Attachment L - KEHP Pharmacy Claims Invoicing Document - PBM RFP 2025.xlsx
XLSX spreadsheet 23 KB Posted
- Attached to
- Pharmacy Benefits Manager (PBM)
- Solicitation number
- RFP-758-2500000221-4
- Issued by
- Elliott County, Kentucky
About this file
This document is a detailed technical specification for the Kentucky Employees' Health Plan (KEHP) Pharmacy Claims Invoicing File, designed for a Pharmacy Benefit Management (PBM) Request for Proposal (RFP) for the year 2025. The file outlines a comprehensive data record structure for pharmacy claims processing, specifying 47 distinct data fields that capture intricate details about pharmacy transactions, including subscriber and patient information, service dates, pharmacy types, claim statuses, and financial components.
The file provides a precise, delimited data format with specific field lengths, positions, and formatting requirements for each data element. Key financial attributes include net amount due, dispensing fees, and rebate identifiers, with each field separated by a '|' delimiter. The record structure supports transaction tracking through unique transaction IDs, enables detailed reporting across various pharmacy dispensing types (ranging from retail to specialty pharmacies), and includes demographic information such as patient gender, date of birth, and service provider details. The technical specification appears designed to facilitate standardized, comprehensive pharmacy claims reporting and invoicing for the Kentucky Employees' Health Plan's pharmacy benefit management procurement process.
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| File | Type | Posted |
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| Attachment M - Census Data - KEHP Formulary Disruption Final.xlsx | XLSX spreadsheet | |
| Attachment O - Census Data - KEHP Rx Plan Designs 2024.xlsx | XLSX spreadsheet | |
| Attachment N - Census Data - KEHP Network Disruption Final.xlsx | XLSX spreadsheet | |
| Final_RFP_758_2500000221_4_SO_FORM.PDF | ||
| Attachment I - KEHP Data Integration Chart - PBM RFP 2025.xlsx | XLSX spreadsheet | |
| Attahment K - BAA.pdf | ||
| Attachment H - Technical Questionnaire - PBM RFP 2025.xlsx | XLSX spreadsheet | |
| Attachment C - Prescriptions Filled from Nov 2023 through Oct 2024.pdf | ||
| Final_RFP_758_2500000221_2_SO_FORM.PDF | ||
| Attachment P - Census Data - KEHP Rx Plan Designs 2025.xlsx | XLSX spreadsheet | |
| Final_RFP_758_2500000221_1_SO_FORM.PDF | ||
| Attachment B - Cost Form - PBM RFP 2025.xlsx | XLSX spreadsheet | |
| Attachment J -DEI Billing Procedure Document.pdf | ||
| Final_RFP_758_2500000221_3_SO_FORM.PDF | ||
| Attachment F - Mandatory Requirements - PBM RFP 2025.xlsx | XLSX spreadsheet |
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Text version
KEHP Pharmacy Claims File
| Claim/Service Detail Record | ||||||
| Field # | Field Name | Format | Size | Start | End | Description/Values |
| 1 | Record Type | A/N | 2 | 1 | 2 | |
| 2 | Delimiter | A/N | 1 | 3 | 3 | Value: '|' |
| 3 | Last Name | A/N | 35 | 4 | 38 | The last name of the Subscriber. |
| 4 | Delimiter | A/N | 1 | 39 | 39 | Value: '|' |
| 5 | First Name | A/N | 25 | 40 | 64 | The first name of the Subscriber. |
| 6 | Delimiter | A/N | 1 | 65 | 65 | Value: '|' |
| 7 | Patient Last Name | A/N | 35 | 66 | 100 | The last name of the patient associated to the claim. |
| 8 | Delimiter | A/N | 1 | 101 | 101 | Value: '|' |
| 9 | Patient First Name | A/N | 25 | 102 | 126 | The first name of the patient associated to the claim. |
| 10 | Delimiter | A/N | 1 | 127 | 127 | Value: '|' |
| 11 | Patient Date of Birth | N | 8 | 128 | 135 | The date of birth of the patient that the claim processed against. |
Format CCYYMMDD
| 12 | Delimiter | A/N | 1 | 136 | 136 | Value: '|' |
| 13 | Patient Gender Code | N | 1 | 137 | 137 | The gender of the patient that the claim processed against. |
Values:
1 = Male 2 = Female 0 = Not Specified
| 14 | Delimiter | A/N | 1 | 138 | 138 | Value: '|' |
| 15 | Date of Service | N | 8 | 139 | 146 | Date the prescription was filled or professional service rendered. |
Format = CCYYMMDD
| 16 | Delimiter | A/N | 1 | 147 | 147 | Value: '|' |
| 17 | Claim Processed Date | N | 8 | 148 | 155 | Date the claim or adjustment is processed. Format = CCYYMMDD |
| 18 | Delimiter | A/N | 1 | 156 | 156 | Value: '|' |
| 19 | Service Provider ID | A/N | 15 | 157 | 171 | Dispensing provider ID number. |
| 20 | Delimiter | A/N | 1 | 172 | 172 | Value: '|' |
| 21 | Pharmacy Dispenser Type | A/N | 2 | 173 | 174 | Type of pharmacy dispensing product: |
1 = Retail 2 = Grocery Store 3 = Department Store 4 = Long Term Care 5 = Mail Order 6 = IV Infusion 7 = Dispensing Physician 8 = Indian Health Services 9 = VA Hospital 10 = State Hospital 11 = Institution 12 = HMO Pharmacy
13= DME
14 = Clinic Pharmacy 15 = Specialty 16 = Nuclear 17 = Military 18 = Compounding 19 = Independent Pharmacy 0 = Other
| 22 | Delimiter | A/N | 1 | 175 | 175 | Value: "|" |
| 23 | Claim Type | A/N | 1 | 176 | 176 | Claim submission type. |
Blank = Not Specified 1 = POS Claim 2 = Batch Claim 3 = Pharmacy Submitted Paper Claim (UCF) 4 = Member Submitted Paper Claim (DMR) 5 = Other
| 24 | Delimiter | A/N | 1 | 177 | 177 | Value: '|' |
| 25 | Cycle End Date | N | 8 | 178 | 185 | Cycle End Date, i.e. the "run through" date of the file. |
Format = CCYYMMDD
| 26 | Delimiter | A/N | 1 | 186 | 186 | Value: '|' |
| 27 | Product/Service ID | A/N | 19 | 187 | 205 | Product ID for the product dispensed. |
Format = MMMMMDDDDPP
| 28 | Delimiter | A/N | 1 | 206 | 206 | Value: '|' |
| 29 | Product/Service Name | A/N | 30 | 207 | 236 | Label or drug name associated to the product dispensed. |
| 30 | Delimiter | A/N | 1 | 237 | 237 | Value: '|' |
| 31 | Record Status Code | A/N | 1 | 238 | 238 | Transaction status as assigned by the processor. |
Blank = Not Specified 1 = Paid 2 = Rejected 3 = Reversed 4 = Adjusted 5 = Captured 6 = Reverse Captured
| 32 | Delimiter | A/N | 1 | 239 | 239 | Value: '|' |
| 33 | Transaction ID | A/N | 18 | 240 | 257 | Unique Claim Identifier (i.e., Doc#, RxClaim/Sequence #, BRT-ID/BRI-NB/Void Indicator) |
A unique number based upon the following format: yyddssssshheee yy = The year submitted ddd = the julian date sssss = the number of seconds into the day hh = hundredths of seconds eee = the engine on which the claim was processed
The Sequence number of 999 is created along with the RxClaim number. The sequence number continues to increment down by one for every new paid or rejected transaction. If a claim is reversed, the reversal transaction retains both the same RxClaim identification of a paid-reversal combination.
| 34 | Delimiter | A/N | 1 | 258 | 258 | Value: "I" | |
| 35 | Alternate ID | A/N | 20 | 259 | 278 | Subscriber Alternate ID. Only populated when Alternate ID is being used by the client. | |
| 36 | Delimiter | A/N | 1 | 279 | 279 | Value: '|' | |
| 37 | Net Amount Due | ||||||
| (Total Amount Billed/Paid) | N | 10 | 280 | 289 | Net amount due from the client to the payer. This is the Total Amount Billed/Paid, not including the dispensing fee. |
Format = s$$$$$$cc s9(6)v99
| 38 | Delimiter | A/N | 1 | 290 | 290 | Value: '|' |
| 39 | Dispensing Fee Amount Due | A/N | 10 | 291 | 300 | Dispensing fees due from the client to the payer. |
Format = s$$$$$$cc s9(6)v99
| 40 | Delimiter | A/N | 1 | 301 | 301 | Value: '|' |
| 41 | Rebate Identifier | A/N | 10 | 302 | 311 | Identifier which ties the dispensed drug to a corresponding rebate category. The rebate category must directly link to rebate reporting which accompanies the rebate payment. |
| 42 | Delimiter | A/N | 1 | 312 | 312 | Value: '|' |
| 43 | Account ID | A/N | 15 | 313 | 327 | Populated with the RxClaim account ID associated to the patient at the time the prescription was filled. |
| 44 | Delimiter | A/N | 1 | 328 | 328 | Value: '|' |
| 45 | Filler | A/N | 1 | 329 | 329 | Blank |
| 46 | Delimiter | A/N | 1 | 330 | 330 | Value: '|' |
| 47 | Invoice Number | A/N | 92 | 331 | 422 | Invoice # for corresponding client invoice |
| Claim/Service Trailer Record | ||||||
| Field # | Field Name | Format | Size | Start | End | Description/Values |
| 1 | Record Type | A/N | 2 | 1 | 2 | |
| 2 | Delimiter | A/N | 1 | 3 | 3 | Value: '|' |
| 3 | Total Record Count | N | 10 | 4 | 13 | The total number of records being submitted, including header and trailer in count. |
| 4 | Delimiter | A/N | 1 | 14 | 14 | Value: '|' |
| 5 | Total Net Amount Due | N | 12 | 15 | 26 | Summarization of Net Amount Due (256) |
Format s$$$$$$$$$$cc s9(10)v99 6 Filler A/N 374 27 400 Spaces
File details come from the government source that posted it. Updated .