United States Health Information Knowledgebase

 

Pharmacy Claims File Submission

Virginia



Name:Pharmacy Claims File Submission
State:Virginia
Definition:Not Provided
VersionAugust 2013 - v1.2

File Specification for Pharmacy Claims File Submission

Data Element ID Data Element Description Type Format Length
HD001 Record Type Not Provided char 2
HD002 Payer Code NAIC code (example: 12345); leave blank if not applicable char 8
HD003 Payer Name Example: char 75
HD004 Beginning Month Not Provided Date CCYYMM 6
HD005 Ending Month Not Provided Date CCYYMM 6
HD006 Record count Total number of records submitted in the medical claims file, excluding header and trailer records int 10
PC001 Payer Payer submitting payments MHDO Submitter Code; MN has its own codes too varchar 8
PC002 Plan ID CMS National Plan ID or NAIC varchar 30
PC003 Insurance Type/Product Code Not Provided char 2
PC004 Payer Claim Control Number Must apply to the entire claim and be unique within the payer's system. varchar 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. tinyint 4
PC006 Insured Group Number Group or policy number - not the number that uniquely identifies the subscriber varchar 30
PC007 Subscriber Social Security Number Subscriber's social security number; Set as null if unavailable varchar 9
PC008 Plan Specific Contract Number Plan assigned subscriber's contract number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the subscriber. varchar 128
PC009 Member Suffix or Sequence Number Unique number of the member within the contract. Must be an identifier that is unique to the member. varchar 20
PC010 Member Identification Code Member's social security number; Set as null if contract number = subscriber's social security number or use an alternate unique identifier such as Medicaid ID. Must be an identifier that is unique to the member. varchar 128
PC011 Individual Relationship Code Member's relationship to insured char 2
PC012 Member Gender Not Provided char 1
PC013 Member Date of Birth Not Provided date CCYYMMDD 8
PC014 Member City Name of Residence City name of member varchar 50
PC015 Member State or Province As defined by the US Postal Service char 2
PC016 Member ZIP Code ZIP Code of member - may include non-US codes; Do not include dash. Plus 4 optional but desired. varchar 11
PC017 Date Service Approved (AP Date) date claim paid if available, otherwise set to Date Prescription Filled date CCYYMMDD 8
PC018 Pharmacy Number Payer assigned pharmacy number. AHFS number is acceptable. varchar 30
PC019 Pharmacy Tax ID Number Federal taxpayer's identification number coded with no punctuation (carriers that contract with outside PBMs will not have this) varchar 10
PC020 Pharmacy Name Name of pharmacy varchar 50
PC021 National Provider ID Number National Provider ID. This data element pertains to the entity or individual directly providing the service. varchar 20
PC022 Pharmacy Location City City name of pharmacy - preferably pharmacy location (if mail order null) varchar 30
PC023 Pharmacy Location State As defined by the US Postal Service (if mail order null) char 2
PC024 Pharmacy ZIP Code ZIP Code of pharmacy - may include non-US codes. Do not include dash. Plus 4 optional but desired (if mail order null) varchar 10
PC024A Pharmacy Country Name Code US for United States varchar 30
PC025 Claim Status Not Provided char 2
PC026 Drug Code NDC Code varchar 11
PC027 Drug Name Text name of drug varchar 80
PC028 New Prescription or Refill Provide '01' for new prescriptions; for refills, provide the refill number varchar 2
PC029 Generic Drug Indicator Not Provided char 2
PC030 Dispensed as Written Code Payers able to map available codes to those listed below char 1
PC031 Compound Drug Indicator Not Provided char 1
PC032 Date Prescription Filled Not Provided date CCYYMMDD 8
PC033 Quantity Dispensed Number of metric units of medication dispensed int 5
PC034 Days Supply Estimated number of days the prescription will last int 3
PC035 Charge Amount Do not code decimal point or provide any punctuation where $1,000.00 converted to 100000 Same for all financial data that follows. int 10
PC036 Paid Amount Includes all health planpayments and excludes all member payments. Do not code decimal point. int 10
PC037 Ingredient Cost/List Price Cost of the drug dispensed. Do not code decimal point. int 10
PC038 Postage Amount Claimed Do not code decimal point. Not typically captured. int 10
PC039 Dispensing Fee Do not code decimal point. int 10
PC040 Co-pay Amount The preset, fixed dollar amount for which the individual is responsible. Do not code decimal point. int 10
PC041 Coinsurance Amount The dollar amount an individual is responsible for - not the percentage. Do not code decimal point. int 10
PC042 Deductible Amount Do not code decimal point. int 10
PC043 Unassigned Reserved for assignment Not Supplied Not Supplied Not Supplied
PC044 Prescribing Physician First Name Physician first name. varchar 25
PC045 Prescribing Physician Middle Name Physician middle name or initial. varchar 25
PC046 Prescribing Physician Last Name Physician last name. varchar 60
PC047 Prescribing Physician Number DEA or NPI number for prescribing physician varchar 20
PC101 Subscriber Last Name Not Provided varchar 128
PC102 Subscriber First Name Not Provided varchar 128
PC103 Subscriber Middle Initial Not Provided char 1
PC104 Member Last Name Not Provided varchar 128
PC105 Member First Name Not Provided varchar 128
PC106 Member Middle Initial Not Provided char 1
PC201 Pharmacy Location Street Address Street address of pharmacy varchar 30
PC202 Member Street Address Street address of member varchar 50
PC203 Carrier Associated with Claim For each claim, the NAIC code of the carrier when a PBM processes claims on behalf of the carrier. Optional if all pharmacy claims processed by data submitters acting as Pharmacy Benefits Managers (PBMs) under contract to a data submitter for carved-out services are submitted by the data submitter with unified member IDs in all files. varchar 8
PC204 Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number For each claim, the carrier specific contract number or subscriber/member social security number when a PBM processes claims on behalf of the carrier. Optional if all pharmacy claims processed by data submitters acting as Pharmacy Benefits Managers (PBMs) under contract to a data submitter for carved-out services are submitted by the data submitter with unified member IDs in all files. varchar 128
PC899 Record Type Not Provided char 2
TR001 Record Type Not Provided char 2
TR002 Payer Code NAIC code (example: 12345); leave blank if not applicable varchar 8
TR003 Payer Name Not Provided varchar 75
TR004 Beginning Month Not Provided Date CCYYMM 6
TR005 Ending Month Not Provided Date CCYYMM 6
TR006 Extraction Date Not Provided Date CCYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type PC
PC003 Insurance Type/Product Code 12 Preferred Provider Organization (PPO)
13 Point of Service (POS)
15 Indemnity Insurance
16 Health Maintenance Organization (HMO) Medicare Advantage
99 Other
CI Commercial Insurance Company
FE Federal Employees Health Benefits Program
HM Health Maintenance Organization
HN HMO Medicare Risk/ Medicare Part C
MA Medicare Part A
MB Medicare Part B
MC Medicaid
MD Medicare Part D
MP Medicare Primary
QM Qualified Medicare Beneficiary
SP Supplemental Policy
TR Tricare
TV Title V
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
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 or Refill 01 New prescription
02 - XX Refill Number
PC029 Generic Drug Indicator 01 branded drug
02 generic drug
PC030 Dispensed as Written Code 0 Not dispensed as written
1 Physician dispensed as written
2 Member dispensed as written
3 Pharmacy dispensed 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
PC899 Record Type PC
TR001 Record Type PC
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