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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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Usual and Customary ChargeAmount charged cash customers for the prescription exclusive of sales tax or other amounts claimed.
Submission Clarification CodeCode indicating that the pharmacist is clarifying the submission.
Service Provider ID QualifierCode qualifying the 'Service Provider ID' (201-B1).
Service Provider IDID assigned to a pharmacy or provider.
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.
Result of Service CodeAction taken by a pharmacist or prescriber in response to a conflict or the result of a pharmacist's professional service.
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.
Quantity DispensedQuantity dispensed expressed in metric decimal units.
Provider ID QualifierCode qualifying the 'Provider ID' (444-E9).
Provider IDUnique ID assigned to the person responsible for the dispensing of the prescription or provision of the service.
Professional Service CodeCode identifying pharmacist intervention when a conflict code has been identified or service has been rendered.
Product/Service ID QualifierCode qualifying the value in 'Product/Service ID' (407-D7).
Product/Service IDID of the product dispensed or service provided.
Product DescriptionDescription of product being submitted.
Processor Control NumberNumber assigned by the processor.
Procedure Modifier CodeIdentifies special circumstances related to the performance of the service.
Prior Authorization Type CodeCode clarifying the 'Prior Authorization Number Submitted' (462-EV) or benefit/plan exemption.
Prior Authorization Number SubmittedNumber submitted by the provider to identify the prior authorization.
Prescription/ Service Reference NumberReference number assigned by the provider for the dispensed drug/product and/or service provided.
Prescription Origin CodeCode indicating the origin of the prescription.
Prescriber Last NameIndividual last name.
Prescriber ID QualifierCode qualifying the 'Prescriber ID' (411-DB).
Prescriber IDID assigned to the prescriber.
Plan NameThe name of the plan.
Place of ServiceCode identifying the place where a drug or service is dispensed or administered.
Pharmacy Zip/Postal CodeCode defining international postal code excluding punctuation of the pharmacy.
Pharmacy Telephone NumberTelephone number of pharmacy.
Pharmacy State/Province AddressState/Province Code of pharmacy.
Pharmacy NameName of pharmacy.
Pharmacy Location CityCity of pharmacy.
Pharmacy AddressThe street address for a pharmacy.
Person CodeCode assigned to a specific person within a family.
Percentage Sales Tax Amount SubmittedPercentage sales tax submitted.
Patient Relationship CodeCode indicating relationship of patient to cardholder.
Patient Paid Amount SubmittedAmount the pharmacy received from the patient for the prescription dispensed.
Patient Last NameIndividual last name.
Patient Gender CodeCode indicating the gender of the individual.
Patient First NameIndividual first name.
Other Payer Reject CodeThe error encountered by the previous "Other Payer" in 'Reject Code' (511-FB).
Other Payer-Patient Responsibility AmountThe patient's cost share from a previous payer.
Other Payer ID QualifierCode qualifying the 'Other Payer ID' (340-7C).
Other Payer IDID assigned to the payer.
Other Payer DatePayment or denial date of the claim submitted to the other payer. Used for coordination of benefits.
Other Payer Amount PaidAmount of any payment known by the pharmacy from other sources.
Other Coverage CodeCode indicating whether or not the patient has other insurance coverage.
Other Amount Claimed SubmittedAmount representing the additional incurred costs for a dispensed prescription or service.
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.
Ingredient Cost SubmittedSubmitted product component cost of the dispensed prescription. This amount is included in the 'Gross Amount Due' (430-DU).
Group IDID assigned to the cardholder group or employer group.
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).
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