Prescription Claims File Data Elements

The Extract Identifier code for this file is RX.

 

Refer to Appendix B, “Prescription Claims Data-Map Process,” for details on how Prescription Claim records are added or updated in the Healthx database.

 

Field #

Field Name

Req.

Len

Type

Notes

1

VersionNumber

K

10

AN

Spec Version Number:  3.04

2

PayorName

R

100

AN

Payor Name

3

GroupNumber

R

20

AN

Payor Assigned Group Number

4

Location

O

12

AN

Location Code

5

BnftPlan

O

10

AN

Benefit Plan for the Claim

6

DateSubmitted

R

8

DT

The date the pharmacy submitted the claim for processing

7

DatePaid

R

8

DT

Paid date of this claim

8

PrescribedDate

R

8

DT

The date the provider wrote the prescription

9

DateFilled

R

8

DT

The dispensing date of the prescription

10

LastChange

O

8

DT

Last Date Changes/Revision Made to Claim

11

MemberID

K

64

AN

ID # of the Member (from their ID card)

12

SSN

R

9

AN

Member's SSN

13

LastName

R

50

AN

Member's Last Name

14

FirstName

R

51

AN

Member’s First Name

15

Address1

R

100

AN

Member’s Address Line One

16

Address2

R

100

AN

Member’s Address Line Two

17

City

R

50

AN

Member’s City

18

State

R

2

AN

Member’s State

19

Zip

R

10

AN

Member’s Zip Code

20

DependentNumber

R

64

AN

Dependent’s ID Number

21

RelCode

R

2

AN

Patient's relationship to member

22

PTName

R

100

AN

Patient's Name

23

PTDOB

R

8

DT

Patient’s Date of Birth

24

PTGender

R

1

AN

Patient's Sex

25

PharmacyID

R

15

AN

The number assigned to the pharmacy by the national association of boards of pharmacy (NABP)

26

PharmacyName

R

50

AN

The name of the pharmacy that dispensed the prescription

27

PharmacyAddress1

R

100

AN

Pharmacy Address line one

28

PharmacyAddress2

R

100

AN

Pharmacy Address line two

29

PharmacyCity

R

50

AN

Pharmacy City

30

PharmacyState

R

2

AN

Pharmacy State

31

PharmacyZip

R

10

AN

Pharmacy Zip

32

PharmacyChain

O

10

AN

Chain or region number of pharmacy

33

PrescriberTINSuffix

R

10

AN

Prescriber's TIN Suffix

34

PrescriberTIN

R

10

AN

Prescriber's Tax ID Number

35

PrescriberName

R

100

AN

Name of Physician writing the prescription

36

PrescriberAddress

R

100

AN

Prescriber's Address line one

37

PrescriberAddress2

R

100

AN

Prescriber's Address line two


 

Field #

Field Name

Req.

Len

Type

Notes

38

PrescriberCity

R

50

AN

Prescriber's City

39

PrescriberState

R

2

AN

Prescriber's State

40

PrescriberZip

R

10

AN

Prescriber's Zip

41

PrescriberSpecCode

O

2

AN

Prescriber's Specialty Code

42

PrescriberSpecDesc

O

100

AN

Prescriber's Specialty Description

43

PrescriberGroupName

O

100

AN

Prescriber's Group Practice Name

44

PPONumber

R

25

AN

Preferred Provider Organization Number

45

PPOName

R

50

AN

Preferred Provider Organization Name

46

NPIN

R

10

AN

National Provider ID

47

PCPTIN

O

16

AN

Tax identification number of members primary care physician

48

PPOFlag

R

1

AN

Indicates if the pharmacy dispensing the prescription is considered in network.
'empty' - Not Specified
Y = In Network
N = Out of Network/Not applicable
O = Out of Area

49

RXNumber

K

32

AN

The number assigned to the prescription by the pharmacy

50

TransactionType

R

1

AN

The media type of the transaction
1 =  Electronic
2 = Paper
3 = Tape
0 = Other

51

TransactionStatus

R

2

AN

Claim transaction type status:
1 = Payable claim
2 = Rejected claim
3 = Reversed claim
4 = duplicate claim
5 = Adjusted claim, 0 = Other

52

RxType

R

1

AN

1 = Single source brand
2 = Branded generic
3 = Generic
4 = Medical supplies
5 = Multi-source brand
6 = Over the Counter Drug
7 = Durable Medical Equipment
0 = Other

53

LabelName

R

30

AN

A descriptive name of the drug, usually the brand name

54

NDCNumber

R

12

AN

The 11-digit National Drug Code (NDC) assigned to the drug product by the drug manufacturer or distributor.

55

RXOrigin

R

1

AN

0 = Retail Claim Type Identifier
1 = Mail Order Claim Type Identifier

56

GenericCode

R

16

AN

Generic drug code

57

MaintDrugFlag

R

1

AN

Indicates if the drug is dispensed is a categorized as maintenance
0 = Acute Item, 1 Maintenance Item


Field #

Field Name

Req.

Len

Type

Notes

58

MACflag

R

1

AN

MAC Pricing used or not

59

DAW

R

1

AN

If the claim was processed with a Dispense As Written (DAW) override, a flag indicating the type of DAW is listed in this column:
0 = No DAW
1 = Prescriber-requested DAW
2 = Member-requested DAW
3 = Pharmacy-requested DAW
4 = Substitution Allowed – Generic not in stock
5 = Substitution Allowed - Brand drug 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

60

MetricUnits

R

16

AN

Quantity of prescription dispensed

61

DaysSupply

R

3

NU

The number of days the quantity of the drug dispensed is to last

62

DrugStrength

R

8

AN

Drug strength to the microgram level

63

RefillCode

R

2

NU

Is the prescription new or a refill
0 = New
1 = Refill

64

MaxRefill

R

2

NU

Number of refill authorized by prescriber (99 = as needed)

65

RefillRemaining

R

2

NU

Number of refills remaining

66

CompoundCode

R

1

AN

Code indicating if the drug is a compound
0 = not specified
1 = not a compound
2 = is a compound

67

AHFS

R

6

AN

Identifies therapeutic category of drug according to the American Hospital Formulary Service classification system.

68

RXClarificationCode

R

1

AN

Code indicating that the provider is clarifying the denial of a previously submitted claim:
0=not specified
1=no override
2=other override
3=vacation supply
4=lost prescription


Field #

Field Name

Req.

Len

Type

Notes

69

DEACode

R

1

AN

Indicates abuse potential for a controlled drug:  
 0 - Not a controlled drug
1 - Used for research only
2 - Most potential for abuse
3 - Less potential for abuse than 2
4 - Less potential for abuse than  2 & 3
5 - Least potential for abuse

70

DX1

R

5

AN

Diagnosis Code1

71

DX2

R

5

AN

Diagnosis Code2

72

DX3

R

5

AN

Diagnosis Code3

73

COBFlag

R

1

AN

Coordination of Benefits code as provided in eligibility indicating if the other coverage exists.

74

TotalCharge

R

12

DE

Amount Charged = Ingredient Cost + Dispensing Fee + Sales Tax

75

DispensingFee

R

12

DE

Amount charged for dispensing the drug

76

TotalDiscount

R

12

DE

Amount saved by use of contract pricing

77

Ineligible

R

12

DE

Amount not covered by insurance (patient responsibility)

78

CoInsurance

R

12

DE

Portion of the total charge the patient is responsible for as a result of a coinsurance percentage plan

79

Copay

R

12

DE

Member co-pay for plan billed

80

Deductible

R

12

DE

Amount applied to member's deductible

81

COB

R

12

DE

Amount paid by member’s primary insurance

82

SalesTax

R

12

DE

Sales Tax for the drug dispensed

83

TotalPenalty

R

12

DE

Sum of all penalty amounts

84

MemResponsibility

R

12

DE

Total of ineligible + co-pay + coinsurance + deductible

85

Paid

R

12

DE

Total Charge - Ineligible - Savings/Discount - COB Amt - Patient Responsibility

86

UNC

R

12

DE

Amount charged cash customers for the prescription exclusive of sales tax or postage

87

IngredientCost

R

12

DE

Ingredient cost of the drug dispensed

88

AWPCost

R

12

DE

Average Wholesale Price per unit for the drug

89

MACPrice

R

12

DE

Maximum Allowable Charge price for the NDC

90

CheckNumber1

R

20

AN

Check Number

91

CheckPaidTo

R

50

AN

Payee name on the check

92

CheckNumber2

R

20

AN

Check Number 2

93

CheckPaidTo2

R

50

AN

Payee name on the check 2

94

MemDAWPenDiff

O

12

DE

Price difference between the brand drug and generic drug which was paid by member as a result of DAW

95

MemDAWPen

O

12

DE

Amount paid by member as a result of DAW


 

Field #

Field Name

Req.

Len

Type

Notes

96

MemExcessClaims

O

12

DE

Amount reallocated to member as a result of the claims limitation rule

97

ExcessMAB

O

12

DE

Amount reallocated to member from client as a result of meeting a limit defined by a Maximum Allowable Benefit rule

98

DrugFormPen

O

12

DE

Additional co-payment amount paid by the member as a result of the drug not in formulary

99

PharmacyNetPen

O

12

DE

Additional co-payment amount paid by the member as a result of out of network Pharmacy co-payment rule

100

PrescribeNetPen

O

12

DE

Additional co-payment amount paid by the member as a result of out of network Prescriber co-payment rule

101

TotalMemPaid

R

12

DE

Total amount paid by member

102

PharmacyDAWPenDiff

O

12

DE

Price difference between the brand drug and generic drug which was paid by the pharmacy as a result of the DAW

103

PharmExcessClaims

O

12

DE

Amount reallocated to the pharmacy as a result of a claim limitation rule

104

TotalPharmacy

O

12

DE

Pharmacy DAW Penalty Difference Amount + the amount of the Pharmacy Excess Claim Limit Amount

105

ExcessOOP

O

12

DE

Amount reallocated to the client from the member as a result of meeting the Maximum Out Of Pocket rule

106

GrpDAWPenDiff

O

12

DE

Price difference the brand drug and generic drug which was paid by the  client as a result of the DAW

107

GrpExcessClaims

O

12

DE

Amount reallocated to client as a result of a claim limitation rule

108

GrpDue

R

12

DE

Amount billed to client for prescription

109

AppliedOOP

O

12

DE

Amount applied toward the appropriate Maximum Out Of Pocket limit

110

AppliedMAB

O

12

DE

Amount applied toward the appropriate Maximum Allowable Benefit limit

111

RejectCode1

O

4

AN

Code describing the reason for the ineligible amount

112

RejectCode2

O

4

AN

Code describing the reason for the ineligible amount

113

RejectCode3

O

4

AN

Code describing the reason for the ineligible amount

114

RejectCode4

O

4

AN

Code describing the reason for the ineligible amount

115

RejectCode5

O

4

AN

Code describing the reason for the ineligible amount

116

RejectCode6

O

4

AN

Code describing the reason for the ineligible amount

117

Comment

O

1000

AN

EOB Comments

118

ProviderComment

O

1000

AN

EOP Comments


Field #

Field Name

Req.

Len

Type

Notes

119

PriceScheduleType

R

1

AN

The schedule used to determine the payable amount for the prescription:  
1 - AWP
2 - Submitted Price
3 - Usual & Customary
4 - Ingredient Cost
5 - MAC Pricing                                                               6 - PPO network contract price
0 - Other Pricing

120

UserDefinedText1

O

255

AN

User Defined Text Field 1

121

UserDefinedText2

O

255

AN

User Defined Text Field 2

122

UserDefinedText3

O

255

AN

User Defined Text Field 3

123

UserDefinedNumeric1

O

12

DE

User Defined Numeric Field 1

124

UserDefinedNumeric2

O

12

DE

User Defined Numeric Field 2

125

UserDefinedNumeric3

O

12

DE

User Defined Numeric Field 3

126

ProdID

K

50

AN

Production Directory ID

127

ActionFlag

R

1

AN

Action to be taken with this record. 
D - Delete
R - Restrict
Blank - Load/Update


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