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Data Elements Related to Workers' Compensation/Property & Casualty Universal Claim Form

Name: Workers' Compensation/Property & Casualty Universal Claim Form
Definition: Universal Claim Forms For Telecommunication 5.1, D.0, and Workers' Compensation/Property and Casualty manual claims processing.
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Basis Of Cost DeterminationCode indicating the method by which 'Ingredient Cost Submitted' (Field 409-D9) was calculated.
Brand/Generic IndicatorDenotes Brand or Generic drug dispensed
Carrier AddressAddress of the carrier.
Carrier Location CityThis field identifies the name of the city in which the carrier is located.
Carrier Location State/Province AddressState of the carrier.
Carrier NameName of the carrier.
Carrier Zip/Postal CodeCode defining international postal code excluding punctuation of the carrier.
Claim/Reference IDIdentifies the claim number assigned by Worker's Compensation Program.
Compound Dispensing Unit Form IndicatorNCPDP standard product billing codes.
Compound Dosage Form Description CodeDosage form of the complete compound mixture.
Compound Ingredient Basis of Cost DeterminationCode indicating the method by which the drug cost of an ingredient used in a compound was calculated.
Compound Ingredient Component CountCount of compound product IDs (both active and inactive) in the compound mixture submitted.
Compound Ingredient Drug CostIngredient cost for the metric decimal quantity of the product included in the compound mixture indicated in 'Compound Ingredient Quantity' (Field 448-ED).
Compound Ingredient Product NameDescription of the ingredient being submitted.
Compound Ingredient QuantityAmount expressed in metric decimal units of the product included in the compound mixture.
Compound Product IDProduct identification of an ingredient used in a compound.
Compound Product ID QualifierCode qualifying the type of product dispensed.
Date of BillingDate the invoice was created. Used only by those entities creating the paper invoice and submitting for payment.
Date Of BirthDate of birth of patient.
Date Of InjuryDate on which the injury occurred.
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.
Date Prescription WrittenDate prescription was written.
Days SupplyEstimated number of days the prescription will last.
Delay Reason CodeCode to specify the reason that submission of the transactions has been delayed.
Dispense As Written (DAW)/ Product Selection CodeCode indicating whether or not the prescriber's instructions regarding generic substitution were followed.
Dispensing Fee SubmittedDispensing fee submitted by the pharmacy. This amount is included in the 'Gross Amount Due' (430-DU).
Document Control NumberInternal number used by the payer or processor to further identify the claim for imaging purposes - Document archival, retrieval and storage
DUR/PPS Level Of EffortCode indicating the level of effort as determined by the complexity of decision-making or resources utilized by a pharmacist to perform a professional service.
Employer City AddressFree-form text for city name.
Employer Contact NameEmployer primary contact.
Employer NameComplete name of employer.
Employer State/Province AddressState/Province Code of the employer.
Employer Street AddressFree-form text for address information.
Employer Telephone NumberTen-digit phone number of employer.
Employer Zip/Postal CodeCode defining international postal code excluding punctuation of the employer.
Fill NumberThe code indicating whether the prescription is an original or a refill.
Flat Sales Tax Amount SubmittedFlat sales tax submitted for prescription. This amount is included in the 'Gross Amount Due' (430-DU).
Generic AvailableDenotes availability of a generic product in the store/facility when brand was dispensed
Gross Amount DueTotal price claimed from all sources. For prescription claim request, field represents a sum of 'Ingredient Cost Submitted' (409-D9), 'Dispensing Fee Submitted' (412-DC), 'Flat Sales Tax Amount Submitted' (481-HA), 'Percentage Sales Tax Amount Submitted' (482-GE), 'Incentive Amount Submitted' (438-E3), 'Other Amount Claimed' (480-H9). For service claim request, field represents a sum of 'Professional Services Fee Submitted' (477-BE), 'Flat Sales Tax Amount Submitted' (481-HA), 'Percentage Sales Tax Amount Submitted' (482-GE), 'Other Amount Claimed' (480-H9).
Ingredient Cost SubmittedSubmitted product component cost of the dispensed prescription. This amount is included in the 'Gross Amount Due' (430-DU).
Jurisdictional Field (1-5)Text field with constraints
Jurisdictional StatePostal State Abbreviation identifying the state which has jurisdiction over the payment of benefits and medical claims for the injured worker. Typically, the Jurisdictional State is the state where the worker was injured.
Net Amount DueFor A: Net amount paid to provider by the payer or net amount due from the client to the payer, determined by trading partner agreement. For Z and W: Net amount due from the payer or their agent to the payee.
Other Amount Claimed SubmittedAmount representing the additional incurred costs for a dispensed prescription or service.
Other Coverage CodeCode indicating whether or not the patient has other insurance coverage.
Other Payer Amount PaidAmount of any payment known by the pharmacy from other sources.
Other Payer DatePayment or denial date of the claim submitted to the other payer. Used for coordination of benefits.
Other Payer IDID assigned to the payer.
Other Payer ID QualifierCode qualifying the 'Other Payer ID' (340-7C).
Other Payer-Patient Responsibility AmountThe patient's cost share from a previous payer.
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