D020_AttachA_RPC_Data_-_revised.xlsx

XLSX spreadsheet 32 KB Posted Aug 30, 2013

Attached to: TRICARE Pharmacy Program, Fourth Generation (TPharm4)
Solicitation number: HT9402-13-R-0001
Issued by: Defense Health Agency

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Attachment A to CDRL D020

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RPC Data Elements

TRICARE Pharmacy Program, Fourth Generation (TPharm4)

Retail Pharmacy Claims (RPC) Data Requirements (updated 2013-06-30)

NOTE: These data requirements are in addition to those specified in TRICARE Systems Manual (TSM).

1.0 General Information

1.1 The TPharm contractor shall submit TED records (batch/voucher header, non-institutional, and provider) to TRICARE Management Activity (TMA) as per TRICARE Systems Manual (TSM). In addition, the contractor shall submit Retail Pharmacy Claims (RPC) data files to TMA as instructed below.

1.2 Retail Pharmacy Claims (RPC) data files are required for all claims processed by the TPharm contractor for drugs and supplies dispensed at or through non-DoD pharmacies. RPC data files are NOT required for claims for administrative services (such as Prior Authorization or Medical Necessity) or for items dispensed through TRICARE Pharmacy Home Delivery (also known as TRICARE Mail Order Pharmacy or TMOP).

1.3 TED records for claims processed by the TPharm contractor for drugs and supplies dispensed at or through non-DoD pharmacies are submitted with BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER (on BATCH/VOUCHER HEADER records) starting with either "1889" or "18D9". Each time the contractor submits or resubmits such TED records, it shall also submit or resubmit "companion" RPC records.

2.0 RPC-Specific Data Communications Technical Requirements

2.1 Communication Protocol: Connect:Direct through MHS B2B Gateway or Connect:Direct using Internet and Secure+.

2.2 Timing and other requirements: First submission shall be submitted at the same time as the first TED submission. Subsequent submissions shall be submitted with subsequent TED submissions.

3.0 RPC-Specific Transmission Records

3.1 The requirement for all electronic transmissions will incorporate the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated standards wherever feasible.

3.2 The first record in each transmission to TMA will be a transmission header, using the following format. Where value is specified under comments, the value must be reported exactly as shown.

TRANSMISSION HEADER RECORD FORMAT

Position(s)	Description	Content	Comment
1-8	Alpha	Data Type	Must be "RPC Data".
9-10	**	Delimiter	Must be "**".
11-22	Alphanumeric	File Name	"RPyyyymmddnnss", where yyyymmdd is the Transmission Date, nn is the TMA-assigned Contractor Number, and ss is the sequence number (01-99) of the file sent on a particular day.
23-24	**	Delimiter	Must be "**".
25-29	Alpha		Must be "FSIZE".
30-Variable	Numeric	File Size	Total number of VOUCHER records and CLAIM records.

Includes transmission header, excludes transmission trailer.

	Variable
(2 positions)	**	Delimiter		Must be "**".
	Variable
(6 positions)	Alpha	Record Type		Must be "RTYPEV".
	Variable
(2 positions)	**	Delimiter		Must be "**".
	Variable
(7 positions)	Alpha			Must be "MAXRLEN".
	Variable
(2 positions)	**	Delimiter		Must be "**".
	Variable	Numeric	Maximum
Record Length		1000.

(Length of the longest variable length record within the transmission.)

	Variable
(2 positions)	**	Delimiter		Must be "**".
	Variable - 80	Blank	Reserved		Must be spaces.
	3.3 Appended to the end of each transmission to TMA will be a transmission trailer record. The format for the transmission trailer record follows:

TRANSMISSION TRAILER RECORD FORMAT

	Position(s)	Description	Content	Comment
	1	Alpha	Record ID	Must be "@" sign.
	2-3	Alphanumeric	Contractor
Number		TMA-assigned Contractor Number.
	4-10	Alphanumeric	Transmission
Date		Enter in YYYYDDD format.
	11-14	Numeric	Voucher Count	Number of VOUCHER records in the transmission.
	15-20	Numeric	Record Count	Total number of VOUCHER records and CLAIM records.

Excludes transmission header and transmission trailer.

21 - 80 Blank Reserved Must be spaces.

4.0 RPC VOUCHER Data Element Layout

4.1 For every TED BATCH/VOUCHER HEADER record with BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER starting with "1889" or "18D9", the contractor shall also submit a matching and identical RPC VOUCHER record.

		NCPDP			POSITION		Corresponding TED Data Element
ELN	ELEMENT NAME	Field #	FORMAT	Width	FROM	THRU	ELN	ELEMENT NAME
0-001	HEADER TYPE INDICATOR	n/a	X	1	1	1	0-001	HEADER TYPE INDICATOR
0-010	CONTRACT NUMBER	n/a	X(13)	13	2	14	0-010	CONTRACT NUMBER
0-015	BATCH/VOUCHER IDENTIFIER	n/a	X	1	15	15	0-015	BATCH/VOUCHER IDENTIFIER
0-025	BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER	n/a	X(8)	8	16	23	0-025	BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER
0-030	BATCH/VOUCHER DATE	n/a	YYYYDDD	7	24	30	0-030	BATCH/VOUCHER DATE
0-035	BATCH/VOUCHER SEQUENCE NUMBER	n/a	X(2)	2	31	32	0-035	BATCH/VOUCHER SEQUENCE NUMBER
0-040	BATCH/VOUCHER RESUBMISSION NUMBER	n/a	X(2)	2	33	34	0-040	BATCH/VOUCHER RESUBMISSION NUMBER
0-045	TOTAL NUMBER OF RECORDS	n/a	9(7)	7	35	41	0-045	TOTAL NUMBER OF RECORDS
0-050	TOTAL AMOUNT PAID	n/a	S9(10)V99	12	42	53	0-050	TOTAL AMOUNT PAID
0-055	INITIAL TRANSMISSION DATE (TMA DERIVED)	n/a	YYYYMMDD	8	54	61	0-055	INITIAL TRANSMISSION DATE (TMA DERIVED)
0-060	TMA BATCH/VOUCHER PROCESSING DATE (TMA DERIVED)	n/a	YYYYMMDD	8	62	69	0-060	TMA BATCH/VOUCHER PROCESSING DATE (TMA DERIVED)
0-065	FUND ACCOUNTING	n/a	S9(8)V99	10	70	79	0-065	FUND ACCOUNTING

5.0 RPC CLAIM Data Element Layout

5.1 For every TED NON-INSTITUTIONAL record submitted together with a TED BATCH/VOUCHER HEADER record with BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER starting with "1889" or "18D9", the contractor shall also submit a companion RPC CLAIM record consisting of data elements listed below.

5.2 Relationship between RPC CLAIM data elements and TED NON-INSTITUTIONAL data elements:

- TED RECORD INDICATOR data: The first 7 data elements, in the first 33 positions, on the RPC CLAIM record shall be identical to the first 7 data elements, and the first 33 positions, on the companion TED NON-INSTITUTIONAL record, as per Chapter 2, Section 2.2 of TSM.

- Other TED data: The next 12 RPC CLAIM elements shall be identical to those on the companion TED NON-INSTITUTIONAL record, albeit in different positions.

- NCPDP data: The rest of the RPC CLAIM elements shall be populated with original claim data as per NCPDP Telecommunication Standard Version D.0 or later.

		NCPDP			POSITION		Corresponding TED Data Element
ELN	ELEMENT NAME	Field #	FORMAT	Width	FROM	THRU	ELN	ELEMENT NAME
X-001	RECORD TYPE INDICATOR	n/a	X(1)	1	1	1	2-001	RECORD TYPE INDICATOR
X-015	FILING DATE	n/a	YYYYDDD	7	2	8	2-015	FILING DATE
X-020	FILING STATE/COUNTRY CODE	n/a	X(3)	3	9	11	2-020	FILING STATE/COUNTRY CODE
X-025	SEQUENCE NUMBER	n/a	X(7)	7	12	18	2-025	SEQUENCE NUMBER
X-030	TIME STAMP	n/a	X(6)	6	19	24	2-030	TIME STAMP
X-035	ADJUSTMENT KEY	n/a	X(1)	1	25	25	2-035	ADJUSTMENT KEY
X-040	DATE TED RECORDS PROCESSED TO COMPLETION	n/a	YYYYMMDD	8	26	33	2-040	DATE TED RECORDS PROCESSED TO COMPLETION
X-055	SERVICE BRANCH CLASSIFICATION CODE (SPONSOR)	n/a	X(1)	1	34	34	2-055	SERVICE BRANCH CLASSIFICATION CODE (SPONSOR)
X-100	TYPE OF SUBMISSION	n/a	X(1)	1	35	35	2-100	TYPE OF SUBMISSION
X-105	CLAIM FORM TYPE/EMC INDICATOR	n/a	X(1)	1	36	36	2-105	CLAIM FORM TYPE/EMC INDICATOR
X-155	END DATE OF CARE	n/a	YYYYMMDD	8	37	44	2-155	END DATE OF CARE
X-170	NATIONAL DRUG CODE	n/a	X(11)	11	45	55	2-170	NATIONAL DRUG CODE
X-185	AMOUNT ALLOWED BY PROCEDURE CODE	n/a	S9(7)V99	9	56	64	2-185	AMOUNT ALLOWED
X-190	AMOUNT PAID BY OTHER HEALTH INSURANCE (OHI)	n/a	S9(7)V99	9	65	73	2-190	AMOUNT PAID BY OTHER HEALTH INSURANCE (OHI)
X-205	AMOUNT PAID BY GOV’T CONTRACTOR BY PROCEDURE CODE	n/a	S9(7)V99	9	74	82	2-205	AMOUNT PAID BY GOV’T CONTRACTOR BY PROCEDURE CODE
X-230	PROVIDER ORGANIZATIONAL NPI NUMBER	n/a	X(15)	15	83	97	2-230	PROVIDER ORGANIZATIONAL NPI NUMBER
X-250	PROVIDER ZIP CODE	n/a	X(9)	9	98	106	2-250	PROVIDER ZIP CODE
X-265	PROVIDER NETWORK STATUS INDICATOR	n/a	X(1)	1	107	107	2-265	PROVIDER NETWORK STATUS INDICATOR
X-305	SPECIAL PROCESSING CODE	n/a	X(8)	8	108	115	2-305	SPECIAL PROCESSING CODE
X-601	Transaction Response Status	112-AN	X(1)	1	116	116	<--- start of Status Segment fields
X-604	Authorization Number	5Ø3-F3	X(20)	20	117	136
X-607	Service Provider ID Qualifier	2Ø2-B2	X(2)	2	137	138	<--- start of Header Segment fields
X-610	Service Provider ID	2Ø1-B1	X(15)	15	139	153
X-613	Date of Service	4Ø1-D1	YYYYMMDD	8	154	161
X-616	Prescription/Service Reference Number Qualifier	455-EM	X(1)	1	162	162	<--- start of Claim Segment fields
X-619	Prescription/Service Reference Number	4Ø2-D2	9(12)	12	163	174
X-622	Product/Service ID Qualifier	436-E1	X(2)	2	175	176
X-625	Product/Service ID	4Ø7-D7	X(19)	19	177	195
X-628	Quantity Dispensed	442-E7	9(7)V999	10	196	205
X-631	Fill Number	4Ø3-D3	9(2)	2	206	207
X-634	Days Supply	4Ø5-D5	9(3)	3	208	210
X-637	Compound Code	4Ø6-D6	9(1)	1	211	211
X-640	Dispense As Written (DAW)/Product Selection Code	4Ø8-D8	X(1)	1	212	212
X-643	Date Prescription Written	414-DE	YYYYMMDD	8	213	220
X-646	Number of Refills Authorized	415-DF	9(2)	2	221	222
X-649	Prescription Origin Code	419-DJ	9(1)	1	223	223
X-652	Submission Clarification Code Count (max = 3)	354-NX	9(1)	1	224	224
X-655	Submission Clarification Code - 1st	42Ø-DK	9(2)	2	225	226
X-658	Submission Clarification Code - 2nd	42Ø-DK	9(2)	2	227	228
X-661	Submission Clarification Code - 3rd	42Ø-DK	9(2)	2	229	230
X-664	Other Coverage Code	3Ø8-C8	9(2)	2	231	232
X-667	Unit of Measure	6ØØ-28	X(2)	2	233	234
X-670	Level of Service	418-DI	9(2)	2	235	236
X-673	Prior Authorization Type Code	461-EU	9(2)	2	237	238
X-676	Prior Auth Number Submitted	462-EV	9(11)	11	239	249
X-679	Route of Administration	995-E2	X(11)	11	250	260
X-682	Dispensing Status	343-HD	X(1)	1	261	261
X-685	Associated Prescription/Service Reference Number	456-EN	9(12)	12	262	273
X-688	Associated Prescription/Service Date	457-EP	YYYYMMDD	8	274	281
X-691	Quantity Prescribed	46Ø-ET	9(7)V999	10	282	291
X-694	Quantity Intended To Be Dispensed	344-HF	9(7)V999	10	292	301
X-697	Days Supply Intended To Be Dispensed	345-HG	9(3)	3	302	304
X-700	Prescriber ID Qualifier	466-EZ	X(2)	2	305	306	<--- start of Prescriber Segment fields
X-703	Prescriber ID	411-DB	X(15)	15	307	321
X-706	Ingredient Cost Submitted	4Ø9-D9	S9(6)V99	8	322	329	<--- start of Pricing Segment fields
X-709	Patient Assignment Indicator (DMR Indicator)	391-MT	X(1)	1	330	330
X-712	Pharmacy Service Type	147-U7	9(2)	2	331	332
X-715	Dispensing Fee Submitted	412-DC	S9(6)V99	8	333	340
X-718	Patient Paid Amount Submitted	433-DX	S9(6)V99	8	341	348
X-721	Usual and Customary Charge	426-DQ	S9(6)V99	8	349	356
X-724	Gross Amount Due	43Ø-DU	S9(6)V99	8	357	364
X-727	Basis of Cost Determination	423-DN	X(2)	2	365	366
X-730	Patient Pay Amount	5Ø5-F5	S9(6)V99	8	367	374
X-733	Ingredient Cost Paid	5Ø6-F6	S9(6)V99	8	375	382
X-736	Dispensing Fee Paid	5Ø7-F7	S9(6)V99	8	383	390
X-739	Other Payer Amount Recognized	566-J5	S9(6)V99	8	391	398
X-742	Total Amount Paid	5Ø9-F9	S9(6)V99	8	399	406
X-745	Basis of Reimbursement Determination	522-FM	9(2)	2	407	408
X-748	Coordination of Benefits/Other Payments Count (max = 3)	337-4C	9(1)	1	409	409	<--- start of Coordination of Benefits/Other Payments Segment fields
X-751	Other Payer Coverage Type 1st	338-5C	X(2)	2	410	411
X-754	Other Payer ID Qualifier 1st	339-6C	X(2)	2	412	413
X-757	Other Payer ID 1st	34Ø-7C	X(10)	10	414	423
X-760	Other Payer Date 1st	443-E8	YYYYMMDD	8	424	431
X-763	Other Payer Amount Paid Count 1st	341-HB	9(1)	1	432	432
X-766	[Sum of] Other Payer Amount Paid 1st	431-DV	S9(6)V99	8	433	440
X-769	Other Payer Reject Count 1st (max = 5)	471-5E	9(2)	2	441	442
X-772	Other Payer Reject Code 1st-1	472-6E	X(3)	3	443	445
X-775	Other Payer Reject Code 1st-2	472-6E	X(3)	3	446	448
X-778	Other Payer Reject Code 1st-3	472-6E	X(3)	3	449	451
X-781	Other Payer Reject Code 1st-4	472-6E	X(3)	3	452	454
X-784	Other Payer Reject Code 1st-5	472-6E	X(3)	3	455	457
X-787	Other Payer Coverage Type 2nd	338-5C	X(2)	2	458	459
X-790	Other Payer ID Qualifier 2nd	339-6C	X(2)	2	460	461
X-793	Other Payer ID 2nd	34Ø-7C	X(10)	10	462	471
X-796	Other Payer Date 2nd	443-E8	YYYYMMDD	8	472	479
X-799	Other Payer Amount Paid Count 2nd (max = 5)	341-HB	9(1)	1	480	480
X-802	[Sum of] Other Payer Amount Paid 2nd	431-DV	S9(6)V99	8	481	488
X-805	Other Payer Reject Count 2nd	471-5E	9(2)	2	489	490
X-808	Other Payer Reject Code 2nd-1	472-6E	X(3)	3	491	493
X-811	Other Payer Reject Code 2nd-2	472-6E	X(3)	3	494	496
X-814	Other Payer Reject Code 2nd-3	472-6E	X(3)	3	497	499
X-817	Other Payer Reject Code 2nd-4	472-6E	X(3)	3	500	502
X-820	Other Payer Reject Code 2nd-5	472-6E	X(3)	3	503	505
X-823	Other Payer Coverage Type 3rd	338-5C	X(2)	2	506	507
X-826	Other Payer ID Qualifier 3rd	339-6C	X(2)	2	508	509
X-829	Other Payer ID 3rd	34Ø-7C	X(10)	10	510	519
X-832	Other Payer Date 3rd	443-E8	YYYYMMDD	8	520	527
X-835	Other Payer Amount Paid Count 3rd	341-HB	9(1)	1	528	528
X-838	[Sum of] Other Payer Amount Paid 3rd	431-DV	S9(6)V99	8	529	536
X-841	Other Payer Reject Count 3rd (max = 5)	471-5E	9(2)	2	537	538
X-844	Other Payer Reject Code 3rd-1	472-6E	X(3)	3	539	541
X-847	Other Payer Reject Code 3rd-2	472-6E	X(3)	3	542	544
X-850	Other Payer Reject Code 3rd-3	472-6E	X(3)	3	545	547
X-853	Other Payer Reject Code 3rd-4	472-6E	X(3)	3	548	550
X-856	Other Payer Reject Code 3rd-5	472-6E	X(3)	3	551	553
X-859	Compound Dosage Form Description Code	45Ø-EF	X(15)	15	554	568	<--- start of Compound Segment fields
X-862	Compound Dispensing Unit Form Indicator	451-EG	9(1)	1	569	569
X-865	Compound Ingredient Component Count (max = 25)	447-EC	9(2)	2	570	571
X-868	Compound Product ID Qualifier - 1st	488-RE	X(2)	2	572	573
X-871	Compound Product ID - 1st	489-TE	X(19)	19	574	592
X-874	Compound Ingredient Quantity - 1st	448-ED	9(7)V999	10	593	602
X-877	Compound Ingredient Drug Cost - 1st	449-EE	S9(6)V99	8	603	610
X-880	Compound Ingredient Basis of Cost Determination - 1st	49Ø-UE	X(2)	2	611	612
X-883	Compound Product ID Qualifier - 2nd	488-RE	X(2)	2	613	614
X-886	Compound Product ID - 2nd	489-TE	X(19)	19	615	633
X-889	Compound Ingredient Quantity - 2nd	448-ED	9(7)V999	10	634	643
X-892	Compound Ingredient Drug Cost - 2nd	449-EE	S9(6)V99	8	644	651
X-895	Compound Ingredient Basis of Cost Determination - 2nd	49Ø-UE	X(2)	2	652	653
X-898	Compound Product ID Qualifier - 3rd	488-RE	X(2)	2	654	655
X-901	Compound Product ID - 3rd	489-TE	X(19)	19	656	674
X-904	Compound Ingredient Quantity - 3rd	448-ED	9(7)V999	10	675	684
X-907	Compound Ingredient Drug Cost - 3rd	449-EE	S9(6)V99	8	685	692
X-910	Compound Ingredient Basis of Cost Determination - 3rd	49Ø-UE	X(2)	2	693	694
	filler		X(306)	306	695	1000

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