United States Health Information Knowledgebase

 

Data Elements Related to Uniform Healthcare Payer Data Standard

Name: Uniform Healthcare Payer Data Standard
Definition: Used by Client Groups, Pharmacy Benefit Managers (PBMs), Fiscal Agents, Vendors, and Administrative Oversight Organizations and state entities to share pharmacy claim data that is used to support statistical reporting, evaluation of healthcare, and state or regional reporting requirements. This standard should only be used for data submission to a state agency or to a state-sponsored healthcare payer data collection initiative.
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Adjudication DateDate the claim or adjustment is processed.
Amount Applied To Periodic DeductibleAmount to be collected from a patient that is included in 'Patient Pay Amount' (505-F5) that is applied to a periodic deductible.
Amount Attributed to Coverage GapAmount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patient being in the coverage gap (for example Medicare Part D Coverage Gap (donut hole)). A coverage gap is defined as the period or amount during which the previous coverage ends and before an additional coverage begins.
Amount Attributed to Processor FeeAmount to be collected from the patient that is included in Patient Pay Amount (505-F5) that is due to the processing fee imposed by the processor.
Amount Attributed To Product SelectionAmount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patient's selection of drug product.
Amount Attributed to Product Selection / Brand DrugAmount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patient's selection of a Brand product.
Amount Attributed to Product Selection / Brand Non-Preferred Formulary SelectionAmount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patient's selection of a Brand Non-Preferred Formulary product.
Amount Attributed to Product Selection / Non-Preferred Formulary SelectionAmount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patient's selection of a Non-Preferred Formulary product.
Amount Attributed to Provider Network SelectionAmount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patient's provider network selection.
Amount Attributed To Sales TaxAmount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to sales tax paid.
Amount Exceeding Periodic Benefit MaximumAmount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patient exceeding a periodic benefit maximum.
Amount Exceeding Periodic Benefit MaximumAmount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to the patient exceeding a periodic benefit maximum.
Amount of CoinsuranceAmount to be collected from the patient that is included in 'Patient Pay Amount' (5(5-F5) that is due to a per prescription coinsurance.
Amount Of CopayAmount to be collected from the patient that is included in 'Patient Pay Amount' (505-F5) that is due to a per prescription copay.
Cardholder IDInsurance ID assigned to the cardholder or identification number used by the plan.
Check DateMember Claims - Actual member check date Non member Claims - Pharmacy check date
City Free-form text for city name.
Claim Processed CodeCode defining which perspective in the possible coordination of benefits flow the payer reflected when adjudicating the claim.
Compound CodeCode indicating whether or not the prescription is a compound.
Creation DateDate the file was created.
Date Of BirthDate of birth of patient.
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.
Days SupplyEstimated number of days the prescription will last.
Dispense As Written (DAW)/ Product Selection CodeCode indicating whether or not the prescriber's instructions regarding generic substitution were followed.
Dispensing Fee PaidDispensing fee paid included in the 'Total Amount Paid' (509-F9).
Drug TypeCode to indicate the type of drug dispensed.
Eligibility Group IDIdentifier of the group that determines eligibility parameters for the member when submitted by the client.
Eligibility/Patient Relationship CodeIndividual Relationship Code. Code indicating the relationship between two individuals or entities.
Encrypted Social Security NumberSocial Security Number which has been encrypted.
Entity Country CodeCode of the country.
Fill Number CalculatedCode identifying whether the prescription is an original (00) or by refill number (01-99) as calculated by system based on historical claims data. This field represents the Fill Number as calculated (not submitted by pharmacy)
First NameFirst name.
Flat Sales Tax Amount PaidFlat sales tax paid which is included in the 'Total Amount Paid' (509-F9).
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).
Health Plan-funded Assistance AmountThe amount from the health plan-funded assistance account for the patient that was applied to reduce Patient Pay Amount (505-F5). This amount is used in Healthcare Reimbursement Account (HRA) benefits only. This field is always a negative amount or zero.
Incentive Amount PaidAmount represents the contractually agreed upon incentive fee paid for specific services rendered. Amount is included in the 'Total Amount Paid' (509-F9).
Ingredient Cost PaidDrug ingredient cost paid included in the 'Total Amount Paid' (509-F9).
Insurance Type/Product CodeThe insurance type or product code for the type of insurance coverage of the individual.
Internal Control NumberNumber assigned by the processor to identify an adjudicated claim when supplied in payer-to-payer coordination of benefits only.
Last NameLast name.
Line CounterLine number for this service. The line counter begins with 1 and is incremented by 1 for each additional service line.
MessageFree form message.
Middle InitialIndividual middle initial.
Middle NameMiddle name of individual.
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 PaidAmount paid for additional costs claimed in 'Other Amount Claimed Submitted' (480-H9).
Other Amount Paid QualifierCode clarifying the value in the 'Other Amount Paid' (565-J4).
Patient Gender CodeCode indicating the gender of the individual.
Patient IDID assigned to the patient.
Patient Pay AmountAmount that is calculated by the processor and returned to the pharmacy as the TOTAL amount to be paid by the patient to the pharmacy; the patient's total cost share, including copayments, amounts applied to deductible, over maximum amounts, penalties, etc.
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