United States Health Information Knowledgebase


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 1-25 of 77

sort Name
sort Definition
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.
Scroll To Top