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Pharmacy Claims File Submission

Massachusetts

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


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.
VersionDecember 1, 2010 - v2.1

File Specification for Pharmacy Claims File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type Header Record Identifier Text HD 2
Multiple versionsHD002 Payer Header Submitter/Carrier ID Text 8
Multiple versionsHD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Text 30
Multiple versionsHD004 Type of File Header Type of File Text PC 2
Multiple versionsHD005 Period Beginning Date Header Period Start Date Date Period CCYYMM 6
Multiple versionsHD006 Period Ending Date Header Period Ending Date Date Period CCYYMM 6
Multiple versionsHD007 Record Count Header Record Count Integer ####### 10
Multiple versionsHD008 Comments Header Carrier Comments Text Free Text Comments 80
Multiple versionsPC001 Payer Carrier Specific Submitter Code as defined by APCD. This must match the Submitter Code reported in HD002 Text 8
Multiple versionsPC002 Plan ID CMS National Plan Identification Number (PlanID) Text 30
Multiple versionsPC003 Insurance Type Code/Product Type / Product Identification Code Text tlkpClaimInsuranceType 2
Multiple versionsPC004 Payer Claim Control Number Payer Claim Control Identification Text Free Text Control Number 35
Multiple versionsPC005 Line Counter Incremental Line Counter Integer #### 4
Multiple versionsPC005A Version Number Claim Service Version Number Integer #### 4
Multiple versionsPC006 Insured Group or Policy Number Carriers group or policy number Text 30
Multiple versionsPC007 Subscriber SSN Subscriber's Social Security Number Text ######### 9
Multiple versionsPC008 Plan Specific Contract Number Plan Specific Contract Number Text 30
Multiple versionsPC009 Member Suffix or Sequence Number Member/Patient's Contract Sequence Number Text 20
Multiple versionsPC010 Member SSN Member/Patient's Social Security Number Text ######### 9
Multiple versionsPC011 Individual Relationship Code Member/Patient to Subscriber Relationship Code Integer tlkpIndividualRelathionshipCode 2
Multiple versionsPC012 Member Gender Member/Patient's Gender Text tlkpGender 1
Multiple versionsPC013 Member Date of Birth Member/Patient's date of birth Date CCYYMMDD 8
Multiple versionsPC014 Member City Name of Residence City name of the Member/Patient Text Free Text Address 50
Multiple versionsPC015 Member State State of the Member/Patient Text External Code Source 2 2
Multiple versionsPC016 Member ZIP Code Zip code of the Member/Patient Text External Code Source 3 11
Multiple versionsPC017 Date Service Approved (AP Date) Date Service Approved Date CCYYMMDD 8
Multiple versionsPC018 Pharmacy Number Pharmacy Number Text 30
Multiple versionsPC019 Pharmacy Tax ID Number Pharmacy Tax Identification Number Text ######### 10
Multiple versionsPC020 Pharmacy Name Name of Pharmacy Text Free Text 100
Multiple versionsPC021 National Pharmacy ID Number National Provider Identification (NPI) of the Provider Text External Code Source 4 20
Multiple versionsPC022 Pharmacy Location City City name of the Pharmacy Text Free Text Address 30
Multiple versionsPC023 Pharmacy Location State State of the Pharmacy Text External Code Source 2 2
Multiple versionsPC024 Pharmacy ZIP Code Zip code of the Pharmacy Text External Code Source 3 11
Multiple versionsPC024A Pharmacy Country Code Country Code of the Pharmacy Text External Code Source 1 3
Multiple versionsPC025 Claim Status Claim Line Status Integer tlkpClaimStatus 2
Multiple versionsPC026 Drug Code National Drug Code (NDC) Text 5-4-2 standard. Do not include hyphens 11
Multiple versionsPC027 Drug Name Name of the drug as supplied Text External Code Source 12 80
Multiple versionsPC028 New Prescription or Refill Prescription Status Indicator Integer 2
Multiple versionsPC029 Generic Drug Indicator Generic Drug Indicator Text tlkpFlagIndicators 1
Multiple versionsPC030 Dispense as Written Code Prescription Dispensing Activity Code Integer tlkpDispenseAsWritten 1
Multiple versionsPC031 Compound Drug Indicator Compound Drug Indicator Text tlkpFlagIndicators 1
Multiple versionsPC032 Date Prescription Filled Prescription filled date Date CCYYMMDD 8
Multiple versionsPC033 Quantity Dispensed Claim line units dispensed Integer ####### 10
Multiple versionsPC034 Days Supply Prescription Supply Days Integer ### 3
Multiple versionsPC035 Charge Amount Amount of provider charges for the claim line Integer DDDDCC 10
Multiple versionsPC036 Paid Amount Amount paid by the carrier for the claim line Integer DDDDCC 10
Multiple versionsPC037 Ingredient Cost/List Price Amount defined as the List Price or Ingredient Cost Integer DDDDCC 10
Multiple versionsPC038 Postage Amount Claimed Amount of postage claimed on the claim line Integer DDDDCC 10
Multiple versionsPC039 Dispensing Fee Amount of dispensing fee for the claim line Integer DDDDCC 10
Multiple versionsPC040 Copay Amount Amount of Copay member/patient is responsible to pay Integer DDDDCC 10
Multiple versionsPC041 Coinsurance Amount Amount of coinsurance member/patient is responsible to pay Integer DDDDCC 10
Multiple versionsPC042 Deductible Amount Amount of deductible member/patient is responsible to pay on the claim line Integer DDDDCC 10
Multiple versionsPC043 Prescribing ProviderID Prescribing Provider Number Text 28
Multiple versionsPC044 Prescribing Physician First Name First name of Prescribing Physician Text Free Text Name 25
Multiple versionsPC045 Prescribing Physician Middle Name Middle initial of Prescribing Physician Text Free Text Name 25
Multiple versionsPC046 Prescribing Physician Last Name Last name of Prescribing Physician Text Free Text Name 60
Multiple versionsPC047 Prescribing Physician DEA Number Prescribing Physicians DEA Number Text 20
Multiple versionsPC048 Prescribing Physician NPI National Provider Identification (NPI) of the Prescribing Physician Text External Code Source 4 20
Multiple versionsPC049 Prescribing Physician Plan Number Prescribing Physicians Carrier Assigned Plan Number Text 30
Multiple versionsPC050 Prescribing Physician License Number Prescribing Physician License Number Text 30
Multiple versionsPC051 Prescribing Physician Street Address Street address of the Prescribing Physician Text Free Text Address 50
Multiple versionsPC052 Prescribing Physician Street Address 2 Secondary Street Address of the Prescribing Physician Text Free Text Address 50
Multiple versionsPC053 Prescribing Physician City City name of the Prescribing Physician Text Free Text Address 30
Multiple versionsPC054 Prescribing Physician State State of the Physician Text External Code Source 2 2
Multiple versionsPC055 Prescribing Physician Zip Zip code of the Prescribing Physician Text External Code Source 3 10
Multiple versionsPC056 Product ID Number Product Identification Number Text ID PR001 20
Multiple versionsPC057 Mail Order pharmacy Mail Order Pharmacy indicator Text tlkpFlagIndicators 1
Multiple versionsPC058 Script number Prescription Number Text 20
Multiple versionsPC059 Recipient PCP ID Member/Patient's PCP ID Number Text 30
Multiple versionsPC060 Single/Multiple Source Indicator Drug Source Indicator Text tlkpPharmacySources 1
Multiple versionsPC061 Member Street Address Street address of the Member/Patient Text Free Text Address 50
Multiple versionsPC062 Billing Provider Tax ID Number The Billing Provider's Federal Tax Identification Number (FTIN) Text ######### 10
Multiple versionsPC063 Paid Date Paid date of the claim line Date CCYYMMDD 8
Multiple versionsPC064 Date Prescription Written Date prescription was prescribed Date CCYYMMDD 8
Multiple versionsPC065 Coordination of Benefits/TPL Liability Amount Amount due from a Secondary Carrier when known Integer DDDDCC 10
Multiple versionsPC066 Other Insurance Paid Amount Amount paid by a Primary Carrier Integer DDDDCC 10
Multiple versionsPC067 Medicare Paid Amount Amount Medicare paid on claim Integer DDDDCC 10
Multiple versionsPC068 Allowed amount Allowed Amount Integer DDDDCC 10
Multiple versionsPC069 Member Self Pay Amount Amount member/patient paid out of pocket on the claim line Integer DDDDCC 10
Multiple versionsPC070 Rebate Indicator Drug Rebate Eligibility Indicator Text tlkpFlagIndicators 1
Multiple versionsPC071 State Sales Tax Amount of applicable sales tax on the claim line Integer DDDDCC 10
Multiple versionsPC072 Delegated Benefit Administrator Organization ID DHCFP assigned Org ID for Benefit Administrator Integer ########## 10
Multiple versionsPC073 Formulary Code Formulary inclusion identifier Text tlkpFlagIndicators 1
Multiple versionsPC074 Route of Administration Pharmaceutical Route of Administration Indicator Text tlkpRouteOfAdministration 2
Multiple versionsPC075 Drug Unit of Measure Units of Measure Text tlkpPharmacyUnitOfMeasure 3
Multiple versionsPC101 Subscriber Last Name Last name of Subscriber Text Free Text Name 60
Multiple versionsPC102 Subscriber First Name First name of the Subscriber Text Free Text Name 25
Multiple versionsPC103 Subscriber Middle Initial Middle initial of Subscriber Text Free Text Name 1
Multiple versionsPC104 Member Last Name Last name of Member/Patient Text Free Text Name 60
Multiple versionsPC105 Member First Name First name of Member/Patient Text Free Text Name 25
Multiple versionsPC106 Member Middle Initial Middle initial of the Member/Patient Text Free Text Name 1
Multiple versionsPC107 CarrierSpecificUniqueMemberID Member/Patient Carrier Unique Identification Text 50
Multiple versionsPC108 CarrierSpecificUniqueSubscriberID Subscriber Carrier Unique Identification Text 50
Multiple versionsPC109 Member Street Address 2 Secondary Street Address of the Member/Patient Text Free Text Address 50
Multiple versionsPC110 Claim Line Type Claim Line Activity Type Code Text tlkpClaimLineType 10
Multiple versionsPC111 Former Claim Number Previous Claim Number Text ID 35
Multiple versionsPC899 Record Type File Type Identifier Text PC 2
Multiple versionsTR001 Record Type Trailer Record Identifier Text TR 2
Multiple versionsTR002 Payer Carrier Specific Submitter Code as defined by APCD. This must match the Submitter Code reported in HD002 Text 8
Multiple versionsTR003 National Plan ID CMS National Plan Identification Number (PlanID) Text 30
Multiple versionsTR004 Type of File This is an indicator that defines the type of file and the data contained within the file. This must match the File Type reported in HD004. Text PC 2
Multiple versionsTR005 Period Beginning Date Trailer Period Start Date Date Period CCYYMM 6
Multiple versionsTR006 Period Ending Date Trailer Period Ending Date Date Period CCYYMM 6
Multiple versionsTR007 Date Processed Trailer Processed Date Date CCYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type HD
HD004 Type of File PC
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
TV Title V
VA Veterans Administration Plan
WC Workers' Compensation
PC011 Individual Relationship Code 1 Spouse
4 Grandfather or Grandmother
5 Grandson or Granddaughter
7 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 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
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
GM Grams
ML Milliliters
PC110 Claim Line Type A Amendment
B Back Out
O Original
R Replacement
V Void
PC899 Record Type PC
TR001 Record Type TR
TR004 Type of File PC
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