N.H. Admin. Code § Ins 4010.03
Table 4010.03(b) Pharmacy Claims File Header Record Layout | ||||
Data Element # | Element | Type | Length (decimal places | Description/Codes/Sources |
HD001 | Record Type | Text | 2 | HD |
HD002 | Payer | Text | 8 | Payer submitting payments. NHID Submitter Code |
HD003 | National Plan ID | Text | 30 | CMS National Plan ID |
HD004 | Type of File | Text | 2 | PC Pharmacy Claims |
HD005 | Period Beginning Date | Date | 8 | Beginning of paid period for claims or beginning of month covered for eligibility |
HD006 | Period Ending Date | Date | 8 | End of paid period for claims or end of month covered for eligibility |
HD007 | Comments | Text | 80 | Submitter may use to document this submission by assigning a filename, system source, etc. |
Table 4010.03 (c) Pharmacy Claims File Trailer Record Layout | ||||
Data Element # | Element | Type | Length (decimal places) | Description/Codes/Sources |
TR001 | Record Type | Text | 2 | TR |
TR002 | Payer | Text | 8 | Payer submitting payments. NHID Submitter Code |
TR003 | National Plan ID | Text | 30 | CMS National Plan ID |
TR004 | Type of File | Text | 2 | PC Pharmacy Claims |
TR005 | Period Beginning Date | Date | 8 | Beginning of paid period for claims or beginning of month covered for eligibility |
TR006 | Period Ending Date | Date | 8 | End of paid period for claims or beginning of month covered for eligibility |
TR007 | Extraction Date | Date | 8 | Date file was created |
TR008 | Record Count | Number | 10 (0) | Total number of records submitted in this file |
Table 4010.03 (d) Pharmacy Claims Detailed File Specification | ||||
Data Element # | Element | Type | Length (decimal places) | Description/Codes/Sources |
PC001 | Payer | Text | 8 | Payer submitting payments NHID Submitter Code |
PC002 | Plan ID | Text | 30 | CMS National Plan ID |
PC003 | Insurance Type/Product Code | Text | 2 | As established by X12 Accredited Standards Committee, available at https://ushik.ahrq.gov/ViewItemDetails?system=sdo& itemKey;=133161000 |
PC004 | Payer Claim Control Number | Text | 35 | Must apply to the entire claim and be unique within the payer's system |
PC005 | Line Counter | Text | 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 |
PC006 | Insured Group Number | Text | 50 | Group or policy number (not the number that uniquely identifies the subscriber) |
PC007 | Subscriber Social Security Number | Text | 9 | Subscriber's social security number. Do not include dashes. Leave blank if not available. |
PC008 | Plan Specific Contract Number | Text | 50 | Plan assigned contract number. Leave blank if Plan Specific Contract Number is subscriber's social security number. If this is a Medicaid claim, provide Medicaid ID. |
PC009 | Member Suffix or Sequence Number | Text | 20 | Uniquely identifies the member within the contract |
PC010 | Member Social Security Number | Text | 9 | Member's social security number. Do not include dashes. Leave blank if not available. |
PC011 | Individual Relationship Code | Text | 2 | See Table 4010.6 (b) Relationship Codes |
PC012 | Member Gender | Text | 1 | M Male |
F Female | ||||
U Unknown | ||||
O Other | ||||
PC013 | Member Date of Birth | Date | 8 | |
PC014 | Member City Name of Residence | Text | 30 | City name of member |
PC015 | Member State | Text | 2 | As defined by the US Postal Service |
PC016 | Member ZIP Code | Text | 9 | ZIP Code of member- may include non- US codes. Do not include dash. |
PC017 | Paid Date (AP Date) | Date | 8 | Paid date or the Pharmacy Benefits Manager's billing date |
PC018 | Pharmacy Number | Text | 30 | Payer assigned pharmacy number. AHFS number is acceptable |
PC019 | Pharmacy Tax ID Number | Text | 10 | Federal taxpayer's identification number (Please provide the pharmacy chain's federal tax identification number, if the individual retail pharmacy's tax ID# is not available.) |
PC020 | Pharmacy Name | Text | 30 | Name of pharmacy |
PC021 | National Pharmacy ID Number | Text | 20 | Required if National Provider ID is mandated for use under HIPAA |
PC022 | Pharmacy Location City | Text | 30 | City name of pharmacy |
PC023 | Pharmacy Location State | Text | 2 | As defined by the US Postal Service |
PC024 | Pharmacy ZIP Code | Text | 9 | ZIP Code of pharmacy - may include non- US codes. Do not include dash |
PC024A | Pharmacy Country Name | Text | 30 | Code US |
PC025 | Service Line Status | Text | 2 | See Table 4010.6 (h) Claim Status |
PC026 | Drug Code | Text | 11 | NDC Code in CMS configuration with leading zeros and no hyphens. |
PC027 | Drug Name | Text | 80 | Text name of drug |
PC028 | New Prescription | Number | 2 (0) | 00 New prescription. 01-99 Number of refill(s) |
PC029 | Generic Drug Indicator | Text | 2 | 01 No, branded drug |
02 Yes, generic drug | ||||
PC030 | Dispense as Written Code | Text | 1 | 0 Not dispensed as written |
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 | ||||
PC031 | Compound Drug Indicator | Text | 1 | N Non-compound drug |
Y Compound drug | ||||
U Non-specified drug compound | ||||
PC032 | Date Prescription Filled | Date | 8 | |
PC033 | Quantity Dispensed | Number | 10 | Number of metric units of medication dispensed |
PC034 | Days' Supply | Number | 3 | Estimated number of days the prescription will last |
PC035 | Charge Amount | Number | 10 (2) | The full, undiscounted total and service-specific charges billed by the provider. |
PC036 | Paid Amount | Number | 10 (2) | Includes any withhold amounts. |
PC037 | Ingredient Cost/List Price | Number | 10 (2) | Cost of the drug dispensed. Do not code decimal point |
PC038 | Postage Amount Claimed | Number | 10 (2) | Postage amount in dollars |
PC039 | Dispensing Fee | Number | 10 (2) | Dispensing fess in dollars |
PC040 | Copay Amount | Number | 10 (2) | The preset, fixed dollar amount for which the individual is responsible. |
PC041 | Coinsurance Amount | Number | 10 (2) | Coinsurance amount in dollars |
PC042 | Deductible Amount | Number | 10 (2) | Deductible amount in dollars |
PC043 | Prescription Number | Text | 20 | Thenumbergenerated by the pharmacy when a newprescriptionis ordered for a person - a uniquecode assigned to a person's prescribed medicine |
PC044 | Prescribing Physician First Name | Text | 35 | Physician first name |
PC045 | Prescribing Physician Middle Name | Text | 25 | Physician middle name |
PC046 | Prescribing Physician Last Name | Text | 60 | Physician last name |
PC047 | Prescribing Physician Number | Text | 20 | Provider NPI |
PC101 | Subscriber Last Name | Text | 60 | |
PC102 | Subscriber First Name | Text | 35 | |
PC103 | Subscriber Middle Initial | Text | 1 | |
PC104 | Member Last Name | Text | 60 | |
PC105 | Member First Name | Text | 35 | |
PC106 | Member Middle Initial | Text | 1 | |
PC203 | Carrier Associated with Claim | Text | 8 | For each claim, the NAIC code of the carrier when a PBM processes claims on behalf of the carrier. Optional if all pharmacy claims processed by a PBM under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files. |
PC204 | Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number | Text | 128 | For each claim, the carrier specific contract number or subscriber/member social security number when a PBM processes claims on behalf of the carrier. Optional if all pharmacy claims processed by a PBM under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files. |
PC211 | Cross Reference Claims ID | Text | 35 | The original Payer Claim Control Number (PC004). Used when a new Payer Claim Control Number is assigned to an adjusted claim. |
PC212 | Allowed amount | Number | 10 (2) | Report the maximum amount contractually allowed for a particular procedure or service. This will vary by provider contract and most often it is less than or equal to the fee charged by the provider. |
PC213 | HIOS Plan ID | Text | 16 | The 16 character HIOS Plan ID (Standard component). Including a five digit issuer ID, two character state ID, three digit product number, four digit standard component number and two digit variant component ID. This field may not be available for all market segments; Leave blank if not available |
PC214 | Claim Processing Level Indicator | Text | 1 | 1 Claim Level |
2 Service Line level | ||||
PC215 | Service Line Type | Text | 1 | Report the code that defines the claim line status in terms of adjudication |
O Original | ||||
V Void | ||||
R Replacement | ||||
B Back Out | ||||
A Amendment | ||||
PC216 | Denied Claim Indicator | Text | 1 | 1 Fully Paid- the entire claim was paid at the allowed amount |
2 Partially denied- some of the claims lines were paid at the allowed amount | ||||
3 Encounter claim- this claim records a service provided that is paid under a non FFS payment arrangement such as capitation | ||||
4 No payment- no payment made for reasons other than non FFS payment arrangement | ||||
PC217 | Denial Reason | Text | 4 | Denial reason code. Required when denied claim indicator = 2 or 4 NCPDP denial reason codes and CARC/RARC code list accepted, available at http://www.wpc-edi.com/reference/codelists/healthcare/health-care-services-decision-reason-codes/ |
PC899 | Record Type | Text | 2 | PC |
PC900 | Mail Order Pharmacy Indicator | Text | 1 | A yes/no indicator that specifies that the pharmacy is a mail order pharmacy. Valid codes: Y=Yes, N=No |
PC901 | In Network Indicator | Text | 1 | A yes/no indicator that specifies that the provider (not the benefit) is within the health plan network. Valid codes: Y=Yes, N=No |
PC902 | Version Number | Number | 4(0) | Version number of this claim. The version number begins with 0 and is incremented by 1 for each subsequent version of that service line |
N.H. Admin. Code § Ins 4010.03