CRS_Drug_ERA_Payment_layout.txt
TXT text file 7 KB Posted
- Attached to
- DDS RFI 25-70008 Medicare Part D Claims Services
- Solicitation number
- 0000037087
- Issued by
- California
About this file
This is a technical copybook layout file for Medicare Part D Pharmacy Benefit Manager (PBM) payment processing, used by the California Department of Developmental Services (DDS) in conjunction with their existing drug claims billing solution. The file defines the data structure and field specifications for PDP payment records transmitted from DSG to CRS for processing through program CP540BC, with records sorted by service date, hospital code, entity code, and account number. The layout accommodates 300 bytes per record and includes 32 defined fields containing patient information, claim details, payment amounts, denial codes, and remittance remarks, with provisions for future expansion through a 35-byte filler section.
The technical specifications include fixed-length fields for claim identifiers, patient demographics, billed and approved amounts, deductibles, copayment information, and six CAS (Claim Adjustment Source) reason codes plus five LQ (Line Item Adjudication) remark codes used for claim processing and reconciliation. Key calculated fields include deductible and coinsurance amounts, approved amounts derived from billed amounts net of deductibles and coinsurance, and net charges calculated as the difference between billed amounts and total payments plus deductions. The file structure was originally created February 1, 2007, with subsequent modifications adding RX numbers (May 2008), CAS reason codes (June 2008), and LQ remark codes (June 2008) to support claims processing requirements specific to Developmental Services client populations receiving pharmacy benefits.
Text of this file
**** Top of data ****
* COPYBOOK CPPDPIRC - PDP PAYMENTS *
* LAYOUT FOR MEDICARE PART D PDP PAYMENT FILE INPUT. *
* DSG PROVIDES INPUT FILE TO CRS FOR PDP PAYMENTS. *
* PGM: CP540BC *
* JOB: DSCRS824 *
* SORT: INPUT WILL BE SORTED PRIOR TO CP540BC PROCESSES. *
* SORTED ON: SERVICE-DATE, HOSP-CD, ENTITY-CD, ACCT-NO. *
* NOTE: INCLUDED 35-BYTE FILLER FOR FUTURE EXPANSION. *
********************* CHANGE LOG *******************************
* 2/1/07 DON CHIPMAN *
* NEW COPYBOOK, LENGTH=300. *
* DSG/CRS MAPPING: *
* 1)P-CRS-ACCT-NO AND P-CRS-HOSP-CD AND P-CRS-ENTITY-CD IS SAME *
* FIELD SENT TO DSG,LABELED AS DBF-CRS-ACCT-NO-INTERNAL AND IS *
* COMPRISED OF ACCOUNT# FOR 12, HOSP-CD FOR 1, ENTITY-CD FOR 2.*
* 2)WS-DED-COINS-AMT IS CALCUATED AS: *
* P-APPLIED-DEDUCT + P-CO-INS-AMT. *
* 3)P-APPROVED-AMT IS CALCULATED AS: *
* P-BILLED-AMT - WS-DED-COINS-AMT(ALSO CALCULATED) *
* 4)AMT-DIFF IS CALCULATED AS: *
* P-BILLED-AMT - P-PROF-AMT. *
* 5)NET-CHARGES IS CALCULATED AS: *
* P-BILLED-AMT - (P-AMT-PAID-PROV + P-APPLIED-DEDUCT + P-CO-INS*
* -AMT). *
* 6)P-HIC: SAME AS 'IR-SUB-NO' FROM THE PAM 'E' RECORD. *
* 7)P-AMT-PAID-PROV: COB-EST-AMT, AKA BILLED AMOUNT. *
* 8)P-DENIAL-CD: NCPDP 5.1 REJECTION CODE FROM PDP...CLAIM DENIED*
* - 'SHOULD' RESULT IN $0 PAYMENT FROM PDP. *
* 9)RX-NO IS ADDED IN THE LAYOUT 05/14/08 *
* 10)P-CAS-REASON-CDS ARE ADDED IN THE LAYOUT 06/13/08 *
* 11)P-LQ-REMARK-CDS ARE ADDED IN THE LAYOUT 06/13/08 *
* 12)P-CO-INS-AMT AKA CLP05 DATA. THIS IS FOR SOME DMH PATIENT *
* COPAYS. *
* 13)P-SERVICE-DATE IS IN MMDDYY FORMAT. *
01 PDP-PMTS-INPUT.
05 P-CRS-ACCT-NO PIC 9(012).
05 P-CRS-HOSP-CD PIC X(001).
05 P-CRS-ENTITY-CD PIC X(002).
05 P-SERVICE-DATE PIC 9(006).
05 P-NDC-CD PIC 9(011).
05 P-RX-NO PIC 9(009).
05 P-PAT-LAST-NAME PIC X(015).
05 P-PAT-FIRST-NAME PIC X(010).
05 P-PLAN-CD PIC X(003).
05 P-PLACE-SRVC PIC 9(002).
05 P-BILLED-AMT PIC S9(006)V99.
05 P-AMT-PAID-PROV PIC S9(006)V99.
05 P-APPROVED-AMT PIC S9(006)V99.
05 P-PROF-AMT PIC S9(006)V99.
05 P-APPLIED-DEDUCT PIC S9(005)V99.
05 P-CO-INS-AMT PIC S9(005)V99.
05 P-CAS-REASON-CD-1 PIC X(010).
05 P-CAS-REASON-CD-2 PIC X(010).
05 P-CAS-REASON-CD-3 PIC X(010).
05 P-CAS-REASON-CD-4 PIC X(010).
05 P-CAS-REASON-CD-5 PIC X(010).
05 P-CAS-REASON-CD-6 PIC X(010).
05 P-LQ-REMARK-CD-1 PIC X(010).
05 P-LQ-REMARK-CD-2 PIC X(010).
05 P-LQ-REMARK-CD-3 PIC X(010).
05 P-LQ-REMARK-CD-4 PIC X(010).
05 P-LQ-REMARK-CD-5 PIC X(010).
05 P-DSG-CLAIM-ID PIC X(013).
05 P-BIN-NO PIC X(010).
05 P-HIC-SUB-NO PIC X(015).
05 PIC X(035).
**** End of data ****
Ref Field Name Picture Type Start End Length **** Top of data ****
1 1 PDP-PMTS-INPUT AN 1 300 300
2 2 P-CRS-ACCT-NO 9(012) ZD 1 12 12
3 2 P-CRS-HOSP-CD X(001) AN 13 13 1
4 2 P-CRS-ENTITY-CD X(002) AN 14 15 2
5 2 P-SERVICE-DATE 9(006) ZD 16 21 6
6 2 P-NDC-CD 9(011) ZD 22 32 11
7 2 P-RX-NO 9(009) ZD 33 41 9
8 2 P-PAT-LAST-NAME X(015) AN 42 56 15
9 2 P-PAT-FIRST-NAME X(010) AN 57 66 10
10 2 P-PLAN-CD X(003) AN 67 69 3
11 2 P-PLACE-SRVC 9(002) ZD 70 71 2
12 2 P-BILLED-AMT S9(006)V99 ZD 72 79 8
13 2 P-AMT-PAID-PROV S9(006)V99 ZD 80 87 8
14 2 P-APPROVED-AMT S9(006)V99 ZD 88 95 8
15 2 P-PROF-AMT S9(006)V99 ZD 96 103 8
16 2 P-APPLIED-DEDUCT S9(005)V99 ZD 104 110 7
17 2 P-CO-INS-AMT S9(005)V99 ZD 111 117 7
18 2 P-CAS-REASON-CD-1 X(010) AN 118 127 10
19 2 P-CAS-REASON-CD-2 X(010) AN 128 137 10
20 2 P-CAS-REASON-CD-3 X(010) AN 138 147 10
21 2 P-CAS-REASON-CD-4 X(010) AN 148 157 10
22 2 P-CAS-REASON-CD-5 X(010) AN 158 167 10
23 2 P-CAS-REASON-CD-6 X(010) AN 168 177 10
24 2 P-LQ-REMARK-CD-1 X(010) AN 178 187 10
25 2 P-LQ-REMARK-CD-2 X(010) AN 188 197 10
26 2 P-LQ-REMARK-CD-3 X(010) AN 198 207 10
27 2 P-LQ-REMARK-CD-4 X(010) AN 208 217 10
28 2 P-LQ-REMARK-CD-5 X(010) AN 218 227 10
29 2 P-DSG-CLAIM-ID X(013) AN 228 240 13
30 2 P-BIN-NO X(010) AN 241 250 10
31 2 P-HIC-SUB-NO X(015) AN 251 265 15
32 2 FILLER X(035) AN 266 300 35
**** End of data ****
Other files
| File | Type | Posted |
|---|---|---|
| DDS_RFI_25-70008_Medicare_Part_D_Claims_Addendum_01.docx | DOCX document | |
| Telecommunication_Guide_D.0.pdf | ||
| CRS_Drug_Billing_Extract_Layout.txt | TXT text file | |
| DDS_RFI_25-70008_Medicare_Part_D_Claims_Services_Final.docx | DOCX document | |
| Pharmacy_Claims_Editor.jpg | JPG image | |
| RFI_25-70008_Responses_to_Questions_11-17-25.docx | DOCX document |
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