication dispensed. numeric 5
Multiple versions14 Drug Supply Estimated number of days of dispensed supply. numeric 3
Multiple versions15 Date Filled Date prescription was filled. numeric CCYYMMDD 8
Multiple versions16 Date Prescription Written Date prescription was written. numeric CCYYMMDD 8
Multiple versions17 Billed Charge Retail amount for drug including dispensing fees and administrative costs. MUST INCLUDE 2 IMPLIED DECIMAL PLACES. numeric 9
Multiple versions18 Reimbursement Amount Amount paid to the pharmacy by payer. Do not include patient copayment or sales tax. MUST INCLUDE 2 IMPLIED DECIMAL PLACES. numeric 9
Multiple versions19 Prescription Claim Number Internal payer claim number used for tracking. numeric 15
Multiple versions20 Prescribing Practitioner Individual National Provider Identifier (NPI) number Federal identifier assigned by the federal government for use in all HIPAA transactions to an individual practitioner. alphanumeric 10
Multiple versions21 Patient Deductible The fixed amount that the patient must pay for covered pharmacy services before benefits are payable. MUST INCLUDE 2 IMPLIED DECIMAL PLACES. numeric 9
Multiple versions22 Patient Coinsurance or Patient Co-payment The specified amount or percentage the patient is required to contribute towards covered pharmacy services after any applicable deductible. MUST INCLUDE 2 IMPLIED DECIMAL PLACES. numeric 9
Multiple versions23 Other Patient Obligations Any patient obligations other than the deductible or coinsurance/co-payment. This could include obligations for non-formulary drugs, non-covered pharmacy services, or penalties. MUST INCLUDE 2 IMPLIED DECIMAL PLACES. numeric 9
Multiple versions24 Date of Enrollment The start date of enrollment for the patient in this delivery system (in this data submission time period). numeric CCYYMMDD 8
Multiple versions25 Date of Disenrollment The end date of enrollment for the patient in this delivery system (in this data submission time period). (see Source Company on page 66) numeric CCYYMMDD 8
Multiple versions26 Source of Processing The source processing the pharmacy claim. alphanumeric 1
Multiple versions27 Payer ID Number Payer assigned submission identification number alphanumeric 4
Multiple versions28 Source System Identify the source system (platforms or business units) from which the data was obtained by using an alphabet letter (A, B, C, D, etc...) For payers with all data coming from one system only, leave the field blank. alphanumeric 1

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Data Element ID Data Element Code Value
1 Record Identifier 2 Pharmacy Services
4 Patient Sex 1 Male
2 Female
3 Unknown
10 Fill Number 1-99 Refill number
00 New prescription/Original
12 Drug Compound 1 Non-compound
2 Compound
26 Source of Processing 1 Processed Internally by Payer
2 Argus Health Systems, Inc.
3 Caremark, LLC
4 Catalyst Rx, Inc.
5 Envision Pharmaceutical Services, Inc.
6 Express Scripts, Inc.
7 Medco Health, LLC
8 National Employee Benefit Companies, Inc. dba/Ideal Scripts
9 NextRx Services, Inc.
A Atlantic Prescription Services, LLC
B Benecard Services, Inc.
C BioScrip PBM Services, LLC
D Futurescripts, LLC
E Health E Systems
F HealthTran, LLC
G Innoviant, Inc.
H MaxorPlus
I Medical Security Card Company
J MedImpact Healthcare Systems, Inc.
K MemberHealth, LLC
L PharmaCare Management Services, LLC
M Prime Therapeutics, LLC
N Progressive Medical, Inc.
O RxAmerica, LLC
P RxSolutions, Inc.
Q Scrip World, LLC
R Tmesys, Inc.
S WellDynerx, Inc.
T Other Source Not Listed
Z Unknown
27 Payer ID Number P020 Aetna Life Insurance Co.
P030 Aetna Health, Inc.
P070 American Republic Insurance Co.
P130 CareFirst BlueChoice, Inc.
P131 CareFirst of Maryland, Inc.
P132 Group Hospitalization & Medical Services, Inc. (GHMSI)
P160 CIGNA Healthcare Mid-Atlantic, Inc.
P180 Connecticut General Life Ins. Co.
P220 Corporate Health Insurance Co.
P280 Assurant Health/Time Insurance Co.
P320 Golden Rule Insurance Co.
P480 Kaiser Permanente Mid-Atlantic States
P500 MAMSI Life and Health Ins. Co.
P520 MD-Individual Practice Association, Inc.
P530 MEGA Life & Health Insurance Co.
P620 Optimum Choice, Inc.
P680 Coventry Healthcare of Delaware, Inc.
P760 State Farm Mutual Automobile Ins. Co.
P820 United Healthcare Insurance Co.
P870 United Healthcare of the Mid-Atlantic, Inc.
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