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Data Elements Related to Universal Claim Form

Name: Universal Claim Form
Definition: 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.
BIN NumberCard Issuer ID or Bank ID Number used for network routing.
Cardholder First NameIndividual first name.
Cardholder IDInsurance ID assigned to the cardholder or identification number used by the plan.
Cardholder Last NameIndividual last name.
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 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.
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.
Diagnosis CodeCode identifying the diagnosis of the patient.
Diagnosis Code QualifierCode qualifying the 'Diagnosis Code' (424-DO).
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.
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).
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).
Group IDID assigned to the cardholder group or employer group.
Ingredient Cost SubmittedSubmitted product component cost of the dispensed prescription. This amount is included in the 'Gross Amount Due' (430-DU).
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.
Other Payer Reject CodeThe error encountered by the previous "Other Payer" in 'Reject Code' (511-FB).
Patient First NameIndividual first name.
Patient Gender CodeCode indicating the gender of the individual.
Patient Last NameIndividual last name.
Patient Paid Amount SubmittedAmount the pharmacy received from the patient for the prescription dispensed.
Patient Relationship CodeCode indicating relationship of patient to cardholder.
Percentage Sales Tax Amount SubmittedPercentage sales tax submitted.
Person CodeCode assigned to a specific person within a family.
Pharmacy AddressThe street address for a pharmacy.
Pharmacy Location CityCity of pharmacy.
Pharmacy NameName of pharmacy.
Pharmacy State/Province AddressState/Province Code of pharmacy.
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