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Pharmacy Claims File Submission

Massachusetts

Versions: Pharmacy Claims File Submission• Pharmacy Claims File Submission• Pharmacy Claims File SubmissionCompare Versions


Name:Pharmacy Claims File Submission
State:Massachusetts
Definition:A MA APCD File Type for reporting all Paid Pharmacy Claim Lines of a given time period. File accommodates Replacement and Void lines.
VersionOctober 1, 2014 - v4.0

File Specification for Pharmacy Claims File Submission

Data Element ID Data Element Description Type Format Length
Multiple versionsHD001 Record Type Header Record Identifier Text char[2] 2
Multiple versionsHD002 Submitter Header Submitter / Carrier ID defined by CHIA Integer varchar[6] 6
Multiple versionsHD003 National Plan ID Header CMS National Plan Identification Number (PlanID) Integer int[10] 10
Multiple versionsHD004 Type of File Defines the file type and data expected. Text char[2] 2
Multiple versionsHD005 Period Beginning Date Header Period Start Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsHD006 Period Ending Date Header Period Ending Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsHD007 Record Count Header Record Count Integer varchar[10] 10
Multiple versionsHD008 Comments Header Carrier Comments Text varchar[80] 80
Multiple versionsHD009 APCD Version Number Submission Guide Version Decimal - Numeric char[3] 3
Multiple versionsPC001 Submitter CHIA defined and maintained unique identifier Integer varchar[6] 6
Multiple versionsPC002 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
Multiple versionsPC003 Insurance Type Code/Product Type / Product Identification Code Lookup Table - Text char[2] 2
Multiple versionsPC004 Payer Claim Control Number Payer Claim Control Identification Text varchar[35] 35
Multiple versionsPC005 Line Counter Incremental Line Counter Integer varchar[4] 4
Multiple versionsPC005A Version Number Claim Service Line Version Number Integer varchar[4] 4
Multiple versionsPC006 Insured Group or Policy Number Group / Policy Number Text varchar[30] 30
Multiple versionsPC007 Subscriber SSN Subscriber's Social Security Number Numeric char[9] 9
Multiple versionsPC008 Plan Specific Contract Number Contract Number Text varchar[30] 30
Multiple versionsPC009 Member Suffix or Sequence Number Member/Patient's Contract Sequence Number Text varchar[20] 20
Multiple versionsPC010 Member SSN Member/Patient's Social Security Number Numeric char[9] 9
Multiple versionsPC011 Individual Relationship Code Patient to Subscriber Relationship Code Lookup Table - Text char[2] 2
Multiple versionsPC012 Member Gender Patient's Gender Lookup Table - Text char[1] 1
Multiple versionsPC013 Member Date of Birth Member/Patient's date of birth Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsPC014 Member City Name of Residence City name of the Member/Patient Text varchar[50] 50
Multiple versionsPC015 Member State State / Province of the Patient External Code Source 2 - Text char[2] 2
Multiple versionsPC016 Member ZIP Code Zip code of the Member / Patient External Code Source 2 - Text varchar[9] 9
Multiple versionsPC017 Date Service Approved (AP Date) Date Service Approved by Payer Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsPC018 Pharmacy Number Pharmacy Number Text varchar[30] 30
Multiple versionsPC019 Pharmacy Tax ID Number Pharmacy Tax Identification Number Numeric char[9] 9
Multiple versionsPC020 Pharmacy Name Name of Pharmacy Text varchar[100] 100
Multiple versionsPC021 National Provider ID - Pharmacy National Provider Identification (NPI) of the Pharmacy External Code Source 3 - Integer int[10] 10
Multiple versionsPC022 Pharmacy Location City City name of the Pharmacy Text varchar[30] 30
Multiple versionsPC023 Pharmacy Location State State of the Pharmacy External Code Source 2 - Text char[2] 2
Multiple versionsPC024 Pharmacy ZIP Code Zip code of the Pharmacy External Code Source 2 - Text varchar[9] 9
Multiple versionsPC024A Pharmacy Country Code Country Code of the Pharmacy External Code Source 1 - Text char[3] 3
Multiple versionsPC025 Claim Status Claim Line Status Lookup Table - Numeric varchar[2] 2
Multiple versionsPC026 Drug Code National Drug Code (NDC) External Code Source 12 - Text char[11] 11
Multiple versionsPC027 Drug Name Name of the drug as supplied External Code Source 12 - Text varchar[80] 80
Multiple versionsPC028 New Prescription or Refill Prescription Status Indicator Numeric char[2] 2
Multiple versionsPC029 Generic Drug Indicator Generic Drug Indicator Lookup Table - Integer int[1] 1
Multiple versionsPC030 Dispense as Written Code Prescription Dispensing Activity Code Lookup Table - Integer int[1] 1
Multiple versionsPC031 Compound Drug Indicator Compound Drug Indicator Lookup Table - Integer int[1] 1
Multiple versionsPC032 Date Prescription Filled Prescription filled date Full Date - Integer int[8] CCYYMMDD 8
Multiple versionsPC033 Quantity Dispensed Claim line units dispensed Quantity - Integer ±varchar[10] 10
Multiple versionsPC034 Day's Supply Prescription Supply Days Quantity - Integer ±varchar[4] 4
Multiple versionsPC035 Charge Amount Amount of provider charges for the claim line Integer ±varchar[10] 10
Multiple versionsPC036 Paid Amount Amount paid by the carrier for the claim line Integer ±varchar[10] 10
Multiple versionsPC037 Ingredient Cost/List Price Amount defined as the List Price or Ingredient Cost Integer ±varchar[10] 10
Multiple versionsPC038 Postage Amount Claimed Amount of postage claimed on the claim line Integer ±varchar[10] 10
Multiple versionsPC039 Dispensing Fee Amount of dispensing fee for the claim line Integer ±varchar[10] 10
Multiple versionsPC040 Copay Amount Amount of Copay member/patient is responsible to pay Integer ±varchar[10] 10
Multiple versionsPC041 Coinsurance Amount Amount of coinsurance member/patient is responsible to pay Integer ±varchar[10] 10
Multiple versionsPC042 Deductible Amount Amount of deductible member/patient is responsible to pay on the claim line Integer ±varchar[10] 10
Multiple versionsPC043 Prescribing ProviderID Prescribing Provider Number Text varchar[30] 30
Multiple versionsPC044 Prescribing Physician First Name First name of Prescribing Physician Text varchar[25] 25
Multiple versionsPC045 Prescribing Physician Middle Name Middle initial of Prescribing Physician Text varchar[25] 25
Multiple versionsPC046 Prescribing Physician Last Name Last name of Prescribing Physician Text varchar[60] 60
Multiple versionsPC047 Prescribing Physician DEA Number Prescribing DEA Text char[9] 9
Multiple versionsPC048 National Provider ID - Prescribing National Provider Identification (NPI) of the Prescribing Provider External Code Source 3 - Integer int[10] 10
Multiple versionsPC049 Prescribing Physician Plan Number Carrier-assigned Provider Plan ID Text varchar[30] 30
Multiple versionsPC050 Prescribing Physician License Number Prescribing Physician License Number Text varchar[30] 30
Multiple versionsPC051 Prescribing Physician Street Address Street address of the Prescribing Physician Text varchar[50] 50
Multiple versionsPC052 Prescribing Physician Street Address 2 Secondary Street Address of the Prescribing Physician Text varchar[50] 50
Multiple versionsPC053 Prescribing Physician City City name of the Prescribing Physician Text varchar[30] 30
Multiple versionsPC054 Prescribing Physician State State of the Physician External Code Source 2 - Text char[2] 2
Multiple versionsPC055 Prescribing Physician Zip Zip code of the Prescribing Physician External Code Source 2 - Text varchar[9] 9
Multiple versionsPC056 Product ID Number Product Identification Text varchar[30] 30
Multiple versionsPC057 Mail Order pharmacy Indicator - Mail Order Option Lookup Table - Integer int[1] 1
Multiple versionsPC058 Script number Prescription Number Text varchar[20] 20
Multiple versionsPC059 Recipient PCP ID Patient's PCP ID Number Text varchar[30] 30
Multiple versionsPC060 Single/Multiple Source Indicator Drug Source Indicator Lookup Table - Integer int[1] 1
Multiple versionsPC061 Member Street Address Street address of the Member/Patient Text varchar[50] 50
Multiple versionsPC062 Billing Provider Tax ID Number The Billing Provider's Federal Tax Identification Number (FTIN) Numeric char[9] 9
Multiple versionsPC063 Paid Date Paid date of the claim line Full Date - Integer int[8] 8
Multiple versionsPC064 Date Prescription Written Date prescription was prescribed Full Date - Integer int[8] 8
Multiple versionsPC065 Coordination of Benefits/TPL Liability Amount Amount due from a Secondary Carrier when known Integer ±varchar[10] 10
Multiple versionsPC066 Other Insurance Paid Amount Amount paid by a Primary / Prior Carrier Integer ±varchar[10] 10
Multiple versionsPC067 Medicare Paid Amount Amount Medicare paid on claim Integer ±varchar[10] 10
Multiple versionsPC068 Allowed amount Allowed Amount Integer ±varchar[10] 10
Multiple versionsPC069 Member Self Pay Amount Amount member/patient paid out of pocket on the claim line Integer ±varchar[10] 10
Multiple versionsPC070 Rebate Indicator Drug Rebate Eligibility Indicator Lookup Table - Integer int[1] 1
Multiple versionsPC071 State Sales Tax Amount of applicable sales tax on the claim line Integer ±varchar[10] 10
Multiple versionsPC072 Delegated Benefit Administrator Organization ID CHIA defined and maintained Org ID for linking across submitters Integer varchar[6] 6
Multiple versionsPC073 Formulary Code Formulary inclusion identifier Lookup Table - Integer int[1] 1
Multiple versionsPC074 Route of Administration Route of Administration Lookup Table - Numeric char[2] 2
Multiple versionsPC075 Drug Unit of Measure Units of Measure Lookup Table - Text char[3] 3
Multiple versionsPC101 Subscriber Last Name Last name of Subscriber Text varchar[60] 60
Multiple versionsPC102 Subscriber First Name First name of Subscriber Text varchar[25] 25
Multiple versionsPC103 Subscriber Middle Initial Middle initial of Subscriber Text char[1] 1
Multiple versionsPC104 Member Last Name Last name of Member/Patient Text varchar[60] 60
Multiple versionsPC105 Member First Name First name of Member/Patient Text varchar[25] 25
Multiple versionsPC106 Member Middle Initial Middle initial of the Member/Patient Text char[1] 1
Multiple versionsPC107 Carrier Specific Unique Member ID Member's Unique ID Text varchar[50] 50
Multiple versionsPC108 Carrier Specific Unique Subscriber ID Subscriber's Unique ID Text varchar[50] 50
Multiple versionsPC109 Member Street Address 2 Secondary Street Address of the Member/Patient Text varchar[50] 50
Multiple versionsPC110 Claim Line Type Claim Line Activity Type Code Lookup Table - Text char[1] 1
Multiple versionsPC111 Former Claim Number Previous Claim Number Text varchar[35] 35
Multiple versionsPC112 Medicare Indicator Indicator - Medicare Payment Applied Lookup Table - Integer int[1] 1
Multiple versionsPC113 Pregnancy Indicator Indicator - Pregnancy Lookup Table - Integer int[1] 1
Multiple versionsPC114 Diagnosis Code ICD Diagnosis Code External Code Source 8 - Text varchar[7] 7
Multiple versionsPC115 ICD Indicator International Classification of Diseases version Lookup Table - Integer int[1] 1
Multiple versionsPC116 Denied Flag Denied Claim Line Indicator Lookup Table - Integer int[1] 1
Multiple versionsPC117 Denial Reason Denial Reason Code Carrier Defined Table - OR - External Code Source 16 Varchar[30] 30
Multiple versionsPC118 Payment Arrangement Type Payment Arrangement Type Value Lookup Table - Numeric char[2] 2
Multiple versionsPC119 GIC ID GIC Member ID Text varchar[9] 9
Multiple versionsPC120 APCD ID Code Member Enrollment Type Lookup Table - Integer int[1] 1
PC121 Claim Line Paid Flag Claim Line Paid Indicator Lookup Table - Integer int[1] 1
Multiple versionsPC899 Record Type File Type Identifier Text char[2] 2
Multiple versionsTR001 Record Type Trailer Record Identifier Text char[2] 2
Multiple versionsTR002 Submitter Trailer Submitter / Carrier ID defined by CHIA Integer varchar[6] 6
Multiple versionsTR003 National Plan ID CMS National Plan Identification Number (PlanID) Integer int[10] 10
Multiple versionsTR004 Type of File Validates the file type defined in HD004. Text char[2] 2
Multiple versionsTR005 Period Beginning Date Trailer Period Start Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsTR006 Period Ending Date Trailer Period Ending Date Date Period - Integer int[6] CCYYMM 6
Multiple versionsTR007 Date Processed Trailer Processed Date Full Date - Integer int[8] CCYYMMDD 8

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Data Element ID Data Element Code Value
HD001 Record Type HD Header Elements
HD004 Type of File PC PHARMACY CLAIM
HD009 APCD Version Number 2.1 Prior Version; valid only for reporting periods prior to October 2013
3.0 Version 3.0; required for reporting periods as of October 2013 No longer valid as of May 2015
4.0 Version 4.0; required for reporting periods October 2013 onward as of May 2015
PC003 Insurance Type Code/Product 09 Self-pay
10 Central Certification
11 Other Non-Federal Programs
12 Preferred Provider Organization (PPO)
13 Point of Service (POS)
14 Exclusive Provider Organization (EPO)
15 Indemnity Insurance
16 Health Maintenance Organization (HMO) Medicare Risk
17 Dental Maintenance Organization (DMO)
AM Automobile Medical
BL Blue Cross / Blue Shield
CC Commonwealth Care
CE Commonwealth Choice
CH Champus
CI Commercial Insurance Co.
DS Disability
HM Health Maintenance Organization
LI Liability
LM Liability Medical
MA Medicare Part A
MB Medicare Part B
MC Medicaid
OF Other Federal Program
TF HSN Trust Fund
TV Title V
VA Veterans Administration Plan
WC Workers' Compensation
ZZ Other
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 Self/Employee
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 F Female
M Male
O Other
U 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
23 Not our claim, forwarded to additional payer(s)
25 Predetermination Pricing Only - no payment
PC029 Generic Drug Indicator 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
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 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
PC057 Mail Order pharmacy 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
PC060 Single/Multiple Source Indicator 1 Multi-source brand
2 Multi-source brand with generic equivalent
3 Single source brand
4 Single source brand with generic equivalent
5 Unknown
PC070 Rebate Indicator 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
PC073 Formulary Code 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
PC074 Route of Administration 00 Not Specified
01 Buccal
02 Dental
03 Inhalation
04 Injection
05 Intraperitoneal
06 Irrigation
07 Mouth / Throat
08 Mucous Membrane
09 Nasal
10 Ophthalmic
11 Oral
12 Other / Misc
13 Otic
14 Perfusion
15 Rectal
16 Sublingual
17 Topical
18 Transdermal
19 Translingual
20 Urethral
21 Vaginal
22 Enteral
PC075 Drug Unit of Measure EA Each
F2 International Units
GM Grams
MEQ Milliequivalent
MG Milligram
ML Milliliters
MM Millimeter
UG Microgram
UU Unit
PC110 Claim Line Type A Amendment
B Back Out
O Original
R Replacement
V Void
PC112 Medicare Indicator 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
PC113 Pregnancy Indicator 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
PC115 ICD Indicator 0 ICD-10
9 ICD-9
PC116 Denied Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
PC118 Payment Arrangement Type 01 Capitation
02 Fee for Service
03 Percent of Charges
04 DRG
05 Pay for Performance
06 Global Payment
07 Other
08 Bundled Payment
09 Payment Amount Per Episode (PAPE) (MassHealth)
PC120 APCD ID Code 0 Unknown / Not Applicable
1 FIG - Fully-Insured Commercial Group Enrollee
2 SIG - Self-Insured Group Enrollee
3 GIC - Group Insurance Commission Enrollee
4 MCO - MassHealth Managed Care Organization Enrollee
5 Supplemental Policy Enrollee
6 ICO - Integrated Care Organization or SCO - Senior Care Option
PC121 Claim Line Paid Flag 1 Yes
2 No
3 Unknown
4 Other
5 Not Applicable
PC899 Record Type PC
TR001 Record Type TR
TR004 Type of File PC
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