N.H. Code Admin. R. Ins 4010.03
(b) Pharmacy Claims File Header Record Layout
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.
(c) Pharmacy Claims File Trailer Record Layout
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
(d) Pharmacy Claims Detailed File Specifications
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
The number generated by the pharmacy when a new prescription is ordered for a person - a unique code 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
Source. #10877, eff 7-10-15; ss by #13136, eff 11-24-20