United States Health Information Knowledgebase

Data Elements Related to Medical Rebate Data Submission Standard

Name:	Medical Rebate Data Submission Standard
Definition:	Provides a standardized format for health plans' rebate submissions to multiple manufacturers throughout the industry.

Results 1-50 of 78

Select All	sort Name	sort Definition
Select 200070000	Adjudication Date	Date the claim or adjustment is processed.
Select 200093000	Allowed Amount	Allowable charges for covered services based on the specially negotiated fee between the provider and MCO.
Select 200189000	Billed Amount	Total reasonable and customary fee providers charge to provide the type of service received
Select 200236000	Claim Number	A unique identifier for a prescription and claim processor
Select 200307000	Contracting Organization (PMO) Contract Number	Contract number assigned by the contracting organization.
Select 200308000	Contracting Organization (PMO) ID Code	ID code assigned by the contracting organization.
Select 200309000	Contracting Organization (PMO) ID Qualifier	Indicates the type of data being submitted in the 'Contracting Organization (PMO) ID Code' (600-66) field.
Select 200311000	Contracting Organization (PMO) Name	The name of the contracting organization.
Select 200343000	Data Level	The level of data being submitted.
Select 200344000	Data Provider ID Code	Code assigned to identify the data provider.
Select 200345000	Data Provider ID Qualifier	Identifies the type of data being submitted in the 'Data Provider ID Code' (601-32) field.
Select 200346000	Data Provider Name	Name of the data provider.
Select 200354000	Date Of Service	Identifies date the prescription was filled or professional service rendered or subsequent payer began coverage following Part A expiration in a long-term care setting only.
Select 200372000	Diagnosis Code	Code identifying the diagnosis of the patient.
Select 200374000	Diagnosis Code Qualifier	Code qualifying the 'Diagnosis Code' (424-DO).
Select 200479000	Encrypted Patient ID Code	Encrypted patient ID.
Select 200487000	Entity Country Code	Code of the country.
Select 200494000	Entity Zip/Postal Code	Code defining international postal code excluding punctuation of the entity indicated.
Select 200526000	Fill Number	The code indicating whether the prescription is an original or a refill.
Select 200543000	Formulary Code	Code assigned by PMO to identify the formulary used.
Select 200571000	Grand Total Quantity	The sum of the 'Total Quantity' (601-39) fields submitted within the 'UD' record type.
Select 200572000	Grand Total Requested Amount	The sum of the 'Requested Rebate Amount' (601-55) fields submitted within the 'UD' record type.
Select 200669000	J Code	A subset of the HCPCS Level II code set with a high-order value of "J" that has been used to identify certain drugs and other items
Select 200670000	J Code Modifier 1	Code specifying drug and other items
Select 200671000	J Code Modifier 2	Code specifying drug and other items
Select 200672000	J Code Modifier 3	Code specifying drug and other items
Select 200673000	J Code Modifier 4	Code specifying drug and other items
Select 200695000	Line Number	Unique number that identifies the record.
Select 200711000	Manufacturer (PICO) Contract Number	Contract number assigned by the manufacturer.
Select 200712000	Manufacturer (PICO) ID Code	Code assigned to identify the manufacturer.
Select 200713000	Manufacturer (PICO) ID Qualifier	Indicates the type of data being submitted in the 'Manufacturer (PICO) ID Code' (600-48) field.
Select 200715000	Manufacturer (PICO) Name	Name of the manufacturer.
Select 200752000	Medical Rebate Version Release Number	Version and release number of standard being submitted
Select 200930000	Patient Liability Amount	Amount of patient's out-of-pocket cost.
Select 201001000	Place of Service	Code identifying the place where a drug or service is dispensed or administered.
Select 201007000	Plan ID Code	ID assigned to identify the plan.
Select 201008000	Plan ID Qualifier	Identifies the type of data being submitted in the 'Plan ID Code' (600-94) field.
Select 201010000	Plan Name	The name of the plan.
Select 201011000	Plan Reimbursed Amount	Total amount the MCO pays to the provider (after removing the co-pay or deductible from the Allowable cost)
Select 201038000	Prescriber ID	ID assigned to the prescriber.
Select 201042000	Prescriber ID Qualifier	Code qualifying the 'Prescriber ID' (411-DB).
Select 201065000	Prescription/ Service Reference Number	Reference number assigned by the provider for the dispensed drug/product and/or service provided.
Select 201066000	Prescription/Service Reference Number Qualifier	Indicates the type of billing submitted.
Select 201067000	Prescription Type	Identifies the prescription as either a new/refill, an adjusted prescription or a reversal.
Select 201113000	Product Description	Description of product being submitted.
Select 201117000	Product/Service ID	ID of the product dispensed or service provided.
Select 201119000	Product/Service ID Qualifier	Code qualifying the value in 'Product/Service ID' (407-D7).
Select 201165000	Quarterly Member Indicator	Number indicating the number of times a member is billed in the billing period.
Select 201196000	Rebate Period End Date	Last day of the rebate period.
Select 201197000	Rebate Period Start Date	First day of the rebate period.

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