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| Field Number |
Title |
Description |
Required (Y/N) |
Preferred (Y/N) |
Notes |
| 1 |
Employer Master Group Number |
A number assigned by the health plan to represent the parent employer group for which all subgroups can be classified under |
N |
Y |
|
| 2 |
Employer Group Name |
The name of the company in which the subscriber is employed and purchased insurance through This name is associated with the Employer Master Group Number |
N |
N |
|
| 3 |
Employer Name |
|
N |
N |
|
| 4 |
Employer Subgroup Number |
A number assigned to represent a division within an employer group |
N |
Y |
|
| 5 |
Employer Subgroup Name |
The name of the division in which the subscriber is employed and purchased insurance through. This is associated with the Employer Subgroup Number |
N |
N |
|
| 6 |
Standard Industrial Classification Code |
A four digit code assigned to an employer group to classify business based on the products or services they provide |
N |
N |
|
| 7 |
Funding Type Code |
The type of arrangement between the employer group or policy holder and the insurance company |
N |
N |
|
| 8 |
Client Subdivision #1 |
Breakdown of employer group level 1 Tiered |
N |
N |
|
| 9 |
Client Subdivision #2 |
Breakdown of employer group level 2 Tiered |
N |
N |
|
| 10 |
Client Subdivision #3 |
Breakdown of employer group level 3 Tiered |
N |
N |
|
| 11 |
Client Subdivision #4 |
Breakdown of employer group level 4 Tiered |
N |
N |
|
| 12 |
Client Subdivision #5 |
Breakdown of employer group level 5 Tiered |
N |
N |
|
| 13 |
Client Subdivision #6 |
Breakdown of employer group level 6 Tiered |
N |
N |
|
| 14 |
Client Subdivision #7 |
Breakdown of employer group level 7 Tiered |
N |
N |
|
| 15 |
Client Subdivision #8 |
Breakdown of employer group level 8 Tiered |
N |
N |
|
| 16 |
Client Subdivision #9 |
Breakdown of employer group level 9 Tiered |
N |
N |
|
| 17 |
Client Subdivision #10 |
Breakdown of employer group level 10 Tiered |
N |
N |
|
| 18 |
Person Identification |
The number assigned by the insurer or employer group to represent the person insured under the policy |
Y |
Y |
|
| 19 |
Subscriber Identifier |
The number assigned by the insurer or employer group to represent the policy holder This person holds the contract with the insurer Subscriber ID of Member ID receiving services |
N |
Y |
|
| 20 |
Relationship Code |
A code identifying the patient's relationship to the policyholder or member relationship to the subscriber |
N |
Y |
|
| 21 |
Coverage Tier Code |
The type of contract that the subscriber holds with the carrier Example : Single, 2 Tier, Family |
N |
N |
|
| 22 |
Benefit Type Code |
The type of insurance coverage related the information on this line (Medical, Pharmacy, LTD, STD, etc) |
N |
Y |
|
| 23 |
Plan Name |
The name of the benefit plan (insurance carrier) through which the member has coverage |
N |
N |
|
| 24 |
Product Type Code |
The type of insurance plan the subscriber/member is enrolled in at coverage date |
N |
N |
|
| 25 |
Benefit Subscription Code |
The benefit plan member was enrolled in |
N |
N |
|
| 26 |
Eligible Date |
The date the member was eligible to be enrolled/covered |
Y |
Y |
|
| 27 |
Coverage Start Date |
Date the member enrolled in the plan |
Y |
Y |
|
| 28 |
Coverage End Date |
Date the member exited the plan |
Y |
Y |
|
| 29 |
Benefit Row ID |
Row sequence for each update |
N |
N |
|
| 30 |
Employee Contribution Indicator |
Indicator is subscriber contributes to a HSA, HCRA, or DCRA fund |
N |
N |
|
| 31 |
Subscriber Hire Date |
The subscriber's date of hired |
N |
N |
|
| 32 |
Subscriber Re-Hire Date |
The date the subscriber was rehired |
N |
N |
|
| 33 |
Subscriber is Smoker |
A yes/no flag indicating if the subscriber is a smoker |
N |
N |
|
| 34 |
Coverage Status Code |
The status of the member's coverage (Disabled, etc…) |
N |
N |
|
| 35 |
Subscriber Type Code |
The status of the subscriber |
N |
N |
|
| 36 |
Benefit Edibility Flag |
An indicator if subscriber is eligible for benefits |
N |
N |
|
| 37 |
Subscriber Type Effective Date |
The date the employee's status was effective or changed |
N |
N |
|
| 38 |
Subscriber Termination Date |
The date the employee was terminated |
N |
N |
|
| 39 |
Subscriber Last Day Worked |
The date of the last day the subscriber was employed by the employer group |
N |
N |
|
| 40 |
Subscriber Hours |
The number of hours the employee works per week |
N |
N |
|
| 41 |
Subscriber Full Tine |
A yes/no flag indicating if the subscriber is full time employee |
N |
N |
|
| 42 |
Subscriber Temporary |
A yes/no flag indicating if the employee is a temporary employee |
N |
N |
|
| 43 |
Subscriber Pay Frequency |
The payment schedule of compensation for employment (ie. Weekly, bi-weekly, monthly) |
N |
N |
|
| 44 |
Subscriber Job Code |
The code for the type of position the employee holds (Manager, Professional, Administrative, etc…) |
N |
N |
|
| 45 |
Subscriber Language Code |
The primary language spoken by the subscriber |
N |
N |
|
| 46 |
Subscriber Work Location |
The location at which the employee works |
N |
N |
|
| 47 |
Subscriber Reporting Location |
The location at which the employee reports |
N |
N |
|
| 48 |
Subscriber Retiree Eligibility Indicator |
A yes/no indicating if the employee is eligible for retirement |
N |
N |
|
| 49 |
Person Marital Status Code |
The member's marital status (Married, Single, Divorced, etc…) |
N |
N |
|
| 50 |
Person Student Status |
The member's student status (Full Time, Part Time, Not a Student) |
N |
N |
|
| 51 |
Subscriber Disabled Indicator |
A yes/no flag indicating if the member is disabled |
N |
N |
|
| 52 |
Other Payer Indicator |
A yes/no indicator if the member is eligible for coverage through another payer (Medicare, Other Carrier, etc…) |
N |
N |
|
| 53 |
Subscriber Union Code |
A code for the union the subscriber is associated with |
N |
N |
|
| 54 |
Subscriber Union Name |
A description for the subscriber union code |
N |
N |
|
| 55 |
Insurance Carrier Identifier |
The insurance carrier that holds the contract with the claimant |
N |
N |
|
| 56 |
Carrier ID Description |
|
N |
N |
|
| 57 |
Dependent Code |
Identify an eligible employee, spouse or dependent(s) |
N |
N |
|
| 58 |
Dependent Code Description |
Description of Dependent Code |
N |
N |
|
| 59 |
Work email address |
Work email address |
N |
N |
|
| 60 |
Work phone number |
work phone number |
N |
N |
|
| 61 |
Employer EIN |
Federal Employer Identification Number UID |
N |
N |
|
| 62 |
Members Date of Birth |
Date of Birth |
Y |
Y |
|
| 63 |
Member Zip Code |
Zip Code of Member |
Y |
Y |
|
| 64 |
Member Gender |
Gender |
Y |
Y |
|
| Minimum Data Requirements Medical Data |
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| Field Number |
Title |
Description |
Required (Y/N) |
Preferred (Y/N) |
Notes |
| 1 |
Employer Master Group Number |
A number assigned by the health plan to represent the parent employer group for which all subgroups can be classified under |
N |
N |
|
| 2 |
Employer Subgroup Number |
A number assigned to represent a division within an employer group |
N |
N |
|
| 3 |
Employer Group Name |
The name of the company in which the subscriber is employed and purchased insurance through. This name is associated with the Employer Master Group Number |
N |
N |
|
| 4 |
Standard Industrial Classification Code |
A four digit code assigned to an employer group to classify business based on the products or services they provide |
N |
N |
|
| 5 |
Funding Type Code |
The type of arrangement between the employer group or policy holder and the insurance company |
N |
N |
|
| 6 |
Person Identification |
The number assigned by the insurer or employer group to represent the claimant or member number for the person receiving services. |
Y |
Y |
|
| 7 |
Subscriber Identifier |
The number assigned by the insurer or employer group to represent the policy holder This person holds the contract with the insurer. Subscriber ID of Member ID receiving services |
N |
Y |
|
| 8 |
Relationship Code |
A code identifying the claimants relationship to the policyholder or member relationship to the subscriber |
N |
N |
|
| 9 |
Coverage Tier |
The type of contract that the subscriber holds with the carrier Example : Single, 2 Tier, Family |
N |
N |
Is required if not given on Eligibility Data |
| 10 |
Gender Code |
The sex of the person receiving treatment (claimant) |
N |
Y |
Is required if not given on Eligibility Data |
| 11 |
Birth Date |
Date of Birth of the claimant |
N |
Y |
|
| 12 |
Patient's Age |
Patient's Age at the time service was rendered |
N |
N |
|
| 13 |
Person Postal Code |
The zip code of the residential address of the claimant |
N |
Y |
Is required if not given on Eligibility Data |
| 14 |
Person Metropolitan Statistical Area |
The geographic segment representing the region where the claimant lives |
N |
N |
|
| 15 |
Person State |
The 2 letter abbreviation of the state of the residential address of the claimant |
N |
N |
|
| 16 |
Person City |
The city the claimant resides |
N |
N |
|
| 17 |
Client Subdivision #1 |
Breakdown of employer group level 1 Tiered |
N |
N |
|
| 18 |
Client Subdivision #2 |
Breakdown of employer group level 2 Tiered |
N |
N |
|
| 19 |
Client Subdivision #3 |
Breakdown of employer group level 3 Tiered |
N |
N |
|
| 20 |
Client Subdivision #4 |
Breakdown of employer group level 4 Tiered |
N |
N |
|
| 21 |
Client Subdivision #5 |
Breakdown of employer group level 5 Tiered |
N |
N |
|
| 22 |
Product Type Code |
The type of product subscriber/member enrolled in at coverage date Carrier specific |
N |
N |
|
| 23 |
Filler2 |
Reserved for future Assignment |
N |
N |
|
| 24 |
Coverage Status Code |
Coverage status at the time of service. Special coverage status to identify member status (Active, Terminated, COBRA, Retired, etc) |
N |
N |
|
| 25 |
Filler3 |
Reserved for future Assignment |
N |
N |
|
| 26 |
Filler4 |
Reserved for future Assignment |
N |
N |
|
| 27 |
Filler5 |
Reserved for future Assignment |
N |
N |
|
| 28 |
Filler6 |
Reserved for future Assignment |
N |
N |
|
| 29 |
Filler7 |
Reserved for future Assignment |
N |
N |
|
| 30 |
Rendering Provider NPI |
The National Provider Identifier Number of the provider who delivers the medical service |
Y |
Y |
|
| 31 |
Rendering Provider Tax ID |
National TAX identifier assigned to provider who delivers the medical service |
Y |
Y |
|
| 32 |
Rendering Provider Name |
The name of the provider who delivers the medical service This can be a facility, hospital, or organization name or a Provider / Physician Name ( First and Last) if an individual |
N |
Y |
|
| 33 |
Rendering Provider Postal Code |
The zip code of the provider who delivers the medical service. |
N |
N |
|
| 34 |
Rendering Provider Metropolitan Statistical Area |
The geographic division of where the provider who delivers the medical service is located |
N |
N |
|
| 35 |
Rendering Provider State |
The state of where the provider who delivers the medical service is located |
N |
N |
|
| 36 |
Rendering Provider City |
The city in which the provider who delivers the medical service is located |
N |
N |
|
| 37 |
Rendering Provider Specialty Code |
Provider CMS Specialty Code - For Physician, this usually represents his/her board registered specialty. For Non-physicians, specialty reflects the type of provider/facility |
Y |
Y |
|
| 38 |
Rendering Provider Taxonomy Code |
National provider specialty code assigned to provider who delivers the medical service |
Y |
Y |
|
| 39 |
Billing Provider National Provider Identifier |
Billing provider's National Provider Identifier |
N |
Y |
|
| 40 |
Billing Provider TAX Identifier |
National TAX identifier assigned to billing provider |
N |
Y |
|
| 41 |
Billing Provider Name |
The name of the provider who bills for the medical service. This can be a facility, hospital, or organization name or a Provider / Physician Name ( First and Last) if an individual |
N |
N |
|
| 42 |
Billing Provider Postal Code |
Billing provider's postal zip code |
N |
N |
|
| 43 |
Billing Provider Metropolitan Statistical Area |
Billing provider's metropolitan service area |
N |
N |
|
| 44 |
Billing Provider State |
Billing provider's state - 2 digit |
N |
N |
|
| 45 |
Billing Provider City |
Billing provider's city |
N |
N |
|
| 46 |
Billing Provider Specialty Code |
Provider CMS Specialty Code - For Physician, this usually represents his/her board registered specialty. For Non-physicians, specialty reflects the type of provider/facility |
N |
Y |
|
| 47 |
Billing Provider Taxonomy Code |
National provider specialty code assigned to billing provider |
N |
Y |
|
| 48 |
Claim Number |
A unique identifier for a claim, including all claims lines, assigned by the health plan or claim system |
Y |
Y |
|
| 49 |
Claim Line Number |
The number representing each line of the claim and associated with an itemize medical bill submitted by provider for payment |
Y |
Y |
|
| 50 |
Claim Status Code |
Indicates if claim is original or adjustment to original. |
N |
Y |
|
| 51 |
Claim Adjustment Reason Code |
A Reason for the denial, pend, hold, voids, manual overrides |
N |
Y |
Is required if needed for Adjustments |
| 52 |
Claim Adjustment Sequence Number |
Sequential Ordering of the Adjustment of the claim. Identifies where in the sequence of adjustments this particular claim falls in. Claim may be adjusted multiple times. |
N |
Y |
Is required if needed for Adjustments |
| 53 |
Authorization Number |
The number associated with a request for prior approval for the services being rendered |
n |
N |
|
| 54 |
Bill Type Code or Type of Bill Code |
A three digit numeric code that describes the type of bill a provider is submitting 1st digit is type of facility 2nd digit is bill classification 3rd digit if frequency |
Y |
Y |
|
| 55 |
Claim Payment System |
The system in which the claim was processed through |
N |
Y |
|
| 56 |
Insurance Carrier Identifier |
The insurance carrier that holds the contract with the claimant |
N |
N |
|
| 57 |
ITS Host Claim Indicator |
Indicates if the claim is from a provider that supplies a member service in a state other than where the member lives. Host Plan does not hold the contract with the Member. Specific to Blue Cross Plans |
N |
N |
|
| 58 |
Is Medicare Primary |
Indicates if Medicare is the primary party responsible for paying the claim |
N |
N |
|
| 59 |
Primary Payer Code |
Indicates what type of insurance carrier has the primary responsibility for paying the claim |
N |
N |
|
| 60 |
Network Status Code |
Code indicating if the provider has an agreement to cover the members within a plan and for which the services were rendered Represents a Participating or Non-Participating Provider |
N |
N |
|
| 61 |
Carrier Business Unit |
The Business Unit (or code) through which the member has coverage |
N |
N |
|
| 62 |
Paid Date |
The date the carrier paid (check cut) the claim |
Y |
Y |
|
| 63 |
Received Date |
The date the carrier received the claim from the provider |
N |
N |
|
| 64 |
Process Date |
The date the carrier processed the claim from the provider or adjudicated the claim |
N |
N |
|
| 65 |
Diagnosis Related Group Code |
A code the classifies the inpatient hospital stay based on condition of the patient and services provided This is the DRG used to pay the claim ( not the submitted DRG) |
N |
Y |
|
| 66 |
Diagnosis Related Group Type Code |
The DRG classification system used (MS (CMS), AP, or APR) to pay the claims Also represents the system related to the DRGcd field |
N |
Y |
|
| 67 |
Diagnosis Related Group Type Description |
A description of the DRG type |
N |
Y |
|
| 68 |
Diagnosis Related Group Version |
The version number of the DRG grouper that is used to pay the claim |
N |
N |
|
| 69 |
Ambulatory Payment Classification Code |
A classification for outpatient facility services used in the prospective payment system |
N |
N |
|
| 70 |
Ambulatory Payment Group Code |
Represents ambulatory outpatient payment group |
N |
N |
|
| 71 |
Service Units Billed |
Quantity submitted or billed by the provider for the services rendered |
Y |
Y |
|
| 72 |
Service Units Paid |
The revised number of units or quantity for the service which was paid |
N |
Y |
|
| 73 |
Billed Amount |
The amount charged on a claim by the provider for the services rendered |
N |
Y |
|
| 74 |
Allowed Amount |
The contracted reimbursable amount for services rendered that the health plan agrees to pay the provider. |
N |
Y |
Is required if no other dollar amounts are given |
| 75 |
Not Covered Amount |
The amount representing uncovered benefit dollars not paid |
N |
N |
|
| 76 |
Coordination of Benefits Savings Amount |
The amount paid by another health insurance plan that the claimant is covered under when they have dual benefits Amount of total charges not paid as a result of being secondary payer |
Y |
Y |
|
| 77 |
Coinsurance Amount |
The amount paid by the claimant after the deductible is met and based on a percentage defined in the benefit plan |
Y |
Y |
|
| 78 |
Copayment Amount |
The fixed dollar amount that the claimant paid for the service rendered defined by their benefit plan |
Y |
Y |
|
| 79 |
Deductible Amount |
The set dollar amount that the claimant is responsible for paying before the insurer will pay |
Y |
Y |
|
| 80 |
Paid Amount |
The amount that is paid by the carrier to the provider Net amount reimbursed by plan per claim line |
Y |
Y |
|
| 81 |
Benefit Status Type Code |
Indicates in or out of network based on the members contract/ benefits (note: NOT provider par status) |
N |
N |
|
| 82 |
Reimbursement Method Code |
A code representing the pricing methodology used to calculate the claim payment amount such as DRG or Percent of Charges |
N |
Y |
|
| 83 |
Reimbursement Method Description |
A description of the Reimbursement Method Code |
N |
N |
|
| 84 |
ICD Type Code |
Represents if the diagnosis codes on the claim follow ICD-9 or ICD- 10 coding |
Y |
Y |
|
| 85 |
Admitting Diagnosis Code |
Diagnosis Code at the time of admission |
N |
N |
|
| 86 |
Discharge Diagnosis Code |
The code representing the condition of the patient upon leaving the hospital |
N |
N |
|
| 87 |
Diagnosis Code #1 |
The first level, primary diagnosis code, representing diagnostic and disease information |
Y |
Y |
|
| 88 |
Diagnosis Code #2 |
Additional diagnosis code |
N |
Y |
|
| 89 |
Diagnosis Code #3 |
Additional diagnosis code |
N |
Y |
|
| 90 |
Diagnosis Code #4 |
Additional diagnosis code |
N |
Y |
|
| 91 |
Diagnosis Code #5 |
Additional diagnosis code |
N |
Y |
|
| 92 |
Diagnosis Code #6 |
Additional diagnosis code |
N |
Y |
|
| 93 |
Diagnosis Code #7 |
Additional diagnosis code |
N |
Y |
|
| 94 |
Diagnosis Code #8 |
Additional diagnosis code |
N |
Y |
|
| 95 |
Diagnosis Code #9 |
Additional diagnosis code |
N |
Y |
|
| 96 |
Diagnosis Code #10 |
Additional diagnosis code |
N |
Y |
|
| 97 |
Diagnosis Code #11 |
Additional diagnosis code |
N |
Y |
|
| 98 |
Diagnosis Code #12 |
Additional diagnosis code |
N |
Y |
|
| 99 |
Diagnosis Code #13 |
Additional diagnosis code |
N |
Y |
|
| 100 |
Diagnosis Code #14 |
Additional diagnosis code |
N |
Y |
|
| 101 |
Diagnosis Code #15 |
Additional diagnosis code |
N |
Y |
|
| 102 |
Diagnosis Code #16 |
Additional diagnosis code |
N |
Y |
|
| 103 |
Diagnosis Code #17 |
Additional diagnosis code |
N |
Y |
|
| 104 |
Diagnosis Code #18 |
Additional diagnosis code |
N |
Y |
|
| 105 |
Diagnosis Code #19 |
Additional diagnosis code |
N |
Y |
|
| 106 |
Diagnosis Code #20 |
Additional diagnosis code |
N |
Y |
|
| 107 |
Diagnosis Code #21 |
Additional diagnosis code |
N |
N |
|
| 108 |
Diagnosis Code #22 |
Additional diagnosis code |
N |
N |
|
| 109 |
Diagnosis Code #23 |
Additional diagnosis code |
N |
N |
|
| 110 |
Diagnosis Code #24 |
Additional diagnosis code |
N |
N |
|
| 111 |
Diagnosis Code #25 |
Additional diagnosis code |
N |
N |
|
| 112 |
Diagnosis Code #26 |
Additional diagnosis code |
N |
N |
|
| 113 |
Diagnosis Code #27 |
Additional diagnosis code |
N |
N |
|
| 114 |
Diagnosis Code #28 |
Additional diagnosis code |
N |
N |
|
| 115 |
Diagnosis Code #29 |
Additional diagnosis code |
N |
N |
|
| 116 |
Diagnosis Code #30 |
Additional diagnosis code |
N |
N |
|
| 117 |
Diagnosis Code #31 |
Additional diagnosis code |
N |
N |
|
| 118 |
Diagnosis Code #32 |
Additional diagnosis code |
N |
N |
|
| 119 |
Diagnosis Code #33 |
Additional diagnosis code |
N |
N |
|
| 120 |
Diagnosis Code #34 |
Additional diagnosis code |
N |
N |
|
| 121 |
Diagnosis Code #35 |
Additional diagnosis code |
N |
N |
|
| 122 |
Diagnosis Code #36 |
Additional diagnosis code |
N |
N |
|
| 123 |
Diagnosis Code #37 |
Additional diagnosis code |
N |
N |
|
| 124 |
Diagnosis Code #38 |
Additional diagnosis code |
N |
N |
|
| 125 |
Diagnosis Code #39 |
Additional diagnosis code |
N |
N |
|
| 126 |
Diagnosis Code #40 |
Additional diagnosis code |
N |
N |
|
| 127 |
Diagnosis Code #41 |
Additional diagnosis code |
N |
N |
|
| 128 |
Diagnosis Code #42 |
Additional diagnosis code |
N |
N |
|
| 129 |
Diagnosis Code #43 |
Additional diagnosis code |
N |
N |
|
| 130 |
Diagnosis Code #44 |
Additional diagnosis code |
N |
N |
|
| 131 |
Diagnosis Code #45 |
Additional diagnosis code |
N |
N |
|
| 132 |
Diagnosis Code #46 |
Additional diagnosis code |
N |
N |
|
| 133 |
Diagnosis Code #47 |
Additional diagnosis code |
N |
N |
|
| 134 |
Diagnosis Code #48 |
Additional diagnosis code |
N |
N |
|
| 135 |
Diagnosis Code #49 |
Additional diagnosis code |
N |
N |
|
| 136 |
Diagnosis Code #50 |
Additional diagnosis code |
N |
N |
|
| 137 |
Present on Admission Code #1 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 138 |
Present on Admission #2 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 139 |
Present on Admission #3 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 140 |
Present on Admission #4 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 141 |
Present on Admission #5 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 142 |
Present on Admission #6 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 143 |
Present on Admission #7 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 144 |
Present on Admission #8 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 145 |
Present on Admission #9 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 146 |
Present on Admission #10 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 147 |
Present on Admission #11 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 148 |
Present on Admission #12 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 149 |
Present on Admission #13 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 150 |
Present on Admission #14 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 151 |
Present on Admission #15 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 152 |
Present on Admission #16 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 153 |
Present on Admission #17 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 154 |
Present on Admission #18 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 155 |
Present on Admission #19 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 156 |
Present on Admission #20 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 157 |
Present on Admission #21 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 158 |
Present on Admission #22 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 159 |
Present on Admission #23 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 160 |
Present on Admission #24 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 161 |
Present on Admission #25 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 162 |
Present on Admission #26 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 163 |
Present on Admission #27 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 164 |
Present on Admission #28 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 165 |
Present on Admission #29 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 166 |
Present on Admission #30 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 167 |
Present on Admission #31 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 168 |
Present on Admission #32 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 169 |
Present on Admission #33 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 170 |
Present on Admission #34 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 171 |
Present on Admission #35 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 172 |
Present on Admission #36 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 173 |
Present on Admission #37 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 174 |
Present on Admission #38 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 175 |
Present on Admission #39 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 176 |
Present on Admission #40 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 177 |
Present on Admission #41 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 178 |
Present on Admission #42 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 179 |
Present on Admission #43 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 180 |
Present on Admission #44 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 181 |
Present on Admission #45 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 182 |
Present on Admission #46 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 183 |
Present on Admission #47 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 184 |
Present on Admission #48 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 185 |
Present on Admission #49 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 186 |
Present on Admission #50 |
A code that represents if a condition or diagnosis is present at the time the order for inpatient admission occurs |
N |
N |
|
| 187 |
ICD Procedure Code #1 |
The chief code that describes the procedure performed on a patient admitted (inpatient) or receiving care at the facility (outpatient) Billed on a facility claim |
N |
Y |
|
| 188 |
ICD Procedure Code Date #1 |
The date in which the principal procedure was performed |
N |
N |
|
| 189 |
ICD Procedure Code #2 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 190 |
ICD Procedure Code Date #2 |
The date related to the procedure that was performed |
N |
N |
|
| 191 |
ICD Procedure Code #3 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 192 |
ICD Procedure Code Date #3 |
The date related to the procedure that was performed |
N |
N |
|
| 193 |
ICD Procedure Code #4 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 194 |
ICD Procedure Code Date #4 |
The date related to the procedure that was performed |
N |
N |
|
| 195 |
ICD Procedure Code #5 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 196 |
ICD Procedure Code Date #5 |
The date related to the procedure that was performed |
N |
N |
|
| 197 |
ICD Procedure Code #6 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 198 |
ICD Procedure Code Date #6 |
The date related to the procedure that was performed |
N |
N |
|
| 199 |
ICD Procedure Code #7 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 200 |
ICD Procedure Code Date #7 |
The date related to the procedure that was performed |
N |
N |
|
| 201 |
ICD Procedure Code #8 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 202 |
ICD Procedure Code Date #8 |
The date related to the procedure that was performed |
N |
N |
|
| 203 |
ICD Procedure Code #9 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 204 |
ICD Procedure Code Date #9 |
The date related to the procedure that was performed |
N |
N |
|
| 205 |
ICD Procedure Code #10 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 206 |
ICD Procedure Code Date #10 |
The date related to the procedure that was performed |
N |
N |
|
| 207 |
ICD Procedure Code #11 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 208 |
ICD Procedure Code Date #11 |
The date related to the procedure that was performed |
N |
N |
|
| 209 |
ICD Procedure Code #12 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 210 |
ICD Procedure Code Date #12 |
The date related to the procedure that was performed |
N |
N |
|
| 211 |
ICD Procedure Code #13 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 212 |
ICD Procedure Code Date #13 |
The date related to the procedure that was performed |
N |
N |
|
| 213 |
ICD Procedure Code #14 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 214 |
ICD Procedure Code Date #14 |
The date related to the procedure that was performed |
N |
N |
|
| 215 |
ICD Procedure Code #15 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 216 |
ICD Procedure Code Date #15 |
The date related to the procedure that was performed |
N |
N |
|
| 217 |
ICD Procedure Code #16 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 218 |
ICD Procedure Code Date #16 |
The date related to the procedure that was performed |
N |
N |
|
| 219 |
ICD Procedure Code #17 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 220 |
ICD Procedure Code Date #17 |
The date related to the procedure that was performed |
N |
N |
|
| 221 |
ICD Procedure Code #18 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 222 |
ICD Procedure Code Date #18 |
The date related to the procedure that was performed |
N |
N |
|
| 223 |
ICD Procedure Code #19 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 224 |
ICD Procedure Code Date #19 |
The date related to the procedure that was performed |
N |
N |
|
| 225 |
ICD Procedure Code #20 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 226 |
ICD Procedure Code Date #20 |
The date related to the procedure that was performed |
N |
N |
|
| 227 |
ICD Procedure Code #21 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 228 |
ICD Procedure Code Date #21 |
The date related to the procedure that was performed |
N |
N |
|
| 229 |
ICD Procedure Code #22 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 230 |
ICD Procedure Code Date #22 |
The date related to the procedure that was performed |
N |
N |
|
| 231 |
ICD Procedure Code #23 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 232 |
ICD Procedure Code Date #23 |
The date related to the procedure that was performed |
N |
N |
|
| 233 |
ICD Procedure Code #24 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 234 |
ICD Procedure Code Date #24 |
The date related to the procedure that was performed |
N |
N |
|
| 235 |
ICD Procedure Code #25 |
Additional procedure performed while admitted or when receiving care at the facility |
N |
N |
|
| 236 |
ICD Procedure Code Date #25 |
The date related to the procedure that was performed |
N |
N |
|
| 237 |
Procedure Code |
A line level code describing the treatment or procedure This field represents bother HCPCS codes and CPT codes |
Y |
Y |
|
| 238 |
Procedure Modifier 1 |
A two digit code that is used to describe variations of the line level procedure code |
N |
Y |
|
| 239 |
Procedure Modifier 2 |
A two digit code that is used to describe variations of the line level procedure code |
N |
N |
|
| 240 |
Procedure Modifier 3 |
A two digit code that is used to describe variations of the line level procedure code |
N |
N |
|
| 241 |
Procedure Modifier 4 |
A two digit code that is used to describe variations of the line level procedure code |
N |
N |
|
| 242 |
Procedure Modifier 5 |
A two digit code that is used to describe variations of the line level procedure code |
N |
N |
|
| 243 |
Revenue Code |
Identifies a specific accommodation or ancillary service for facility claims |
Y |
Y |
|
| 244 |
National Drug Code |
The unique code that identifies a drug product as defined by the National Drug Data File This is an 11 digit number that identifies the manufacturer (first 5 digits assigned by FDA), product name, and package size of the prescription |
N |
Y |
|
| 245 |
Admission Type Code |
A code indicating the priority of the admission. Ex Urgent , Elective |
N |
N |
|
| 246 |
Admission Referral Source Code |
Identifies the place where the patient was identified as needing admission to the facility |
N |
N |
|
| 247 |
Admission Date |
The date on which the patient was admitted for an inpatient stay |
N |
N |
|
| 248 |
Admission Time |
Time of day the patient was admitted |
N |
N |
|
| 249 |
Discharge Date |
The date on which the patient was discharged from an inpatient stay |
N |
N |
|
| 250 |
Discharge Time |
Time of day the patient was discharged |
N |
N |
|
| 251 |
Discharge Code |
The final place or setting to which the patient was discharged |
N |
N |
|
| 252 |
Service Start Date |
The start date of the service rendered |
Y |
Y |
|
| 253 |
Service End Date |
The date the service ended |
Y |
Y |
|
| 254 |
Place of Service Code |
A code representing the place or setting in which the health care service was rendered |
Y |
Y |
|
| 255 |
Severity of Illness Code |
Classification of a disease level and consumption of resources Associated with APR DRG's only |
N |
N |
|
| 256 |
Birth Weight |
The weight of a newborn baby (who is the claimant) |
N |
N |
|
| 257 |
Claim Payment Status Code |
A code indicating if the claim line is paid or denied |
N |
Y |
|
| Minimum Data Requirements for Pharmacy Data |
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| Field Number |
Title |
Description |
Required (Y/N) |
Preferred (Y/N) |
Notes |
| 1 |
Employer Master Group Number |
A number assigned by the health plan to represent the parent employer group for which all subgroups can be classified under |
N |
N |
|
| 2 |
Employer Subgroup Number |
A number assigned to represent a division within an employer group |
N |
N |
|
| 3 |
Employer Group Name |
The name of the company in which the subscriber is employed and purchased insurance through This name is associated with the Employer Master Group Number |
N |
N |
|
| 4 |
Standard Industrial Classification Code |
A four digit code assigned to an employer group to classify business based on the products or services they provide |
N |
N |
|
| 5 |
Funding Type Code |
The type of arrangement between the employer group or policy holder and the insurance company |
N |
N |
|
| 6 |
Person Identification |
The number assigned by the insurer or employer group to represent the claimant or member number for the person receiving the prescription |
Y |
Y |
|
| 7 |
Subscriber Identifier |
The number assigned by the insurer or employer group to represent the policy holder This person holds the contract with the insurer Subscriber ID of Member ID receiving services |
N |
N |
|
| 8 |
Relationship Code |
A code identifying the patient's relationship to the policyholder or member relationship to the subscriber |
N |
N |
|
| 9 |
Coverage Tier |
The type of contract that the subscriber holds with the carrier Example : Single, 2 Tier, Family |
N |
N |
|
| 10 |
Gender Code |
The sex of the person receiving treatment (claimant) |
N |
N |
|
| 11 |
Birth Date |
Date of Birth of the claimant |
N |
N |
|
| 12 |
Patient's Age |
Patient's Age at the time service was rendered |
N |
N |
|
| 13 |
Person Postal Code |
The zip code of the residential address of the claimant |
N |
N |
|
| 14 |
Person Metropolitan Statistical Area |
The geographic segment representing the region where the claimant lives |
N |
N |
|
| 15 |
Person State |
The 2 letter abbreviation of the state of the residential address of the claimant |
N |
N |
|
| 16 |
Person City |
The city the claimant resides |
N |
N |
|
| 17 |
Client Subdivision #1 |
Breakdown of employer group level 1 Tiered |
N |
N |
|
| 18 |
Client Subdivision #2 |
Breakdown of employer group level 2 Tiered |
N |
N |
|
| 19 |
Client Subdivision #3 |
Breakdown of employer group level 3 Tiered |
N |
N |
|
| 20 |
Client Subdivision #4 |
Breakdown of employer group level 4 Tiered |
N |
N |
|
| 21 |
Client Subdivision #5 |
Breakdown of employer group level 5 Tiered |
N |
N |
|
| 22 |
Product Type Code |
The type of product subscriber enrolled in at coverage date Carrier specific |
N |
N |
|
| 23 |
Coverage Status Code |
Coverage status at the time of service Special coverage status to identify member status (Active, Terminated, COBRA, Retired, etc) |
N |
N |
|
| 24 |
Pharmacy ID |
Pharmacy Provider NCPDP Number |
Y |
Y |
|
| 25 |
Pharmacy Tax ID |
Pharmacy Tax ID Number |
N |
Y |
|
| 26 |
Pharmacy Name |
Pharmacy Name |
N |
N |
|
| 27 |
Pharmacy Chain Name |
The name of the chain to which the pharmacy belongs |
N |
N |
|
| 28 |
Pharmacy Postal Code |
Pharmacy 5 Digit Postal Code |
N |
N |
|
| 29 |
Pharmacy Metropolitan Statistical Area |
Pharmacy Metropolitan Statistical Area |
N |
N |
|
| 30 |
Pharmacy State |
The state of where the pharmacy dispensing the medication is located |
N |
N |
|
| 31 |
Pharmacy City |
The city of where the pharmacy dispensing the medication is located |
N |
N |
|
| 32 |
Pharmacy Type Code |
The channel in which the drug is distributed/dispensed to the patient such as Retail, Mail Order, Grocery etc… |
N |
Y |
|
| 33 |
Prescribing Provider NPI |
Prescribing Provider NPI |
N |
Y |
|
| 34 |
Prescribing Provider Tax ID |
Prescribing Provider Tax ID Number |
N |
Y |
|
| 35 |
Prescribing Provider Name |
The name of the provider who prescribes the medication. This can be a facility, hospital, or organization name or a Provider / Physician Name ( First and Last) if an individual |
N |
N |
|
| 36 |
Prescribing Provider Postal Code |
Provider 5 Digit Postal Code |
N |
N |
|
| 37 |
Prescribing Provider MSA |
The geographic division of where the provider who prescribes the medication is located |
N |
N |
|
| 38 |
Prescribing Provider State |
The state of where the provider who prescribes the medication is located |
N |
N |
|
| 39 |
Prescribing Provider City |
The city in which the provider who prescribes the medication is located |
N |
N |
|
| 40 |
Prescribing Provider Specialty Code |
The CMS Specialty Code - For Physician, this usually represents his/her board registered specialty. For Non-physicians, specialty reflects the type of provider/facility |
N |
N |
|
| 41 |
Prescribing Taxonomy Code |
National provider specialty code assigned to provider who prescribes the medication |
N |
N |
|
| 42 |
Claim Number |
A unique identifier for a claim, including all claims lines, assigned by the health plan |
Y |
Y |
|
| 43 |
Claim Status Code |
Indicates if the claim is original or adjustment to the original |
N |
Y |
Is required if needed for adjustments |
| 44 |
Claim Adjustment Reason Code |
A Reason for the denial, pend, hold, voids, manual overrides |
N |
Y |
Is required if needed for adjustments |
| 45 |
Claim Adjustment Sequence Number |
The sequential ordering of the original claim and adjustments |
N |
Y |
Is required if needed for adjustments |
| 46 |
Claim Payment Status Code |
A code indicating if the claim line is paid or denied |
N |
Y |
|
| 47 |
Paid Date |
The date the carrier paid (check cut) the claim |
Y |
Y |
|
| 48 |
Received Date |
The date the carrier received the claim from the pharmacy or member |
N |
N |
|
| 49 |
Billed Amount |
The amount charged on a claim by the pharmacy for prescription |
N |
N |
|
| 50 |
Allowed Amount |
The contracted reimbursable amount for the prescription that the health plan agrees to pay the pharmacy. |
N |
Y |
Is required if no other dollar amounts are given |
| 51 |
Not Covered Amount |
The amount representing uncovered benefit dollars not paid |
N |
N |
|
| 52 |
Coordination of Benefits Savings Amount |
The amount paid by another health insurance plan that the claimant is covered under when they have dual benefits Amount of total charges not paid as a result of being secondary payer |
N |
N |
|
| 53 |
Coinsurance Amount |
The amount paid by the claimant after the deductible is met and based on a percentage defined in the benefit plan |
N |
N |
|
| 54 |
Copay Amount |
The fixed dollar amount that the claimant paid for the prescription defined by their benefit plan |
N |
N |
|
| 55 |
Deductible Amount |
The set dollar amount that the claimant is responsible for paying before the insurer will pay |
N |
N |
|
| 56 |
Paid Amount |
The amount that is paid by the carrier to the provider Net amount reimbursed by plan per claim line |
N |
N |
|
| 57 |
Prior Authorization Number |
The number associated with a request for prior approval for the prescription |
N |
N |
|
| 58 |
Prescription Date |
Date the script was written by provider |
N |
N |
|
| 59 |
Process Date |
The date the carrier processed the claim from the pharmacy or adjudicated the claim |
N |
N |
|
| 60 |
Filled Date |
Date the script was filled or processed by the pharmacy |
Y |
Y |
|
| 61 |
Customary Charge Amount |
Usual and Customary charge amount for the script |
N |
N |
|
| 62 |
Ingredient Cost |
The amount paid to the pharmacy for the drug itself. Dispensing Fees and other amounts are not included |
Y |
Y |
|
| 63 |
Dispensing Fee |
The amount paid to the pharmacy for dispensing the medication. This should only include the transfer of possession of the drug from the pharmacy, including charges for mixing drugs, delivery, and overhead. |
Y |
Y |
|
| 64 |
Administration Fee |
Carrier's administration costs for the claim. |
N |
N |
|
| 65 |
Sales Tax |
The amount paid to the pharmacy to cover sales tax. |
Y |
Y |
|
| 66 |
Adjustment Amount |
The amount added or deducted to the original paid amount based reconsideration/ determination |
N |
N |
|
| 67 |
Person Paid Amount |
The total amount paid by the member and not be the health plan. |
N |
N |
|
| 68 |
Capitation Amount |
A fixed amount |
N |
N |
|
| 69 |
ICD Type Code |
Represents if the diagnosis codes on the claim follow ICD-9 or ICD- 10 coding |
N |
N |
|
| 70 |
ICD Diagnosis |
The first level, primary diagnosis code, representing diagnostic and disease information |
N |
N |
|
| 71 |
Is Refill |
A yes/no value to determine if the prescription is refill versus a new/original prescription. |
N |
Y |
|
| 72 |
Dispensed as Written Code |
Code indicating whether or not the prescriber's instructions regarding generic substitution were followed |
Y |
Y |
|
| 73 |
Quantity Dispensed |
The dispensed quantity based on the unit of measure |
Y |
Y |
|
| 74 |
Days Supplied |
The actual number of days the prescription should last based on the dispensed amount. |
Y |
Y |
|
| 75 |
Days Supplied Basis |
Reasoning for days worth of medication filled |
Y |
Y |
|
| 76 |
National Drug Code |
The unique code that identifies a drug product as defined by the National Drug Data File This is an 11 digit number that identifies the manufacturer (first 5 digits assigned by FDA), product name, and package size of the prescription |
Y |
Y |
|
| 77 |
Drug Name |
The formal generic name or the trade name of the prescription being dispensed |
N |
N |
|
| 78 |
Drug Strength |
A number that shows the strength of the drug being dispensed |
N |
N |
|
| 79 |
Dosage Form |
The type of form in which the drug is dispensed, such as capsules, tablets, liquids |
N |
N |
|
| 80 |
Unit of Measure Cd |
The unit the dose is measured in (mg, ml, etc) |
N |
N |
|
| 81 |
Is Formulary |
A yes/no value to represent whether the prescription drug was paid as included in the plan's formulary |
N |
Y |
|
| 82 |
Is Specialty |
A yes/no value to indicate if the medication is considered a specialty drug. Specialty drugs are high cost drugs that treat complex conditions. |
N |
N |
|
| 83 |
Drug Tier Code |
The level in which a drug is categorized based on the formulary |
N |
N |
|
| 84 |
Is Maintenance |
A yes/no value to represent medications that are taken on an ongoing basis to treat chronic conditions. |
N |
N |
|
| 85 |
Is Compound Drug Code |
A yes/no value to represent medications that are prepared by a pharmacist who mixes or adjusts drug ingredients or customize a medication to meet a patients individual needs |
N |
N |
|
| 86 |
Is Generic |
A yes/no indicator to represent if the drug being dispensed is a generic drug. |
N |
N |
|
| 87 |
Generic Code |
The number of generic manufacturers or the drug being dispensed at the time of adjudication |
N |
N |
|
| 88 |
Generic Code Number |
The five digit number assigned by the First Data Bank to uniquely identify a combination of ingredient, strength, form, and route of the drug being dispensed |
N |
N |
|
| 89 |
Is Controlled Substance |
A yes/no indicator to represent a drug or chemical whose manufacture, possession, or use is regulated by the government (DEA) |
N |
N |
|
| 90 |
Therapeutic Class Code |
The category that a drug is grouped under based on chemical characteristics, structure and how it is used to treat a specific disease |
N |
N |
|
| 91 |
Primary Payer Code |
Indicates what type of insurance carrier has the primary responsibility for paying the claim |
N |
N |
|
| 92 |
Fill Number Code |
This is the NDCPD fill number associated with the claim. This will be 0 for first fill, 1 for second fill, 2 for third fill, and so forth… |
N |
N |
|
| 93 |
Prescription Reference Number |
Reference number assigned by the provider for the dispensed drug/product |
N |
N |
|
| 94 |
Number of Authorized Refills |
The number of authorized refills for the prescription being filled |
N |
N |
|
| 95 |
Prescription Origin Code |
The origin of the prescription |
N |
N |
|
| 96 |
Prior Authorization Type Code |
The code to clarify the type of prior authorization for the prescription |
N |
N |
|
| 97 |
Submission Clarification Code |
A code used by a pharmacist to clarify a reason for the claim and prescription |
N |
N |
|
| 98 |
Gross Amount Due |
Total price claimed from all sources The sum of Ingredient Cost, Dispensing Fee, Flat Sales Tax Amount, Percentage Sales Tax Amount, Incentive Amount, Other Amount |
N |
N |
|
| 99 |
Incentive Amount Submitted |
A fee submitted by the pharmacy for contractually agreed upon services |
N |
N |
|
| 100 |
Percentage Sales Tax Amount Submitted |
The percentage of sales tax amount submitted |
N |
N |
|
| 101 |
Other Amount |
Any additional fees that are not defined elsewhere. |
N |
N |
|
| 102 |
Basis of Cost Determination Code |
Identifies how the reimbursement amount was calculated for the Ingredient Cost |
N |
N |
|
| 103 |
Client Code |
The Certilytics assigned identifier to represent a unique client |
N |
N |
|
| 104 |
Compound Type Code |
A code for the category of the drug being compounded |
N |
N |
|
| 105 |
Route of Administration Code |
The path in which a drug is taken into the body |
N |
N |
|
| 106 |
Client |
The source of the claim information |
N |
N |
|
| 107 |
Insurance Carrier Identifier |
The insurance carrier that holds the contract with the claimant |
N |
N |
|
| Minimum Data Requirements for Vision Data |
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| Field Number |
Title |
Description |
Required (Y/N) |
Preferred (Y/N) |
Notes |
| 1 |
Employer Master Group Number |
A number assigned by the health plan to represent the parent employer group for which all subgroups can be classified under |
N |
N |
|
| 2 |
Employer Group Name |
The name of the company in which the subscriber is employed and purchased insurance through This name is associated with the Employer Master Group Number |
N |
N |
|
| 3 |
Employer Name |
|
N |
N |
|
| 4 |
Employer Subgroup Number |
A number assigned to represent a division within an employer group |
N |
N |
|
| 5 |
Employer Subgroup Name |
The name of the division in which the subscriber is employed and purchased insurance through. This is associated with the Employer Subgroup Number |
N |
N |
|
| 6 |
Standard Industrial Classification Code |
A four digit code assigned to an employer group to classify business based on the products or services they provide |
N |
N |
|
| 7 |
Funding Type Code |
The type of arrangement between the employer group or policy holder and the insurance company |
N |
N |
|
| 8 |
Client Subdivision #1 |
Breakdown of employer group level 1 Tiered |
N |
N |
|
| 9 |
Client Subdivision #2 |
Breakdown of employer group level 2 Tiered |
N |
N |
|
| 10 |
Client Subdivision #3 |
Breakdown of employer group level 3 Tiered |
N |
N |
|
| 11 |
Client Subdivision #4 |
Breakdown of employer group level 4 Tiered |
N |
N |
|
| 12 |
Client Subdivision #5 |
Breakdown of employer group level 5 Tiered |
N |
N |
|
| 13 |
Client Subdivision #6 |
Breakdown of employer group level 6 Tiered |
N |
N |
|
| 14 |
Client Subdivision #7 |
Breakdown of employer group level 7 Tiered |
N |
N |
|
| 15 |
Client Subdivision #8 |
Breakdown of employer group level 8 Tiered |
N |
N |
|
| 16 |
Client Subdivision #9 |
Breakdown of employer group level 9 Tiered |
N |
N |
|
| 17 |
Client Subdivision #10 |
Breakdown of employer group level 10 Tiered |
N |
N |
|
| 20 |
Person Identification |
The number assigned by the insurer or employer group to represent the person insured under the policy |
N |
N |
|
| 21 |
Subscriber Identifier |
The number assigned by the insurer or employer group to represent the policy holder This person holds the contract with the insurer Subscriber ID of Member ID receiving services |
N |
N |
|
| 22 |
Benefit Type Code |
The type of insurance coverage related the information on this line (Medical, Pharmacy, LTD, STD, etc) |
N |
N |
|
| 23 |
Product Type Code |
The type of insurance plan the subscriber/member is enrolled in at coverage date |
N |
N |
|
| 24 |
Benefit Subscription Code |
The benefit plan member was enrolled in |
N |
N |
|
| 25 |
Claim Number |
A unique identifier for a claim, including all claims lines, assigned by the health plan or claim system |
Y |
Y |
|
| 26 |
Claim Line Number |
The number representing each line of the claim and associated with an itemize medical bill submitted by provider for payment |
Y |
Y |
|
| 27 |
Claim Status Code |
Indicates if claim is original or adjustment to original. |
N |
N |
|
| 28 |
Claim Adjustment Reason Code |
A Reason for the denial, pend, hold, voids, manual overrides |
N |
N |
|
| 29 |
Claim Adjustment Sequence Number |
Sequential Ordering of the Adjustment of the claim. Identifies where in the sequence of adjustments this particular claim falls in. Claim may be adjusted multiple times. |
N |
N |
|
| 30 |
Claim Payment System |
The system in which the claim was processed through |
N |
N |
|
| 31 |
Paid Date |
The date the carrier paid (check cut) the claim |
Y |
Y |
|
| 32 |
Received Date |
The date the carrier received the claim from the provider |
N |
N |
|
| 33 |
Process Date |
The date the carrier processed the claim from the provider or adjudicated the claim |
N |
N |
|
| 34 |
Service Units Billed |
Quantity submitted or billed by the provider for the services rendered |
Y |
Y |
|
| 35 |
Service Units Paid |
The revised number of units or quantity for the service which was paid |
N |
N |
|
| 36 |
Billed Amount |
The amount charged on a claim by the provider for the services rendered |
N |
N |
|
| 37 |
Allowed Amount |
The contracted reimbursable amount for services rendered that the health plan agrees to pay the provider. |
N |
N |
|
| 38 |
Not Covered Amount |
The amount representing uncovered benefit dollars not paid |
N |
N |
|
| 39 |
Coordination of Benefits Savings Amount |
The amount paid by another health insurance plan that the claimant is covered under when they have dual benefits Amount of total charges not paid as a result of being secondary payer |
N |
N |
|
| 40 |
Coinsurance Amount |
The amount paid by the claimant after the deductible is met and based on a percentage defined in the benefit plan |
Y |
Y |
|
| 41 |
Copayment Amount |
The fixed dollar amount that the claimant paid for the service rendered defined by their benefit plan |
Y |
Y |
|
| 42 |
Deductible Amount |
The set dollar amount that the claimant is responsible for paying before the insurer will pay |
Y |
Y |
|
| 43 |
Paid Amount |
The amount that is paid by the carrier to the provider Net amount reimbursed by plan per claim line |
Y |
Y |
|
| 44 |
Benefit Status Type Code |
Indicates in or out of network based on the members contract/ benefits (note: NOT provider par status) |
N |
N |
|
| 45 |
Network Status Code |
Code indicating if the provider has an agreement to cover the members within a plan and for which the services were rendered Represents a Participating or Non-Participating Provider |
N |
N |
|
| 46 |
ICD Type Code |
Represents if the diagnosis codes on the claim follow ICD-9 or ICD- 10 coding |
Y |
Y |
|
| 47 |
Diagnosis Code #1 |
The first level, primary diagnosis code, representing diagnostic and disease information |
Y |
Y |
|
| 48 |
Procedure Code |
A line level code describing the treatment or procedure This field represents bother HCPCS codes and CPT codes |
Y |
Y |
|
| 49 |
Procedure Modifier 1 |
A two digit code that is used to describe variations of the line level procedure code |
N |
N |
|
| 50 |
Procedure Modifier 2 |
A two digit code that is used to describe variations of the line level procedure code |
N |
N |
|
| 51 |
Rendering Provider NPI |
The National Provider Identifier Number of the provider who delivers the medical service |
Y |
Y |
|
| 52 |
Rendering Provider Tax ID |
National TAX identifier assigned to provider who delivers the medical service |
Y |
Y |
|
| 53 |
Rendering Provider Postal Code |
The zip code of the provider who delivers the medical service. |
N |
N |
|
| 54 |
Rendering Provider Name |
The name of the provider who delivers the medical service This can be a facility, hospital, or organization name or a Provider / Physician Name ( First and Last) if an individual |
N |
N |
|
| 55 |
Rendering Provider Specialty Code |
Provider CMS Specialty Code - For Physician, this usually represents his/her board registered specialty. For Non-physicians, specialty reflects the type of provider/facility |
Y |
Y |
|
| 56 |
Rendering Provider Taxonomy Code |
National provider specialty code assigned to provider who delivers the medical service |
Y |
Y |
|
| 57 |
Billing Provider National Provider Identifier |
Billing provider's National Provider Identifier |
N |
Y |
|
| 58 |
Billing Provider TAX Identifier |
National TAX identifier assigned to billing provider |
N |
Y |
|
| 59 |
Billing Provider Postal Code |
Billing provider's postal zip code |
N |
N |
|
| 60 |
Billing Provider Name |
The name of the provider who bills for the medical service. This can be a facility, hospital, or organization name or a Provider / Physician Name ( First and Last) if an individual |
N |
N |
|
| 61 |
Billing Provider Metropolitan Statistical Area |
Billing provider's metropolitan service area |
N |
N |
|
| 62 |
Billing Provider State |
Billing provider's state - 2 digit |
N |
N |
|
| 63 |
Billing Provider City |
Billing provider's city |
N |
N |
|
| 64 |
Place of Service Code |
A code representing the place or setting in which the health care service was rendered |
Y |
Y |
|
| 65 |
Service Start Date |
The start date of the service rendered |
Y |
Y |
|
| 66 |
Claim Payment Status Code |
A code indicating if the claim line is paid or denied |
N |
N |
|
| 67 |
Carrier ID |
CarrierIDCd |
N |
N |
|