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Pharmacy Claims File Submission

Tennessee

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Name:Pharmacy Claims File Submission
State:Tennessee
Definition:Not Provided
VersionJanuary 31, 2014 - v1.0

File Specification for Pharmacy Claims File Submission

Data Element ID Data Element Description Type Format Length
ADJ_TYP_CD Adjustment Type Code Client-specific code for the type of adjustment for the claim. The corresponding Medstat Advantage Suite standard field is Adjustment Type Code Medstat. Char 1
CHARGE Gross Amount Due This field contains the gross amount due (total charges) for the service as reported by the provider. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
CLAIM Payer Claim Control Number This field contains the Payer Claim Control Number element reported by the payer. In general, the claim number is associated with all service lines of the bill. Multiple pharmacy records therefore may share the same claim number. This number must apply to the entire claim and be unique within the payer's system. Text 53
CLAIM_STATUS Claim Status This field contains the status of the claim as reported by the payer. Numeric 2
COINSURANCE Coinsurance amount This payer-supplied field contains the dollar amount that a member must pay toward the cost of a covered service. In many health insurance plans, the member's coinsurance responsibility is capped after a certain dollar amount of eligible expenses has been incurred. Not all carriers can distinguish between the mutually exclusive fields of Copay Amount (COPAY) and Coinsurance Amount. To determine the total out-of-pocket/member responsibility for this service, you must sum these two fields with Deductible Amount (DEDUCTIBLE). This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
COMPOUND_DRUG Compound Drug Indicator This payer-supplied field indicates whether or not this is a compound drug. Char 1
COPAY Copay Amount This payer-supplied field contains the preset, fixed dollar amount payable by a member, often on a per-visit/-service basis. Not all carriers can distinguish between the mutually exclusive fields of Copay Amount and Coinsurance Amount (COINSURANCE). To determine the total out-of-pocket/member responsibility for this service, you must sum these two fields with the Deductible Amount (DEDUCTIBLE). This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
DAW 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 to be filled as written. Char 1
DAY_SUPPLY Days Supply This payer-supplied field contains the actual Days Supply for the prescription based on the Quantity Dispensed element (QTY). This field may contain a negative value. Numeric (Signed) 6
DEDUCTIBLE Deductible amount This payer-supplied field contains the dollar amount that a member must pay before health plan benefits will begin to reimburse for services. It is usually an annual amount of all healthcare costs that are not covered by the member's insurance plan. To determine the total out-of-pocket/member responsibility for this service, you must sum this field with both Copay Amount (COPAY) and Coinsurance Amount (COINSURANCE). This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
DISPENSE_FEE Dispensing Fee This field contains the amount charged for dispensing as reported by the payer. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
DRUG_NAME Drug Name This payer-supplied field contains the text name of the drug indicated in the National Drug Code element (NDC). Text 80
FILL_DATE Date Prescription Filled This field contains the date the prescription was filled as reported by the payer. In ASCII-formatted extracts, this field is presented in a CCYYMMDD format. Date CCYYMMDD 8
GENERIC Generic Drug Indicator This payer-supplied field indicates whether the drug is a branded drug or a generic drug. Text 1
INGREDIENT_COST 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. This field may contain a negative value. Decimal (signed) 14
LINE Line Counter This field contains the line number for this service as reported by the payer. The Line Counter begins with 1 and is incremented by 1 for each additional service line of a claim. Numeric 4
MEMBERIDN Member ID Number This field generally represents a unique combination of member fields unique to the payer. This field should not be used to aggregate all records associated with a member. Char 15
ORIG_CLM_ID Original Claim ID number This field is used with adjustments. If the claim id number changes to a different number due to an adjustment then this field will be populated with the original claim id number. Char 11
NDC National Drug Code This field contains the National Drug Code for this claim as reported by the payer. Each drug product listed under Section 510 of the Federal Food, Drug, and Cosmetic Act is assigned a unique 10-digit, three-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/vendor code, is assigned by the FDA. A labeler is any firm that manufactures, repacks, 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. Numeric 2
NEWPR New Prescription or Refill This payer-supplied field can be used to determine if this is a new prescription. Valid codes include: Note that a value of 01 may have been reported if the specific number of the prescription refill was unavailable. Text 53
PAID_RX Paid Amount (RX Paid Amount) This payer-supplied field contains the total dollar amount paid to the provider, including all health plan payments and excluding withhold amounts and all member payments. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
PAID_DATE First Paid Date and Last Paid Date While multiple paid dates may occur for the same claim as part of the adjudication process, this field contains the Last Paid Date associated with the claim. For claims that were not adjusted, this is the actual paid date. Its source is the Date Service Approved element reported by the payer in the pharmacy claims data. In ASCII-formatted extracts, this field is presented in a CCYYMMDD format. Date CCYYMMDD 8
PAYERCODE Payer Code This field contains the data reporter code for the payer or data reporter submitting payments. The first two characters indicate the data collection state and the third character indicates the type of data reporter. A single payer may have multiple data reporter codes because the payer is submitting from more than one system or from more than one location. All data reporter codes associated with a single payer will have the same first seven characters. A suffix in the eighth position may be used to distinguish the location and/or system variations. Char 8
PAYER PAYER This field contains the Payer ID Number. This code is used to identify the data reporter. Its source is the Payer element reported by the payer in the pharmacy claims data. Text 8
PID_RX Pharmacy ID number Pharmacy Claims This field contains the payer-assigned provider number. Its source is the Service Provider Number element reported by the payer in the pharmacy claims data. Text 40
PLAN_NPI National Plan ID This payer-supplied field contains the National Plan ID for the data reporter. This field is not populated. Text 30
POSTAGE Postage Amount Claimed This field contains the cost of postage included in the Paid Amount field (PAID) as reported by the payer. This is a money field containing dollars and cents. This field may contain a negative value. Decimal (signed) 14
PRODUCT Standardized Product Code This field contains the code identifying the member's type of insurance or insurance product. Its source is the Insurance Type / Product Code element reported by the payer in the pharmacy claims data. Char 6
QTY Quantity Dispensed This field contains the total unit dosage as reported by the payer. This field may contain a negative value. Decimal (signed) 14
RX_PRVIDN Prescribing Physician ID Number This field contains the prescribing physician's ID number. This field cannot be used to aggregate all claims associated with a physician. Numeric 20
SVC_PHARMIDN Servicing Pharmacy ID Number This field contains the servicing pharmacy ID number. This field cannot be used to aggregate all claims associated with a pharmacy. Numeric 20
THIRTY_DAY_EQUIV Thirty Day Equivalency This field is used to indicate the number of thirty day equivalencies associated with this prescription. It is based upon the Days Supply field (DAY_SUPPLY). Numeric 3
VERSION_NUM Claim Version This field indicates the claim version number, which is used if the payer adjudicates claims based on a versioning system. Its source is the Version Number element reported by the payer in the medical claims data. See additional documentation on a detailed explanation of versioning. Numeric 4
FILLER FILLER This field is reserved for additional fields that may be added in the future. Char 500

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Data Element ID Data Element Code Value
ADJ_TYP_CD Adjustment Type Code O Original
R Replacement
V Void
CLAIM_STATUS 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 none
COMPOUND_DRUG Compound Drug Indicator N no compound
U not specified
Y compound
DAW 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 Subsitution not allowed - brand drug mandated by law
8 Subsitution allowed - generic drug not available in marketplace
9 Other
GENERIC Generic Drug Indicator N No, Branded Drug
Y Yes, Generic Drug
NEWPR New Prescription or Refill 00 New prescription
01-99 Number of refill(s)
PAYERCODE Payer Code TNC Commercial data reporter
TNG Governmental payer
PRODUCT Standardized Product Code 12 Medicare Secondary Working Aged Beneficiary or Spouse with an Employer's 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 Workers Compensation
16 Medicare Secondary Public Health Service or Other Federal Agency
41 Medicare Secondary Black Lung
42 Medicare Secondary Veterans Administration
43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health
47 Medicare Secondary, Other Liability Insurance is Primary
ACA Affordable Care Act
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 / Medicare Part C
HS Special Low Income Medicare Beneficiary
IN Indemnity
MA Medicare Part A
MB Medicare Part B
MCTNCR Tennessee Medicaid (TennCare)
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
WC Worker's Compensation
XXTNAC AccessTN
XXTNCV CoverTN
XXTNKD CoverKids
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