Rx Claims

field name object type validation description primary key rxclaim string required the unique identifier for this rx claim service line may be a combination of claim id + service line number claim primary key rxclaim string required the unique identifier for this rx claim group block of business id group string required identifier for corresponding block of business, account, or root level division group id group string required identifier for corresponding client/group group name group string optional name of group group tin group string optional tin (tax id) of group group hierarchy 1 group string optional first level breakdown of group (location) group hierarchy 1 description group string optional description of first level breakdown group hierarchy 2 group string optional second level breakdown of group (division) group hierarchy 2 description group string optional description of second level breakdown group hierarchy 3 group string optional third level breakdown of group group hierarchy 3 description group string optional description of third level breakdown group funding arrangment group string optional self funded, fully insured, etc subscriber primary key subscriber string required a key that defines the uniqueness of this subscriber this should match the key used in other datasets subscriber id subscriber string required member identifier (or subscriber if subscriberprimarykey is equivalent to primarykey) often shared among a family this member will be considered the subscriber if the subscriberprimarykey is equal to this row's primarykey) subscriber person code subscriber string required person code corresponding to this member often 00 for member and 01, 02, 03, etc for dependents in the order they were registered subscriber alternate id subscriber string optional alternative identifier of member subscriber ssn subscriber fields ssn optional ssn for member some vendors will not be able to accept a family without at least a subscriber ssn subscriber employer id subscriber string optional employee identifier of subscriber subscriber first name subscriber string optional first name of member subscriber middle name subscriber string optional middle name of member subscriber last name subscriber string optional last name of member subscriber date of birth subscriber fields yyyymmdd optional date of birth of member subscriber address line 1 subscriber string optional address line 1 of member subscriber address line 2 subscriber string optional address line 2 of member subscriber address line 3 subscriber string optional address line 3 of member subscriber city subscriber string optional city of member subscriber state subscriber enum state optional two character state code conforming to the iso 3166 2\ us subdivision codes such as al, ak, az, ar, ca, co, etc subscriber postal code subscriber string optional postal code of member may include 6 or 10 characters subscriber country code subscriber enum country optional two character country code conforming to iso 3166 1 alpha 2 member primary key member string required a key that defines the uniqueness of this member this should match the key used in other datasets member id member string required member identifier (or subscriber if subscriberprimarykey is equivalent to primarykey) often shared among a family this member will be considered the subscriber if the subscriberprimarykey is equal to this row's primarykey) member person code member string required person code corresponding to this member often 00 for member and 01, 02, 03, etc for dependents in the order they were registered member alternate id member string optional alternative identifier of member member relationship member enum relationship optional member's relationship to subscriber e g , su = subscriber/self, sp = spouse, ch = child, de = other dependent, etc member ssn member fields ssn optional ssn for member some vendors will not be able to accept a family without at least a subscriber ssn member first name member string optional first name of member member middle name member string optional middle name of member member last name member string optional last name of member member preferred first name member string optional preferred first name of member, if applicable and known member prefix member string optional prefix (e g , mr , mrs , dr ) for member member suffix member string optional suffix (e g , jr , sr , iii) for member member gender member enum gender optional gender of member f, m, o, u = female, male, other, unknown member sex member enum sex optional sex of member f, m, o, u = female, male, other, unknown member date of birth member fields yyyymmdd optional date of birth of member member date of death member fields yyyymmdd optional date of death for member member address line 1 member string optional address line 1 of member member address line 2 member string optional address line 2 of member member address line 3 member string optional address line 3 of member member city member string optional city of member member state member enum state optional two character state code conforming to the iso 3166 2\ us subdivision codes such as al, ak, az, ar, ca, co, etc member postal code member string optional postal code of member may include 6 or 10 characters member country member enum country optional two character country code conforming to iso 3166 1 alpha 2 member coverage status coverage enum coveragestatus optional coverage status of member a,d,h,i,p,r,s,t = active,deceased,hold,inactive,pending,retired,suspended,terminated claim id rxclaim string required claim number / identifier if you use claim segments, you could exclude it here to provide greater optionality to group claims together based on segment/suffix claim segment rxclaim string conditionally required claim segment/suffix/extension often used to identify reversal or correction claims sometimes it is a suffix of the claim id/number required if used and not included in claim id claim parent id rxclaim string conditionally required id of the parent claim, if applicable must include the unique claim number claim alternate id rxclaim string recommended if there is an alternate id for the claim it is recommended that it be included claim line number rxclaim string required claim line number claim status rxclaim string required claim status code paid, denied, pending, finalized, rejected, withdrawn, in process, reversed claim source rxclaim string optional edi, key plan id rxclaim string required id of the plan plan name rxclaim string required the name given to the plan plan year rxclaim fields yyyy required the plan year that this claim applies to plan tpa id plan string recommended id of the third party administrator (tpa) for member plan tpa name plan string recommended name of the third party administrator (tpa) for member network id rxclaim string recommended id of the pricer of the claim network name rxclaim string recommended name of the pricer of the claim network status indicator rxclaim string required in = in network, on = out of network contract id rxclaim string recommended identifier of the contract applicable to this claim received date rxclaim fields yyyymmdd required the date that the claim was recieved adjudication date rxclaim fields yyyymmdd conditionally required date of adjudication paid date rxclaim fields yyyymmdd conditionally required date claim was paid last modified date rxclaim fields yyyymmdd required date the claim was last modified total charge rxclaim decimal as string required original total amount billed total allowed rxclaim decimal as string required maximum amount insurer will cover for this service line total paid rxclaim decimal as string required total amount paid for a service total paid = plan paid + member pay amount plan paid rxclaim decimal as string required amount paid by insurance plan part of total paid copay amount rxclaim decimal as string required fixed amount member pays when receiving service part of member pay amount deductible amount rxclaim decimal as string required amount member pays before insurance starts to pay part of member pay amount coinsurance amount rxclaim decimal as string required amount member pays after deductible has been met part of member pay amount coinsurance percentage rxclaim decimal as string optional the applicable coinsurance percentage member pay amount rxclaim decimal as string required amount member is responsible for member pay amount = copay amount + deductible amount + coinsurance amount + ineligible amount precert penalty amount rxclaim decimal as string optional precertification penalty amount added to claim part of member's liability payee rxclaim string recommended the unique identifier for this claim service line may be a combination of claim id + service line number check number rxclaim string optional check number for payment of claim subrogation status rxclaim enum optional subrogration status of claim if applicable acc = accident, mt = mass tort, n =none, wc = workers comp o = other subrogation paid amount rxclaim decimal as string recommended amount paid by due to accident/etc via subrogation cob other insurance type rxclaim enum optional other insurance type other, medicare, medicaid benefit code rxclaim string optional code for benefit applied to claim line benefit description rxclaim string optional description of benefit applied to claim line diagnosis code system rxclaim string required identifies icd9 vs icd10 diagnosis codes primary rxclaim string required icd 9 or icd 10 code(s) that appear on a claim there can be multiple icd codes sent diagnosis codes description primary rxclaim string required icd 9 or icd 10 code(s) description that appear on a claim authorization primary key rxclaim string conditionally required prior authorization number/id prescribing provider primary key provider string required unique identifier for the physician who rendered the service prescribing provider first name provider string required first name of the rendering physician prescribing provider last name provider string required last name of the rendering physician prescribing provider npi provider string recommended national provider identifier of the rendering physician prescribing provider tin provider string required tax identification number of the rendering physician prescribing provider id provider string optional internal identifier for the prescribing provider prescribing provider address line 1 provider string required first line of the rendering physician's address prescribing provider address line 2 provider string optional second line of the rendering physician's address, if applicable prescribing provider city provider string required city where the rendering physician is located prescribing provider state provider string required state where the rendering physician is located prescribing provider postal code provider string required postal code of the rendering physician prescribing provider country provider string required country code of the rendering physician prescribing provider specialty code provider string required specialty code of the rendering provider prescribing provider specialty code description provider string required description of the specialty code of the rendering provider pharmacy claim id rxclaim string required pharmacy claim id pharmacy name rxclaim string required pharmacy name pharmacy data source id rxclaim string recommended pharmacy data source id pharmacy federal tax id rxclaim string required pharmacy federal tax id pharmacy npi rxclaim string required pharmacy npi pharmacy ncpdp id rxclaim string recommended pharmacy ncpdp id pharmacy nabp number rxclaim string recommended pharmacy nabp number pharmacy address 1 rxclaim string recommended pharmacy address 1 pharmacy address 2 rxclaim string recommended pharmacy address 2 pharmacy city rxclaim string recommended pharmacy city pharmacy state rxclaim string recommended pharmacy state pharmacy zip rxclaim string recommended pharmacy zip pharmacy phone rxclaim string recommended pharmacy phone ingredient cost amount rxclaim decimal as string recommended ingredient cost amount dispensing fee amount rxclaim decimal as string recommended dispensing fee amount sales tax amount rxclaim decimal as string recommended sales tax amount awp unit price rxclaim decimal as string recommended average wholesale price (awp) unit price drug mac amount rxclaim decimal as string recommended maximum allowable cost (mac) amount manufacturer discount program paid rxclaim decimal as string recommended manufacturer discount program paid drug pricing type rxclaim enum optional methodology used to price the claim avg = average generic price, awp = average wholesale price, gea = generic equivalent average price, inc = ingredient cost, mac = maximum allowable cost, sbm = submitted price, u = unknown, u\&c = usual & customary, o = other pbm rxclaim string recommended name of the pbm fill date rxclaim fields yyyymmdd recommended date prescription was filled written date rxclaim fields yyyymmdd recommended date prescription was written drug strength rxclaim string recommended strength of the drug total fills rxclaim int recommended number of refills authorized fill number rxclaim int recommended refill number days supply rxclaim decimal as string recommended days supply dispensed daw status rxclaim enum dawstatus recommended as defined by the ncpdp 0=no product selection indicated 1=substitution not allowed by prescriber 2=substitution allowed patient requested product dispensed 3=substitution allowed pharmacist selected product dispensed 4=substitution allowed generic drug not in stock 5=substitution allowed brand drug dispensed as generic 6=override 7=substitution not allowed brand drug mandated by law 8=substitution allowed generic drug not available in marketplace 9=other drug is otc rxclaim string recommended y/n otc indicator drug generic name rxclaim string recommended generic drug name drug gpi rxclaim int recommended medispan gpi number drug multisource code rxclaim enum multisourcecode recommended this is the medispan multisource code m = multi source brand, o=original brand, n=single source brand, y=generic drug prescription number rxclaim string recommended identifier for the prescription formulary status rxclaim string recommended y/n should be y if the drug is part of a formulary tier formulary tier rxclaim decimal as string recommended rxagile formulary tier number mail order rxclaim string recommended y/n drug ndc rxclaim string recommended ndc code drug name rxclaim string recommended drug name drug is generic rxclaim string recommended y/n should be y if drug multisource code is y drug therapeutic class rxclaim string recommended identifies the pharmacological therapeutic category of the product according to the american hospital formulary service (ahfs) system drug maintenance indicator rxclaim string recommended y/n y = maintenance drug (typically dispensed at mail order), n = acute therapy (typically dispensed at retail) drug compound indicator rxclaim string recommended n=drug is not compound, y=drug is compound drug is specialty rxclaim string recommended y/n set to y if the drug is identified as a specialty medication quantity dispensed rxclaim decimal as string recommended number of units, grams, milliliters, other if compounded item, total of all ingredients will be supplied as quantity dispensed usual customary reasonable amount claimline money optional u\&c charge for the drug dosage form rxclaimline enum optional tablet granules solution capsule powder kit tablet soluble liquid tablet disintegrating solution reconstituted tablet delayed release disintegrating route of administration rxclaimline enum optional oral \ topical \ intravenous \ intramuscular \ subcutaneous \ inhalation \ rectal \ transdermal \ sublingual \ intradermal \ other \ not applicable dea class code rxclaimline string optional gpi description rxclaimline string optional description of the gpi bin rxclaimline string optional id number used for network routing processor control number rxclaimline string optional processor control number custom 1 private rxclaim string optional custom field custom 2 private rxclaim string optional custom field custom 3 private rxclaim string optional custom field custom 4 private rxclaim string optional custom field custom 5 private rxclaim string optional custom field custom 6 private rxclaim string optional custom field custom 7 private rxclaim string optional custom field custom 8 private rxclaim string optional custom field custom 9 private rxclaim string optional custom field custom 10 private rxclaim string optional custom field