CRS_Drug_Billing_Extract_Layout.txt
TXT text file 17 KB Posted
- Attached to
- DDS RFI 25-70008 Medicare Part D Claims Services
- Solicitation number
- 0000037087
- Issued by
- California
About this file
This file is a technical specification document for the Drug Claims Billing (PDP) file layout used by the California Department of Developmental Services (DDS) in its Medicare Part D claims processing system. The document provides detailed COBOL data structure definitions for a 343-byte record format (version 5.1 as of February 6, 2007, updated September 30, 2008) that captures comprehensive pharmacy claim information. The specification includes field definitions for multiple record segments: BIN number, transaction code, PCN, service provider identification (supporting both NPI and NCPDP number qualifiers), patient demographics (name, date of birth, gender), date of service, place of service, insurance segment data (cardholder ID, group ID, patient relationship code), claim disposition status, prescription details (including prescriber identification supporting both NPI and DEA number qualifiers, quantity dispensed, days supply, refills, and date written), and pricing segment data (ingredient cost, dispensing fee, usual and customary charge, and gross amount due). Each field is precisely mapped with start position, end position, and length specifications to ensure accurate data transmission and processing.
The document serves as a technical reference for vendors and internal systems involved in generating, validating, and processing drug billing claims within the DDS Medicare Part D program. The file layout supports the capture of clinical and operational data including basis of cost, DUR/PPS sequence identifiers, reason for service codes, professional service codes, result of service codes, prior authorization types and codes, and internal account tracking. The specification includes field initialization values and format specifications (numeric with decimals, alphanumeric, and zero-filled decimal types) necessary for standardized claim submission and processing workflows. This technical specification would be essential for any organization bidding on or supporting the DDS's Medicare Part D claims services, as referenced in RFI 25-70008, which seeks solution alternatives to replace the existing drug claims billing solution.
Text of this file
**** Top of data ****
* PDP DRUG BILL FILE LAYOUT - 343 BYTES AS OF 02/06/2007 *
* 084462 - INITIALIZE FIELD CORRESPONDING TO THE E4-6 *
* IN THE 5.1 TO SPACES. 09/30/2008 CEO *
01 DRUG-BILL-RECORD.
02 DBF-BIN-NO PIC 9(06) VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-VERSION-NO PIC X(02) VALUE '51'.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-TRANS-CD PIC X(02) VALUE 'B1'.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PCN PIC X(10) VALUE SPACES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-TRANS-CNT PIC X(01) VALUE '1'.
02 FILLER PIC X(01) VALUE '!'.
** '01' FOR NPI NUMBER ----- '07' FOR NCPDP NUMBER
02 DBF-SERV-PROV-ID-QUAL PIC X(02) VALUE '01'.
** 02 DBF-SERV-PROV-ID-QUAL PIC X(02) VALUE '07'.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-SERV-PROV-ID PIC X(15) VALUE SPACES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-DATE-OF-SERV PIC 9(08) VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-SWARE-VENDOR-CERT PIC X(10) VALUE SPACES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PAT-SEG-ID PIC X(02) VALUE '01'.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-DATE-OF-BIRTH PIC 9(08) VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PLACE-OF-SERV PIC 9(02) VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PAT-GENDER PIC 9(01) VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PAT-FIRST-NAME PIC X(12) VALUE SPACES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PAT-LAST-NAME PIC X(15) VALUE SPACES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-INS-SEG-ID PIC X(02) VALUE '04'.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-CARDHOLDER-ID PIC X(20) VALUE SPACES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-GROUP-ID PIC X(15) VALUE SPACES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PAT-RELAT-CD PIC 9(01) VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-CLAIM-SEG-ID PIC X(02) VALUE '07'.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-DISP-STATUS PIC X(01) VALUE SPACES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-OTH-COV-CD PIC 9(02) VALUE 01.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PRES-SERV-REF-QUAL PIC X(01) VALUE '1'.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PRES-SERV-REF-NO PIC 9(09) VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PROD-SERV-ID-QUAL PIC X(02) VALUE '03'.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PROD-SERV-ID PIC X(19) VALUE SPACES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-QTY-DISP PIC 9(07)V999 VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-FILL-NO PIC 9(02) VALUE 0.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-DAYS-SUPPLY PIC 9(03) VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-COMPOUND-CD PIC 9(01) VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-DAW-CD PIC X(01) VALUE SPACES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-DATE-PRES-WRITTEN PIC 9(08) VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-NO-REFILLS PIC 9(02) VALUE 0.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PRES-ORIGIN-CD PIC 9(01) VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PRES-SEG-ID PIC X(02) VALUE '03'.
02 FILLER PIC X(01) VALUE '!'.
** '01' FOR NPI NUMBER ----- '12' FOR DEA NUMBER
** 02 DBF-PRES-ID-QUAL PIC X(02) VALUE '01'.
02 DBF-PRES-ID-QUAL PIC X(02) VALUE '12'.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PRES-ID PIC X(10) VALUE SPACES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PRICING-SEG-ID PIC X(02) VALUE '11'.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-INGRE-COST-SUB PIC 9(06)V99 VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-DISP-FEE-SUB PIC 9(06)V99 VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-USUAL-CUST-CHARGE PIC 9(06)V99 VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-GROSS-AMT-DUE PIC 9(06)V99 VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-BASIS-OF-COST PIC X(02) VALUE '07'.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-DUR-PPS-SEQ-ID PIC X(02) VALUE '08'.
02 FILLER PIC X(01) VALUE '!'.
**----- 084462 -----------------------------------------------**
02 DBF-REASON-SERV-CD PIC X(02) VALUE ' '.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PROF-SERV-CD PIC X(02) VALUE ' '.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-RESULT-OF-SERV-CD PIC X(02) VALUE ' '.
02 FILLER PIC X(01) VALUE '!'.
**----- 084462 -----------------------------------------------**
02 DBF-DUR-PPS-CD-CNT PIC 9(01) VALUE 1.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-CRS-ACCT-NO-INTERNAL PIC X(15) VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PERSON-CD PIC X(03) VALUE '001'.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PLAN-CODE PIC X(03) VALUE SPACES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PRIOR-AUTH-TYPE PIC 9(02) VALUE ZEROES.
02 FILLER PIC X(01) VALUE '!'.
02 DBF-PRIOR-AUTH-CODE PIC 9(11) VALUE ZEROES.
**** End of data ****
Ref Field Name Picture Type Start End Length **** Top of data ****
1 1 DRUG-BILL-RECORD AN 1 343 343
2 2 DBF-BIN-NO 9(06) ZD 1 6 6
3 2 FILLER X(01) AN 7 7 1
4 2 DBF-VERSION-NO X(02) AN 8 9 2
5 2 FILLER X(01) AN 10 10 1
6 2 DBF-TRANS-CD X(02) AN 11 12 2
7 2 FILLER X(01) AN 13 13 1
8 2 DBF-PCN X(10) AN 14 23 10
9 2 FILLER X(01) AN 24 24 1
10 2 DBF-TRANS-CNT X(01) AN 25 25 1
11 2 FILLER X(01) AN 26 26 1
12 2 DBF-SERV-PROV-ID-QUAL X(02) AN 27 28 2
13 2 FILLER X(01) AN 29 29 1
14 2 DBF-SERV-PROV-ID X(15) AN 30 44 15
15 2 FILLER X(01) AN 45 45 1
16 2 DBF-DATE-OF-SERV 9(08) ZD 46 53 8
17 2 FILLER X(01) AN 54 54 1
18 2 DBF-SWARE-VENDOR-CERT X(10) AN 55 64 10
19 2 FILLER X(01) AN 65 65 1
20 2 DBF-PAT-SEG-ID X(02) AN 66 67 2
21 2 FILLER X(01) AN 68 68 1
22 2 DBF-DATE-OF-BIRTH 9(08) ZD 69 76 8
23 2 FILLER X(01) AN 77 77 1
24 2 DBF-PLACE-OF-SERV 9(02) ZD 78 79 2
25 2 FILLER X(01) AN 80 80 1
26 2 DBF-PAT-GENDER 9(01) ZD 81 81 1
27 2 FILLER X(01) AN 82 82 1
28 2 DBF-PAT-FIRST-NAME X(12) AN 83 94 12
29 2 FILLER X(01) AN 95 95 1
30 2 DBF-PAT-LAST-NAME X(15) AN 96 110 15
31 2 FILLER X(01) AN 111 111 1
32 2 DBF-INS-SEG-ID X(02) AN 112 113 2
33 2 FILLER X(01) AN 114 114 1
34 2 DBF-CARDHOLDER-ID X(20) AN 115 134 20
35 2 FILLER X(01) AN 135 135 1
36 2 DBF-GROUP-ID X(15) AN 136 150 15
37 2 FILLER X(01) AN 151 151 1
38 2 DBF-PAT-RELAT-CD 9(01) ZD 152 152 1
39 2 FILLER X(01) AN 153 153 1
40 2 DBF-CLAIM-SEG-ID X(02) AN 154 155 2
41 2 FILLER X(01) AN 156 156 1
42 2 DBF-DISP-STATUS X(01) AN 157 157 1
43 2 FILLER X(01) AN 158 158 1
44 2 DBF-OTH-COV-CD 9(02) ZD 159 160 2
45 2 FILLER X(01) AN 161 161 1
46 2 DBF-PRES-SERV-REF-QUAL X(01) AN 162 162 1
47 2 FILLER X(01) AN 163 163 1
48 2 DBF-PRES-SERV-REF-NO 9(09) ZD 164 172 9
49 2 FILLER X(01) AN 173 173 1
50 2 DBF-PROD-SERV-ID-QUAL X(02) AN 174 175 2
51 2 FILLER X(01) AN 176 176 1
52 2 DBF-PROD-SERV-ID X(19) AN 177 195 19
53 2 FILLER X(01) AN 196 196 1
54 2 DBF-QTY-DISP 9(07)V999 ZD 197 206 10
55 2 FILLER X(01) AN 207 207 1
56 2 DBF-FILL-NO 9(02) ZD 208 209 2
57 2 FILLER X(01) AN 210 210 1
58 2 DBF-DAYS-SUPPLY 9(03) ZD 211 213 3
59 2 FILLER X(01) AN 214 214 1
60 2 DBF-COMPOUND-CD 9(01) ZD 215 215 1
61 2 FILLER X(01) AN 216 216 1
62 2 DBF-DAW-CD X(01) AN 217 217 1
63 2 FILLER X(01) AN 218 218 1
64 2 DBF-DATE-PRES-WRITTEN 9(08) ZD 219 226 8
65 2 FILLER X(01) AN 227 227 1
66 2 DBF-NO-REFILLS 9(02) ZD 228 229 2
67 2 FILLER X(01) AN 230 230 1
68 2 DBF-PRES-ORIGIN-CD 9(01) ZD 231 231 1
69 2 FILLER X(01) AN 232 232 1
70 2 DBF-PRES-SEG-ID X(02) AN 233 234 2
71 2 FILLER X(01) AN 235 235 1
72 2 DBF-PRES-ID-QUAL X(02) AN 236 237 2
73 2 FILLER X(01) AN 238 238 1
74 2 DBF-PRES-ID X(10) AN 239 248 10
75 2 FILLER X(01) AN 249 249 1
76 2 DBF-PRICING-SEG-ID X(02) AN 250 251 2
77 2 FILLER X(01) AN 252 252 1
78 2 DBF-INGRE-COST-SUB 9(06)V99 ZD 253 260 8
79 2 FILLER X(01) AN 261 261 1
80 2 DBF-DISP-FEE-SUB 9(06)V99 ZD 262 269 8
81 2 FILLER X(01) AN 270 270 1
82 2 DBF-USUAL-CUST-CHARGE 9(06)V99 ZD 271 278 8
83 2 FILLER X(01) AN 279 279 1
84 2 DBF-GROSS-AMT-DUE 9(06)V99 ZD 280 287 8
85 2 FILLER X(01) AN 288 288 1
86 2 DBF-BASIS-OF-COST X(02) AN 289 290 2
87 2 FILLER X(01) AN 291 291 1
88 2 DBF-DUR-PPS-SEQ-ID X(02) AN 292 293 2
89 2 FILLER X(01) AN 294 294 1
90 2 DBF-REASON-SERV-CD X(02) AN 295 296 2
91 2 FILLER X(01) AN 297 297 1
92 2 DBF-PROF-SERV-CD X(02) AN 298 299 2
93 2 FILLER X(01) AN 300 300 1
94 2 DBF-RESULT-OF-SERV-CD X(02) AN 301 302 2
95 2 FILLER X(01) AN 303 303 1
96 2 DBF-DUR-PPS-CD-CNT 9(01) ZD 304 304 1
97 2 FILLER X(01) AN 305 305 1
98 2 DBF-CRS-ACCT-NO-INTERNAL X(15) AN 306 320 15
99 2 FILLER X(01) AN 321 321 1
100 2 DBF-PERSON-CD X(03) AN 322 324 3
101 2 FILLER X(01) AN 325 325 1
102 2 DBF-PLAN-CODE X(03) AN 326 328 3
103 2 FILLER X(01) AN 329 329 1
104 2 DBF-PRIOR-AUTH-TYPE 9(02) ZD 330 331 2
105 2 FILLER X(01) AN 332 332 1
106 2 DBF-PRIOR-AUTH-CODE 9(11) ZD 333 343 11
**** End of data ****
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