Attachment C - Claims File Layouts.pdf

Pharmacy Claims Data Layout

Data Fields Definition

Unique Claimant ID Number Unique PBM Assigned number that identifies a claimant within their system.

Subscriber ID Number Primary plan members assigned number which should be constant for entire family

Group ID Number Plan/PBM Group ID

Sub Group ID Number Plan/PBM Group ID

Patient Relationship Code / Person Code

Patients relationship to primary plan member

Patient Date Of Birth Patient Date Of Birth

Patient Sex Patient Sex

Pharmacy NABP/NPI Number

Nationally assigned number which identifies dispensing pharmacy

Pharmacy Type NABP or NPI

Pharmacy Name Pharmacy Name

Pharmacy ZIP Code Pharmacy ZIP Code

Pharmacy Chain Code Pharmacy Chain Code

Pharmacy Chain Name Pharmacy Chain Name

Claim Number PBM Claim identification number

Fill Date Dispensing date of prescription

Billing Date Date of script used for billing purposes

New/Refill Code Code identifying whether patient has previously received a prescription for a given drug.

DAW Code Code that indicates reason for dispensing of Multi-Source product given Generic availability.

MAC Indicator Code indicating whether Generic MAC pricing was utilized.

Days Supply Dispensed Number of days that dispensed medication will last.

Metric Units Dispensed Number of units (quantity) of medication dispensed.

Ingredient Cost Ingredient cost charged for medication dispensed (discounted AWP cost).

Dispensing Fee Dispensing fee charged by pharmacy for medication dispensed.

Tax State sales tax charged if applicable.

Copay Amount Collected Amount of copay collected for medication dispensed.

Coinsurance Amount Collected

Amount of coinsurance collected for medication dispensed.

Deductible Amount Collected

Amount of deductible collected for medication dispensed.

Formulary Indicator (Y/N) Code indicating whether medication dispensed is on PBM's/Plan's Formulary listing.

Formulary Tier Tier # for drug dispensed

Amount Paid Total amount paid by Plan for medication dispensed

Usual and Customary Amount

The usual and customary amount charged for dispensed medication.

Excess Copay Amount If excess copay retention is allowed, amount of additional copay/ancillary charge collected from member.

Member Copay Differential/DAW Penalty Amount

Amount of DAW penalty/ancillary charge collected from member.

Pharmacy DAW Penalty Amount

Amount of DAW penalty/ancillary charge collected from the pharmacy.

Average Wholesale Price The Average Wholesale Price associated with Quantity of medication dispensed as calculated by PBM.

Mail/Retail Indicator Code indication whether medication was dispensed at Retail or Mail Order pharmacy.

Attachment B: Claims File Layouts

Retail 90 Indicator Code indicating that drug was dispensed at Retail 90.

Limited Distribution Drug Indicator

Code indicating that drug is a Limited Distribution Drug.

Multi-Source Drug Indicator Code indicating that drug is Branded, but, available from multiple manufacturers (I.e.

has Generic or Brand equivalents)

Single Source Drug Indicator Code indicating that drug is Branded and has no Generic equivalents.

Generic Drug Indicator Code indicating that drug is a Generic.

Single Source Exclusivity Indicator

Code indicating that a Generic is under exclusivity period and available from limited number of manufacturers.

Specialty Drug Indicator Code indicating that drug is a Specialty Drug.

Maintenance Drug Indicator Code indicating that a drug is maintenance drug

Submission Type Code indicating whether claim was submitted electronically (point of sale, or, in traditional paper form.)

NDC Code 11 digit code that identifies drug and dosage form dispensed.

Drug Name Name of drug dispensed.

Drug Strength Strength of drug dispensed.

AHFS Therapeutic Class Code

American Hospital Formulary Service Code indicating therapeutic category of drug (I.e.

cardiovascular, anti-infective, etc)

FDB Generic Therapeutic Class Code

First data bank Code indicating therapeutic category of drug (I.e. cardiovascular, anti-infective, etc)

Compound Drug Indicator Code indicating whether medication is a compound (Mix of Other drugs) prepared at the pharmacy.

Claim Type (Payment/Reversal)

Code indicating whether claim is original or a reversal.

Physician ID Number Unique number that identifies prescribing physician.

EBD DAILY EXTRACT FILE - As of 08/25/21 Record Length 1622

Nbr Field Name Example Data EBD Field size Required UB/1500 Notes HA Notes/Questions HA Field Size QCA Comments QCA Field Length 1 plan_source Gold, Silver or Bronze,HA, etc. Pic X(6) Required Gold, Silver, or Bronze. HA will be used for 2011 plan year run-out Health Advantage Claims Pic X(6) 2 file_date 20120101 Pic X(8) Required Date file generated. Typically the day the file is generated is the day it will be posted extract date Pic X(8) Date file was generated or date claims were processed?answer-generated 3 batch_number 1 Pic 9. Required If more than one batch is sent in a day, increment Pic 9.

4 claim_number Pic X(12) Required ICN Pic X(12) 12 digits max 5 claim_line Pic x(4) Required service line Pic x(4) three digits max 6 patient_control_number Pic x(35) claim Pic x(20) 35 Characters 7 adj_ind VarChar(x) Optional Null value is initial claim; R=Readjudication of a paid claim; Z=readjudication of a reje service line > 00 y Pic x 8 interim_bill N Pic x Required Y or N Inpatient bill defined by f Pic x 9 patient_id 99999901 Pic x(8) Required Must be 8 digit EBD Member Number EBD supplied Pic x(8)

10 alternate_id PGX99999901 Pic x(16) number used by carrier to identify patient its prefix + member number? is this Social Security Number?

11 patient_gender F Pic x Required M or F member Pic x 12 patient_dob 19570821 Pic x(8) Required member Pic x(8) 13 patient_status Pic x(2) Optional Discharge Status when discharged from facility discharge from claim Pic x(2) Is this required with an inpatient UB? Yes 14 received_date 20110926 Pic x(8) Required ymdrcvd from service_x Pic x(8) 15 per_diem_flag Pic x(2) Optional Y if claim is lumped together Null if claim is split First 2 bytes of FEESHCED Pic x(2) Is this required? Only if claim is lumped together 16 preauth_number Pic x(30) Optional if previously provided by AHH include here authorization number se Pic x(30) 17 bill_type Pic x(4) UB UB Pic x(3) four digits 18 statement_from 20110925 Pic x(8) UB claim Pic x(8) 19 statement_to 20110925 Pic x(8) UB claim Pic x(8) 20 first_date 20101227 Pic x(8) 1500 YMDEFF Pic x(8) 21 last_date 20101227 Pic x(8) 1500 YMDEND Pic x(8) 22 covered_days Pic 9(9) Days from service_x Pic 9(9) Is this on the auth file from AHH?

23 non_covered_days Pic 9(9) If line denied calculate YM Pic 9(9) 24 coins_days Pic 9(9) UB On UB table Pic 9(9) Need more information on data definition 25 admit_date 20110825 Pic x(8) UB ymdADMIT claim Pic x(8) 26 admit_hour Pic 9(2) TIMEADMIT claim Pic 9(2) 27 admit_type Pic x(2) 28 admit_source Pic x(2) UB Pic x(2) 29 discharge_date Pic x(8) claim Pic x(8) 30 discharge_hour pic 9(2) claim pic 9(2) 31 discharge_status Pic x(2) claim Pic x(2) 32 medical_record_num Pic x(12) claim Pic x(12) 33 condition_code_1 Pic x(2) UB UB Pic x(2) 34 condition_code_2 Pic x(2) UB UB Pic x(2) 35 condition_code_3 Pic x(2) UB UB Pic x(2) 36 condition_code_4 Pic x(2) UB UB Pic x(2) 37 condition_code_5 Pic x(2) UB UB Pic x(2) 38 condition_code_6 Pic x(2) UB UB Pic x(2) 39 condition_code_7 Pic x(2) UB UB Pic x(2) 40 occurrence_code_1a Pic x(2) UB ub_occur Pic x(2) 41 occurrence_date_1a Pic x(8) ub_occur Pic x(8) 42 occurrence_code_2a Pic x(2) ub_occur Pic x(2) 43 occurrence_date_2a Pic x(8) ub_occur Pic x(8) 44 occurrence_code_3a Pic x(2) ub_occur Pic x(2) 45 occurrence_date_3a Pic x(8) ub_occur Pic x(8) 46 occurrence_code_4a Pic x(2) ub_occur Pic x(2) 47 occurrence_date_4a Pic x(8) ub_occur Pic x(8) 48 occurrence_code_1b Pic x(2) ub_occur Pic x(2) 49 occurrence_date_1b Pic x(8) ub_occur Pic x(8) 50 occurrence_code_2b Pic x(2) ub_occur Pic x(2) 51 occurrence_date_2b Pic x(8) ub_occur Pic x(8) 52 occurrence_code_3b Pic x(2) ub_occur Pic x(2) 53 occurrence_date_3b Pic x(8) ub_occur Pic x(8) 54 occurrence_code_4b Pic x(2) ub_occur Pic x(2) 55 occurrence_date_4b Pic x(8) ub_occur Pic x(8) 56 value_code_1a Pic x(2) ub ub_value Pic x(2) 57 value_amount_1a Pic 9(9) ub ub_value Pic 9(9) 58 value_code_2a Pic x(2) ub ub_value Pic x(2) 59 value_amount_2a Pic 9(9) ub ub_value Pic 9(9) 60 value_code_3a Pic x(2) ub ub_value Pic x(2) 61 value_amount_3a Pic 9(9) ub ub_value Pic 9(9) 62 value_code_1b Pic x(2) ub ub_value Pic x(2) 63 value_amount_1b Pic 9(9) ub ub_value Pic 9(9) 64 value_code_2b Pic x(2) ub ub_value Pic x(2) 65 value_amount_2b Pic 9(9) ub ub_value Pic 9(9) 66 value_code_3b Pic x(2) ub ub_value Pic x(2) 67 value_amount_3b Pic 9(9) ub ub_value Pic 9(9) 68 value_code_1c Pic x(2) ub ub_value Pic x(2) 69 value_amount_1c Pic 9(9) ub ub_value Pic 9(9) 70 value_code_2c Pic x(2) ub ub_value Pic x(2) 71 value_amount_2c Pic 9(9) ub ub_value Pic 9(9) 72 value_code_3c Pic x(2) ub ub_value Pic x(2) 73 value_amount_3c Pic 9(9) ub ub_value Pic 9(9) 74 value_code_1d Pic x(2) ub ub_value Pic x(2) 75 value_amount_1d Pic 9(9) ub ub_value Pic 9(9) 76 value_code_2d Pic x(2) ub ub_value Pic x(2) 77 value_amount_2d Pic 9(9) ub ub_value Pic 9(9) 78 value_code_3d Pic x(2) ub ub_value Pic x(2) 79 value_amount_3d Pic 9(9) ub ub_value 80 asg_ben_ind Pic x(2) Optional UB UB accept assignment ind Pic x(2) 81 patient_last_name Pic x(36) MEMBER member Pic x(36) 35 characters max 82 patient_first_name Pic x(26) MEMBER member Pic x(26) 25 characters max 83 patient_initial Pic x MEMBER member Pic x 1 character 84 patient_relationship Pic x(2) Required UB Use 834 Relationship Codes see next tab up codeset class_x from Pic x(2) Does this need to be mapped in any special way? 1 character 85 icd-flag Pic x(2) 09 or 10 to indicate ICD-9 or ICD-10 Would you like a flag to id pic x 86 prin_ICD-9_diag_code 32723 Pic x(6) CLAIM; additional field fo Pic x(6) 87 Present_on_Admit_prin_ICD-9_diag_code Pic x(1) Y-Present at inpatient adm Pic x(1) 88 other_ICD_9_diag_code_1 Pic x(6) claim_d_p Additional field for ICD10 Pic x(6) 89 other_ICD_9_diag_code_2 Pic x(6) claim_d_p AMISUR table has OTHER Pic x(6) 90 other_ICD_9_diag_code_3 Pic x(6) claim_d_p Pic x(6)

91 other_ICD_9_diag_code_4 Pic x(6) claim_d_p Pic x(6) 92 other_ICD_9_diag_code_5 Pic x(6) claim_d_p Pic x(6) 93 other_ICD_9_diag_code_6 Pic x(6) claim_d_p Pic x(6) 94 other_ICD_9_diag_code_7 Pic x(6) claim_d_p Pic x(6) 95 other_ICD_9_diag_code_8 Pic x(6) claim_d_p Pic x(6) 96 prin_ICD-10_diag_code 32723 Pic x(8) CLAIM; additional field fo Pic x(8) 97 Present_on_Admit_prin_ICD-10_diag_code Pic x(1) Y-Present at inpatient admit - N-Not present inpatient admit U-insufficient data determine W-provider cannot determine Blank-exempt from POA reporting or not used or unreported 98 other_ICD-10_diag_code_1 Pic x(8) claim_d_p Additional field for ICD10 Pic x(8) 99 other_ICD-10_diag_code_2 Pic x(8) claim_d_p AMISUR table has OTHER Pic x(8)

100 other_ICD-10_diag_code_3 Pic x(8) claim_d_p Pic x(8) 101 other_ICD-10_diag_code_4 Pic x(8) claim_d_p Pic x(8) 102 other_ICD-10_diag_code_5 Pic x(8) claim_d_p Pic x(8) 103 other_ICD-10_diag_code_6 Pic x(8) claim_d_p Pic x(8) 104 other_ICD-10_diag_code_7 Pic x(8) claim_d_p Pic x(8) 105 other_ICD-10_diag_code_8 Pic x(8) claim_d_p Pic x(8) 106 Admit_ICD-9_diag_code 32723 Pic x(6) CLAIM; additional field fo Pic x(6) 107 Present_on_Admit_Admit_ICD-9_diag_code Pic x(1) Y-Present at inpatient admit - N-Not present inpatient admit U-insufficient data determine W-provider cannot determine Blank-exempt from POA reporting or not used or unreported 108 Admit_ICD-10_diag_code_1 Pic x(8) claim_d_p Additional field for ICD10 Pic x(8) 109 Present_on_Admit_Admit_ICD-10_diag_code Pic x(1) Y-Present at inpatient admit - N-Not present inpatient admit U-insufficient data determine W-provider cannot determine Blank-exempt from POA reporting or not used or unreported 110 prin_icd9_proc_code Pic x(6) UB Pic x(6) 111 prin_icd9_proc_code_date Pic x(8) UB Pic x(8) 112 other_icd9_proc_code_1 Pic x(6) CLAIM_D_P Pic x(6) 113 other_icd9_proc_code_1_date Pic x(8) UB? Pic x(8) 114 other_icd9_proc_code_2 Pic x(6) Pic x(6) 115 other_icd9_proc_code_2_date Pic x(8) Pic x(8) 116 other_icd9_proc_code_3 Pic x(6) Pic x(6) 117 other_icd9_proc_code_3_date Pic x(8) Pic x(8) 118 other_icd9_proc_code_4 Pic x(6) Pic x(6) 119 other_icd9_proc_code_4_date Pic x(8) Pic x(8) 120 other_icd9_proc_code_5 Pic x(6) Pic x(6) 121 other_icd9_proc_code_5_date Pic x(8) Pic x(8) 122 prin_icd10_proc_code Pic x(12) Pic x(12) 123 prin_icd10_proc_code_date Pic x(8) Pic x(8) 124 other_icd10_proc_code_1 Pic x(12) Pic x(12) 125 other_icd10_proc_code_1_date Pic x(8) Pic x(8) 126 other_icd10_proc_code_2 Pic x(12) Pic x(12) 127 other_icd10_proc_code_2_date Pic x(8) Pic x(8) 128 other_icd10_proc_code_3 Pic x(12) Pic x(12) 129 other_icd10_proc_code_3_date Pic x(8) Pic x(8) 130 other_icd10_proc_code_4 Pic x(12) Pic x(12) 131 other_icd10_proc_code_4_date Pic x(8) Pic x(8) 132 other_icd10_proc_code_5 Pic x(12) Pic x(12) 133 other_icd10_proc_code_5_date Pic x(8) Pic x(8) 134 proc_code _HCPCS_code A7035 Pic X(6) SERVICE_X Pic X(6) 135 proc_code_mod_1 Pic x(2) SERVICE_X Pic x(2) 136 proc_code_mod_2 Pic x(2) 137 proc_code_mod_3 Pic x(2) 138 proc_code_mod_4 Pic x(2) 139 place_of_service 12 Pic x(2) SERVICE_X Pic x(2) 140 revenue_code Pic x (4) SERVICE_X Pic x (4) 141 drg Pic x(4) claim (after we have ass Pic x(4) 142 billed_units Pic 9(9) UNITS SERVICE_X Pic 9(9) Max is 9,999,999,999,999,999.99 143 charges 49.69 Pic 9(16)v99 decimal is required AMT_CHARGE SERVICE_X Pic 9(9) Max is 9,999,999,999,999,999.99 144 charges_not_covered 20.27 Pic 9(16)v99 decimal is required AMT_DENY SERVICE_X Pic 9(9) Max is 9,999,999,999,999,999.99 145 allowed_amount 29.42 Pic 9(16)v99 decimal is required AMT_ALLOW SERVICE_X Pic 9(9) Max is 9,999,999,999,999,999.99 146 copay_amount Pic 9(16)v99 decimal is required AMT_COPAY SERVICE_X Pic 9(9) Max is 9,999,999,999,999,999.99 147 coins_amount 2.94 Pic 9(16)v99 decimal is required AMT_COINS SERVICE_X Pic 9(9) Max is 9,999,999,999,999,999.99 148 deductible_amount Pic 9(16)v99 decimal is required AMT_DED SERVICE_X Pic 9(9) Max is 9,999,999,999,999,999.99 149 cob_amount Pic 9(16)v99 decimal is required AMTTPP SERVICE_X (O Pic 9(9) Max is 9,999,999,999,999,999.99 150 paid_amount 26.48 Pic 9(16)v99 decimal is required AMTPAY SERVICE_X Pic 9(9) Max is 9,999,999,999,999,999.99 151 patient_responsibility_amount 2.94 Pic 9(16)v99 SUBROUTINE CAL calculated by our balancin Pic 9(9) 152 remarks -1 Pic X(3) Remark summary Pic X(2) 153 remarks -2 Pic X(3) pad to left with zeros for numeric pad to right with spaces for txt Pic X(2) 154 remarks -3 Pic X(3) Pic X(2) 155 remarks -4 Pic X(3) Pic X(2) 156 remarks -5 Pic X(3) Pic X(2) 157 remarks -6 Pic X(3) Pic X(2) 158 Anesthesia Claim Pic x Optional Required if Y Procedure codes 00100 thru 01999 The 9 codes are 99100, 99116, 99135, 99140 159 Institutional or Professional P Pic x Required I or P claim type claim; presen Pic x 160 Network Pic x(3) In-In Network; OON-Out of Network; Ext-In Extended (wrap) network; PIN-Pay as if In Network, "MC "= Medicaid Recoups 161 servicing_provider_taxid 123456789 pic x(9) Optional At a minimum either the provider Taxid, or Carrier ID or NPI is required - Provider re payto tax id from claim_d pic x(9) 162 servicing_provider_carrier_id 5N223 Pic X(12) Optional Provider rendering the service ABCBS legacy number; re Pic X(12) 163 servicing_provider_NPI 123456789 Pic x(10) Required Provider rendering the service payto NPI; rendering doc Pic x(10) 164 Pay-To_provider_taxid 123456789 pic x(9) Optional If the provider being paid is different from the rendering/servicing provider payto tax id from claim_d pic x(9) We will be providing the Rendering provider information.

165 Pay_To_provider_carrier_id 5N223 Pic X(12) Optional ABCBS legacy number; re Pic X(12) 166 Pay_To_provider_NPI 123456789 Pic x(10) Required payto NPI; rendering doc Pic x(10) 167 admit_carrier_provider_id Pic x(12) Optional Pic x(12) 168 admit_provider_NPI Pic x(10) Optional Pic x(10) 169 referring_carrier_provider_id Pic x(12) ABCBS 5 digit number sePic x(12) 170 referring_provider_NPI Pic x(12) NPI claim_d Pic x(12) Need more information - EOB Code?

171 attending_physician Pic x(12) Optional KR will let us know Pic x(12) 172 other_physician_1 Pic x(30) Optional UB UB Pic x(30) 173 other_physician_2 Pic x(30) Optional UB UB Pic x(30) 174 counter_copay_amount 12500 Pic 9(16)v99 2 decimal places is implied AMT_COPAY SERVICE_X Pic 9(9) Max is 9,999,999,999,999,999.99 175 counter_coins_amount Pic 9(16)v99 AMT_COINS SERVICE_X Pic 9(9) Max is 9,999,999,999,999,999.99 176 counter_deductible_amount Pic 9(16)v99 AMT_DED SERVICE_X Pic 9(9) Max is 9,999,999,999,999,999.99 177 CO-45 Pic 9(16)v99 Charges exceed your contracted/legislated fee arrangement. Pic 9(9) Max is 9,999,999,999,999,999.99 178 CO-237 Pic 9(16)v99 Legislated/Regulatory Penalty Pic 9(9) Max is 9,999,999,999,999,999.99 179 CO-253 Pic 9(16)v99 Medicare EOB sequestration payment reduction Pic 9(9) Max is 9,999,999,999,999,999.99 180 CO-94 Pic 9(16)v99 Processed in Excess of charges Pic 9(9) Max is 9,999,999,999,999,999.99 181 CO-59 Pic 9(16)v99 Processed based on multiple or concurrent procedure rules Pic 9(9) Max is 9,999,999,999,999,999.99 182 CO-132 Pic 9(16)v99 Prearranged demonstration project adjustment Pic 9(9) Max is 9,999,999,999,999,999.99 182 Amount_Withhold Pic 9(16)v99 Contractual amount of withholding service_x Pic 9(9) Max is 9,999,999,999,999,999.99

183 ndc_code Pic x(12) NDC Code Pic x(12) 184 drug_name Pic x(72) Drug Name Pic x(72) 185 code_description Pic x(72) Porcedure Code Description Pic x(72)