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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.
Results 51-77 of 77

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Pharmacy Telephone NumberTelephone number of pharmacy.
Pharmacy Zip/Postal CodeCode defining international postal code excluding punctuation of the pharmacy.
Place of ServiceCode identifying the place where a drug or service is dispensed or administered.
Plan NameThe name of the plan.
Prescriber IDID assigned to the prescriber.
Prescriber ID QualifierCode qualifying the 'Prescriber ID' (411-DB).
Prescriber Last NameIndividual last name.
Prescription Origin CodeCode indicating the origin of the prescription.
Prescription/ Service Reference NumberReference number assigned by the provider for the dispensed drug/product and/or service provided.
Prior Authorization Number SubmittedNumber submitted by the provider to identify the prior authorization.
Prior Authorization Type CodeCode clarifying the 'Prior Authorization Number Submitted' (462-EV) or benefit/plan exemption.
Procedure Modifier CodeIdentifies special circumstances related to the performance of the service.
Processor Control NumberNumber assigned by the processor.
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).
Professional Service CodeCode identifying pharmacist intervention when a conflict code has been identified or service has been rendered.
Provider IDUnique ID assigned to the person responsible for the dispensing of the prescription or provision of the service.
Provider ID QualifierCode qualifying the 'Provider ID' (444-E9).
Quantity DispensedQuantity dispensed expressed in metric decimal units.
Reason For Service CodeCode identifying the type of utilization conflict detected by the prescriber or the pharmacist or the reason for the pharmacist's professional service.
Result of Service CodeAction taken by a pharmacist or prescriber in response to a conflict or the result of a pharmacist's professional service.
Route of AdministrationThis is an override to the "default" route referenced for the product. For a multi-ingredient compound, it is the route of the complete compound mixture.
Service Provider IDID assigned to a pharmacy or provider.
Service Provider ID QualifierCode qualifying the 'Service Provider ID' (201-B1).
Submission Clarification CodeCode indicating that the pharmacist is clarifying the submission.
Usual and Customary ChargeAmount charged cash customers for the prescription exclusive of sales tax or other amounts claimed.
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