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.
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Adjudication DateDate the claim or adjustment is processed.
Allowed AmountAllowable charges for covered services based on the specially negotiated fee between the provider and MCO.
Billed AmountTotal reasonable and customary fee providers charge to provide the type of service received
Claim NumberA unique identifier for a prescription and claim processor
Contracting Organization (PMO) Contract NumberContract number assigned by the contracting organization.
Contracting Organization (PMO) ID CodeID code assigned by the contracting organization.
Contracting Organization (PMO) ID QualifierIndicates the type of data being submitted in the 'Contracting Organization (PMO) ID Code' (600-66) field.
Contracting Organization (PMO) NameThe name of the contracting organization.
Data LevelThe level of data being submitted.
Data Provider ID CodeCode assigned to identify the data provider.
Data Provider ID QualifierIdentifies the type of data being submitted in the 'Data Provider ID Code' (601-32) field.
Data Provider NameName of the data provider.
Date Of ServiceIdentifies 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.
Diagnosis CodeCode identifying the diagnosis of the patient.
Diagnosis Code QualifierCode qualifying the 'Diagnosis Code' (424-DO).
Encrypted Patient ID CodeEncrypted patient ID.
Entity Country CodeCode of the country.
Entity Zip/Postal CodeCode defining international postal code excluding punctuation of the entity indicated.
Fill NumberThe code indicating whether the prescription is an original or a refill.
Formulary CodeCode assigned by PMO to identify the formulary used.
Grand Total QuantityThe sum of the 'Total Quantity' (601-39) fields submitted within the 'UD' record type.
Grand Total Requested AmountThe sum of the 'Requested Rebate Amount' (601-55) fields submitted within the 'UD' record type.
J CodeA 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
J Code Modifier 1Code specifying drug and other items
J Code Modifier 2Code specifying drug and other items
J Code Modifier 3Code specifying drug and other items
J Code Modifier 4Code specifying drug and other items
Line NumberUnique number that identifies the record.
Manufacturer (PICO) Contract NumberContract number assigned by the manufacturer.
Manufacturer (PICO) ID CodeCode assigned to identify the manufacturer.
Manufacturer (PICO) ID QualifierIndicates the type of data being submitted in the 'Manufacturer (PICO) ID Code' (600-48) field.
Manufacturer (PICO) NameName of the manufacturer.
Medical Rebate Version Release NumberVersion and release number of standard being submitted
Patient Liability AmountAmount of patient's out-of-pocket cost.
Place of ServiceCode identifying the place where a drug or service is dispensed or administered.
Plan ID CodeID assigned to identify the plan.
Plan ID QualifierIdentifies the type of data being submitted in the 'Plan ID Code' (600-94) field.
Plan NameThe name of the plan.
Plan Reimbursed AmountTotal amount the MCO pays to the provider (after removing the co-pay or deductible from the Allowable cost)
Prescriber IDID assigned to the prescriber.
Prescriber ID QualifierCode qualifying the 'Prescriber ID' (411-DB).
Prescription/ Service Reference NumberReference number assigned by the provider for the dispensed drug/product and/or service provided.
Prescription/Service Reference Number QualifierIndicates the type of billing submitted.
Prescription TypeIdentifies the prescription as either a new/refill, an adjusted prescription or a reversal.
Product DescriptionDescription of product being submitted.
Product/Service IDID of the product dispensed or service provided.
Product/Service ID QualifierCode qualifying the value in 'Product/Service ID' (407-D7).
Quarterly Member IndicatorNumber indicating the number of times a member is billed in the billing period.
Rebate Period End DateLast day of the rebate period.
Rebate Period Start DateFirst day of the rebate period.
Record Purpose IndicatorIdentifies the purpose of the record being submitted.
Record TypeType of record being submitted.
Reimbursement DateDate provider was reimbursed for product being reported.
Requested Rebate AmountThe total rebate being requested for the reported product.
Segment 1The business segmentation of rebates to permit one file to go to each manufacturer.
Segment 2The business segmentation of rebates to permit one file to go to each manufacturer.
Segment 3The business segmentation of rebates to permit one file to go to each manufacturer.
Segment 4The business segmentation of rebates to permit one file to go to each manufacturer.
Segment 5The business segmentation of rebates to permit one file to go to each manufacturer.
Segment 6The business segmentation of rebates to permit one file to go to each manufacturer.
Segment Qualifier 1Indicates for the Segment Field the definition of how the rebates are stratified in the batch number.
Segment Qualifier 2Indicates for the Segment Field the definition of how the rebates are stratified in the batch number.
Segment Qualifier 3Indicates for the Segment Field the definition of how the rebates are stratified in the batch number.
Segment Qualifier 4Indicates for the Segment Field the definition of how the rebates are stratified in the batch number.
Segment Qualifier 5Indicates for the Segment Field the definition of how the rebates are stratified in the batch number.
Segment Qualifier 6Indicates for the Segment Field the definition of how the rebates are stratified in the batch number.
Service Provider Country CodeIndicates the country of the provider.
Service Provider IDID assigned to a pharmacy or provider.
Service Provider ID QualifierCode qualifying the 'Service Provider ID' (201-B1).
Service Provider State/Province AddressState/Province Code of the service provider
Submit CodeThe code on the file defining the type of submission for the entire batch (identified by the batch number). Indicates the action to perform on the submitted file.
Therapeutic Class CodeCode assigned to product being reported.
Therapeutic Class Code QualifierIdentifies type of data being submitted in the 'Therapeutic Class Code' (601-25) field.
Therapeutic Class DescriptionA text description of the 'Therapeutic Class Code' (601-25) field.
Total QuantityTotal quantity being submitted.
Total Record CountTotal number of records being submitted, including header and trailer.
Transmission DateDate the file was created.
Unit Of MeasureNCPDP standard product billing codes.
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