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Number
Field Name
Length
From
Thru
Description
Record Type
9(2)
Constant "54"
Region Code (1)
X(10)
Vendor Number
X(15)
Usually pharmacy NABP number
Œ
Á
Carrier Number. Pharmacy network associated with
group/benefit
Payment Batch Number
9(10)
EOB cycle number
Payment
Batch Date
9(8)
YYYYMMDD
Member Number
X(13)
ID Number of patient
Person Code\ Family position of patient. Example: 01 = insured. 02 =
spouse. 03 or greater = dependents
Relationship
Code
X(1)’ R e l a t i o n s h i p
t o
i n s u r e d .
O n l y
N C P D P
s t a n d a r d
c o d e s
a r e
r e p o r t e d .
N o n - s t a n d a r d
c o d e s
a r e
r e p o r t e d
a s
D
.
I
=
I n s u r e d .
S
=
S p o u s e .
D
=
D e p e n d e n t
Group Number
Group number of member
Division Number1 Allows for a
subset of employees within a company
Date of Birth
Last Name
X(50)1 Reference only -not to be used as
key information
Headquarter Code
X(5)
Assigned by MedImpact
Chain
ID
For internal use
Ingredient Cost
9(8)V99- Discounted ingredient
cost - 2 Decimal places
Claim ID
X(14)I
Claim number a different
claim number will be used for each prescription.
TCC Standard Code
X(2)
Therapeutic Class Code
Generic Product
Flag3 0=Non-Drug Item, 1=Generic, 2=Brand, 3=Multi Source
Claim
Created Date
X(8)3 D a t e
c l a i m
r e c e i v e d / c r e a t e d
b y
M e d I m p a c t
Y Y Y Y M M D D
Region code (2)
Region Code (2)
Rx
Number
Prescription number
Prescriber ID
Usually DEA #
Prescriber ID Type
X(30)- Usually the abbreviation
"DEA"
NDC Number
9(11)• National Drug Code number, must have format of
55555-4444-22 where 55555 indicates the maker, 4444 indicates the drug
and 22 indicates the packaging.
Date of Service
YYYYMMDD. Fill
date
Metric Quantity$ Quantity of drug (No decimal values)
DAW
Code
9(1)² 0 = No DAW. 1 = Physician DAW. 2 = Patient DAW. 3 =
Pharmacy DAW. 4 = No generic in stock. 5 = Brand as generic. 6 =
Override. 7 = Brand by law. 8 = Generic not available
Compound Code) Blank, 0, 1 = Non-compound. 2 = Compound
Approval
Number
Prior Authorization Number
Days Supply\ Number of days prescription should last based on doses
per day and the total number of doses
New/Refill Code
00 = New. 01 =
Refill
Filler
9(5)ƒ Formerly the deductible amount. Deductible
amount in this position will be obsolete as of 1/1/2002. See new field
position 693-700.
9(3)V99‚ Formerly the Tax Amount field. Tax amount
in this position will be obsolete as of 01/01/2004. See new field
position 737 to 743.
Facility CodeØ
Member's facility code : Facility code is the clinic
or Vendor that has that patient at that time the claim is run. This
field is what triggers which pharmacy that a patient could go to. It is
a physical address.
COB Code
0
=
N o t
S p e c i f i e d
N o r m a l
P r o c e s s i n g .
1
=
P r i m a r y
C o v e r a g e
N o r m a l
p r o c e s s i n g .
2
=
S e c o n d a r y
C o v e r a g e
R e j e c t .
3
=
D o u b l e
C o v e r a g e
N o
c o p a y .
4
=
D o u b l e
C o v e r a g e
N o
c o p a y
( C O B I I ) .
6
=
S e c o n d a r y
C o v e r a g e
S o f t
m e s s a g e .
9
=
R e s e r v e d
f o r
s p e c i a l
p u r p o s e
Medicare Codeo Medicare coverage for the member (subscriber or spouse
only) If the member has Medicare as the primary coverage
B = Medicare
part B only
=
M = Part A & B
R = Renal dialysis
Medicare Part D
Y = Yes, specifics undefined
D
Formulary Flag® Drug on formulary, "Y" Is part of Formulary, "N",
Is outside Formulary. "O" (Other) There is no Formulary. The Claim was
adjudicated under a benefit that has no formulary
Member Residence
Code' Member Residence Code. (NCPDP standard)
Other Coverage
Code8 Pharmacy submitted other coverage code. (NCPDP
standard)- Eligibility Clarification Code0 Eligibility clarification
code. (NCPDP standard)
Dispensing Fee. Professional dispensing fee - 2 decimal places
Billed AmountF Amount billed or submitted by pharmacy before copay - 2
decimal places
Total Costf Adjudicated Drug Cost. (Allowed drug cost). Field length
includes 2 decimal places. - 2 decimal places
Paid AmountU Amount paid to the pharmacy. Field length includes 2
decimal places. 2 decimal places
Generic Code Number% Generic product
identification number
Used Price Code] 1 = AWP. 2 = Baseline. 3 =
HCFA. 4 = MAC. 5 = HCFA/MAC. 6 = MMAC. 9 = Other. 9 = Other
Claim
Status Code» 0 = NEW. 1 = Approved and Paid. 2 = Denied. 3 = Reversed
original claim. 4 = Reversal entry against original claim. 5 = Dual
Claim. 6 = Dual Claim Reversed. 7 = Dual Claim Reversal
Region Code
(3)
Region Code 3
Paid Date YYYYMMDD. Date of check payment
Check Number? Pharmacy or member reimbursement check number for claim
payment
Message Field Code
X(3)" MedImpact error # for paper claims
Out of Pocket
9(6)V99E Sum of all charges to Member. Field length
includes 2 decimal places.
Drug CategoryU G = Generic, P = Preferred,N = Non-preferred , S =
Special, O = Other (not specified)
Payment Type Code• 1 = Pay to
pharmacy as calculated, 2 = Pay to pharmacy as billed, 3 = Pay to member
as billed, 4 = Pay to member as calculated
Sex
M = Male, F =
Female
General Text Message
X(61)
Claim record comment line
NAF
Dispensing Fee= Usually blank filled. Field length includes 2 decimal
places.
NAF Paid Amount
Benefit Code(
Benefit code that claim processed under.
Copay Amount, Member Co-payment on claim. 2 decimal places
NAF
Ingredient Cost
9(10)V99
Reference Number
Claim number being
reversed
AHFS Therapeutic Code
X(6)4 American Hospital Formulary
Service therapeutic code
Label Name% Drug name, strength, and dosage form
Claim Source
Code< P = POS, D = Data entered, H or F = File/Data load from
tape
Undiscounted awp unit price
9(14)V99999
When requested. 2 decimal places
Member First
Name
First Name of member
Member Age
9(3)
Age of member
Drug Name (Brand)
Name of Drug
Deductible AmountU Amount of claim applied to member
deductible. Field length includes 2 decimal places.
PCP ID Number
X(18)
Primary Care Physician ID Number
Alternate
Member Number
Tax Amount (New)
9(7)V99
2 decimal places
X(7)
Generic Flag< Blank = Unspecified, 1 = Multiple Sources, 2 = Single
Source
Physician First Name
X(51)
First Name of
Physician
Physician Last Name
Last Name of Physician
Metric Decimal
Quantity$ This is the complete metric quantity
Member Number
Overflow
X(11)
Pharmacy Name
Pharmacy Medi-Cal ID
Pharmacy Medi-Cal id
Date Rx
Written
Submitted by pharmacy (YYYYMMDD)
Part D type indicatorV 1 =
OTC. 2 = Part D Covered. 3 = Part B Covered. 4 = Medicaid wrap.
Blank = N/A
Pharmacy Address
Pharmacy City
Pharmacy St
Pharmacy Zip
Pharmacy Phone
Pharmacy Tax Id
X(20)
Pharmacy Tax ID
TCC
Standard Description
X(29)
AHFS Therapeutic Description
Pharmacy
County
Medicaid No
Social Security Number
9(9)
Class Code9 Drug class code, F = Federal Legend, O = Over The Counter
Vendor NPI No.5 NPI associated with Vendor NCPDP No. (when
available)#
(National Provider Identifier)
Submitted Vendor ID
code
0 1
=
N P I
0 7
=
N C P D P
( N A B P ) M may
also be any of the 15 other codes allowed by NCPDP in the original claim
Prescriber NPI No.7 NPI associated with Prescriber DEA No. (when
available)
Submitted Prescriber ID code
1 2
=
D E A
HICL
X(05)@ H I C L
d r u g
i d e n t i f i e r
o n l y
p o p u l a t e d
f o r
d r u g
d a t a
s u b s c r i b e r s .
HICL Description< H I C L
D e s c r i p t i o n
o n l y
p o p u l a t e d
f o r
d r u g
d a t a
s u b s c r i b e r s .
GTC
Code
X(02)V G e n e r i c
T h e r a p e u t i c
C l a s s
C o d e
( S m a r t
K e y )
o n l < B y populated for drug
data subscribers.
GTC DescriptionG G T C
D e s c r i p t i o n
( S m a r t
K e y )
o n l y
p o p u l a t e d
f o r
d r u g
d a t a
s u b s c r i b e r s .
STC
Code
X(04)X S p e c i f i c
T h e r a p e u t i c
C l a s s
C o d e
( S m a r t
K e y )
o n l y
p o p u l a t e d
f o r
d r u g
d a t a
s u b s c r i b e r s .
STC
DescriptionG S T C
D e s c r i p t i o n
( S m a r t
K e y )
o n l y
p o p u l a t e d
f o r
d r u g
d a t a
s u b s c r i b e r s .
Drug Name
Example: LEXAPRO
Drug Strength
Example: 20 MG
Drug Dosage Form
Example:TABLET
Value Options
Physician State License No'
Based on Data provided by
Facility NPI
Facility ID field
340B Indicator ( Carrier)
Usually
Carrier Number
Drug Generic Name
Generic Name for Drug
Always
Member Number Combined
x(30)L Combination of existing Member
Number X(13) and Member Number Overflow X(11)
Refills
Available
(9)10< Difference between # of Fills Field and Refill
Number field
340B Wholesale Account9 340B Wholesale Distribution
Accout for Coverd entity site
Standard Wholesale Account7 Standard
Wholesale Account for Association for Pharmacy
PBM Claim Fee (Admin
Fee)
PBM Fee - 2 decimal places$ Data Submission Specs - From BHO
PBMÿ
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