United States Health Information Knowledgebase

 

Pharmacy Claims File Submission

New Hampshire



Name:Pharmacy Claims File Submission
State:New Hampshire
Definition:"Pharmacy claims file" means a data file containing service level remittance information from all non-denied adjudicated claims for each prescription including, but not limited to: (1) Member demographics; (2) Provider information; (3) Charge/payment information; and (4) National drug codes
VersionSeptember 10, 2012

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 submitting payments NHID Submitter Code Text 8
HD003 National Plan ID CMS National Plan ID Text 30
HD004 Type of File Not provided Text 2
HD005 Period Beginning Date Beginning of paid period for claims Beginning of month covered for eligibility Integer CCYYMM 6
HD006 Period Ending Date End of paid period for claims End of month covered for eligibility Integer CCYYMM 6
HD007 Record Count Total number of records submitted in this file Integer 10
HD008 Comments Submitted may use to document this submission by assigning a filename, system source, etc. Text 80
PC001 Payer Payer submitting payments NHID Submitter Code Text 8
PC002 Plan ID CMS National Plan ID Text 30
PC003 Insurance Type/Product Code Not provided Text 2
PC004 Payer Claim Control Number Must apply to the entire claim and be unique within the payer's system Text 35
PC005 Line Counter Line number for this service The line counter begins with 1 and is incremented by 1 for each additional service line of a claim Integer 4
PC006 Insured Group Number Group or policy number - not the number that uniquely identifies the subscriber Text 30
PC007 Subscriber Social Security Number Subscriber's social security number (this data element will be de-identified by the NHpreprocessor application) Set as null if unavailable Text 30
PC008 Plan Specific Contract Number Plan assigned contract number (this data element will be de-identified by the NHpreprocessor application) Set as null if contract number = subscriber's social security number Text 30
PC009 Member Suffix or Sequence Number Uniquely numbers the member within the contract Integer 2
PC010 Member Identification Code Member's social security number Set as null if unavailable (this data element will be de-identified by the NHpreprocessor application) Text 30
PC011 Individual Relationship Code Member's relationship to insured Integer 2
PC012 Member Gender Not provided Integer 1
PC013 Member Date of Birth Not provided Date CCYYMMDD 8
PC014 Member City Name of Residence City name of member Text 30
PC015 Member State As defined by the US Postal Service Text 2
PC016 Member ZIP Code ZIP Code of member - may include non-US codes Do not include dash Text 9
PC017 Date Service Approved (AP Date) (Generally the same as the paid date or the Pharmacy Benefits Manager's billing date) Date CCYYMMDD 8
PC018 Pharmacy Number Payer assigned pharmacy number AHFS number is acceptable Text 30
PC019 Pharmacy Tax ID Number Federal taxpayer's identification number (Please provide the pharmacy chain's federal tax identification number, if the individual retail pharmacy's tax ID# is not available.) Text 10
PC020 Pharmacy Name Name of pharmacy Text 30
PC021 National Pharmacy ID Number Required if National Provider ID is mandated for use under HIPAA Text 20
PC022 Pharmacy Location City City name of pharmacy - preferably pharmacy location Text 30
PC023 Pharmacy Location State As defined by the US Postal Service Text 2
PC024 Pharmacy ZIP Code ZIP Code of pharmacy - may include non- US codes Do not include dash Text 10
PC024A Pharmacy County Name Not provided Text 30
PC025 Claim Status Not provided Integer 2
PC026 Drug Code NDC Code Text 11
PC027 Drug Name Text name of drug Text 80
PC028 New Prescription 00 New prescription. 01-99 Number of refill(s) ('01' should be used for all refills, if the specific number of the prescription refill is not available) Integer 2
PC029 Generic Drug Indicator Not provided Text 1
PC030 Dispense as Written Code Not provided Integer 1
PC031 Compound Drug Indicator Not provided Text 1
PC032 Date Prescription Filled Not provided Date CCYYMMDD 8
PC033 Quantity Dispensed Number of metric units of medication dispensed Integer 5
PC034 Days Supply Estimated number of days the prescription will last Integer 3
PC035 Charge Amount Do not code decimal point Decimal 10
PC036 Paid Amount Includes all health plan payments and excludes all member payments Do not code decimal point Decimal 10
PC037 Ingredient Cost/List Price Cost of the drug dispensed Do not code decimal point Decimal 10
PC038 Postage Amount Claimed Do not code decimal point Decimal 10
PC039 Dispensing Fee Do not code decimal point Decimal 10
PC040 Copay Amount The preset, fixed dollar amount for which the individual is responsible Do not code decimal point Decimal 10
PC041 Coinsurance Amount Do not code decimal point Decimal 10
PC042 Deductible Amount Do not code decimal point Decimal 10
PC043 Place holder Not provided Not Supplied Not Supplied Not Supplied
PC044 Prescribing Physician First Name Physician first name Text 25
PC045 Prescribing Physician Middle Name Physician middle name Text 25
PC046 Prescribing Physician Last Name Physician last name Text 50
PC047 Prescribing Physician Number Carriers and health claims processors shall code using the payer assigned provider number. This number should be the identifier used by the payer for internal identification purposes, and does not routinely change. Text 30
PC101 Subscriber Last Name (this data element will be de-identified by the NH preprocessor application) Text 128
PC102 Subscriber First Name (this data element will be de-identified by the NH preprocessor application) Text 128
TR001 Record Type Not provided Text 2
TR002 Payer Payer submitting payments NHID Submitter Code Text 8
TR003 National Plan ID CMS National Plan ID Text 30
TR004 Type of File Not provided Text 2
TR005 Period Beginning Date Beginning of paid period for claims Beginning of month covered for eligibility Integer CCYYMM 6
TR006 Period Ending Date End of paid period for claims End of month covered for eligibility Integer CCYYMM 6
TR007 Date Processed Not provided Date CCYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type HD
HD004 Type of File PC Pharmacy Claims
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 Advantage
AM Automobile Medical
DS Disability
HM Health Maintenance Organization
LI Liability
LM Liability Medical
MA Medicare Part A
MB Medicare Part B
MC Medicaid
MD Medicare Part D
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
3 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
PC028 New Prescription 00 New prescription
01-99 Number of refill(s)
PC029 Generic Drug Indicator N No, branded drug
Y Yes, generic 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 compound
Y Compound drug
TR001 Record Type TR
TR004 Type of File PC Pharmacy Claims
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