C.M.R. 90, 590, ch. 243, app 590-243-E-2
Data Element # | Data Element Name | National Council for Prescription Drug Programs Field # |
PC001 | Submitter | 879-N2 |
PC002 | Payor | 569-J8 |
PC003 | Insurance Type/Product Code | A90 |
PC004 | Payor Claim Control Number | 993-A7 |
PC005 | Line Counter | A91 |
PC006 | Insured Group or Policy Number | 246 |
PC007 | Subscriber Social Security Number | A89 |
PC008 | Plan Specific Contract Number | 302-C2 |
PC009 | Member Suffix or Sequence Number | 303-C3 |
PC010 | Member Identification Code | 332-CY |
PC011 | Individual Relationship Code | 247 |
PC012 | Member Gender | 305-C5 |
PC013 | Member Date of Birth | 304-C4 |
PC014 | Member City Name | 728-SU |
PC015 | Member State or Province | 729-TA |
PC016 | Member ZIP Code | 730-TC |
PC017 | Date Service Approved (AP Date) | 578 |
PC018 | Pharmacy Number | 201-B1 |
PC019 | Pharmacy Tax ID Number | N/A |
PC020 | Pharmacy Name | 833-5P |
PC021 | National Provider ID - Pharmacy Provider | 201-B1 |
PC022 | Pharmacy Location City | 728-SU |
PC023 | Pharmacy Location State | 729-TA |
PC024 | Pharmacy ZIP Code | 730-TC |
PC024A | Pharmacy Country Code | A93-1T |
PC025 | Claim Status | A88 |
PC026 | Drug Code | 407-D7 |
PC027 | Drug Name | 397 |
PC028 | New Prescription | 254 |
PC029 | Generic Drug Indicator | 425-DP |
PC030 | Dispense as Written Code | 408-D8 |
PC031 | Compound Drug Indicator | 406-D6 |
PC032 | Date Prescription Filled | 401-D1 |
PC033 | Quantity Dispensed | 442-E7 |
PC034 | Days' Supply | 405-D5 |
PC035 | Charge Amount | 430-DU |
PC036 | Paid Amount | 281 |
PC037 | Ingredient Cost/List Price | 506-F6 |
PC038 | Postage Amount Claimed | N/A |
PC039 | Dispensing Fee | 507-F7 |
PC040 | Co-pay Amount | 518-FI |
PC041 | Coinsurance Amount | 572-4U |
PC042 | Deductible Amount | 517-FH |
PC043 | Patient Pay Amount | 505-F5 |
PC044 | Prescribing Physician First Name | 717 |
PC045 | Prescribing Physician Middle Name | A92 |
PC046 | Prescribing Physician Last Name | 716 |
PC047 | Prescribing Physician DEA | 411-DB |
PC048 | Prescribing Physician NPI | 411-DB |
PC101 | Subscriber Last Name | 716 |
PC102 | Subscriber First Name | 717 |
PC103 | Subscriber Middle Name | 718 |
PC104 | Member Last Name | 716 |
PC105 | Member First Name | 717 |
PC106 | Member Middle Name | 718 |
PC107 | Member Address Line 1 | B08-7A |
PC108 | Member Address Line 2 | B09-7B |
PC109 | Member Country Code | A43-1K |
PC110 | In-Plan Network Indicator | N/A |
PC111 | Placeholder | N/A |
PC112 | Member Age | N/A |
PC113 | Substance Use Disorder (SUD) Indicator | N/A |
PC114 | Total POS Rebate Amount | N/A |
PC115 | Member POS Rebate Amount | N/A |
PC116 | Pharmacy Benefits Manager Compensation Amount | N/A |
PC899 | Record Type | A94 |
C.M.R. 90, 590, ch. 243, app 590-243-E-2