Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 590 - MAINE HEALTH DATA ORGANIZATION › Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS › Appendix 590-243-E-1 - Maine Health Data Organization Pharmacy Claims File Specifications

Current through 2024-29, July 17, 2024
Data Element
								#
Data Element Name
Date Effective
Type
Maximum Length
Description/Codes/Sources
PC001
Submitter
1/1/2003
Text
8
MHDO-assigned identifier of payor submitting claims
								data. Do not leave blank.
PC002
Payor
7/1/2012
Text
8
MHDO-assigned code of the insurer/underwriter in
								the case of premiums-based coverage, or of the administrator in the case of
								self-funded coverage. Do not leave blank.
PC003
Insurance Type/Product
								Code
1/1/2003
Text
2
Code identifying the type of insurance policy
								within a specific insurance program. Refer to Appendix A 16 Medicare Part C MD
								Medicare Part D SP Supplemental Policy
PC004
Payor Claim Control
								Number
1/1/2003
Text
35
Must apply to the entire claim and be unique within
								the payor's system. Shall be left blank when the payor indicates the record
								contains 42 CFR Part 2 SUD-related data by setting the value of PC113 =
								'Y'.
PC005
Line Counter
4/1/2004
Number
4
Line number for this service The line counter
								begins with 1 and is incremented by 1 for each additional service line of a
								claim. Shall be left blank when the payor indicates the record contains 42 CFR
								Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC006
Insured Group or Policy
								Number
1/1/2003
Text
30
Group or policy number - not the number that
								uniquely identifies the Subscriber Shall be left blank when the payor indicates
								the record contains 42 CFR Part 2 SUD-related data by setting the value of
								PC113 = 'Y'.
PC007
Subscriber Social Security
								Number
1/1/2003
Text
9
Subscriber's social security number Leave blank if
								unavailable. Shall be left blank when the payor indicates the record contains
								42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC008
Plan Specific Contract
								Number
1/1/2003
Text
80
Plan-assigned contract number Leave blank if
								contract number = subscriber's social security number. Shall be left blank when
								the payor indicates the record contains 42 CFR Part 2 SUD-related data by
								setting the value of PC113 = 'Y'.
PC009
Member Suffix or Sequence
								Number
1/1/2003
Text
20
Uniquely numbers the member within the contract
								Shall be left blank when the payor indicates the record contains 42 CFR Part 2
								SUD-related data by setting the value of PC113 = 'Y'.
PC010
Member Identification
								Code
1/1/2003
Text
50
Member's social security number
Leave blank if unavailable
Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 =
								'Y'.
PC011
Individual Relationship
								Code
1/1/2003
Text
2
Member's relationship to insured
Refer to Appendix A
Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 =
								'Y'.
PC012
Member Gender
1/1/2003
Number
1
Refer to Appendix A
Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 =
								'Y'.
PC013
Member Date of Birth
1/1/2003
Text
8
CCYYMMDD
Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 =
								'Y'.
PC014
Member City Name
4/1/2004
Text
30
City name of member
Refer to Appendix A
Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 =
								'Y'.
PC015
Member State or
								Province
4/1/2004
Text
2
As defined by the US Postal Service and Canada Post
								Refer to Appendix A Shall be left blank when the payor indicates the record
								contains 42 CFR Part 2 SUD-related data by setting the value of PC113 =
								'Y'.
PC016
Member ZIP Code
1/1/2003
Text
11
ZIP Code of member - may include non-US codes Do
								not include dash Refer to Appendix A Shall be left blank when the payor
								indicates the record contains 42 CFR Part 2 SUD-related data by setting the
								value of PC113 = 'Y'.
PC017
Date Service Approved (AP
								Date)
1/1/2003
Text
8
CCYYMMDD
The value 'CCYY0101', where CCYY is the year in
								which the service was approved, shall be used when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 =
								'Y'.
PC018
Pharmacy Number
1/1/2003
Text
30
Payor-assigned pharmacy number Not required if
								PC021 is populated.
PC019
Pharmacy Tax ID Number
1/1/2003
Text
10
Federal taxpayer's identification
								number
PC020
Pharmacy Name
1/1/2003
Text
100
Name of pharmacy
PC021
National Provider ID - Pharmacy
								Provider
4/1/2004
Text
20
National Provider ID for Pharmacy
This data element pertains to the entity or
								individual directly providing the service.
Refer to Appendix A
PC022
Pharmacy Location City
4/1/2004
Text
30
City name of pharmacy - preferably pharmacy
								location Refer to Appendix A
PC023
Pharmacy Location
								State
4/1/2004
Text
2
As defined by the US Postal Service and Canada Post
								Refer to Appendix A
PC024
Pharmacy ZIP Code
1/1/2003
Text
11
ZIP Code of pharmacy - may include non-US codes Do
								not include dash.
Refer to Appendix A
PC024A
Pharmacy Country Code
1/1/2010
Text
30
Use ISO 3166-1 alpha-2 country codes. Refer to
								Appendix A.
PC025
Claim Status
1/1/2003
Text
2
Refer to Appendix A
PC026
Drug Code
1/1/2003
Text
11
NDC Code
Refer to Appendix A
PC027
Drug Name
1/1/2003
Text
80
Text name of drug
PC028
New Prescription or
								Refill
1/1/2003
Text
2
00 New prescription 01-99 Number of
								refill
PC029
Generic Drug Indicator
1/1/2003
Text
1
N No, branded drug Y Yes, generic drug
PC030
Dispense as Written
								Code
1/1/2003
Text
1
Refer to Appendix A
PC031
Compound Drug
								Indicator
4/1/2004
Text
1
N Non-compound drug
U Non-specified drug compound
Y Compound drug
PC032
Date Prescription
								Filled
1/1/2003
Text
8
CCYYMMDD
The value 'CCYY0101', where CCYY is the year in
								which the service was approved, shall be used when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 =
								'Y'.
PC033
Quantity Dispensed
1/1/2003
Number
10
Number of metric units of medication dispensed.
								Code decimal point.
PC034
Days' Supply
1/1/2003
Number
3
Estimated number of days the prescription will
								last
PC035
Charge Amount
1/1/2003
Number
10
Do not code decimal point. Two decimal places
								implied.
PC036
Paid Amount
1/1/2003
Number
10
Includes all health plan payments and excludes all
								member payments. Do not deduct POS rebate amount, if applicable. Do not include
								Pharmacy Benefits Manager Compensation.
Do not code decimal point. Two decimal places
								implied.
PC037
Ingredient Cost/List
								Price
1/1/2003
Number
10
Cost of the drug dispensed
Do not code decimal point. Two decimal places
								implied.
PC038
Postage Amount Claimed
4/1/2004
Number
10
Do not code decimal point. Two decimal places
								implied.
PC039
Dispensing Fee
1/1/2003
Number
10
Do not code decimal point. Two decimal places
								implied.
PC040
Co-pay Amount
1/1/2003
Number
10
The preset, fixed dollar amount for which the
								individual is responsible. Do not deduct POS rebate amount, if
								applicable.
Do not code decimal point. Two decimal places
								implied.
PC041
Coinsurance Amount
1/1/2003
Number
10
The dollar amount an individual is responsible for
								- not the percentage. Do not deduct POS rebate amount, if applicable.
Do not code decimal point. Two decimal places
								implied.
PC042
Deductible Amount
1/1/2003
Number
10
Do not deduct POS rebate amount, if
								applicable.
Do not code decimal point. Two decimal places
								implied.
PC043
Patient Pay Amount
1/1/2013
Number
10
Amount that is calculated by the payor and returned
								to the pharmacy as the total amount to be paid by the patient to the pharmacy.
								$0 is acceptable; if "data not available" leave blank.
Do not include decimal point. Two decimal places
								implied.
PC044
Prescribing Physician First
								Name
7/1/2006
Text
40
Physician first name Optional if PC047 is
								filled.
PC045
Prescribing Physician Middle
								Name
7/1/2006
Text
25
Physician middle name or initial Optional if PC047
								is filled.
PC046
Prescribing Physician Last
								Name
7/1/2006
Text
60
Physician last name. Optional if PC047 is
								filled.
PC047
Prescribing Physician
								DEA
7/1/2006
Text
20
DEA for prescribing physician
PC048
Prescribing Physician
								NPI
10/1/2014
Text
20
NPI for prescribing physician Refer to Appendix
								A
PC101
Subscriber Last Name
1/1/2010
Text
60
The subscriber last name Shall be left blank when
								the payor indicates the record contains 42 CFR Part 2 SUD-related data by
								setting the value of PC113 = 'Y'.
PC102
Subscriber First Name
1/1/2010
Text
35
The subscriber first name Shall be left blank when
								the payor indicates the record contains 42 CFR Part 2 SUD-related data by
								setting the value of PC113 = 'Y'.
PC103
Subscriber Middle Name
1/1/2010
Text
25
The subscriber middle name or initial Shall be left
								blank when the payor indicates the record contains 42 CFR Part 2 SUD-related
								data by setting the value of PC113 = 'Y'.
PC104
Member Last Name
1/1/2010
Text
60
The member last name Shall be left blank when the
								payor indicates the record contains 42 CFR Part 2 SUD-related data by setting
								the value of PC113 = 'Y'.
PC105
Member First Name
1/1/2010
Text
35
The member first name Shall be left blank when the
								payor indicates the record contains 42 CFR Part 2 SUD-related data by setting
								the value of PC113 = 'Y'.
PC106
Member Middle Name
1/1/2010
Text
25
The member middle name or initial Shall be left
								blank when the payor indicates the record contains 42 CFR Part 2 SUD-related
								data by setting the value of PC113 = 'Y'.
PC107
Member Address Line 1
2/1/2019
Text
55
Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 =
								'Y'.
PC108
Member Address Line 2
2/1/2019
Text
55
Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 =
								'Y'.
PC109
Member Country Code
2/1/2019
Text
2
Use ISO 3166-1 alpha-2 country codes. Refer to
								Appendix A.
Shall be left blank when the payor indicates the
								record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 =
								'Y'.
PC110
In-Plan Network
								Indicator
2/1/2021
Text
1
Use this field to specify if services from the
								requested Pharmacy Provider were provided within the health plan network. Valid
								values are: N=No; Y=Yes.
PC111
Placeholder
2/1/2025
N/A
0
Leave blank. Payment Arrangement Type Indicator
								retired
PC112
Member Age
2/1/2025
Text
3
Member's calculated age as of the service date.
								Round to the nearest integer. For ages GREATER THAN EQUAL TO 90, indicate
								'90'.
PC113
Substance Use Disorder (SUD)
								Indicator
2/1/2025
Text
1
Indicates whether a record contains 42 CFR Part 2
								SUD-related data or not. Valid values are:
N = Record does not contain 42 CFR Part 2
								SUD-related data. Send all available values of all requested fields.
Y = Record contains 42 CFR Part 2 SUD-related data.
								The following fields shall be left blank: PC004-PC016; and
								PC101-PC109.
PC114
Total POS Rebate
								Amount
2/1/2025
Number
10
The total dollar amount of all reductions to
								amounts paid by the health plan or an individual member resulting from POS
								(point-of-sale) rebates. The total POS rebate amount should be reported in full
								and should not be deducted from either plan paid or member copay, deductible,
								or coinsurance amounts. Do not code decimal point. Two decimal places
								implied.
PC115
Member POS Rebate
								Amount
2/1/2025
Number
10
The dollar amount of all reductions to amounts paid
								by an individual member resulting from POS rebates. The member POS rebate
								amount should not be deducted from member copay, deductible, or coinsurance
								amounts. Do not code decimal point. Two decimal places implied.
PC116
PBM Compensation
								Amount
2/1/2025
Number
10
The value of payments made by the payor to its
								pharmacy benefits manager that is not paid to the pharmacy The pharmacy
								benefits manager compensation amount should not be included in the plan paid
								amount. PBM compensation does not include any compensation paid by a
								manufacturer, developer, or labeler for the performance of services.
Do not code decimal point. Two decimal places
								implied.
PC899
Record Type
1/1/2003
Text
2
PC
To ensure the security of personally identifiable
								information and personal health information that is submitted to the MHDO Data
								Warehouse and to reduce file transmission times, MHDO requires submitters to
								compress and encrypt all files before uploading to the warehouse. This
								file-level encryption will ensure the confidentiality of all data that are
								submitted to the warehouse, not just individual fields.