Are denied claims to be reported? No. Wholly denied prescription claims should not be reported at this time. If for some reason a prescription has multiple claim lines and the claim pays but a line in that claim denies, all claim lines should be sent, similar to the denied claim line philosophy used in medical claims. Denied line items of an adjudicated claim aid with utilization analysis. 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 PC110 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.
5 Period Beginning Date 11/8/12 Date Period - Integer Century Year - CCYYMM int[6] Header Period Start Date Report the Year and Month of the reported submission period in CCYYMM format. This date period must be repeated in HD006, TR005 and TR006. This same date must be selected in the upload application for successful transfer. Mandatory 100% HM 6 Period Ending Date 11/8/12 Date Period - Integer Century Year Month - CCYYMM int[6] Header Period Ending Date Report the Year and Month of the reporting submission period in CCYYMM format. This date period must match the date period reported in HD005 and be repeated in TR005 and TR006. Mandatory 100% HM 7 Record Count 11/8/12 Integer Counter Header Record Report the total number of records submitted within this file. Do not report leading zeros, space fill, decimals, or any special characters. Mandatory 100% HM 8 11/8/12 Text Free Text Field Header Carrier Comments May be used to document the submission by assigning a filename, system source, compile identifier, etc. Optional 0% HO 9 APCD Version Number 2/2016 Decimal - Numeric ID Version char[3] Submission Guide Version Report the version number as presented on the APCD Pharmacy File Submission Guide in 0.0 Format. Sets the intake control for editing elements. Version must be accurate or else file will drop. EXAMPLE: 3.0 = Version 3.0 Mandatory 100% HM Code Description 2.1 Prior Version; valid only for reporting periods prior to October 2013 3.0 Version 3.0; required for reporting periods as of October 2013 No longer valid as of May 2015 4.0 Version 4.0; required for reporting periods October 2013 onward; No longer valid as of August 2016 5.0 Version 5.0; required for reporting periods October 2013 onward as of August 2016; No longer valid as of August 2017 6.0 Version 6.0; required for reporting periods October 2013 onward as of August 2017
WC Workers' Compensation ZZ Other PC 4 Payer Claim Control Number 6/24/10 Text ID Claim Number Payer 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 claim. 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 Group or Policy Number 6/24/10 Text ID 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% A2 PC 8 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 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% A2 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% A2 PC 11 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 12 Individual Code 6/24/10 Lookup Table - Text char[2] Patient to Subscriber Relationship Code Report the value that defines the Patient's relationship to the Subscriber. EXAMPLE: 20 = Self / Employee All 85% B Value Description 01 Spouse
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 three-character country code as defined by ISO 3166-1, Alpha 3. All 90% B PC 27 Claim Status 11/8/12 Lookup - 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 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 claim, 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 digit 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 Count 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 - 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 Other 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 0 Not dispensed as written PC 33 Drug Indicator 11/8/12 Lookup - 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 4 5 Not Applicable PC 34 Date Filled 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Prescription filled date Report the date the pharmacy filled AND dispensed prescription to the patient in CCYYMMDD Format. All 99% A0 PC 35 Quantity Dispensed 11/8/12 Quantity - Integer Counter line units dispensed Report the number of metric units of medication dispensed. All 99% A1 PC 36 Day’s Supply 11/8/12 Quantity - Integer Days Prescription Prescription Supply Days Report the number of days the prescription will last if taken as prescribed. All 99% A2
PC 47 Physician Middle Name 6/24/10 Text Name Middle Provider Middle initial of Prescribing Physician Report the middle name of the prescribing physician here. All 2% C PC 48 Physician Last Name 6/24/10 Text Name Last Provider Last name of Prescribing Physician Report the last name of the prescribing physician here. All 50% B PC 49 Physician DEA Number 6/24/10 Text ID DEA char[9] Prescribing DEA Report the Primary DEA number for the prescribing physician All 80% B PC 50 National Provider ID - External Code Source 3 - Integer External Code Source 3 - National Provider ID int[10] National Provider Identification (NPI) of the Prescribing Provider Report the Primary National Provider ID (NPI) of the Prescribing Provider in This ID should be found on the Provider File in the NPI element (PV039). This element is looking to capture the NPI of an individual physician, not a group. All 95% A2 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 value 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 state 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 62 Source Indicator 11/8/12 Lookup Table - Integer int[1] Drug Source Indicator Report the value that defines the availability of the pharmaceutical. EXAMPLE: 1 = Multi-source brand All 98% A2 Value Description 1 Multi-source brand 2 brand with generic equivalent 3 Single source brand 4 Single source brand with generic equivalent 5 Unknown PC 63 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 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.Reminder: Must not be an SSN. 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 79 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 80 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 81 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 82 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 83 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 84 Carrier Specific Unique Member ID 11/8/12 Text ID Link to ME107 Member's Unique ID Report the identifier the carrier / submitter uses internally to uniquely identify the member. Used to validate Unique Member ID and link back to Member Eligibility (ME107). All 100% A0 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 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 87 Claim Line Type 11/8/12 Lookup Table - Text tlkpClaimLineType char[1] Claim Line Activity Type Code Report the code that defines the claim 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 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 Value 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 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PC 91 Diagnosis Code 11/8/12 External Code Source 8 - Text External Code Source 8 - International Classification of Disease varchar[7] ICD Diagnosis Code Report the ICD Diagnosis Code when applicable. All 1% B PC 92 ICD Indicator 11/8/12 Lookup Table - Integer tlkpICDIndicator int[1] International Classification of Diseases version Report the that defines whether the diagnoses on claim are ICD9 or ICD10. EXAMPLE: 9 = ICD9 Required when PC114 is populated 100% B Value Description 9 ICD-9 0 ICD-10 PC 93 Denied Flag 11/8/12 Lookup Table - Integer tlkpFlagIndicators int[1] Denied Claim Line Indicator Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line was denied. Required when PC025 = 04 100% A0 Description 1 Yes 2 No 3 Unknown 4 Other
5 Not Applicable PC 94 Denial Reason 11/8/12 Carrier Defined - OR - External Code Source 16 External Code Source 16 - Reason Codes -OR – Carrier Defined Denial Reason Code Report the code that defines the reason for denial of the claim line. Carrier must submit denial reason codes in separate table to the APCD. Required when PC116 = 1 98% A2 PC 95 Payment Type 11/8/12 Lookup Table - Numeric char[2] Payment Arrangement Type Value Report the value that defines the contracted payment methodology for this claim line. EXAMPLE: 02 = Fee for Service All 98% A0 Value Description 01 Capitation 02 Fee for Service 03 Percent of Charges 04 DRG 05 Pay for Performance 06 Global Payment 07 Other 08 Bundled Payment 09 Payment Amount Per Episode (PAPE) (MassHealth). (09 Valid for HD002 = MassHealth orgid ONLY ) PC 96 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 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 - 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 PC 98 Claim Line Paid Flag Lookup Table - Integer tlkpFlagIndicators int[1] Line Paid Indicator Report the value that defines the element. EXAMPLE: 1 = Yes, Claim Line was paid. Required 100% B Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PC 99 Record Type 6/24/10 Text ID File char[2] File Type Identifier Report PC here. This validates the type of file and the data contained within the file. This must match HD004. All 100% A0 1 Record Type 6/24/10 Text ID Record char[2] Trailer Record Identifier Report TR here. Indicates the end of the data file. Mandatory 100% TM 2 Submitter 11/8/12 Integer ID Submitter varchar[6] Trailer Submitter / Carrier ID defined by CHIA Report the Unique Submitter ID as defined by CHIA here. This must match the Submitter ID reported in HD002. Mandatory 100% TM 3 National Plan ID 11/8/12 Integer ID Nat'l PlanID int[10] CMS National Plan Identification Number (PlanID) Do not report any 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. Situational 0% TS 4 Type of File 6/24/10 Text ID File char[2] Validates the file type defined in HD004. Report PC here. This must match the File Type reported in HD004. Mandatory 100% TM 5 Period Beginning Date 6/24/10 Date Period - Integer Century Year Month - CCYYMM int[6] Trailer Period Start Date Report the Year and Month of the reported submission period in CCYYMM format. This date period must match the date period reported in HD005 and HD006. Mandatory 100% TM