Health care data and information submitted by Health Care Payers to CHIA is not a public record. No public disclosure of any health plan information or data shall be made unless specifically authorized under 957 CMR 5.00 . Acronyms Frequently Used APCD – All-Payer Claims Database CHIA – Center for Health Information and Analysis CSO – Computer Services Organization DBA – Delegated Benefit Administrator DBM – Dental Benefit Manager DOI – Division of Insurance GIC – Group Insurance Commission ID – Identification; Identifier MA APCD – Massachusetts’ All-Payer Claims Database NPI – National Provider Identifier PBM – Pharmacy Benefit Manager QA – Quality Assurance RA – Risk Adjustment; Risk Adjuster TME / RP – Total Medical Expense / Relative Pricing TPA – Third Party Administrator The File Types: DC – Dental Claims MC – Medical Claims ME – Member Eligibility PC – Pharmacy Claims PR – Product File PV – Provider File BP – Benefit Plan Control Total File SD – Supplemental Diagnosis Code File (Connector Risk Adjustment plans only)
Should previously paid but now Voided claims be reported? Yes. Claims that were paid and reported in one period and voided by either the Provider or the Carrier should be reported in the next file. See below. The reporting of Zero Paid Pharmacy Claims aids with the analysis of services utilized, Member Eligibility and deductibles applied. What types of claims are to be included? The Pharmacy Claims file is used to report any pharmacy claim sent to and paid by the Carrier / PBM. CHIA has adopted the most widely used specification at this time to allow for comprehensive analysis. The word ‘Member’ is used in the specification. Are ‘Member’ and ‘Patient’ used synonymously? Yes. Member and Patient are to be used in the same manner in this specification Member is used in the claim specification to strengthen the reporting bond between Member Eligibility and the pharmacy claims attached to a Member. If claims are processed by a third-party administrator, who is responsible for submitting the data and how should the data be submitted? In instances more than one entity administers a health plan, the health care carrier and third-party administrators are responsible for submitting data according to the specifications and format defined in the Submission Guides. CHIA expects each party to report the Organization ID of the other party in the Delegated Benefit Organization ID (PC072) field to assist in linkage between the health care carrier and the third party administrator. CHIA’s objective is to create a comprehensive database that must include data from all health care carriers and all their vendors (TPAs, PBMs, DBAs, CSOs, etc.) to complete the view of the health service delivery system. Types of Data collected in the Pharmacy Claim File Submitter-assigned Identifiers CHIA requires various Submitter-assigned identifiers for matching-logic to the other files, Product and Member Eligibility. Some examples of these elements include PC003, PC006, PC107 and PC108. These elements will be used by CHIA to aid with the
File Guideline and Layout Legend File: Identifies the file per element as well as the Header and Trailer Records that repeat on all MA APCD File Types. Headers and Trailers are Mandatory as a whole, with just a few elements allowing situational reporting. Col: Identifies the column the data resides in when reported Elmt: This is the number of the element in regards to the file type Data Element Name: Provides identification of basic data required Date Modified: Identifies the last date that an element was adjusted Type: Defines the data as Decimal, Integer, Numeric or Text. Additional information provided for identification, e.g., Date Period – Integer Type Description: Used to group like-items together for quick identification Format / Length: Defines both the reporting length and element min/max requirements. See below: char[n] – this is a length element of [n] characters, cannot report below or above [n]. This can be any type of data, but is governed by the type listed for the element, Text vs. Numeric. varchar[n] – this is a variable length field of max [n] characters, cannot report above [n]. This can be any type of data, but is governed by the type listed for the element, Text vs. Numeric. int[n] – this is a fixed type and length element of [n] for numeric reporting only. This cannot be anything but numeric with no decimal points or leading zeros. The plus/minus symbol (±) in front on any of the Formats above indicate that a negative can be submitted in the element under specific conditions. Example: When the Claim Line Type (MC138) = V (void) or B (backout) then certain claim values can be negative. Description: Short description that defines the data expected in the element Element Submission Guideline: Provides detailed information regarding the data required as well as constraints, exceptions and examples. Condition: Provides the condition for reporting the data %: Provides the base percentage that the MA APCD is expecting in volume of data in regards to condition requirements.
PC 2 National Plan ID 11/8/12 Integer ID Nat'l PlanID int[10] CMS National Plan Identification Number (PlanID) Do not report any value here until National PlanID is fully implemented. This is a unique identifier as outlined by Centers for Medicare and Medicaid Services (CMS) for Plans or Sub plans All 0% Z PC 3 Insurance Type Lookup Table - Text char[2] Type / Product Identification Code Report the code that defines the type of insurance which this patient's claim line was processed. EXAMPLE: HM = HMO All 95% A2 Code Description 09 Self-pay 10 Central Certification 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization (DMO) AM Automobile Medical BL Blue / Blue Shield CC Commonwealth Care CE Commonwealth Choice CH Champus CI Commercial Insurance Co. DS Disability HM Health Maintenance Organization LI Liability LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program TF HSN Fund TV Title V VA Veterans Administration Plan WC Workers' Compensation ZZ Other
PC 4 Payer Claim Control Number 6/24/10 Text ID Claim Number Claim Control Identification Report the Unique identifier within the payer's system that applies to the entire claim All 100% A0 PC 5 Line Counter 11/8/12 Integer ID Count varchar[4] Incremental Line Counter Report the line number for this service within the Start with 1 and increment by 1 for each additional line. Do not start with 0, include alphas or special characters. All 100% A0 PC 6 Version Number 7/6/10 Integer Counter varchar[4] Claim Service Line Version Number Report the version number of this claim service line. The version number begins with 0 and is incremented by 1 for each subsequent version of that service line. No alpha or special characters. All 100% A0 PC 7 Insured or Policy Number 6/24/10 Text ID Group Group / Policy Number Report the number that defines the insured group or policy. Do not report the number that uniquely identifies the subscriber or member All 98% C PC 8 Subscriber SSN 11/8/12 Numeric ID Tax char[9] Subscriber's Social Security Number Report the Subscriber's SSN here; used to validate Unique Member ID; will not be passed into analytic file. Do not use hyphen. If not available do not report any value here All 85% B PC 9 Plan Specific Contract Number 6/24/10 Text ID Contract Contract Number Report the Plan assigned contract number. Do not include values in this element that will distinguish one member of the family from another. This should be the contract or certificate number for the subscriber and all of the dependents. All 98% C PC 10 Member Suffix or Sequence Number 6/24/10 Text ID Sequence Contract Sequence Number Report the unique number / identifier of the member within the contract All 98% B PC 11 Member SSN 11/8/12 Numeric ID Tax char[9] Social Security Number Report the patient's social security number here; used to validate Unique Member ID; will not be passed into analytic file. Do not use hyphen. If not available do not report any value here All 98% B
PC 24 Pharmacy Location State 11/8/12 External Code Source 2 - Text Address External Code Source 2 - States char[2] State of the Pharmacy Report the state where the dispensing pharmacy is located. All 90% B PC 25 Pharmacy ZIP Code 11/8/12 External Code Source 2 - Text Address Zip External Code Source 2 - Zip Codes varchar[9] Zip code of the Pharmacy Report the 5 or 9 digit Zip Code as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. All 90% B PC 26 Pharmacy Country Code 12/1/10 External Code Source 1 - Text Address Country External Code Source 1 - Countries char[3] Country Code of the Pharmacy Report the country code as defined by ISO 3166-1, Alpha 3 All 90% B PC 27 Claim Status 11/8/12 Lookup Table - Numeric tlkpClaimStatus varchar[2] Claim Line Status Report the value that defines the payment status of this claim line All 98% A0 Value Description 1 Processed as primary 2 Processed as secondary 3 Processed as tertiary 4 Denied 19 Processed as primary, forwarded to additional payer(s) 20 Processed as secondary, forwarded to additional payer(s) 21 Processed as tertiary, forwarded to additional payer(s) 22 Reversal of previous payment 23 Not our forwarded to additional payer(s) 25 Predetermination Pricing Only - no payment PC 28 Drug Code 11/8/12 External Code Source 12 - Text External Code Source 12 - National Drug Codes char[11] National Drug Code (NDC) Report the NDC Code as defined by the FDA in 11 format (5-4-2) without hyphenation All 98% A0
PC 29 Drug Name External Code Source 12 - Text External Code Source 12 - National Drug Names Name of the drug as supplied Report the name of the drug that aligns to the National Drug Code. Do not report generic names with brand National Drug Codes All 95% B PC 30 New or Refill 6/24/10 Numeric ID char[2] Prescription Status Indicator Report the status of prescription by numeric value. EXAMPLE: 00 = new prescription; First Refill = 01, etc. All 99% A0 PC 31 Generic Drug Indicator 11/8/12 Lookup Table - Integer tlkpFlagIndicators int[1] Generic Drug Indicator Report the value that defines the element. EXAMPLE: 1 = Yes, the drug reported is a generic. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 5 Not Applicable PC 32 Dispense as Written Code 6/24/10 Lookup Table - Integer int[1] Prescription Dispensing Activity Code Report the value that defines how the drug was dispensed. EXAMPLE: 0 = Not dispensed as written All 98% C Value Description 1 Physician dispense as written 2 Member dispense as written 3 Pharmacy dispense as written 4 No generic available 5 Brand dispensed as generic 6 Override 7 Substitution not allowed, brand drug mandated by law 8 Substitution allowed, generic drug not available in marketplace 9 Other 0 Not dispensed as written PC 33 Drug Indicator 11/8/12 Lookup Table - Integer tlkpFlagIndicators int[1] Compound Drug Indicator Report the value that defines the element. EXAMPLE: 1 = Yes, drug is a compound. All 98% A2 Value Description 1 Yes 2 No 3 Unknown
PC 51 Physician Plan Number 11/8/12 Text ID Plan Provider Plan ID Report the prescriber's plan number here. Do not report any here if not contracted with the carrier. All 10% C PC 52 Physician License Number 11/8/12 Text ID License Prescribing Physician License Number Report the license number for the provider identified in PC043. For a doctor this is the medical license for a this is the practice license. Do not use zero-fill. If not available, or not applicable, such as for a group or corporate entity, do not report any value here. All 10% B PC 53 Physician Street Address 6/24/10 Text Address 1 Provider Street address of the Prescribing Physician Report the street address of the Prescribing Physician All 10% C PC 54 Physician Street Address 2 6/24/10 Text Address 2 Provider Secondary Street Address of the Prescribing Physician Report the street address of the Prescribing Physician that may contain office number, suite number of PO Box. All 2% C PC 55 Physician City 6/24/10 Text Address City Provider City name of the Prescribing Physician Report the Prescribing Physician City All 10% C PC 56 Physician State 11/8/12 External Code Source 2 - Text Address State External Code Source 2 - States char[2] State of the Physician Report the state of the prescribing physician here. All 10% C PC 57 Physician Zip 11/8/12 External Code Source 2 - Text Address Zip External Code Source 2 - Zip varchar[9] Zip code of the Prescribing Physician Report the 5 or 9 digit Zip Code as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. All 10% C
PC 64 Billing Provider Tax ID Number 11/8/12 Numeric ID Tax char[9] The Billing Provider's Federal Tax Identification Number (FTIN) Report the Federal Tax ID of the Billing Provider here. Do not use hyphen or alpha prefix. All 90% C PC 65 Paid Date 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Paid date of the claim line Report the date that appears on the check and/or remit and/or explanation of benefits and corresponds to any and all types of payment in CCYYMMDD Format. This can be the same date as Processed Date. EXAMPLE: Claims paid in full, partial or zero paid All 99% A0 PC 66 Date Written 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Date prescription was prescribed Report the date that was written on the prescription or called-in by the physician's office in CCYYMMDD Format. All 98% B PC 67 of Liability Amount 11/8/12 Integer Currency Amount due from a Secondary Carrier when known Report the amount that another carrier / insurer is liable for after submitting payer has processed this claim line. Report 0 if there is no COB / TPL amount. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when PC025 = 19, 20 or 21 98% A2 PC 68 Other Insurance Paid Amount 11/8/12 Integer Currency Amount paid by a Primary / Prior Carrier Report the amount that a prior payer has paid for this claim line. Indicates the submitting Payer is 'secondary' to the prior payer. Only report 0 if the Prior Payer paid 0 towards this claim line, else do not report any value here. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when PC025 = 02, 03, 20, or 21 98% A2
PC 73 State Sales Tax 11/8/12 Integer Currency Amount of applicable sales tax on the claim line Report the amount of state sales tax applied to this claim line. Report 0 if state sales tax does not apply. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when PC023 does not = MA 98% A2 PC 74 Delegated Benefit ID 11/8/12 Integer ID Link to OrgID varchar[6] CHIA defined and maintained Org ID for linking across submitters Riskholders report the of the DBA here. DBAs report the OrgID of the insurance carrier here. This element contains the CHIA assigned organization ID for the DBA. Contact the APCD for the appropriate value. If no DBA is affiliated with this claim line do not report any value here: i.e., do not repeat the OrgID from PC001 All 98% A2 PC 75 Formulary Code 11/8/12 Lookup Table - Integer tlkpFlagIndicators int[1] Formulary inclusion identifier Report the value that defines the element. EXAMPLE: 1 = Yes, drug is on the formulary. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PC 76 Route of 11/8/12 Lookup Table - Numeric char[2] of Administration Report Pharmaceutical Route of Administration Indicator that defines method of drug administration. EXAMPLE: 11 = Oral All 80% A2 Value Description 01 Buccal 02 Dental 03 Inhalation 04 Injection 05 Intraperitoneal 06 Irrigation 07 Mouth / Throat 08 Mucous Membrane 09
10 Ophthalmic 11 Oral 12 Other / Misc 13 Otic 14 Perfusion 15 Rectal 16 Sublingual 17 Topical 18 Transdermal 19 Translingual 20 Urethral 21 Vaginal 22 Enteral 00 Not Specified PC 77 Drug Unit of Measure Lookup Table - Text char[3] Units of Measure Report the code that defines the unit of measure for drug dispensed. EXAMPLE: EA = Each All 80% A1 Code Description EA Each F2 International Units GM Grams ML Milliliters MG Milligram MEQ Milliequivalent MM Millimeter UG Microgram UU Unit PC 78 Subscriber Last Name Text Name Last Subscriber Last name of Subscriber Report the last name of the subscriber. Used to validate Unique Member ID. Last name should exclude all punctuation, including hyphens and apostrophes, and be reported in case. Name should be contracted where punctuation is removed, do not report spaces. EXAMPLE: O'Brien becomes OBRIEN; becomes CARLTONSMYTHE All 98% B
PC 85 Carrier Specific Unique Subscriber ID 11/8/12 Text ID Link to ME117 Subscriber's Unique ID Report the identifier the carrier / submitter uses internally to uniquely identify the subscriber. Used to validate Unique Member ID and link back to Member Eligibility (ME117) All 100% A0 PC 86 Member Street Address 2 11/8/12 Text Address 2 Member Secondary Street Address of the Member/Patient Report the address of member which may include apartment number or suite, or other secondary information besides the street. Used to validate Unique Member ID. All 0% B PC 87 Line Type 11/8/12 Lookup Table - Text tlkpClaimLineType char[1] Claim Line Activity Type Code Report the code that defines the line status in terms of adjudication. EXAMPLE: O = Original All 98% A2 Code Description O Original V Void R Replacement B Back Out A Amendment PC 88 Former Claim Number 12/1/10 Text ID Claim Number Previous Claim Number Report the Claim Control Number (PC004) that was originally sent in a prior filing that this line corresponds to. When reported, this data cannot equal its own PC004. Use of “Former Claim Number” to version claims can only be used if approved by the APCD. Contact the APCD for conditions of use. All 0% B PC 89 Medicare Indicator 11/8/12 Lookup Table - Integer tlkpFlagIndicators int[1] Indicator - Medicare Payment Applied Report the value that defines the element. EXAMPLE: 1 = Yes, Medicare paid for part or all of services All 100% A0 Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PC 90 Pregnancy Indicator Lookup Table - Integer tlkpFlagIndicators int[1] Indicator - Pregnancy Report the value that defines the element. EXAMPLE: 1 = Yes, the patient is pregnant Required when PC012=F 98% A2
Value Description 01 Capitation 02 Fee for Service 03 Percent of Charges 04 DRG 05 Pay for Performance 06 Global Payment 07 08 Bundled Payment 09 Payment Amount Per Episode (PAPE) (MassHealth) (09 for HD002 = MassHealth orgid ONLY ) PC 96 GIC ID 11/8/12 Text ID GIC varchar[9] GIC Member ID Report the GIC Member Identification number as provided to GIC Plan Submitters. If not applicable do not report any value here Required when = 3 100% A0 PC 97 APCD ID Code Lookup Table - Integer tlkpADCDIdentifier int[1] Member Enrollment Type Report the value that describes the member's / subscriber's enrollment into one of the predefined categories; aligns enrollment to appropriate editing and thresholds. EXAMPLE: 1 = FIG - Fully Insured Commercial Group Enrollee. All 100% A2 Value Description 1 FIG - Fully-Insured Commercial Group Enrollee 2 SIG - Self-Insured Group Enrollee 3 GIC - Group Insurance Commission Enrollee 4 MCO - MassHealth Managed Care Organization Enrollee 5 Supplemental Policy Enrollee 6 ICO – Integrated Care Organization or SCO – Senior Care Option 0 Unknown / Not Applicable