C.M.R. 90, 590, ch. 243, app 590-243-E-1

Current through 2024-51, December 18, 2024

Appendix 590-243-E-1 - Maine Health Data Organization Pharmacy Claims File Specifications

Data Element #	Data Element Name	Date Effective	Type	Maximum Length	Description/Codes/Sources
PC001	Submitter	1/1/2003	Text	8	MHDO-assigned identifier of payor submitting claims data. Do not leave blank.
PC002	Payor	7/1/2012	Text	8	MHDO-assigned code of the insurer/underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage. Do not leave blank.
PC003	Insurance Type/Product Code	1/1/2003	Text	2	Code identifying the type of insurance policy within a specific insurance program. Refer to Appendix A 16 Medicare Part C MD Medicare Part D SP Supplemental Policy
PC004	Payor Claim Control Number	1/1/2003	Text	35	Must apply to the entire claim and be unique within the payor's system. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC005	Line Counter	4/1/2004	Number	4	Line number for this service The line counter begins with 1 and is incremented by 1 for each additional service line of a claim. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC006	Insured Group or Policy Number	1/1/2003	Text	30	Group or policy number - not the number that uniquely identifies the Subscriber Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC007	Subscriber Social Security Number	1/1/2003	Text	9	Subscriber's social security number Leave blank if unavailable. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC008	Plan Specific Contract Number	1/1/2003	Text	80	Plan-assigned contract number Leave blank if contract number = subscriber's social security number. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC009	Member Suffix or Sequence Number	1/1/2003	Text	20	Uniquely numbers the member within the contract Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC010	Member Identification Code	1/1/2003	Text	50	Member's social security number Leave blank if unavailable Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC011	Individual Relationship Code	1/1/2003	Text	2	Member's relationship to insured Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC012	Member Gender	1/1/2003	Number	1	Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC013	Member Date of Birth	1/1/2003	Text	8	CCYYMMDD Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC014	Member City Name	4/1/2004	Text	30	City name of member Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC015	Member State or Province	4/1/2004	Text	2	As defined by the US Postal Service and Canada Post Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC016	Member ZIP Code	1/1/2003	Text	11	ZIP Code of member - may include non-US codes Do not include dash Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC017	Date Service Approved (AP Date)	1/1/2003	Text	8	CCYYMMDD The value 'CCYY0101', where CCYY is the year in which the service was approved, shall be used when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = 'Y'.
PC018	Pharmacy Number	1/1/2003	Text	30	Payor-assigned pharmacy number Not required if PC021 is populated.
PC019	Pharmacy Tax ID Number	1/1/2003	Text	10	Federal taxpayer's identification number
PC020	Pharmacy Name	1/1/2003	Text	100	Name of pharmacy
PC021	National Provider ID - Pharmacy Provider	4/1/2004	Text	20	National Provider ID for Pharmacy This data element pertains to the entity or individual directly providing the service. Refer to Appendix A
PC022	Pharmacy Location City	4/1/2004	Text	30	City name of pharmacy - preferably pharmacy location Refer to Appendix A
PC023	Pharmacy Location State	4/1/2004	Text	2	As defined by the US Postal Service and Canada Post Refer to Appendix A
PC024	Pharmacy ZIP Code	1/1/2003	Text	11	ZIP Code of pharmacy - may include non-US codes Do not include dash. Refer to Appendix A
PC024A	Pharmacy Country Code	1/1/2010	Text	30	Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A.
PC025	Claim Status	1/1/2003	Text	2	Refer to Appendix A
PC026	Drug Code	1/1/2003	Text	11	NDC Code Refer to Appendix A
PC027	Drug Name	1/1/2003	Text	80	Text name of drug
PC028	New Prescription or Refill	1/1/2003	Text	2	00 New prescription 01-99 Number of refill
PC029	Generic Drug Indicator	1/1/2003	Text	1	N No, branded drug Y Yes, generic drug
PC030	Dispense as Written Code	1/1/2003	Text	1	Refer to Appendix A
PC031	Compound Drug Indicator	4/1/2004	Text	1	N Non-compound drug U Non-specified drug compound Y Compound drug
PC032	Date Prescription Filled	1/1/2003	Text	8	CCYYMMDD The value 'CCYY0101', where CCYY is the year in which the service was approved, shall be used when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = 'Y'.
PC033	Quantity Dispensed	1/1/2003	Number	10	Number of metric units of medication dispensed. Code decimal point.
PC034	Days' Supply	1/1/2003	Number	3	Estimated number of days the prescription will last
PC035	Charge Amount	1/1/2003	Number	10	Do not code decimal point. Two decimal places implied.
PC036	Paid Amount	1/1/2003	Number	10	Includes all health plan payments and excludes all member payments. Do not deduct POS rebate amount, if applicable. Do not include Pharmacy Benefits Manager Compensation. Do not code decimal point. Two decimal places implied.
PC037	Ingredient Cost/List Price	1/1/2003	Number	10	Cost of the drug dispensed Do not code decimal point. Two decimal places implied.
PC038	Postage Amount Claimed	4/1/2004	Number	10	Do not code decimal point. Two decimal places implied.
PC039	Dispensing Fee	1/1/2003	Number	10	Do not code decimal point. Two decimal places implied.
PC040	Co-pay Amount	1/1/2003	Number	10	The preset, fixed dollar amount for which the individual is responsible. Do not deduct POS rebate amount, if applicable. Do not code decimal point. Two decimal places implied.
PC041	Coinsurance Amount	1/1/2003	Number	10	The dollar amount an individual is responsible for - not the percentage. Do not deduct POS rebate amount, if applicable. Do not code decimal point. Two decimal places implied.
PC042	Deductible Amount	1/1/2003	Number	10	Do not deduct POS rebate amount, if applicable. Do not code decimal point. Two decimal places implied.
PC043	Patient Pay Amount	1/1/2013	Number	10	Amount that is calculated by the payor and returned to the pharmacy as the total amount to be paid by the patient to the pharmacy. $0 is acceptable; if "data not available" leave blank. Do not include decimal point. Two decimal places implied.
PC044	Prescribing Physician First Name	7/1/2006	Text	40	Physician first name Optional if PC047 is filled.
PC045	Prescribing Physician Middle Name	7/1/2006	Text	25	Physician middle name or initial Optional if PC047 is filled.
PC046	Prescribing Physician Last Name	7/1/2006	Text	60	Physician last name. Optional if PC047 is filled.
PC047	Prescribing Physician DEA	7/1/2006	Text	20	DEA for prescribing physician
PC048	Prescribing Physician NPI	10/1/2014	Text	20	NPI for prescribing physician Refer to Appendix A
PC101	Subscriber Last Name	1/1/2010	Text	60	The subscriber last name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC102	Subscriber First Name	1/1/2010	Text	35	The subscriber first name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC103	Subscriber Middle Name	1/1/2010	Text	25	The subscriber middle name or initial Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC104	Member Last Name	1/1/2010	Text	60	The member last name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC105	Member First Name	1/1/2010	Text	35	The member first name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC106	Member Middle Name	1/1/2010	Text	25	The member middle name or initial Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC107	Member Address Line 1	2/1/2019	Text	55	Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC108	Member Address Line 2	2/1/2019	Text	55	Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC109	Member Country Code	2/1/2019	Text	2	Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.
PC110	In-Plan Network Indicator	2/1/2021	Text	1	Use this field to specify if services from the requested Pharmacy Provider were provided within the health plan network. Valid values are: N=No; Y=Yes.
PC111	Placeholder	2/1/2025	N/A	0	Leave blank. Payment Arrangement Type Indicator retired
PC112	Member Age	2/1/2025	Text	3	Member's calculated age as of the service date. Round to the nearest integer. For ages GREATER THAN EQUAL TO 90, indicate '90'.
PC113	Substance Use Disorder (SUD) Indicator	2/1/2025	Text	1	Indicates whether a record contains 42 CFR Part 2 SUD-related data or not. Valid values are: N = Record does not contain 42 CFR Part 2 SUD-related data. Send all available values of all requested fields. Y = Record contains 42 CFR Part 2 SUD-related data. The following fields shall be left blank: PC004-PC016; and PC101-PC109.
PC114	Total POS Rebate Amount	2/1/2025	Number	10	The total dollar amount of all reductions to amounts paid by the health plan or an individual member resulting from POS (point-of-sale) rebates. The total POS rebate amount should be reported in full and should not be deducted from either plan paid or member copay, deductible, or coinsurance amounts. Do not code decimal point. Two decimal places implied.
PC115	Member POS Rebate Amount	2/1/2025	Number	10	The dollar amount of all reductions to amounts paid by an individual member resulting from POS rebates. The member POS rebate amount should not be deducted from member copay, deductible, or coinsurance amounts. Do not code decimal point. Two decimal places implied.
PC116	PBM Compensation Amount	2/1/2025	Number	10	The value of payments made by the payor to its pharmacy benefits manager that is not paid to the pharmacy The pharmacy benefits manager compensation amount should not be included in the plan paid amount. PBM compensation does not include any compensation paid by a manufacturer, developer, or labeler for the performance of services. Do not code decimal point. Two decimal places implied.
PC899	Record Type	1/1/2003	Text	2	PC
To ensure the security of personally identifiable information and personal health information that is submitted to the MHDO Data Warehouse and to reduce file transmission times, MHDO requires submitters to compress and encrypt all files before uploading to the warehouse. This file-level encryption will ensure the confidentiality of all data that are submitted to the warehouse, not just individual fields.