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Pharmacy Claims File Submission

Vermont



Name:Pharmacy Claims File Submission
State:Vermont
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: member demographics; provider information; charge/payment information; and national drug codes.
VersionOctober 2008

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; Text 8
HD003 National Plan Id CMS National Plan ID; This is not yet available. Code as null 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 the file Integer 10
HD008 Comments Payer comments Text 80
PC001 Payer Payer submitting payments; Text 8
PC002 National CMS National Plan ID; This is not yet available. Code as null Text 30
PC003 Insurance Type/Produ ct Code Type of Insurance Product Text 2
PC004 Payer Claim Control Number Unique claim identifier Text 35
PC005 Line Counter Claim line number for service rendered Integer 4
PC006 Insured Group Number Group number or Policy Number Text 30
PC007 Encrypted Subscriber Unique Identificatio n Number Subscriber's social security number; used to create unique member ID Text 128
PC008 Plan Specific Contract Number Do not include values in this field that will distinguish one member of the family from another. If submitted, this should be the contract or certificate number for the subscriber and all of his/her dependents Text 128
PC009 Member Suffix or Sequence Number The unique number of the member within the contract. Integer 20
PC010 Member Identification Code Member's social security number; used to create unique member ID Text 128
PC011 Individual Relationship Code Member's relationship to insured Integer 2
PC012 Member Gender Member's gender Integer 1
PC013 Member Date of Birth Not provided Date CCYYMMDD 8
PC014 Member City Name of Residence The city location of the member. Text 30
PC015 Member State or Province As defined by the US Postal Service Text 2
PC016 Member ZIP Code ZIP Code of member - may include non-US codes. Text 9
PC017 Date Service Approved (AP Date) Not provided Date CCYYMMDD 8
PC018 Pharmacy Number Payer assigned pharmacy number Text 30
PC019 Pharmacy Tax ID Number Federal taxpayer's identification number 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 Pharmacy City Text 30
PC023 Pharmacy Location State Location of pharmacy state Text 2
PC024 Pharmacy ZIP Code ZIP Code of pharmacy- may include non-US codes Do not include dash Text 10
PC024A Pharmacy Country Name Code US for United States Text 30
PC025 Claim Status Status of claim Integer 2
PC026 Drug Code NDC Code Text 11
PC027 Drug Name Name of drug Text 80
PC028 New Prescription or Refill New prescription or refill number Integer 2
PC029 Generic Drug Indicator Generic indicator Text 1
PC030 Dispense as Written Code Dispense as written Integer 1
PC031 Compound Drug Indicator Compound drug ID Text 1
PC032 Date Prescription Filled Not provided Text CCYYMMDD 8
PC033 Quantity Dispensed Quantity of drug dispensed Integer 5
PC034 Days Supply Days of supply for drug Integer 3
PC035 Charge Amount Do not code decimal point Decimal 10
PC036 Paid Amount Do not code decimal point Decimal 10
PC037 Ingredient Cost/List Price 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 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
PC044 Prescribing Physician First Name Physician first name. Required if PC047 is not filled Text 25
PC045 Prescribing Physician Middle Name Physician middle name or initial. Required if PC047 is not filled Text 25
PC046 Prescribing Physician Last Name Physician last name. Required if PC047 is not filled Text 60
PC047 Prescribing Physician Number DEA number for prescribing physician Text 9
PC101 Encrypted Subscriber Last Name Encrypted subscriber last name, used to create unique member ID Text 128
PC102 Encrypted Subscriber First Name Encrypted subscriber first name, used to create unique member ID Text 128
PC103 Encrypted Subscriber Middle Initial Encrypted subscriber middle initial, used to create unique member ID Text 1
PC104 Encrypted Member Last Name Encrypted member last name, used to create unique member ID Text 128
PC105 Encrypted Member First Name Encrypted member first name, used to create unique member ID Text 128
PC106 Encrypted Member Middle Initial Encrypted member middle initial, used to create unique member ID Text 1
PC899 Record Type Not provided Text 2
TR001 Record Type Not provided Text 2
TR002 Payer Payer Code Text 8
TR003 National Plan ID CMS National Plan ID; This is not yet available. Code as null 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 YYYYMM 6
TR006 Period Ending Date End of paid period for Claims End of month covered for Eligibility 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
HD004 Type of File PC Pharmacy Claims
PC899 Record Type PC
TR001 Record Type TR
TR004 Type of File PC Pharmacy Claims
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