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Pharmacy Claims File Submission

Minnesota



Name:Pharmacy Claims File Submission
State:Minnesota
Definition:"Health care claims data" means information included in an institutional, professional, or pharmacy drug claim or equivalent encounter information transaction for a covered individual that is required under Minnesota Statutes, section 62J.536.
VersionMay 2009

File Specification for Pharmacy Claims File Submission

Data Element ID Data Element Description Type Format Length
HD001 Record Type Not Provided Text 2
HD002 Payer Payer Code Text 8
HD004 Type of File Not Provided Text 2
HD005 Period Beginning Date Not Provided Integer CCYYMM 6
HD006 Period Ending Date Not Provided Integer CCYYMM 6
HD007 Record Count Total number of records submitted in the file Integer 10
HD008 Comments Payer comments Text 80
PC001 Payer This field contains the NCDMS assigned submitter code for the data submitter. The first two characters of the submitter code indicate Minnesota and the third character designates the type of submitter. MNC Commercial carrier MNG Governmental agency MNT Third Party Administrator MNU Unlicensed entity A single data submitter may have multiple submitter codes because the data submitter is submitting from more than one system or from more than one location. All submitter codes associated with a single data submitter will have the same first 6 characters. A suffix will be used to distinguish the location and/or system variations. This field contains a constant value and is primarily used for tracking compliance by data submitter. Text 8
PC003 Insurance Type/ Product Code This field contains the insurance type or product code that indicates the type of insurance coverage the individual has. Text 6
PC004 Payer Claim Control Number This field contains the claim number used by the data submitter to internally track the claim. In general the claim number is associated with all service lines of the bill. It must apply to the entire claim and be unique within the data submitter's system. Text 35
PC005 Line Counter This field contains the line number for this service. The line counter begins with 1 and is incremented by 1 for each additional service line of a claim. This field is used in algorithms to determine the final payment for the service. If the data submitter's processing system assigns an internal line counter for the adjudication process, that number may be submitted in place of the line number submitted by the provider. This should be discussed with NCDMS staff. Integer 4
PC008 Plan Specific Contract Number This field contains the data submitter assigned contract number for the subscriber. This field is encrypted using the same algorithm across all data submitters and is not available in the analytical data warehouse. When this field is populated, it forms the core of the unique member identification code. Set as null if unavailable. Text 128
PC011 Individual Relationship Code This field contains the member's relationship to the subscriber or the insured. Integer 2
PC012 Member Gender This field contains the gender of the member. Integer 1
PC013 Member Date of Birth This field contains the member's date of birth with a format of CCYYMMDD. During the encryption process, this field is used to calculate age as of the date the prescription was filled. The field is then encrypted. This data element will not be transmitted in unencrypted form.. Date CCYYMMDD 8
PC014 Member City Name of Residence This field contains the member's city of residence. Text 30
PC015 Member State or Province The member state or province contains the 2 character abbreviation code used by the US Postal Service. Text 2
PC016 Member ZIP Code This field contains ZIP Code of the member. Text 5
PC017 Date Service Approved (AP Date) This field contains the date the record was approved for payment. This is generally referred to as the paid date and reported with a CCYYMMDD format. May submit batch date. Date CCYYMMDD 8
PC018 Pharmacy Number Payer assigned pharmacy number. Required if PC021 is not filled. Text 30
PC020 Pharmacy Name This field contains the name of the pharmacy. Text 30
PC021 National Pharmacy ID Number The field contains the National Provider Identification (NPI) number and pertains to the entity or individual directly providing the service. Required if PC018 is not filled. Text 20
PC025 Claim Status This field contains the status of the claim as reported by the data submitter. It will be used in the algorithms to determine the final payment for this service. Text 2
PC026 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. Text 11
PC027 Drug Name This field contains the text name of drug as supplied by the data submitter. Voluntary - not required Text 80
PC028 New Prescription or Refill This field can be used to determine if this is a new prescription. It contains the prescription number. Integer 2
PC029 Generic Drug Indicator This field indicates whether the drug is a branded drug or a generic drug. Text 1
PC030 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. Integer 1
PC031 Compound Drug Indicator This field indicates if this is a compound drug or not. 0 Not specified 1 No Compound 2 Compound Text 1
PC032 Date Prescription Filled This field contains the date the prescription was filled. Data is reported in a CCYYMMDD format. Text CCYYMMDD 8
PC033 Quantity Dispensed This field contains the total unit dosage in metric units. This field may be negative. Integer 5
PC034 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. Integer 3
PC035 Gross Amount Due 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 and may contain a negative value. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Decimal 10
PC036 Total Amount Paid 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. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Decimal 10
PC036A Other Amount Paid This field contains the amount paid for additional costs claimed in "Other Amount Claimed Submitted (480-H9)." This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Decimal 10
PC036B Other Payer Amount Recognized This field contains the total dollar amount of any payment from another source, including coupons. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Decimal 10
PC037 Ingredient Cost/List Price This field contains the cost of the drug that was dispensed as reported by the data submitter. This is a money field containing dollars and cents with an implied decimal point. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Decimal 10
PC039 Dispensing Fee Paid 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. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Decimal 10
PC040 Copay / Co- insurance Amount This field contains the pre-set, fixed dollar amount payable by a member, often on a per script basis. This is a money field containing dollars and cents with an implied decimal point. This field may contain a negative value. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Decimal 10
PC042 Deductible Amount Do not code decimal point. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Decimal 10
PC043 Patient Pay Amount Amount that is calculated by the payer and returned to the pharmacy as the total amount to be paid by the patient to the pharmacy. 0$ is acceptable; code "data not available" as 9999999999. Only 1% of submissions can contain 9999999999. Decimal 10
PC044 Prescribing Physician First Name This is the first name of the prescribing physician. This will be used to create a master provider index for Minnesota providers encompassing medical service providers, prescribing providers and medical homes. Since there is currently no HIPAA equivalent field for prescribing physician first name, this is a voluntary field. Text 25
PC045 Prescribing Physician Middle Name This is the middle name or initial of the prescribing physician. This will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Since there is currently no HIPAA equivalent field for prescribing physician middle initial, this is a voluntary field. Text 25
PC046 Prescribing Physician Last Name This is the last name of the prescribing physician. This will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Text 60
PC047 Prescribing Physician DEA / Legacy Number This field contains either the DEA number, the data submitter's legacy, pre-NPI number, or the Minnesota Health Care Program ID for the prescribing physician. This will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Required if PC048 is not filled. D DEA ID number L Legacy ID number M MHCP O Other Text 9
PC048 Prescribing Physician National Provider Identification Number This field contains the National Provider Identification (NPI) number for the prescribing physician. This will be used to create a master provider index for Minnesota providers encompassing both medical service providers and prescribing providers. Required if PC047 is not filled. Text 20
PC101 Subscriber Last Name Subscriber last name, used to create a unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. Text 128
PC102 Subscriber First Name Subscriber first name, used to create unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. Text 128
PC103 Subscriber Middle Initial Subscriber middle initial, used to create unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. Text 1
PC104 Member Last Name Member last name, used to create a unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. Text 128
PC105 Member First Name Member first name, used to create a unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. Text 128
PC106 Member Middle Initial Member middle initial, used to create unique de-identified member ID. It is encrypted at the data submitter's site. This data element will not be available in the data warehouse. Text 1
PC899 Record Type This field indicates the type of record. PC Pharmacy Claims This is an administrative field required by NCDMS and populated with a constant value. Text 2
TR001 Record Type Value TR Text 2
TR002 Payer Payer Code Text 8
TR004 Type of File PC = Pharmacy Drug Claims Text 2
TR005 Period Beginning Date Not Provided Integer YYYYMM 6
TR006 Period Ending Date Not Provided Integer YYYYMM 6
TR007 Date Processed Date file was created Date CCYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type HD Header Record
HD004 Type of File PC Pharmacy Drug Claims
PC001 Payer MNC Commercial carrier
MNG Governmental agency
MNT Third Party Administrator
MNU Unlicensed entity
PC003 Insurance Type/ Product Code 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
16 Medicare Secondary Public Health Service 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
47 Medicare Secondary, Other Liability Insurance is Primary
CP Medicare Conditionally Primary
D Disability
DB Disability Benefits
EP Exclusive Provider Organization
HM Health Maintenance Organization (HMO)
HN Health Maintenance Organization (HMO) Medicare Risk
HS Special Low Income Medicare Beneficiary
IN Indemnity
MA Medicare Part A
MB Medicare Part B
MCFFSM Medical Assistance - Fee-for-service Medical Assistance
MCMDHO Medical Assistance - MN Disability Health Options
MCMISC Medical Assistance - Other managed care program within Medical Assistance
MCMSHO Medical Assistance - MN Senior Health Options
MCPMAP Medical Assistance - Prepaid Medical Assistance Program
MCSNBC Medical Assistance - Special Needs Basic Care
MD Medicare Part D
MH Medigap Part A
MI Medigap Part B
MP Medicare Primary
PR Preferred Provider Organization (PPO)
PS Point of Service (POS)
QM Qualified Medicare Beneficiary
SP Supplemental Policy
XXCDEP Non-Medical-Assistance Public Program - Chemical Dependency
XXGAMC Non-Medical-Assistance Public Program - General Assistance Medical Care
XXHIVA Non-Medical-Assistance Public Program - HIV/AIDS
XXMCHA Non-Medical-Assistance Public Program - Minnesota Comprehensive Health Association
XXMISC Non-Medical-Assistance Public Program - Other non-Medical Assitance public program
XXMNCR Non-Medical-Assistance Public Program - MinnesotaCare
PC011 Individual Relationship Code 01 Covered Individual is Policy holder
02 Spouse
03 Child
04 Other
PC012 Member Gender 1 Male
2 Female
3 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
25 Predetermination pricing only - no payment
PC028 New Prescription or Refill 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 0 Not specified
1 No Compound
2 Compound
PC047 Prescribing Physician DEA / Legacy Number D DEA ID number
L Legacy ID number
M MHCP
O Other
PC899 Record Type PC Pharmacy Claims
TR001 Record Type TR Trailer Record
TR004 Type of File PC Pharmacy Drug Claims
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