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
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