Data Dictionary 201504

DATADICTIONARY
ThisdocumentprovidesthedataelementdefinitionsthathavebeendefinedandapprovedbytheMaintenanceandControlWorkGroup.
ThedefinitionssupportthevariousfileandtelecommunicationsformatsthathavebeenapprovedbytheNCPDPmembership.
April215
NationalCouncilforPrescriptionDrugPrograms
924EastRaintreeDrive
Scottsdale,AZ8526
Phone: (48)4771
Fax:
(48)767142
email: ncpdp@ncpdp.org
DataDictionary
COPYRIGHT()NationalCouncilforPrescriptionDrugPrograms,Inc.
215
ThisworkisownedbyNationalCouncilforPrescriptionDrugPrograms,Inc.,924E.RaintreeDrive,Scottsdale,AZ8526,(48)4771,ncpdp@ncpdp.org,andprotectedbythecopyrightlawsof
theUnitedStates.17U.S.C.11,et.seq.PermissionisgiventoCouncilmemberstocopyandusetheworkoranypartthereofinconnectionwiththebusinesspurposesoftheCouncilmembers.
Theworkmaynotbechangedoraltered.Theworkmaynotbesold,usedorexploitedforcommercialpurposes.ThispermissionmayberevokedbyNationalCouncilforPrescriptionDrugPrograms,
Inc.,atanytime.TheNationalCouncilforPrescriptionDrugsPrograms,Inc.isnotresponsibleforanyerrorsordamageasaresultoftheuseofthework.
NCPDPrecognizestheconfidentialityofcertaininformationexchangedelectronicallythroughtheuseofitsstandards.Usersshouldbefamiliarwiththefederal,state,andlocallaws,regulationsand
codesrequiringconfidentialityofthisinformationandshouldutilizethestandardsaccordingly.
NOTICE:Inaddition,thisNCPDPStandardcontainscertaindatafieldsandelementsthatmaybecompletedbyuserswiththeproprietaryinformationofthirdparties.Theuseanddistributionofthird
parties'proprietaryinformationwithoutsuchthirdparties'consent,ortheexecutionofalicenseorotheragreementwithsuchthirdparty,couldsubjecttheusertonumerouslegalclaims.Allusersare
encouragedtocontactsuchthirdpartiestodeterminewhethersuchinformationisproprietaryandifnecessary,toconsultwithlegalcounseltomakearrangementsfortheuseanddistributionof
suchproprietaryinformation.
Publishedby:
CopyrightJune1999NCPDP
CopyrightAugust1999NCPDP
CopyrightSeptember1999NCPDP
CopyrightJune2NCPDP
CopyrightSeptember2NCPDP
CopyrightNovember2NCPDP
CopyrightMay21NCPDP
CopyrightJanuary22NCPDP
CopyrightJune22NCPDP
CopyrightDecember22NCPDP
CopyrightFebruary23NCPDP
CopyrightOctober23
CopyrightNovember23NCPDP
Copyright@May24NCPDP
Copyright@August24NCPDP
Copyright@October24NCPDP
Copyright@January25NCPDP
PublicationDates
Copyright@May25NCPDP
Copyright@July25NCPDP
Copyright@June26NCPDP
Copyright@September26NCPDP
Copyright@April27NCPDP
Copyright@July27NCPDP
Copyright@June28
Copyright@October28
Copyright@April29
Copyright@June29
Copyright@October29
Copyright@January21
Copyright@March21
Copyright@June21
Copyright@September21
Copyright@December21
Copyright@April211
Copyright@July211
Copyright@October211
Copyright@January212
Copyright@April212
Copyright@July212
Copyright@April213
Copyright@July213
Copyright@April214
Copyright@July214
Copyright@April215
DATA DICTIONARY
TABLEOFCONTENTS
I.
INTRODUCTION..................................................................................................................................................................................................................................................... 8
II.
DATAELEMENTS ................................................................................................................................................................................................................................................... 4
III.
AppendixANUMERICCROSSREFERENCEFORDATAELEMENTSWITHNUMERICIDENTIFIERS .......................................................................................................................... 166
IV.AppendixBCROSSREFERENCEOFFIELDSUSEDINNCPDPSCRIPTTOTHEMODELDRIVENSCHEMAS .................................................................................................................... 183

VI.AppendixCPUBLICATIONMODIFICATIONS............................................................................................................................................................................................................ 186
A. SEPTEMBER1999
187
1. TelecommunicationStandardVersion5Release1
B. JUNE2
187
187
2. EnrollmentStandardVersion2Release
3. PaymentTapeFormatVersion3Release
4. ManufacturerRebateUtilization,Plan,Formulary,andMarketBasketFlatFileFormatVersion2Release1
6, BatchStandardVersion1Release1
C. SEPTEMBER2
187
188
190
192
192
192
192
D. NOVEMBER2
192
192
E.
MAY21
192
193
F.
1. SCRIPTStandardVersion3Release1
AUGUST21
193
193
G. JANUARY22
193
193
1. TelecommunicationStandardVersion6Release
3. ManufacturerRebateStandardVersion3.1
4. PaymentReconciliationStandardVersion4Release
5. DataDictionaryModifications
H. JUNE22
193
193
194
195
196
196
I.
DECEMBER22
196
196
-1April215
NationalCouncilforPrescriptionDrugPrograms,Inc.
CopyrightedMaterialsSeeCopyrightStatementforAllowedUse
DATA DICTIONARY
J.
1. ManufacturerRebateStandardVersion3Release2
FEBRUARY23
196
197
K. AUGUST23
197
197
OCTOBER23
197
197
M.
NOVEMBER23
197
197
198
1. ManufacturerRebateStandardVersion3Release2NewpublicationdateofNovember23
N.
MAY24
198
198
198
O.
AUGUST24
198
198
1. TelecommunicationStandardVersionA.
P. OCTOBER24
198
199
2. TelecommunicationStandardVersionA.1
Q.
JANUARY25
199
199
199
1. SCRIPTStandardVersions7.and7.1
R. MAY25
199
199
L.
1. TelecommunicationStandardVersionB.
JULY25
199
199
1. TelecommunicationStandardVersionC.
2. SCRIPTStandardVersions8.
T. OCTOBER25
199
200
200
1. TelecommunicationStandardVersionC.1
2. Formulary&BenefitStandardVersion1.
3. SCRIPTStandardVersions8.1and9.
U. JUNE26
200
201
204
204
V. SEPTEMBER26
204
204
1. PostAdjudicationStandardVersion1.
W.
OCTOBER26
204
211
212
S.
-2April215
DATA DICTIONARY
1. SCRIPTStandardVersion1.
X. JANUARY27
212
212
Y.
APRIL27
212
212
Z.
1. ManufacturerRebateStandardVersion4Release1
JULY27
212
217
1.
2.
3.
AA.
TelecommunicationVersionDRelease
MedicaidSubrogationImplementationGuideVersion3Release
SCRIPTStandardImplementationGuideVersion1Release1andVersion1Release2
JANUARY28
217
223
224
224
1.
2.
3.
4.
BB.
FinancialInformationReportingStandardImplementationGuideVersion1Release
PostAdjudicationStandardImplementationGuideVersion2Release
PrescriptionTransferStandardImplementationGuideVersion1Release
SCRIPTStandardImplementationGuideVersion1Release3
JUNE28
224
225
226
229
229
1. FormularyandBenefitStandardImplementationGuideVersion2Release
2. SCRIPTStandardImplementationGuidesVersion1Release4andVersion1Release5
CC. OCTOBER28
229
230
230
1.
2.
3.
DD.
230
231
231
235
TelecommunicationStandardImplementationGuideVersionDRelease1
SCRIPTStandardImplementationGuidesVersion1Release6
UniversalClaimFormandWorkersCompensation/Property&CasualtyForm
APRIL29
1. PostAdjudicationStandardImplementationGuideVersion2Release1
2. SCRIPTStandardImplementationGuideVersion1Release7
EE.
JUNE29
235
235
235
1.
2.
3.
4.
5.
FF.
235
236
238
238
238
238
PriorAuthorizationStandardImplementationGuideVersion1Release
PostAdjudicationStandardImplementationGuideVersion2Release1andVersion
UniversalClaimForm
OCTOBER29
1. FinancialInformationReportingStandardImplementationGuideVersion1Release1
2. DataDictionary
GG. JANUARY21
238
239
239
1. FinancialInformationReportingStandardImplementationGuideVersion1Release2
2. PrescriptionTransferStandardImplementationGuideVersion1Release1
239
239
-3April215
DATA DICTIONARY
HH.
240
MARCH21
1. TelecommunicationStandardImplementationGuideVersionDRelease3
II. JUNE21
240
240
240
JJ. SEPTEMBER21
240
241
241
1.
2.
3.
KK.
DataDictionary
DECEMBER21
241
241
241
241
1.
2.
3.
4.
5.
6.
LL.
ManufacturerRebateStandardVersion5Release
FormularyandBenefitStandardVersion3Release
SpecializedImplementationGuideVersion21121
SCRIPTStandardImplementationGuideVersion21121
DataDictionary
APRIL211
241
242
242
242
246
252
253
2. DataDictionary
MM.
JULY211
253
253
253
1.
2.
3.
4.
5.
6.
7.
8.
NN.
MedicalRebateDataSubmissionStandardImplementationGuideVersion1Release
ManufacturerRebateUtilization,Plan,Formulary,MarketBasket,andReconciliationFlatFileStandardImplementationGuideVersion5Release1
SpecializedStandardImplementationGuideVersion21171
AuditTransactionStandardImplementationGuideVersion1Release
ConnectivityOperatingRuleVersion1.
DataDictionary
OCTOBER211
253
255
256
257
257
259
259
259
259
1.
2.
3.
4.
5.
6.
OO.
UniformHealthcarePayerDataStandardImplementationGuideVersion1Release
RetireeDrugSubsidyStandardImplementationGuideVersion1Release
DataDictionary
JANUARY212
259
261
262
262
262
262
263
-4April215
DATA DICTIONARY
1. TelecommunicationStandardImplementationGuideVersionDRelease9
2. SCRIPTStandardImplementationGuideVersion21211
PP. APRIL212
263
263
263
2. SpecializedStandardImplementationGuideVersion21231
QQ. JULY212
263
263
264
1. DataDictionary
RR. OCTOBER212
264
264
1. DataDictionary
SS.
JANUARY213
264
264
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
TT.
PostAdjudicationStandardImplementationGuideVersion4Release1
FormularyandBenefitStandardImplementationGuideVersion4Release
ManufacturerRebateUtilization,Plan,Formulary,MarketBasket,andReconciliationFlatFileStandardImplementationGuideVersion6Release
MedicalRebatesDataSubmissionStandardImplementationGuideVersion2Release
PrescriptionFileTransferStandardImplementationGuideVersion3Release
PriorAuthorizationTransferStandardImplementationGuideVersion2Release
TelecommunicationStandardImplementationGuideVersionERelease
TelecommunicationStandardImplementationGuideVersionERelease1
APRIL213
264
268
268
269
269
269
269
270
270
270
271
271
271
272
273
274
274
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
UU.
DataDictionary
WorkersCompensation/Property&CasualtyUniversalClaimForm
AuditTransactionStandardImplementationGuideVersion2Release1
MedicalRebatesDataSubmissionStandardImplementationGuideVersion2Release1
UniversalClaimForm
UniformHealthcarePayerDataStandardImplementationGuideVersion2Release1
PrescriptionFileTransferStandardImplementationGuideVersion3Release1
JULY213
274
274
275
275
276
276
276
276
277
277
277
277
-5April215
DATA DICTIONARY
1.
2.
3.
4.
VV.
SpecilaizedImplementationGuideVersion21371
DataDictionary
OCTOBER213
277
279
280
280
280
1.
2.
3.
4.
5.
WW.
FormularyandBenefitStandardImplementationGuideVersion4Release1
PrescriptionTransferStandardImplementationGuideVersion3Release2
JANUARY214
280
281
281
282
282
283
1.
2.
3.
XX.
DataDictionary
ManufacturerRebateUtilization,Plan,Formulary,MarketBasket,andReconciliationFlatFileStandardImplementationGuideVersion7Release
APRIL214
283
283
283
284
1.
2.
3.
4.
5.
6.
7.
8.
YY.
UniformStandardImplementationGuideVersion22
PostAdjudicationStandardImplementationGuideVersion43
TelecommunicationStandardImplementationGuideVersionE5
AuditTransactionStandardImplementationGuideVersion3
MedicalRebateDataSubmissionStandardImplementationGuideVersion2Release2
JULY214
284
284
284
284
284
285
285
285
286
1.
2.
3.
4.
5.
ZZ.
DataDictionary
PrescriptionTransferStandardImplementationGuideVersion33
OCTOBER214
286
286
286
286
287
287
1.
2.
3.
4.
AAA.
FormularyandBenefitStandardImplementationGuideVersion42
JANUARY215
287
287
288
288
288
1. FormularyandBenefitStandardImplementationGuideVersion43
2. BenefitIntegrationStandardImplementationGuideVersion1
BBB. APRIL215
288
288
290
-6April215
DATA DICTIONARY
2. SpecializedStandardImplementationGuideVersion21541
-7April215
290
291
DATA DICTIONARY
I.
INTRODUCTION
PresentedinthisdocumentarethedataelementdefinitionsthathavebeendefinedandapprovedbytheMaintenanceandControl(MC)WorkGroupoftheNationalCouncilfor
PrescriptionDrugPrograms(NCPDP).ThedefinitionssupportthevariousfileandtelecommunicationformatsthathavebeenapprovedbytheNCPDPmembership.
Thedataelementdefinitionsshouldbeusedbyallpersonswhowanttoknowwhen,whereandhowspecificdataelementsareusedintheapprovedfileformats.TheNCPDP
StandardsMatrixdocumentisanimportantreferenceforuse.Itcontainsahighleveloverviewofthelatestversion/releaseand/orthemostcommonlyusedofthestandards
andimplementationguides,aswellasNCPDPsDataDictionaryandExternalCodeList.Thisdocumentprovidesversion/release/publicationreferencechartsforapprovedand
draftNCPDPstandards/implementationguides.
TheExternalCodeList(ECL)containsvaluesfordataelementswithintheNCPDPStandards.AllDataElementswhosevaluesresideintheECLwillhaveanindicatorofSeeECLin
theValuesColumnofthisdocument.PleaserefertotheappropriateECLpublication.
Note:DataelementswithintheClaimsBillingTapeFormat,DisketteBillingFormat,ClaimPaymentTapeFormat,andMemberEnrollmentStandardhavebeenexcludedfromthe
ECL,withinfrequentexceptions,sincethesestandardsarenotpresentlymaintainedorupdated.Thefewexceptionswouldbeforthosedataelementsthathavesharedcodelists
withdataelementsincludedintheECLforthemaintainedNCPDPStandards.
Various appendices provide lists of reject (and adjustment) codes. In addition, a crossreference for Field Name changes has been provided. Reject Codes for the
TelecommunicationStandardarelistedintheExternalCodeList(ECL)document.
NOTE:APPENDIXCPUBLICATIONMODIFICATIONSPROVIDESALISTINGOFALLAPPROVEDDATAELEMENTCHANGESFORALLNCPDPSTANDARDS.THEUPDATESINCLUDE
ALLMODIFICATIONSMADESINCETHELASTQUARTERLYPUBLICATIONOFTHEDATADICTIONARYANDAPPEARINBOLDPRINT.
Changes or additions to the NCPDP Data Dictionary and/or External Code List should be submitted on a Data Element Request Form (DERF). The process for submitting,
reviewing,approvingandimplementingdataelementchangesisdescribedinthisdocument.ForacopyofthemostcurrentDERFformpleasecontacttheCouncilofficeorsee
www.ncpdp.org.RefertotheDERFforinstructionsoncompletingandsubmittingtheform.
TheMCMaintenanceandControlWorkGroupmeetsquarterlyattheJointTechnicalWorkGroupMeetingstoconsiderrequestsfortheadditionand/ormodificationofdata
elements.Additionsandmodificationsthathavebeenapprovedbythemembershipatlargewillbepublishedquarterly.NCPDPpledgesitscommitmenttomaintain,modify,
enhanceanddisseminateinformationpertainingtotheDataDictionaryconsistentwiththegoalsoftheorganizationanditsmembership.
STANDARDFORMATSKEY(THROUGHOUTDOCUMENT)
I
= BenefitIntegration
Standard
A = PostAdjudicationStandard
B = BatchStandard
J
= MedicalRebateData
Q = SpecializedImplementation
SubmissionStandard
Guide
E = AuditTransactionStandard
K
= OperatingRules
R = ManufacturerRebateStandard
F = Formulary&BenefitStandard
L
= RetireeDrugSubsidy
S
= SCRIPTStandard
G = MedicaidSubrogation
N = FinancialInformationReporting
T
= TelecommunicationStandard
H = HealthCareIDCard
-8April215
DATA DICTIONARY
U = BillingUnitStandard
Compensation/Property&
Y
= UniformHealthcarePayerData
CasualtyUniversalClaimForm
Standard
V = PrescriptionTransferStandard
X
=
PriorAuthorizationTransfer
Z
=
UniversalClaimForm
W = Workers
FIELDandNAMEofFIELD
TheapprovalofthemodelgeneratedschemasforSCRIPTandSpecializedImplementationGuidehasintroducedXMLfields.TheXMLelementsarelistedinthemainbodyofthe
DataDictionary.NotetheXMLelementsdonotsupportFieldNumbersandthenamingconventionincludesnospacesintheFieldName.
FIELDFORMATVALUES
Thefollowingfieldformatvaluesaresupported.
"N"=UnsignedNumeric,alwaysrightjustified,zerofilledandwhenusedfordollarfields,havedefaultvaluesofzeros.
Example:
9(7)v999represents9999999.999
"D"=SignedNumeric,signisinternalandtrailing(seesectionInternalRepresentationofOverpunchSigns),zeroalwayspositive,alwaysrightjustified,zerofilleddollar
centsamountwith2positionstotherightoftheimplieddecimalpoint,allotherpositionstotheleftoftheimplieddecimalpointandwhenusedfordollarfields,have
defaultvaluesofzeros.
Example:
"D"fieldsoflength8represent$$$$$$cc
"A/N"=Alpha/Numeric,uppercasewhenalpha,alwaysleftjustified,spacefilled,uppercase,printablecharactersanddefaultvaluesofspaces
Example:
X(14)represents1234ABC44bbbbb
NX=NumericExtended,arealwaysrightjustifiedandzerofilled,withtherightmostpositionreservedforthesign.Thefieldmustbeblankwhennotreported.The
symbol b indicates a blank or a positive value. The symbol indicates a negative value. Zeros represent a valid numeric value and do not meannull. All
decimalsareimpliednotexplicit.
Example:
9999v99representsanegative9999.99
9999v99brepresentsapositive9999.99
R=Numeric9withdecimalpoint
Fornumericvaluesthathaveavaryingnumberofdecimalpositions,adecimaldataelementmaycontainanexplicitdecimalpointandisused.Thisdataelementtypeis
representedasR.
Thedecimalpointalwaysappearsifitisatanyplaceotherthantherightmostposition.Ifthevalueisaninteger(decimalpointattherightmostposition),thedecimal
pointshouldbeomitted.Fornegativevalues,theleadingminussign()isused.Absenceofasignindicatesapositivevalue.Theplussign(+)shouldnotbetransmitted.
Leadingzerosshouldbesuppressedunlessnecessarytosatisfyaminimumlengthrequirement.Trailingzerosfollowingthedecimalpointshouldbesuppressedunless
necessary to indicate precision. The use of triad separators (for example, the commas in 1,,, ,) is prohibited. The length of a decimal type data
elementdoesnotincludethedecimalpoint.Avalueof12345.67isvalidinafielddefinedwithamaximumlengthof7.
Example:
Atransmittedvalueof12.34representsadecimalvalueof12.34.
-2April215
DATA DICTIONARY
A transmitted value of 25.4 when applied to a monetary use represents

$25.4.
There are certain data fields that allow an explicit decimal point in the Alpha/Numeric representation. See Implementation Guide for decimal discussion for specific data
elements.
ThefollowingfieldformatvaluesaresupportedinXML.
an=asequenceofcharacters,alphanumericthatmusthaveatleast1nonblankcharacter,noconstrainttolengthofthecontent(string).Whenlengthisconstrained,
isshownasx(#)suchasx(15),x(14).
n=numericintheallowablevaluesthatmustbesentwithatleastonevalidvalue.Shownas9(18),9(2).
xsd:boolean=thetypeofanexpressionwithtwopossiblevalues,"True"and"False".
BooleanCode=NCPDPdefinedbackwardscompatibletypeofexpressionwithtwopossiblevalues,YandN.
DateTimeFormat=CCYYMMDDTHH:MM:SS
DateFormat=CCYYMMDD
FormatLimitations/Requirements
Ifafieldrequiresexplicitformatlimitations/requirements,itwillbespecifiedinthisdocument.Forexample,EmployerID(333CZ)hasexplicitformatrequirements.
RulesforDemographicFields
ThefollowingrulesapplytothecreationofdemographicfieldsusedbyallNCPDPstandards.Exceptionswhengrantedarenotedinthecommentsofthefield(i.e.,compatibility
issueswithexternalstandards).
OrganizationalNames
FieldLengthis7(x7)
IndividualNames
Separatefieldsmustbecreatedforfirstname,middlename(ifrequired)andlastname.FieldLengthoffirstnameandlastnameis35.
StreetAddress
FieldLengthis4(x4)
AddressLine1andAddressLine2arecreated.
City
Currentrange:1835characters
Allnewcityfieldsare35characters.
State/ProvinceAddress
Allstate/provincecodesare2characters
FieldnamingconventionisState/ProvinceAddress
-2April215
DATA DICTIONARY
CountryCode
Allcodesare2characters
Zip/PostalCodes
Allcodesare15characters
FieldnamingconventionisZip/PostalCode
TelephoneNumber
FieldLengthis1(9(1))
SeparatefieldmustbecreatedforExtensionwithalengthof8(9(8))
Faxnumbersarenotincludedinthisrule.
INTERNALREPRESENTATIONOFOVERPUNCHSIGNS
UNITS
SIGNEDPOSITIVE
SIGNEDNEGATIVE
Digit
1
2
3
4
5
6
7
8
9
Graphics
{
A
B
C
D
E
F
G
H
I
Oct
173
11
12
13
14
15
16
17
11
111
Dec
123
65
66
67
68
69
7
71
72
73
Hex
7B
41
42
43
44
45
46
47
48
49
Graphics
}
J
K
L
M
N
O
P
Q
R
Oct
175
112
113
114
115
116
117
12
121
122
Dec
125
74
75
76
77
78
79
8
81
82
Hex
7D
4A
4B
4C
4D
4E
4F
5
51
52
NOTE: If you are not implementing Telecommunication Version 5. or higher, please refer to the appropriate data dictionary version and ECL publication to ensure the
appropriatefieldlength,definitionsandvaluesareapplied.
AnyquestionsregardingthecontentortheintentoftheinformationpresentedhereinshouldbeaddressedtotheCounciloffice:
924EastRaintreeDrive
Scottsdale,AZ8526
Phone
(48)4771
Fax
(48)767142
email
ncpdp@ncpdp.org
-3April215
DATA DICTIONARY
II.
DATAELEMENTS
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
9BN
AbsoluteRow
Number
Theabsoluteroworlinenumber
inthefilethatcontainstheerror.
9(1)
6186
AcceptedQuantity
Totalquantityacceptedfor
payment.
9(11)v999b
or
9(11)v999
15
Format=99999999999v999bor99999999999v999
Note:
b=Space
=Negativesign
512FC
Accumulated
DeductibleAmount
Amountindollarsmetbythe
patient/familyinadeductible
plan.
s9(6)v99
T,A
Format=s$$$$$$cc
Examples:Thedeductibleamountonthepatients
planis$1..Thepatientpurchasestwo
prescriptions,onefor$15.andanotherfor
$35..Theaccumulateddeductibleatthatpoint
wouldbe$5..Thisfieldwouldreflect:5{.
653S4
652S3
AccumulatedGross
CoveredDrugCost
Amount
Accumulated
PatientTrueOutOf
PocketAmount
Theaccumulatedcostincurred
bytheplanforcoveredPartD
drugsincludingamountspaidby
oronbehalfofanenrolleeand
includingcertaindispensingfees,
butnotincludingadministrative
costs.
s9(6)v99
Theaccumulatedcostfor
coveredPartDdrugsincurredby
apatientthatareapplicable
towardstheoutofpocketlimit
setbytheCentersforMedicare
andMedicaidServices(CMS).
s9(6)v99
Format=s$$$$$$cc
Example:Iftheamountis$5.5thisfieldwould
reflect:55{.
Format=s$$$$$$cc
reflect:55{.
B67
AccumulatorAction
Code
Describestheaccumulator
event/actionthatisrequestedby
thesenderandtheactiontobe
takenbythereceiver.
x(2)
SeeECL
B68
Accumulator
AppliedAmount
Amountappliedtothe
associatedaccumulator.
9(8)v99
ForI:Format=$$$$$$$$cc
Negativedollardesignationishandledwiththeuse
oftheActionCode(711)field
-4April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
B69
Accumulator
BalanceBenefit
Type
Coderepresentingfamilyor
individualbenefit
x(1)
SeeECL
B7
Accumulator
BalanceQualifier
Identifiesthetypeof
accumulatorbalancebeing
reported.
x(2)
SeeECL
B71
Accumulator
BalanceCount
Thenumberofaccumulator
balancegroupingstofollow.
9(2)
B72
AccumulatorBenefit
PeriodAmount
Thetotalaccruedamountforthe
benefitperiod.Forabenefit
yearitisnormallyknownasYTD
or(yeartodate)amount.
9(8)v99
B73
Accumulator
ChangeSourceCode
Codeindicatingtheactivitythat
causedtheaccumulatorchange.
x(1)
SeeECL
655S6
AccumulatorMonth
Identifiestheaccumulatormonth
basedondateofserviceof
claimsactivity.
9(2)
SeeECL
656S7
AccumulatorMonth
Count
CountofAccumulatorMonth
(655S6)occurrences.
9(2)
B74
Accumulator
NetworkIndicator
Indicatesthetypeof
accumulationbasedonnetwork
contractingstatus
x(1)
SeeECL
B75
Accumulator
ReferenceTime
Stamp
Thedateandtimethe
accumulatorwasadjustedbythe
senderoftherecord.
x(26)
26
Format:CCYYMMDDHH.MM.SS.mmmmmm
B76
Accumulator
RemainingBalance
Amountremainingforthe
associatedaccumulatorwithin
thebenefitperiod.
9(8)v99
B77
Accumulator
SpecificCategory
Type
Identifiestheaccumulator
specificcondition/disease.
x(2)
SeeECL
65S1
AccumulatorYear
Identifiestheaccumulatoryear.
9(4)
Format=CCYY
CC=Century
YY=Year
-5April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
AcknowledgementI
D
Respondercontrolreference
Thisfieldmaybeusedasatrace
numberbetweentrading
partners. ForResupplyInthe
LTCenvironmentthisisthe
prescriptionnumberassignedby
thefacility.
x(35)
S,Q
35
AcknowledgementR
eason
Additionaltextualinformation
regardinginterventionand/or
acknowledgmentassociatedwith
aDUEconflict.
x(1)
711
ActionCode
Processingactionrequested.
x(1)
3692Q
Additional
Documentation
TypeID
Uniqueidentifierforthedata
beingsubmitted.
x(3)
SeeECL
AdditionalFreeText
Freetext
x(2)
AdditionalFreeTextI
ndicator
Indicatesiftheprescriberis
allowedtosupplyadditionalfree
textwiththeiranswertothe
question.
x(2)
SeeECL
AdditionalMessageI
ndicator
Designatesifasubsequent
transactionwillbesent.
xsd:boolean
526FQ
AdditionalMessage
Information
Freetextmessage.
x(1)x(4)
x(1)
x(2)
F,N
V,X
131UG
AdditionalMessage
Information
Continuity
Indicatescontinuityofthetext
foundinthecurrentrepetitionof
AdditionalMessageInformation
(526FQ)withthetextfoundin
thenextrepetitionthatfollows.
x(1)
SeeECL
13UF
AdditionalMessage
InformationCount
CountoftheAdditionalMessage
Information(526FQ)
occurrencesthatfollow.
9(2)
-6April215
DATA DICTIONARY
FIELD
DEFINITIONOFFIELD
132UH
AdditionalMessage
Information
Qualifier
Formatqualifierofthe
(526FQ)thatfollows.Eachvalue
mayoccuronlyonceper
transactionandvaluesmustbe
orderedsequentially(numeric
charactersprecedealpha
characters,i.e.,9,AZ).
x(2)
SeeECL
AdditionalRefillsAut
horized
Numberofadditionalrefills
authorized.
9(2)
AdditionalTraceNum
ber
Tracenumberbetweentrading
partners.
x(3)
S,Q
63MY
AddressCount
Countofaddressoccurrences.
9(1)
Comments:ForPrescriptionTransfer,fields
includedintheset/logicalgroupingare:Address
Qualifier(64NA),EffectiveDate(69NG),
AddressLine1(726SR),AddressLine2(727SS),
City(728SU),State(729TA),Zip/PostalCode(73
TC).
AddressLine1
Firstlineofaddressinformation.
x(4)
S,Q
726SR
AddressLine1
Firstlineofaddressinformation.
x(4)
A,R,V
Comments:ForPrescriptionTransfer,qualifiedby
ADDRESSQUALIFIER(64NA)
AddressLine2
Secondlineofaddress
information.
x(4)
S,Q
727SS
AddressLine2
Secondlineofaddress
information.
x(4)
A,R,V
Comments:Secondlineofstreetaddress.Usedonly
iffirstlinewillnotaccommodateacomplete
address.
64NA
AddressQualifier
Qualifieroftheaddress.
9(2)
SeeECL
AddressTypeQualifie
r
an
S,Q
SeeECL
A28ZR
Adjudicated
PaymentType
9(2)
SeeECL
QualifiestheToorFrom.
Thetypeofprescriptionbenefit
planthatadjudicatedandpaid
theprimaryamountofthe
prescriptionasreportedbythe
planinaresponse.
FIELD
FORMAT
STANDARD
FORMATS
NAMEOFFIELD
FIELD
LENGTH
VALUES
-7April215
COMMENTS/EXAMPLES
Comments:QualifiesAdditionalMessage
Information(526FQ).
DATA DICTIONARY
FIELD
578
23
6171
617
6172
NAMEOFFIELD
AdjudicationDate
AdjudicationTime
AdjustedQuantity
AdjustedRebatePer
Unit
AdjustedVariance
Difference
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
Datetheclaimoradjustmentis
processed.
9(8)
A,R,J,Y
Timetheclaimoradjustmentis
processed.
9(6)
AcorrectionbetweentheTotal
Quantity(6139)submitted
andtheAcceptedQuantity
(6186).
9(11)v999b
or
9(11)v999
Thedollardifferencebetween
theRebatePerUnitAmount
(6152)andthePaidPerUnit
Amount(6195).
9(5)v99999
9b
or
9(5)v99999
9
TheTotalQuantity(6139)
timestheAdjustedRebatePer
Unit(617)amount.
9(9)v99bor
9(9)v99
FIELD
LENGTH
8
VALUES
COMMENTS/EXAMPLES
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
A,R
Format=HHMMSS
HH=Hours
MM=Minutes
SS=Seconds
15
Format=99999999999v999bor99999999999v999
Note:
b=Space
=Negativesign
12
Format=$$$$$ccccccbor$$$$$cccccc
Note:
b=Space
=Negativesign
12
Format=$$$$$$$$$ccbor$$$$$$$$$cc
Note:
b=Space
=Negativesign
24
AdjustmentReason
Code
Reasonforadjustment
x(3)
__________
A
_________
3
_________
_____________________________________
x(1)
SeeECL
ForA:
Comments:Codesdefinedbyprocessor.
25
AdjustmentType
Typeofadjustment.
x(1)
SeeECL
AdministrationIndic
ator
Indicatestheactiontobetaken
ontheAdministrationfields.
an
SeeECL
AdministrationTimin
gClarifyingFreeText
Usedtoaddclaritytothe
administrationtimingfor
elementsthatcannotbe
codified.
x(255)
255
AdministrationTimin
gEventCode
Thecoderepresentingthe
AdministrationTimingEventText.
an
QualifiedbyAdministrationTimingEventQualifier.
-8April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
AdministrationTimin
gEventQualifier
Qualifiertoidentifythecode
systembeingused.
an
SeeECL
AdministrationTimin
gEventText
Thetextualrepresentationof
AdministrationTimingEventCode.
an
AdministrationTimin
gModifierCode
AdministrationTimingModifierTe
xt.
an
Qualifiedby
AdministrationTimingModifierQualifier.
AdministrationTimin
gModifierQualifier
systembeingused.
an
SeeECL
AdministrationTimin
gModifierText
Thetextualrepresentationofthe
AdministrationTimingModifierCo
de.Usedtoclarifyorspecify
whenthemedicationistobe
administeredrelativetothe
actualtimingevent.
an
AdministrationTimin
gNumericValue
Thenumericvalueforthe
administrationevent,suchas30
(minutes).
9(18)
18
AdministrationTimin
gUnitsCode
AdministrationTimingUnitsText.
an
QualifiedbyAdministrationTimingUnitsQualifier.
AdministrationTimin
gUnitsQualifier
systembeingused.
an
SeeECL
AdministrationTimin
gUnitsText
AdministrationTimingUnitsCode.
an
26
AdministrativeFee
Amount
Administrativefeechargeper
claim.
s9(2)v99
Format=s$$cc
reflect:55{.
27
AdministrativeFee
EffectIndicator
Indicateshowthetransaction
shouldbecountedfor
administrativefee
determination.
x(1)
SeeECL
28
Age
CalculatedfromDateofBirth
(34C4).
9(3)
Format=YYY
Y=Year
-9April215
DATA DICTIONARY
FIELD
A74
NAMEOFFIELD
AllergyDrugProduct
CodedQualifier
AllowedAmount
DEFINITIONOFFIELD
Thecodelistusedtoidentifythe
drugproducttowhichthe
patientisallergic.
FIELD
FORMAT
an
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
SeeECL
12
Theamountofthepatientcopayordeductibleis
notdeductedfromthisamount.
b=Space
=Negativesign
Allowablechargesforcovered
servicesbasedonthespecially
negotiatedfeebetweenthe
providerandMCO.
9(9)v99b
or9(9)v99
33CW
AlternateID
Personidentifiertobeusedfor
controlledproductreporting.
Identifiermaybethatofthe
patientorthepersonpickingup
theprescriptionasrequiredby
thegoverningbody.
x(2)
724ST
AlternateID
Number
AlternateIDnumberassignedto
thecardholderorfamily
member.
x(2)
V,X
Comments:AlternateIDnumberidentifying
member.
B621M
AlternativesGroup
ID
IDassignedbypayertomatch
theFormularyAlternatives
Triggersrecord.
x(4)
91BP
AlternativesID
IDforthealternativelist
x(1)
B631N
AlternativesList
Type
IndicatesthetypeofAlternatives
List.
x(2)
SeeECL
- 10 April215
DATA DICTIONARY
FIELD
517FH
NAMEOFFIELD
AmountAppliedTo
PeriodicDeductible
DEFINITIONOFFIELD
Amounttobecollectedfroma
patientthatisincludedin
PatientPayAmount(55F5)
thatisappliedtoaperiodic
deductible.
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
s9(6)v99
_______
T,A
_________
8
_______
9(6)v99
or
9(5)v99
VALUES
COMMENTS/EXAMPLES
ForT,A:Format=s$$$$$$cc
Examples:Apatienthasa$5.deductibleto
meet.Thepatientsfirstprescriptioncosts$95..
Theamountappliedtotheperiodicdeductible
wouldreflect$5..Thisfieldwouldreflect:
5{.
Apatienthasa$1.deductibletomeet.The
patienthaspreviouslymet$8.ofthe
deductible.Thenextprescriptionpurchasedcosts
$42.Theamountappliedtotheperiodic
deductiblewouldreflect$2..Thisfieldwould
reflect:2{.
ForY:
Format=$$$$$$ccor$$$$$cc
Note:
=Negativesign
Thisminus()signoccupiesaposition,sothe
dollarsthatcanbesupportedareonedigitlessthan
apositivedollaramount.
SeeimportantinformationintheUniform
HealthcarePayerDataStandardfordollarfield
usage.
137UP
AmountAttributed
toCoverageGap
Amounttobecollectedfromthe
thatisduetothepatientbeingin
thecoveragegap(forexample
MedicarePartDCoverageGap
(donuthole)).Acoveragegapis
definedastheperiodoramount
duringwhichtheprevious
coverageendsandbeforean
additionalcoveragebegins.
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
reflect:55{.
ForY:
Note:
=Negativesign
usage.
- 11 April215
DATA DICTIONARY
FIELD
571NZ
NAMEOFFIELD
AmountAttributed
toProcessorFee
DEFINITIONOFFIELD
patientthatisincludedinPatient
PayAmount(55F5)thatisdue
totheprocessingfeeimposedby
theprocessor.
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
__________
9(8)v99
__________
_________
VALUES
COMMENTS/EXAMPLES
reflect:55{.
ForY:
Note:
=Negativesign
usage.
Thisfielddoesnotsupportnegativedollar
amounts.
519FJ
AmountAttributed
ToProductSelection
thatisduetothepatients
selectionofdrugproduct.
s9(6)v99
_______
A
_________
8
________
9(6)v99
or
9(5)v99
ForA:Format=s$$$$$$cc
NOTE:SunsettedfieldusedinPostAdjudication
Version2.withspecificusageasdefinedin
implementationguide.
ForY:
Note:
=Negativesign
usage.
- 12 April215
DATA DICTIONARY
FIELD
134UK
NAMEOFFIELD
DEFINITIONOFFIELD
AmountAttributed
toProductSelection
/BrandDrug
selectionofaBrandproduct.
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
__________
9(8)v99
__________
_________
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
VALUES
AmountAttributed
toProductSelection
/BrandNon
PreferredFormulary
Selection
selectionofaBrandNon
PreferredFormularyproduct.
AmountAttributed
toProductSelection
/NonPreferred
FormularySelection
selectionofaNonPreferred
Formularyproduct.
reflect:55{.
ForY:
Note:
=Negativesign
usage.
135UM
reflect:55{.
ForY:
Note:
=Negativesign
usage.
amounts.
136UN
COMMENTS/EXAMPLES
- 13 April215
reflect:55{.
ForY:
Note:
=Negativesign
usage.
DATA DICTIONARY
FIELD
133UJ
NAMEOFFIELD
AmountAttributed
toProvider
NetworkSelection
DEFINITIONOFFIELD
providernetworkselection.
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
VALUES
COMMENTS/EXAMPLES
reflect:55{.
ForY:
Note:
=Negativesign
usage.
523FN
AmountAttributed
ToSalesTax
thatisduetosalestaxpaid.
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
__________
9(8)v99
__________
_________
Examples:Thepatientmayberequiredtopaysome
portionofthesalestaxonaprescription.Ifthe
patientpays1.5%ofthesalestaxona$5.
prescription,thisfieldwouldreflect:7E.
ForY:
Note:
=Negativesign
usage.
amounts.
- 14 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
52FK
AmountExceeding
PeriodicBenefit
Maximum
DEFINITIONOFFIELD
thatisduetothepatient
exceedingaperiodicbenefit
maximum.
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
VALUES
COMMENTS/EXAMPLES
Examples:Thepatientisallowedaspecificbenefit
amount.Whenthemaximumbenefitamountis
exceeded,theremainderoftheprescriptionpriceis
addedtotheamountthepatientpaysinfield55
F5.Iftheamountexceededis$32.56,thisfield
wouldreflect:325F.
ForY:
Note:
=Negativesign
usage.
5724U
Amountof
Coinsurance
thatisduetoaperprescription
coinsurance.
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
reflect:55{.
ForY:
Note:
=Negativesign
usage.
- 15 April215
DATA DICTIONARY
FIELD
518FI
NAMEOFFIELD
AmountOfCopay
DEFINITIONOFFIELD
thatisduetoaperprescription
copay.
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
__________
9(8)v99
__________
_________
VALUES
COMMENTS/EXAMPLES
reflect:55{.
ForY:
Note:
=Negativesign
usage.
amounts.
6173
AmountPaidThis
Transaction
Dollaramountpaidwiththis
transaction.
9(9)v99bor
9(9)v99
12
Note:
b=Space=
Negativesign
Answer
Valuefortheanswer.
x(2)
AnswerValue
Codedreferencevalueforthe
answer.
x(255)
255
AnticipatedReturnD
ate
Thedateonwhichthepatientis
expectedtoreturntothecare
facility.
xsd:date
AppealCaseID
IDassignedbythepayerto
identifythespecificappeal
request.
x(35)
35
A95
ApplicationID
ApplicationIDassignedbyCMS
tothePlanSponsorapplyingfor
theRetireeDrugSubsidy.
9(1)
5486F
ApprovedMessage
Code
Messagecode,onanapproved
claim/service,communicating
theneedforanadditionalfollow
up.
x(3)
T,E
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
SeeECL
- 16 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
5475F
ApprovedMessage
CodeCount
CountoftheApprovedMessage
Code(5486F)occurrences.
9(1)
457EP
Associated
Prescription/
ServiceDate
DateoftheAssociated
Prescription/ServiceReference
Number(456EN).
9(8)
T,A
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
582X
Associated
Prescription/
ServiceFillNumber
RelatedFillNumbertowhichthe
claim/serviceisassociated.
9(2)
58XY
Associated
Prescription/
ServiceProviderID
RelatedServiceProviderIDto
whichtheclaim/serviceis
associated.
x(15)
15
Comments:QualifiedbyAssociated
Prescription/ServiceProviderIDQualifier(579XX).
Associated
Prescription/Service
ProviderIDQualifier
CodequalifyingtheAssociated
Prescription/ServiceProviderID
(58XY)towhichthe
claim/serviceisrelated.
x(2)
Associated
Prescription/
ServiceReference
Number
RelatedPrescription/Service
ReferenceNumber(42D2)to
whichtheserviceisassociated.
9(12)
Associated
Prescription/Service
ReferenceNumber
Qualifier
CodequalifyingtheAssociated
Prescription/ServiceReference
NumberID(456EN)towhich
theclaim/serviceisrelated.
x(2)
AttachmentControl
Number
Indicatesthecontrolnumberof
theattachment.
an
AttachmentData
Theactualattachment.
xsd:base64
Binary
AttachmentSource
Thesourceoftheattachment.
an
A48
AuditControl
Identification
Internalidentificationassigned
bytheauditentitytoidentifythis
transaction.
x(3)
579XX
456EN
581XZ
SeeECL
Comments:QualifiesAssociated
Prescription/ServiceProviderID(58XY).
T,A
12
Comment:QualifiedbyAssociated
Prescription/ServiceReferenceNumberQualifier
(579XX)
SeeECL
Comments:QualifiesAssociated
Prescription/ServiceReferenceNumber(456EN).
- 17 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
A62
AuditElement
Response1
IndicatesstatusoftheAudit
ElementType.
x(2)
SeeECL
A63
AuditElement
Response2
ElementType.
x(2)
SeeECL
A64
AuditElement
Response3
ElementType.
x(2)
SeeECL
A65
AuditElement
Response4
ElementType.
x(2)
SeeECL
A66
AuditElement
Response5
ElementType.
x(2)
SeeECL
A57
AuditElementType
1
Indicatestypeofinformationfor
associatedPrescription/Service
ReferenceNumber(s).
x(2)
SeeECL
A58
AuditElementType
2
ReferenceNumber(s).
x(2)
SeeECL
A59
AuditElementType
3
ReferenceNumber(s).
x(2)
SeeECL
A6
AuditElementType
4
ReferenceNumber(s).
x(2)
SeeECL
A61
AuditElementType
5
ReferenceNumber(s).
x(2)
SeeECL
A56
AuditRangeEnd
Indicatestheendingoftheaudit
rangeofdata.
x(19)
15
A54
AuditRange
Qualifier
Indicatesthetypeofrangebeing
requested.
9(2)
SeeECL
A55
AuditRangeStart
Indicatesthebeginningofthe
auditrangeofdata.
x(19)
15
A47
AuditRequestType
Typeofauditbeingrequested.
x(2)
SeeECL
- 18 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
A49
AuditSponsor
Payer,PlanSponsororPBMwho
isrequestingtheauditbe
performed.
x(3)
AuthorizationNumb
er
SeeAuthorizationNumber(53
F3)
an
53F3
Authorization
Number
Numberassignedbythe
processortoidentifyan
authorizedtransaction.
x(2)
T,A,N,E
498PH
Authorized
RepresentativeCity
Address
Freeformtextforcityname.
x(2)
B341U
Authorized
Representative
CountryCode
Codeofthecountry.
x(2)
SeeECL
498PE
Authorized
RepresentativeFirst
Name
Firstnameofthepatients
authorizedrepresentative.
x(35)
35
498PF
Authorized
RepresentativeLast
Name
Lastnameofthepatients
x(35)
35
498PJ
Authorized
Representative
State/Province
Address
State/ProvinceCodeofthe
x(2)
SeeECL
B137D
Authorized
Representative
StreetAddressLine
1
Freeformtextforaddressline1
information.
x(4)
B148B
Authorized
Representative
StreetAddressLine
2
information.
x(4)
- 19 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
498PK
Authorized
Representative
Zip/PostalCode
Codedefininginternational
postalcodeofauthorized
representative,excluding
punctuation.
x(15)
15
Comments:WhenusedforUSZIPCodeThisleft
justifiedfieldcontainsthefivedigitzipcode,and
mayincludethefourdigitexpandedzipcodein
whichthepatient'sauthorizedrepresentativeis
located.
Examples:Ifthezipcodeis987654321,thisfield
wouldreflect:987654321.
Ifthezipcodeis98765,thisfieldwouldreflect:
98765leftjustified.
WhenusedforCanadianPostalCodeThisleft
justifiedfieldcontainsthethreedigitforward
sortationarea(FSA)followedbyaspace,then
followedbyaLocalDeliveryUnit.(FormatA0A
0A0,whereAisaletterand0isadigit,withaspace
separatingthethirdandfourthcharacters.)
Examples:
A0E3B0
A1L2T8
29
AverageCostPer
QuantityUnitPrice
AverageCostPerQuantityas
definedbyprocessor.
s9(5)v9(4)
Format=s$$$$$cccc
AverageGeneric
UnitPrice
AverageGenericPriceperunitas
definedbyprocessor.
s9(5)v9(4)
AverageWholesale
UnitPrice
AverageWholesalePriceperunit
forthedrugasdefinedby
processor.
s9(5)v9(4)
BasisofCalculation
Coinsurance
Codeindicatinghowthe
Coinsurancereimbursement
amountwascalculatedfor
PatientPayAmount(55F5).
x(2)
T,A
x(2)
T,A
x(2)
T,A
21
211
5734V
347HJ
BasisOfCalculation
Copay
346HH
BasisOfCalculation
DispensingFee
CodeindicatinghowtheCopay
reimbursementamountwas
calculatedforPatientPay
Amount(55F5).
calculatedforDispensingFee
Paid(57F7).
reflect:55{.
A
Format=s$$$$$cccc
reflect:55{.
Format=s$$$$$cccc
reflect:55{.
SeeECL
SeeECL
SeeECL
- 20 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
348HK
BasisOfCalculation
FlatSalesTax
calculatedforFlatSalesTax
AmountPaid(558AW).
x(2)
T,A
349HM
BasisOfCalculation
PercentageSales
Tax
calculatedforPercentageSales
TaxAmountPaid(559AX).
x(2)
T,A
423DN
BasisOfCost
Determination
Codeindicatingthemethodby
which'IngredientCost
Submitted'(Field49D9)was
calculated.
x(2)
T,Z,W
522FM
BasisOf
Reimbursement
Determination
Codeidentifyinghowthe
calculatedforIngredientCost
Paid(56F6).
9(2)
T,A
498PD
BasisOfRequest
Codedescribingthereasonfor
priorauthorizationrequest.
x(2)
VALUES
SeeECL
SeeECL
SeeECL
SeeECL
SeeECL
COMMENTS/EXAMPLES
Comments:Usedbyprocessortodetermine
appropriatemodulesandeditingfortheprior
authorizationtransaction.
865C
BatchNumber
Thisnumberisassignedbythe
processor/sender.
9(7)
ForA,V,X,I:
B
_________
A,V,X,I
ForB:
Format=CCYYDDD
CC=Century
YY=Year
DDD=Juliandate
Anumbergeneratedbythe
sendertouniquelyidentifythis
batchfromothers,especially
whenmultiplebatchesmaybe
sentinoneday.
Examples:22252=September9,22
ForA,V,X,I:
Format=9999999
Example:Abatchnumberof4113wouldbe
4113or4113
Bed
Thebedofthepatient.
x(1)
S,Q
671W1
Bed
Thebedofthepatient.
x(1)
BeeperExtension
Extensionofthebeepernumber.
9(8)
S,Q
- 21 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
BeeperNumber
DEFINITIONOFFIELD
Beepernumberoftheentity.
FIELD
FORMAT
9(1)
STANDARD
FORMATS
S,Q
FIELD
LENGTH
1
VALUES
COMMENTS/EXAMPLES
Format=AAAEEENNNN
AAA=AreaCode
EEE=ExchangeCode
NNNN=Number
BeeperSupportsSMS
Indicationthenumberaccepts
textmessages.
BooleanCod
e
S,Q
SeeECL
BenefitAmount
Representstheamountofthe
overriddenamounttobeapplied
inplaceofthestandardplan
benefit.
9(7)v99
Format=$$$$$$$cc
A1
BenefitAmount
TimePeriod
DefineshowtheBenefitAmount
Typeoverrideistobeapplied
duringatimeperiodand
correspondstotheplansbenefit
accrualperiod.
9(1)
SeeECL
A2
BenefitAmount
Type
Representswhichofthebenefit
accumulationtypesisbeing
overriddenandalsohasan
optiontooverrideallbenefit
amounts.Thisamountisusually
settoanamountoutsideofthe
normalplanbenefitcoverage
level.
9(1)
SeeECL
A3
BenefitAmount
UsedToDate
Indicatestheaggregatedamount
ofbenefitusedtodateagainsta
previouslyapprovedoverride
amount.
9(7)v99
Format=$$$$$$$cc
761
BenefitEffective
Date
Effectivedateofthebenefit.
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
757U6
BenefitID
Assignedbyprocessortoidentify
asetofparameters,benefits,or
coveragecriteriausedto
adjudicateaclaim.
x(15)
A,T
15
Comments:Note:ForPartD,usedtoidentifythe
PBP(PlanBenefitPackage)Number.
- 22 April215
DATA DICTIONARY
FIELD
394MW
NAMEOFFIELD
BenefitStage
Amount
DEFINITIONOFFIELD
FIELD
FORMAT
Theamountofclaimallocatedto
theMedicarePartDbenefit
stage,allocatedtoother
Medicarebenefit,orpaidbyan
alternativebenefitcoordinated
withorbytheresponding
MedicarePartDpayeras
identifiedbytheBenefitStage
Qualifier(393MV).
s9(6)v99
STANDARD
FORMATS
T,A
FIELD
LENGTH
8
VALUES
COMMENTS/EXAMPLES
Format=s$$$$$$cc
reflect:55{.
Comments: Fieldsincludedintheset/logical
groupingare:
BenefitStageQualifier(393MV)
BenefitStageAmount(394MW)
Comments: QualifiesBenefitStageAmount(392
MW).
392MU
BenefitStageCount
CountofBenefitStageAmount
(394MW)occurrences.
9(1)
393MV
BenefitStage
Qualifier
CodequalifyingtheBenefit
StageAmount(394MW).
x(2)
T,R,A
SeeECL
759
BenefitTermination
Date
Datethatbenefitwillterminate.
(Coveragecontinuesthrough
midnightofdatesubmitted).
9(8)
212
BenefitType
Indicatesthetypeofacceptable
claimsforthegroupbasedon
theBenefitsetup.
x(1)
A,I
SeeECL
A75
BilledAmount
Totalreasonableandcustomary
feeproviderschargetoprovide
thetypeofservicereceived
9(9)v99b
12
BillingCycleEnd
Date
Cycleenddate.
9(8)
117TR
BillingEntityType
Indicator
Acodethatidentifiestheentity
submittingthebilling
transaction.
9(2)
SeeECL
A67
BillingSequence
CodeIdentifyingthebilling
sequenceoftheclaim.
x(2)
SeeECL
213
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
or9(9)v99
b=Space
=Negativesign
A
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
- 23 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
Comments: EachprocessorwillneedtohaveanIIN
(formerlyBIN)assignedby:
AmericanNationalStandardsInstitute
25West43rdStreet
NewYork,NY136
(212)64249
oraProcessorNumberassignedby:
924ERaintreeDr
Scottsdale,AZ85267518
Phone:(48)4771
Fax:(48)767142
Contact:NCPDPProviderServices
http://www.ncpdp.org
11A1
BINNumber
CardIssuerIDorBankIDNumber
usedfornetworkrouting.
9(6)
T,N,Z,E
BodyMetricQualifier
Qualifiertoidentifythebody
metricbeingused(eitherweight
orsurfacearea).
an
BodyMetricValue
Expressesthevalueofthebody
metric.
9(18)
18
BodyType
TheXMLtransactiontypes.
n/a
S,Q
686
Brand/Generic
Indicator
DenotesBrandorGenericdrug
dispensed
x(1)
W,I
BusinessName
Nameofthebusiness.
x(35)
S,Q
35
CalculatedDoseNum
eric
Expressesthenumericvalueof
thecalculateddose.
9(18)
18
CalculatedDoseUnit
OfMeasureCode
Coderepresentingthe
CalculatedDoseUnitOfMeasureTe
xt.
an
Qualifiedby
CalculatedDoseUnitOfMeasureQualifier.
CalculatedDoseUnit
OfMeasureQualifier
systembeingused.
an
SeeECL
CalculatedDoseUnit
OfMeasureText
CalculatedDoseUnitOfMeasureCo
de.
an
SeeECL
QualifiedbyBodyMetricQualifier.
Format=9(15)v9(3)
SeeECL
SeeECL
- 24 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
CalculatedPrescripti
onSellingPrice
Calculatedsellingpriceforthe
prescription.CouldbeUsualand
CustomaryorGrossAmountDue.
FIELD
FORMAT
an
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
Format=s$$$$$$$$.cctothelengthofthedollar
amountexchanged.
Ifnegative,theisused.Ifpositive,nosignisused
anddoesnotoccupyaposition.
=Negativesign
.=Decimalpoint
Example:Iftheamountisapositive$5.5thisfield
wouldreflect:5.5
Example:Iftheamountisanegative$5.5this
fieldwouldreflect:5.5
214
CardholderDateOf
Birth
DateofBirthofMember.
CardholderFirst
Name
Individualfirstname.
CardholderID
32C2
CardholderID
312CC
9(8)
Format=CCYYMMDD
CC=CenturyYY=Year
MM=MonthDD=Day
x(12)
x(35)
T,Z
12
35
InsuranceIDassignedtothe
cardholderoridentification
numberusedbytheplan.
x(35)
S,Q
35
InsuranceIDassignedtothe
cardholderoridentification
numberusedbytheplan.
x(2)
_______
T,A,N,Z,V,X,I 2
_________
_______
Sizeof128isusedinUniformHealthcarePayer
DataStandardforpossibleencrypteddata.
x(128)
128
CardholderLast
Name
Individuallastname.
x(15)
x(35)
T,Z
V,I
15
35
Examples:SMITH
A36
CardPurposeCode
Codetoidentifythereasonthe
HealthCarecardisissued.
x(1)
SeeECL
871D
CarrierAddress
Addressofthecarrier.
x(25)
25
327CR
CarrierID
CarriercodeassignedinWorkers
CompensationProgram.
x(1)
313CD
Examples:JOHN
Note:FieldsizefortheTelecommunication
Standarddoesnotconformtothedemographic
rulestoremaincompatiblewithPDF417IDCard
sizelimit.
Note:FieldsizefortheTelecommunication
Standarddoesnotconformtothedemographic
rulestoremaincompatiblewithPDF417IDCard
sizelimit.
- 25 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
891F
CarrierLocationCity
Thisfieldidentifiesthenameof
thecityinwhichthecarrieris
located.
x(18)
18
811G
CarrierLocation
State/Province
Address
Stateofthecarrier.
x(2)
SeeECL
8111H
CarrierName
Nameofthecarrier.
x(25)
25
215
CarrierNumber
AccountNumberassignedduring
installation.
x(1)
A,I
8131J
CarrierZip/Postal
Code
postalcodeofthecarrier,
excludingpunctuation.
x(15)
15
Comments:
WhenusedforUSZIPCodeThisleftjustifiedfield
containsthefivedigitzipcode,andmayincludethe
fourdigitexpandedzipcode.
98765leftjustified.
CensusEffectiveDate
Thedatethatcensuseventwas
effective.
xsd:date
Examples:
A0E3B0
A1L2T8
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CFOrderID
UniqueIdentifierassignedbythe
pharmacyfortheprescription
fulfillmentorder.
an
- 26 April215
DATA DICTIONARY
FIELD
663
NAMEOFFIELD
ChangeDate
DEFINITIONOFFIELD
FIELD
FORMAT
Identifiesthedatethechangeis
effective.
9(8)
STANDARD
FORMATS
FIELD
LENGTH
8
VALUES
COMMENTS/EXAMPLES
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
SeeECL
664
ChangeIdentifier
Identifiestypeofchangebeing
made.
x(1)
R,F
ChangeOfPrescriptio
nStatusCode
UsedintheCANRXmessage
whentheprescriberwishes
tonotifythepharmacytono
longercontinuedispensing
anyopenrefillsonan
activeprescriptionortocancela
prescriptionthathasnotyet
beendispensed.
an
SeeECL
ChangeReasonText
Explanationofthereasonforthe
changerequest.
x(26)
26
216
CheckDate
MemberClaimsActualmember 9(8)
checkdate
NonmemberClaimsPharmacy
checkdate
A,Y
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
ChildResistantPacka
ge
Indicatortheprescription
requireschildresistant
packaging.
BooleanCod
e
SeeECL
ChoiceID
identifytheanswerchoicefora
question.
x(35)
35
ChoiceText
Answerchoicetext.
x(2)
City
x(35)
S,Q
35
728SU
City
x(2)
_____
x(3)
R,V
_________
A,Y
2
________
3
- 27 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
A4
ClaimCostCeiling
OverrideAmount
Representseitherthespecific
copayGrossAmountDueorthe
GrossAmountDueCeilingthat
thepriorauthorizationis
overriding.
9(7)v99
Format=$$$$$$$cc
217
ClaimDateReceived
InTheMail
Datepaperclaimwasreceivedin
themail.
9(8)
Format=CCYYMMDD
218
ClaimMediaType
Claimsubmissiontypecode.
x(1)
SeeECL
6168
ClaimNumber
Auniqueidentifierfora
prescriptionandclaimprocessor
x(2)
R,J
A5
ClaimOrigination
Fromtheplan'sperspective,the
method/system/applicationby
whichthepayerreceivedthe
claim.
9(1)
SeeECL
A88
ClaimProcessed
Code
Codedefiningwhichperspective
inthepossiblecoordinationof
benefitsflowthepayerreflected
whenadjudicatingtheclaim.
x(2)
SeeECL
435DZ
Claim/ReferenceID
Identifiestheclaimnumber
assignedbyWorkers
CompensationProgram.
x(3)
T,A,W
219
ClaimSequence
Number
Indicatesthesequenceofthis
claimwithinthesetofclaims
submitted.
9(5)
A,E
ClarifyingFreeText
Usedtoaddclarityfortheentire
structuredSigforelementsthat
cannotbecodifiedwithinthe
specificsections.
x(255)
255
22
ClientAssigned
LocationCode
Thelocationofthemember
withintheClient'sCompanyfrom
Clienteligibilitywhensubmitted
bytheclient.
x(2)
221
ClientFormulary
Flag
Indicatesthatclienthasa
formulary.
x(1)
SeeECL
CC=Century
YY=Year
MM=Month
DD=Day
- 28 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
65NB
ClientName
Nameofclient.
x(7)
V,X
222
ClientPassThrough
InformationfromClienteligibility
whensubmittedbytheclient.
x(2)
_______
A
________
2
_______
x(5)
223
ClientPricingBasis
OfCost
whichingredientcostsubmitted
iscalculatedbasedonclient
pricing.
x(2)
SeeECL
224
ClientSpecificData
Tradingpartnersmutuallyagreed
uponspecificdatadefinedby
client.
x(5)
ClinicalInfoFormatsR
equested
Typesofclinicalinformation
formatsthesendercanhandle.
an
SeeECL
493XE
ClinicalInformation
Counter
Counternumberofclinical
informationmeasurement
set/logicalgrouping.
9(1)
Comments:Fieldsinthelogicalset/groupingmay
include:
MeasurementDate(494ZE)
MeasurementTime(495H1)
MeasurementDimension(496H2)
MeasurementUnit(497H3)
MeasurementValue(499H4)
ClinicalInformation
Qualifier
Qualifieshowthe
PrimaryDiagnosiswasobtained.
an
ClinicalInfoTypesRe
quested
Requestedpatientclinical
informationtypes.
an
ClinicalSignificanceC
ode
Codeidentifyingthesignificance
orseveritylevelofaclinical
eventascontainedinthe
originatingdatabase.
an
528FS
ClinicalSignificance
Code
Codeidentifyingthesignificance
orseveritylevelofaclinical
eventascontainedinthe
originatingdatabase.
x(1)
ClinicName
Nameofclinic.
x(7)
S,Q
SeeECL
SeeECL
SeeECL
SeeECL
- 29 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
138UQ
CMSLowIncome
CostSharing(LICS)
Level
A33ZX
CMSPartDContract
ID
997G2
CMSPartDDefined
QualifiedFacility
CoAgentCode
DEFINITIONOFFIELD
Freeformtextthatprovidesthe
lowincomesubsidycopaylevel
foraPartDpatient.
DesignationassignedbyCMS
thatidentifiesaspecific
MedicarePartDsponsor.
FIELD
FORMAT
x(2)
STANDARD
FORMATS
FIELD
LENGTH
VALUES
x(5)
N,A
Indicatesthatthepatientresides
inafacilitythatqualifiesforthe
CMSPartDbenefit.
x(1)
T,A
SeeECL
Identifiesthecoexistingagent
contributingtotheDURevent
(drugordiseaseconflictingwith
theprescribeddrugorprompting
pharmacistprofessionalservice).
an
COMMENTS/EXAMPLES
Format=Ifyesornoissupported,thefieldcontains
YorN.
Format=Ifdollarrangessupported,theformatis
$nn/$nn/$nnwheretheliteral$isused,thenthe
dollaramount,thentheliteral/toseparate
ranges.Ifonlyonedollaramountissupported,the
formatis$nn.Thedollaramountisvariable,suchas
n,nn,nnn.
Format=Ifpercentageissupported,theformatis
nn%/nn%/nn%wheretheliteral%isused,then
thepercentageamount,thentheliteral/to
separateranges.Ifonlyonepercentageis
supported,theformatisnn%.Thepercentage
amountisvariable,suchasn,nn,nnn.Anindividual
percentageamountmustnotbelargerthannnn
(1).
Examples:
Y
N
y=yes
n=no
$
$2/$5
$1/$3
15%
1%/25%/5%
Format=ANNNN
QualifiedbyCoAgentQualifier.
WhenCoAgentCodeisused,theCoAgentQualifier
mustbepresent.
CoAgentCodeDescri
ption
CoAgentCode
an
CoAgentQualifier
Codequalifyingthevaluein
CoAgentCode.
an
SeeECL
WhenCoAgentQualifierissent,theCoAgentCode
mustbepresent.
Coating
Drugcoatingfromadrugimprint
database.
an
- 30 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
COBCarrierSubmit
Amount
Theamountsubmittedbythe
COBcarrier.
226
COBPrimaryClaim
Type
Forsecondarycoordinationof
x(1)
benefitsclaims.Indicatesthe
claimtypeoftheprimaryclaim.
228
COBPrimaryPayer
AmountPaid
225
229
23
231
232
234
235
236
237
238
COBPrimaryPayer
Coinsurance
COBPrimaryPayer
Copay
COBPrimaryPayer
Deductible
COBPrimaryPayer
ID
s9(6)v99
s9(6)v99
VALUES
Coinsuranceamountaccording
toprimarypayerforproductor
service.
Copayamountaccordingto
primarypayerforproductor
service.
Deductibleamountaccordingto
primarypayerforproductor
service.
COMMENTS/EXAMPLES
Format=s$$$$$$cc
SeeECL
Format=s$$$$$$cc
reflect:55{.
Amountpaidbyprimarypayer
forproductorservice.
s9(6)v99
Format=s$$$$$$cc
reflect:55{.
s9(6)v99
Format=s$$$$$$cc
reflect:55{.
s9(6)v99
Format=s$$$$$$cc
reflect:55{.
x(1)
Format=s$$$$$$cc
IDassignedtoprimarypayer.
Amountpaidbysecondarypayer
forproductorservice.
s9(6)v99
COBSecondary
PayerCoinsurance
Coinsuranceamountaccording
tosecondarypayerforproduct
orservice.
s9(6)v99
COBSecondary
PayerCopay
Copayamountaccordingto
secondarypayerforproductor
service.
s9(6)v99
COBSecondary
PayerID
FIELD
LENGTH
reflect:55{.
COBSecondary
PayerAmountPaid
COBSecondary
PayerDeductible
STANDARD
FORMATS
Deductibleamountaccordingto
secondarypayerforproductor
service.
IDassignedtosecondarypayer.
reflect:55{.
A
Format=s$$$$$$cc
reflect:55{.
Format=s$$$$$$cc
reflect:55{.
s9(6)v99
Format=s$$$$$$cc
reflect:55{.
x(1)
- 31 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
CodedReferenceCod
e
Thecodefromthesource.
an
Comments:QualifiedbyCodedReferenceQualifier.
CodedReferenceDes
cription
CodedReferenceCode.
an
CodedReferenceQu
alifier
systembeingused.
an
SeeECL
CodedSystemVersio
n
Theversionofthecodesystem
used.
an
Color
Drugcolorfromadrugimprint
database.
an
239
Communication
TypeIndicator
ForMailServiceClaimsOnly
Identifiesthetypeof
communicationusedbyeither
prescriberorpatienttoinitiate
therequestforthefill.
x(2)
SeeECL
ComparisonOperato
r
Codethatconveysthe
relationshipbetweenthe
answeredvaluetoaquestion
andadefinedboundary.
an
SeeECL
ComparisonValue
Valuefortheboundaryofthe
comparison.
9(18)
18
CompoundCode
Codeindicatingwhetherornot
theprescriptionisacompound.
an
SeeECL
46D6
CompoundCode
theprescriptionisacompound.
9(1)
T,A,R,V,Y
SeeECL
451EG
Compound
DispensingUnit
FormIndicator
NCPDPstandardproductbilling
codes.
9(1)
T,Z,W
SeeECL
45EF
CompoundDosage
FormDescription
Code
Dosageformofthecomplete
compoundmixture.
x(15)
T,Z,W
15
SeeECL
A6
CompoundIndicator
Codeindicatingiftheprior
authorizationappliesto
compoundedproductsonly.
9(1)
SeeECL
- 32 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
49UE
Compound
IngredientBasisof
CostDetermination
whichthedrugcostofan
ingredientusedinacompound
wascalculated.
x(2)
T,A,Z,W
SeeECL
447EC
Compound
Ingredient
ComponentCount
CountofcompoundproductIDs
(bothactiveandinactive)inthe
compoundmixturesubmitted.
9(2)
T,A,Z,W
449EE
Compound
IngredientDrug
Cost
Ingredientcostforthemetric
decimalquantityoftheproduct
includedinthecompound
mixtureindicatedinCompound
IngredientQuantity(Field448
ED).
s9(6)v99
T,A,Z,W
COMMENTS/EXAMPLES
ForTelecommunication:
Comments:Fieldsincludedintheset/logical
groupingare:
CompoundProductID(488RE)
CompoundProductID(489TE)
CompoundIngredientBasisofCostDetermination
(49UE)
CompoundIngredientQuantity(448ED)
CompoundIngredientDrugCost(449EE)
CompoundIngredientModifierCodeCount(362
2G)CompoundIngredientModifierCode(3632H)
Format=s$$$$$$cc
reflect:55{
CompoundIngredien
tItemDescription
Nameofdrug.
x(15)
15
3632H
Compound
IngredientModifier
Code
Identifiesspecialcircumstances
relatedtothe
dispensing/paymentofthe
productasidentifiedinthe
CompoundProductID(489TE).
x(2)
SeeECL
3622G
Compound
IngredientModifier
CodeCount
Codeindicatingthenumberof
CompoundIngredientModifier
Code(3632H)
9(2)
CompoundIngredien
tProductCode
Codeidentifyingthecompound
ingredientproductbeing
reported.
an
CompoundIngredien
tProductCodeQualifi
er
Thecodelistdefiningthe
CompoundIngredientProductCod
e.
an
SeeECL
689
Compound
IngredientProduct
Name
Descriptionoftheingredient
beingsubmitted.
x(3)
Z,W
- 33 April215
SeealsoDrugDescription.
DATA DICTIONARY
FIELD
448ED
A32ZW
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
Compound
IngredientQuantity
Amountexpressedinmetric
decimalunitsoftheproduct
mixture.
9(7)v99999
99
T,A,Z,W
Compound
PreparationTime
Measurementinminutesforthe
preparationofthecompound.
9(4)
FIELD
LENGTH
14
VALUES
COMMENTS/EXAMPLES
Format=9999999.9999999
Format=MMMM
M=Minute
Comment:3secondsandabove,roundtothe
nextminute.29secondsandbelow,rounddown.
489TE
CompoundProduct
ID
Productidentificationofan
ingredientusedinacompound.
x(19)
T,A,Z,W
19
Comments:QualifiedbyCompoundProductID
Qualifier(488RE).
488RE
CompoundProduct
IDQualifier
Codequalifyingthetypeof
productdispensed.
x(2)
T,A,Z,W
SeeECL
Comments:QualifiesCompoundProductID(489
TE).
CompoundQuantity
CodeListQualifier
Qualifies
CompoundQuantityValue.
an
SeeECL
CompoundQuantity
Value
decimalunitsoftheproduct
mixture.
9(14)
14
QualifiedbyCompoundQuantityCodeListQualifier.
452EH
CompoundRouteof
Administration
Codefortherouteof
administrationofthecomplete
compoundmixture.
9(2)
SeeECL
NOTE:SunsettedfieldusedinPostAdjudication
Version2.withspecificusageasdefinedin
implementationguide.
996G1
CompoundType
Clarifiesthetypeofcompound.
x(2)
T,A
SeeECL
Consent
PatientConsentIndicator
an
S,Q
SeeECL
B11
ContactPersonFirst
Name
FirstNameofcontactperson.
x(35)
35
B12
ContactPersonLast
Name
Lastnameofcontactperson.
x(35)
35
665
Contracting
Organization(PMO)
ContractNumber
Contractnumberassignedbythe
contractingorganization.
x(15)
R,J
15
666
Contracting
Organization(PMO)
IDCode
IDcodeassignedbythe
contractingorganization.
x(17)
R,J
17
Format=9999999.9999999
- 34 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
SeeECL
COMMENTS/EXAMPLES
671
Contracting
Organization(PMO)
IDQualifier
Indicatesthetypeofdatabeing
submittedintheContracting
Organization(PMO)IDCode
(666)field.
x(2)
R,J
6164
Contracting
Organization(PMO)
MarketBasketCode
Themarketbasketnameorcode
beingsubmittedtoPICOto
identifymarketbasketbeing
submitted.
x(17)
17
643
Contracting
Organization(PMO)
Name
Thenameofthecontracting
organization.
x(7)
R,J
667
Contracting
Organization(PMO)
TotalLivesCovered
Thetotalnumberoflives(the
sumofenrolleesanddependents
ortheproductofenrolleesand
calculationmultiplier)coveredby
thecontractingorganization.
9(9)b
or
9(9)
Format=999999999bor999999999
ContractNumber
AccountNumberassignedduring
installationforsegmentsof
business
x(8)
________
A,T
________
8
_________
x(15)
15
Countofotherpayment
occurrences.
9(1)
24U1
3374C
Coordinationof
Benefits/Other
PaymentsCount
Note
b=space
=negativesign
groupingare:
OtherPayerCoverageType(3385C)
OtherPayerIDQualifier(3396C)
OtherPayerID(347C)
OtherPayerDate(443E8)
OtherPayerAmountPaid(431DV)
OtherPayerPatientResponsibilityAmount
Qualifier(351NP)
OtherPayerPatientResponsibilityAmount(352
NQ)
OtherPayerAmountPaidCount(341HB)
OtherPayerAmountPaidQualifier(342HC)
BenefitStageCount(392MU)
BenefitStageQualifier(393MV)
BenefitStageAmount(394MW)
OtherPayerPatientResponsibilityAmountCount
(353NR)
orifrejected
OtherPayerRejectCount(4715E)andOther
PayerRejectCode(4726E)
- 35 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
A7
Copay/Coinsurance
OverrideAmount
Representseitherthespecific
copaydollaramountor
coinsuranceratethatisdefined
inthepriorauthorizationandis
qualifiedbythe
Copay/CoinsuranceOverride
Type(A8).
9(7)v99
Format=$$$$$$$cc
A8
Copay/Coinsurance
OverrideType
Indicatorusedtorepresent
whetherornottheoverrideis
definedasaflatdollaramountor
asapercentage,andisusually
outsideofthenormalplan
benefitcoveragelevel.
Percentagemaybeconsidereda
coinsuranceamount.
9(1)
SeeECL
A9
CopayConjunction
Sequence
Thesequenceinwhichamulti
tieredcopaystructureshouldbe
applied.
9(1)
96BU
CopayID
Themembershippopulationto
whichthecopayruleapplies.
x(4)
97BV
CopayListID
IDforthebenefitcopaylist
x(1)
Comments:QualifiedbyCopayListType(98BW).
98BW
CopayListType
Codeidentifyingthetypeof
copaybeingconveyed
x(2)
SeeECL
241
CopayModifierID
UniquedruglistIDthatis
coordinatedforusewiththe
clientscopaysetup.Processor
definedcodes.
x(1)
99BX
CopayTier
ThismedicationsTier;an
indicationofthecosttothe
patient.Lowervaluesrepresent
lowercosttothepatient(e.g.,
Tier1islesscostlytothepatient
thanTier2)
9(2)
A39
CopayWaiver
Amount
Dollaramountfundedbythird
partyforacopaywaiverprogram
whereaclientfundsaportionof
theircopayamountiftheyselect
acertaindrug.
s9(6)v99
Comments:QualifiesCopayListID(97BV).
Format=s$$$$$$cc
reflect:55{
- 36 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
CostDifference
Amount
Differencebetweenclient
contractedamountandthe
pharmacyormembersubmitted
amount.
s9(6)v99
Counsel
Indicatorthepatienthas
requestedcounselingforthe
medication.
BooleanCod
e
SeeECL
CounselNotes
Counselingtexttobeprintedon
thedocumentationprovidedto
thepatient.
an
CouponNumber
Identifiesthepromotionnumber
orsample.
x(35)
35
486ME
CouponNumber
Uniqueserialnumberassignedto
theprescriptioncoupons.
x(15)
15
485KE
CouponType
Codeindicatingthetypeof
couponbeingused.
x(2)
487NE
CouponValue
Amount
Valueofthecoupon.
s9(6)v99
242
Format=s$$$$$$cc
reflect:55{
SeeECL
Format=s$$$$$$vcc
Examples:Ifthecouponvalueamountis$1.,
thisfieldwouldreflect:1{.
91BY
CoverageID
Themembershippopulationto
whichthecoverageruleapplies.
x(4)
911BZ
CoverageListID
IDforthecoveragerule
x(1)
Comments:QualifiedbyCoverageListType(912
B3).
912B3
CoverageListType
coveragerulebeingconveyed
x(2)
SeeECL
Comments:QualifiesCoverageListID(911BZ).
Created
ElementinUsernameTokenfor
thecreationofthetransaction.
SOAP.
xsd:dateTim
e
S,Q
DateTimeFormat= CCYYMMDDTHH:MM:SS
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example:2111T8:15:22
- 37 April215
DATA DICTIONARY
FIELD
88K2
NAMEOFFIELD
CreationDate
DEFINITIONOFFIELD
Datethefilewascreated.
FIELD
FORMAT
9(8)
STANDARD
FORMATS
B,A,V,X,Y,L,I
FIELD
LENGTH
8
VALUES
COMMENTS/EXAMPLES
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
88K3
CreationTime
Timethefilewascreated.
9(4)
B,A,V,X,L,I
Format=HHMM
HH=Hour
MM=Minute
CurrentAmount
PaidToDate
Thecumulativedollaramountof
rebatespaidtodate.
9(9)v99bor
9(9)v99
CurrentRebatePer
Unit
Thecurrentrebateperunit
amountafteradjustment.
9(5)v99999
9bor
9(5)v99999
9
CurrentUnits
DisputedToDate
Thecumulativenumberofunits
indispute.
9(11)v999b
or
9(11)v999
CurrentUnitsPaid
ToDate
paidtodate.
9(11)v999b
or
9(11)v999
CurrentUnitsTo
Date
submittedforrebatecalculation.
9(11)v999b
or
9(11)v999
913B4
DataInError
Copyofthebaddata
x(1)
6131
DataLevel
Thelevelofdatabeing
submitted.
x(2)
R,J
6132
DataProviderID
Code
Codeassignedtoidentifythe
dataprovider.
x(17)
R,J
17
618
6181
6182
6183
6184
12
Note:
b=Space
=Negativesign
12
Note:
b=Space
=Negativesign
15
Format=99999999999v999bor99999999999v999
Note:
b=Space
=Negativesign
15
Format=99999999999v999bor99999999999v999
Note:
b=Space
=Negativesign
15
Format=99999999999v999bor99999999999v999
Note:
b=Space
=Negativesign
SeeECL
- 38 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
VALUES
SeeECL
6137
DataProviderID
Qualifier
Identifiesthetypeofdatabeing
submittedintheDataProvider
IDCode(6132)field.
x(2)
R,J
6133
DataProviderName
Nameofthedataprovider.
x(7)
R,J
532FW
DatabaseIndicator
Codeidentifyingthesourceof
druginformationusedforDUR
processingortodefinethe
databaseusedforidentifyingthe
product.
x(1)
T,A
DatatypesVersion
ElementdefineswhichNCPDP
datatypesschemaisbeingused.
an
S,Q
SeeECL
589
DateofBilling
Datetheinvoicewascreated.
Usedonlybythoseentities
creatingthepaperinvoiceand
submittingforpayment.
9(8)
Dateofbirthofpatient.
xsd:dateTim
eor
xsd:date
DateOfBirth
SeeECL
S,Q
COMMENTS/EXAMPLES
Format=MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
- 39 April215
DATA DICTIONARY
FIELD
34C4
NAMEOFFIELD
DateOfBirth
DEFINITIONOFFIELD
Dateofbirthofpatient.
FIELD
FORMAT
9(8)
STANDARD
FORMATS
T,A,Z,V,W,X,
Y,L,I
FIELD
LENGTH
8
VALUES
COMMENTS/EXAMPLES
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
WhenusedontheUCFandWorkers
Compensation/Property&CasualtyForms,the
Format=MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
Examples:IfapatientwasbornonJuly27,197,
thisfieldwouldreflect:197727.
434DY
DateOfInjury
Dateonwhichtheinjury
occurred.
9(8)
T,A,W
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
WhenusedontheWorkers
Compensation/Property&CasualtyForm,the
Format=MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
Examples:IfinjuryoccurredonJuly1,1999,field
- 40 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DateOfLastOfficeVisi
t
DEFINITIONOFFIELD
Dateofthelastofficevisitfor
thisdiagnosis.
FIELD
FORMAT
xsd:dateTim
eor
xsd:date
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
DateOfService
SeeDateofService(41D1)
xsd:dateTim
e
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
41D1
DateOfService
Identifiesdatetheprescription
wasfilledorprofessionalservice
renderedorsubsequentpayer
begancoveragefollowingPartA
expirationinalongtermcare
settingonly.
9(8)
R,T,A,Z,V,
W,J,E,Y,I
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Format=MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
Examples:Iftheprescriptionwasdispensedon
April22,2,thisfieldwouldreflect2422.
- 41 April215
DATA DICTIONARY
FIELD
414DE
654S5
NAMEOFFIELD
DatePrescription
Written
DateTime
DEFINITIONOFFIELD
Dateprescriptionwaswritten.
FIELD
FORMAT
9(8)
STANDARD
FORMATS
T,A,Z,V,W
FIELD
LENGTH
8
VALUES
COMMENTS/EXAMPLES
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Format=MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
Dateandtimeoftheitemfrom
theoriginator,expressedin
CoordinatedUniversalTime
(UTC).
x(17)
17
Examples:ForaprescriptionwrittenonAugust1,
1999,fieldwouldreflect:199981.
Format=CCYYMMDDhhmmssmss(Formatofdate
timewhereCC=TwodigitCentury,YY=Twodigit
Year,MM=Twodigitmonth(1through12),DD=
Twodigitdayofmonth(1through31),hh=Two
digitHour(through23),mm=Twodigit
minutes(through59),ss=Twodigitsecond
(through59),mss=Threedigitmillisecond
(through999))
Ifgranularityisnotdesired,theappropriate
subsequentdigitsmustnotbesent.Forexample,if
month,day,andyearisonlytobetransmitted,the
fieldwouldcontain291122.
Thegranularitymustbeexpressedcompletelyfor
thedigitsexpressed.Ifmonth,day,year,hours,and
secondsaretobetransmitted,thefieldwould
contain2911221533.Itisincorrecttoexpress
thisexamplewithoutbothdigitsofseconds(33).
- 42 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DateValidated
DEFINITIONOFFIELD
Thedatewhenmaterial
obligationswereverified.
FIELD
FORMAT
xsd:dateor
xsd:datetim
e
STANDARD
FORMATS
S,Q
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
DaysSupply
Estimatednumberofdaysthe
prescriptionwilllast.
x(35)
S,Q
35
45D5
DaysSupply
Estimatednumberofdaysthe
prescriptionwilllast.
9(3)
R,T,A,V,Z,W
,X,Y,I
Examples: Theprescriptionisestimatedtolast3
days.Thisfieldwouldreflect:3
345HG
DaysSupply
IntendedToBe
Dispensed
Dayssupplyformetricdecimal
quantityofmedicationthat
wouldbedispensedonoriginal
dispensingifinventorywere
available.Usedinassociation
withaPorCinDispensing
Status(343HD).
9(3)
T,A
988MB
DaysSupplyPer
Copay
Thedayssupplyassociatedwith
thestatedcopayterms
9(3)
A1
DaysSupplyUsedto
Date
Accumulatedauthorizedamount
ofdayssupplyusedtodate
9(3)
- 43 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
DeadlineForReply
Expirationdateofthecase.
FIELD
FORMAT
xsd:dateTim
eor
xsd:date
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
DEAScheduleCode
ValuedefiningtheDEAschedule
ofthemedication.
an
SeeECL
DefaultNextQuestio
nID
Indicatesthenext<QuestionID>
thatshouldbeanswered
regardlessoftheanswer
providedtothisquestionor
END.
x(35)
35
357NV
DelayReasonCode
Codetospecifythereasonthat
submissionofthetransactions
hasbeendelayed.
9(2)
T,Z,W
SeeECL
DeliveredID
Initiatorreferenceidentifier.
x(35)
S,Q
35
DeliveredOnDate
Dateordateandtime
prescriptionwasreceivedat
facility.
xsd:dateTim
eor
xsd:date
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
- 44 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
DeliveryLocation
Ifpatientspecifiesadelivery,this
isthelocationforthedelivery.
an
SeeECL
DeliveryRequest
Indicatorofwhetherpatient
requestsdeliveryofprescription.
an
SeeECL
Description
Text
an
S,Q
DescriptionCode
Rejectcodesusedbyresponder
whotakesresponsibilityfor
transaction.
an
S,Q
SeeECL
8185F
DestinationName
Thedestinationnametowhom
thefileisbeingsent.
x(7)
424DO
DiagnosisCode
Codeidentifyingthediagnosisof
thepatient.
x(15)
R,T,F,A,Z,J
15
Comments:QualifiedbyaDiagnosisCodeQualifier
(492WE).Theformatmustadheretotheowners
codesetrulesandformats.
491VE
DiagnosisCode
Count
Countofdiagnosisoccurrences.
9(1)
groupingare:
DiagnosisCodeQualifier(492WE)
DiagnosisCode(424DO)
SeeECL
492WE
DiagnosisCode
Qualifier
CodequalifyingtheDiagnosis
Code(424DO).
x(2)
T,F,A,Z,J
DigitalSignatureIndi
cator
True/Falseindicatingthe
prescriptionhasbeendigitally
signed
xsd:boolean
DigitalSignatureVers
ion
Elementdefineswhichdigitial
signatureversionisbeingused.
an
SeeECL
DigestValue
Usedtoconfirmthatallfields
havebeenincludedinthedigital
signature.ApplyaSHA1HASH
andbase64Encodetheresult.
x(35)
35
DigestValueiscomposedoffields
concatenatedtogetherandthen
encoded.
TheDigestValueistheresultofa
SHA1Hash,whichisalways16
bitsor2bytes.
- 45 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
67ND
DiscontinueDate
Dateonorafterwhichthe
prescriptionisnolongerfillable.
9(8)
66NC
DiscontinueDate
Qualifier
CodequalifyingDiscontinueDate
(67NC).
x(1)
SeeECL
DiscountAmount
Amountofdiscountthatwas
appliedtotheprescription.
an
amountexchanged.
=Negativesign
.=Decimalpoint
wouldreflect:5.5
A72
Discrepancy
Amount
Thefinancialvaluethatthe
pharmacywillbechargedback
duetotheresultsoftheaudit.
9(6)v(2)
A68
DiscrepancyCode1
Thereason/findingsforthe
ChargeBackAmount.
x(5)
SeeECL
A69
DiscrepancyCode2
ChargeBackAmount.
x(5)
SeeECL
A7
DiscrepancyCode3
ChargeBackAmount.
x(5)
SeeECL
A71
Discrepancy
Message
FreeTextadditionalinformation
tofurtherdefinethediscrepancy
found.
x(2)
A11
DispenseAsWritten
(DAW)Difference
Indicatortodeterminewherethe
costdifferentialoftheDAW
differenceshouldbeshifted.
9(1)
SeeECL
48D8
DispenseAsWritten
(DAW)/Product
SelectionCode
theprescribersinstructions
regardinggenericsubstitution
werefollowed.
x(1)
R,T,A,V,Z,W
,Y,I
SeeECL
SeeSubstitutionCodeforSCRIPTStandard
- 46 April215
DATA DICTIONARY
FIELD
149U9
57F7
NAMEOFFIELD
DispensingFee
Contracted/
Reimbursable
Amount
DispensingFeePaid
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
Informationalfieldusedwhen
OtherPayerPatient
ResponsibilityAmount(352NQ)
orPatientPayAmount(55F5)
isusedforreimbursement.
Amountisequaltocontractedor
reimbursabledispensingfeefor
productbeingdispensed.
s9(6)99
Dispensingfeepaidincludedin
theTotalAmountPaid(59
F9).
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
VALUES
COMMENTS/EXAMPLES
Format=s$$$$$$cc
reflect:55{
ForT:Examples:Ifthedispensingfeepaidis$3.5,
ForY:
Note:
=Negativesign
usage.
412DC
DispensingFee
Submitted
Dispensingfeesubmittedbythe
pharmacy.Thisamountis
includedinthe'GrossAmount
Due'(43DU).
s9(6)v99
T,Z,W
Format=s$$$$$$cc
Examples:Ifthepharmacysubmitteda$5.62
dispensingfee,thisfieldwouldreflect:56B.
DispensingRequestC
ode
Codeconveyingapharmacy
dispensingactionassociatedwith
aCensusevent.
an
SeeECL
343HD
DispensingStatus
Codeindicatingthequantity
dispensedisapartialfillorthe
completionofapartialfill.Used
onlyinsituationswhere
inventoryshortagesdonotallow
thefullquantitytobedispensed.
x(1)
T,A,R
SeeECL
6185
DisputedQuantity
Thenumberofunitsthatarein
questionorthedifference
betweentheTotalQuantity
(6139)andtheAccepted
Quantity(6186).
9(11)v999b
or
9(11)v999
15
Format=99999999999v999bor99999999999v999
- 47 April215
Note:
b=Space
=Negativesign
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
682
DocumentControl
Number
Internalnumberusedbythe
payerorprocessortofurther
identifytheclaimforimaging
purposesDocumentarchival,
retrievalandstorage
x(2)
Z,W
B78
Document
ReferenceIdentifier
Thereferencenumberassigned
bytheproviderfortheservice.
x(15)
15
B79
Document
ReferenceIdentifier
Qualifier
DocumentReferenceIdentifier
(B78).
x(2)
SeeECL
DoNotFill
Usedformedicationsorderedby
aprescriberbutnotrequiring
dispensingatthistime,butmay
berequiredforadministration
andmaybeavailablefordrugto
druginteractions.
an
SeeECL
243
DosageFormCode
Dosageformcodeforproduct
identified.
x(4)
ValuesareTradingPartnerDefined
A12
DosagePerDay
Thedosageperdaythatis
approvedbytheprior
authorizationandisusuallyover
orunderthenormalplanlimits
orclinicalguidelines.
9(7)v999
Format=9999999.999
DoseAmountText
DoseAmountwhendoseamount
cannotexpressedasaunitof
measure.
an
DoseAmountTextCo
de
DoseAmountText.
an
QualifiedbyDoseAmountTextQualifier.
DoseAmountTextQu
alifier
systembeingused.
an
SeeECL
DoseCalculationClari
fyingFreeText
Usedtoaddclaritytothedose
calculationforelementsthat
cannotbecodified.
x(255)
255
DoseClarifyingFreeT
ext
Usedtoaddclaritytothedose
forelementsthatcannotbe
codified.
x(255)
255
- 48 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
DoseDeliveryMetho
dCode
DoseDeliveryMethodText.
an
QualifiedbyDoseDeliveryMethodQualifier.
DoseDeliveryMetho
dModifierCode
DoseDeliveryMethodModifierTex
t.
an
QualifiedbyDoseDeliveryMethodModifierQualifier
DoseDeliveryMetho
dModifierQualifier
systembeingused.
an
SeeECL
DoseDeliveryMetho
dModifierText
DoseDeliveryMethodModifierCo
de.
an
Modifiesthemethodinwhich
thedoseisdelivered.Ancillary
informationneededtobetter
understandthedeliverymethod.
DoseDeliveryMetho
dQualifier
systembeingused.
an
SeeECL
DoseDeliveryMetho
dText
DoseDeliveryMethod.Thisisthe
methodinwhichthedoseis
delivered(describeshowthe
doseisadministered/consumed)
an
DoseFormCode
DoseFormText.
an
QualifiedbyDoseFormQualifier.
Comment:FMTTermfromNCIfor
DoseFormCodeQualifier
AterminologysubsetforNCPDPthatcontains
conceptsthatqualifythestrengthandstrengthunit
ofmeasureassociatedwiththeprescribedproduct
(e.g.Tablet,Inhaler,Patch,Ointment,Suppository,
Capsule,DropSolution,Cream,etc).
DoseFormQualifier
systembeingused.
an
SeeECL
DoseFormText
DoseFormCode.
an
DoseQuantity
Thenumericexpressionofthe
dose.
9(18)
18
- 49 April215
DATA DICTIONARY
FIELD
FIELD
FORMAT
STANDARD
FORMATS
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
LENGTH
VALUES
DoseRangeModifier
UsedtosignifythattheSig
containsmorethanonedoseina
rangeoroption.
an
SeeECL
DosingBasisNumeric
Expressesthenumericvalueof
thedosingbasis.
9(18)
18
DosingBasisRangeM
odifier
UsedtosignifythattheSig
containsmorethanonedose
whichrepresentadoserange
(TO)orcontainsadoseoption
(OR).
an
SeeECL
DosingBasisUnitOfM
easureCode
DosingBasisUnitofMeasureText.
an
QualifiedbyDosingBasisUnitOfMeasureQualifier.
DosingBasisUnitOfM
easureQualifier
systembeingused.
an
SeeECL
DosingBasisUnitOfM
easureText
DosingBasisUnitOfMeasureCode.
an
DrugAdminReasonC
ode
Codeidentifyingthereasonfor
themessage.
an
SeeECL
DrugAdminReasonT
ext
Additionaltextualinformation
regardingthemessage.
x(1)
244
DrugCategoryCode
Thedrugcategorytowhicha
specifieddrugbelongs.Each
drugcategorycodeisassociated
withaspecificdrugcategory.
x(1)
ValuesareTradingPartnerDefined
DrugCoverageStatus
Code
Code identifying the coverage

statusoftheprescribeddrug.
x(2)
SeeECL
DrugDBCode
Codevaluetodefinethe
referencenumberGPI,GCNSeq
#,GFC,DDID,SmartKey,GM,
MultumMMDC,MultumDrugID,
etc
an
QualifiedbyDrugDBCodeQualifier.
DrugDBCodeQualifie
r
QualifiesDrugDBCode.
an
SeeECL
DrugDescription
Nameofdrug.
x(15)
15
SeealsoCompoundIngredientItemDescription.
- 50 April215
COMMENTS/EXAMPLES
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
516FG
DrugDescription
Nameofdrug.
x(3)
x(6)
R
3

V
6
915B6
DrugReference
Number
Identifierforthedrugfrom
proprietarydrugsources
x(35)
35
Comments:QualifiedbyDrugReferenceQualifier
(916B7).
917B8
DrugReference
NumberAlternative
Identifierforthealternativedrug
fromproprietarydrugsources
x(35)
35
Alternative(918B9).
919CS
DrugReference
NumberSource
proprietarydrugsources
x(35)
35
Source(92CT).
921CU
DrugReference
NumberStepDrug
proprietarydrugsourcesthatis
recommendedtobetriedfirst
x(35)
35
StepDrug(922CV).
916B7
DrugReference
Qualifier
Codevaluethatidentifiesthe
sourceandtypefortheDrug
ReferenceNumber.
x(3)
SeeECL
Comments:QualifiesDrugReferenceNumber(915
B6).
918B9
DrugReference
QualifierAlternative
ReferenceNumberAlternative.
x(3)
SeeECL
Comments:QualifiesDrugReferenceNumber
Alternative(918B9).
92CT
DrugReference
QualifierSource
ReferenceNumberSource.
x(3)
SeeECL
CodequalifyingthevalueinDrugReference
NumberSource(919CS).
922CV
DrugReference
QualifierStepDrug
ReferenceNumberStepDrug.
x(3)
SeeECL
CodequalifyingthevalueinDrugReference
NumberStepDrug(921CU).
DrugShape
Drugshapetextfromadrug
imprintdatabase.
an
425DP
DrugType
Codetoindicatethetypeofdrug
dispensed.
9(1)
A,X,Y
Descriptiveinformationthat
furtherdefinesthereferenced
DURalert.
x(1)
durationforelementsthat
cannotbecodified.
x(255)
255
57NS
DURAdditionalText
DurationClarifyingFr
eeText
SeeECL
- 51 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
DurationNumericVal
ue
Thenumericdurationunits.
9(18)
18
DurationText
DurationUnitsCode.
an
DurationTextCode
DurationUnitsText.
an
QualifiedbyDurationTextQualifier.
DurationTextQualifi
er
systembeingused.
an
SeeECL
476H6
DURCoAgentID
Identifiesthecoexistingagent
contributingtotheDURevent
(drugordiseaseconflictingwith
theprescribeddrugorprompting
pharmacistprofessionalservice).
x(19)
T,A
19
Comments:QualifiedbyDURCoAgentID
Qualifier(475J9).
475J9
DURCoAgentID
Qualifier
CodequalifyingthevalueinDUR
CoAgentID(476H6).
x(2)
T,A,S
SeeECL
544FY
DURFreeText
Message
Textthatprovidesadditional
detailregardingaDURconflict.
x(3)
Comments:Responsedatamayprovide:
drugnamesinvolvedinaninteraction
reporteddiseasecontraindication
otherapplicableDURinformation
4737E
DUR/PPSCode
Counter
Counternumberforeach
DUR/PPSset/logicalgrouping.
9(1)
groupingare:
ReasonofServiceCode(439E4)
ProfessionalServiceCode(44E5)
ResultofServiceCode(441E6)
DUR/PPSLevelofEffort(4748E)
DURCoAgentIDQualifier(475J9)
DURCoAgentID(476H6)
4748E
DUR/PPSLevelOf
Effort
Codeindicatingthelevelofeffort
asdeterminedbythecomplexity
ofdecisionmakingorresources
utilizedbyapharmacistto
performaprofessionalservice.
9(2)
T,A,Z,W
SeeECL
- 52 April215
DATA DICTIONARY
FIELD
567J6
NAMEOFFIELD
DUR/PPSResponse
CodeCounter
DEFINITIONOFFIELD
FIELD
FORMAT
Counternumberforeach
DUR/PPSresponseset/logical
grouping.
9(1)
STANDARD
FORMATS
FIELD
LENGTH
1
VALUES
groupingare:
ReasonforServiceCode(439E4)
ClinicalSignificanceCode(528FS)
OtherPharmacyIndicator(529FT)
PreviousDateofFill(53FU)
QuantityofPreviousFill(531FV)
DatabaseIndicator(532FW)
OtherPrescriberIndicator(533FX)
DURFreeTextMessage(544FY)
DURAdditionalText(57NS)
68NF
EasyOpenCap
Indicator
Codeindicatingpatientrequires
useofeasyopencapornot.
x(1)
SeeECL
ECLVersion
externalcodelistschemaisbeing
used.
an
S,Q
SeeECL
EffectiveDate
Thebeginningdateordateand
time.
xsd:dateor
xsd:datetim
e
S,Q
69NG
EffectiveDate
Datetheinformationwasvalid.
9(8)
ElectronicMail
Theelectronicmailaddressof
theentity.
x(8)
S,Q
COMMENTS/EXAMPLES
- 53 April215
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
DATA DICTIONARY
FIELD
NAMEOFFIELD
39C9
Eligibility
ClarificationCode
DEFINITIONOFFIELD
Codeindicatingthatthe
pharmacyisclarifyingeligibility
forapatient.
FIELD
FORMAT
9(1)
STANDARD
FORMATS
T,A
FIELD
LENGTH
1
VALUES
SeeECL
COMMENTS/EXAMPLES
Examples:Thepatienthasbecomeastudentbut
eligibilityhasnotyetbeenupdated.Thepharmacy
canindicate3sothatthecarriermayoverride
eligibilityforthispatient.
245
EligibilityCOB
Indicator
CoordinationofBenefitscodeas
providedonClienteligibility.
x(1)
SeeECL
246
EligibilityGroupID
Identifierofthegroupthat
determineseligibilityparameters
forthememberwhensubmitted
bytheclient.
x(15)
A,Y
15
247
Eligibility/Patient
RelationshipCode
IndividualRelationshipCode.
Codeindicatingtherelationship
betweentwoindividualsor
entities.
9(2)
A,Y
SeeECL
248
EligibleCoverage
Code
CoverageLevelCode.Code
indicatingthelevelofcoverage
beingprovidedfortheinsured.
x(3)
SeeECL
669
EligiblePlan
Indicateswhetherornottheplan
iseligibleforrebates.
x(1)
317CH
EmployerCity
Address
x(2)
T,W
B177H
EmployerContact
FirstName
Firstnameoftheemployers
primarycontact.
x(35)
35
B187J
EmployerContact
LastName
Lastnameoftheemployers
primarycontact.
x(35)
35
321CL
EmployerContact
Name
Employerprimarycontact.
x(3)
Examples:JOHNSMITH
EmployerCountry
Code
Codeofthecountry.
B351V
SeeECL
Examples:CHICAGO
x(2)
SeeECL
- 54 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
333CZ
EmployerID
IDassignedtoemployer.
x(15)
15
315CF
EmployerName
Completenameofemployer.
x(3)
T,W
COMMENTS/EXAMPLES
Comments:TheInternalRevenueService,
DepartmentoftheTreasury,assignstheEmployer
ID.Theformatofthisfieldisninedigitswitha
hyphen,asin.Thehyphenmustbe
transmittedaspartoftheEmployerIDNumber.
InformationontheEmployerIDmaybefoundat
http://www.irs.ustreas.gov/.
Examples:GENERALMOTORSCORPORATION
318CI
Employer
State/Province
Address
employer.
x(2)
T,W
SeeECL
316CG
EmployerStreet
Address
Freeformtextforaddress
information.
x(3)
Examples:123MAINSTREET
B158D
EmployerStreet
AddressLine1
information.
x(4)
B167G
EmployerStreet
AddressLine2
information.
x(4)
32CK
Employer
TelephoneNumber
Tendigitphonenumberof
employer.
9(1)
T,W
Format=AAAEEENNNN
AAA=AreaCode
EEE=ExchangeCode
NNNN=Number
Examples:Aphonenumberof2125551212would
reflect:2125551212.
B197K
Employer
TelephoneNumber
Extension
Extensionofthetelephone
number.
9(8)
- 55 April215
Format=99999999
DATA DICTIONARY
FIELD
319CJ
NAMEOFFIELD
EmployerZip/Postal
Code
DEFINITIONOFFIELD
postalcodeoftheemployer,
FIELD
FORMAT
x(15)
STANDARD
FORMATS
T,W
FIELD
LENGTH
15
VALUES
COMMENTS/EXAMPLES
justifiedfieldcontainsthefivedigitzipcodeand
whichtheemployerislocated.
98765leftjustified.
Examples:
A0E3B0
A1L2T8
6135
EncryptedPatientID
Code
EncryptedpatientID.
x(17)
R,J
17
A89
EncryptedSocial
SecurityNumber
SocialSecurityNumberwhich
hasbeenencrypted.
x(128)
128
EndDate
Thefinaldateordateandtime.
xsd:dateor
xsd:datetim
e
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
776
EntityAddressLine
1
Firstlineoftheaddressofthe
entityindicated.
x(4)
- 56 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
777
EntityAddressLine
2
Secondlineoftheaddressofthe
entityindicated.
x4)
778
EntityCity
Cityinwhichtheentityindicated
islocated.
x(2)
B5
EntityContactFirst
Name
Firstnameofcontactwithinthe
entityindicated.
x(35)
35
B6
EntityContactLast
Name
Lastnameofcontactwithinthe
entityindicated.
x(35)
35
B361W
EntityCountryCode
Codeofthecountry.
x(2)
E,J,R,V,Y,A
SeeECL
A52
EntityEmail
Emailaddressoftheentity
indicated.
x(8)
A53
EntityFaxNumber
FaxNumberoftheentity
indicated.
9(1)
78
EntityName
Completenameoftheentity
indicated.
x(7)
782
Entity
State/Province
Address
entity.
x(2)
SeeECL
783
EntityTelephone
Number
Telephonenumberoftheentity
indicated.
9(1)
Format=AAAEEENNNN
EntityTelephone
NumberExtension
number.
9(8)
B7
AAA=AreaCode
EEE=ExchangeCode
NNNN=Number
E
- 57 April215
Format=99999999
DATA DICTIONARY
FIELD
784
NAMEOFFIELD
EntityZip/Postal
Code
DEFINITIONOFFIELD
postalcodeoftheentity
indicated,excludingpunctuation.
FIELD
FORMAT
x(15)
STANDARD
FORMATS
R,J,E
FIELD
LENGTH
15
VALUES
COMMENTS/EXAMPLES
Comments:
98765leftjustified.
Examples:
A0E3B0
A1L2T8
A51
EstimatedArrival
TimeDescription
577G3
EstimatedGeneric
Savings
Estimatedearliesttimeauditor
willarriveforauditatthe
pharmacyusingpharmacylocal
time.
Theamount,notincludedinthe
TotalAmountPaid(59F9),that
thepatientwouldhavesavedif
theyhadchosenthegenericdrug
insteadofthebranddrug.
x(3)
s9(6)v99
Format=s$$$$$$cc
reflect:55{
249
Ethnicity
ExcessCopay
Amount
Theculturalheritageofthe
entity.
Amountofthecopaythat
exceedstheapprovedamount
forthisclaim.
an
SeeECL
s9(6)v99
Format=s$$$$$$cc
reflect:55{
- 58 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
ExpirationDate
Thefinaldateordateandtime.
xsd:dateor
xsd:datetim
e
S,Q
61NH
ExpirationDate
Dateonwhichcoverageisno
longereffective.
9(8)
923DD
ExtractDate
Datethefilewasextractedfrom
theinternalsourcesystem
9(8)
3885J
FacilityCityAddress
Freeformtextforfacilitycity
name
x(2)
B371X
FacilityCountry
Code
Codeofthecountry.
x(2)
SeeECL
3368C
FacilityID
IDassignedtothepatients
clinic/hostparty.
x(1)
x(35)
T,A
35
FacilityIdentification
Identificationofthefacility.
x(35)
S,Q
35
SeeECL
FacilityName
Nameidentifyingthelocationof
theservicerendered.
x(7)
S,Q
3853Q
FacilityName
Nameidentifyingthelocationof
theservicerendered.
x(7)
T,V
Note:Thisisnotthenameofthedispensing
pharmacy.
- 59 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
3873V
Facility
State/Province
Address
facility.
x(2)
SeeECL
B27M
FacilityStreet
AddressLine1
FreeformtextforFacility
addressline1information.
x(4)
B217N
FacilityStreet
AddressLine2
FreeformtextforFacility
x(4)
FacilityUnit
Theunitofthepatient.
x(35)
S,Q
35
672W2
FacilityUnit
Theunitofthepatient.
x(35)
35
3896D
FacilityZip/Postal
Zone
postalzoneexcluding
punctuationandblanks
x(15)
15
785SV
FamilyIDNumber
IDnumberthatrepresentsthat
family.
x(2)
V,I
Comments:UsedtolinkfamilieswhenuniqueID
numbersareassignedtoeachmember.
FaxExtension
Extensionofthefaxnumber.
9(8)
S,Q
Format=99999999
FaxNumber
Faxnumberoftheentity.
9(1)
S,Q
Format=AAAEEENNNN
AAA=AreaCode
EEE=ExchangeCode
NNNN=Number
textmessages.
BooleanCod
e
S,Q
SeeECL
FaxSupportsSMS
25
FDADrugEfficacy
Code
Aonepositionfieldwhichmarks
aparticulardrugasbeing
declaredlessthaneffectiveby
theFoodandDrug
Administration.
x(1)
SeeECL
251
FederalUpperLimit
Indicator
IndicatesifaFederalUpperLimit
existsforthedrug.
x(1)
SeeECL
252
FederalDEA
Schedule
Thecontrolledsubstance
scheduleasdefinedbytheDrug
EnforcementAdministration.
x(1)
A,E
SeeECL
253
FederalUpperLimit
UnitPrice
FederalUpperLimitUnitPriceas
definedbyprocessor.
s9(5)v9(4)
Format=s$$$$$cccc
reflect:55{
- 60 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
611NJ
FileStructureType
Indicatestypeofstructureof
recordsupported.
9(1)
SeeECL
72MC
FileType
Codeidentifyingwhetherthefile
containedistestorproduction
data.
x(1)
B,F,A,V,X,I
SeeECL
FillNumber
Thecodeindicatingwhetherthe
prescriptionisanoriginalora
refill.
9(2)
S,Q
SeeECL
Thisfieldmustalwaysbetwosignificantdigits(e.g.
1,2,8,14,99).
43D3
FillNumber
Thecodeindicatingwhetherthe
prescriptionisanoriginalora
refill.
9(2)
T,A,R,V,Z,W
,J,E
SeeECL
254
FillNumber
Calculated
Codeidentifyingwhetherthe
prescriptionisanoriginal()or
byrefillnumber(199)as
calculatedbysystembasedon
historicalclaimsdata.Thisfield
representstheFillNumberas
calculated(notsubmittedby
pharmacy)
9(2)
A,Y
SeeECL
A13
Fills/RefillsUsedTo
Date
Indicatesthenumberoffillsor
refillsusedtodatebyapatient
againstanexistingAnnualFillor
AnnualRefilloverride.
9(2)
FinalCompoundPhar
maceuticalDosageFo
rm
Drugform,inacode.Dosage
formcode.Pharmaceutical
DosageForm.
an
SeeECL
924DH
FirstCopayTerm
FirstCopayterm(flatcopay
amountorpercentcopay)tobe
considered
x(1)
SeeECL
FirstName
Firstname.
x(35)
S,Q
35
717SX
FirstName
Firstname.
x(35)
_______
A,L,V,X 35
_________
_______
x(128)
128
R(1)
925ES
FlatCopayAmount
Fixedcopayamount
Format=$$$$$$$.cc
Comments:Nodollarsign.Decimalrequiredifvalue
includescents.Thelengthincludesthedecimal
point.Currency:USD
- 61 April215
DATA DICTIONARY
FIELD
558AW
NAMEOFFIELD
FlatSalesTax
AmountPaid
DEFINITIONOFFIELD
Flatsalestaxpaidwhichis
includedintheTotalAmount
Paid(59F9).
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
VALUES
COMMENTS/EXAMPLES
ForTandA:Format=s$$$$$$cc
Examples:Iftheflatsalestaxpaidis$2.6.this
fieldwouldreflect:26{.
ForY:
Note:
=Negativesign
usage.
481HA
FlatSalesTax
AmountSubmitted
Flatsalestaxsubmittedfor
prescription.Thisamountis
includedintheGrossAmount
Due(43DU).
s9(6)v99
T,Z,W
Format=s$$$$$$cc
Comments:.Thesubmissionofsalestaxisgoverned
byregulatoryagencies(state,local,parish,etc).If
thesalestaxreportedisaflatrate,thenitisafixed
amountforacertaindollarvalue(forexamplefor
$xxxitisacertainamount).Forexample,for$1
theflatrateis$1.99.Thisflatrateisthenreported
inFlatSalesTaxAmountSubmitted(481
HA).Examples:Iftheflatsalestaxamount
submittedis$3.8,thisfieldwouldreflect:3H.
Flavor
Drugflavorfromadrugimprint
database.
an
FMTVersion
TheversionofFMT(Federal
MedicationTerminologies)from
NCIbeingusedforNCPDPDrug
StrengthFormTerminology.
an
FollowUpRequest
Indicatortoallowpharmaciesto
tellprescribersthatthisisa
followupRefillRequestor
ChangeRequesttransaction.The
fieldisnotsentonanoriginal
request.
9(1)
Format
standardsyntaxexchange
includedwithinapayload
envelope.
an
Comment:GovernedbyNCIThesaurus.
SeeECL
SeeECL
- 62 April215
DATA DICTIONARY
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
NAMEOFFIELD
FIELD
LENGTH
VALUES
673
FormularyBenefit
DesignType
Identifiesthetypeofformulary
benefitdesignutilizedbythe
plan.
x(4)
SeeECL
674
FormularyCode
CodeassignedbyPMOto
identifytheformularyused.
x(17)
R,J
17
255
FormularyCode
Type
IndicateshowtheFormulary
Benefitissetup.Asdefinedby
processor.
x(1)
675
Formulary
Description
Descriptionoftheformulary
usedbythePMO.
x(3)
256
FormularyFileID
IdentifiestheformularyIDused
duringadjudicationoftheclaim.
x(15)
15
926FF
FormularyID
IDfortheformularylist
x(1)
F,T
989MF
FormularyName
Namefortheformularylist
x(35)
35
A84
FormularyStart
Date
Representsthedateonwhich
theformularybecameeffective.
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
927FP
FormularyStatus
Statusofthedrugwithinthe
formulary.
x(2)
SeeECL
Comments:Thehigherthenumberforthe
preferredlevel,themorepreferredthedrugis
257
FormularyStatus
IndicatestheFormularystatusof
theDrug.
x(1)
A,I
SeeECL
A85
Formulary
TerminationDate
Representsthedateonwhich
theformularywasterminated.
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
FrequencyOfEncoun
tersApprovedCode
Thecodeexpressedasaunitof
timefor
TotalNumberEncountersApprove
d.
an
Qualifiedby
FrequencyOfEncountersApprovedCodeQualifier.
- 63 April215
COMMENTS/EXAMPLES
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
FrequencyOfEncoun
tersApprovedCodeQ
ualifier
systembeingusedfor
FrequencyOfEncountersApprove
dCode
an
SeeECL
FrequencyOfEncoun
tersApprovedText
Textualrepresentationof
TotalNumberOfEncountersAppro
vedperunitoftime
(FrequencyOfEncountersApprove
dCode).
an
FrequencyNumericV
alue
Thenumericintervalforthe
event.Usedtodefinea
frequencyofadministration.
9(18)
18
FrequencyUnitsCod
e
FrequencyUnitsText.
an
QualifiedbyFrequencyUnitsQualifier.
FrequencyUnitsQual
ifier
systembeingused.
an
SeeECL
FrequencyUnitsText
FrequencyUnitsCode.
an
From
Theidentificationnumberofthe
sender.
an
S,Q
QualifiedbyAddressTypeQualifier.
Gender
Codeidentifyingthegenderof
theindividual.
an
S,Q
SeeECL
721MD
GenderCode
Codeidentifyingthegenderof
theindividual.
x(1)
_________
9(1)
F
_________
A
SeeECL
687
GenericAvailable
Denotesavailabilityofageneric
productinthestore/facility
whenbrandwasdispensed
x(1)
SeeECL
126UA
GenericEquivalent
ProductID
Identifiesthegenericequivalent
ofthebrandproductdispensed.
x(19)
19
Comments:QualifiedbyGenericEquivalent
ProductIDQualifier(125TZ).Qualifier(118TS).
125TZ
GenericEquivalent
ProductIDQualifier
CodequalifyingtheGeneric
EquivalentProductID(126UA).
X(2)
SeeECL
Comments:QualifiesGenericEquivalentProduct
ID(126UA).
26
GenericIndicator
Distinguishesifproductpricedas x(1)
GenericorBrandedproduct:As
definedbyprocessor.
- 64 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
261
GenericName
Genericnameoftheproduct
identifiedinProduct/Service
Name.
x(3)
6187
GrandTotal
AcceptedQuantity
ThesumoftheAccepted
Quantity(6186)fields
submittedwithintheRDrecord
type.
9(11)v999b
or
9(11)v999
15
Format=99999999999v999bor99999999999v999
GrandTotalPaid
Amount
ThesumofthePaidRebate
Amount(6196)fields
submittedwithintheRSrecord
typeORthesumofthePaid
Amount1(175WH),Paid
Amount2(176WJ),Paid
Amount3(177WK),Paid
Amount4(178WL),andPaid
Amount5(179WM)fields
submittedwithintheRDrecord
type.
9(9)v99b
or
9(9)v99
GrandTotal
Quantity
ThesumoftheTotalQuantity
(6139)fieldssubmittedwithin
theUDrecordtype.
9(11)v999b
or
9(11)v999
R,J
6188
6141
Note:
b=Space
=Negativesign
12
Note:
b=Space
=Negativesign
15
Format=$$$$$$$$$$$ccbor$$$$$$$$$$$$cc
Ifdetailrecordscontainthisfield,thetotalis
requiredonthetrailerrecord.
Note
b=Space
=NegativeSign
6142
GrandTotal
RequestedAmount
ThesumoftheRequested
RebateAmount(6155)fields
submittedwithintheUDrecord
type.
9(9)v99b
or
9(9)v99
R,J
12
Ifdetailrecordscontainthisfield,thetotalisrequired
onthetrailerrecord.
Note
b=Space
=NegativeSign
- 65 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
43DU
GrossAmountDue
A97
GrossRetireeCost
DEFINITIONOFFIELD
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
Totalpriceclaimedfromall
sources.Forprescriptionclaim
request,fieldrepresentsasum
ofIngredientCostSubmitted
(49D9),DispensingFee
Submitted(412DC),FlatSales
TaxAmountSubmitted(481
HA),PercentageSalesTax
AmountSubmitted(482GE),
IncentiveAmountSubmitted
(438E3),OtherAmount
Claimed(48H9).Forservice
claimrequest,fieldrepresentsa
sumofProfessionalServicesFee
Submitted(477BE),FlatSales
TaxAmountSubmitted(481
HA),PercentageSalesTax
AmountSubmitted(482GE),
OtherAmountClaimed(48
H9).
s9(6)v99
T,A,Z,W
_______
_________
_______
9(6)v99
or
9(5)v99
__________
9(8)v99
__________
_________
TotalofallGrossRetireeCosts
fortheretireethatisvalidfor
SubsidyBilling.
9(1)v99
VALUES
COMMENTS/EXAMPLES
ForT,A,Z,W:Format=s$$$$$$cc
Examples:Ifthegrossamountdueis$14.95,this
fieldwouldreflect:149E.
ForY:
Note:
=Negativesign
usage.
amounts.
12
Format=$$$$$$$$$$cc
GrossRetireeCost=Thesumofingredientcost+
dispensingfee+taxforMedicareDcovereddrugs
includedbytheothervendorinsubsidybilling
(Note:Thiscostdoesnotsupportasign.)
GroupID
IDassignedtothecardholder
grouporemployergroup.
x(35)
S,Q
35
31C1
GroupID
grouporemployergroup.
x(15)
R,T,A,N,V,Z,
X,E,I
15
GroupName
Nameofgroupbeingsubmitted.
x(7)
S,Q
HasAutomatedInsuli
nDevice
Thisflagidentifiesthatthe
patienthasanautomatedinsulin
device.
BooleanCod
e
SeeECL
51F1
HeaderResponse
Status
Codeindicatingthestatusofthe
transmission.
x(1)
T,N,E
SeeECL
- 66 April215
DATA DICTIONARY
FIELD
DEFINITIONOFFIELD
A35
HealthCareIDCard
QualifierCode
Codesthatenablecardissuersto
includeinformationsuchas
effectivedatesofbenefit
coverage,cardholderaddress,
dependentnamesandperson
codes,gendercodes,datesof
birth,etc.andsupportfull
implementationofmachine
readableinformationon
HealthcareIDCards.
x(2)
SeeECL
263
HealthCare
Reimbursement
AccountAmount
Applied
Clientdefinedbenefitthat
providesfundstopatientsthat
canbeusedtooffsetOutof
Pocketexpenses.
s9(6)v99
Format=s$$$$$$cc
HealthCare
Reimbursement
AccountAmount
Remaining
Clientdefinedbenefitthat
providesfundstopatientsthat
canbeusedtooffsetOutof
Pocketexpenses.
s9(6)v99
264
FIELD
FORMAT
STANDARD
FORMATS
NAMEOFFIELD
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
reflect:55{
A
Note:ForthefixedformatPostAdjudication
Standardifthisfieldisnotapplicable,thefield
shouldcontain9999999I
Format=s$$$$$$cc
reflect:55{
- 67 April215
DATA DICTIONARY
FIELD
129UD
NAMEOFFIELD
DEFINITIONOFFIELD
HealthPlanfunded
AssistanceAmount
Theamountfromthehealth
planfundedassistanceaccount
forthepatientthatwasapplied
toreducePatientPayAmount
(55F5).Thisamountisusedin
HealthcareReimbursement
Account(HRA)benefitsonly.This
fieldisalwaysanegativeamount
orzero.
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
s9(6)v99
T,A
_______
_________
_______
ForT,A:Comments:Thisfieldwillbereturnedona
PAID(P)orDuplicatePaid(D)transactionwhena
patientmeetstheplanfundedassistancecriteria.
9(6)v99
or
9(5)v99
Format=s$$$$$$cc
reflect:55{
HealthPlanfundedAssistanceAmountispartof
thepatientpayamountcalculationandisusedto
reportbacktotheproviderandpatienttheportion
ofPatientPayAmount(55F5)thatwasreduced
duetothisplanfundedassistance.Inthis
transaction,thepatientpaysthevaluereportedin
PatientPayAmount(55F5)howeverwithoutthis
field;thepatientwouldhavebeenrequiredtopay
ahigherdollaramount.NOTE:Thereisnocredit
cardtransactioninvolvedinthistypeofPatient
SpendingAssistance,asinaFlexibleSpending
Account(FSA).
ForY:
Note:
=Negativesign
usage.
558F
HelpDesk
TelephoneNumber
Phonenumberofthehelpdesk.
x(1)
Format=AAAEEENNNN
AAA=AreaCode
EEE=ExchangeCode
NNNN=Number
Comments:QualifiedbyHelpDeskTelephone
NumberQualifier(5497F).
reflect:2125551212.
B227P
HelpDesk
TelephoneNumber
Extension
number
9(8)
Format=99999999
5497F
HelpDesk
TelephoneNumber
Qualifier
Codequalifyingthephone
numberintheHelpDesk
TelephoneNumber(558F).
x(2)
SeeECL
- 68 April215
DATA DICTIONARY
FIELD
265
NAMEOFFIELD
HoldHarmless
Amount
DEFINITIONOFFIELD
Amountpayabletomember
whenpaperclaimsamount
exceedsPharmacyNetwork
Reimbursement.
FIELD
FORMAT
s9(6)v99
STANDARD
FORMATS
FIELD
LENGTH
8
VALUES
COMMENTS/EXAMPLES
Format=s$$$$$$cc
reflect:55{
Home
TelephoneExtension
Extensionofthehometelephone
number.
9(8)
S,Q
Format=99999999
HomeTelephoneNu
mber
Hometelephonenumberofthe
entity.
9(1)
S,Q
Format=AAAEEENNNN
AAA=AreaCode
EEE=ExchangeCode
NNNN=Number
HomeTelephoneSup
portsSMS
textmessages.
BooleanCod
e
S,Q
SeeECL
673W3
HoursOf
Administration
Indicatesthespecifictime(s)
whentheprescribedmedication
istobeadministered
x(7)
Comments:Timesshouldbeexpressedinthe
facilityslocaltime,usingtwentyfourhourmilitary
timeformat.Multipletimesshouldbeseparated
withacommadelimiter,e.g.:9,17
representing9:AMand5:PMfacilitylocal
time.
Imprint1
Imprint1ondrugfromadrug
imprintdatabase.
an
Imprint2
Imprint2ondrugfromadrug
imprintdatabase.
an
612NK
InactivePrescription
Indicator
Indicatesthattheprescriptionis
consideredinactiveandis
thereforenolongerfillable.
x(1)
SeeECL
Comments:Theactiveprescriptionmayormaynot
berefillablebaseduponotherfactors.
- 69 April215
DATA DICTIONARY
FIELD
521FL
NAMEOFFIELD
IncentiveAmount
Paid
DEFINITIONOFFIELD
Amountrepresentsthe
contractuallyagreedupon
incentivefeepaidforspecific
servicesrendered.Amountis
includedinthe'TotalAmount
Paid'(59F9).
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
VALUES
COMMENTS/EXAMPLES
Examples:Iftheincentiveamountpaidis$4.55,this
fieldwouldreflect:45E.
ForY:
Note:
=Negativesign
usage.
438E3
IncentiveAmount
Submitted
Amountrepresentsafeethatis
submittedbythepharmacyfor
contractuallyagreedupon
services.Thisamountisincluded
inthe'GrossAmountDue'(43
DU).
s9(6)v99
Format=s$$$$$$cc
Examples:Iftheincentiveamountsubmittedis
$4.5,thisfieldwouldreflect:45{.
IndicationClarifyingF
reeText
indicationforelementsthat
cannotbecodified.
x(255)
255
IndicationCode
IndicationText.
an
QualifiedbyIndicationQualifier.
IndicationPrecursor
Code
IndicationPrecursorText.
an
QualifiedbyIndicationPrecursorQualifier.
IndicationPrecursor
Qualifier
systembeingused.
an
SeeECL
IndicationPrecursor
Text
IndicationPrecursorCode.
an
IndicationQualifier
systembeingused.
an
SeeECL
IndicationText
IndicationText.
an
IndicationValueCod
e
IndicationValueText.
an
QualifiedbyIndicationValueQualifier.
- 70 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
IndicationValueQual
ifier
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
systembeingused.
an
SeeECL
IndicationValueText
IndicationValueCode..
an
IndicationValueUnit
Thenumericexpressionofa
valuewhenitappliestoan
Indication.
9(18)
18
IndicationValueUnit
OfMeasureCode
IndicationValueUnitOfMeasureTe
xt.
an
Qualifiedby
IndicationValueUnitOfMeasureQualifier.
IndicationValueUnit
OfMeasureQualifier
systembeingused.
an
SeeECL
IndicationValueUnit
OfMeasureText
IndicationValueUnitOfMeasureC
ode.
an
IndicationVariableM
odifier
Usedtoexpresswhenthereis
morethanoneIndicationasto
whetheralltheindicationsmust
apply(AND)orifanyofthe
indicationscanapply(OR).
an
SeeECL
IngredientCost
Ingredientcostofthemedication
dispensed.
an
amountexchanged.
=Negativesign
.=Decimalpoint
wouldreflect:5.5
- 71 April215
DATA DICTIONARY
FIELD
148U8
56F6
NAMEOFFIELD
IngredientCost
Contracted/
Reimbursable
Amount
IngredientCostPaid
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
Informationalfieldusedwhen
OtherPayerPatient
orPatientPayAmount(55F5)
isusedforreimbursement.
Amountisequaltocontractedor
reimbursableamountfor
productbeingdispensed.
s9(6)99
Drugingredientcostpaid
includedintheTotalAmount
Paid(59F9).
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
VALUES
COMMENTS/EXAMPLES
Format=s$$$$$$cc
reflect:55{
Examples:Iftheingredientcostpaidis$15.,
ForY:
Note:
=Negativesign
usage.
49D9
IngredientCost
Submitted
Submittedproductcomponent
costofthedispensed
prescription.Thisamountis
includedinthe'GrossAmount
Due'(43DU).
s9(6)v99
T,A,Z,W
Format=s$$$$$$cc
Comments:Thisfieldcanbefurtherdefinedby
usingtheBasisofCostDeterminationField423DN.
Examples:Iftheingredientcostsubmittedis
$65.,thisfieldwouldreflect:65{.
266
InNetworkIndicator
Indicatesifthepharmacy
dispensingtheprescriptionis
consideredinnetwork.
x(1)
A,I
SeeECL
InstructionIndicator
Indicatestheactiontobetaken
ontheInstructionfields.
an
SeeECL
InsulinDependent
Flagtoidentifyifthepatientis
Insulindependent.
BooleanCod
e
SeeECL
267
InsuranceCode
Specialgroup/memberdataas
suppliedoneligibilityrecord
whensuppliedbytheclient.
x(2)
A,I
- 72 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
A9
Insurance
Type/ProductCode
Theinsurancetypeorproduct
codeforthetypeofinsurance
coverageoftheindividual.
x(6)
SeeECL
B488M
IntermediaryID
IntermediaryIDassignedtothe
typeentity.
x(2)
B448G
IntermediaryID
Count
CountofIntermediaryIDType
Code(B458H),Intermediary
TypeEntity(B468J),
IntermediaryIDQualifier(B47
8K),IntermediaryID(B488M),
IntermediaryIDState/Province
Address(B498N)and
IntermediaryIDRelationship
Code(B58P)occurrences.
9(1)
B558U
IntermediaryID
CountryCode
TheassociatedPostalcountry
codeoftheassociated
IntermediaryID.
x(2)
(2)
SeeECL
B478K
IntermediaryID
Qualifier
CodequalifyingtheIntermediary
ID(B488M).
x(2)
SeeECL
B58P
IntermediaryID
RelationshipCode
tothepatient.
9(1)
SeeECL
B498N
IntermediaryID
State/Province
Address
Thepostalstatecode
abbreviationthatisusedin
conjunctionwiththe
IntermediaryIDQualifierandthe
IntermediaryIDfieldstoidentify
whatstatetheidentificationis
from.
x(2)
SeeECL
B458H
IntermediaryIDType
Code
IntermediaryID(B488M).
x(2)
IntermediaryIDType
Entity
CodeIdentifyingthetypeof
entityassociatedwiththe
IntermediaryID(B488M).
x(2)
B518Q
Intermediary
Message
Freeformmessage.
x(1)x(2)
12
993A7
InternalControl
Number
Numberassignedbythe
processortoidentifyan
adjudicatedclaimwhensupplied
inpayertopayercoordinationof
benefitsonly.
x(3)
T,Y
B468J
SeeECL
SeeECL
- 73 April215
DATA DICTIONARY
FIELD
DEFINITIONOFFIELD
268
InternalMailOrder
(Prescription/Servic
e)Reference
Number
Fielddesignatingtheinternal
prescriptionnumberassignedby
pharmacies.
x(15)
15
IntervalNumericValu
e
Thenumerictimebetween
events.Usedtodefinean
Intervalofadministration.
9(18)
18
IntervalUnitsCode
IntervalUnitsText.
an
QualifiedbyIntervalUnitsQualifier.
IntervalUnitsQualifi
er
systembeingused.
an
IntervalUnitsText
IntervalUnitsCode.
an
269
InvoicedAmount
Amountinvoicedforthis
transaction.Determinedby
Processor.
s9(9)v99
_________
A
________
11
________
ForA:Format=s$$$$$$$$$cc
9(8)V99
15VF
InvoicedAmount1
Thedollaramountrequestedfor
thisspecificcalculationtype.
151VG
InvoicedAmount2
152VH
InvoicedAmount3
153VJ
InvoicedAmount4
FIELD
FORMAT
STANDARD
FORMATS
NAMEOFFIELD
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
FIELD
LENGTH
VALUES
SeeECL
COMMENTS/EXAMPLES
reflect:55{
amounts.
Note
b=Space
=NegativeSign
12
12
Note
b=Space
=NegativeSign
12
Note
b=Space
=NegativeSign
12
Note
b=Space
=NegativeSign
- 74 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
154VK
InvoicedAmount5
DEFINITIONOFFIELD
69ZG
155VL
InvoicedDate
InvoicedPerUnit
Amount1
Thedatethisclaimwasincluded
onaninvoice.
Thecalculationamountataper
unitlevel.
156VM
InvoicedPerUnit
Amount2
unitlevel.
157VN
InvoicedPerUnit
Amount3
unitlevel.
158VP
InvoicedPerUnit
Amount4
unitlevel.
159VQ
InvoicedPerUnit
Amount5
unitlevel.
16VR
InvoicePrice1
Thepriceusedforthe
calculation.
161VS
InvoicePrice2
Thepriceusedforthe
calculation.
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
9(5)v99999
9b
or
9(5)v99999
9
12
Note
b=Space
=NegativeSign
x(8)
Format=CCYYMMDD
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
12
12
12
12
12
12
12
- 75 April215
CC=Century
YY=Year
MM=Month
DD=Day
Note
b=Space
=NegativeSign
Note
b=Space
=NegativeSign
Note
b=Space
=NegativeSign
Note
b=Space
=NegativeSign
Note
b=Space
=NegativeSign
Note
b=Space
=NegativeSign
Note
b=Space
=NegativeSign
DATA DICTIONARY
FIELD
162VT
NAMEOFFIELD
InvoicePrice3
DEFINITIONOFFIELD
Thepriceusedforthe
calculation.
163VU
InvoicePrice4
Thepriceusedforthe
calculation.
164VV
InvoicePrice5
Thepriceusedforthe
calculation.
165VW
InvoiceRate1
Therateusedforthecalculation.
166VX
InvoiceRate2
167VY
InvoiceRate3
168VZ
InvoiceRate4
169WA
InvoiceRate5
FIELD
FORMAT
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(3)v99999
b
or
9(3)v99999
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
12
12
12
Format=$$$$$ccccccbor$$$$$ccccccNote
b=Space
=NegativeSign
Format=999v99999bor999v99999
Note
b=Space
=NegativeSign
Format=999v99999bor999v99999
Note
b=Space
=NegativeSign
Format=999v99999bor999v99999
Note
b=Space
=NegativeSign
Format=999v99999bor999v99999
Note
b=Space
=NegativeSign
Format=999v99999bor999v99999
9(3)v99999
bor
9(3)v99999
9(3)v99999
b
or
9(3)v99999
9(3)v99999
b
or
9(3)v99999
9(3)v99999
b
or
9(3)v99999
Note
b=Space
=NegativeSign
Format=$$$$$ccccccbor$$$$$ccccccNote
b=Space
=NegativeSign
Note
b=Space
=NegativeSign
17WB
171WC
InvoiceType1
InvoiceType2
Descriptionoftransactiontype.
x(3)
x(3)
R
R
3
3
SeeECL
SeeECL
172WD
InvoiceType3
x(3)
SeeECL
173WF
InvoiceType4
x(3)
SeeECL
- 76 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
174WG
InvoiceType5
x(3)
SeeECL
IsDateTimeRequired
Indicateswhetherdatetime
formatisrequiredfordate
answer.
BooleanCod
e
SeeECL
IsEAppealSupported
Indicatesifpayersupports
electronicappealssubmission.
BooleanCod
e
SeeECL
IsFreeText
Indicatesiftheanswertothe
questionisfreetext.
BooleanCod
e
SeeECL
IsNumeric
Indicatesiftheanswertothe
questionisnumeric.
BooleanCod
e
SeeECL
IsPatientNotified
Indicatesiftheprescriberhas
notifiedthepatientthatthe
prescriberhasrequestedthePA
Requestbecancelled.
BooleanCod
e
SeeECL
A76
JCode
AsubsetoftheHCPCSLevelII
codesetwithahighordervalue
of"J"thathasbeenusedto
identifycertaindrugsandother
items
x(6)
Seebelowforalistofcodes:
http://www.cms.hhs.gov/hcpcsreleasecodesets/an
hcpcs/list.asp
A77
JCodeModifier1
Codespecifyingdrugandother
items
x(2)
A78
JCodeModifier2
items
x(2)
A79
JCodeModifier3
items
x(2)
A8
JCodeModifier4
items
x(2)
688
JurisdictionalField
(15)
Textfieldwithconstraints
x(3)
- 77 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
SeeECL
COMMENTS/EXAMPLES
683
JurisdictionalState
PostalStateAbbreviation
identifyingthestatewhichhas
jurisdictionoverthepaymentof
benefitsandmedicalclaimsfor
theinjuredworker.Typically,the
JurisdictionalStateisthestate
wheretheworkerwasinjured.
x(2)
LabelCode
Codeassociatedwiththe
warninglabeltobeincludedon
theprescriptionvial.
an
613NM
LabelDirections
Prescriptionlabeldirections.
x(2)
LabelGraphicCode
Graphiccodeassociatedwiththe
an
LabelPriority
Priorityassociatedwiththe
LabelText
Textassociatedwiththewarning
tobeincludedonthe
prescriptionvial.
an
LanguageNameCode
Thelanguagethepatientbest
understandsandcommunicates
with(read,write,speak)
x(3)
S,Q
LastFillDate
Lastdemand(lastfill)dateor
dateandtime.
xsd:dateor
xsd:datetim
e
S,Q
SeeECL
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
- 78 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
LastKnownBIN
Number
LastknownCardIssuerIDor
BankIDNumberusedfor
networkroutingusedona
previousclaim.
9(6)
B593H
LastKnown
CardholderID
LastknowninsuranceIDassigned
tothecardholderor
identificationnumberusedby
theplanusedonaprevious
claim.
x(2)
B583G
LastKnownGroup
ID
LastknownIDassignedtothe
cardholdergrouporemployer
groupusedonapreviousclaim.
x(15)
15
B573F
LastKnown
ProcessorControl
Number
Lastknownnumberassignedby
theprocessorusedonaprevious
claim.
x(1)
LastName
Lastname.
x(35)
S,Q
35
716SY
LastName
Lastname.
x(35)
_______
A,L,V,X 35
_______
_________
x(128)
128
Lengthoftimethephysician
expectsthepatienttorequire
useoftheordereditem.
9(3)
Codequalifyingthelengthof
need.
9(2)
B563E
372R
3712S
LengthofNeed
LengthofNeed
Qualifier
COMMENTS/EXAMPLES
Comments:SeeBINNumber(11A1).
QualifiedbyLengthofNeedQualifier(3712S).
SeeECL
QualifiesLengthofNeed(372R).
Note:Ifvalueis6,lengthofneedwouldbe1.
418DI
LevelOfService
A98
LimitReduction
Codingindicatingthetypeof
servicetheproviderrendered.
Totallimitreductionapplicable
totheretireesGrossRetiree
Cost.
9(2)
T,A
9(1)v99
12
SeeECL
Format=$$$$$$$$$$cc
A91
LineCounter
Linenumberforthisservice.The
linecounterbeginswith1andis
incrementedby1foreach
additionalserviceline.
9(4)
6143
LineNumber
Uniquenumberthatidentifies
therecord.
x(11)
R,J
11
- 79 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
27
LineOfBusiness
Code
LineofBusinessCodefromClient
eligibilityorasdefinedbytrading
partneragreement.
x(6)
928FR
ListAction
Indicateswhetherthisisa
replacementlist,listupdatesora
listdelete
x(1)
SeeECL
929FZ
ListEffectiveDate
Datethelistgoesintoeffect
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
93F2
LoadStatus
Codeexplainingthestatusofthe
load
x(2)
SeeECL
LOINCVersion
TheversionofLogical
ObservationIdentifierNames
andCodes(LOINC)beingused.
an
LotExpiration
Theexpirationdateassociated
withaspecificlotnumberofa
medication.
xsd:dateor
xsd:datetim
e
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
LotNumber
Numberassignedbythe
manufacturertoabatchof
medicationsfortracking.
an
LowerBoundCompar
isonOperator
Codethatconveysthe
andadefinedlowerboundary.
an
SeeECL
LowerBoundCompar
isonValue
Valueforthelowerboundaryof
thecomparison.
9(18)
18
- 80 April215
DATA DICTIONARY
FIELD
271
NAMEOFFIELD
MACPrice
DEFINITIONOFFIELD
FIELD
FORMAT
Indicatestheunitmaximum
allowablecostpriceforthe
product/serviceasdefinedby
theprocessor.
s9(5)v9(4)
STANDARD
FORMATS
FIELD
LENGTH
9
VALUES
COMMENTS/EXAMPLES
Format=s$$$$$cccc
reflect:55{
272
MACReduced
Indicator
Indicatesifaclaimpaymentwas
reducedduetoaMAC
(MaximumAllowableCost)
program.
x(1)
SeeECL
MailboxID
Identificationofthemailbox.
x(35)
S,Q
35
MailOrder
IndicatorthatCentralFillOrderis
tobeshippedsomewhereother
thanrequestingpharmacy.
BooleanCod
e
SeeECL
273
MaintenanceDrug
Indicator
Indicatesifthedrugisa
maintenancedrugunderthe
client'sbenefitplan.
x(1)
SeeECL
ManufacturerName
Nameofthemanufacturer.
an
647
Manufacturer
(PICO)Contract
Number
Contractnumberassignedbythe
manufacturer.
x(15)
R,J
15
648
Manufacturer
(PICO)IDCode
Codeassignedtoidentifythe
manufacturer.
x(17)
R,J
17
672
Manufacturer
(PICO)IDQualifier
Indicatesthetypeofdatabeing
submittedintheManufacturer
(PICO)IDCode(648)field.
x(2)
R,J
6165
Manufacturer
(PICO)Market
BasketCode
Thisisthenameorcodeforthe
marketbasketbeingsubmitted
tothePMO.
x(17)
17
65
Manufacturer
(PICO)Name
Nameofthemanufacturer.
x(7)
R,J
6163
MarketBasket
Description
Descriptionofmarketbasket
beingsubmitted.
x(3)
6162
MarketBasketStart
Date
Theeffectivedateofthemarket
basket.
9(8)
Format=CCYYMMDD
SeeECL
CC=Century
YY=Year
MM=Month
DD=Day
- 81 April215
DATA DICTIONARY
FIELD
6161
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
8
VALUES
COMMENTS/EXAMPLES
MarketBasket
TerminationDate
Theterminationdateofthe
marketbasket.
9(8)
Format=CCYYMMDD
Markings
Drugmarkingtextfromadrug
imprintdatabase.
an
932GA
MaximumAge
Maximumageatwhichthedrug
iscovered(inclusive).
9(3)
Comments:QualifiedbyMaximumAgeQualifier
(931F8)
931F8
MaximumAge
Qualifier
Codequalifyingthemaximum
age.
x(1)
SeeECL
Comments:QualifiesMaximumAge(932GA)
933GB
MaximumAmount
Maximumamountforaquantity
limit.
R(1)
Comments: QualifiedbyMaximumAmount
Qualifier(934GC).
CC=Century
YY=Year
MM=Month
DD=Day
IfMaximumAmountQualifier=DL(Dollar
Amount),Format=9999999.99Ifdollaramount,no
dollarsign.Decimalrequiredifvalueincludescents.
Currency:USDThelengthincludesthedecimal
point.ForallothervaluesofMaximumAmount
Qualifier,Format=9999999999withnoimplicitor
explicitdecimalpoint.
934GC
MaximumAmount
Qualifier
Thisfieldqualifiestheamountin
theMaximumAmount(933GB).
x(2)
SeeECL
Comments:QualifiesMaximumAmount(933GB).
935GF
MaximumAmount
TimePeriod
Typeoftimeperiodassociated
withtheoverallMaximum
AmountQualifier(934GC).
x(2)
SeeECL
937GH
MaximumAmount
TimePeriodEnd
Date
EndingdateofSpecificDate
Range
9(8)
Format=CCYYMMDD
MaximumAmount
TimePeriodStart
Date
StartingdateofSpecificDate
Range
9(8)
MaximumAmount
TimePeriodUnits
Numberofunitsassociatedwith
theoverallMaximumAmount
TimePeriod(935GF)
9(4)
936GG
938GJ
CC=Century
YY=Year
MM=Month
DD=Day
F
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
- 82 April215
Format=9999
DATA DICTIONARY
FIELD
939GK
NAMEOFFIELD
MaximumCopay
DEFINITIONOFFIELD
FIELD
FORMAT
Maximumtotalcopaytobepaid
bythepatient
R(1)
STANDARD
FORMATS
FIELD
LENGTH
1
VALUES
COMMENTS/EXAMPLES
Format=$$$$$$$.cc
point.Currency:USD
94GM
MaximumCopay
Tier
Providestherangewithinwhich
theCopayTierisstated.The
highestCopayTierwithinthat
range
9(2)
MaximumDoseRestr
ictionClarifyingFreeT
ext
maximumdoserestrictionfor
elementsthatcannotbe
codified.
x(255)
255
MaximumDoseRestr
ictionDurationUnits
Code
Thecoderepresentedbythe
MaximumDoseRestrictionDuratio
nUnitsText.
an
Qualifiedby
MaximumDoseRestrictionUnitsQualifier
MaximumDoseRestr
ictionDurationUnits
Qualifier
systembeingused.
an
SeeECL
MaximumDoseRestr
ictionDurationUnits
Text
MaximumDoseRestrictionDuratio
nUnitsCode.
an
MaximumDoseRestr
ictionDurationValue
Thenumericrepresentationof
themaximumdoserestriction
duration.
9(18)
18
MaximumDoseRestr
ictionFormCode
MaximumDoseRestrictionFormT
ext.
an
Qualifiedby
MaximumDoseRestrictionFormQualifier.
MaximumDoseRestr
ictionFormQualifier
systembeingused.
an
SeeECL
MaximumDoseRestr
ictionFormText
MaximumDoseRestrictionFormC
ode.
x(255)
255
- 83 April215
DATA DICTIONARY
FIELD
FIELD
FORMAT
STANDARD
FORMATS
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
MaximumDoseRestr
ictionNumericValue
DefinesaMaximumDose,sothat
theSigcanrepresentthe
concept,'Nottoexceed_____.'
ExpressionofaDoseMaximum
involvesplacingthecoredose
valueinthisfieldandtheunits
andvariablesinthefieldsthat
follow.
9(18)
18
MaximumDoseRestr
ictionUnitsCode
MaximumDoseRestrictionUnitsTe
xt.
an
QualifiedbyMaximumDoseRestrictionQualifier.
MaximumDoseRestr
ictionUnitsQualifier
systembeingused.
an
SeeECL
MaximumDoseRestr
ictionUnitsText
MaximumDoseRestrictionUnitsC
ode.
an
B663N
MaximumDrugsPer
StepGroup
Thisisthemaximumnumberof
drugsthatmaybetriedinthe
stepgroup.Notusedfor
alternatives.
9(2)
494ZE
MeasurementDate
Dateclinicalinformationwas
collectedormeasured.
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
496H2
Measurement
Dimension
Codeindicatingtheclinical
domainoftheobservedvaluein
MeasurementValue(499H4).
x(2)
SeeECL
495H1
MeasurementTime
Timeclinicalinformationwas
collectedormeasured.
9(4)
Format=HHMM
HH=Hour
MM=Minute
Examples:Reportedinmilitarytime.Twooclock
P.M.=14.
497H3
MeasurementUnit
Codeindicatingthemetricor
Englishunitsusedwiththe
clinicalinformation.
x(2)
SeeECL
- 84 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
MeasurementValue
Actualvalueofclinical
information.
9(18)
18
499H4
MeasurementValue
Actualvalueofclinical
information.
x(15)
15
Comments:BloodpressureenteredinXXX/YYY
formatinwhichXXX=systolic,/=divider,andYYYis
diastolic.TemperatureenteredinXXX.Xformat
alwaysincludingdecimalpoint.
116N6
MedicaidAgency
Number
115N5
MedicaidID
Number
362B
113N3
MedicaidIndicator
Numberassignedbyprocessorto
identifytheindividualMedicaid
Agencyorrepresentative.
Auniquememberidentification
numberassignedbythe
MedicaidAgency.
TwocharacterStatePostalCode
indicatingthestatewhere
Medicaidcoverageexists.
MedicaidPaid
AmountpaidbytheMedicaid
Amount Agency.
x(15)
T,G
15
x(2)
T,G
x(2)
s9(6)V99
T,G
SeeECL
Format=s$$$$$$cc
reflect:55{
A81
MedicalRebate
VersionRelease
Number
Versionandreleasenumberof
standardbeingsubmitted
x(5)
SeeECL
114N4
Medicaid
SubrogationInternal
Control
Number/Transactio
nControlNumber
(ICN/TCN)
Claimnumberassignedbythe
MedicaidAgency.
x(2)
T,G
x(2)
SeeECL
9(2)
T,
SeeECL
A73
MedicareDrug
CoverageCode
139UR
MedicarePartD
CoverageCode
Codetoindicateiftheclaimwas
processedunderthePartDDrug
Benefit,thePartBDrugBenefit,
ordoesnotapply.
Codeindicatingthepositionof
MedicarePartDinthebilling
order.
- 85 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
A34ZY
MedicarePartD
PlanBenefit
Package(PBP)
IdentifierassignedbyCMSofa
particularplanbenefitpackage
(BenefitCategory)withina
MedicarePartDcontract.
9(3)
N,A
274
MedicarePlanCode
Thisrepresentsifthememberis
eligibleforMedicarecoverageas
providedineligibilitydata.
x(1)
SeeECL
275
MedicareRecovery
DispensingIndicator
Fieldtoindicateifdayssupplyon
prescriptionwasreduceddueto
planlimits.
x(1)
SeeECL
276
MedicareRecovery
Indicator
FieldtoindicateifMedicarewas
billedinordertorecoverfunds
forcurrentorpreviousclaims
billedtotheclient.
x(1)
SeeECL
3592A
MedigapID
PatientsIDassignedbythe
MedigapInsurer
x(2)
683
MembershipCount
Qualifier
Furtherspecifiesthe
membershipperiodqualifierin
ordertocalculatethedata
submittedintheMembership
TotalCount(688)field.
x(1)
686
MembershipPeriod
Qualifier
Identifiestheperiodoftimefor
whichthemembershipcounts
cover.
x(1)
687
Membership
ReportingPeriod
StartDate
Thefirstdayofthemembership
reportingperiod.
9(8)
MembershipTotal
Count
Thetotalnumberofpersons
covered(thesumofenrollees
anddependentsortheproduct
ofenrolleesandthecalculation
multiplier).
9(9)b
or9(9)
MembershipType
Qualifier
Identifiesthetypeof
membershipbeingreported.
x(1)
688
689
SeeECL
SeeECL
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Format=999999999bor999999999
Note
b=Space
=NegativeSign
SeeECL
- 86 April215
DATA DICTIONARY
FIELD
277
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
8
VALUES
COMMENTS/EXAMPLES
MemberSubmit
Amount
IngredientCostassubmittedby
member(Paperclaimsonly).
s9(6)v99
Format=s$$$$$$cc
278
MemberSubmitted
ClaimPayment
ReleaseDate
Indicatesthedatethemember
submittedclaimbecame
payable,whichcoulddifferfrom
thecheckdate.
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
279
MemberSubmitted
ClaimProgramCode
Aonepositionfieldindicating
thetypeofmembersubmitted
claimprogramusedtoprocess
thisclaim.
x(1)
SeeECL
A38
MemberSubmitted
ClaimRejectCode
Formembersubmittedclaims;a
processorspecifiedlist.
X(3)
54F4
Message
Freeformmessage.
x(1)x(2) B,T,N,
_______
_________
x(8)
Y,I
12
________
8
ForallstandardsbutBenefitIntegrationand
UniformHealthcarePayerData:Comments:
Variablelengthisfrom12characters.
reflect:55{
MessageID
Tracenumber.Aunique
referenceidentifierforthe
transmission,generatedfromthe
senderoftherequestandthe
senderoftheresponse.When
generatedfromthesender,itis
thenechoedbackinthe
responsemessageinthefield
RelatesToMessageID.Thevalue
inthisfieldmustbepresentin
RelatesToMessageIDon
subsequenttransactions(suchas
RefillRequest,CancelRx,etc)to
tiebacktoanoriginal
transmission.
x(35)
S,Q
35
941GN
MessageLong
Textmessage.
x(2)
MessageRequestCo
de
Toclarifyatransaction.
an
S,Q
SeeECL
942GP
MessageShort
Textmessage.
x(1)
- 87 April215
DATA DICTIONARY
FIELD
FIELD
FORMAT
STANDARD
FORMATS
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
MessageToFollowM
essageIdentifier
Thespecificmessageidentifier
thatmaybesentintheresponse
toprovidetheoriginalrequester
linkagefromtheoriginalrequest
tothisresponse.
x(35)
35
MiddleInitial
Individualmiddleinitial.
x(35)
S,Q
35
718SZ
MiddleInitial
Individualmiddleinitial.
x(1)
_______
A,V,X,L,I
_________
1
_______
x(128)
128
A92
MiddleName
Middlenameofindividual.
x(25)
25
MIMEType
Definesthecontentnatureofthe
AttachmentData.Itisan
InternetstandarddefinedinRFC
245,RFC246,RFC247,RFC
4288,RFC4289andRFC249.
an
SeeECL
944GR
MinimumAge
Minimumageatwhichthedrug
iscovered(inclusive).
9(3)
Comments:QualifiedbyMinimumAgeQualifier
(943GQ)
943GQ
MinimumAge
Qualifier
CodequalifyingtheMinimum
Age(944GR).
x(1)
SeeECL
Comments:QualifiesMinimumAge(944GR)
945GS
MinimumCopay
Minimumtotalcopaytobepaid
bythepatient
R(1)
Format=$$$$$$$.cc
point.Currency:USD
B653M
MinimumDrugsPer
StepGroup
Thisistheminimumnumberof
drugsthatmustbetriedinthe
stepgroup.Therangeisbetween
0(groupoptional)toNwhereN
is<=theNumberofDrugstoTry
(951GY).Notusedfor
alternatives.
9(2)
MonographText
MonographTexttobeprinted
withtheCentralFillorder.
an
B613K
MonthofLastPaid
Claim
Identifiesthemonthusedona
previousclaim.
9(2)
- 88 April215
Format=MMMM=Month
DATA DICTIONARY
FIELD
FORMAT
STANDARD
FORMATS
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
LENGTH
VALUES
614NW
MostRecentDate
Filled
Dateofthemostrecentfill.
9(8)
MTMActionCode
Coderepresentingthereasonfor
theservice.
an
QualifiedbyMTMActionCodeQualifier.
MTMActionCodeQu
alifier
systembeingusedfor
MTMActionCode.
an
SeeECL
MTMActionFreeText
FreeTextfieldtobeusedonlyif
reasonidentifieddoesnothavea
codelist(MTMActionCode).
an
MTMActionText
MTMActionCode.
an
MTMPayerCaseIden
tifier
Uniqueidentifierassignedbythe
payertothiscase.
MTMPayerCaseIdentifieris
subservienttothepatient
identifier.(Apatientmayhave
multiplecases,distinguishedby
multiplecaseidentifiers.)
an
MultipleInstruction
Modifier
morethanoneSigastowhether
alltheSigsmustapply(AND)orif
anyoftheSigscanapply(OR)or
iftheSigsaresequential(THEN),
inthesequencedefinedbythe
occurrenceofthe<Instruction>.
an
SeeECL
MultipleVehicleMod
ifier
Denotesifforaninstanceof
morethanonevehicleifall
vehiclesareusedtogether(AND),
orifeachofthelistedvehiclesis
anoption(OR).(TO)isusedifthe
VehicleUnitOfMeasureprovides
forarange.
an
SeeECL
28
NameSuffix
Individualnamesuffix.
x(1)
39BM
NarrativeMessage
Freeformtext
x(2)
- 89 April215
COMMENTS/EXAMPLES
FormatCCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
DATA DICTIONARY
FIELD
NAMEOFFIELD
NeededNoLaterTha
nDate
DEFINITIONOFFIELD
Forthefacilitytorelaytothe
longtermcarepharmacythe
timeframewhenmedicationis
neededfordelivery.
FIELD
FORMAT
xsd:dateTim
e
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
NeededNoLaterTha
nReason
281
NetAmountDue
Freetextadditionalinstructions.
ForA:
Netamountpaidtoproviderby
thepayerornetamountdue
fromtheclienttothepayer,
determinedbytradingpartner
agreement.
ForZandW:
Netamountduefromthepayer
ortheiragenttothepayee.
x(7)
s9(6)v99
A,Z,W
ForA,Z,W:Format=s$$$$$$cc
_______
_________
_______
9(6)v99
or
9(5)v99
reflect:55{ForY:
Note:
=Negativesign
usage.
5452F
Network
ReimbursementID
Fielddefinedbytheprocessor.It
identifiesthenetwork,forthe
coveredmember,usedto
calculatethereimbursementto
thepharmacy.
x(1)
T,A
NewPassword
Containsthenewpassword.
an
S,Q
B4BT
NextAvailableFill
Date
Dateonwhichthisprescription
willhavepassedtheplan's
minimumconsumption
requirementsandmaybe
consideredforastandardrefill.
9(8)
14US
NextMedicarePart
DEffectiveDate
FuturedatePartDcoverage
beginsforthepatient.
9(8)
- 90 April215
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
DATA DICTIONARY
FIELD
DEFINITIONOFFIELD
141UT
NextMedicarePart
DTerminationDate
FuturedatePartDcoverageends
forthepatient
9(8)
NextQuestionID
Indicatesthenext<QuestionID>
thatshouldbeansweredifthis
answerchoiceisselectedor
END.
x(35)
35
SeeECL
NoKnown
Indicatesifthesenderdoesnot
knowofanyspecificcategories
ofinformationforthispatient.
an
SeeECL
FIELD
FORMAT
STANDARD
FORMATS
NAMEOFFIELD
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
NoKnownAllergies
Indicatesifthesenderdoesnot
knowofanyspecificallergiesfor
thispatient.
x(1)
SeeECL
Nonce
ElementinUsernameToken.
SOAP.
n/a
S,Q
948GV
NonListedBrand
OverTheCounter
FormularyStatus
Tellsthereceiverhowtotreat
nonlistedbrandedoverthe
counterdrugs.
x(2)
SeeECL
preferredlevel,themorepreferredthedrugis.
949GW
NonListedGeneric
OverTheCounter
FormularyStatus
nonlistedgenericoverthe
counterdrugs.
x(2)
SeeECL
946GT
NonListed
PrescriptionBrand
FormularyStatus
nonlistedprescriptionbranded
drugs.
x(2)
SeeECL
947GU
NonListed
PrescriptionGeneric
FormularyStatus
nonlistedprescriptiongeneric
drugs.
x(2)
SeeECL
95GX
NonListedSupplies
FormularyStatus
nonlistedsupplies.
x(2)
SeeECL
282
NonPOSClaim
OverrideCode
Usedforbypassingsystemedits
fornonPointofSale(POS)claims
and/ormodifyingpricinglogic.
x(1)
SeeECL
Note
Freetext.
x(21)
S,Q
21
- 91 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
NumberOfCycles
Numberofcyclesauthorized.
9(3)
951GY
NumberofDrugsTo
Try
Thenumberofdrugstotry
withinaclass,subclass,or
pharmacologicalclass.
9(2)
616PU
NumberOfFills
Remaining
Numberoffillsauthorizedbythe
prescriberthathavenotyetbeen
dispensed.
9(2)
SeeRefillsRemaining.
615NY
NumberOfFillsTo
Date
Numberoftimesthis
prescriptionhasbeenfilledto
date.
9(2)
692ZJ
NumberOfGeneric
Manufacturers
Numberofmanufacturersthat
producethisgenericdrug
providedbydrugcompendium.
9(3)
NumberOfRefills
Therefillquantityofthe
prescription.
9(2)
415DF
NumberofRefills
Authorized
Numberofrefillsauthorizedby
theprescriber.
9(2)
T,A,V
SeeECL
6159
NumeratorIndicator
Productispartofnumeratorand
denominatorofmarketshare
calculation.
x(1)
SeeECL
ObservationDate
Thedateordateandtimeon
whichtheobservationwas
made.
xsd:dateor
xsd:datetim
e
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
ObservationNotes
Freetextoftheobservation.
x(14)
14
- 92 April215
DATA DICTIONARY
FIELD
FIELD
FORMAT
STANDARD
FORMATS
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
OfficeOfPharmacyAf
fairsID
HealthResourcesandServices
Administration(HRSA)Officeof
PharmacyAffairs(OPA)
IdentificationCodeassociated
withtheeligibilityofthis
prescriptionfordrugspurchased
pursuanttorightsunderSection
340BofthePublicHealthService
Actof1992.
x(15)
15
Informationisfoundat
http://opanet.hrsa.gov/opa/CESearch.aspx
OldPassword
Containstheoldpassword.
an
S,Q
B8
OptionalData
Indicator
Indicatorthatoptionalfinancial
amountsarepresent.
x(1)
SeeECL
OrderCaptureMetho
d
Codeconveyingthemethodby
whichtheorderwasdefinedby
theprescriberandcapturedin
theprescribingsystem.
an
SeeECL
6192
OriginalAmount
Invoiced
Thefirstdollaramountinvoiced.
9(9)v99b
or
9(9)v99
12
283
OriginalClaim
ReceivedDate
Thedatethepharmacy
submittedtheclaim
electronicallyforapaperclaim
matchingprogram.
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
617RQ
OriginalDispensed
Date
Dateofthefirstfillforthe
prescription.
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
A44ZL
OriginalDispensed
Quantity
Productinitiallydispensed
amountexpressedinmetric
decimalunits.
9(7)v999
Format=9999999.999
445EA
OriginallyPrescribed
Product/Service
Code
Codeoftheinitiallyprescribed
productorservice.
x(19)
T.V
19
Comments:QualifiedbyOriginallyPrescribed
Product/ServiceCodeQualifier(453EJ).
Note:
b=Space
=Negativesign
- 93 April215
DATA DICTIONARY
FIELD
FIELD
FORMAT
STANDARD
FORMATS
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
453EJ
Product/ServiceID
Qualifier
'OriginallyPrescribed
Product/ServiceCode(Field445
EA).
x(2)
T,V
SeeECL
446EB
Quantity
Productinitiallyprescribed
amountexpressedinmetric
decimalunits.
9(7)v999
Format=9999999.999
6193
6194
48H9
OriginalRebatePer
Unit
Theoriginalamountperunit.
9(5)v99999
9b
or
9(5)v99999
9
OriginalUnits
Invoiced
Thenumberofunitsoriginally
invoiced.
9(11)v999b
or
9(11)v999
OtherAmount
ClaimedSubmitted
Amountrepresentingthe
additionalincurredcostsfora
dispensedprescriptionor
service.
s9(6)v99
T,Z,W
12
Note:
b=Space
=Negativesign
15
Format=99999999999v999bor99999999999v999
Note:
b=Space
=Negativesign
Format=s$$$$$$cc
Comments:QualifiedbyOtherAmountClaimed
SubmittedQualifier(479H8).
Examples:Iftheotheramountclaimedsubmittedis
$12.55,thisfieldwouldreflect:125E.
478H7
479H8
OtherAmount
ClaimedSubmitted
Count
Countofotheramountclaimed
submittedoccurrences.
OtherAmount
ClaimedSubmitted
Qualifier
Codeidentifyingtheadditional
incurredcostclaimedinOther
AmountClaimedSubmitted
(48H9).
9(1)
groupingare:
OtherAmountClaimedSubmittedQualifier(479
H8)
OtherAmountClaimSubmitted(48H9)
x(2)
SeeECL
- 94 April215
DATA DICTIONARY
FIELD
565J4
NAMEOFFIELD
DEFINITIONOFFIELD
OtherAmountPaid
Amountpaidforadditionalcosts
claimedinOtherAmount
ClaimedSubmitted(48H9).
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
VALUES
COMMENTS/EXAMPLES
reflect:55{
Comments:QualifiedbyOtherAmountPaid
Qualifier(564J3).
ForY:
Note:
=Negativesign
usage.
563J2
OtherAmountPaid
Count
Countoftheotheramountpaid
occurrences.
9(1)
groupingare:
OtherAmountPaidQualifier(564J3)
OtherAmountPaid(565J4)
564J3
OtherAmountPaid
Qualifier
Codeclarifyingthevalueinthe
OtherAmountPaid(565J4).
x(2)
T,A,Y
SeeECL
38C8
OtherCoverage
Code
thepatienthasotherinsurance
coverage.
9(2)
T,A,R,Z,W
SeeECL
431DV
OtherPayer
AmountPaid
Amountofanypaymentknown
bythepharmacyfromother
sources.
s9(6)v99
T,Z,W
Format=s$$$$$$cc
341HB
OtherPayer
AmountPaidCount
Countofthepayeramountpaid
occurrences.
9(1)
342HC
OtherPayer
AmountPaid
Qualifier
CodequalifyingtheOtherPayer
AmountPaid(431DV).
x(2)
SeeECL
566J5
OtherPayer
AmountRecognized
Totalamountrecognizedbythe
processorofanypaymentfrom
anothersource.
s9(6)v99
T,A
Format=s$$$$$$cc
Examples:Iftheotherpayeramountpaidis$32.56,
thisfieldwouldreflect:325F.
Examples:Iftheotherpayeramountrecognizedis
$5.27.Thisfieldwouldreflect:52G.
- 95 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
144UX
OtherPayerBenefit
EffectiveDate
OtherPayerseffectivedateof
thepatientsbenefit.
9(8)
145UY
OtherPayerBenefit
TerminationDate
OtherPayersterminationdate
ofthepatientsbenefit.
9(8)
99MG
OtherPayerBIN
Number
Thesecondary,tertiary,etc.card
issuerorbankIDnumberused
fornetworkrouting.
9(6)
356NU
OtherPayer
CardholderID
CardholderIDforthismember
thatisassociatedwiththePayer
noted.
x(2)
3385C
OtherPayer
CoverageType
OtherPayerID(347C).
x(2)
SeeECL
443E8
OtherPayerDate
Paymentordenialdateofthe
claimsubmittedtotheother
payer.Usedforcoordinationof
benefits.
9(8)
T,Z,W
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Format=MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
Examples:Iftheprimarypayerdenialdatewas
August1,1999,thisfieldwouldreflect:199981.
992MJ
OtherPayerGroup
ID
grouporemployergroupbythe
secondary,tertiary,etc.payer.
x(15)
15
- 96 April215
DATA DICTIONARY
FIELD
127UB
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
OtherPayerHelp
DeskTelephone
Number
Phonenumberoftheother
payershelpdesk.
x(1)
B237Q
OtherPayerHelp
DeskTelephone
NumberExtension
number
9(8)
Format=99999999
347C
OtherPayerID
IDassignedtothepayer.
x(1)
T,V,Z,W
Comments:QualifiedbyOtherPayerIDQualifier
(3396C).
Format=AAAEEENNNN
AAA=AreaCode
EEE=ExchangeCode
NNNN=Number
reflect:2125551212.
355NT
OtherPayerID
Count
Countofotherpayerswith
paymentresponsibility.
9(1)
T,V
3396C
OtherPayerID
Qualifier
CodequalifyingtheOtherPayer
ID(347C).
x(2)
T,V,Z,W
SeeECL
143UW
OtherPayerPatient
RelationshipCode
Codeassignedbytheotherpayer
toindicatetherelationshipof
patienttocardholder.
9(1)
SeeECL
352NQ
OtherPayerPatient
Responsibility
Amount
Thepatientscostsharefroma
previouspayer.
s9(8)v99
T,A,Z,W
OtherPayerPatient
Responsibility
AmountCount
CountofOtherPayerPatient
andOtherPayerPatient
ResponsibilityAmountQualifier
(351NP)occurrences.
9(2)
353NR
Comments:
OtherPayerCoverageType(3385C)
OtherPayerIDQualifier(3396C)
OtherPayerID(347C)
OtherPayerProcessorControlNumber(991MH)
OtherPayerCardholderID(356NU)
OtherPayerGroupID(992MJ)
OtherPayerPersonCode(142UV)
OtherPayerHelpDeskPhoneNumber(127UB)
OtherPayerPatientRelationshipCode(143UW)
OtherPayerBenefitEffectiveDate(144UX)
OtherPayerBenefitTerminationDate(145UY)
Format=s$$$$$$$$cc
reflect:55{
- 97 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
351NP
OtherPayerPatient
Responsibility
AmountQualifier
CodequalifyingtheOther
PayerPatientResponsibility
Amount(352NQ).
x(2)
T,A
SeeECL
142UV
OtherPayerPerson
Code
Codeassignedbytheotherpayer
toaspecificpersonwithina
family.
x(3)
991MH
OtherPayer
ProcessorControl
Number
Anumberthatuniquely
identifiesthesecondary,tertiary,
etc.payertotheprocessor.
x(1)
T,V
4726E
OtherPayerReject
Code
Theerrorencounteredbythe
previousOtherPayerinReject
Code(511FB).
x(3)
T,Z,W
4715E
OtherPayerReject
Count
CountofOtherPayerReject
Code(4726E)occurrences.
9(2)
Comments:Numberofrejectcodesidentifiedby
thepreviousOtherPayerinRejectCount(51
FA).
529FT
OtherPharmacy
Indicator
Codeindicatingthepharmacy
responsiblefortheprevious
eventinvolvedintheDUR
conflict.
9(1)
SeeECL
533FX
OtherPrescriber
Indicator
Codecomparingtheprescriberof
thecurrentprescriptiontothe
prescriberofthepreviouslyfilled
conflictingprescription.
9(1)
SeeECL
OtherReason
Codeindicatingthereasonfor
priorauthorizationopen.
an
SeeECL
OtherTelephoneExt
ension
Extensionoftheothertelephone
number.
9(8)
S,Q
Format=99999999
OtherTelephoneNu
mber
Othertelephonenumberofthe
entity.
9(1)
S,Q
Format=AAAEEENNNN
AAA=AreaCode
EEE=ExchangeCode
NNNN=Number
OtherTelephoneSup
portsSMS
textmessages.
BooleanCod
e
S,Q
SeeECL
- 98 April215
Comments:Thisfieldissubmittedbythe
pharmacistforthepurposeofqualifyingtheentry
intheOtherPayerPatientResponsibilityAmount
field.
DATA DICTIONARY
FIELD
284
691ZH
NAMEOFFIELD
DEFINITIONOFFIELD
OutOfPocketApply
Amount
Amountappliedtooutofpocket
expense.
s9(6)v99
OutOfPocket
RemainingAmount
Dollarsremaininguntilpatientis
totallyinbenefitpayingnooutof
pocketexpenses.
s9(6)v99
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
8
VALUES
COMMENTS/EXAMPLES
Format=s$$$$$$cc
reflect:55{
Format=s$$$$$$cc
reflect:55{
953HP
OutofPocketRange
End
Ifthecopayvariesaccordingto
thepatientsoutofpocket,thisis
theupperrangevalue.
R(1)
Format=$$$$$$$.cc
includescents.Currency:USDThelengthincludes
thedecimalpoint.
Blankindicatesnoupperlimittorange.
952GZ
OutofPocketRange
Start
Ifthecopayvariesaccordingto
thepatientsoutofpocket,thisis
thelowerrangevalue.
R(1)
PACaseID
x(35)
35
633SN
PackageAcquisition
Cost
identifythespecificcase.
Theperpackageacquisitioncost
oftheproduct.
s9(6)v99
175WH
PaidAmount1
Theamountpaidforthisspecific
calculationtype.
176WJ
PaidAmount2
calculationtype.
177WK
PaidAmount3
calculationtype.
Format=$$$$$$$.cc
includescents.Currency:USDThelengthincludes
thedecimalpoint.
9(9)v99b
or
9(9)v99
9(9)v99b
or
9(9)v99
9(9)v99b
or
9(9)v99
12
12
12
- 99 April215
Formats$$$$$$cc
reflect:55{
Note
b=Space
=NegativeSign
Note
b=Space
=NegativeSign
Note
b=Space
=NegativeSign
DATA DICTIONARY
FIELD
178WL
NAMEOFFIELD
PaidAmount4
DEFINITIONOFFIELD
calculationtype.
179WM
PaidAmount5
calculationtype.
18WN
PaidBasePrice1
Thepriceusedinthepaid
amountcalculations.
181WP
PaidBasePrice2
amountcalculations.
182WQ
PaidBasePrice3
amountcalculations.
183WR
PaidBasePrice4
amountcalculations.
184WS
PaidBasePrice5
amountcalculations.
6195
185WT
PaidPerUnit
Amount
Theamountperunitthatispaid.
PaidPerUnit
Amount1
Theamountpaidcalculatedata
perunitlevel.
FIELD
FORMAT
STANDARD
FORMATS
9(9)v99b
or
9(9)v99
9(9)v99b
or
9(9)v99
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
12
12
Note
b=Space
=NegativeSign
12
Note
b=Space
=NegativeSign
12
Note
b=Space
=NegativeSign
12
Note
b=Space
=NegativeSign
12
Note
b=Space
=NegativeSign
12
Note
b=Space
=NegativeSign
Note
b=Space
=NegativeSign
12
Note:
b=Space
=Negativesign
12
- 100 April215
Note
b=Space
=NegativeSign
DATA DICTIONARY
FIELD
186WU
187WV
188WW
189WX
19WY
NAMEOFFIELD
PaidPerUnit
Amount2
PaidPerUnit
Amount3
PaidPerUnit
Amount4
PaidPerUnit
Amount5
PaidQuantity1
DEFINITIONOFFIELD
perunitlevel.
perunitlevel.
perunitlevel.
perunitlevel.
Thequantityacceptedfor
paymentprocessing.
191WZ
PaidQuantity2
paymentprocessing.
192XA
PaidQuantity3
paymentprocessing.
193XB
PaidQuantity4
paymentprocessing.
194XC
PaidQuantity5
paymentprocessing.
FIELD
FORMAT
STANDARD
FORMATS
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(5)v99999
9b
or
9(5)v99999
9
9(11)v999b
or
9(11)v999
9(11)v999b
or
9(11)v999
9(11)v999b
or
9(11)v999
9(11)v999b
or
9(11)v999
9(11)v999b
or
9(11)v999
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
12
12
Note
b=Space
=NegativeSign
12
Note
b=Space
=NegativeSign
12
Note
b=Space
=NegativeSign
15
Note
b=Space
=NegativeSign
Format=99999999999v999b or99999999999v999
15
Note
b=Space
=NegativeSign
Format=99999999999v999b or99999999999v999
15
Note
b=Space
=NegativeSign
Format=99999999999v999b or99999999999v999
15
Note
b=Space
=NegativeSign
Format=99999999999v999b or99999999999v999
15
Note
b=Space
=NegativeSign
Format=99999999999v999b or99999999999v999
- 101 April215
Note
b=Space
=NegativeSign
DATA DICTIONARY
FIELD
195XD
NAMEOFFIELD
PaidRate1
DEFINITIONOFFIELD
Therateusedtocalculatethe
paidamount.
PaidRate2
PaidRate3
PaidRate4
PaidRate5
9(3)v99999
b
or
9(3)v99999
9(3)v99999
b
or
9(3)v99999
9(3)v99999
b
or
9(3)v99999
Thetotalrebateamountpaid
withintheRSrecordtypefor
thereportedproduct.
9(9)v99b
or
9(9)v99
Freetext.
x(2)
x(35)
35
paidamount.
paidamount.
paidamount.
6196
PaidRebateAmount
PANote
PAReferenceID
COMMENTS/EXAMPLES
199XJ
VALUES
9(3)v99999
b
or
9(3)v99999
paidamount.
198XH
FIELD
LENGTH
197XG
STANDARD
FORMATS
9(3)v99999
b
or
9(3)v99999
196XF
FIELD
FORMAT
Identifierestablishedbythe
prescribingsystemsendinga
PAInitiationRequestinthe
solicitedmodelorPARequestin
theunsolicitedmodeltoinitiate
theprocesstorequestprior
authorization.Theidentifier
mustbeechoedinany
subsequentpriorauthorization
transactionsrelatedtothat
requestforpriorauthorization
(includingpriorauthorization
appealandcanceltransactions).
Theidentifiermustbeuniqueper
prescribingsystem.
Format=$$$cccccbor$$$ccccc
Note
b=Space
=NegativeSign
Note
b=Space
=NegativeSign
Note
b=Space
=NegativeSign
Note
b=Space
=NegativeSign
Note
b=Space
=NegativeSign
12
Note:
b=Space
=Negativesign
- 102 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
Password
PAStructuresVersion
391MT
PatientAssignment
Indicator(Direct
Member
Reimbursement
Indicator)
Codetoindicateapatients
choiceonassignmentofbenefits.
PatientCityAddress
323CN
theuserspassword.SOAP.
ElementdefineswhichNCPDPpa
structuresschemaisbeingused.
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
n/a
S,Q
an
S,Q
SeeECL
x(1)
SeeECL
Note:CurrentlyusedbyprovidersofMedicarePart
B
x(2)
T,W
Examples:CHICAGO
A431K
PatientCountry
Code
Thecountryofthepatients
permanentresidence.
x(2)
T,A
SeeECL
35HN
31CA
PatientEMail
Address
TheEMailaddressofthepatient
(member).
x(8)
T,V
PatientFirstName
x(12) T,Z,W,G 12
__________ __________ _________
Examples:JSMITH@NCPDP.ORG
x(35)
_________
V,X
__________
35
_________
x(25)
25
Examples:JOHN
Note:FieldsizefortheTelecommunicationand
MedicaidSubrogationStandardsdoesnotconform
tothedemographicrulestoremaincompatible
withPDF417IDCardsizelimit.
35C5
PatientGender
Code
Codeindicatingthegenderofthe
individual.
9(1)
T,A,V,Z,W,X,
Y,I
SeeECL
332CY
PatientID
IDassignedtothepatient.
x(2)
_______
T,A,V,W,X,I
_________
2
_______
x(128)
128
ForT,A,V,W,X :Comments: QualifiedbyPatientId

Qualifier(331CX)
ForA:SeePostAdjudicationImplementationGuide
forrestrictiononuseoffieldindifferentrecords.)
A22YR
PatientID
Associated
State/Province
Address
State/ProvinceCodeassociated
withthePatientIDQualifier
(331CX)andthePatientID(332
CY).
x(2)
SeeECL
PatientIdentification
Identificationofthepatient.
x(35)
S,Q
35
SeeECL
B381Y
PatientID
AssociatedCountry
Code
Codeofthecountry.
x(2)
SeeECL
- 103 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
331CX
PatientIDQualifier
CodequalifyingthePatientID
(332CY).
x(2)
T,A,V,W,X
SeeECL
618RR
PatientIDQualifier
Count
CountofpatientIDoccurrences
9(1)
includedintheset/logicalgroupingare:PatientID
Qualifier(331CX),PatientID(332CY).
311CB
PatientLastName
Individuallastname.
x(15)
x(35)
T,Z,W,G 15
V,X,I
35
Examples:SMITH
9(11)b
or9(11)
s9(1)v99
R,J
6144
PatientLiability
Amount
Amountofpatientsoutof
pocketcost.
12
Note:FieldsizefortheTelecommunicationand
MedicaidSubrogationStandardsdoesnotconform
tothedemographicrulestoremaincompatible
withPDF417IDCardsizelimit.
ForManufacturerRebateStandard:
Format=$$$$$$$$$$$bor$$$$$$$$$$$
Note
b=Space
=NegativeSign
ForPrescriptionTransferStandard:
Format=s$$$$$$$$$$cc
285
433DX
PatientFormulary
RebateAmount
Creditthepatientreceiveson
thisclaimfromthedrug
manufacturer.
s9(6)v99
PatientPaid
AmountSubmitted
Amountthepharmacyreceived
fromthepatientforthe
prescriptiondispensed.
s9(6)v99
Format=s$$$$$$cc
reflect:55{
T,Z,W
Comments:Thisfieldisnotusedincoordinationof
benefittransactionstopasspatientliability
informationtoadownstreampayer.SeeOther
PayerPatientResponsibilityAmount(352NQ)
Format=s$$$$$$cc
Examples:Ifthepatientpaidamountsubmittedis
PatientPayAmount
SeePatientPayAmountNumber
(55F5)
an
amountexchanged.
=Negativesign
.=Decimalpoint
wouldreflect:5.5
- 104 April215
DATA DICTIONARY
FIELD
55F5
NAMEOFFIELD
DEFINITIONOFFIELD
PatientPayAmount
Amountthatiscalculatedbythe
processorandreturnedtothe
pharmacyastheTOTALamount
tobepaidbythepatienttothe
pharmacy;thepatientstotal
costshare,including
copayments,amountsappliedto
deductible,overmaximum
amounts,penalties,etc.
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
__________
9(8)v99
Examples:Ifthepatientpayamountis$56.96,this
fieldwouldreflect:569F.
__________
_________
ForY:
Note:
=Negativesign
reflect:55{
usage.
amounts.
PatientRelationship
Code
Codeindicatingrelationshipof
an
S,Q
36C6
PatientRelationship
Code
Codeindicatingrelationshipof
9(1)
T,A,V,Z,X,I
3844X
PatientResidence
Codeidentifyingthepatients
placeofresidence.
9(2)
T,A,V
575EQ
PatientSalesTax
Amount
Patientsalestaxresponsibility.
Thisfieldisnotacomponentof
thePatientPayAmount(55F5)
formula.
s9(6)v99
PatientSpendDown
Amount
Claimdollarsappliedtopatient's
spenddownaccount(example
FlexibleSpendingAccount).
s9(6)v99
324CO
Patient
State/Province
Address
patient.
x(2)
T,W,I
SeeECL
322CM
PatientStreet
Address
Freeformtextforaddress
information.
x(3)
Examples:123MAINSTREET
286
SeeECL
SeeECL
SeeECL
SeeResidenceCode.
Format=s$$$$$$cc
reflect:55{
Format=s$$$$$$cc
reflect:55{
- 105 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
B87A
PatientStreet
AddressLine1
information.
x(4)
T,G
B97B
PatientStreet
AddressLine2
information.
x(4)
T,G
326CQ
PatientTelephone
Number
Phonenumberofpatient.
9(1)
T,W
Format=AAAEEENNNN
AAA=AreaCode
EEE=Exchange
NNNN=Number
Examples:Ifthephonenumberis(313)5551212,
thisfieldwouldreflect:3135551212.
325CP
PatientZip/Postal
Code
postalcodeofthepatient,
x(15)
T,W
15
whichthepatientislocated.
98765leftjustified.
Examples:
A0E3B0
A1L2T8
569J8
PayerID
IDofthepayer.
x(1)
T,V,Y
Comments:QualifiedbyPayerIDQualifier(568
J7).
PayerIdentification
Identificationofthepayer.
x(8)
S,Q
SeeECL
568J7
PayerIDQualifier
Codeindicatingthetypeofpayer
ID.
x(2)
T,V
SeeECL
Comments:QualifiesPayerID(569J8).
PayerName
Nameofthepayer.
x(7)
S,Q
PayerResponsibility
Code
Indicatestheinsurancetype.
an
S,Q
7
SeeECL
- 106 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
Payload
DEFINITIONOFFIELD
Thetransactionorfileina
transmission.
FIELD
FORMAT
an
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
Forexample anNCPDPTelecommunicationD.
ClaimBillingtransaction,oraBatch1.2file,orASC
X1227HealthCareEligibilityBenefitInquiry
transaction,version51X279A1.
Note:containsabooleanattributeofwhether
PayloadisBase64encoded(trueorfalse).
PayloadEnvelopeVer
sion
Codeuniquelyidentifyingthe
versionofthepayloadenvelope.
an
SeeECL
Format:CCYYMM
PayloadEnvelopeRef
erenceID
Identifierestablishedbythe
senderthatmustbeechoedback
ontheresponse.
x(5)
287
Payment/Reference
ID
IdentifiesIDassignedbysender
toreferenceindividualpharmacy
andmemberreimbursement.
CheckorEFTtracenumber.
x(3)
288
PayrollClass
Afielddefinedbytheclient
x(1)
indicatingthepayrollclassofthe
member.
SeeECL
122TW
PayToCityAddress
Cityoftheentitytoreceive
paymentforclaim.
x(2)
T,W
B391Z
PaytoCountryCode
Codeofthecountry.
x(2)
SeeECL
119TT
PayToID
Identifyingnumberoftheentity
toreceivepaymentforclaim.
x(15)
T,W
15
Comments:QualifiedbyPayToQualifier(118TS).
12TU
PayToName
Nameoftheentitytoreceive
paymentforclaim.
x(2)
x(7)
685
PayToPhone
Number
Telephonenumberofthepayee
9(1)
118TS
PayToQualifier
CodequalifyingthePayToID
(119TT).
x(2)
T,W
SeeECL
Format=AAAEEENNNN
AAA=AreaCode
EEE=ExchangeCode
NNNN=Number
Examples:Aphonenumberof2125551212
isenteredas:2125551212.
Comments:QualifiesPayToID(119TT).
- 107 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
123TX
PaytoState/
ProvinceAddress
payee.
x(2)
T,W
SeeECL
121TV
PayToStreet
Address
Streetaddressoftheentityto
receivepaymentforclaim.
x(3)
B247R
PayToStreet
AddressLine1
Line1ofstreetaddressofthe
entitytoreceivepaymentfor
claim.
x(4)
B257S
PayToStreet
AddressLine2
Line2ofstreetaddressofthe
entitytoreceivepaymentfor
claim.
x(4)
124TY
PayToZip/Postal
Code
postalcodeofthePayToentity,
x(15)
T,W
15
Comments:
fourdigitexpandedzipcodeinwhichthepatientis
located.
98765leftjustified.
Examples:
A0E3B0
A1L2T8
PBMMemberID
PayerassignedUniqueMember
ID.
x(8)
B81
PenaltyAmount
Nonreimbursableamount
incurredbypatientbasedon
benefitparameters.
9(8)v99
Format=$$$$$$$$cc
amounts.
- 108 April215
DATA DICTIONARY
FIELD
559AX
NAMEOFFIELD
PercentageSales
TaxAmountPaid
DEFINITIONOFFIELD
Amountofpercentagesalestax
paidwhichisincludedinthe
TotalAmountPaid(59F9).
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
VALUES
COMMENTS/EXAMPLES
ForT,A:Format=s$$$$$$ccExamples:Ifthe
percentagesalestaxpaidis$3.62,thisfieldwould
reflect:36B.
ForY:
Note:
=Negativesign
usage.
482GE
PercentageSales
TaxAmount
Submitted
Percentagesalestaxsubmitted.
s9(6)v99
T,Z,W
Format=s$$$$$$cc
Comments:Thesubmissionofsalestaxisgoverned
byregulatoryagencies(state,local,parish,etc)..
Examples:Ifthepercentagesalestaxamount
submittedis$4.47,thisfieldwouldreflect:44G.
561AZ
PercentageSales
TaxBasisPaid
Codeindicatingthepercentage
salestaxpaidbasis.
x(2)
T,A
484JE
PercentageSales
TaxBasisSubmitted
Codeindicatingthebasisfor
percentagesalestax.
x(2)
SeeECL
SeeECL
Comments:.Thesubmissionofsalestaxisgoverned
byregulatoryagencies(state,local,parish,etc).
56AY
PercentageSales
TaxRatePaid
Percentagesalestaxrateusedto
calculatePercentageSalesTax
AmountPaid(559AX).
s9(3)v9999
T,A
Format=s999.9999
483HE
PercentageSales
TaxRateSubmitted
Percentagesalestaxrateusedto
calculatePercentageSalesTax
AmountSubmitted(482GE).
s9(3)v9999
Comments:Thesubmissionofsalestaxisgoverned
byregulatoryagencies(state,local,parish,etc).
Format=s999.9999
954HQ
PercentCopayRate
Percentagecopayrate
R(1)
- 109 April215
Comments:Percentageexpressedasadecimal
(e.g.,.through1.represents%through
1%)
Thelengthincludesthedecimalpoint.
DATA DICTIONARY
FIELD
NAMEOFFIELD
PeriodEnd
DEFINITIONOFFIELD
Thedateordateandtimethat
thereferencedperiodexpires.
FIELD
FORMAT
xsd:dateor
xsd:datetim
e
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
PersonCode
Codeassignedtoaspecific
personwithinafamily.
x(3)
S,Q
33C3
PersonCode
Codeassignedtoaspecific
personwithinafamily.
x(3)
R,T,A,N,V,Z,
X,Y,I
EnrollmentStandardExamples:
Examples:
1=Cardholder
2=Spouse
3999=DependentsandOthers(including
secondspouses,etc.)
PharmacistIdentifica
tion
Identificationofthepharmacist.
x(35)
SeeECL
636TD
PharmacistInitials
Theinitialsofthepharmacist.
x(3)
8295L
PharmacyAddress
Thestreetaddressfora
pharmacy.
x(2)
Z,W
289
PharmacyClass
Code
Indicatesclassofthepharmacy.
x(1)
Comments:QualifiedbyPharmacyClassCode
Qualifier(15).
15
PharmacyClass
CodeQualifier
CodequalifyingthePharmacy
ClassCode(289).
x(1)
SeeECL
Comments:QualifiesPharmacyClassCode(289).
29
PharmacyDispenser
Type
Typeofpharmacydispensing
product.
x(2)
Comments: QualifiedbyPharmacyDispenserType
Qualifier(146).
146
PharmacyDispenser
TypeQualifier
CodequalifyingthePharmacy
DispenserType(29).
x(1)
SeeECL
- 110 April215
Comments:QualifiesPharmacyDispenserType
(29).
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
PharmacyIdentificati
on
Identificationofthepharmacy.
x(35)
S,Q
SeeECL
8315N
PharmacyLocation
City
Cityofpharmacy.
x(18)
Z,W
18
8335P
PharmacyName
Nameofpharmacy.
x(2)
_________
x(7)
Z,W
_________
A,Y,V
2
________
7
PharmacyRequested
Refills
Numberofrefillsthepharmacyis
requesting.
9(2)
147U7
PharmacyService
Type
Thetypeofservicebeing
performedbyapharmacywhen
differentcontractualtermsexist
betweenapayerandthe
pharmacy,orwhenbenefitsare
baseduponthetypeofservice
performed.
9(2)
T,R
SeeECL
PharmacySpecialty
Specialtyofpharmacy.
x(1)
S,Q
SeeECL
8326F
Pharmacy
State/Province
Address
State/ProvinceCodeof
pharmacy.
x(2)
Z,W
SeeECL
8345Q
Pharmacy
TelephoneNumber
Telephonenumberofpharmacy.
9(1)
Z,W
Format=AAAEEENNNN
PharmacyType
SeePharmacyType(955HR)
x(1)
SeeECL
955HR
PharmacyType
TypeofPharmacy.
x(1)
SeeECL
AAA=AreaCode
EEEExchangeCode
NNNN=Number
- 111 April215
DATA DICTIONARY
FIELD
8355R
NAMEOFFIELD
PharmacyZip/Postal
Code
DEFINITIONOFFIELD
postalcodeofthepharmacy,
FIELD
FORMAT
x(9)
STANDARD
FORMATS
Z,W
FIELD
LENGTH
9
VALUES
COMMENTS/EXAMPLES
whichthepharmacyislocated.
98765leftjustified.
Examples:
A0E3B0
A1L2T8
Note:Sizeofthisfieldhasnotbeenmodifiedtothe
standardx(15)becauseitisusedintheUniversal
ClaimFormsforwhichsizecanbedeterminedby
font.
37C7
PlaceofService
Codeidentifyingtheplacewhere
adrugorserviceisdispensedor
administered.
9(2)
T,A,Z,J
SeeECL
291
PlanBenefitCode
Determinesthemethodbywhich
InsulinandOTCclaimsarepaid.
Definedbyprocessor.
x(2)
292
PlanCutback
ReasonCode
Indicatesthetypeofcutback,if
any,imposedbyplan.
x(1)
SeeECL
A86
PlanEligibilityStart
Date
Representsthelaterofeither,
thedatethePlanestablisheda
relationshipwiththePMO,or
thedatethePlanbecameeligible
underthePMO'scontractwith
thePICO.
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
- 112 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
A87
PlanEligibility
TerminationDate
Representstheearlierofeither,
thedatethePlanseveredtheir
relationshipwiththePMO,or
thedatethePlannolongerwas
eligibleunderthePMO'scontract
withthePICO.
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
524FO
PlanID
Assignedbytheprocessorto
identifyasetofparameters,
benefit,orcoveragecriteriaused
toadjudicateaclaim.
x(8)
694
PlanIDCode
IDassignedtoidentifytheplan.
x(17)
R,J
17
695
PlanIDQualifier
submittedinthePlanIDCode
(694)field.
x(1)
R,J
SeeECL
696
PlanName
Thenameoftheplan.
x(3)
x(7)
R,J
A82
PlanReimbursed
Amount
TotalamounttheMCOpaysto
theprovider(afterremovingthe
copayordeductiblefromthe
Allowablecost)
9(9)v99b
12
b=Space
=Negativesign
PlanSalesTax
Amount
Plansalestaxresponsibility.This
fieldisnotacomponentofthe
formula.
s9(6)v99
Format=s$$$$$$cc
PlanType
Identifiesthetypeofplan.
x(4)
5742Y
611
or9(9)v99
reflect:55{
R,A
SeeECL
- 113 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
PostalCode
DEFINITIONOFFIELD
postalcodeexcluding
punctuation.
FIELD
FORMAT
an
STANDARD
FORMATS
S,Q
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
Comments:
PostalCodemustbemailableinthecountry.
located.
98765leftjustified.
Examples:
A0E3B0
A1L2T8
956HS
PreferenceLevel
Iftherearemultiplealternatives
foragivenSourcedrug,thisis
thepayersorderofpreference
(ahighernumberequalsgreater
preference).
9(2)
SeeECL
Comments:Ahighernumberindicatesmore
preferred.
293
Preferred
AlternativeFileID
Indicatesthepreferred
alternativefileIDnumberused
todetermineprocessing.
x(1)
555AT
PreferredProduct
CostShareIncentive
Amountofpatientscopay/cost
shareincentiveforpreferred
product.
s9(6)v99
Format=s$$$$$$cc
Examples:Ifthepreferredproductcopayis$6.
5519F
PreferredProduct
Count
Countofpreferredproduct
occurrences.
9(1)
groupingare:
PreferredProductIDQualifier(552AP)
PreferredProductID(553AR)
PreferredProductIncentive(554AS)
PreferredProductCostShareIncentive(555AT)
PreferredProductDescription(556AU)
- 114 April215
DATA DICTIONARY
NAMEOFFIELD
556AU
PreferredProduct
Description
Freetextmessage.
x(4)
553AR
PreferredProduct
ID
Alternateproductrecommended
bytheplan.
x(19)
19
Comments:QualifiedbyPreferredProductID
Qualifier(552AP).
552AP
PreferredProduct
IDQualifier
productIDsubmittedin
PreferredProductID(553AR).
x(2)
SeeECL
554AS
PreferredProduct
Incentive
Amountofpharmacyincentive
availableforsubstitutionof
preferredproduct.
s9(6)v99
Format=s$$$$$$cc
Prefix
Prefixofthename.
x(1)
S,Q
PregnancyIndicator
Codeindicatingthepatientas
pregnantornonpregnant.
BooleanCod
e
SeeECL
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
Examples:Ifthepreferredproductincentiveis
3352C
PregnancyIndicator
Codeindicatingthepatientas
pregnantornonpregnant.
x(1)
T,V
SeeECL
294
PrescribedDays
Supply
Indicatestheoriginaldayssupply
oftheprescription.Appliesto
internalMailServiceonly.
9(3)
619RW
PrescribedProduct
Description
Thenameofthedrugor
compoundprescribed.
x(6)
A26ZP
PrescriberAlternate
ID
AnalternateIDassignedtothe
prescriber.
x(15)
15
B43A
PrescriberAlternate
IDAssociated
CountryCode
Codeofthecountry.
x(2)
SeeECL
A27ZQ
PrescriberAlternate
IDAssociated
State/Province
Address
withthePrescriberAlternateID
Qualifier(A25ZM)andthe
PrescriberAlternateID(A26ZP).
x(2)
SeeECL
A25ZM
PrescriberAlternate
IDQualifier
AcodequalifyingthePrescriber
AlternateID(A26ZP)
x(2)
SeeECL
- 115 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
B413B
PrescriberID
AssociatedCountry
Code
Codeofthecountry.
x(2)
SeeECL
295
Prescriber
CertificationStatus
Indicatesaproviders
certificationinthehealthplan
program.
x(2)
SeeECL
3662M
PrescriberCity
Address
Freeformtextforprescribercity
name.
x(2)
T,W
B423C
PrescriberCountry
Code
Codeofthecountry.
x(2)
SeeECL
3642J
PrescriberFirst
Name
x(12)
x(35)
12
35
411DB
PrescriberID
IDassignedtotheprescriber.
x(15)
T,A,R,V,Z,W
,X,J,Y,E
15
RegardingtheTelecommunicationStandard:
Comments:QualifiedbyPrescriberIDQualifier
(466EZ)fortheTelecommunicationsStandard.
A24ZK
PrescriberID
Associated
State/Province
Address
withthePrescriberIDQualifier
(466EZ)andthePrescriberID
(411DB).
x(2)
SeeECL
62RX
PrescriberIDCount
CountofprescriberID
occurrences.
9(2)
includedintheset/logicalgroupingare:Prescriber
IDQualifier(466EZ),PrescriberID(411DB).
PrescriberIdentificat
ion
Identificationoftheprescriber.
x(35)
S,Q
SeeECL
466EZ
PrescriberID
Qualifier
CodequalifyingthePrescriber
ID(411DB).
x(2)
T,A,R,V,Z,W
,X,J,Y,E
SeeECL
427DR
PrescriberLast
Name
Individuallastname.
x(15)
x35
Z,W
15
35
Examples:BROWN
PrescriberOrderNu
mber
Thisisthereferencenumber
assignedbytheprescribing
system.
x(35)
S,Q
35
A14
PrescriberOverride
Type
Theoverridesinclusionor
exclusionparametersasit
appliestotheprescribernetwork
foraplan.
9(1)
SeeECL
- 116 April215
Note:Somevendorscarrythroughlifeof
prescription;otherschangeperprescriptionorder.
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
PrescriberProvidedA
nswer
Freetextanswerprovidedby
prescriber.
x(2)
PrescriberProvidedN
umericAnswer
Numericanswerprovidedby
prescriber.
9(18)
18
PrescriberSpecialty
Specialtyofprescriber.
x(1)
S,Q
SeeECL
621RY
PrescriberSpecialty
Specialtyofprescriber.
x(1)
SeeECL
622RZ
PrescriberSpecialty
Count
Countofspecialtyoccurrences.
9(1)
includedintheset/logicalgroupingare:Prescriber
Specialty(621RY).
3672N
Prescriber
State/Province
Address
prescriber.
x(2)
T,W
SeeECL
3652K
PrescriberStreet
Address
Freeformtextforprescriber
addressinformation.
x(3)
B277U
PrescriberStreet
AddressLine1
x(4)
B287V
PrescriberStreet
AddressLine2
x(4)
3722T
Prescriber/Supplier
DateSigned
Thedatetheformwas
completedandsignedbythe
orderingphysician.
9(8)
296
Prescriber
TaxonomyCode
Thetaxonomyisdefinedasa
classificationschemethat
codifiesprovidertypeand
providerareaofspecialization.
x(1)
498PM
Prescriber
TelephoneNumber
Tendigitphonenumberofthe
prescriber.
9(1)
T,W
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
SeeECL
Format=AAAEEENNNN
AAA=AreaCode
EEE=ExchangeCode
NNNN=Number
Examples:Thisfieldwouldreflectthetelephone
numberof(414)5551212as4145551212.
- 117 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
B267T
Prescriber
TelephoneNumber
Extension
number
9(8)
Format=99999999
3682P
Prescriber
Zip/PostalZone
postalzoneexcluding
punctuationandblanks.
x(15)
T,W
15
PrescriptionDelivery
Method
Themethodthroughwhichthe
originalelectronicallycreated
transactionwasdeliveredtoits
intendedrecipient.Thepresence
ofthisvaluewillconfirmtothe
originalsenderthedelivery
methodultimatelyemployedto
successfullydeliverthe
transactiontoitsintended
recipient;clarityinultimate
deliverymethodwillassistwith
anytroubleshootingor
transactiontracingthatmaytake
place.
an
S,Q
419DJ
PrescriptionOrigin
Code
Codeindicatingtheoriginofthe
prescription.
9(1)
T,A,W,Z,R
297
PrescriptionOver
TheCounter
Indicator
Theindicatorthatspecifiesthis
prescriptionisafederal/legend
(RXprescriptiononly)ornon
prescriptiondrug(OTC).
x(1)
SeeECL
PrescriptionPrevious
lyFilled
Indicateswhetherthe
prescriptionhasbeenpreviously
filled.
BooleanCod
e
SeeECL
Thetotalamountpaidbyall
plansinvolvedorcash
prescriptionsellingprice.
an
PrescriptionSellPrice
SeeECL
SeeECL
amountexchanged.
=Negativesign
.=Decimalpoint
wouldreflect:5.5
- 118 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
42D2
Prescription/
ServiceReference
Number
Referencenumberassignedby
theproviderforthedispensed
drug/productand/orservice
provided.
9(12)
Prescription/
ServiceReference
NumberQualifier
Indicatesthetypeofbilling
submitted.
x(1)
6149
PrescriptionType
Identifiestheprescriptionas
eitheranew/refill,anadjusted
prescriptionorareversal.
9(1)b
or9(1)
53FU
PreviousDateofFill
Dateprescriptionwaspreviously
filled.
9(8)
455EM
DEFINITIONOFFIELD
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
T,A,R,V,Z,W
,X,J,E
12
ForTelecommunicationStandard:
R,T,A,X,J,E,
W,X
SeeECL
Comments:QualifiesPrescription/Service
ReferenceNumber(42D2).
R,J
SeeECL
T,X
Format=CCYYMMDD
QualifiedbyPrescription/ServiceReference
NumberQualifier(455EM).
CC=Century
YY=Year
MM=Month
DD=Day
Examples:Iftheprescriptionwaspreviouslyfilled
onAugust1,1999,thisfieldwouldreflect:
199981.
421DL
PrimaryCare
ProviderID
IDassignedtotheprimarycare
provider.Usedwhenthepatient
isreferredtoasecondarycare
provider.
x(15)
T,A
15
Comments:QualifiedbyPrimaryCareProviderID
Qualifier(4682E).
4682E
PrimaryCare
ProviderIDQualifier
CodequalifyingthePrimaryCare
ProviderID(421DL).
x(2)
T,A
SeeECL
474E
PrimaryCare
ProviderLastName
Individuallastname.
x(35)
35
PrimaryDiagnosisCo
deDescription
PrimaryDiagnosisCode.
an
PrimaryDiagnosisCo
deQualifierCode
Qualifiesthecodelistusedfor
thePrimaryDiagnosis.
an
SeeECL
PrimaryDiagnosisVal
ue
Codefortheprimarydiagnosis
an
QualifiedbyPrimaryDiagnosisCodeQualifierCode.
621
PriorAmountPaid
Thecumulativedollaramountof
previouslypaidrebates.
9(9)v99b
or
9(9)v99
12
- 119 April215
Note:
b=Space
=Negativesign
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
PrimaryTelephoneE
xtension
Extensionofthepreferred
telephonenumber.
9(8)
S,Q
Format=99999999
PrimaryTelephoneN
umber
Preferredtelephonenumberof
theentity.
9(1)
S,Q
PrimaryTelephoneS
upportsSMS
textmessages.
BooleanCod
e
S,Q
SeeECL
PriorAuthorization
Identifiesthepriorauthorization.
x(35)
35
A15
PriorAuthorization
CreateDate
Thedatethepriorauthorization
recordwascreatedinsenders
system.
9(8)
Format=CCYYMMDD
498RB
PriorAuthorization
DollarsAuthorized
Amountauthorizedintheprior
authorization.
s9(6)v99
Format=s$$$$$$cc
Example:Iftheamountis$5.5,thisfieldwould
reflect:55{
498PS
PriorAuthorization
EffectiveDate
Datethepriorauthorization
becameeffective.
9(8)
T,X
Format=CCYYMMDD
Format=AAAEEENNNN
AAA=AreaCode
EEE=ExchangeCode
NNNN=Number
CC=Century
YY=Year
MM=Month
DD=Day
CC=Century
YY=Year
MM=Month
DD=Day
Comments:Providedbytheprocessortothe
pharmacytoindicatethedateonwhichtheprior
authorizationbecameeffective.
498PT
PriorAuthorization
ExpirationDate
ends.
9(8)
T,X
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
authorizationapprovalexpires.
498PY
PriorAuthorization
NumberAssigned
Uniquenumberidentifyingthe
priorauthorizationassignedby
theprocessor.
9(11)
T,A,X
11
- 120 April215
Comments:Providedtothepharmacybythe
processortobeusedbythepharmacyforbilling,
andifapplicable,reversalpurposes.
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
A16
PriorAuthorization
NumberofFills
Authorized
Thenumberoffillsallowedtobe
coveredbytheprior
authorizationandisusuallyover
orunderthenormalplan
limitations.
9(2)
498PW
PriorAuthorization
NumberOfRefills
Authorized
Numberofrefillsauthorizedby
thepriorauthorization.
9(2)
T,X
462EV
PriorAuthorization
NumberSubmitted
Numbersubmittedbythe
providertoidentifytheprior
authorization.
9(11)
T,A,V,Z,W,X
11
498PR
PriorAuthorization
ProcessedDate
requestwasprocessed.
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
authorizationtransactionwasprocessed.
498RA
PriorAuthorization
Quantity
Amountauthorizedexpressedin
metricdecimalunits.
9(7)v999
PriorAuthorization
Quantity
Accumulated
Accumulatedauthorizedamount
expressedinmetricdecimal
units.
9(7)v999
A17
PriorAuthorization
ReasonCode
Codeclarifyingtheexplanation
oftheplanbenefitoverride
classification.
9(3)
PriorAuthorizationSt
atus
Thestatusoftheprescriptions
priorauthorizationasknownby
thesender.
x(1)
SeeECL
498PP
PriorAuthorization
Supporting
Documentation
Freetextmessage.
x(1)x(5)
15
Comments:Couldbeused,ifapplicable,tosupply
informationnotalreadyincludedinNCPDPdata
fieldsthatmayberequiredtoprocessaprior
authorizationtransaction.
498PX
T,X
Format=9999999.999
processortoconveythenumberofunits
authorized.
T,X
Format=9999999.999
processortodeterminequantityremainingfor
billing.
SeeECL
- 121 April215
DATA DICTIONARY
FIELD
461EU
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
9(2)
PriorAuthorization
UpdateDate
Thedatethepriorauthorization
recordwaslastupdatedinthe
senderssystem.
9(8)
Priority
Priorityassociatedwiththe
CentralFillOrder.
an
622
PriorUnitsDisputed
Thenumberofunitsindispute.
9(11)v999b
or
9(11)v999
15
Format=99999999999v999bor99999999999v999
Thenumberofunitspreviously
paid.
9(11)v999b
or
9(11)v999
PriorUnitsPaid
SeeECL
COMMENTS/EXAMPLES
CodeclarifyingthePrior
AuthorizationNumber
Submitted(462EV)or
benefit/planexemption.
623
VALUES
PriorAuthorization
TypeCode
A18
T,A,Z,W
FIELD
LENGTH
(SeeECLforEmergencyDisaster
StandardValues)
X
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Note:
b=Space
=Negativesign
15
Format=99999999999v999bor99999999999v999
Note:
b=Space
=Negativesign
ProblemNameCode
Codeofproblem.
an
QualifiedbyProblemNameCodeQualifier.
ProblemNameCode
Qualifier
QualifiesProblemNameCode.
an
SeeECL
ProblemNameCode
Text
Textofproblem.
an
ProblemTypeCode
problem.
an
SeeECL
459ER
ProcedureModifier
Code
Identifiesspecialcircumstances
relatedtotheperformanceof
theservice.
x(2)
T,Z,W
SeeECL
458SE
ProcedureModifier
CodeCount
CountoftheProcedureModifier
Code(459ER)occurrences.
9(2)
14A4
ProcessorControl
Number
Numberassignedbythe
processor.
x(1)
T,N,V,Z,E
8395V
ProcessorName
Nameoftheprocessor.
x(7)
- 122 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
395
ProcessorPayment
ClarificationCode
Providesadditionalinformation
ofthestatusofthepaymentof
theclaim.
x(2)
SeeECL
B82
ProcessorRouting
Identification
Usedtotriggertheprocessat
thehostsystem
x(2)
396
ProcessorSpecific
Data
Tradingpartnersmutuallyagreed
uponspecificdatadefinedby
processor.
x(5)
ProductCode
Codeidentifyingtheproduct
beingreported.
an
S,Q
QualifiedbyProductQualifierCode.
6118
ProductCode
Codeidentifyingtheproduct
beingreported.
x(17)
A,X
17
Comments:QualifiedbyProductCodeQualifier
(6119).
6119
ProductCode
Qualifier
submittedintheProductCode
(6118)field.
x(1)
A,X
SeeECL
6158
ProductDaily
Consumption
Avaluethattheunitswouldbe
dividedbytoconverttodaysof
therapy,canister,etc.forthe
calculationofmarketshare.
9(2)v99b
or
9(2)v99
Format=99v99bor99v99
612
ProductDescription
Descriptionofproductbeing
submitted.
x(3)
R,V,Z,W,J
6121
ProductDosage
Form
Thedosageformofthereported
product.
x(3)
957HT
ProductName
HealthPlan
Userrecognizablehealthplan
productname
x(35)
35
ProductQualifierCod
e
Thecodelistdefiningthe
ProductCode.
an
S,Q
SeeECL
47D7
Product/ServiceID
IDoftheproductdispensedor
serviceprovided.
x(19)
T,F,A,R,V,Z,
W,X,J,Y,E,I
19
Note:
b=Space
=NegativeSign
Format=MMMMMDDDDPP
MMMMM=Manufacturer'sAssignedNumber
DDDD=DrugID
PP=PackageSize
Comments:QualifiedbyProduct/ServiceID
Qualifier(436E1)IfProductServiceIDQualifier
(436E1)is3=NDC
- 123 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
958HU
Product/ServiceID
Alternative
IDofthepreferredalternative
drug.
x(19)
19
436E1
Product/ServiceID
Qualifier
'Product/ServiceID'(47D7).
x(2)
T,F,A,R,V,Z,
W,X,J,Y,E,I
SeeECL
959HV
Product/ServiceID
Qualifier
Alternative
Product/ServiceIDAlternative
x(2)
SeeECL
961HX
Product/ServiceID
QualifierStepDrug
Product/ServiceIDStepDrug
x(2)
SeeECL
963HZ
Product/ServiceID
QualifierSource
Product/ServiceIDSource
x(2)
SeeECL
962HY
Product/ServiceID
Source
Identifierforthedrugforwhich
thealternativeisgiven.
x(19)
19
96HW
Product/ServiceID
StepDrug
Identifierforthedrugthatis
recommendedtobetriedfirst
x(19)
19
397
Product/Service
Name
ProductorServiceDescriptionor
ProductLabelName.
x(3)
_______
A,I
_________
3
_______
(8)
6124
ProductStrength
Thestrengthoftheproduct.
x(15)
A,V,W
15
964JA
ProductType
Codetoindicatethetypeof
product.
x(1)
SeeECL
ProfessionalService
Code
Codeidentifyingintervention
performedwhenaconflicthas
beendetected.
an
SeeECL
44E5
ProfessionalService
Code
Codeidentifyingpharmacist
interventionwhenaconflictcode
hasbeenidentifiedorservicehas
beenrendered.
x(2)
T,A,Z,W
SeeECL
Examples:Ifthepharmacistspokewiththepatient
asaresultofaconflictcodebeingtransmittedona
prescription,thefieldwouldreflectP.
- 124 April215
DATA DICTIONARY
FIELD
B336G
NAMEOFFIELD
DEFINITIONOFFIELD
ProfessionalService
Fee
Contracted/Reimbu
rsementAmount
Informationalfieldusedwith
servicebillingswhenOther
PayerPatientResponsibility
Amount(352NQ)orPatientPay
Amount(55F5)isusedfor
reimbursement.Amountisequal
tocontractedorreimbursable
amountforservicebeing
rendered.
FIELD
FORMAT
s9(6)v99
STANDARD
FORMATS
FIELD
LENGTH
8
VALUES
COMMENTS/EXAMPLES
Format=s$$$$$$cc
reflect:55{.
562J1
ProfessionalService
FeePaid
Amountrepresentingthe
contractuallyagreeduponfeefor
professionalservicesrendered.
Thisamountisincludedinthe
TotalAmountPaid(59F9).
s9(6)v99
T,A
_______
_________
_______
9(6)v99
or
9(5)v99
Examples:Iftheprofessionalservicefeepaidis
$5.5thisfieldwouldreflect:55{.
ForY:
Note:
=Negativesign
usage.
477BE
ProfessionalService
FeeSubmitted
Amountsubmittedbythe
providerforprofessionalservices
rendered.
s9(6)v99
Format=s$$$$$$cc
Examples:IftheProfessionalServiceFeeSubmitted
is$7.,thisfieldwouldreflect:7{.
ProhibitRefillReques
t
Allowstheprescribertoindicate
tothepharmacythatthe
pharmacyshouldneverrequest
refillsforthisspecific
prescriptionbyanytechnique.
xsd:boolean
3612D
ProviderAccept
Assignment
Indicator
Codeindicatingwhetherthe
provideracceptsassignment.
x(1)
SeeECL
444E9
ProviderID
UniqueIDassignedtotheperson
responsibleforthedispensingof
theprescriptionorprovisionof
theservice.
x(15)
T,Z
15
Comments:QualifiedbyProviderIDQualifier
(465EY).
- 125 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
ProviderIdentificati
on
Identificationoftheprovider.
x(35)
S,Q
SeeECL
465EY
ProviderIDQualifier
CodequalifyingtheProviderID
(444E9).
x(2)
T,Z
SeeECL
ProviderSpecialty
Specialtyofprovider.
x(1)
S,Q
599Y2
PurchaserCity
Address
TheCitynameassociatedtothe
addressofthepurchaserofthe
product/service.
x(2)
PurchaserCountry
Code
TheassociatedPostalcountry
codeofthepurchaserofthe
product/service.
x(2)
PurchaserDateof
Birth
TheDateofBirthofthe
purchaseroftheproduct/service.
9(8)
596YZ
PurchaserFirst
Name
TheFirstNameofthepurchaser
oftheproduct/service.
x(35)
35
595YY
PurchaserGender
Code
TheGenderofthepurchaserof
theproduct/service.
9(1)
592YV
PurchaserID
TheIDnumberusedtoidentify
thepurchaserofthe
product/service.
QualifiedbyPurchaserID
Qualifier.
x(2)
677Y5
594YX
SeeECL
Examples:CHICAGO
SeeECL
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
SeeECL
Comments:QualifiedbyPurchaserIDQualifier
(591YU).
B433D
PurchaserID
AssociatedCountry
Code
Codeofthecountry.
x(2)
SeeECL
593YW
PurchaserID
Associated
State/Province
Address
State/PostalCodeassociated
withthePurchaserIDQualifier
(591YU)andPurchaserID(592
YV).
x(2)
SeeECL
591YU
PurchaserID
Qualifier
CodeindicatingthetypeofID
usedinthePurchaserIDfield.
QualifiesPurchaserID(592YV).
9(2)
SeeECL
Comments:QualifiesPurchaserID(592YV).
- 126 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
597Y
PurchaserLast
Name
TheLastNameofthepurchaser
oftheproduct/service.
x(35)
35
A23YS
Purchaser
RelationshipCode
frompurchasertopatient.
x(2)
SeeECL
675Y3
Purchaser
State/Province
Address
purchaser.
x(2)
B297W
PurchaserStreet
AddressLine1
information.
x(4)
B37X
PurchaserStreet
AddressLine2
information.
x(4)
676Y4
Purchaser
Zip/PostalCode
postalcodeofthepurchaserof
theproduct/service,excluding
punctuation.
x(15)
15
SeeECL
Comments: WhenusedforUSZIPCode Thisleft

justifiedfieldcontainsthefivedigitzipcodeand
mayincludethefourdigitexpandedzipcode.
98765leftjustified.
Examples:
A0E3B0
A1L2T8
A99
QualifiedCovered
RetireeHICN
HIC#foreachcoveredindividual
whomtheRDSPlanSponsoris
seekingthesubsidy.
x(11)
11
B1
QualifiedCovered
RetireeSSN
SocialSecurityNumberforeach
coveredindividualwhomthe
RDSPlanSponsorisseekingthe
subsidy.
x(9)
QuantityCodeListQu
alifier
QualifiesQuantityValue.
an
SeeECL
- 127 April215
DATA DICTIONARY
FIELD
DEFINITIONOFFIELD
442E7
QuantityDispensed
Quantitydispensedexpressedin
metricdecimalunits.
9(7)v999
T,A,V,Z,W,Y,
I
623SA
QuantityDispensed
ToDate
Totalnumberofmetricdecimal
unitsthathavebeendispensed
tothispoint.
9(7)v999
QuantityIntended
ToBeDispensed
Metricdecimalquantityof
medicationthatwouldbe
dispensedonoriginalfillingif
inventorywereavailable.Usedin
associationwithaPorCin
DispensingStatus(343HD).
9(7)V999
QuantityOf
PreviousFill
decimalunitsoftheconflicting
agentthatwaspreviouslyfilled.
9(7)v999
QuantityPrescribed
decimalunits.
9(7)v999
344HF
531FV
46ET
QuantityValue
Thequantityoftheprescription
e.g.thecountoftabletsor
numberofgrams.
FIELD
FORMAT
STANDARD
FORMATS
NAMEOFFIELD
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
Format=9999999.999
Format=9999999.999
T,A
Format=9999999.999
Format=9999999.999
T,A,V
Format=9999999.999
9(11)
11
QualifiedbyQuantityCodeListQualifier.
Format=99999999.999
Thecompoundfinalquantity.
QuantityUnitOfMea
sureCode
Conceptsoftheintendedor
actualdispensedquantityunitof
measure(e.g.,1Pack,1Inhaler,
17grams,3tablets,473ML,3
Eaches.Uponbilling,thisdatais
translatedtoMilliliters,Grams,
forEaches.
an
SeeECL
A83
QuarterlyMember
Indicator
Numberindicatingthenumberof
timesamemberisbilledinthe
billingperiod.
x(2)
SeeECL
3834K
Question
Alphanumeric
Response
Alphanumericresponsetoa
question(partofthequestion
information).
x(3)
- 128 April215
DATA DICTIONARY
FIELD
384G
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
9(8)
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
QuestionDate
Response
Dateresponsetoaquestion
(partofthequestion
information)
QuestionDollar
AmountResponse
DollarAmountresponsetoa
question(partofthequestion
information).
s9(9)v99
QuestionID
identifythequestion.
x(35)
QuestionLevel
Indicatesthatallquestionswith
thisIDarerelated.
x(35)
3824J
QuestionNumeric
Response
Numericresponsetoaquestion
(partofthequestion
information).
9(11)
11
3784B
Question
Number/Letter
Identifiesthequestion
number/letterthatthequestion
responseappliesto(partofthe
questioninformation).
x(3)
3772Z
Question
Number/Letter
Count
CountofQuestion
Number/Letteroccurrences.
9(2)
Fieldsincludedintheset/logicalgroupingare:
QuestionNumber/Letter(3784B),Question
PercentResponse(3794D),QuestionDate
Response(384G),QuestionDollarAmount
Response(3814H),QuestionNumericResponse
(3824J),QuestionAlphanumericResponse(383
4K)
3794D
QuestionPercent
Response
Percentresponsetoaquestion
(partofthequestion
information).
9(3)v99
Examples:25.75%=2575or.5%=5
QuestionSetComme
nt
Commentsfromtheprovider
answeringthequestionset.
x(2)
QuestionSetDescrip
tion
Descriptiveinformationabout
thequestionset.
x(2)
QuestionSetID
identifythequestionset.
x(7)
QuestionSetTitle
Titleofthequestionset.
x(7)
3814H
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Format=s$$$$$$$$$cc
11
reflect:55{
ValuestobedeterminedbyTradingPartner
Agreement
- 129 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
QuestionText
Textofthequestion.
x(2)
Race
Thebiologicaldescentofthe
entity.
an
SeeECL
Codeincludesacheckdigit.
RateOfAdministrati
on
Theamountoftimefora{single}
dosetobeadministered.
x(11)
11
RateUnitOfMeasure
Code
RateUnitOfMeasureText.
an
QualifiedbyRateUnitOfMeasureQualifier
RateUnitOfMeasure
Qualifier
systembeingused.
an
RateUnitOfMeasure
Text
RateUnitOfMeasureCodeforthe
periodoftimeinwhichthedose
istobeadministered.
an
ReactionCoded
Patientreactiontotheproblem
reported
an
SeeECL
ReasonCode
Codesusedinresponse
messagesbytheultimate
receiver.
x(3)
S,Q
SeeECL
ReasonForMTMServ
iceCode
Coderepresentingthereasonfor
theservice.
an
QualifiedbyReasonForMTMServiceCodeQualifier.
ReasonForMTMServ
iceCodeQualifier
systembeingusedfor
ReasonForMTMServiceCode.
an
SeeECL
ReasonForMTMServ
iceFreeText
reasonidentifieddoesnothavea
codelist
(ReasonForMTMServiceCode)
an
ReasonForMTMServ
iceText
ReasonForMTMServiceCode.
an
439E4
ReasonForService
Code
utilizationconflictdetectedby
theprescriberorthepharmacist
orthereasonforthe
pharmacistsprofessional
service.
x(2)
T,A,Z,W
SeeECL
SeeECL
- 130 April215
DATA DICTIONARY
FIELD
DEFINITIONOFFIELD
ReasonForSubstituti
onCodeUsed
Restrictedtextforsubmitterto
definetheirclarificationbasisfor
Substitutioncodeapplied.
an
SeeECL
615
RebateBatch
Number
batchbeingsubmitted.
x(15)
15
Comments:Canbeinvoicenumber.
6151
RebateDaysSupply
Dayssupplyoftheproductbeing
reported.
9(3)b
or9(3)
Format=999bor999
RebatePerUnit
Amount
Amountperunitbeing
submitted.
9(5)v99999
9b
or
9(5)v99999
9
RebatePeriodEnd
Date
Lastdayoftherebateperiod.
9(8)
R,J
RebatePeriodStart
Date
Firstdayoftherebateperiod.
RebateVersion
ReleaseNumber
Versionandreleasenumberof
standardbeingsubmitted.
88K7
ReceiverID
Anidentificationnumberofthe
endpointreceiverofthedatafile.
A19
ReceiverName
628
629
6152
639
638
613
FIELD
FORMAT
STANDARD
FORMATS
NAMEOFFIELD
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
Note
b=Space
=NegativeSign
12
Note
b=Space
=NegativeSign
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
9(8)
R,J
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
x(5)
SeeECL
Format=VV.RR
VV=Version
RR=Release
x(24)
x(3)
B,A,V,E 24
F,I
3
Businessnameofentityreceiving
theinformation.
x(7)
ReconciliationError
Description
DescriptionoftheR99Reason
Code.
x(3)
ReconciliationLine
Number
Uniquenumberthatidentifies
therecord.
x(11)
11
- 131 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
621
Reconciliation
ReasonCode
Thiscodeindicatesthereason
forthedispute.
x(3)
SeeECL
6211
Reconciliation
StatusCode
Indicateshowthelineisbeing
adjudicated.
x(1)
SeeECL
6212
Reconciliation
Transmission
ControlNumber
wholetransmission.
x(9)
751M9
RecordCount
ForBatchStandard:Includesthe
totalnumberofrecordsinthe
batch,includingtheheaderand
trailerrecords.
9(1)
B,F,V,E,I
BatchStandard:
Comments:Datatrailersegmentrecordcount=
totalnumberofenrollmentsegmentsinthe
processorset.
ForFormulary&Benefit
Standard:Thecountofthedetail
recordsbetweenthesubordinate
headerandthetrailerrecords.
RecordCountdoesnotinclude
thesubordinateheaderand
trailerrecords,orthefileheader
ortrailerrecords.
Filetrailersegmentrecordcount=totalnumberof
enrollmentsegmentsintheentirefile.
ForPrescriptionTransfer
Standard:Includesthetotal
numberofrecordswithinthe
groupedrecordsheaderand
trailer,includingtheheaderand
trailerinthecount.
ForAuditandBenefit
IntegrationStandards:Total
numberofdetailsrecords
includedintransmission
624SB
RecordDelimiter
Thisfieldisusedtodelimitthe
endofthedatarecord.
x(1)
Comments:ForPrescriptionTransfer,Carriage
Return(CR)=Hex'D
398
RecordIndicator
Actiontobetakenontherecord.
x(1)
SeeECL
B83
RecordLength
Lengthofthefile.
9(5)
6153
RecordPurpose
Indicator
Identifiesthepurposeofthe
recordbeingsubmitted.
x(1)
R,J
SeeECL
399
RecordStatusCode
Identifiesthetransactionstatus
asassignedbytheprocessor.
x(1)
A,Y
SeeECL
- 132 April215
DATA DICTIONARY
FIELD
614
NAMEOFFIELD
RecordType
DEFINITIONOFFIELD
Typeofrecordbeingsubmitted.
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
2
R,A,V,X,J,
E,Y,L,I
x(3)
x(2)
VALUES
COMMENTS/EXAMPLES
SeeECL
RefillsRemaining
Thenumberofrefillsremaining
intheprescription.
9(2)
SeeNumberOfFillsRemaining(616PU).
6147
Reimbursement
Amount
Theamountthattheplan
reimbursesthepharmacy.
9(9)v99b
or9(9)v99
12
Reimbursement
Date
Dateproviderwasreimbursed
forproductbeingreported.
9(8)
R,J
6148
Reimbursement
Qualifier
Identifiesthecontentofthedata
submittedinthe
ReimbursementAmount(61
47)field.
x(2)
SeeECL
511FB
RejectCode
Codeindicatingtheerror
encountered.
x(3)
x(4)
T,A,N,V,E,I
SeeECL
51FA
RejectCount
CountofRejectCode(511FB)
occurrences.
9(2)
B,T,N
5464F
RejectField
Occurrence
Indicator
Identifiesthecounternumberor
occurrenceofthefieldthatis
beingrejected.Usedtoindicate
rejectsforrepeatingfields.
9(2)
878
RejectOverride
Code
Indicatesthereasonforpayinga
claimwhenoverrideisused.
x(1)
SeeECL
6154
Note
b=Space
=NegativeSign
8
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
- 133 April215
groupingare:
RejectCode(511FB)
RejectFieldOccurrenceIndicator(5464F)
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
RelatesToMessageI
D
Usedintheconversation
(messagestring)tolinkthe
currentmessagetothemost
recentmessageyoureceived
fromyourtradingpartner.In
<RelatesToMessageID>usethe
latest<MessageID>inthe
conversation(messagestring)
youreceivedfromyourtrading
partnerthatwasnotautility
message(forexample,nota
GetMessage,Status,Verifyor
Error).
x(35)
S,Q
35
A3ZT
ReleasedDate
Identifiesthedatethe
prescriptionwasrelinquished
fromthedispensingfacilityto
thepatientorpurchaser.
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:AdateofJuly27,29wouldbe:
29727.
A31ZU
514FE
ReleasedTime
RemainingBenefit
Amount
Indicatesthetimethe
prescriptionwasrelinquished
fromthedispensingfacilityto
thepatientorpurchaser.Thisis
thelocaltimethatcorresponds
withtheReleasedDate(A3ZT)
9(6)
Amountremainingina
patient/familyplanwitha
periodicmaximumbenefit.
s9(6)v99
Format=HHMMSS
Example:(ReportedinMilitaryTime)
TwoOClockP.M.=14
T,A
Format=s$$$$$$cc
reflect:55{
Note:{(Nobenefitremaining)
- 134 April215
DATA DICTIONARY
FIELD
513FD
NAMEOFFIELD
Remaining
DeductibleAmount
DEFINITIONOFFIELD
Amountnotmetbythe
patient/familyinthedeductible
plan.
FIELD
FORMAT
s9(6)v99
STANDARD
FORMATS
T,A
FIELD
LENGTH
8
VALUES
COMMENTS/EXAMPLES
Format=s$$$$$$cc
Examples:Thepatienthas$5.deductible.The
patientpays$2.foraprescription.The
remainingdeductibleis$3.,andthisfield
wouldreflect:3{.
625SC
RemainingQuantity
Quantitynotyetdispensed.
9(7)V999
Format=9999999.999
A29ZS
ReportedPayment
Type
Thetypeofprescriptionbenefit
planthatadjudicatedandpaid
fortheprescription.
615
ReportingPeriod
EndDate
ForPostAdjudicationand
9(8)
UniformHealthcarePayerData:
_______
Thelastdayoftheperiodbeing
reportedinthefile. 9(6)
9(2)
SeeECL
R,A
_________
8
_______
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
ForManufacturerRebates:The
lastdayoftheperiodbeing
reportedintheplanflatfile.
ForUniformHealthcarePayerDataStandard,
Format=CCYYMM
CC=Century
YY=Year
MM=Month
616
ReportingPeriod
StartDate
ForPostAdjudicationand
UniformHealthcarePayerData:
Thefirstdayoftheperiodbeing
reportedinthefile.
9(8)
_______
R,A
_________
8
_______
9(6)
ForManufacturerRebate:The
firstdayoftheperiodbeing
reportedintheplanflatfile.
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
ForUniformHealthcarePayerDataStandard,
Format=CCYYMM
CC=Century
YY=Year
MM=Month
- 135 April215
DATA DICTIONARY
NAMEOFFIELD
6155
RequestedRebate
Amount
Thetotalrebatebeingrequested
forthereportedproduct.
9(9)v99b
or(9)v99
R,J
Requested
ResponseDate
Dateassociatedwiththe
TransmissionFileType(986KJ).
9(8)
RequestPeriod
BeginDate
Thebeginningdateofneed.
9(8)
RequestPeriod
DateBegin
Beginningdateforaprior
authorizationrequest.
A5
3742V
498PB
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
FIELD
LENGTH
12
VALUES
COMMENTS/EXAMPLES
Note
b=Space
=NegativeSign
Format:CCYYMMDD
ForDeskTopAudits:theduedatefortheinitial
auditrequest,theendofanappealperiodoran
appealhearingdateasdefinedbytheauditing
entity.
ForInStoreAudits:thedateofthestorevisitbyan
auditor,theendofanappealperiod,oranappeal
hearingdate.
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Comments:Usedbyprocessortodetermine
startingdateofapriorauthorizationrequest.
498PC
RequestPeriod
DateEnd
Endingdateforaprior
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Comments:Usedbyprocessortodeterminethe
endingdateforapriorauthorizationrequest.
3752W
RequestPeriod
Recert/RevisedDate
Theeffectivedateoftherevision
orrecertificationprovidedby
thecertifyingphysician.
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
- 136 April215
DATA DICTIONARY
FIELD
FIELD
FORMAT
STANDARD
FORMATS
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
LENGTH
RequestReferenceN
umber
Thereceiver'sidentification
numberforthetransactionbeing
returned.UsedinGetMessage
transaction.
x(35)
S,Q
35
3732U
RequestStatus
Codeidentifyingtypeofrequest.
x(1)
VALUES
COMMENTS/EXAMPLES
SeeECL
498PA
RequestType
Codeidentifyingtypeofprior
x(1)
1
SeeECL
Comments:Usedbyprocessortodistinguishreason
forpriorauthorizationrequest.
ResidenceCode
Codeidentifyingthepatients
placeofresidence.
9(2)
SeeECL
SeePatientResidence(3844X).
968JF
ResourceLinkType
Identifiesthetypeofcoverage
informationcontainedattheURL
containedinURL(987MA).
x(2)
SeeECL
B528R
Response
Intermediary
AuthorizationCount
CountofResponseIntermediary
AuthorizationTypeID(B538S),
ResponseIntermediary
AuthorizationTypeIDand
IntermediaryMessage.
9(1)
B548T
Response
Intermediary
AuthorizationID
Valueindicatingintermediary
authorization.
x(2)
(2)
B538S
Response
Intermediary
AuthorizationType
ID
Valueindicatingthe
authorizationtypefrom
intermediaryprocessing.
9(2)
SeeECL
ResultOfActionCode
Coderepresentingtheresultof
theaction.
an
QualifiedbyResultOfActionCodeQualifier.
ResultOfActionCode
Qualifier
systembeingusedfor
ResultOfActionCode.
an
SeeECL
ResultOfActionFree
Text
resultidentifieddoesnothavea
codelist(ResultOfActionCode).
an
ResultOfActionText
ResultOfActionCode.
an
- 137 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
441E6
ResultofService
Code
Actiontakenbyapharmacistor
prescriberinresponsetoa
conflictortheresultofa
pharmacistsprofessional
service.
x(2)
T,A,Z,W
ResumeDateTime
Thedateandtimeatwhich
administrationofamedicationis
resumedafterbeingsuspended.
xsd:datetim
e
VALUES
SeeECL
COMMENTS/EXAMPLES
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
ReturnReceipt
6213
RevisedInvoice
Amount
Used to request return receipt. If

thisfieldissubmittedwith1inthe
request,aVerifytransactionistobe
sent from the recipient at some
time.
x(3)
S,Q
SeeECL
TheOriginalRebatePerUnit
(6193)isdifferentthanthe
CurrentRebatePerUnit(61
81).Thedollaramountofthe
CurrentUnitstimestheCurrent
RebatePerUnit.
9(9)v99b
or
9(9)v99
12
Room
Theroomofthepatient.
x(1)
S,Q
674W4
Room
Theroomofthepatient.
x(1)
995E2
Routeof
Administration
Thisisanoverridetothe
defaultroutereferencedfor
theproduct.Foramulti
ingredientcompound,itisthe
routeofthecompletecompound
mixture.
x(11)
T,A,Z,W
11
SeeECL
RouteOfAdministrat
ionClarifyingFreeTex
t
Usedtoaddclaritytotheroute
ofadministrationforelements
thatcannotbecodified.
x(255)
255
RouteOfAdministrationText.
an
QualifiedbyRouteOfAdministrationQualifier.
Note:
b=Space
=Negativesign
RouteOfAdministrat
ionCode
- 138 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
STANDARD
FORMATS
FIELD
FORMAT
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
RouteOfAdministrat
ionQualifier
systembeingused.
an
SeeECL
RouteOfAdministrat
ionText
RouteOfAdministrationCode.
an
RxBarcode
Barcoderepresentationof
prescriptionasdesignatedby
pharmacy.
an
RxFillConfirmIndicat
or
Indicatesthetransferredto
pharmacysupportsFillStatus
messages.
BooleanCod
e
SeeECL
RxFillIndicator
Indicatesthetypeoffillstatus
transactionstheprescriber
wouldliketoreceiveforthis
patient/medication.
an
SeeECL
IDfromRxNormdatabase.
x(15)
969JG
RxNormCode
15
Comments:QualifiedbyRxNormQualifier(97JH).
97JH
RxNormQualifier
CodequalifyingtheRxNormcode
submittedinRxNormCode
(969JG).
x(3)
RxReferenceNumbe
r
Theprescriptionnumber
assignedbythepharmacy
system.
x(35)
S,Q
35
RxRefillMessage
Numberofrefillsremainingand
expirationdateofprescription.
an
681ZF
SalesTransactionID
Areferenceidentifierassignedto
thesaletransactionasassigned
bythemerchant.
x(8)
454EK
Scheduled
PrescriptionID
Number
SecondaryDiagnosis
CodeDescription
Theserialnumberofthe
prescriptionblank/form.
x(12)
12
an
SecondaryDiagnosis
CodeQualifierCode
Qualifiesthecodelistusedfor
theSecondaryDiagnosis.
an
SeeECL
SecondaryDiagnosis
Value
Codeforthesecondary
diagnosis.
an
QualifiedbySeconaryDiagnosisCodeQualifierCode.
SecondaryDiagnosisCode.
- 139 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
SecondaryIdentifica
tion
ForSenderPassword.Thisfield
isusedforthesender'spassword
totherecipient'ssystem.
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
x(35)
S,Q
35
ForReceiverMaybeusedasa
secondaryidentificationofthe
recipient.OrMaybeusedto
identifytheswitch.
971JJ
SectionColumnIn
Error
Columnnumberthatcontains
theerror
9(2)
SeeTransactionLevel
AttachmentControl
Number
Indicatestoseeattachmentat
thetransactionlevelinsteadof
anattachmentatacompleted
answerlevelandprovidesthe
controlnumber.
an
638XK
Segment1
Thebusinesssegmentationof
rebatestopermitonefiletogo
toeachmanufacturer.
x(2)
R,J
639XL
Segment2
toeachmanufacturer.
x(2)
R,J
64XM
Segment3
toeachmanufacturer.
x(2)
R,J
641XN
Segment4
toeachmanufacturer.
x(2)
R,J
642XP
Segment5
toeachmanufacturer.
x(2)
R,J
643XQ
Segment6
toeachmanufacturer.
x(2)
R,J
111AM
Segment
Identification
Identifiesthesegmentinthe
requestand/orresponse.
x(2)
T,N
SeeECL
71
SegmentIdentifier
Uniquerecordtyperequiredon
Enrollment/BatchTransaction
Standard.
x(2)
ForBatchStandard:
SeeECL
- 140 April215
DATA DICTIONARY
FIELD
644XR
DEFINITIONOFFIELD
SegmentQualifier1
IndicatesfortheSegmentField
thedefinitionofhowtherebates
arestratifiedinthebatch
number.
number.
number.
number.
number.
number.
x(2)
R,J
SeeECL
x(2)
R,J
SeeECL
x(2)
R,J
SeeECL
x(2)
R,J
SeeECL
x(2)
R,J
SeeECL
x(2)
R,J
SeeECL
SeeECL
FIELD
FORMAT
STANDARD
FORMATS
NAMEOFFIELD
FIELD
LENGTH
645XS
SegmentQualifier2
646XT
SegmentQualifier3
647XU
SegmentQualifier4
648XV
SegmentQualifier5
649XW
SegmentQualifier6
SelectMultiple
Indicatesifmultiplechoicescan
beselectedtoanswerthe
question.
BooleanCod
e
679Y9
SellerID
Theidentificationoftheperson
responsiblefordispensingthe
prescriptionorprovisionofthe
service.
x(7)
68ZB
SellerIDQualifier
CodeindicatingthetypeofID
usedintheSellerIdentification
(xxxxx).
9(2)
59YT
SellerInitials
Theinitialsoftheperson
responsiblefordispensingthe
prescriptionorprovisionof
service.
x(3)
VALUES
SeeECL
- 141 April215
COMMENTS/EXAMPLES
DATA DICTIONARY
FIELD
88K1
NAMEOFFIELD
SenderID
DEFINITIONOFFIELD
Anidentificationnumber
assignedtothesenderofthe
databytheprocessor/receiverof
thedata.
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
x(24)
24
x(3)
F,I
x(6)
VALUES
COMMENTS/EXAMPLES
626SD
SenderName
Businessnameofentitysending
theinformation.
x(7)
V,X
973JM
SenderParticipant
Password
TradingPartnerDefined
PasswordfortheSource
Participant
x(1)
B84
SenderReference
Number
Areferencenumberassignedby
thesenderthatistobeechoed
backintheresponse.
x(3)
SenderSoftwareDev
eloper
Thetextfieldthatidentifiesthe
entityresponsibleforthe
softwarethatgeneratedthe
transaction.Thedevelopermay
beasoftwarevendoror,ifthe
softwarewasdevelopedin
house,thedeveloperisthe
entityactuallysendingthe
transaction(e.g.,achain).The
valuetransmittedisdetermined
bythe
SenderSoftwareDeveloper.
x(35)
S,Q
35
SenderSoftwarePro
duct
softwaredevelopersproduct,as
determinedbythesoftware
developer.
x(35)
S,Q
35
SenderSoftwareVer
sionRelease
x(35)
S,Q
35
x(24)
_______
A,V,L
________
24
_______
x(1)
versionandreleaseofthe
softwareproduct,asdetermined
bythesoftwaredeveloper.
Thisisnottobeusedtoblock
transactions.
879N2
SendingEntity
Identifier
Partycreatingthedataenclosed
ortheentityforwhomthedata
isbeingenclosed.
- 142 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
627SF
SendingPharmacy
ID
IDofsendingpharmacy.
x(35)
35
SentTime
Thedateofthetransmission.
xsd:dateTim
e
S,Q
COMMENTS/EXAMPLES
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
SequenceNumber
Sequencenumbertoindicatethe
orderanswerchoicesshouldbe
displayedtotheprescriber.
9(3)
886
ServiceProvider
ChainCode
ProcessorspecificIDassignedto
achainbyprocessor.
x(7)
A,E
585YN
ServiceProvider
CityAddress
Thecitynameoftheaddressof
theserviceprovider.
x(2)
A931T
ServiceProvider
CountryCode
Indicatesthecountryofthe
provider.
x(2)
Y,T,J,A
SeeECL
887
ServiceProvider
CountyCode
Indicatesthecountyofthe
pharmacy
x(3)
Comments:Tradingpartnerdefined.
Examples:CHICAGO
- 143 April215
DATA DICTIONARY
FIELD
21B1
NAMEOFFIELD
ServiceProviderID
DEFINITIONOFFIELD
IDassignedtoapharmacyor
provider.
FIELD
FORMAT
x(15)
STANDARD
FORMATS
R,T,A,V,Z,W
,X,J,E,Y,I
FIELD
LENGTH
15
VALUES
COMMENTS/EXAMPLES
Comments:IfNCPDPProviderIdentification
NumberorDispensingPhysicianIDNumber
assignedbyNCPDP,thisisthefollowingformat:
Format=SSNNNNC
SS=Statecode(seeECL)
NNNN=Numberassignedtospecificpharmacyor
dispensingphysicianwithinthestate
C=Checkdigitwiththeremainingpositionsblank.
Thecheckdigitiscalculatedasfollows:Ifthe
numberis123456
1+3+5=9(sumthe1st,3rd,&5thdigits)
+(2+4+6)x2=24(2timesthesumof2nd,4th,&6th
digits)
33(theunitsdigitisthecheck
digit)
Thecheckdigitis3,givingthefullnumber
1234563.
QualifiedbyServiceProviderIDQualifier(22
B2).
22B2
ServiceProviderID
Qualifier
CodequalifyingtheService
ProviderID(21B1).
x(2)
T,A,R,V,Z,W
,X,J,E,Y,I
SeeECL
583YK
ServiceProvider
Name
Thenameoftheserviceprovider
businessassociatedtothe
serviceproviderID(21B1).
x(7)
Example:XYZGROCERYMART
A2
ServiceProvider
OverrideType
Theoverridesinclusionor
exclusionparametersasit
appliestothepharmacynetwork
foraplan.
9(1)
586YP
ServiceProvider
State/Province
Address
serviceprovider
x(2)
T,J
B317Y
ServiceProvider
StreetAddressLine
1
Line1ofthestreetaddressof
theserviceprovider.
x(4)
B327Z
ServiceProvider
StreetAddressLine
2
Line2ofthestreetaddressof
theserviceprovider.
x(4)
SeeECL
SeeECL
- 144 April215
DATA DICTIONARY
FIELD
587YQ
NAMEOFFIELD
ServiceProvider
Zip/PostalCode
DEFINITIONOFFIELD
postalcodeoftheservice
provider,excludingpunctuation.
FIELD
FORMAT
x(15)
STANDARD
FORMATS
FIELD
LENGTH
15
VALUES
COMMENTS/EXAMPLES
Comments:
containsthefivedigitzipcodeandmayincludethe
98765leftjustified.
Examples:
A0E3B0
A1L2T8
ServiceReasonCode
Codeidentifyingthetypeofconflict
detected.
an
SeeECL
WhenServiceReasonCodeissentfromtheprescriberto
thepharmacist,theServiceResultCodeismandatory.
WhentheServiceReasonCodeissentfromthe
pharmacisttotheprescriber,theServiceResultCode
isconditional.
ServiceResultCode
Actiontakeninresponsetoa
conflict.
an
SeeECL
ServiceTypeCoded
Medicationlistcontainsall
currentmedicationordersasof
thecurrentdateandtimeofthe
response,forthepatient
indicated.Currentstatusis
determinedbythepointofcare
responder.Currentis
medicationorderswhichhave
notbeendiscontinued.
x(3)
SeeECL
SeverityCoded
Severityofthepatientsreaction
totheproblemreported.
an
SeeECL
- 145 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
ShippingAmount
DEFINITIONOFFIELD
Amountofshippingcostthatwas
appliedtotheprescription.
FIELD
FORMAT
an
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
amountexchanged.
=Negativesign
.=Decimalpoint
wouldreflect:5.5
ShippingMethod
Textindicatingtheshipping
methodfortheorder.
an
ShipToteIdentificati
on
Uniquenumberassignedbythe
CentralFillFacilityforthe
shippingtote.
an
SignatureValue
DigestValuethathasbeensigned
withaPrivateKey,base64
encodetheresults.
an
SigText
SigTextcontainseither1)
completelyfreetextwithno
correspondingcodifiedcontent
OR2)ageneratedstructured
Englishversionofthestructured
sigcontentthatfollowsthesig
grammarintheXML.TheSigText
shouldhavenomoreandnoless
thenwhatisinthestructuredSig
content.
an
SiteOfAdministratio
nClarifyingFreeText
Usedtoaddclaritytothesiteof
administrationforelementsthat
cannotbecodified.
x(255)
255
SiteOfAdministrationClarifyingFreeText
SiteOfAdministratio
nCode
SiteOfAdministrationText.
an
QualifiedbySiteOfAdministrationQualifier
SiteOfAdministratio
nQualifier
systembeingused.
an
SeeECL
- 146 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
SiteOfAdministratio
nText
SiteOfAdministrationCode.Itis
thesiteofadministration.
an
Smoker
Codeindicatingthepatientasa
smokerornonsmoker.
BooleanCod
e
SeeECL
3341C
Smoker/Non
SmokerCode
Codeindicatingthepatientasa
smokerornonsmoker.
x(1)
T,V
SeeECL
SNOMEDAdverseEv
entCode
Typeofproductandintolerance.
an
SeeECL.
SNOMEDAdverseEv
entText
Textofthe
SNOMEDAdverseEventCode.
an
SNOMEDVersion
TheversionofTheSystematized
NomenclatureofHumanand
VeterinaryMedicine(SNOMED)
beingused.
an
Comment:GovernedbySNOMED.
11AK
SoftwareVendor/
CertificationID
IDassignedbytheswitchor
processortoidentifythe
softwaresource.
x(1)
T,N
SoldDate
Thedateordateandtimethe
productwassold.
xsd:dateTim
eor
xsd:date
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
SourceDescription
Nameofthemedicationhistory
source.
x(35)
35
QualifiedbySourceQualifier.
972JK
SourceName
NameofSourcesupplyingthe
formularyFormularySource
x(7)
- 147 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
SourceOfInformatio
n
Senderindicateswherethe
senderreceivedtheallergy
informationifknown.
x(1)
SeeECL
SourceQualifier
QualifiestheSourceDescription.
x(3)
SeeECL
429DT
SpecialPackaging
Indicator
Codeindicatingthetypeof
dispensingdose.
9(1)
T,A
SeeECL
A37
SpecialtyClaim
Indicator
Indicateswhetheraclaimwas
filledbyaspecialtypharmacyor
aspecialtydrug.
x(1)
SeeECL
128UC
SpendingAccount
AmountRemaining
Thebalancefromthepatients
spendingaccountafterthis
transactionwasapplied.
s9(6)v99
T,A
Format=s$$$$$$cc
reflect:55{
Species
Abasicbiologicalclassification
containingindividualsthat
resembleoneanotherandmay
interbreed.
an
SeeECL
SplitScript
Twoprescriptionsforthesame
medicationthataresenttotwo
differententitiesforfulfillment.
x(1)
SeeECL
StartDate
Thebeginningdateordateand
time.
xsd:dateor
xsd:datetim
e
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
- 148 April215
DATA DICTIONARY
FIELD
617
NAMEOFFIELD
StartDate
DEFINITIONOFFIELD
Thefirstdayofeligibility.
FIELD
FORMAT
9(8)
STANDARD
FORMATS
FIELD
LENGTH
8
VALUES
COMMENTS/EXAMPLES
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
StateProvince
TheState/ProvinceCodeofthe
address.
an
S,Q
SeeECL
729TA
State/Province
Address
TheState/ProvinceCodeofthe
address.
x(2)
R,A,V,Y
SeeECL
StatusCode
Codesusedtorelaysuccessfulor
rejectedcommunications.
an
S,Q
SeeECL
B641P
StepMedications
GroupID
IDassignedbypayertomatch
theCoverageInformationDetail
StepMedications(SM)Triggers
record.
x(4)
974JN
StepOrder
Thesuggestedorderinwhichthe
stepmedicationistobetried
x(1)
SeeECL
StopIndicatorText
x(255)
255
StopIndicatorTextCode.The
eventthatindicatesthe
completionofthedurationof
useorreasontostop.
StopIndicatorTextCo
de
StopIndicatorText.
an
QualifiedbyStopIndicatorTextQualifier.
systembeingused.
an
SeeECL
StopIndicatorTextQ
ualifier
- 149 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
StrengthForm
Conceptsthatqualifythe
strengthandstrengthunitof
measureassociatedwiththe
prescribedproduct(e.g.,
Amoxicillin25mgTablet,
AllbuterolHFA17gramsInhaler,
Cefaclor25MG/5ML
Suspension,Fentanyl12mcg/hr
Patch,Epinephrine.3mg
[impliedperdose]AutoInjector,
Timolol.25%Ophthalmic
Drops,Sprintec28DayPack,
Hydrocortisone1%Ointment).
an
SeeECL
StrengthUnitOfMea
sure
Conceptsofdosageform
strength(e.g.,25mg,25
MG/5ML),adeliveryrate(e.g.,
12mcg/hr,adosageform
concentration(e.g.,.5%,1%),
thedosagereleasedfromasingle
deliverydeviceactuation(e.g.,
9mcg[impliedasper
inhalation],5grams),thedays
supplyorquantityinapackage
(e.g.,28day,6grams).
an
SeeECL
StrengthValue
Drugstrength.
x(7)
StructuresVersion
structuresschemaisbeingused.
an
S,Q
SeeECL
A21
SubgroupID
Furtherdefinitionofclient
populationdivisions.Further
definesGroupID(31C1).
x(15)
15
42DK
Submission
ClarificationCode
Codeindicatingthatthe
pharmacistisclarifyingthe
submission.
9(2)
T,A,Z,W,E
SeeECL
Examples:Sincethepatientwillbeoutofstatefor
thenextthreemonths,theyhaverequesteda
threemonthsupplyoftheirmedication.This
situationcancausetheclaimtoreject,becauseit
wasrefilledtoosoon.Byindicatingan3,the
processorismadeawareofthesituation,andcan
properlyadjudicatetheclaim.
354NX
Submission
ClarificationCode
Count
CountoftheSubmission
ClarificationCode(42DK)
occurrences.
9(1)
- 150 April215
DATA DICTIONARY
FIELD
888
NAMEOFFIELD
SubmissionNumber
DEFINITIONOFFIELD
Indicatesthenumberoftimesa
datasethasbeenresent.
STANDARD
FORMATS
FIELD
LENGTH
x(2)
_________
A,E
__________
2
_________
9(4)
FIELD
FORMAT
VALUES
COMMENTS/EXAMPLES
SeeECL
6136
SubmitCode
Thecodeonthefiledefiningthe
typeofsubmissionfortheentire
batch(identifiedbythebatch
number).Indicatestheactionto
performonthesubmittedfile.
x(2)
R,J
SeeECL
SubstitutedBrandDr
ug
Nameofthebrandmedication
thatthedispensedmedication
wassubstituted.
an
SubstitutionCode
theprescribersinstructions
regardinggenericsubstitution
werefollowed.
an
SeeECL
SubstitutionMessag
e
Substitutionmessagetobe
printedontheprescriptionlabel.
an
Suffix
Namesuffix.
x(1)
S,Q
SupervisorIdentifica
tion
Identificationofthesupervisor.
x(35)
S,Q
SeeECL
SupervisorSpecialty
Specialtyofsupervisor.
x(1)
S,Q
SeeECL
SupplyIndicator
Identifiesthattheprescriptionis
foraDiabeticSupplyand
additionalinformation
supportingtherationalebehind
theprescriptionandthepatient
conditionandreviewshouldbe
includedintheprescription.
BooleanCod
e
SeeECL
3762X
Supporting
Documentation
Freetextmessage
x(65)
65
- 151 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
SuspendDateTime
DEFINITIONOFFIELD
FIELD
FORMAT
Thedateandtimeatwhich
administrationofamedicationis
suspended
xsd:datetim
e
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
TargetedTypeOfSer
viceCode
Coderepresentingthetargeted
service.
an
QualifiedbyTargetedTypeOfServiceCodeQualifier.
TargetedTypeOfSer
viceCodeQualifier
systembeingusedfor
TargetedTypeOfServiceCode.
an
SeeECL
TargetedTypeOfSer
viceFreeText
targetedserviceidentifieddoes
nothaveacodelist
(TargetedTypeOfServiceCode)
an
TargetedTypeOfSer
viceText
TargetedTypeOfServiceCode.
an
557AV
TaxExempt
Indicator
Codeindicatingthepayerand/or
thepatientisexemptfromtaxes.
x(1)
T,A
SeeECL
TechnicianInitials
InitialsoftheTechnician
performingtheorderentryof
theprescription.
an
637TF
TechnicianInitials
Theinitialsofthepharmacy
technician.
x(3)
732TB
TelephoneNumber
Telephonenumber.
9(1)
A,V,X,L
Format=AAAEEENNNN
AAA=AreaCode
EEE=ExchangeCode
NNNN=Number
628SG
TelephoneNumber
Count
Countofphonenumber
occurrences.
9(1)
- 152 April215
groupingforPrescriptionTransferare:Telephone
NumberQualifier(629SH),EffectiveDate(69
NG).TelephoneNumber(732TB)
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
B18A
TelephoneNumber
Extension
number.
9(8)
A,V,X,L
Format=99999999
629SH
TelephoneNumber
Qualifier
telephonenumber.
X(2)
SeeECL
ForPrescriptionTransfer,qualifiesTelephone
Number(732TB).
TemplateID
Auniqueidentifierforthe
templateused.
x(35)
35
713
TerminationDate
Datethatgroupormembers
participationinthisgroupwill
terminate.Coveragecontinues
throughmidnightofthe
terminationdate.
9(8)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
TertiaryIdentificatio
n
Usedasatertiaryidentification
oftherecipient.
x(35)
S,Q
35
TertiaryIdentifier
Usedasatertiaryidentifier,
basedontradingpartner
agreementsorneedofthe
originatingsystem.
x(3)
S,Q
TestingFrequency
Identifiesthemaximumnumber
oftimesperdaythepatientisto
testtheirbloodglucoselevels.
9(2)
TestingFrequencyN
otes
Thisisanotesfieldandis
expectedtobealonghand
explanationbytheprescriberto
supportthetestingfrequency.
x(21)
21
TestMessage
Indicateswhetherthe
transactionistestorlive.
9(1)
S,Q
SeeECL
Text
code.
an
88K4
TextIndicator
Thisfieldisusedtoidentifythe
beginningandendingofthedata
record.
x(1)
B,V
Comments:
ForBatch
Startoftext(STX)=x2
Endoftext(ETX)=x3
ForPrescriptionTransfer
LineFeed(LF)=Hex'A'
- 153 April215
DATA DICTIONARY
FIELD
DEFINITIONOFFIELD
A461S
TextMessageType
Identifiesthetypeofcoverage
informationcontainedattheURL
containedinURL(987MA).
x(2)
SeeECL
889
Therapeutic
Chapter
Aneightpositionfield
representingthetherapeutic
chapter;fromformularyfileas
definedbyprocessor
x(8)
6125
TherapeuticClass
Code
Codeassignedtoproductbeing
reported.
x(17)
R,A,J,I
17
Comments:QualifiedbyTherapeuticClassCode
Qualifier(6126).
6126
TherapeuticClass
CodeQualifier
Identifiestypeofdatabeing
submittedintheTherapeutic
ClassCode(6125)field.
x(1)
R,A,J,I
SeeECL
6127
TherapeuticClass
Description
Atextdescriptionofthe
TherapeuticClassCode(61
25)field.
x(3)
R,J
B2
Threshold
Reduction
9(1)v99
12
Format=$$$$$$$$$$cc
678Y6
TimeofService
Totalthresholdreduction
applicabletotheretireesGross
RetireeCost.
FIELD
FORMAT
STANDARD
FORMATS
NAMEOFFIELD
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
Thetimeatwhichtheserviceis
performedaslocaltimethatwill
correspondwiththeactualdate
ofservice.
9(6)
Format=HHMMSS
HH=Hours
MM=Minutes
SS=Seconds
TimePeriodBasisCod
e
TimePeriodBasisText.
an
TimePeriodBasisQu
alifier
systembeingused.
an
TimePeriodBasisTex
t
TimePeriodBasisCode.Expresses
thetimeunitofmeasureforthe
calculateddose.
an
TimeZoneDifference
Quantity
an
TimeZoneIdentifier
an
Thetimezonedifference
quantityisHHMMoffsetfrom
theCoordinatedUniversalTime
(UTC).
Definesthetimezoneusedby
thesender.
QualifiedbyTimePeriodBasisQualifier.
SeeECL
SeeECL
- 154 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
TimingClarifyingFre
eText
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
UsedtoaddclaritytotheTiming
codified.
x(255)
255
To
Theidentificationnumberofthe
receiver.
an
S,Q
TotalAmountBrandP
enalty
Thetotalamountofpenaltyby
allplansinvolvedforthe
selectionofabrandnamedrug.
an
VALUES
COMMENTS/EXAMPLES
QualifiedbyAddressTypeQualifier.
amountexchanged.
=Negativesign
.=Decimalpoint
wouldreflect:5.5
- 155 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
59F9
TotalAmountPaid
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
S9(6)v99
_________
S9(8)v99
T,E
_________
8
_________
DEFINITIONOFFIELD
Totalamounttobepaidbythe
claimsprocessor(i.e.pharmacy
receivable).Representsasumof
IngredientCostPaid(56F6),
DispensingFeePaid(57F7),
FlatSalesTaxAmountPaid
(558AW),PercentageSalesTax
AmountPaid(559AX),
IncentiveAmountPaid(521FL),
ProfessionalServiceFeePaid
(562J1),OtherAmountPaid
(565J4),lessPatientPay
Amount(55F5)andOther
PayerAmountRecognized(566
J5).
VALUES
COMMENTS/EXAMPLES
ForTandE:Comments:Format=s$$$$$$cc
reflect:55{
PrescriptionResponseFormula:
IngredientCostPaid(56F6)
+DispensingFeePaid(57F7)
+IncentiveAmountPaid(521FL)
+OtherAmountPaid(565J4)
+FlatSalesTaxAmountPaid(558AW)
+PercentageSalesTaxAmountPaid(559AX)
OtherPayerAmountRecognized(566J5)
=TotalAmountPaid(59F9)
ServiceResponseFormula:
ProfessionalServiceFeePaid(562J1)
+FlatSalesTaxAmountPaid(558AW)
+PercentageSalesTaxAmountPaid(559AX)
+OtherAmountPaid(565J4)
OtherPayerAmountRecognized(566J5)
=TotalAmountPaid(59F9)
amounts.
894
TotalAmountPaid
ByAllSources
Totalamountoftheprescription
regardlessofpartyresponsible
forpayment.
s9(6)v99
979JT
TotalErrors
Totalnumberoferrorsforentire
file.Somerowscouldhavemore
thanoneerror.
9(1)
693
TotalGrossAmount
Due
Totalsumofthegrossamount
duefieldsontheclaimlevel.
s9(1)v99
12
TotalNetAmount
Due
SummarizationofNetAmount
Due(281).
s9(1)v99
895
Format=s$$$$$$cc
reflect:55{
reflect:55{
A
12
reflect:55{
- 156 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
TotalNumberOfEnc
ountersApproved
Numberofencountersapproved
forthisTypeOfServiceCode
withintheEffectiveDateand
ExpirationDate.
9(4)
613
TotalNumberof
Formularies
TotalnumberofFOrecordsin
thesubmission.
9(9)b
or9(9)
Format=999999999bor999999999
TotalNumberOf
Plans
TotalnumberofPDrecordsin
thesubmission.
9(9)b
or9(9)
TotalNumberOf
Prescriptions
Valueistotalnetnumberof
prescriptions.
9(7)b
or9(7)
618
614
Note
b=Space
=NegativeSign
1
Format=999999999bor999999999
Note
b=Space
=NegativeSign
Format=9999999bor9999999
Forsummarylevelrecordsonly
Note
b=Space
=NegativeSign
63SJ
TotalNumberOf
SendingAnd
ReceivingPharmacy
Records
TotalnumberofPrescription
Detailinformation.
9(8)
ForPrescriptionTransfer,recordcountofsegment
"RX"(PrescriptionDetailRecord)records,including
thecorresponding"SR"(Sending&Receiving
PharmacyRecord)and"ST"(Sending&Receiving
PharmacyTotalRecord)records.
TotalNumberPackag
es
Thetotalnumberofpackages
includedintheCentralFillOrder.
TotalNumberVials
Thetotalnumberofprescription
vialsincludedintheCentralFill
Order.
694
TotalPatientPay
Amount
Totalsumofthepatientpay
amountfieldsontheclaimlevel.
s9(1)v99
12
TotalQuantity
Totalquantitybeingsubmitted.
9(11)v999b
or
9(11)v999
6139
reflect:55{
R,J
15
- 157 April215
Format=99999999999v999bor99999999999v999
Note
b=Space
=NegativeSign
DATA DICTIONARY
FIELD
619
NAMEOFFIELD
DEFINITIONOFFIELD
TotalRecordCount
Totalnumberofrecordsbeing
submitted,includingheaderand
trailer.
FIELD
FORMAT
9(1)b
or9(1)
________
9(1)
STANDARD
FORMATS
R,J
A,V,X,L
FIELD
LENGTH
11
_______
1
VALUES
COMMENTS/EXAMPLES
ForRebates:
Format=9999999999bor9999999999
Note
b=Space
=NegativeSign
ForPostAdjudication:
Comments:Includeheaderandtrailerincount.
Forotherstandards:
Format=9999999999
978JS
TotalRecords
TotalRecordsProcessed
9(1)
F,Y
Comments:Donotincludethefileheaderand
trailerinthiscount.TotalRecordsinfileminus2.
98JU
TotalRowsInError
Numberofrowsinfilethathave
errors
9(1)
ToteBarcode
Barcoderepresentationforthe
shippingtote.
an
13A3
TransactionCode
transaction.
x(2)
T,N
SeeECL
19A9
TransactionCount
Countoftransactionsinthe
transmission.
x(1)
T,N
SeeECL
Comments:Atransactioncountof>1isnot
allowedforEligibilityandPriorAuthorization
transactions.
TransactionDomain
businessdomainschemaisbeing
used.
an
S,Q
SeeECL
TransactionErrorCo
de
an
S,Q
SeeECL
896
TransactionID
Internallyassigneduniqueclaim
IDbythepayer.
x(3)
A,I
651S2
Transaction
Identifier
x(21)
21
Theuniquevalueassignedbythe
Facilitatorthatrelatesthe
Inquiry,Exchange(s),andUpdate
transactionstoeachother.
TransactionIDCross
Reference
Foradjustments,IDassociated
withoriginalclaim.
x(3)
A,I
897
- 158 April215
DATA DICTIONARY
FIELD
88K5
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
Transaction
ReferenceNumber
Areferencenumberassignedby
theprovidertoeachofthedata
recordsinthebatchorrealtime
transactions.Thepurposeofthis
numberistofacilitatethe
processofmatchingthe
transactionresponsetothe
transaction.Thetransaction
referencenumberassigned
shouldbereturnedinthe
response.
x(1)
STANDARD
FORMATS
T,B
FIELD
LENGTH
1
VALUES
COMMENTS/EXAMPLES
Comments:Tobeassignedbyprovider.
112AN
Transaction
ResponseStatus
Codeindicatingthestatusofthe
transaction.
x(1)
T,N,E,I
TransactionStandar
d
standardincludedwithina
payloadenvelope.
an
TransactionVersion
Elementdefinestheversionof
theTransactionDomainschema
isbeingused.
an
S,Q
SeeECL
631SK
TransferFlag
Indicatesprevioustransfer
historyoftheprescription.
x(1)
SeeECL
Comments:Valueisfromsendingpharmacy's
perspective.Indicateswhetherprescriptionhas
beentransferredornot.
TransferRequest
Indicatestheprescriptions
requestedtobetransferred.
an
SeeECL
SeeECL
SeeECL
Comments:Ifacodevalueotherthanstatedis
submitted,theWSDLcontainsthespecificSOAP
fault.
TransferType
Indicateswhethertherequesting
orsourcepharmacy.
an
SeeECL
632SM
TransferType
Indicatesfilecontent.
x(1)
SeeECL
981JV
TransmissionAction
Indicateswhetherthisisa
replacementfile,fileupdatesor
afiledelete
x(1)
F,A
SeeECL
6156
Transmission
ControlNumber
wholetransmission.
x(9)
x(1)
- 159 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
611
TransmissionDate
DEFINITIONOFFIELD
Datethefilewascreated.
FIELD
FORMAT
9(8)
STANDARD
FORMATS
R,F,J,E,I
FIELD
LENGTH
8
VALUES
COMMENTS/EXAMPLES
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
982JW
986KJ
TransmissionDate
Originating
Dateoriginalincomingfilewas
created.
9(8)
TransmissionFile
Type
Identifierofthefiletype
x(3)
_________
F,E
__________
3
_________
x(2)
Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
SeeECL
B85
TransmissionID
Uniqueidentifierforthe
transmission.
x(5)
983JX
Transmission
NumberOriginating
Transmissionnumberofthe
originalincomingfileprocessed
x(1)
984JY
TransmissionTime
Timethefilewascreated
9(8)
F,I
Format=HHMMSSDD
985JZ
Format=HHMMSSDD
TransmissionTime
Originating
Timeoriginalincomingfilewas
created.
9(8)
88K6
TransmissionType
Avaluetodefinethetypeof
transmissionbeingsent.
x(1)
B,E,I
SeeECL
TransportVersion
transportschemaisbeingused.
an
S,Q
SeeECL
TriggerText
TriggerTextCode.Theeventthat
indicatesthecompletionofthe
durationofuseorreasontostop.
an
TriggerTextCode
TriggerText.
an
QualifiedbyTriggerTextQualifier.
TriggerTextQualifier
systembeingused
an
SeeECL
- 160 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
A94
TypeOfFile
ThetypeofUniformHealthcare
PayerDataStandardRecord.
x(2)
SeeECL
TypeOfServiceCode
Coderepresentingtheservice.
an
QualifiedbyTypeOfServiceCodeQualifier.
TypeOfServiceCode
Qualifier
systembeingusedfor
TypeOfServiceCode.
an
SeeECL
TypeOfServiceFreeT
ext
serviceidentifieddoesnothavea
codelist(TypeOfServiceCode).
an
TypeOfServiceGrou
pSetting
an
SeeECL
Clarifieswhetherthe
TypeOfServiceistobeconducted
inagroupsetting.
TypeOfServiceText
TypeOfServiceCode.
an
UCUMVersion
TheversionofTheUnifiedCode
forUnitsofMeasure(UCUM)
beingused.
an
B3
UniqueBenefit
OptionIdentifier
RetireeDrugSubsidyPlan
SponsorassignedIDtoidentifya
specificbenefitdesign.
x(2)
634SP
UniqueRecord
Identifier
IDassignedthatmakesthis
recordunique.
x(3)
QualifiedbyUniqueRecordIdentifierQualifier
(635SQ).
635SQ
UniqueRecord
IdentifierQualifier
CodequalifyingUniqueRecord
Identifier(634SP).
x(2)
SeeECL
QualifiesUniqueRecordIdentifier(634SP)
UnitOfMeasure
Adivisionofquantityacceptedas
astandardofmeasurement.
an
SeeECL
628
UnitOfMeasure
NCPDPstandardproductbilling
codes.
x(2)
R,T,A,W,J
SeeECL
UnitOfUse
Indicatortheproductrequires
specialquantityconsideration.
BooleanCod
e
SeeECL
- 161 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
UpperBoundCompa
risonOperator
Codethatconveysthe
andadefinedupperboundary.
an
SeeECL
UpperBoundCompa
risonValue
Valuefortheupperboundaryof
thecomparison.
9(18)
18
987MA
URL
Thewebpageaddress.
x(255)
F,T
255
898
UserBenefitID
MembersbenefitIDbasedupon
UserGroupNumberfrom
Eligibilitywhensubmittedby
Client.
x(1)
899
UserCoverageID
MemberscoverageIDbased
uponUserGroupNumber
submittedbyClientoneligibility
data.
x(1)
Username
theuser.SOAP.
n/a
S,Q
426DQ
Usualand
CustomaryCharge
Amountchargedcashcustomers
fortheprescriptionexclusiveof
salestaxorotheramounts
claimed.
s9(6)v99
T,A,,W,Z
Format=s$$$$$$cc
VariableAdministrati
onTimingModifier
morethanonetimeasto
whetherthetimesareall
requiredtobeused(AND)orif
anyofthetimescanbeused
(OR).(TO)isusedifthe
AdministrationTimingprovides
forarange.
an
VariableFrequency
Modifier
morethanoneFrequencyasto
whetherthefrequenciesareall
anyofthefrequenciescanbe
used(OR/TO).
an
VariableIntervalMo
difier
morethanoneIntervalasto
whethertheintervalsareall
an
Examples:Iftheusualandcustomarychargeis
$32.56,thisfieldwouldreflect:325F.
SeeECL
SeeECL
SeeECL
- 162 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
anyoftheintervalscanbeused
(OR/TO).
Vehicle
VehicleCode.
an
VehicleClarifyingFre
eText
Usedtoaddclaritytothevehicle
codified.
x(255)
255
VehicleCode
VehicleText.
an
QualifiedbyVehicleQualifier
VehicleQualifier
systembeingused.
an
VehiclePrepositionC
ode
VehiclePrepositionText.
an
QualifiedbyVehiclePrepositionQualifier.
VehiclePrepositionQ
ualifier
systembeingused.
an
SeeECL
VehiclePrepositionT
ext
VehiclePrepositionCode.
x(255)
255
VehicleQuantity
Avolume,expressedinavalue.
9(18)
18
VehicleUnitOfMeas
ureCode
VehicleUnitOfMeasureText.
an
QualifiedbyVehicleUnitOfMeasureQualifier.
VehicleUnitOfMeas
ureQualifier
systembeingused.
an
VehicleUnitOfMeas
ureText
VehicleUnitOfMeasureCode.
an
VerifyStatusCode
an
S,Q
Version
AversionfortheContinuityof
CareRecord(CCR)supported.
x(35)
35
12A2
Version/Release
Number
Codeuniquelyidentifyingthe
transmissionsyntaxand
correspondingDataDictionary.
x(2)
A,B, T,F,G,
N,V,X,E,Y,L,I
SeeECL
SeeECL
SeeECL
SeeECL
- 163 April215
DATA DICTIONARY
FIELD
A451R
NAMEOFFIELD
VeterinaryUse
Indicator
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
Toindicatethattheprescription
wasdispensedforuseon
somethingotherthanhuman.
x(1)
SeeECL
Physicalconditionidentifier.
an
SeeECL
QualifiestheMeasurementvalue.
VitalSign
6215
WithheldInvoice
Amount
TheDisputedQuantity(6185)
timesthePaidPerUnitAmount
(6195).
Workers
Compensation/Prop
ertyAndCasualty
Indicator
Codeidentifyingwhetherthe
submissionisforWorkers'
CompensationorProperty&
Casualty.
WorkTelephoneExte
nsion
Extensionoftheworktelephone
number.
WorkTelephoneNu
mber
WorkTelephoneSup
portsSMS
588
9(9)v99b
or
9(9)v99
x(2)
12
Note:
b=Space
=Negativesign
SeeECL
9(8)
S,Q
Format=99999999
Worktelephonenumberofthe
entity.
9(1)
S,Q
textmessages.
BooleanCod
e
S,Q
SeeECL
Dateordateandtimeissued.
xsd:dateor
xsd:datetim
e
Format=AAAEEENNNN
AAA=AreaCode
EEE=ExchangeCode
NNNN=Number
WrittenDate
DateFormat=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Example:2111
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
- 164 April215
DATA DICTIONARY
FIELD
NAMEOFFIELD
DEFINITIONOFFIELD
FIELD
FORMAT
STANDARD
FORMATS
FIELD
LENGTH
VALUES
COMMENTS/EXAMPLES
X59Data
Base64encodedrawbytesofthe
X59certificate(whichcontains
thePublicKey).Usedbythe
receivertovalidatethedigital
signature.
an
B63J
YearofLastPaid
Claim
Identifiestheyearusedona
previousclaim.
9(4)
Format=CCYYCC=CenturyYY=Year
ZipCode
postalzoneexcluding
punctuationandblanks.
an
S,Q
73TC
Zip/PostalCode
postalcodeexcluding
punctuation.
x(15)
R,A,V,Y
15
Comments:
located.
98765leftjustified.
Examples:
A0E3B0
A1L2T8
- 165 April215
DATA DICTIONARY
III.
AppendixANUMERICCROSSREFERENCEFORDATAELEMENTSWITHNUMERICIDENTIFIERS
(Fieldsinlowlighthavebeendeletedbutaremaintainedinthenumericcrossreferencetableforhistoricpurposes)
NUMERICCROSSREFERENCE
NameOfField
Field
Standard
Formats
NameOfField
Field
Standard
Formats
11A1
BINNumber
T,N,Z,E
13UF
AdditionalMessageInformationCount
12A2
Version/ReleaseNumber
B,T,F,A,N,V,X,E,Y,L,G,
I
131UG
AdditionalMessageInformationContinuity
13A3
TransactionCode
T,N
14A4
ProcessorControlNumber
T,N,V,Z,E
19A9
TransactionCount
T,N
11AK
SoftwareVendor/CertificationID
T,N
111AM
SegmentIdentification
T,N
112AN
TransactionResponseStatus
T,N,E,I
113N3
MedicaidPaidAmount
T,G
114N4
MedicaidSubrogationInternalControl
Number/TransactionControlNumber(ICN/TCN)
T,G
115N5
MedicaidIDNumber
T,G
116N6
MedicaidAgencyNumber
117TR
132UH
AdditionalMessageInformationQualifier
133UJ
AmountAttributedtoProviderNetworkSelection
T,Y
134UK
AmountAttributedtoProductSelection/BrandDrug
T,Y,I
135UM
AmountAttributedtoProductSelection/NonPreferred
FormularySelection
T,Y
136UN
AmountAttributedtoProductSelection/BrandNon
PreferredFormularySelection
T,Y
137UP
AmountAttributedtoCoverageGap
T,Y
138UQ
CMSLowIncomeCostSharing(LICS)Level
139UR
MedicarePartDCoverageCode
14US
NextMedicarePartDEffectiveDate
T,G
141UT
NextMedicarePartDTerminationDate
BillingEntityTypeIndicator
142UV
OtherPayerPersonCode
118TS
PayToQualifier
T,W
143UW
OtherPayerPatientRelationshipCode
119TT
PayToID
T,W
144UX
OtherPayerBenefitEffectiveDate
12TU
PayToName
T,W
145UY
OtherPayerBenefitTerminationDate
121TV
PayToStreetAddress
T,W
146
PharmacyDispenserTypeQualifier
122TW
PayToCityAddress
T,W
147U7
PharmacyServiceType
T,R
123TX
PaytoState/ProvinceAddress
T,W
148U8
IngredientCostContracted/ReimbursableAmount
124TY
PayToZip/PostalZone
T,W
149U9
DispensingFeeContracted/ReimbursableAmount
125TZ
GenericEquivalentProductIDQualifier
15VF
InvoicedAmount1
126UA
GenericEquivalentProductID
151VG
InvoicedAmount2
127UB
OtherPayerHelpDeskTelephoneNumber
152VH
InvoicedAmount3
128UC
SpendingAccountAmountRemaining
153VJ
InvoicedAmount4
129UD
HealthPlanfundedAssistanceAmount
T,Y
154VK
InvoicedAmount5
- 166 April215
DATA DICTIONARY
NameOfField
Field
155VL
InvoicedPerUnitAmount1
Standard
Formats
NameOfField
Field
Standard
Formats
185WT
PaidPerUnitAmount1
156VM
186WU
PaidPerUnitAmount2
157VN
187WV
PaidPerUnitAmount3
158VP
188WW
PaidPerUnitAmount4
159VQ
189WX
PaidPerUnitAmount5
16VR
InvoicePrice1
19WY
PaidQuantity1
161VS
InvoicePrice2
191WZ
PaidQuantity2
162VT
InvoicePrice3
192XA
PaidQuantity3
163VU
InvoicePrice4
193XB
PaidQuantity4
164VV
InvoicePrice5
194XC
PaidQuantity5
165VW
InvoiceRate1
195XD
PaidRate1
166VX
InvoiceRate2
196XF
PaidRate2
167VY
InvoiceRate3
197XG
PaidRate3
168VZ
InvoiceRate4
198XH
PaidRate4
169WA
InvoiceRate5
199XJ
PaidRate5
17WB
InvoiceType1
21B1
ServiceProviderID
T,A,R,V,Z,W,X,J,E,Y,I
171WC
InvoiceType2
22B2
ServiceProviderIDQualifier
T,A,R,V,Z,W,X,J,E,Y,I
172WD
InvoiceType3
23
AdjudicationTime
A,R
173WF
InvoiceType4
24
AdjustmentReasonCode
A,I
174WG
InvoiceType5
25
AdjustmentType
175WH
PaidAmount1
26
AdministrativeFeeAmount
176WJ
PaidAmount2
27
AdministrativeFeeEffectIndicator
177WK
PaidAmount3
28
Age
178WL
PaidAmount4
29
AverageCostPerQuantityUnitPrice
179WM
PaidAmount5
21
AverageGenericUnitPrice
18WN
PaidBasePrice1
211
AverageWholesaleUnitPrice
181WP
PaidBasePrice2
212
BenefitType
A,I
182WQ
PaidBasePrice3
213
BillingCycleEndDate
183WR
PaidBasePrice4
214
CardholderDateofBirth
184WS
PaidBasePrice5
215
CarrierNumber
A,I
- 167 April215
DATA DICTIONARY
NameOfField
Field
216
CheckDate
217
218
Standard
Formats
NameOfField
Field
Standard
Formats
A,Y
248
EligibleCoverageCode
ClaimDateReceivedInTheMail
249
ExcessCopayAmount
ClaimMediaType
25
FDADrugEfficacyCode
219
ClaimSequenceNumber
A,E
251
FederalUpperLimitIndicator
22
ClientAssignedLocationCode
252
FederalDEASchedule
A,E
221
ClientFormularyFlag
253
FederalUpperLimitUnitPrice
222
ClientPassThrough
A,I
254
FillNumberCalculated
A,Y
223
ClientPricingBasisOfCost
255
FormularyCodeType
224
ClientSpecificData
256
FormularyFileID
225
COBCarrierSubmitAmount
257
FormularyStatus
A,I
226
COBPrimaryClaimType
26
GenericIndicator
228
COBPrimaryPayerAmountPaid
261
GenericName
229
COBPrimaryPayerCoinsurance
263
HealthCareReimbursementAccountAmountApplied
23
COBPrimaryPayerCopay
264
231
COBPrimaryPayerDeductible
Remaining
232
COBPrimaryPayerID
265
HoldHarmlessAmount
234
COBSecondaryPayerAmountPaid
266
InNetworkIndicator
A,I
235
COBSecondaryPayerCoinsurance
267
InsuranceCode
A,I
236
COBSecondaryPayerCopay
268
InternalMailOrder(Prescription/Service)Reference
Number
237
COBSecondaryPayerDeductible
269
InvoicedAmount
A,I
238
COBSecondaryPayerID
27
LineOfBusinessCode
239
CommunicationTypeIndicator
271
MACPrice
24U1
ContractNumber
A,T,I
272
MACReducedIndicator
241
CopayModifierID
273
MaintenanceDrugIndicator
242
CostDifferenceAmount
274
MedicarePlanCode
243
DosageFormCode
275
MedicareRecoveryDispensingIndicator
244
DrugCategoryCode
276
MedicareRecoveryIndicator
245
EligibilityCOBIndicator
277
MemberSubmitAmount
246
EligibilityGroupID
A,Y
278
MemberSubmittedClaimPaymentReleaseDate
247
Eligibility/PatientRelationshipCode
A,Y
- 168 April215
DATA DICTIONARY
NameOfField
Field
Standard
Formats
NameOfField
Field
Standard
Formats
279
MemberSubmittedClaimProgramCode
311CB
PatientLastName
T,V,Z,W,X,I
28
NameSuffix
312CC
CardholderFirstName
T,V,Z
281
NetAmountDue
A,Z,W,Y
313CD
CardholderLastName
T,V,Z,I
282
NonPOSClaimOverrideCode
314CE
HomePlan
283
OriginalClaimReceivedDate
315CF
EmployerName
T,W
284
OutOfPocketApplyAmount
316CG
EmployerStreetAddress
285
PatientMedicareFormularyRebateAmount
317CH
EmployerCityAddress
T,W
286
PatientSpendDownAmount
318CI
EmployerState/ProvinceAddress
T,W
287
Payment/ReferenceID
319CJ
EmployerZip/PostalZone
T,W
288
PayrollClass
32CK
EmployerTelephoneNumber
T,W
289
PharmacyClassCode
321CL
EmployerContactName
T,W
29
PharmacyDispenserType
322CM
PatientStreetAddress
T,W
291
PlanBenefitCode
323CN
PatientCityAddress
T,W
292
PlanCutbackReasonCode
324CO
PatientState/ProvinceAddress
T,W,I
293
PreferredAlternativeFileID
325CP
PatientZip/PostalZone
T,W
294
PrescribedDaysSupply
326CQ
PatientPhoneNumber
T,W
295
PrescriberCertificationStatus
327CR
CarrierID
296
PrescriberTaxonomyCode
33CW
AlternateID
297
PrescriptionOverTheCounterIndicator
331CX
PatientIDQualifier
T,A,V,W,X
299
ProcessorDefinedPriorAuthorizationReasonCode
332CY
PatientID
T,A,V,W,X,Y,I
31C1
GroupID
R,T,A,N,V,Z,X,E,I
333CZ
EmployerID
32C2
CardholderID
T,A,N,V,Z,X,Y,I
3341C
Smoker/NonSmokerCode
T,V
33C3
PersonCode
R,T,A,N,V,Z,X,Y,I
3352C
PregnancyIndicator
T,V
34C4
DateOfBirth
T,A,V,Z,W,X,Y,L,I
3368C
FacilityID
T,A,V
35C5
PatientGenderCode
T,A,V,Z,W,X,Y,I
3374C
CoordinationOfBenefits/OtherPaymentsCount
36C6
PatientRelationshipCode
T,A,V,Z,X,I
3385C
OtherPayerCoverageType
37C7
PlaceofService
T,Z,J
3396C
OtherPayerIDQualifier
T,V,Z,W
38C8
OtherCoverageCode
T,A,R,Z,W
347C
OtherPayerID
T,V,Z,W
39C9
EligibilityClarificationCode
T,A
341HB
OtherPayerAmountPaidCount
31CA
PatientFirstName
T,V,Z,W,X,I
342HC
OtherPayerAmountPaidQualifier
- 169 April215
DATA DICTIONARY
NameOfField
Field
Standard
Formats
NameOfField
Field
Standard
Formats
343HD
DispensingStatus
T,A,R
3742V
RequestPeriodBeginDate
344HF
QuantityIntendedToBeDispensed
T,A
3752W
RequestPeriodRecert/RevisedDate
345HG
DaysSupplyIntendedToBeDispensed
T,A
3762X
SupportingDocumentation
346HH
BasisofCalculationDispensingFee
T,A
3772Z
QuestionNumber/LetterCount
347HJ
BasisofCalculationCopay
T,A
3784B
QuestionNumber/Letter
348HK
BasisofCalculationFlatSalesTax
T,A
3794D
QuestionPercentResponse
349HM
BasisOfCalculationPercentageSalesTax
T,A
384G
QuestionDateResponse
35HN
PatientEMailAddress
T,V
3814H
QuestionDollarAmountResponse
351NP
OtherPayerPatientResponsibilityAmountQualifier
T,A
3824J
QuestionNumericResponse
352NQ
T,A,Z,W
3834K
QuestionAlphanumericResponse
353NR
3844X
PatientResidence
T,V
354NX
SubmissionClarificationCodeCount
3853Q
FacilityName
T,V
355NT
OtherPayerIDCount
T,V
3873V
FacilityState/ProvinceAddress
356NU
OtherPayerCardholderID
3885J
FacilityCityAddress
357NV
DelayReasonCode
T,Z,W
3896D
FacilityZip/PostalZone
3592A
MedigapID
39BM
NarrativeMessage
362B
MedicaidIndicator
391MT
3612D
ProviderAcceptAssignmentIndicator
PatientAssignmentIndicator(DirectMember
ReimbursementIndicator)
3622G
CompoundIngredientModifierCodeCount
392MU
BenefitStageCount
3632H
CompoundIngredientModifierCode
393MV
BenefitStageQualifier
T,R
394MW
3642J
PrescriberFirstName
T,W
BenefitStageAmount
3652K
PrescriberStreetAddress
T,W
395
ProcessorPaymentClarificationCode
3662M
PrescriberCityAddress
T,W
396
ProcessorSpecificData
397
Product/ServiceName
A,Y,I
398
RecordIndicator
399
RecordStatusCode
A,Y
41D1
DateOfService
R,T,A,V,Z,W,J,E,Y,I
42D2
Prescription/ServiceReferenceNumber
R,T,A,V,Z,W,X,J,E
43D3
FillNumber
T,A,R,V,Z,W,J,E
45D5
DaysSupply
R,T,A,V,Z,W,X,Y,I
3672N
PrescriberState/ProvinceAddress
T,W
3682P
PrescriberZip/PostalZone
T,W
3692Q
AdditionalDocumentationTypeID
372R
LengthofNeed
3712S
LengthofNeedQualifier
3722T
Prescriber/SupplierDateSigned
3732U
RequestStatus
- 170 April215
DATA DICTIONARY
NameOfField
Field
Standard
Formats
NameOfField
Field
Standard
Formats
46D6
CompoundCode
T,A,R,V,Y
442E7
QuantityDispensed
T,A,V,Z,W,Y,I
47D7
Product/ServiceID
T,F,A,R,V,Z,W,X,J,Y,E,
I
443E8
OtherPayerDate
T,Z,W
444E9
ProviderID
T,Z
445EA
OriginallyPrescribedProduct/ServiceCode
T,V
446EB
OriginallyPrescribedQuantity
447EC
CompoundIngredientComponentCount
T,Z,W
448ED
CompoundIngredientQuantity
T,A,Z,W
449EE
CompoundIngredientDrugCost
T,A,Z,W
45EF
CompoundDosageFormDescriptionCode
T,Z,W
451EG
CompoundDispensingUnitFormIndicator
T,Z,W
453EJ
OriginallyPrescribedProduct/ServiceIDQualifier
T,V
454EK
ScheduledPrescriptionIDNumber
455EM
T,A,R,Z,W,X,J,E
456EN
AssociatedPrescription/ServiceReferenceNumber
T,A
457EP
AssociatedPrescription/ServiceDate
T,A
458SE
ProcedureModifierCodeCount
459ER
ProcedureModifierCode
T,Z,W
48D8
DispenseAsWritten(DAW)/ProductSelectionCode
R,T,A,V,Z,W,Y,I
49D9
IngredientCostSubmitted
T,A,Z,W
411DB
PrescriberID
R,T,A,V,Z,W,X,J,Y,E
412DC
DispensingFeeSubmitted
T,Z,W
414DE
DatePrescriptionWritten
T,A,V,Z,W
415DF
NumberOfRefillsAuthorized
T,A,V
418DI
LevelOfService
T,A
419DJ
PrescriptionOriginCode
T,A,R
42DK
SubmissionClarificationCode
T,A,Z,W,E
421DL
PrimaryCareProviderID
T,A
423DN
BasisOfCostDetermination
T,Z,W
424DO
DiagnosisCode
R,T,F,A,Z,J
425DP
DrugType
A,X,Y
426DQ
UsualAndCustomaryCharge
T,A,Z,W
427DR
PrescriberLastName
T,Z,W
429DT
SpecialPackagingIndicator
T,A
43DU
GrossAmountDue
T,A,Z,W,Y,I
431DV
OtherPayerAmountPaid
T,Z,W
433DX
PatientPaidAmountSubmitted
T,Z,W
434DY
DateOfInjury
T,A,W
435DZ
Claim/ReferenceID
T,A,W
436E1
Product/ServiceIDQualifier
T,F,A,R,V,Z,W,X,J,Y
,E,I
438E3
439E4
ReasonForServiceCode
T,A,Z,W
44E5
ProfessionalServiceCode
T,A,Z,W
441E6
ResultOfServiceCode
T,A,Z,W
46ET
QuantityPrescribed
T,A,V
461EU
PriorAuthorizationTypeCode
T,A,Z,W
462EV
PriorAuthorizationNumberSubmitted
T,A,V,Z,W,X
463EW
IntermediaryAuthorizationTypeID
464EX
IntermediaryAuthorizationID
465EY
ProviderIDQualifier
T,Z
466EZ
PrescriberIDQualifier
T,A,R,V,Z,W,X,J,Y,E
4682E
PrimaryCareProviderIDQualifier
T,A
474E
PrimaryCareProviderLastName
4715E
OtherPayerRejectCount
4726E
OtherPayerRejectCode
T,Z,W
4737E
DUR/PPSCodeCounter
4748E
DUR/PPSLevelOfEffort
T,A,Z,W
- 171 April215
DATA DICTIONARY
NameOfField
Field
475J9
DURCoAgentIDQualifier
476H6
477BE
Standard
Formats
NameOfField
Field
AuthorizedRepresentativeState/ProvinceAddress
Standard
Formats
T,A,S
498PJ
DURCoAgentID
T,A
498PK
AuthorizedRepresentativeZip/PostalZone
ProfessionalServiceFeeSubmitted
T,A
498PM
PrescriberTelephoneNumber
T,W
478H7
OtherAmountClaimedSubmittedCount
498PP
PriorAuthorizationSupportingDocumentation
479H8
OtherAmountClaimedSubmittedQualifier
498PR
PriorAuthorizationProcessedDate
48H9
OtherAmountClaimedSubmitted
T,Z,W
498PS
PriorAuthorizationEffectiveDate
T,X
481HA
FlatSalesTaxAmountSubmitted
T,Z,W
498PT
PriorAuthorizationExpirationDate
T,X
482GE
PercentageSalesTaxAmountSubmitted
T,Z,W
498PW
PriorAuthorizationNumberOfRefillsAuthorized
T,X
483HE
PercentageSalesTaxRateSubmitted
498PX
PriorAuthorizationQuantityAccumulated
T,X
484JE
PercentageSalesTaxBasisSubmitted
498PY
PriorAuthorizationNumberAssigned
T,X
485KE
CouponType
498RA
PriorAuthorizationQuantity
T,X
486ME
CouponNumber
498RB
PriorAuthorizationDollarsAuthorized
487NE
CouponValueAmount
499H4
MeasurementValue
488RE
CompoundProductIDQualifier
T,A,Z,W
51F1
HeaderResponseStatus
T,N,E
489TE
CompoundProductID
T,A,Z,W
53F3
AuthorizationNumber
T,A,N,E
49UE
CompoundIngredientBasisOfCostDetermination
T,A,Z,W
54F4
Message
B,T,N,E,Y,I
491VE
DiagnosisCodeCount
55F5
PatientPayAmount
T,A,Y,I
492WE
DiagnosisCodeQualifier
T,F,A,Z,J
56F6
IngredientCostPaid
T,A,Y
493XE
ClinicalInformationCounter
57F7
DispensingFeePaid
T,A,Y
494ZE
MeasurementDate
59F9
TotalAmountPaid
T,E,I
495H1
MeasurementTime
51FA
RejectCount
B,T,N
496H2
MeasurementDimension
511FB
RejectCode
T,F,A,N,V,E,I
497H3
MeasurementUnit
512FC
AccumulatedDeductibleAmount
T,A
498PA
RequestType
513FD
RemainingDeductibleAmount
T,A
498PB
RequestPeriodDateBegin
514FE
RemainingBenefitAmount
T,A
498PC
RequestPeriodDateEnd
T,A
516FG
DrugDescription
R,V
498PD
BasisOfRequest
517FH
AmountAppliedToPeriodicDeductible
T,A,Y
498PE
AuthorizedRepresentativeFirstName
518FI
AmountOfCopay/Coinsurance
T,A,Y,I
498PF
AuthorizedRepresentativeLastName
519FJ
AmountAttributedToProductSelection
A,Y
498PH
AuthorizedRepresentativeCityAddress
52FK
AmountExceedingPeriodicBenefitMaximum
T,A,Y
- 172 April215
DATA DICTIONARY
NameOfField
Field
Standard
Formats
NameOfField
Field
Standard
Formats
521FL
IncentiveAmountPaid
T,A,Y
563J2
OtherAmountPaidCount
522FM
BasisOfReimbursementDetermination
T,A
564J3
OtherAmountPaidQualifier
T,A,Y
523FN
AmountAttributedToSalesTax
T,A,Y,I
565J4
OtherAmountPaid
T,A,Y
524FO
PlanID
566J5
OtherPayerAmountRecognized
T,A
526FQ
T,F,N,V,X
567J6
DUR/PPSResponseCodeCounter
528FS
ClinicalSignificanceCode
568J7
PayerIDQualifier
T,V
529FT
OtherPharmacyIndicator
569J8
PayerID
T,V,Y
53FU
PreviousDateOfFill
T,X
57NS
DURAdditionalText
531FV
QuantityOfPreviousFill
571NZ
AmountAttributedtoProcessorFee
T,A,Y,I
532FW
DatabaseIndicator
T,A
5724U
AmountofCoinsurance
T,A,Y
533FX
OtherPrescriberIndicator
5734V
BasisofCalculationCoinsurance
T,A
544FY
DURFreeTextMessage
5742Y
PlanSalesTaxAmount
5452F
NetworkReimbursementID
T,A
575EQ
PatientSalesTaxAmount
5464F
RejectFieldOccurrenceIndicator
577G3
EstimatedGenericSavings
5475F
ApprovedMessageCodeCount
578
AdjudicationDate
A,R,J,Y
5486F
ApprovedMessageCode
T,E
579XX
AssociatedPrescription/ServiceProviderIDQualifier
5497F
HelpDeskTelephoneNumberQualifier
58XY
AssociatedPrescription/ServiceProviderID
558F
HelpDeskTelephoneNumber
581XZ
PreferredProductCount
Qualifier
5519F
552AP
PreferredProductIDQualifier
582X
AssociatedPrescription/ServiceFillNumber
553AR
PreferredProductID
583YK
ServiceProviderName
554AS
PreferredProductIncentive
585YN
ServiceProviderCityAddress
555AT
PreferredProductCopayIncentive
586YP
ServiceProviderState/ProvinceCodeAddress
T,J
587YQ
ServiceProviderZip/PostalCode
588
Workers'Compensation/PropertyAndCasualtyIndicator
589
DateofBilling
59YT
SellerInitials
591YU
PurchaserIDQualifier
592YV
PurchaserID
593YW
PurchaserIDAssociatedState/ProvinceCode
556AU
PreferredProductDescription
557AV
TaxExemptIndicator
T,A
558AW
T,A,Y
559AX
PercentageSalesTaxAmountPaid
T,A,Y
56AY
PercentageSalesTaxRatePaid
T,A
561AZ
PercentageSalesTaxBasisPaid
T,A
562J1
T,A,Y
- 173 April215
DATA DICTIONARY
NameOfField
Field
Standard
Formats
NameOfField
Field
Standard
Formats
594YX
PurchaserDateofBirth
675
FormularyDescription
595YY
PurchaserGenderCode
676
FormularyNonFormularyCoPayConfidential
596YZ
PurchaserFirstName
677
FormularyProductCoPayAmount
597Y
PurchaserLastName
678
GenericProductCoPayAmount
599Y2
PurchaserCityAddress
679
HierarchicalLevelTerminology
628
UnitOfMeasure
R,T,A,W,J
68
MailOrderIDCode
638
RebatePeriodStartDate
R,J
681
MailOrderIDQualifier
639
RebatePeriodEndDate
R,J
682
MembershipCalculationMultiplier
643
ContractingOrganization(PMO)Name
R,J
683
MembershipCountQualifier
647
Manufacturer(PICO)ContractNumber
RJ
684
MembershipDependents
648
Manufacturer(PICO)IDCode
R,J
685
MembershipEnrollees
65
Manufacturer(PICO)Name
R,J
686
MembershipPeriodQualifier
657
AdjudicatorIDCode
687
MembershipReportingPeriodStartDate
658
AdjudicatorIDQualifier
688
MembershipTotalCount
659
AdjudicatorName
689
MembershipTypeQualifier
66
BrandedGenericCoPayConfidential
69
NonFormularyProductCoPayAmount
661
BrandedProductCoPayAmount
691
PlanAffiliationParentPlanID
662
CalculationMultiplier
692
PlanAffiliationParentPlanIDQualifier
663
ChangeDate
693
PlanDegreeManaged
664
ChangeIdentifier
R,F
694
PlanIDCode
R,J
665
ContractingOrganization(PMO)ContractNumber
R,J
695
PlanIDQualifier
R,J
666
ContractingOrganization(PMO)IDCode
R,J
696
PlanName
R,Z,J
667
ContractingOrganization(PMO)TotalLivesCovered
697
PlanTotalAdjudicatorsRecords
668
Dependents
698
PlanTotalFormularyBenefitDesignRecords
669
EligiblePlan
699
PlanTotalMailOrderRecords
67
Enrollees
611
PlanType
R,A
671
ContractingOrganization(PMO)IDQualifier
R,J
612
PlanTypeService
672
Manufacturer(PICO)IDQualifier
R,J
613
RebateVersionReleaseNumber
673
FormularyBenefitDesignType
614
RecordType
R,F,A,V,X,J,E,Y,L,I
674
FormularyCode
R,J
615
ReportingPeriodEndDate
R,A,Y
- 174 April215
DATA DICTIONARY
NameOfField
Field
Standard
Formats
NameOfField
Field
Standard
Formats
616
ReportingPeriodStartDate
R,A,Y
6136
SubmitCode
R,J
617
StartDate
6137
DataProviderIDQualifier
R,J
618
TotalNumberOfPlans
6139
TotalQuantity
R,J
619
TotalRecordCount
R,A,V,X,J,L
614
TotalNumberOfPrescriptions
611
TransmissionDate
R,F,J,E,I
6141
GrandTotalQuantity
R,J
6111
MailOrderName
6142
GrandTotalRequestedAmount
R,J
6112
CostIndexPointHighValue
6143
LineNumber
R,J
6113
CostIndexPointLowValue
6144
PatientLiabilityAmount
R,V,J
6114
DollarSignRating
6147
ReimbursementAmount
6115
FormularyManagerCompanyName
6148
ReimbursementQualifier
PrescriptionType
R,J
6116
FormularyManagerPersonName
6149
6117
FormularyProductCoPayConfidential
615
RebateBatchNumber
6118
ProductCode
A,X
6151
RebateDaysSupply
6119
ProductCodeQualifier
A,X
6152
RebatePerUnitAmount
612
ProductDescription
R,V,Z,W,J
6153
RecordPurposeIndicator
R,J
6121
ProductDosageForm
R,V
6154
ReimbursementDate
R,J
6122
ProductFormularyStatusCode
6155
RequestedRebateAmount
R,J
6123
ProductGenericName
6156
TransmissionControlNumber
R,F
ProductDailyConsumption
6124
ProductStrength
R,A,V,W
6158
6125
TherapeuticClassCode
R,A,J,I
6159
NumeratorIndicator
6126
TherapeuticClassCodeQualifier
R,A,J,I
616
NumberOfMarketProductRecords
6127
TherapeuticClassDescription
R,J
6161
MarketBasketTerminationDate
6128
TherapeuticUseCode
6162
MarketBasketStartDate
6129
TherapeuticUseDescription
6163
MarketBasketDescription
613
TotalNumberOfFormularies
6164
ContractingOrganization(PMO)MarketBasketCode
6131
DataLevel
R,J
6165
Manufacturer(PICO)MarketBasketCode
OriginatorIDCode
6132
DataProviderIDCode
R,J
6166
6133
DataProviderName
R,J
6167
OriginatorName
6134
DosageFormIDCode
6168
ClaimNumber
R,J
6135
EncryptedPatientIDCode
R,J
6169
TotalNumberOfMarketBasketRecords
- 175 April215
DATA DICTIONARY
NameOfField
Field
Standard
Formats
NameOfField
Field
Standard
Formats
617
AdjustedRebatePerUnit
63MY
AddressCount
6171
AdjustedQuantity
64NA
AddressQualifier
6172
AdjustedVarianceDifference
65NB
ClientName
V,X
6173
AmountPaidThisTransaction
66NC
DiscontinueDateQualifier
618
CurrentAmountPaidToDate
67ND
DiscontinueDate
6181
CurrentRebatePerUnit
68NF
EasyOpenCapIndicator
6182
CurrentUnitsDisputedToDate
69NG
EffectiveDate
6183
CurrentUnitsPaidToDate
61NH
ExpirationDate
6184
CurrentUnitsToDate
611NJ
FileStructureType
6185
DisputedQuantity
612NK
InactivePrescriptionIndicator
6186
AcceptedQuantity
613NM
LabelDirections
6187
GrandTotalAcceptedQuantity
614NW
MostRecentDateFilled
6188
GrandTotalPaidAmount
615NY
NumberOfFillsToDate
6189
InterestAmount
616PU
NumberOfFillsRemaining
6192
OriginalAmountInvoiced
617RQ
OriginalDispensedDate
6193
OriginalRebatePerUnit
618RR
PatientIDQualifierCount
6194
OriginalUnitsInvoiced
619RW
PrescribedProductDescription
6195
PaidPerUnitAmount
62RX
PrescriberIDCount
6196
PaidRebateAmount
621RY
PrescriberSpecialty
621
PriorAmountPaid
622RZ
PrescriberSpecialtyCount
622
PriorUnitsDisputed
623SA
QuantityDispensedToDate
623
PriorUnitsPaid
624SB
RecordDelimiter
628
ReconciliationErrorDescription
625SC
RemainingQuantity
629
ReconciliationLineNumber
626SD
SenderName
V,X
621
ReconciliationReasonCode
627SF
SendingPharmacyID
6211
ReconciliationStatusCode
628SG
TelephoneNumberCount
6212
ReconciliationTransmissionControlNumber
629SH
TelephoneNumberQualifier
6213
RevisedInvoiceAmount
63SJ
6214
TotalRemittance
TotalNumberOfSendingAndReceivingPharmacy
Records
6215
WithheldInvoiceAmount
631SK
TransferFlag
- 176 April215
V
V
DATA DICTIONARY
NameOfField
Field
Standard
Formats
NameOfField
Field
Standard
Formats
632SM
TransferType
662V1
PriorAuthorizationQuestionNumber
633SN
PackageAcquisitionCost
663V2
PriorAuthorizationApplicability
634SP
UniqueRecordIdentifier
664V3
PriorAuthorizationRequiredQuestion
635SQ
UniqueRecordIdentifierQualifier
665V4
PriorAuthorizationResponseType
636TD
PharmacistInitials
666V5
PriorAuthorizationQuestionText
637TF
TechnicianInitials
667V6
PriorAuthorizationBasisQuestionSequenceNumber
638XK
Segment1
R,J
668V7
PriorAuthorizationComparisonType
639XL
Segment2
R,J
669V8
PriorAuthorizationBasisValue
64XM
Segment3
R,J
67V9
PriorAuthorizationAnswerValue
641XN
Segment4
R,J
671W1
Bed
642XP
Segment5
R,J
672W2
FacilityUnit
643XQ
Segment6
R,J
673W3
HoursOfAdministration
644XR
SegmentQualifier1
R,J
674W4
Room
645XS
SegmentQualifier2
R,J
675Y3
PurchaserAddressState/ProvinceCode
646XT
SegmentQualifier3
R,J
676Y4
PurchaserZip/PostalCode
647XU
SegmentQualifier4
R,J
677Y5
PurchaserCountryCode
648XV
SegmentQualifier5
R,J
678Y6
TimeofService
649XW
SegmentQualifier6
R,J
679Y9
SellerID
65S1
AccumulatorYear
68ZB
SellerIDQualifier
651S2
TransactionIdentifier
681ZF
SalesTransactionID
652S3
AccumulatedPatientTrueOutOfPocketAmount
682
DocumentControlNumber
Z,W
653S4
AccumulatedGrossCoveredDrugCostAmount
683
JurisdictionalState
654S5
DateTime
685
PayToPhoneNumber
655S6
AccumulatorMonth
686
Brand/GenericIndicator
W,I
656S7
AccumulatorMonthCount
687
GenericAvailable
657T5
PriorAuthorizationFormID
688
JurisdictionalField(15)
658T6
PriorAuthorizationFormTitle
689
CompoundIngredientProductName
Z,W
659T7
PriorAuthorizationQuestionCode
69ZG
InvoicedDate
66T8
PriorAuthorizationQuestionCodeQualifier
691ZH
OutOfPocketRemainingAmount
661T9
PriorAuthorizationQuestionSequence
692ZJ
NumberOfGenericManufacturers
- 177 April215
DATA DICTIONARY
NameOfField
Field
Standard
Formats
NameOfField
Field
Standard
Formats
693
TotalGrossAmountDue
871D
CarrierAddress
694
TotalPatientPayAmount
891F
CarrierLocationCity
71
SegmentIdentifier
811G
CarrierLocationState
72MC
FileType
B,F,V,X,i
8111H
CarrierName
711
ActionCode
8131J
CarrierZipCode
713
TerminationDate
8185F
DestinationName
716SY
LastName
A,V,X,Y,L
8295L
PharmacyAddress
Z,W
717SX
FirstName
A,V,X,Y,L
8315N
PharmacyLocationCity
Z,W
718SZ
MiddleInitial
A,V,X,Y,L,i
8326F
PharmacyLocationState
Z,W
721MD
GenderCode
F,A
8335P
PharmacyName
A,V,Z,W,Y
724ST
AlternateIDNumber
V,X
8345Q
PharmacyTelephoneNumber
Z,W
726SR
AddressLine1
R,A,V
8355R
PharmacyZipCode
Z,W
727SS
AddressLine2
R,A,V
8395V
ProcessorName
728SU
City
R,A,Y
878
RejectOverrideCode
729TA
State
R,A,V,Y
879N2
SendingEntityIdentifier
A,V,E,Y,L
73TC
Zip/PostalCode
R,A,V,Y
88K1
SenderID
B,F,L,i
732TB
TelephoneNumber
A,V,X,L
88K2
CreationDate
B,A,V,X,Y,L,i
751M9
RecordCount
B,F,V,E,i
88K3
CreationTime
B,A,V,X,L,i
757U6
BenefitID
A,T
88K4
TextIndicator
B,V
759
BenefitTerminationDate
88K5
TransactionReferenceNumber
B,T
761
BenefitEffectiveDate
88K6
TransmissionType
B,E,i
776
EntityAddressLine1
88K7
ReceiverID
B,F,A,V,E,i
777
EntityAddressLine2
886
ServiceProviderChainCode
A,E
778
EntityCity
887
ServiceProviderCountyCode
78
EntityName
888
SubmissionNumber
A,E,i
782
EntityState
889
TherapeuticChapter
783
EntityTelephoneNumber
894
TotalAmountPaidByAllSources
784
EntityZip/PostalCode
R,J,E
895
TotalNetAmountDue
785SV
FamilyIDNumber
V,i
896
TransactionID
A,i
865C
BatchNumber
B,A,V,X,i
897
TransactionIDCrossReference
A,i
- 178 April215
DATA DICTIONARY
NameOfField
Field
Standard
Formats
NameOfField
Field
Standard
Formats
898
UserBenefitID
931F8
MaximumAgeQualifier
899
UserCoverageID
932GA
MaximumAge
9BN
AbsoluteRowNumber
933GB
MaximumAmount
91BP
AlternativesID
934GC
MaximumAmountQualifier
93BR
ClassIDStepDrug
935GF
MaximumAmountTimePeriod
96BU
CopayID
936GG
MaximumAmountTimePeriodStartDate
97BV
CopayListID
937GH
MaximumAmountTimePeriodEndDate
98BW
CopayListType
938GJ
MaximumAmountTimePeriodUnits
99BX
CopayTier
939GK
MaximumCopay
91BY
CoverageID
94GM
MaximumCopayTier
911BZ
CoverageListID
941GN
MessageLong
912B3
CoverageListType
942GP
MessageShort
913B4
DataInError
943GQ
MinimumAgeQualifier
914B5
DrugQualifierStepDrug
944GR
MinimumAge
915B6
DrugReferenceNumber
945GS
MinimumCopay
916B7
DrugReferenceQualifier
946GT
NonListedPrescriptionBrandFormularyStatus
917B8
DrugReferenceNumberAlternative
947GU
NonlistedPrescriptionGenericFormularyStatus
918B9
DrugReferenceQualifierAlternative
948GV
NonlistedBrandOverTheCounterFormularyStatus
919CS
DrugReferenceNumberSource
949GW
NonlistedGenericOverTheCounterFormularyStatus
92CT
DrugReferenceQualifierSource
95GX
NonlistedSuppliesFormularyStatus
921CU
DrugReferenceNumberStepDrug
951GY
NumberofDrugsToTry
922CV
DrugReferenceQualifierStepDrug
952GZ
OutofPocketRangeStart
923DD
ExtractDate
953HP
OutofPocketRangeEnd
924DH
FirstCopayTerm
954HQ
PercentCopayRate
925ES
FlatCopayAmount
955HR
PharmacyType
926FF
FormularyID
F,T
956HS
PreferenceLevel
927FP
FormularyStatus
957HT
ProductNameHealthPlan
928FR
ListAction
958HU
929FZ
ListEffectiveDate
959HV
Product/ServiceIDQualifierAlternative
93F2
LoadStatus
96HW
- 179 April215
DATA DICTIONARY
NameOfField
Field
Standard
Formats
NameOfField
Field
Standard
Formats
961HX
Product/ServiceIDQualifierStepDrug
995E2
RouteofAdministration
T,Z,W
962HY
996G1
CompoundType
963HZ
Product/ServiceIDQualifierSource
997G2
CMSPartDDefinedQualifiedFacility
964JA
ProductType
BenefitAmount
966JC
RelativeCost
A1
BenefitAmountTimePeriod
967JD
RelativeCostLimit
A2
BenefitAmountType
968JF
ResourceLinkType
A3
BenefitAmountUsedToDate
969JG
RxNormCode
A4
ClaimCostCeilingOverrideAmount
97JH
RxNormQualifier
A5
ClaimOrigination
971JJ
SectionColumnInError
A6
CompoundIndicator
972JK
SourceName
A7
Copay/CoinsuranceOverrideAmount
973JM
SenderParticipantPassword
A8
Copay/CoinsuranceOverrideType
974JN
StepOrder
A9
CopayConjunctionSequence
976JQ
SubclassIDStepDrug
A1
DaysSupplyUsedtoDate
978JS
TotalRecords
F,Y
A11
DispenseAsWritten(DAW)Difference
979JT
TotalErrors
A12
DosagePerDay
98JU
TotalRowsInError
A13
Fills/RefillsUsedToDate
981JV
TransmissionAction
F,A
A14
PrescriberOverrideType
982JW
TransmissionDateOriginating
A15
PriorAuthorizationCreateDate
983JX
TransmissionNumberOriginating
A16
PriorAuthorizationNumberofFillsAuthorized
984JY
TransmissionTime
F,i
A17
PriorAuthorizationReasonCode
985JZ
TransmissionTimeOriginating
A18
PriorAuthorizationUpdateDate
986KJ
TransmissionFileType
F,E,i
A19
ReceiverName
987MA
URL
F,T
A2
ServiceProviderOverrideType
988MB
DaysSupplyPerCopay
A21
SubgroupID
989MF
FormularyName
A22YR
PatientIDAssociatedState/ProvinceAddress
99MG
OtherPayerBINNumber
A23YS
PurchaserRelationshipCode
991MH
OtherPayerProcessorControlNumber
T,V
A24ZK
PrescriberIDAssociatedState/ProvinceAddress
992MJ
OtherPayerGroupID
A25ZM
PrescriberAlternateIDQualifier
993A7
InternalControlNumber
T,Y
A26ZP
PrescriberAlternateID
- 180 April215
DATA DICTIONARY
NameOfField
Field
Standard
Formats
A27ZQ
PrescriberAlternateIDAssociatedState/Province
Address
A28ZR
AdjudicatedPaymentType
A29ZS
ReportedPaymentType
A3ZT
ReleasedDate
A31ZU
ReleasedTime
A32ZW
CompoundPreparationTime
A33ZX
CMSPartDContractID
A34ZY
MedicarePartDPlanBenefitPackage(PBP)
A35
HealthCareIDCardQualifierCode
A36
CardPurposeCode
A37
SpecialtyClaimIndicator
A38
MemberSubmittedClaimRejectCode
A39
CopayWaiverAmount
A431K
PatientCountryCode
A44ZL
OriginalDispensedQuantity
A451R
VeterinaryUseIndicator
A461S
TextMessageType
A47
AuditRequestType
A48
AuditControlIdentification
A49
AuditSponsor
A5
RequestedResponseDate
A51
EstimatedArrivalTimeDescription
A52
EntityEmail
A53
EntityFaxNumber
A54
AuditRangeQualifier
A55
AuditRangeStart
A56
AuditRangeEnd
A57
AuditElementType1
A58
AuditElementType2
NameOfField
Field
Standard
Formats
A59
AuditElementType3
A6
AuditElementType4
A61
AuditElementType5
A62
AuditElementResponse1
A63
A64
A65
A66
A67
BillingSequence
A68
DiscrepancyCode1
A69
DiscrepancyCode2
A7
DiscrepancyCode3
A71
DiscrepancyMessage
A72
DiscrepancyAmount
A73
MedicareDrugCoverageCode
A74
AllowedAmount
A75
BilledAmount
A76
JCode
A77
JCodeModifier1
A78
JCodeModifier2
A79
JCodeModifier3
A8
JCodeModifier4
A81
MedicalRebateVersionReleaseNumber
A82
PlanReimbursedAmount
A83
QuarterlyMemberIndicator
A84
FormularyStartDate
A85
FormularyTerminationDate
A86
PlanEligibilityStartDate
A87
PlanEligibilityTerminationDate
A88
ClaimProcessedCode
- 181 April215
DATA DICTIONARY
NameOfField
Field
Standard
Formats
NameOfField
Field
Standard
Formats
A89
EncryptedSocialSecurityNumber
B217N
FacilityStreetAddressLine2
A9
InsuranceType/ProductCode
B227P
HelpDeskTelephoneNumberExtension
A91
LineCounter
B237Q
OtherPayerHelpDeskTelephoneNumberExtension
A92
MiddleName
B247R
PayToStreetAddressLine1
A931T
ServiceProviderCountryCode
B257S
A94
TypeOfFile
B267T
PrescriberTelephoneNumberExtension
A95
ApplicationID
B277U
PrescriberStreetAddressLine1
A97
GrossRetireeCost
B287V
A98
LimitReduction
B297W
PurchaserStreetAddressLine1
A99
QualifiedCoveredRetireeHICN
B37X
B1
QualifiedCoveredRetireeSSN
B317Y
ServiceProviderStreetAddressLine1
B2
ThresholdReduction
B327Z
B3
UniqueBenefitOptionIdentifier
B336G
B4
NextAvailableFillDate
ProfessionalServiceFeeContracted/Reimbursement
Amount
B341U
B5
EntityContactFirstName
AuthorizedRepresentativeCountryCode
B351V
EmployerCountryCode
B361W
EntityCountryCode
E,J,R,V,Y,A
B371X
FacilityCountryCode
B381Y
PatientIDAssociatedCountryCode
B391Z
PaytoCountryCode
B43A
PrescriberAlternateIDAssociatedCountryCode
B413B
PrescriberIDAssociatedCountryCode
B423C
PrescriberCountryCode
B433D
PurchaserIDAssociatedCountryCode
B448G
IntermediaryIDCount
IntermediaryIDTypeCode
B468J
IntermediaryIDTypeEntity
B478K
IntermediaryIDQualifier
B488M
IntermediaryID
B6
EntityContactLastName
B7
EntityTelephoneNumberExtension
B87A
PatientStreetAddressLine1
T,G
B97B
T,G
B18A
TelephoneNumberExtension
A,V,X,L
B11
ContactPersonFirstName
B12
ContactPersonLastName
B137D
AuthorizedRepresentativeStreetAddressLine1
B148B
B158D
EmployerStreetAddressLine1
B167G
B177H
EmployerContactFirstName
B187J
EmployerContactLastName
B197K
EmployerTelephoneNumberExtension
B27M
B458H
- 182 April215
DATA DICTIONARY
NameOfField
Field
B498N
IntermediaryIDState/ProvinceAddress
B58P
B518Q
Standard
Formats
NameOfField
Field
Standard
Formats
B68
AccumulatorAppliedAmount
IntermediaryIDRelationshipCode
B69
AccumulatorBalanceBenefitType
IntermediaryMessage
B7
AccumulatorBalanceQualifier
B528R
ResponseIntermediaryAuthorizationCount
B71
AccumulatorBalanceCount
B538S
ResponseIntermediaryAuthorizationTypeID
B72
AccumulatorBenefitPeriodAmount
B548T
ResponseIntermediaryAuthorizationID
B73
AccumulatorChangeSourceCode
B558U
IntermediaryIDCountryCode
B74
AccumulatorNetworkIndicator
B563E
LastKnownBINNumber
B75
AccumulatorReferenceTimeStamp
B573F
LastKnownProcessorControlNumber
B76
AccumulatorRemainingBalance
B583G
LastKnownGroupID
B77
AccumulatorSpecificCategoryType
B593H
LastKnownCardholderID
B78
B63J
YearofLastPaidClaim
B79
DocumentReferenceIdentifierQualifier
B613K
MonthofLastPaidClaim
B8
OptionalDataIndicator
B621M
AlternativesGroupID
B81
PenaltyAmount
B631N
AlternativesListType
B82
ProcessorRoutingIdentification
B641P
StepMedicationsGroupID
B83
RecordLength
B653M
MinimumDrugsPerStepGroup
B84
SenderReferenceNumber
B85
TransmissionID
B663N
MaximumDrugsPerStepGroup
B67
AccumulatorActionCode
IV.AppendixBCROSSREFERENCEOFFIELDSUSEDINNCPDPSCRIPTTOTHEMODELDRIVENSCHEMAS
ThiscrossreferencetablecontainsfieldsusedinpreviousversionsofNCPDPSCRIPTStandardthatusedfourdigitfieldidentifiers(OldFieldID).Thefieldsarecross
referencedtotheXMLnameincurrentversionsofNCPDPSCRIPT.
OldField
ID
EDIFieldName
NewFieldName
OldField
ID
EDIFieldName
NewFieldName
7944
7943
7942
S36
AdministrationTimingCode
AdministrationTimingCodeQualifier
AdministrationTimingText
ADVERSEEVENTDATECOMPOSITE
EffectiveDate
7919
BodyMetricQualifier
BodyMetricQualifier
792
326
BodyMetricValue
MessageFunction
S37
789
ADVERSEEVENTTYPECOMPOSITE
Bed
AdverseEvent
Bed
BodyMetricValue
BodyType
BecameexplicitelementsforXML
TransactionTypes,e.g.
NewRx
RefillRequest
- 183 April215
DATA DICTIONARY
OldField
ID
7921
7924
7923
7922
7893
681
1131
1131
1131
1131
1131
1131
355
S23
83
I17
85
S44
4711
3229
25
7996
813
7892
EDIFieldName
CalculatedDoseNumeric
CalculatedDoseUnitofMeasureCode
Qualifier
CalculatedDoseUnitofMeasureText
ChangeofPrescriptionStatusFlag
ClinicalInformationQualifier
CodeListQualifierDiagnosisCodeQualifier
(Primary)
CodeListQualifierDiagnosisCodeQualifier
(Secondary)
CodeListQualifierQuantityQualifier(X12
DE673)
CodeListQualifierResponseCode
CodeListQualifierRejectCode
CodeListQualifierCommunicationNumber
(X12DE365)
CodeListResponsibilityAgency
CODESYSTEMCOMPOSITE(Sig)
CompoundCode
COMPOUNDINGREDIENTCOMPOSITE
CompoundIngredientItemDescription
COMPOUNDEDPRESCRIPTIONROUTEOF
ADMINISTRATIONCOMPOSITE
Condition/Response,codedPatientConsent
Indicator
CountrySubentityIdentification
Date/Time/PeriodQualifier(X12DE432)
DEAScheduleNCPDPDEASchedule
Terminology
DispensingRequestCode
DoNotFill/ProfileFlag
NewFieldName
OldField
ID
EDIFieldName
NewFieldName
RefillResponse
RxChangeRequest
RxChangeResponse
CancelRx
Census
RxHistoryRequest
CalculatedDoseUnitOfMeasureCodeQualifi
er
CalculatedDoseUnitofMeasureText
ChangeOfPrescriptionStatusCode
PrimaryDiagnosisCodeQualifierCode
7878
Dosage
Directions
7879
S25
7925
S26
793
796
795
799
798
797
794
7913
7912
7911
791
7914
7915
7925
7918
7917
7916
7885
S38
S18
7998
7997
7883
7884
7881
788
7882
S31
7963
7964
7966
7965
7888
7897
84
DosageIdentification
DOSECOMPOSITE
DoseBasisRangeModifier
DOSECALCULATIONCOMPOSITE
DoseCompositeIndicator
DoseDeliveryMethodCode
DoseDeliveryMethodCodeQualifier
DoseDeliveryMethodModifierCode
DoseDeliveryMethodModifierCodeQualifier
DoseDeliveryMethodModifierText
DoseDeliveryMethodText
DoseFormCode
DoseFormText
DoseQuantity
DoseRangeModifier
DosingBasisNumericValue
DosingBasisRangeModifier
DosingBasisUnitofMeasureCode
DosingBasisUnitofMeasureCodeQualifier
DosingBasisUnitofMeasureText
DrugCoverageStatusCode
DRUG PRODUCTCODEDCOMPOSITE
DRUGUSEEVALUATIONCOMPOSITE
DUEAcknowledgementReason
DUEClinicalSignificanceCode
DUECoAgentID
DUECoAgentIDQualifier
DUEProfessionalServiceCode
DUEReasonForServiceCode
DUEResultOfServiceCode
DURATIONCOMPOSITE
DurationNumericValue
DurationText
DurationTextCode
DurationTextCodeQualifier
FacilityUnit
FillNumber
FinalCompoundPharmaceuticalDosageForm
NCPDPDrugStrengthFormTerminology
791
817
7953
FMTVersion
FollowUpRequest
Frequency NumericValue
Notdefined
Dose
DoseCalculation
DoseFormCode
DoseFormText
DoseQuantity
DoseRangeModifier
DosingBasisUnitOfMeasureCodeQualifier
DrugCodedType
DrugUseEvaluationType
AcknowledgementReason
CoAgentID
CoAgentQualifier
ServiceReasonCode
ServiceResultCode
Duration
DurationText
DurationTextCode
FacilityUnit
FillNumber
FinalCompoundPharmaceuticalDosageF
orm
NCPDPDrugStrengthForm
Terminology
FMTVersion
FollowUpRequest
FrequencyNumericValue
SecondaryDiagnosisCodeQualifierCode
QuantityCodeListQualifier
ReasonCode
DescriptionCode
CommunicationTypeQualifier
Becameexplicitelements,e.g.,
CompoundProductCodeQualifier
Allergy/DrugProductCoded/CodeListQualifi
er
CodeSystem
CompoundCode
CompoundIngredient
RouteOfAdministration
Consent
State
DateElements
Becameexplicitelementse.g.,
SoldDate
ExpirationDate
WrittenDate,etc.
DEAScheduleCode
DoNotFill
- 184 April215
DATA DICTIONARY
OldField
ID
EDIFieldName
NewFieldName
OldField
ID
EDIFieldName
NewFieldName
7956
7955
7954
S34
7978
7977
7976
7979
7981
798
7982
7983
7986
7985
FrequencyUnitsCode
FrequencyUnitsCodeQualifier
FrequencyUnitsText
INDICATIONCOMPOSITE
IndicationPrecursorCode
IndicationPrecursorCodeQualifier
IndicationPrecursorText
IndicationText
IndicationTextCode
IndicationTextCodeQualifier
IndicationValueText
IndicationValueUnit
IndicationValueUnitofMeasureCode
Qualifier
IndicationValueUnitofMeasureText
IndicationVariableModifier
IndividualRelationship,coded
IntervalNumericValue
IntervalUnitsCode
IntervalUnitsCodeQualifier
IntervalUnitsText
ItemDescriptionIdentification
ItemDescriptionLong
ItemFormCode
NCPDPDrugStrengthFormTerminology
FrequencyUnitsCode
FrequencyUnitsText
Indication
IndicationText
IndicationTextCode
IndicationValueText
IndicationValueUnit
IndicationValueUnitOfMeasureCodeQualifi
er
IndicationValueUnitofMeasureText
IntervalUnitsCode
IntervalUnitsText
ItemDescriptionLong
DrugStrengthForm
NCPDPDrugStrengthForm
Terminology
Value
StrengthUnitOfMeasure
NCPDPDrugStrengthUnitOfMeasure
Terminology
LanguageNameCode
MaximumDoseRestriction
MaximumDoseRestrictionCode
MaximumDoseRestrictionCodeQualifier
MaximumDoseRestrictionNumericValue
MaximumDoseRestrictionUnitsCode
MaximumDoseRestrictionUnitsText
MaximumDoseRestrictionVariableDuration
Modifier
MaximumDoseRestrictionVariableNumeric
Value
MaximumDoseRestrictionVariableUnitsCod
e
MaximumDoseRestrictionVariableUnitsCod
eQualifier
MaximumDoseRestrictionVariableUnitsText
7887
6311
MeasurementDataQualifier
MeasurementDimension,coded(Values
whenreferencingX12DE738)
MeasurementUnitCode
NCPDPMeasurementUnitCodeTerminology
MeasurementUnitCode
NCPDPMeasurementUnitCode
Terminology
MessageRequestCode
MultipleAdministrationTimingModifier
MultipleRouteOfAdministrationModifier
MultipleSigModifier
MultipleSiteOfAdministrationTimingModifi
er
MultipleVehicleModifier
NeededNoLaterThan
NeededNoLaterThanReason
NoKnownAllergies
OrderCaptureMethod
OtherCompoundInformationType
7984
7987
971
7958
7961
796
7959
79
81
7992
89
7993
3453
S33
7969
7969
7967
797
7968
7975
7971
7974
7973
7972
ItemQuantity
ItemStrengthCode
NCPDPDrugStrengthUnitOfMeasure
Terminology
LanguageNameCode
MAXIMUMDOSERESTRICTIONCOMPOSITE
MaximumDoseRestrictionCode
MaximumDoseRestrictionVariableDuration
Modifier
MaximumDoseRestrictionVariableNumeric
Value
MaximumDoseRestrictionVariableUnits
Code
MaximumDoseRestrictionVariableUnits
CodeQualifier
7995
4343
7945
7937
7899
7941
7933
16
7894
7999
815
S43
7886
814
816
7994
82
7891
S42
S41
475
799
7946
7949
7948
MessageFunction,coded
MultipleRouteofAdministrationModifier
MultipleSigModifier
MultipleSiteofAdministrationTiming
Modifier
NeededNoLaterThan
NoKnownAllergies
OrderCaptureMethod
OTHERCOMPOUNDINFORMATION
COMPOSITE
PatientIdentifier
PayerResponsibilityCode
PersonCode
PotencyUnitCode
NCPDPQuantityUnitOfMeasureTerminology
Note:TheactualCODEvaluesarenotusedin
XMLstandards.
PrescriptionDeliveryMethod
PriorAuthorizationStatus
PROBLEMNAMECODEDCOMPOSITE
(DiagnosisGeneral)
PROBLEMTYPECOMPOSITE
(DiagnosisGeneral)
ProviderCoded
Becameexplicitelements,e.g.
MedicalRecordIdentificationNumber
Commercial
IndividualPolicyNumber
MedicareNumber
MedicaidNumber
PersonCode
QuantityUnitOfMeasureCode
NCPDPQuantityUnitOfMeasure
Terminology
ProblemNameCoded
ProblemType
ExplicitProviderNameTypes,e.g.
MandatoryPrescriberType
MandatoryPharmacyType
SupervisorTypeMandatoryFacilityType
ProviderSpecialtycode
Specialty
(replacing477ProviderSpecialty,coded
(X12DE1222)
RateofAdministration
RateofAdministration
RateUnitofMeasureCode
RateUnitOfMeasureCode
RateUnitofMeasureCodeQualifier
RateUnitOfMeasureCodeQualifier
- 185 April215
DATA DICTIONARY
OldField
ID
EDIFieldName
NewFieldName
OldField
ID
EDIFieldName
NewFieldName
7947
S39
811
812
1153
RateUnitofMeasureText
REACTIONCODEDCOMPOSITE
ReasonCode(REQSegment)
ReasonText
ReferenceQualifierGenericDatabase,Prior
Authorization
ReferenceQualifier(X12DE128)(IDs)
Note: PriorAuthorizationQualifier uses the CODE
values.
RateUnitOfMeasureText
ReactionCoded
DrugAdminReasonCode
DrugAdminReasonText
DrugDBCodeQualifier
S3
794
7939
S29
7938
79
17
7991
Timing
SiteofAdministrationCode
SiteOfAdministrationCodeQualifier
SiteOfAdministration
SiteOfAdministrationText
SNOMEDVersion
HistorySourceType
SourceCodeList NCICode
7896
8
7895
915
SigTIMINGCOMPOSITE
SiteofAdministrationCode
SiteofAdministrationCodeQualifier
SITEOFADMINISTRATIONCOMPOSITE
SiteofAdministrationText
SNOMEDVersion
Source
SourceCodeList
Note:TheactualCODE(AA,AB,etc)values
arenotusedinXMLstandards.
SourceDescription
SourceofInformation
SourceQualifier
StatusType,coded
S35
7988
35
7952
7951
795
229
7957
7962
S27
7926
7928
7927
7929
7932
7931
793
STOPCOMPOSITE
StopIndicator SIGSegment
TestIndicator
TimePeriodBasisCode
TimePeriodBasisCodeQualifier
TimePeriodBasisText
TimeZoneIdentifier
VariableFrequencyModifier
VariableIntervalModifier
VEHICLECOMPOSITE
VehicleName
VehicleNameCode
VehicleNameCodeQualifier
VehicleQuantity
VehicleUnitofMeasureCode
VehicleUnitofMeasureCodeQualifier
VehicleUnitofMeasureText
1153
IdentificationElements
Becameexplicitelements,e.g.
PatientIdentification,
PayerIdentification,
FacilityIdentification,
PharmacyIdentification,
PrescriberIdentification,
SupervisorIdentification,
ProviderIdentification,
PriorAuthorizationQualifier.
RefillsRemaining
RepeatingSIG
Room
RouteOfAdministration
RouteOfAdministrationCode
RouteOfAdministrationCodeQualifier
RouteOfAdministrationText
ServiceTypeCoded
SenderSoftwareType
81
S22
7889
S28
7936
7935
7934
771
S45
RefillQuantity
REPEATINGSigCOMPOSITE
Room
ROUTEOFADMINISTRATIONCOMPOSITE
RouteofAdministrationCode
RouteofAdministrationCodeQualifier
RouteofAdministrationText
ServiceType,coded
SENDERSOFTWARECOMPOSITE
86
SenderSoftwareDeveloper
87
SenderSoftwareProduct
88
SenderSoftwareVersionRelease
S4
SEVERITYCODEDCOMPOSITE
SeverityCoded
S24
SIGFREETEXTSTRINGCOMPOSITE
FreeText
7989
SigFreeText
SigFreeText
792
7898
SigFreeTextStringIndicator
SigSequencePositionNumber
VI.AppendixCPUBLICATIONMODIFICATIONS
- 186 April215
SourceDescription
SourceOfInformation
SourceQualifier
StatusCode,
TransactionErrorCode,
VerifyStatusCode
Stop
StopIndicator
TestMessage
TimePeriodBasisCode
TimePeriodBasisText
TimeZoneIdentifier
Vehicle
VehicleName
VehicleNameCode
VehicleQuantity
VehicleUnitOfMeasureCode
VehicleUnitOfMeasureCodeQualifier
VehicleUnitOfMeasureText
DATA DICTIONARY
A.
SEPTEMBER1999
1.
TelecommunicationStandardVersion5Release1
ThefollowingcodevalueswereapprovedforinclusionintheDataDictionary.
Field439E4ReasonforServiceCode
CD=ChronicDiseaseManagement
LK=LockInRecipient
PH=PreventiveHealthCare
RE=SuspectedEnvironmentalRisk
SC=SuboptimalCompliance
Field441E6ResultofServiceCode
3K=InstructionsUnderstood
3N=MedicationAdministered
Field12A2Version/ReleaseNumber
51=Version5.1
B.
JUNE2
1.
ThefollowingcodevalueswereapprovedforinclusionintheDataDictionary.
Field496H2MeasurementDimension
18=Cholesterol
19=LowDensityLipoprotein(LDL)
2=HighDensityLipoprotein(HDL)
21=Triglycerides(TG)
22=BoneMineralDensity(BMDTScore)
23=ProthrombinTime(PT)
24=Hemoglobin(Hb;Hgb)
25=Hematocrit(Hct)
26=WhiteBloodCellCount(WBC)
27=RedBloodCellCount(RBC)
28=HeartRate
29=AbsoluteNeutrophilCount(ANC)
3=ActivatedPartialThromboplastinTime(APTT)
31=CD4Count
32=PartialThromboplastinTime(PTT)
33=TCellCount
34=INRInternationalNormalizedRatio
Field497H3MeasurementUnit
19=Ratio
2=SIUnits
- 187 April215
DATA DICTIONARY
21=Millimoles(mmol/l)
22=Seconds
23=Gramsperdeciliter(g/dl)
24=Cellspercubicmillimeter(cells/cumm)
25=1,,cellspercubicmillimeter(millioncells/cumm)
26=Standarddeviation
27=Beatsperminute
ThefollowingaredataelementsthatwereapprovedforinclusionintheDataDictionary.
Field
FieldName
Number
Addition
PatientEMailAddress
35HN
X
12A2
2.
Action
Deletion
Modification
Addedvalue:52=Version5.2
EnrollmentStandardVersion2Release
Field
FieldName
Number
Addition
ActionCode
711
AlternateBenefitID
753
X
AlternateEnrollmentVerificationCode
754
X
AlternateFinancialVerificationCode
755
X
AlternateGroupNumber
756
X
AlternateIDNumber
724
761
X
BenefitID
757
X
BenefitQualifier
758
X
759
X
BillingLevelIndicator
76
X
CardProductionIndicator
762
X
CardholderID
32C2
CarrierID
CaseManager
Claim/ReferenceID
327CR
763
435DZ
ClientIDCode
ClientIDCodeQualifier
CopayCalculationCode
CopayDollarAmount
CopayEffectiveDate
CopayPercentageAmount
CopayQualifier
CopayTerminationDate
CoveredThroughQualifier
DataCategory
DateOfInjury
61
62
764
765
766
767
768
769
77
73
434DY
Action
Deletion
Modification
Updatevalues:removedP=Purge;C=Change;addedS=Suspend
Fieldlengthexpandedfrom18to2
Fieldnamechange:CardholderIDNumbertoCardholderID,definition,fieldlengthexpanded
from18to2
Fieldnamechange:CarrierIDNumbertoCarrierID,definition
X
Fieldnamechange:Claim/ReferenceIDNumbertoClaim/ReferenceID,fieldlengthexpanded
from14to3,definition
X
X
X
X
X
X
X
X
X
Updatevalues:addedC=ComboGroup&Member;G=GroupOnly,definition
X
- 188 April215
DATA DICTIONARY
DependentAdultCoverageIndicator
DependentAdultCoveredThroughAge
Field
Number
749
75
DependentCoverageIndicator
DependentCoveredThroughAge
DependentCoveredThroughDate
DiagnosisCode
DisabledDependentCoverageIndicator
DURTypeIndicator
EarlyRefillPercentage
EffectiveDate
EligibilityType
EmployerID
EnrollmentRelationshipCode
EnrollmentTaxExemptIndicator
EnrollmentVersion/ReleaseNumber
743
744
885
424DO
492WE
747
771
772
712
773
333CZ
715
774
775
EntityAddressLine1
EntityAddressLine2
EntityCity
EntityContactName
EntityName
EntitySegmentQualifier
EntityState
FamilyIDNumber
FileType
FirstName
GenderCode
GroupName
GroupID
GroupSequenceNumber
HierarchyLevelName
HierarchyLevelNumber
IDCardReasonCode
IndustryClassificationCode
MaximumCopayAmount
MemberSequenceNumber
MinimumCopayAmount
NumberofIDCards
OriginalEffectiveDate
OriginatorName
OtherCoverageCode
776
777
778
779
78
781
782
783
784
785
72
717
721
786
31C1
787
788
789
79
791
792
71
793
794
714
76
38C8
PlanIDExtension
733
FieldName
Action
Addition
Deletion
Modification
Definition
Fieldnamechange:DependentAdultCoveredThruAgetoDependentAdultCoveredThrough
Age
Definition
Fieldnamechange:DependentCoveredThruAgetoDependentCoveredThroughAge
X
X
X
Definition
X
X
Definition
X
X
Definition
X
Fieldnamechange:Version/ReleaseNumbertoEnrollmentVersion/ReleaseNumber,deleted
value1=1994Version1.Format,addvalue2=1999Version2.Format
X
X
X
X
X
X
X
X
X
X
Definition
Definition
Definition,updatevalue:Blank=Unknown;1=Male;2=Female
X
Fieldnamechange:GroupNumbertoGroupID
X
X
X
X
X
X
Fieldnamechange:IDCardCodetoIDCardReasonCode
Fieldnamechange:SequenceNumbertoMemberSequenceNumber
X
X
Definition
Definition,Fieldlengthexpandedfrom2to3
Fieldlengthexpandedfrom1to2,updatevalues:added5=Managedcareplandenial;
6=Othercoveragedeniednotparticipatingprovider;7=Othercoverageexistsnotineffect
onDOS;8=Claimisbillingforcopay
Definition
- 189 April215
DATA DICTIONARY
FieldName
PregnancyIndicator
PrescriberID
PrimaryCareProviderTerminationDate
PrimaryPharmacyEffectiveDate
PrimaryPharmacyIDQualifier
PriorApprovalAmount
ProcessorIndicator
RelationshipCoverageEffectiveDate
ReportLevelIndicator
SegmentIdentifier
SignificantOtherCoverageIndicator
SpouseCoverageIndicator
StudentCoverageIndicator
StudentCoveredThroughAge
StudentCoveredThroughDate
TelephoneNumber
WorkersCompensationEffectiveDate
WorkersCompensationOriginalEffectiveDate
WorkersCompensationTerminationDate
Zip/PostalCode
3.
Field
Number
3352C
411DB
466EZ
421DL
4682E
795
739
496
797
77
74
798
71
799
3341C
742
745
746
884
732
12A2
881
882
883
73
Action
Addition
X
X
X
Deletion
Modification
Fieldlengthreducedfrom18to15
X
X
Definition
X
X
Definition,updatevalues:M=Maintenance/ChangesOnly;T=FullFilewithTerms
Definition
X
Updatevalues,added:11GroupDemographics;12GroupBenefits;13GroupCopay;18Group
CopayProcessorDefined;19GroupBenefitsProcessorDefined;42MemberBenefits;43
MemberCopays;48MemberCopayProcessorDefined;49MemberBenefitsProcessor
Defined;5WorkersCompensation;51WorkersCompensationDemographics;59Workers
CompensationProcessorDefined;89GroupProcessorDefined
X
X
Definition
Definition
Fieldnamechange:StudentCoveredThruAgetoStudentCoveredThroughAge
X
X
X
ReplacedbyEnrollmentVersion/ReleaseNumber
X
X
X
Fieldnamechange:ZipCodetoZip/PostalCode,definition,fieldlengthexpandedfrom9to15
PaymentTapeFormatVersion3Release
Whilethenewstandardremainsa368byterecord,thefieldpositionswillnolongerbethesameastheywereinthepreviousPaymentReconciliationStandardv3..Thedataelementnamesandfieldlengthsinthisrevised
standardwereupdatedtobecompliantwithTelecommunicationsVersion5.Inaddition,datefieldswereupdatedtobeY2Kcompliant,andnewfieldshavebeenadded.Thesechangeshavecausedthefieldpositionsinall
oftherecordtypestobeadjusted.
Action
Field
FieldName
Number
Addition
Deletion
Modification
AmountBilled
845B
AmountPaid
876FB
AmountAdjusted
8723Z
AmountRejected
851C
AuthorizationNumber
53F3
X
BalanceForward
88KC
X
BankAccount
88KK
X
BankRoutingID
88KH
X
- 190 April215
DATA DICTIONARY
FieldName
BatchAmount
BatchNumber
CarrierZipCode
CheckAmount
CheckNumber
ClaimCount
ClaimTransmissionFee
CoPayAmount
DispensingFeePaid
DollarsBilled
DollarsPaid
DollarsAdjusted
DollarsRejected
FundDestinationName
FundDestinationID
GroupID
IncentiveAmountPaid
IngredientCostBilled
IngredientCostPaid
Message
NonClaimAdjustmentDollars
NonClaimTransmissionFeeDollars
OpenBalance
OtherAmountPaid
PatientPayAmount
PaymentCycleStartDate
PaymentCycleEndDate
PendingClaimCount
PharmacyCount
RejectedClaimCount
SalesTax
TotalBatchAmount
TotalClaimCount
TotalDollarsAdjusted
TotalDollarsBilled
TotalDollarsPaid
TotalDollarsRejected
TotalNonClaimAdjustmentDollars
TotalNonClaimTransmissionFeeDollars
TotalPendingClaimCount
TotalRejectedClaimCount
TransactionType
Field
Number
522FM
88KR
865C
8131J
88KS
88KG
8145
88KF
8175E
57F7
8225H
8734A
8211M
8241N
88K8
88K9
31C1
521FL
8271
56F6
54F4
88KQ
88KP
88KT
565J4
55F5
88KA
88KB
88KM
835M
455EM
421DL
562J1
88KN
41DA
88U2
88KU
88KY
88KW
88KX
88KZ
88U5
88U4
88KV
88U3
88KD
12A2
Action
Addition
X
X
Deletion
Modification
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
ReplacedCoPayAmount(8175E)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Updatevalues:added3=1999
- 191 April215
DATA DICTIONARY
4.
ManufacturerRebateUtilization,Plan,Formulary,andMarketBasketFlatFileFormatVersion2Release1
Field
FieldName
Number
Addition
ClaimNumber
6168
X
ContractingOrganization(PMO)MarketBasketCode
6164
X
Manufacturer(PICO)MarketBasketCode
6165
X
MarketBasketDescription
6163
X
MarketBasketStartDate
6162
X
MarketBasketTerminationDate
6161
X
NumberofMarketProductRecords
616
X
NumeratorIndicator
6159
X
OriginatorIDCode
6166
X
OriginatorName
6167
X
ProductDailyConsumption
6158
X
RecordType
614
TotalNumberOfMarketBasketRecords
6169
X
5.
Modification
Updatevalues:addedMB=MarketBasketRecord,MP=MarketProductRecord
Field
FieldName
Number
Addition
UnitDoseIndicator
429DT
12A2
6,
Action
Deletion
Action
Deletion
Modification
Updatevalue:4=CustomPackaging
BatchStandardVersion1Release1
Batch1.1addedtoVersion/ReleaseNumber(12A2).
C.
SEPTEMBER2
1.
Field
FieldName
Number
Addition
BasisofCostDetermination
423DN
12A2
D.
Action
Deletion
Modification
Updatevalue:8=DisproportionateSharePricing/PublicHealthService
NOVEMBER2
1.
FieldName
Field
- 192 April215
Action
DATA DICTIONARY
E.
Number
528FS
351NP
352NQ
353NR
12A2
Addition
Deletion
Modification
Updatevalue:9=Undetermined
X
X
X
MAY21
1.
SCRIPTStandardVersion3Release1
DataelementsthathavebeencreatedbyNCPDPforusageintheSCRIPTStandardhavebeenincorporatedintoAppendixJSCRIPTDataElementsofthisdocument.
ThefollowingwereapprovedmodificationstotheDataDictionary.
Action
Field
AppendixorFieldName
Number
Addition
Deletion
Modification
475J9
Add:StoStandardFormatsColumninDataDictionary
ReasonforServiceCode
439E4
44E5
ResultofServiceCode
441E6
F.
AUGUST21
1.
Field
FieldName
Number
Addition
DURAdditionalText
57NS
X
12A2
G.
Action
Deletion
Modification
JANUARY22
1.
TelecommunicationStandardVersion6Release
Field
FieldName
Number
Addition
456EN
42D2
12A2
2.
Action
Deletion
Modification
FieldLengthExpandedfrom7to9
FieldLengthExpandedfrom7to9
Addedvalue:6=Version6.
Field
FieldName
Number
Addition
Action
Deletion
- 193 April215
Modification
DATA DICTIONARY
DatabaseIndicator
OtherPayerID
OtherPayerIDCount
Field
Number
532FW
492WE
356NU
347C
355NT
3396C
461EU
6119
42DK
SubmissionClarificationCodeCount
354NX
6126
463EW
12A2
FieldName
Action
Addition
Deletion
Modification
ValueChange3toMicromedex/MedicalEconomics
ValueChange6toFirstDataBankMDDBProductLine
X
CommentsAddRESPONSESTATUSSEGMENT
X
CommentsAddRESPONSESTATUSSEGMENT
DefinitionChangetoCodeclarifyingthePriorAuthorizationNumberSubmitted(462EV)or
benefit/planexemption.
ValuesChange1toFirstDataBankGenericCodeNumber(GCN),2toFirstDataBankGeneric
ProductIdentifier(GPI),4toFirstDataBankDrugDescriptorIdentifier(DDID)
ValueAdd1MeetsPlanLimitationsThepharmacycertifiesthatthetransactionisin
compliancewiththeprogramspoliciesandrulesthatarespecifictotheparticularproduct
beingbilled.
RejectCodeAddNXM/ISubmissionClarificationCodeCount
ValuesChange1toFirstDataBankGenericCodeNumber(GCN),2toFirstDataBankGeneric
ProductIdentifier(GPI),4toFirstDataBankDrugDescriptorIdentifier(DDID)
CommentsAdd:UsageChangeCheckImplementationGuidewhenvalue=99
AppendixKPRODUCT/SERVICEQUALIFIERupdatedwiththefollowingvaluechange:
NOTE:Product/ServiceQualifierCodesweremovedtotheECL.
Value
14
15
16
17
19
22
Definition
FirstDataBankGenericProductIdentifier(GPI)
FirstDataBankGenericCodeNumber(GCN)
Micromedex/MedicalEconomicsGenericFormulationCode(GFC)
FirstDataBankDrugDescriptorIdentifier(DDID)
Micromedex/MedicalEconomicsGenericMaster(GM)
FirstDataBankMDDBProductLineDiagnosisCode(Note:MDDBisnotanacronym)
3.
ManufacturerRebateStandardVersion3.1
Field
FieldName
Number
Addition
AdjustedQuantity
6171
X
AdjustedRebatePerUnit
617
X
6172
X
AmountPaidThisTransaction
6173
X
Baseline
6177
X
BaselineDescription
6178
X
BaselineQualifier
6179
X
BasePrice
6174
X
BasePriceDescription
6175
X
BasePriceType
6176
X
CurrentAmountPaidToDate
618
X
CurrentRebatePerUnit
6181
X
Action
Deletion
- 194 April215
Modification
DATA DICTIONARY
FieldName
CurrentUnitsDisputedToDate
CurrentUnitsPaidToDate
CurrentUnitsToDate
DisputedQuantity
FFAcceptedMetricDecimalQuantity
GrandTotalAcceptedMetricDecimalQuantity
GrandTotalPaidRebateAmount
InterestAmount
LevelAchieved
NumberofRebateTypeRecords
OriginalAmountInvoiced
OriginalRebatePerUnit
OriginalUnitsInvoiced
PaidPerUnitAmount
PaidRebateAmount
Performance
PerformanceDescription
PerformanceQualifier
PriorAmountPaid
PriorUnitsDisputed
PriorUnitsPaid
RebateRate
RebateType
RebateTypeDescription
RebateVarianceAmount
ReconciliationErrorDescription
ReconciliationLineNumber
ReconciliationStatusCode
ReconciliationTransmissionControlNumber
RecordType
RevisedInvoiceAmount
TotalRemittance
WithheldInvoiceAmount
Field
Number
6182
6183
6184
6185
6186
6187
6188
6189
619
6191
6192
6193
6194
6195
6196
6197
6198
6199
621
622
623
624
625
626
627
628
629
621
6211
6212
614
6213
6214
6215
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
Modification
ValuesAddRDReconciliationDetailRecord,RTRebateTypeRecord
X
X
X
4.
PaymentReconciliationStandardVersion4Release
Field
FieldName
Number
Addition
AmountPaid
876FB
FundDestinationID
88K9
FundDestinationName
88K8
TransactionType
88KD
Action
Deletion
X
Modification
UseTotalAmountPaid(59F9)
FormatChangefromx(25)to9(1)
FormatChangefrom9(1)tox(25)
DefinitionAdd:Definesthestatusofthebilledtransaction.
- 195 April215
DATA DICTIONARY
5.
DataDictionaryModifications
AppendixorFieldName
Field
Number
AppendixJUnitedStatesandCanadianProvincePostalService
Abbreviations
PriorAuthorization/MedicalCertificationCodeandNumber
416DG
461EU
Action
Addition
Deletion
Modification
ValuesAdd:NTNorthwestTerritories,NUNunavut,YTYukonValueChangeQCQuebec.
Note:ThistablewasmovedtotheECL.
ValueChange7fromAFDC(AidtoFamilieswithDependentChildren)toTANF(Temporary
AssistanceforNeedyFamilies)
ValueChange7fromAFDC(AidtoFamilieswithDependentChildren)toTANF(Temporary
AssistanceforNeedyFamilies)
H.
JUNE22
1.
AppendixorFieldName
DelayReasonCode
Field
Number
357NV
12A2
Action
Addition
X
Deletion
Modification
I.
DECEMBER22
1.
ManufacturerRebateStandardVersion3Release2
Field
Number
6119
6126
AppendixorFieldName
Action
Addition
Deletion
Modification
ValuesAdded:
5FirstDataBankMedicationNameIdentifier(FDBMedNameID)
6FirstDataBankRoutedMedicationIdentifier(FDBRoutedMedID)
7FirstDatabankRoutedDosageFormMedicationIdentifier(FDBRoutedDosageFormMed
ID)
8FirstDataBankMedicationIdentifier(FDBMedID)
ValuesAdded:
5FirstDataBankMedicationNameIdentifier(FDBMedNameID)
6FirstDataBankRoutedMedicationIdentifier(FDBRoutedMedID)
7FirstDatabankRoutedDosageFormMedicationIdentifier(FDBRoutedDosageFormMed
ID)
8FirstDataBankMedicationIdentifier(FDBMedID)
- 196 April215
DATA DICTIONARY
J.
FEBRUARY23
1.
AppendixorFieldName
K.
Field
Number
12A2
Action
Addition
Deletion
Modification
AUGUST23
1.
AppendixorFieldName
EmployerID
Field
Number
333CZ
Action
Addition
Deletion
AppendixKProduct/ServiceQualifier
NOTE:Product/ServiceQualifierCodesweremovedtotheECL
12A2
Modification
CommentsAdded:
TheInternalRevenueService,DepartmentoftheTreasury,assignstheEmployerID.Theformat
ofthisfieldisninedigitswithahyphen,asin.Thehyphenmustbetransmitted
aspartoftheEmployerIDNumber.InformationontheEmployerIDmaybefoundat
http://www.irs.ustreas.gov/.
Columnaddedforcomments.
Valuenamechangeon4fromUniversalProductNumber(UPN)toHealthIndustryBusiness
CommunicationCouncil(HIBCC).
Valuenamechangeon12fromInternationalArticleNumberingSystem(EAN)toGlobalTrade
IdentificationNumber(GTIN).
L.
OCTOBER23
1.
PatientLocation
Field
Number
37C7
571NZ
12A2
AppendixorFieldName
Action
Addition
Deletion
Modification
ValuesAdded:
12EndStageRenalDiseaseTreatmentFacility
X
2.
AppendixorFieldName
RejectCode
Field
Number
511FB
Action
Addition
Deletion
Modification
ValuesAdded:
- 197 April215
DATA DICTIONARY
AppendixorFieldName
(ValuesAddedtoAppendixFVERSION5REJECTCODESFOR
TELECOMMUNICATIONSTANDARDSubsectionN)NOTE:Reject
CodesforTelecommunicationweremovedtotheECL
Field
Number
Action
Addition
Deletion
12A2
Modification
SFOtherPayerAmountPaidCountDoesNotMatchNumberOfRepetitions
SGSubmissionClarificationCodeCountDoesNotMatchNumberofRepetitions
SHOtherPayerPatientResponsibilityAmountCountDoesNotMatchNumberofRepetitions
M.
NOVEMBER23
1.
ManufacturerRebateStandardVersion3Release2NewpublicationdateofNovember23
ReleaseoftheNovember23DataDictionaryisapprovedforuseonlybytheManufacturerRebateStandardVersion3.2fortheExternalCodeList(ECL)process.
2.
FollowingarechangesmadetotheDataDictionaryinpreparationfortheincorporationoftheECLprocess:
INTRODUCTIONChangedtoaddverbiagetoexplaintheECLprocessasitimpactstheDataDictionaryandDERFsubmission.
BODYSeeECL"wasindicatedintheValuesColumnofallDataElementsincludedintheExternalCodeListandvaluesremoved.ReferencesintheComments/ExamplesColumntoseeAppendiceswithintheRebate
ImplementationGuideforvalueswereremoved.
APPENDICESFVERSION5REJECTCODESFORTHETELECOMMUNICATIONSTANDARD,KPRODUCT/SERVICEQUALIFIER,andLUNITEDSTATESANDCANADIANPROVINCEPOSTALSERVICEABBREVIATIONSwereremoved
andremainingappendicesreorderedaccordingly.
N.
MAY24
1.
AppendixorFieldName
ProcedureModifierCodeCount
O.
Field
Number
458SE
12A2
Action
Addition
Deletion
Modification
FieldSizeChanged from9(1)to9(2)
AUGUST24
1.
TelecommunicationStandardVersionA.
AppendixorFieldName
DiagnosisCode
Field
Number
424DO
12A2
514FE
Action
Addition
Deletion
Modification
Comments:ChangedwordinganddeletedExamples
Addedvalue:A=VersionA.
Comments:CorrectedNoteto{
- 198 April215
DATA DICTIONARY
P.
OCTOBER24
1.
AppendixorFieldName
OtherCoverageCode
TransactionType
Field
Number
38C8
88KD
Action
Addition
Deletion
Addition
Deletion
Modification
Values:Correctedvaluestoshowas1digitratherthan2digits(removedleadingzero).
Values:Correctedvaluestoshowas1digitratherthan2digits(removedleadingzero).
2.
TelecommunicationStandardVersionA.1
AppendixorFieldName
Field
Number
12A2
Action
Modification
Addedvalue:A1=VersionA.1
Q.
JANUARY25
1.
SCRIPTStandardVersions7.and7.1
UpdatestoAppendixJSCRIPTDATAELEMENTSofthisdocumentnoted.
R.
MAY25
1.
TelecommunicationStandardVersionB.
AppendixorFieldName
PatientResidence
PatientLocation
AppendixAALPHABETICCROSSREFERENCE
AppendixBNUMERICCROSSREFERENCE
Field
Number
3844X
37C7
Action
Addition
X
12A2
X
X
Deletion
Modification
FieldNameChangedtoPlaceofService,DefinitionChanged,Values:Existingdeletedandnew
addedtoECL
Addedvalue:B=VersionB.
AddedPatientResidence;DeletedPatientLocationandAddedPlaceofService
AddedPatientResidence;DeletedPatientLocationandAddedPlaceofService
S.
JULY25
1.
TelecommunicationStandardVersionC.
AppendixorFieldName
Field
- 199 April215
Action
DATA DICTIONARY
PrescriberFirstName
FacilityName
FacilityStreetAddress
FacilityCityAddress
FacilityZip/PostalZone
NarrativeMessage
AdditionalDocumentationTypeID
LengthofNeed
LengthofNeedQualifier
Prescriber/SupplierDateSigned
RequestStatus
RequestPeriodBeginDate
RequestPeriodRecert/RevisedDate
SupportingDocumentation
QuestionNumber/LetterCount
QuestionNumber/Letter
QuestionPercentResponse
QuestionDateResponse
QuestionDollarAmountResponse
QuestionNumericResponse
QuestionAlphanumericResponse
Number
3642J
3652K
3662M
3672N
3682P
3853Q
3863U
3873V
3885J
3896D
39BM
3692Q
372R
3712S
3722T
3732U
3742V
3752W
3762X
3772Z
3784B
3794D
384G
3814H
3824J
3834K
111AM
12A2
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
Modification
AddedValues:14=AdditionalDocumentation,15=Facility,16=Narrative
AddedValue:C=VersionC.
AddedNewFieldsShownAbove
X
X
2.
SCRIPTStandardVersions8.
T.
OCTOBER25
1.
TelecommunicationStandardVersionC.1
AppendixorFieldName
Field
Number
Action
Addition
Deletion
- 200 April215
Modification
DATA DICTIONARY
AppendixorFieldName
OtherPayerBINNumber
OtherPayerGroupID
TransactionReferenceNumber
Field
Number
99MG
991MH
992MJ
88K5
Action
Addition
X
X
X
Deletion
Modification
DefinitionChanged;AddedTelecommunicationtoStandardFormat;AddedSegmentsto
Comments/Examples
AddedtoComments/Examples;REQUESTINSURANCESEGMENT.
AddedValue:C1=VersionC.1
356NU
12A2
X
X
2.
Formulary&BenefitStandardVersion1.
AppendixorFieldName
Field
Number
Action
Addition
FrontMatterofDD
AbsoluteRowNumber
AlternativesID
ChangeIdentifier
ClassID
ClassIDStepDrug
ClassName
ClassificationID
CopayID
CopayListID
CopayListType
CopayTier
CoverageID
CoverageListID
CoverageListType
DataInError
DaysSupplyPerCopay
DiagnosisCode
DrugReferenceNumber
DrugReferenceQualifier
DrugReferenceNumberAlternative
DrugReferenceQualifierAlternative
DrugReferenceNumberSource
9BN
526FQ
91BP
664
92BQ
93BR
94BS
95BT
96BU
97BV
98BW
99BX
91BY
911BZ
912B3
913B4
988MB
424DO
492WE
914B5
915B6
916B7
917B8
918B9
919CS
Deletion
Modification
AddedtoStandardFormatsF=Formulary&BenefitFormatandnewFieldFormatTypeR
=Numeric9withdecimalpointwithexplanation.
X
AddedFtoStandardFormatsandFieldFormatandFieldLengthofx(1)forF
X
AddedFtoStandardFormats
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
- 201 April215
DATA DICTIONARY
DrugReferenceQualifierSource
DrugReferenceNumberStepDrug
DrugReferenceQualifierStepDrug
ExtractDate
FileType
FirstCopayTerm
FlatCopayAmount
FormularyID
FormularyName
FormularyStatus
GenderCode
Field
Number
92CT
921CU
922CV
923DD
72MC
924DH
925ES
926FF
989MF
927FP
721MD
ListAction
ListEffectiveDate
LoadStatus
MaximumAgeQualifier
MaximumAge
MaximumAmount
MaximumAmountQualifier
MaximumAmountTimePeriod
MaximumAmountTimePeriodStartDate
MaximumAmountTimePeriodEndDate
MaximumAmountTimePeriodUnits
MaximumCopay
MaximumCopayTier
MessageLong
MessageShort
MinimumAgeQualifier
MinimumAge
MinimumCopay
NonListedPrescriptionBrandFormularyStatus
NonlistedPrescriptionGenericFormularyStatus
NonlistedBrandOverTheCounterFormularyStatus
NonlistedGenericOverTheCounterFormularyStatus
NonlistedSuppliesFormularyStatus
NumberofDrugsToTry
OutofPocketRangeStart
OutofPocketRangeEnd
PercentCopayRate
PharmacyType
PreferenceLevel
ProductNameHealthPlan
928FR
929FZ
93F2
931F8
932GA
933GB
934GC
935GF
936GG
937GH
938GJ
939GK
94GM
941GN
942GP
943GQ
944GR
945GS
946GT
947GU
948GV
949GW
95GX
951GY
952GZ
953HP
954HQ
955HR
956HS
957HT
AppendixorFieldName
Action
Addition
X
X
X
X
Deletion
Modification
AddedFtoStandardFormatsandaddedfieldIDofMC
X
X
X
X
X
DefinitionChanged,AddedFtoStandardFormatsanddeletedM,andaddedfieldIDof
MD
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
- 202 April215
DATA DICTIONARY
Product/ServiceID
Product/ServiceIDQualifierAlternative
Product/ServiceIDQualifierStepDrug
Product/ServiceIDQualifierSource
ProductType
ReceiverID
RecordCount
RecordType
Field
Number
47D7
436E1
958HU
959HV
96HW
961HX
962HY
963HZ
964JA
88K7
751M9
614
RejectCode
511FB
RelativeCost
RelativeCostLimit
ResourceLinkType
RxNormCode
RxNormQualifier
SectionColumnInError
SenderID
SourceName
SenderParticipantPassword
StepOrder
SubclassID
SubclassIDStepDrug
SubclassName
TotalRecords
TotalErrors
TotalRowsInError
TransmissionAction
TransmissionControlNumber
TransmissionDate
TransmissionDateOriginating
TransmissionNumberOriginating
TransmissionTime
TransmissionTimeOriginating
URL
966JC
967JD
968JF
969JG
97JH
971JJ
88K1
972JK
973JM
974JN
975JP
976JQ
977JR
978JS
979JT
98JU
981JV
6156
611
982JW
983JX
984JY
985JZ
986KJ
987MA
12A2
AppendixorFieldName
Action
Addition
Deletion
Modification
AddedFtoStandardFormatsandAddednewvalueof28totheECL
X
X
X
X
X
X
X
AddedFtoStandardFormatsandAddedFieldFormatandFieldLengthofx(3)forF
AddedFtoStandardFormats,AddeddefinitionforF,andAddedfieldIDofM9
AddedFtoStandardFormats,AddedFieldFormatandFieldLengthofx(3)forF,andAdded
valuesforFtotheECL
AddedFtoStandardFormats,AddedFieldFormatandFieldLengthofx(4)forF,andAdded
valuesforFasanewappendixtotheECL
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
AddedFtoStandardFormatsandAddedFormulary&Benefittovalueof1
- 203 April215
DATA DICTIONARY
AppendixorFieldName
Field
Number
Action
Addition
X
Deletion
Addition
X
X
X
X
X
X
X
X
X
Deletion
Modification
3.
SCRIPTStandardVersions8.1and9.
U.
JUNE26
1.
AppendixorFieldName
AmountofCoinsurance
CompoundIngredientModifierCodeCount
MedicaidIndicator
MedigapID
PatientSalesTax
PlanSalesTax
ProviderAcceptAssignmentIndicator
AmountofCopay/Coinsurance
BasisofCalculation
V.
Field
Number
5724U
5734V
3632H
3622G
362B
3592A
575EQ
5742Y
3612D
518FI
347HJ
351NP
Action
Modification
NameofFieldChangedtoAmountofCopay;DefinitionChanged
DefinitionChanged
AddedValue:7ChangedValue:5DefinitionfromAmountofcopay/coinsurance(518FI)as
reportedbypreviouspayertoAmountofcopay(518FI)asreportedbypreviouspayer.
AddedNewFieldsShownAboveandNameChangefor518FI
AddedNewFieldsShownAboveandNameChangefor518FI
12A2
X
X
SEPTEMBER26
1.
PostAdjudicationStandardVersion1.
AppendixorFieldName
AdjudicationDate
AdjudicationTime
AdjustmentType
AdministrativeFeeAmount
Field
Number
578
23
24
25
26
Action
Addition
X
X
X
X
X
Deletion
- 204 April215
Modification
DATA DICTIONARY
AppendixorFieldName
AdministrativeFeeEffectIndicator
Age
BenefitType
BillingCycleEndDate
CardholderDateofBirth
CarrierNumber
CheckDate
ClaimDateReceivedInTheMail
ClaimMediaType
ClaimSequenceNumber
ClientAssignedLocationCode
ClientFormularyFlag
ClientPassThrough
ClientPricingBasisOfCost
ClientSpecificData
COBCarrierSubmitAmount
COBPrimaryClaimType
COBPrimaryPayerAllowedAmount
COBPrimaryPayerAmountPaid
COBPrimaryPayerCoinsurance
COBPrimaryPayerCopay
COBPrimaryPayerDeductible
COBPrimaryPayerID
COBSecondaryPayerAllowedAmount
COBSecondaryPayerAmountPaid
COBSecondaryPayerCoinsurance
COBSecondaryPayerCopay
COBSecondaryPayerDeductible
COBSecondaryPayerID
CommunicationTypeIndicator
ContractNumber
CopayModifierID
CostDifferenceAmount
DosageFormCode
DrugCategoryCode
EligibilityCOBIndicator
EligibilityGroupID
EligibleCoverageCode
Field
Number
27
28
29
21
211
212
213
214
215
216
217
218
219
22
221
222
223
224
225
226
227
228
229
23
231
232
233
234
235
236
237
238
239
24
241
242
243
244
245
246
247
248
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
- 205 April215
Modification
DATA DICTIONARY
AppendixorFieldName
ExcessCopayAmount
FDADrugEfficacyCode
FederalUpperLimitIndicator
FederalDEASchedule
FormularyCodeType
FormularyFileID
FormularyStatus
GCNNumber
GCNSequenceNumber
GenericIndicator
GenericName
GenericProductIdentifier
HealthCareReimbursementAccountAmountAppliedRemaining
HoldHarmlessAmount
InNetworkIndicator
InsuranceCode
InternalMailOrder(Prescription/Service)ReferenceNumber
InvoicedAmount
LineOfBusinessCode
MACPrice
MACReducedIndicator
MaintenanceDrugIndicator
MedicarePlanCode
MedicareRecoveryDispensingIndicator
MedicareRecoveryIndicator
MemberSubmitAmount
MemberSubmittedClaimPaymentReleaseDate
MemberSubmittedClaimProgramCode
NameSuffix
NetAmountDue
NonPOSClaimOverrideCode
OriginalClaimReceivedDate
OutOfPocketApplyAmount
PatientSpendDownAmount
Payment/ReferenceID
PayrollClass
PharmacyClassCode
Field
Number
249
25
251
252
253
254
255
256
257
258
259
26
261
262
263
264
265
266
267
268
269
27
271
272
273
274
275
276
277
278
279
28
281
282
283
284
285
286
287
288
289
29
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
- 206 April215
Modification
DATA DICTIONARY
PlanBenefitCode
PlanCutbackReasonCode
PreferredAlternativeFileID
PrescribedDaysSupply
PrescriberCertificationStatus
PrescriberTaxonomyCode
PrescriptionOverTheCounterIndicator
ProcedureCode
ProcessorDefinedPriorAuthorizationReasonCode
ProcessorPaymentClarificationCode
ProcessorSpecificData
Product/ServiceName
RecordIndicator
RecordStatusCode
RejectOverrideCode
ServiceProviderCountyCode
SubmissionNumber
TherapeuticChapter
TherapeuticClassCodeAHFS
TherapeuticClassCodeGeneric
TherapeuticClassCodeSpecific
TherapeuticClassCodeStandard
TotalAmountPaidByAllSources
TotalNetAmountDue
TransactionID
UserBenefitID
UserCoverageID
AddressLine1
Field
Number
291
292
293
294
295
296
297
298
299
395
396
397
398
399
878
879
886
887
888
889
89
891
892
893
894
895
896
897
898
899
726
AddressLine2
727
BatchNumber
865C
BenefitID
757
AppendixorFieldName
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
Modification
FieldSizechange:Currently3Changeto:55forPostAdjudication
CommentChangefrom:Firstlineofstreetaddressofmember.Maybeonlylineofaddress.To:
Firstlineofstreetaddress.Maybeonlylineofaddress.
CommentChangefrom:Secondlineofstreetaddressofmember.Usedonlyiffirstlinewillnot
accommodateacompleteaddress.To:Secondlineofstreetaddress.Usedonlyiffirstlinewill
notaccommodateacompleteaddress.
ChangeCommentFrom"Format=CCYYDDDCC=CenturyYY=YearDDD=JuliandateExamples:
22252=September9,22".Changeto:"ForB,P,C,andD:Format=CCYYDDDCC=Century
YY=YearDDD=JuliandateExamples:22252=September9,22.ForA,anumbergenerated
bythesendertouniquelyidentifythisbatchfromothers,especiallywhenmultiplebatches
maybesentinoneday."
DefinitionChangeFrom"Benefitassignedbyprocessoridentifyingspecificplandesignassigned
togroupormember."Changeto:Assignedbyprocessortoidentifyasetofparameters,
- 207 April215
DATA DICTIONARY
AppendixorFieldName
Field
Number
City
728
DatabaseIndicator
532FW
DrugType
FirstName
425DP
717
GenderCode
721MD
LastName
716
MiddleInitial
718
PatientIDQualifier
331CX
PharmacyName
ProductStrength
8335P
6124
RecordType
614
615
616
State
729
TotalRecordCount
619
TransmissionAction
981JV
AccumulatedDeductibleAmount
12A2
512FC
517FH
571NZ
519FJ
523FN
52FK
Action
Addition
Deletion
Modification
benefits,orcoveragecriteriausedtoadjudicateaclaim."
DefinitionChangeFrom"Cityinwhichmemberresides."Changeto "Freeformtextforcity
name."FieldSizechange:Currently2Changeto:3forPostAdjudication
DefinitionChangeFrom:CodeidentifyingthesourceofdruginformationusedforDUR
processing.Changeto:CodeidentifyingthesourceofdruginformationusedforDUR
processingortodefinethedatabaseusedforidentifyingtheproduct.ValuesAdded:6=
Redbook,7=Multum
ValuedAdded:5=MultisourceBrand
DefinitionChangeFrom"Member'sfirstname."Changeto:"Firstname".FieldSizeChange:
Currently15Changeto:25forPostAdjudication
DefinitionChangeFrom"Codeidentifyingthegenderoftheindividualmember."Changeto:
"Codeidentifyingthegenderoftheindividual."FieldFormatChangetoNumericforPost
Adjudication
DefinitionChangeFrom "Lastnameofthemember(required)."Changeto "Lastname".Field
Sizechange:Currently25Changeto:35forPostAdjudication
DefinitionChangeFrom:Themiddleinitialofthemember.Changeto Individualmiddle
initial.
ValuesAdded:4=NonSSNbasedpatientidentifierassignedbyhealthplan,5=SSNbased
patientidentifierassignedbyhealthplan
DefinitionChange: ThestrengthoftheproductidentifiedintheProductCode(6118)
field."Changeto"Thestrengthoftheproduct."
ValuesAdded:PA=PostAdjudicationHistoryHeaderRecord,DE=PostAdjudicationHistory
DetailRecord,CD=PostAdjudicationHistoryCompoundDetailRecord,PT=PostAdjudication
HistoryTrailerRecord,PW=PostAdjudicationUtilizationHeaderRecord,PU=Post
AdjudicationUtilizationDetailRecord,PX=PostAdjudicationUtilizationCompoundDetail
Record,PY=PostAdjudicationUtilizationTrailerRecord
DefinitionChange"Thelastdayoftheperiodbeingreportedintheplanflatfile."Changeto
"Thelastdayoftheperiodbeingreportedinthefile."or"ForManufacturerRebates:Thelast
dayoftheperiodbeingreportedintheplanflatfile.ForPostAdjudicationHistory:Thelastday
oftheperiodbeingreportedinthefile."
DefinitionChange"Thefirstdayoftheperiodbeingreportedintheplanflatfile."Changeto
"Thefirstdayoftheperiodbeingreportedinthefile."or"ForManufacturerRebate:Thefirst
dayoftheperiodbeingreportedintheplanflatfile.ForPostAdjudicationHistory:Thefirstday
oftheperiodbeingreportedinthefile.".
DefinitionChange"Abbreviationofstateinwhichmemberresides." Changeto "Abbreviation
ofstate."
Formatchange.ForPostAdjudication::9(1)
CommentChangeforPostAdjudicationadd:Includeheaderandtrailerincount.
ValuesAdded:O=OriginalSubmission(New),C=Correction/Adjustmenttoapreviousbatch,
D=Deletionofapreviousbatch,P=Replacementofapreviousbatch(deletefollowedbyadd)
ValueAdded:PostAdjudication1Version1.
AddAforPostAdjudicationtotheStandardsFormatColumn
- 208 April215
DATA DICTIONARY
AppendixorFieldName
AmountofCoinsurance
AmountOfCopay
AssociatedPrescription/ServiceDate
AuthorizationNumber
BasisOfCalculationCopay
BasisOfCalculationDispensingFee
BasisOfCalculationFlatSalesTax
BasisOfCalculationPercentageSalesTax
CardholderID
Claim/ReferenceID
CompoundCode
CompoundIngredientBasisOfCostDetermination
CompoundProductID
CompoundRouteOfAdministration
CreationDate
CreationTime
DateOfBirth
DateOfInjury
DateOfService
DaysSupply
DaysSupplyIntendedToBeDispensed
DiagnosisCode
DispensingFeePaid
DispensingStatus
DURCoAgentID
DUR/PPSLevelOfEffortCode
EligibilityClarificationCode
FacilityID
FileType
FillNumber
Field
Number
5724U
518FI
457EP
456EN
53F3
5734V
347HJ
346HH
348HK
349HM
522FM
32C2
435DZ
46D6
49UE
447EC
449EE
448ED
489RE
488TE
452EH
88K2
88K3
34C4
434DY
41D1
414DE
45D5
345HG
424DO
492WE
48D8
57F7
343HD
476H6
475J9
4748E
39C9
3368C
72MC
43D3
558AW
Action
Addition
Deletion
Modification
AddAforPostAdjudicationtotheStandards FormatColumn
- 209 April215
DATA DICTIONARY
GrossAmountDue
GroupID
IncentiveAmountPaid
IngredientCostPaid
LevelOfService
NetworkReimbursementID
OtherAmountPaid
OtherCoverageCode
Field
Number
43DU
31C1
521FL
56F6
49D9
418DI
5452F
415DF
565J4
564J3
38C8
566J5
352NQ
351NP
PatientGenderCode
PatientID
PatientPayAmount
PercentageSalesTaxRatePaid
PersonCode
PlanType
PrescriberID
PrescriberLocationCode
PrimaryCareProviderLocationCode
Product/ServiceID
35C5
332CY
55F5
36C6
559AX
561AZ
56AY
33C3
611
466EZ
411DB
4671E
419DJ
42D2
455EM
421DL
4682E
469H5
498PY
462EV
461EU
459ER
47D7
436E1
AppendixorFieldName
Action
Addition
Deletion
Modification
AddAforPostAdjudicationtotheStandardsFormatColumn;ValueAdded:8=7=Amount
AttributedtoProductSelection(519FJ)forNonpreferredFormularyasreportedbyprevious
payer.ValueChanged:From2=AmountAttributedtoProductSelection(519FJ)asreportedby
previouspayer.To2=AmountAttributedtoProductSelection(519FJ)forBrandasreportedby
previouspayer.
- 210 April215
DATA DICTIONARY
AppendixorFieldName
QuantityDispensed
QuantityPrescribed
ReasonForServiceCode
ReceiverID
RejectCode
ResultOfServiceCode
ServiceProviderID
TaxExemptIndicator
TelephoneNumber
UnitDoseIndicator
UnitOfMeasure
UsualAndCustomaryCharge
Zip/PostalCode
Field
Number
44E5
562J1
442E7
344HF
46ET
439E4
88K7
511FB
514FE
513FD
441E6
21B1
22B2
42DK
557AV
732
429DT
628
426DQ
73
Action
Addition
Deletion
X
X
Modification
AddAforPostAdjudicationtotheStandards FormatColumn
AddAforPostAdjudicationtothe StandardsFormatColumn
AddedNewFieldsandIndicatedAforExistingFieldsShownAbove
AddedNewFieldsandIndicatedAforExistingFieldsShownAbove
2.
AppendixorFieldName
PatientAssignmentIndicator(DirectMemberReimbursement
Indicator)
BenefitStageCount
BenefitStageAmount
AmountAttributedToProductSelectionQualifier
Field
Number
391MT
392MU
393MV
394MW
576MQ
351NP
Action
Addition
X
Deletion
Modification
X
X
X
X
12A2
X
X
AddedValue:8=AmountAttributed toProductSelection(519FJ)forNonpreferredFormulary
asreportedbypreviouspayer.ModifiedValue:From2=AmountAttributedtoProduct
Selection(519FJ)asreportedbypreviouspayer.To2=AmountAttributedtoProductSelection
(519FJ)forBrandasreportedbypreviouspayer.
- 211 April215
DATA DICTIONARY
W.
OCTOBER26
1.
SCRIPTStandardVersion1.
X.
JANUARY27
1.
CompoundType
EstimatedGenericSavings
UnitDoseIndicator
Field
Number
993A7
995E2
996G1
997G2
577G3
3385C
429DT
URL
RejectCode
CompoundRouteofAdministration
42DK
987MA
511FB
452EH
12A2
AppendixorFieldName
Action
Addition
X
X
X
X
X
Deletion
Modification
AddedValuesSeeECL
NameChangetoSpecialPackagingIndicatorandDefinitionChangeAddedValues
SeeECL
AddedValuesSeeECL
AddedTforTelecommunicationtotheStandardsFormatColumn
Added,Removed,andModifiedValuesSeeECL
DeletedTforTelecommunicationtotheStandardsFormatColumninordertousenewdata
elementRouteofAdministration(995E2)
X
X
Y.
APRIL27
1.
ManufacturerRebateStandardVersion4Release1
AppendixorFieldName
InvoicedAmount1
InvoicedAmount2
InvoicedAmount3
InvoicedAmount4
InvoicedAmount5
Field
Number
15VF
151VG
152VH
153VJ
154VK
155VL
156VM
Action
Addition
X
X
X
X
X
X
X
Deletion
- 212 April215
Modification
DATA DICTIONARY
AppendixorFieldName
InvoicePrice1
InvoicePrice2
InvoicePrice3
InvoicePrice4
InvoicePrice5
InvoiceRate1
InvoiceRate2
InvoiceRate3
InvoiceRate4
InvoiceRate5
InvoiceType1
InvoiceType2
InvoiceType3
InvoiceType4
InvoiceType5
PaidAmount1
PaidAmount2
PaidAmount3
PaidAmount4
PaidAmount5
PaidBasePrice1
PaidBasePrice2
PaidBasePrice3
PaidBasePrice4
PaidBasePrice5
PaidPerUnitAmount1
PaidPerUnitAmount2
PaidPerUnitAmount3
PaidPerUnitAmount4
PaidPerUnitAmount5
PaidQuantity1
PaidQuantity2
PaidQuantity3
PaidQuantity4
PaidQuantity5
PaidRate1
PaidRate2
PaidRate3
PaidRate4
Field
Number
157VN
158VP
159VQ
16VR
161VS
162VT
163VU
164VV
165VW
166VX
167VY
168VZ
169WA
17WB
171WC
172WD
173WF
174WG
175WH
176WJ
177WK
178WL
179WM
18WN
181WP
182WQ
183WR
184WS
185WT
186WU
187WV
188WW
189WX
19WY
191WZ
192XA
193XB
194XC
195XD
196XF
197XG
198XH
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
- 213 April215
Modification
DATA DICTIONARY
PaidRate5
Segment1
Segment2
Segment3
Segment4
Segment5
Segment6
SegmentQualifier1
SegmentQualifier2
SegmentQualifier3
SegmentQualifier4
SegmentQualifier5
SegmentQualifier6
PharmacyServiceType
AdjudicationDate
AdjudicationTime
AdjustedQuantity
Baseline
BaselineDescription
BaselineQualifier
BasePrice
BasePriceDescription
BasePriceType
CompoundCode
DataLevel
Field
Number
199XJ
638XK
639XL
64XM
641XN
642XP
643XQ
644XR
645XS
646XT
647XU
648XV
649XW
147U7
578
23
6171
6172
6177
6178
6179
6174
6175
6176
393MV
46D6
6131
DispensingStatus
DisputedQuantity
FFAcceptedMetricDecimalQuantity
343HD
6185
784
6186
FFActionCode
6136
AppendixorFieldName
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
Modification
AddedRebatesToStandardsFormatColumn
DefinitionChanged
DefinitionChanged
DeletedField
DeletedField
DeletedField
DeletedField
DeletedField
DeletedField
Values:DeletedCI=ContractingorganizationpharmacyIDlevel,CZ=Contractingorganization
pharmacyzipcodelevel,PI=PlanpharmacyIDlevel,PZ=Planpharmacyzipcodelevel;Added
RS=ReconciliationdetailStateMedicaid,US=UtilizationdetailStateMedicaid
DefinitionChanged
Added RebatesToStandardsFormatColumn
NameChanged:
From:FFAcceptedMetricDecimalQuantity
To:AcceptedQuantity
NameChanged:
From:FFActionCode
To:SubmitCode
ValuesChanged:
To:
=Originalorinitialsubmissionofdata.
2=CorrectionorAdjustmenttoprevioussubmissionrebateperiod.
3=Deleteentireprevioussubmissionrebateperiod.
5=Replaceentirepreviouslysubmittedrebateperiod.
- 214 April215
DATA DICTIONARY
FFContractingOrganization(PMO)IDQualifier
Field
Number
671
FFDataProviderIDQualifier
6137
FFManufacturer(PICO)IDQualifier
672
FFNew/RefillCode
FFPrescriberIDQualifier
FFTotalMetricDecimalQuantity
6157
6138
6139
FFTotalNumberOfPrescriptions
614
FillNumber
GrandTotalAcceptedMetricDecimalQuantity
43D3
6187
GrandTotalMetricDecimalQuantity
6141
GrandTotalPaidRebateAmount
6188
GrandTotalRequestedRebateAmount
6142
LevelAchieved
NumberofRebateTypeRecords
OtherCoverageCode
PaidRebateAmount
Performance
PerformanceDescription
PerformanceQualifier
619
6191
38C8
6196
6197
6198
6199
AppendixorFieldName
Action
Addition
Deletion
Modification
NameChanged:
From:FFContractingOrganization(PMO)IDQualifier
To:ContractingOrganization(PMO)IDQualifier
FormatChanged:
From:x(1)
To:x(2)
NameChanged:
From:FFDataProviderIDQualifier
To:DataProviderIDQualifier
FormatChanged:
From:x(1)
To:x(2)
NameChanged:
From:FFManufacturer(PICO)IDQualifier
To:Manufacturer(PICO)IDQualifier
FormatChanged:
From:x(1)
To:x(2)
DeletedField
DeletedField
NameChanged:
From:FFTotalMetricDecimalQuantity
To:TotalQuantity
NameChanged:
From:FFTotalNumberOfPrescriptions
To:TotalNumberOfPrescriptions
AddedRebatesToStandardsFormatColumnandmovevaluestoECL
NameChanged:
From:GrandTotalAcceptedMetricDecimalQuantity
To:GrandTotalAcceptedQuantity
NameChanged:
From:GrandTotalMetricDecimalQuantity
To:GrandTotalQuantity
DefinitionChanged
DefinitionChange
NameChanged:
From:GrandTotalPaidRebateAmount
To:GrandTotalPaidAmount
NameChanged:
From:GrandTotalRequestedRebateAmount
To:GrandTotalRequestedAmount
DeletedField
DeletedField
DefinitionChange
DeletedField
DeletedField
DeletedField
- 215 April215
DATA DICTIONARY
PharmacyIDCode
PharmacyIDQualifier
PharmacyZipCode
PlanReimbursementAmount
Field
Number
6145
6146
8355R
6147
PlanReimbursementQualifier
6148
AppendixorFieldName
PrescriberID
411DB
466EZ
Prescription/
ServiceReferenceNumberQualifier
42D2
455EM
ProductCode
ProductGenericName
Product/ServiceID
6118
6119
6123
47D7
436E1
Action
Addition
Deletion
Modification
DeletedField
DeletedField
DeletedRebatesToStandardsFormatColumn
NameChanged:
From:PlanReimbursementAmount
To:ReimbursementAmount
NameChanged:
From:PlanReimbursementQualifier
To:ReimbursementQualifier
DefinitionChanged
FormatChanged:
From:x(1)
To:x(2)
ValuesChanged(Addedzeroduetoformatchange)
1=Includesdispensingfee
2=Excludesdispensingfee
FormatChangeForRebates:
From:x(1)
To:x(15)
AddValuesforRebate:
A=AMAorMedicalEducation(ME)number
B=AOADoctorofOsteopathy(DO)number
C=ContractingOrganizationPMOnumber
D=DEAnumber
H=HIBCCHIN
M=Manufacturer(PICO)assignednumber
P=NationalProviderId
T=Telephonenumber
Z=MutuallyagreeduponIdnumber
AddValuesforRebate:
RebatesStandardValues:
1=Telecommunicationv5.16.Rx7bytes
2=Telecommunicationv7.C.4Rx9bytes
3=TelecommunicationvDorhigherRx12bytes
Z=TradingPartnerDefined
DeletedField
DeletedField
DefinitionChange
- 216 April215
DATA DICTIONARY
RebateRate
RebateType
RebateTypeDescription
RebateVarianceAmount
Field
Number
624
625
626
627
613
621
RecordType
614
ServiceProviderID
21B1
22B2
AppendixorFieldName
Z.
Action
Addition
Deletion
X
X
Modification
DeletedField
DeletedField
DeletedField
DeletedField
AddValue:
4.1=Version4.1
(AddtoECL)
AppendixNameChanged:(InECL)
From:APPENDIXFCMSRECONCILIATIONREASONCODESFORDETAIL(RD)RECORDS
To:APPENDIXFCMSRECONCILIATIONREASONCODESFORDETAIL(RS)RECORDS
Values:DeletedRT=RebateTypeRecord
Added
US=UtilizationDetailStateFormat
RS=ReconciliationDetailStateFormat
AddedNewFieldsandAdjustedStandardUsageasShownAbove
JULY27
1.
TelecommunicationVersionDRelease
AppendixorFieldName
BillingEntityTypeIndicator
PayToQualifier
PayToID
PayToName
PayToStreetAddress
PayToCityAddress
PayToZip/PostalZone
GenericEquivalentProductIDQualifier
GenericEquivalentProductID
AdditionalMessageInformationCount
AdditionalMessageInformationContinuity
AdditionalMessageInformationQualifier
Field
Number
117TR
118TS
119TT
12TU
121TV
122TW
123TX
124TY
125TZ
126UA
128UC
129UD
13UF
131UG
132UH
133UJ
134UK
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
- 217 April215
Modification
DATA DICTIONARY
AppendixorFieldName
Field
Number
135UM
Action
Addition
X
AmountAttributedtoProductSelection/NonPreferredFormulary
Selection
AmountAttributedtoProductSelection/BrandNonPreferred
FormularySelection
CMSLowIncomeCostSharing(LICS)Level
MedicarePartDCoverageCode
NextMedicarePartDEffectiveDate
NextMedicarePartDTerminationDate
OtherPayerPersonCode
OtherPayerPatientRelationshipCode
OtherPayerBenefitEffectiveDate
OtherPayerBenefitTerminationDate
OtherPayerHelpDeskPhoneNumber
PharmacyServiceType
IngredientCostContracted/ReimbursableAmount
DispensingFeeContracted/ReimbursableAmount
OtherCoverageCode
136UN
137UP
138UQ
139UR
14US
141UT
142UV
143UW
144UX
145UY
127UB
147U7
148U8
149U9
38C8
X
X
X
X
X
X
X
X
X
X
PreferredProductCopayIncentive
PreferredProductCount
555AT
5519F
461EU
OtherAmountClaimedSubmittedQualifier
479H8
564J3
351NP
AmountAttributedtoProductSelectionQualifier
526FQ
519FJ
576MQ
ApprovedMessageCode
5486F
Deletion
Modification
AddedTelecommunicationToStandardsFormatColumn
X
X
Values: Modifydefinition:8=Claimisbillingforpatientfinancialresponsibilityonly;3=Other
CoverageBilledclaimnotcovered;=NotspecifiedbypatientDelete:5=Managedcareplan
denial;6=Othercoveragedeniednotparticipatingprovider;7=Othercoverageexistsnotin
effectonDOS
Fieldnameto:PreferredProductCostShareIncentive
CommentsChangeto: PreferredProductCostShareIncentive(555AT)
Values:Change4=ExemptionfromCopayand/orCoinsurance;Add 9=Emergency
Preparedness=Codeusedtooverrideclaimeditsduringanemergencysituation.
Values: DeleteBlank=NotSpecified
Values: ChangeBlank=NotSpecified(ThisvalueisnotallowedfortheTelecommunication
Standard)
Values:Add9=AmountattributedtoHealthPlanAssistanceAmount(129UD)asreportedby
previouspayer;1=AmountAttributedtoProviderNetworkSelection(133UJ)asreportedby
previouspayer.;11=AmountAttributedtoProductSelectionBrandNonPreferred
FormularySelection(136UN)asreportedbypreviouspayer.;12=AmountAttributedto
CoverageGap(137UP)thatwascollectedfromthepatientduetoacoveragegap.;13=
AmountAttributedtoProcessorFee(571NZ)asreportedbypreviouspayer.Change
2=AmountAttributedtoProductSelectionBrandDrug(134UK)asreportedbyprevious
payer.8=AmountAttributedtoProductSelectionNonPreferredFormularySelection(135
UM)asreportedbypreviouspayer.
Format=Changefromx(1)x(2) to X(1)x(4)
DeleteuseoftheTelecommunicationStandardforthisfield.
DeleteFieldTelecommunicationistheonlyStandardthatusesthisfield.GreyoutinDDas
notused.
Values: Add
4
FilledDuringTransitionBenefit
5
FilledDuringTransitionBenefit/PriorAuthorizationRequired
6
FilledDuringTransitionBenefit/NonFormulary
7
FilledDuringTransitionBenefit/OtherRejection
- 218 April215
DATA DICTIONARY
AppendixorFieldName
Field
Number
TransactionCode
112AN
13A3
AuthorizedRepresentativeCityAddress
498PH
498PE
498PF
498PJ
AuthorizedRepresentativeStreetAddress
498PG
498PK
BINNumber
11A1
DateofInjury
DaysSupplyIntendedtobeDispensed
434DY
345HG
DispensingFeePaid
DispensingStatus
57F7
412DC
343HD
558AW
481HA
GroupID
31C1
Action
Addition
Deletion
Modification
8
EmergencyFillSituation
9
EmergencyFillSituation/PriorAuthorizationRequired
1
EmergencyFillSituation/NonFormulary
11
EmergencyFillSituation/Otherrejection
12
LevelofCareChange
13
LevelOfCareChange/PriorAuthorizationRequired
14
LevelOfCareChange/NonFormulary
15
LevelOfCareChange/Otherrejection
Values:AddB=Benefit;Comments:Remove Comments: Usedintheresponsestatussegment.
Values: AddD1=PredeterminationofBenefits;S1=ServiceBilling;S2=ServiceReversal ;
S3=ServiceRebill
Comments:Remove Comments: Requiredbysomeplanstocapturethisinformation,if
applicable.
applicable.
applicable.
applicable.
Comments:RemoveComments: Requiredbysomeplanstocapturethisinformation,if
applicable.
applicable.
Comments:Change BINtoIINwhenreferencingANSI.NotethatIINisformerlyBIN.Addnote
aboutcontactingNCPDPforProcessorBINNumber.
Comments:EachprocessorwillneedtohaveaBINIIN(formerlyBIN)assignedby:
AmericanNationalStandardsInstitute;5West43rdStreet;NewYork,NY136
(212)64249
oraProcessorNumberassignedby:
NationalCouncilforPrescriptionDrugPrograms;924ERaintreeDr;Scottsdale,AZ;8526
7518;Phone:(48)4771;Fax:(48)767142;Contact:NCPDPProviderServices;
http://www.ncpdp.org
Comments:Remove Comments: ThisfieldisusedprimarilyforWorker'sCompensationClaims.
Comments:Remove Comments: Ifsendingthisfield,anassumptionismadethatQuantity
IntendedToBeDispensed(344HF)isalsosent.
Comments:Remove Comments: Includedintheprescriptionresponse.
Comments:Remove Comments: Includedintheprescriptionrequest.
Comments:RemoveComments: Afullquantitydispensedisindicatedbyeithernotsendingor
notpopulatingthisfield.
Values:DeleteBlank=NotSpecified
Comments:Remove Comments: IncludedinPrescriptionandServiceResponse.
Comments:RemoveComments: IncludedinthePrescriptionClaimandServiceClaimRequest.
AddThesubmissionofsalestaxisgovernedbyregulatoryagencies(state,local,parish,etc).If
thesalestaxreportedisaflatrate,thenitisafixedamountforacertaindollarvalue(for
examplefor$xxxitisacertainamount).Forexample,for$1theflatrateis$1.99.Thisflat
rateisthenreportedinFlatSalesTaxAmountSubmitted(481HA).
Comments:Remove Comments:Processordefinedvaluetocommunicatetheoriginators
groupingofthecardholder.
- 219 April215
DATA DICTIONARY
IncentiveAmountPaid
IngredientCostPaid
Field
Number
521FL
438E3
56F6
49D9
463EW
445EA
OriginallyPrescribedQuantity
446EB
48H9
OtherAmountPaid
565J4
431DV
566J5
356NU
OtherPayerIDCount
355NT
352NQ
PatientID
332CY
PatientIDQualifier
331CX
433DX
PatientPayAmount
55F5
559AX
482GE
PersonCode
33C3
PrescriberLastName
427DR
PriorAuthorizationDollarsAuthorized
498RB
498RA
AppendixorFieldName
Action
Addition
Deletion
Modification
Comments:Remove Comments: Includedintheprescriptionresponse.
Comments:Remove Comments: IncludedinthePrescriptionResponse.
Comments:Remove Comments: IncludedinthePrescriptionRequest.
Comments:ChangeFrom: Comments:UsageChangeCheckImplementationGuidewhen
value=99To:Comments:SeeImplementationGuide(UnderClaimSegmentinSpecific
SegmentDiscussion)whenvalue=99.
Comments:Remove Usedtoprovidenecessarydatatocalculatetheexactdifferenceincost
betweentheprescribedproductandthedispensedproduct.
Comments:Remove Toprovidedatanecessarytocalculatetheexactdifferenceincost
betweentheprescribedproductandthedispensedproduct.Forusewiththerapeutic
interchangeonly.
Comments:Remove IncludedinthePrescriptionClaimandServiceClaimRequest.
AmountisincludedintheGrossAmountDue(43DU).
Comments:Remove
Comments:IncludedinPrescriptionandServiceResponse.
DefinitionChange
Comments:RemoveComments:IncludedinthePrescriptionandServiceClaimRequest.
DefinitionChange
Comments:RemoveComments:IncludedinPrescriptionandServiceResponse.
Comments:RemoveComments:Requiredonarejectedresponsewhenavailable.Changefrom
ResponseStatusSegment.toResponseCoordinationofBenefits/OtherPayersSegment.
Comments:RemoveComment: Requiredonarejectedresponsewhenthesenderisproviding
otherpayerinformationChangefromResponseStatusSegment.toResponseCoordinationof
Benefits/OtherPayersSegment.
Comments:Remove Comment: Thisfieldissubmittedbythepharmacistforthepurposeof
billingthepatientsfinancialresponsibilityasreportedbythepreviouspayer.
Comments:Remove Comment:Thisfieldisusedtouniquelyidentifythepatientforpurposes
otherthanbilling.
Values:DeleteBlank=NotSpecifiedAdd6=MedicaidID
Comments:Remove Comments: IncludedinthePrescriptionandServiceClaimRequest. Add
Comments:.Thisfieldisnotusedincoordinationofbenefittransactionstopasspatentliability
informationtoadownstreampayer.SeeOtherPayerPatientResponsibilityAmount(352NQ)
Comments:Remove Comments: IncludedinPrescriptionandServiceResponse.
Comments:RemoveComments: Includedinprescriptionclaimandserviceclaimrequest.This
amountisincludedintheGrossAmountDue(43DU).
AddComments:.Thesubmissionofsalestaxisgovernedbyregulatoryagencies(state,local,
parish,etc).
Comments:Remove underTelecommunication Comments: PersonCodeisoptionallyusedin
conjunctionwiththeCardholderID,Field32C2,touniquelyidentifyfamilymemberswithin
thecardholderID.
Comments:RemoveComments:Thisfieldisusedsometimeswhenaprescribernumberis
unknownornotavailable.
Examples:Remove Examples: Providedtothepharmacybytheprocessortobeusedbythe
pharmacytobilltheplan.Ifthepriorauthorizationdollarsauthorizedis$76.thisfieldwould
reflect:76{.
Comments:Reword Comments: Providedtothepharmacybytheprocessortoallow conveythe
- 220 April215
DATA DICTIONARY
AppendixorFieldName
Field
Number
498PX
ProfessionalServiceFeeSubmitted
562J1
477BE
344HF
514FE
TransactionCount
19A9
469H5
4671E
466EZ
4682E
22B2
DispenseAsWrittenProductSelectionCode
48D8
Action
Addition
Deletion
Modification
pharmacytodispense thenumberofunitsauthorized.
Comments:Reword Comments: Providedtothepharmacybytheprocessortobeused bythe
pharmacyforbilling,andifapplicable,reversalpurposes.todeterminequantityremainingfor
billing.
Comments:Remove Comments: IncludedintheServiceResponse.
Comments:Remove Comments: IncludedintheServiceRequest.Thisamountisincludedinthe
GrossAmountDue(43DU).
Comments:Remove Ifsendingthisfield,anassumptionismadethatDaysSupplyIntended To
BeDispensed(345HG)isalsosent.
Examples:Remove Examples: Patienthas$1.benefits.Thepatientpays$4.fora
prescription.Theremainingbenefitamountwouldbe$6.,andthisfieldwouldreflect:
6{.
Comments:RewordFrom: Fieldvaluedefaultsto1.Avalue>1appliestoalltransaction
codesexceptEandPtransactions.To:Atransactioncountof>1isnotallowedfor
EligibilityandPriorAuthorizationtransactions.
Value:DeleteBlank=NotSpecified
DeletedusebytheTelecommunicationStandard
DeletedusebytheTelecommunicationStandard
Values:Add15=HCID(HCIDea)=A1character,alphanumericidentifierassignedbyNCPDP
toidentifyauthorizedprescribersofdrugs.Change99=Other=usedtoidentifytheHCIdea
numberorotherhealthplansandenumeratingorganizationsnotlistedabove.;Blank=Not
Specified(ThisvalueisnotallowedfortheTelecommunicationStandard)
toidentifyauthorizedprescribersofdrugs.Change99=Other=usedtoidentifytheHCIdea
numberorotherhealthplansandenumeratingorganizationsnotlistedabove.;Blank=Not
Specified(ThisvalueisnotallowedfortheTelecommunicationStandard)
toidentifyauthorizedprescribersofdrugs.ChangeBlank=NotSpecified(Thisvalueisnot
allowedfortheTelecommunicationStandard);99=Other=usedtoidentifytheHCIdea
numberorotherhealthplansandenumeratingorganizationsnotlistedabove.
Values: ChangeNameandDefinitionFrom:9=OtherThisvalueisreservedandcurrentlynotin
use.NCPDPdoesnotrecommenduseofthisvalueatthepresenttime.PleasecontactNCPDPif
youintendtousethisvalueanddocumenthowitwillbeutilizedbyyourorganization.To:
9=SubstitutionAllowedByPrescriberbutPlanRequestsBrandPatient'sPlanRequestedBrand
ProductToBeDispensedThisvalueisusedwhentheprescriberhasindicated,inamanner
specifiedbyprevailinglaw,thatgenericsubstitutionispermitted,buttheplan'sformulary
requeststhebrandproduct.Thissituationcanoccurwhentheprescriberwritesthe
prescriptionusingeitherthebrandorgenericnameandtheproductisavailablefrommultiple
sources;ChangeDefinitionFrom:=NoProductSelectionIndicatedThisisthefielddefault
valuethatisappropriatelyusedforprescriptionswhereproductselectionisnotanissue.
Examplesincludeprescriptionswrittenforsinglesourcebrandproductsandprescriptions
writtenusingthegenericnameandagenericproductisdispensed.To:=NoProduct
SelectionIndicatedThisisthefielddefaultvaluethatisappropriatelyusedfor
prescriptionsforsinglesourcebrand,cobranded/colicensed,orgenericproducts.Foramulti
sourcebrandedproductwithavailablegeneric(s),DAWisnotappropriate,andmayresultin
areject.From:1=SubstitutionNotAllowedbyPrescriberThisvalueisusedwhentheprescriber
indicates,inamannerspecifiedbyprevailinglaw,thattheproductistobeDispensedAs
WrittenTo:1=SubstitutionNotAllowedbyPrescriberThisvalueisusedwhentheprescriber
indicates,inamannerspecifiedbyprevailinglaw,thattheproductistobeDispensedAs
- 221 April215
DATA DICTIONARY
AppendixorFieldName
Field
Number
DateofService
41D1
42DK
ContractNumber
24U1
BenefitID
757U6
DateofBirth
FormularyID
34C4
926FF
3385C
OtherPayerGroupID
992MJ
OtherPayerID
347C
3396C
991MH
PatientFirstName
PatientLastName
OtherPayerAmountPaidQualifier
31CA
311CB
342HC
CardholderID
42D2
456EN
32C2
PercentageSalesTaxRateSubmitted
483HE
PercentageSalesTaxBasisSubmitted
484JE
BasisofReimbursementDetermination
561AZ
522FM
5734V
347HJ
BasisOfCalculationCopay
Action
Addition
Deletion
Modification
Written.DAW1isbasedonprescriberinstructionandnotproductclassification.
DefinitionChange
Values: Add19=SplitBilling indicatesthequantitydispensedistheremainderbilledtoa
subsequentpayerwhenMedicarePartAexpires.Usedonlyinlongtermcaresettings.Change
=NotSpecified,Default(ThisvalueisnotallowedfortheTelecommunicationStandard)
Comments:AddResponseInsuranceAdditionalInformation Segment.;FieldID AddU1;Add
toTelecommunicationforStandardFormats;DefinitionChange
Comments:AddResponseInsuranceAdditionalInformation Segment. Note:ForPartD,used
toidentifythePBP(PlanBenefitPackage)Number.;FieldIDAddU6;Addto
TelecommunicationforStandardFormats;DefinitionChange
Comments:AddResponsePatientSegment.
Comments:AddResponseInsuranceAdditionalInformation Segment.; Addto
TelecommunicationforStandardFormats
Comments:AddResponseCoordinationofBenefits/OtherPayersSegment
Values:Remove98=Coupon;99=Composite
Comments:AddResponseCoordinationofBenefits/OtherPayersSegment; Remove Response
StatusSegment
StatusSegment
StatusSegment
Values:RemoveBlank=NotSpecified;9=Coupon
StatusSegment
Values: RemoveBlank=NotSpecified;8=SumofAllReimbursements;98=Coupon;
99=Other
Format=ChangeFrom9(9)To 9(12)
Format=ChangeFrom9(9)To 9(12)
DefinitionChange
Comments:AddResponseInsuranceSegment.
Comments:AddComments:. Thesubmissionofsalestaxisgovernedbyregulatoryagencies
(state,local,parish,etc).
Comments:AddComments:. Thesubmissionofsalestaxisgovernedbyregulatoryagencies
(state,local,parish,etc).
Values:Delete1=GrossAmountDue
Values: Delete1=GrossAmountDue
Values:Add14=OtherPayerPatientResponsibilityAmount Indicatesreimbursementwas
basedontheOtherPayerPatientResponsibilityAmount(352NQ);15=PatientPayAmount
IndicatesreimbursementwasbasedonthePatientPayAmount(55F5).;16=Coupon
PaymentIndicatesreimbursementwasbasedontheCouponValueAmount(487NE)
submittedorcouponamountdeterminedbytheprocessor.
Values:ChangeBlank=NotSpecified(ThisvalueisnotallowedfortheTelecommunication
Standard);=NotSpecified(ThisvalueisnotallowedfortheTelecommunicationStandard)
- 222 April215
DATA DICTIONARY
AppendixorFieldName
BasisOfCalculationDispensingFee
Field
Number
346HH
423DN
528FS
CompoundCode
46D6
488RE
CouponType
DatabaseIndicator
485KE
532FW
492WE
475J9
HelpDeskPhoneNumberQualifier
NumberofRefillsAuthorized
5497F
415DF
453EJ
PreferredProductIDQualifier
552AP
419DJ
455EM
436E1
ProviderIDQualifier
RejectCode
TaxExemptIndicator
465EY
353NR
511FB
557AV
12A2
BasisOfCostDetermination
2.
Action
Addition
Deletion
Modification
Values:ChangeBlank=NotSpecified(Thisvalueisnotallowedforthe Telecommunication
Standard);=NotSpecifiedDefault
Values:Define9=Undeterminedavaluetodescribeaprofessionalservicewithvariableor
unknownseverity.
Standard)
Standard)
(ReferenceSectionII,AppendixB1Product/ServiceQualifieroftheECL)
Standard)
Standard)
Standard)
Values:Change=NoRefillsAuthorized
Values: DeleteBlank=NotSpecified;=NotSpecified
Values: DeleteBlank=NotSpecified(ReferenceSectionII,
AppendixB1Product/ServiceQualifieroftheECL)
Values:Change=NotKnown
Standard)
Values: DeleteBlank=NotSpecified(ReferenceSectionII,
AppendixB1Product/ServiceQualifieroftheECL)
Format=Increasedto9(2)
SeeECLfornewrejectcodes.
DefinitionChange;Values:2deletedand3and4addedValuesmovedtoECL
AddedValue:D=VersionD.
AddedNewFieldsand AdjustedStandardUsageasShownAbove
X
X
AppendixorFieldName
MedicaidPaidAmount
Field
Number
113N3
Action
Addition
X
Deletion
- 223 April215
Modification
DATA DICTIONARY
AppendixorFieldName
MedicaidSubrogationInternalControlNumber/TransactionControl
Number(ICN/TCN)
MedicaidIDNumber
MedicaidAgencyNumber
RejectCode
Field
Number
114N4
115N5
116N6
511FB
12A2
Action
Addition
X
Deletion
Modification
X
X
SeeECLfornewrejectcodes.
AddedValue:3=Version3.
AddedNewFieldsasShownAbove
AddedNewFieldsasShownAbove
X
X
3.
AA.
JANUARY28
1.
FinancialInformationReportingStandardImplementationGuideVersion1Release
AccumulatorYear
TransactionIdentifier
AccumulatedPatientTrueOutOfPocketAmount
AccumulatedGrossCoveredDrugCostAmount
DateTime
AccumulatorMonth
AccumulatorMonthCount
BINNumber
TransactionCode
Field
Number
65S1
651S2
652S3
653S4
654S5
655S6
656S7
11A1
13A3
TransactionCount
SoftwareVendor/CertificationID
14A4
19A9
11AK
111AM
CardholderID
GroupID
PersonCode
Message
32C2
31C1
33C3
51F1
54F4
112AN
AppendixorFieldName
Action
Addition
X
X
X
X
X
X
X
Deletion
Modification
AddedNforFinancialInformationReporting ToStandardsFormatColumn
AddedNforFinancialInformationReportingToStandardsFormatColumnSee ECLfornew
values.
AddedNforFinancialInformationReportingToStandardsFormatColumn
values.
AddedNforFinancialInformationReportingToStandardsFormatColumnSee ECLfor
applicablevalues.
- 224 April215
DATA DICTIONARY
AuthorizationNumber
RejectCount
Field
Number
53F3
51FA
526FQ
RejectCode
511FB
12A2
AppendixorFieldName
Action
Addition
Deletion
X
X
Modification
AddedNforFinancialInformationReportingToStandardsFormatColumnUsesfieldlength
of1
rejectcodes.
Added NforFinancialInformationReportingToStandardsFormatColumn SeeECLfornew
values.
AddedFieldsasShownAbove
2.
AppendixorFieldName
PharmacyDispenserTypeQualifier
PharmacyClassCodeQualifier
FormularySelection
Selection
BenefitStageAmount
CompoundType
GCNNumber
GCNSequenceNumber
GenericProductIdentifier
PatientResidence
PharmacyClassCode
Field
Number
146
15
137UP
519FJ
134UK
136UN
Action
Addition
X
X
Deletion
Modification
AddedAforPostAdjudication ToStandardsFormatColumn
DeletedfieldnotusedinPostAdjudicationVersion2.
AddedAforPostAdjudicationToStandardsFormatColumn
135UM
133UJ
393MV
394MW
997G2
452EH
996G1
258
259
262
129UD
3844X
289
AddedAforPostAdjudicationToStandardsFormatColumn SeeECLfornewvalue.
DeletedcommentsSeevaluesinNCPDPPharmacyDatabaseFilesStandardImplementation
Guide
DeletedcommentsSeevaluesinNCPDPPharmacyDatabaseFilesStandardImplementation
Guide
ThisfieldhadbeendeletedfromtheApril27DD(usedintheRebatesStandard).Addedback
29
PlaceofService
37C7
4671E
469H5
6119
X
X
X
X
X
X
X
- 225 April215
DATA DICTIONARY
Field
Number
AppendixorFieldName
ProductCode
6118
RecordStatusCode
RecordType
TherapeuticClassCodeAHFS
TherapeuticClassCodeGeneric
TherapeuticClassCodeSpecific
TherapeuticClassCodeStandard
399
614
995E2
886
128UC
89
891
892
893
6125
6126
12A2
Action
Addition
Deletion
X
X
X
X
X
X
Modification
intotheDDforuseinPostAdjudicationVersion2.SeeECLforvalues
ThisfieldhadbeendeletedfromtheApril27DD(usedintheRebatesStandard).Addedback
intotheDDforuseinPostAdjudicationVersion2.
DeletedvalueofblankinECL
Valuesmodificationandaddition.SeeECL
Formatchangedfromnumerictoalphanumeric
SeeECLfornewvalues.
3.
AppendixorFieldName
AddressCount
AddressQualifier
Bed
ClientName
DiscontinueDateQualifier
DiscontinueDate
EasyOpenCapIndicator
EffectiveDate
ExpirationDate
FacilityUnit
FileStructureType
HoursOfAdministration
InactivePrescriptionIndicator
LabelDirections
MostRecentDateFilled
NumberOfFillsToDate
NumberOfFillsRemaining
OriginalDispensedDate
PrescribedProductDescription
FieldNumber
63MY
64NA
671W1
65NB
66NC
67ND
68NF
69NG
61NH
672W2
611NJ
673W3
612NK
613NM
614NW
615NY
616PU
617RQ
619RW
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
- 226 April215
Modification
DATA DICTIONARY
AppendixorFieldName
FieldNumber
PackageAcquisitionCost
PatientIDQualifierCount
PharmacistInitials
PrescriberIDCount
PrescriberSpecialty
PrescriberSpecialtyCount
QuantityDispensedToDate
RecordDelimiter
RemainingQuantity
Room
SenderName
SendingPharmacyID
TechnicianInitials
TelephoneNumberCount
TelephoneNumberQualifier
TotalNumberOfSendingAndReceivingPharmacy
Records
TransferFlag
TransferType
UniqueRecordIdentifier
UniqueRecordIdentifierQualifier
AddressLine1
633SN
618RR
636TD
62RX
621RY
622RZ
623SA
624SB
625SC
674W4
626SD
627SF
637TF
628SG
629SH
63SJ
AddressLine2
727SS
526FQ
AlternateIDNumber
BatchNumber
CardholderFirstName
724ST
865C
312CC
CardholderID
CardholderLastName
32C2
313CD
City
CompoundCode
CreationDate
CreationTime
DateOfBirth
DateOfService
DaysSupply
DestinationName
728SU
46D6
88K2
88K3
34C4
41D1
414DE
45D5
8185F
631SK
632SM
634SP
635SQ
726SR
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
Modification
X
X
X
X
AddedVforPrescriptionTransferToStandardsFormatColumn AddFieldIDAddComments:
ForPrescriptionTransfer,qualifiedbyADDRESSQUALIFIER(64NA)
AddedVforPrescriptionTransferToStandardsFormatColumn AddFieldID
AddedVforPrescriptionTransferToStandardsFormatColumn Fieldformatincreasedto2
forPrescriptionTransfer
AddedVforPrescriptionTransferToStandardsFormatColumn
AddedVforPrescription TransferToStandardsFormatColumn
AddedVforPrescriptionTransferToStandardsFormat Column AddFieldID
- 227 April215
DATA DICTIONARY
AppendixorFieldName
FieldNumber
DrugDescription
48D8
516FG
FacilityID
3368C
FacilityName
FamilyIDNumber
FileType
FillNumber
FirstName
GroupID
LastName
MiddleInitial
OtherPayerID
OtherPayerIDCount
PatientEMailAddress
PatientFirstName
3853Q
785SV
72MC
43D3
717SX
31C1
716SY
718SZ
415DF
445EA
453EJ
347C
355NT
3396C
991MH
35HN
31CA
PatientGenderCode
PatientIDQualifier
PatientID
PatientLastName
35C5
331CX
332CY
311CB
6144
PatientResidence
PayerID
PayerIDQualifier
PersonCode
PharmacyName
PregnancyIndicator
PrescriberID
ProcessorName
36C6
3844X
569J8
568J7
33C3
8335P
3352C
411DB
466EZ
42D2
462EV
14A4
8395V
Action
Addition
Deletion
Modification
AddedVforPrescriptionTransferToStandardsFormatColumnDefinitionChangeANDField
formatincreasedto6forPrescriptionTransfer
AddedVforPrescriptionTransferToStandardsFormatColumn SeeECLforvaluesadded
AddedVforPrescriptionTransferToStandardsFormatColumn Fieldformatchangedfor
PrescriptionTransfer
AddedVforPrescriptionTransferToStandardsFormatColumn ModificationtoComment
- 228 April215
DATA DICTIONARY
AppendixorFieldName
Action
FieldNumber
ProductDescription
ProductDosageForm
612
6121
Product/ServiceID
47D7
Addition
Deletion
Modification
AddedVforPrescription TransferToStandardsFormatColumn
436E1
ProductStrength
QuantityDispensed
QuantityPrescribed
ReceiverID
6124
442E7
46ET
88K7
RecordCount
751M9
RecordType
RejectCode
ServiceProviderID
State
TelephoneNumber
TextIndicator
TotalRecordCount
Zip/PostalCode
614
511FB
879N2
21B1
22B2
3341C
729TA
732TB
88K4
619
12A2
73TC
AddedVforPrescriptionTransferToStandardsFormatColumn DefinitionChangedfor
PrescriptionTransfer
AddedVforPrescriptionTransferToStandardsFormatColumnSeeECLfornewrejectcodes.
AddedVforPrescriptionTransferToStandardsFormatColumn AddComment
SeeECLfornewvalues.
X
X
4.
BB.
JUNE28
1.
AppendixorFieldName
Field
Number
657T5
658T6
659T7
66T8
Action
Addition
X
X
X
X
Deletion
- 229 April215
Modification
DATA DICTIONARY
AppendixorFieldName
SeeECLPublicationofJune28forAddedFieldValues
Field
Number
661T9
662V1
663V2
664V3
665V4
666V5
667V6
668V7
669V8
67V9
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
Modification
2.
SCRIPTStandardImplementationGuidesVersion1Release4andVersion1Release5
CC.
OCTOBER28
1.
AppendixorFieldName
AssociatedPrescription/ServiceProviderIDQualifier
AssociatedPrescription/ServiceProviderID
AssociatedPrescription/ServiceReferenceNumberQualifier
AssociatedPrescription/ServiceFillNumber
ServiceProviderName
ServiceProviderStreetAddress
ServiceProviderCityAddress
SellerInitials
SellerID
SellerIDQualifier
SalesTransactionID
PurchaserIDQualifier
PurchaserID
Field
Number
579XX
58XY
581XZ
582X
583YK
584YM
585YN
586YP
587YQ
59YT
679Y9
68ZB
681ZF
591YU
592YV
593YW
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
- 230 April215
Modification
DATA DICTIONARY
AppendixorFieldName
PurchaserDateofBirth
PurchaserGenderCode
PurchaserFirstName
PurchaserLastName
PurchaserStreetAddress
PurchaserCityAddress
PurchaserCountryCode
TimeofService
SeeECLPublicationofOctober28forAddedFieldValues
2.
Field
Number
594YX
595YY
596YZ
597Y
598Y1
599Y2
675Y3
676Y4
677Y5
678Y6
456EN
Action
Addition
X
X
X
X
X
X
X
X
X
X
Deletion
Modification
Addednewcomment
X
X
SCRIPTStandardImplementationGuidesVersion1Release6
AppendixorFieldName
ResultofServiceCode
Field
Number
439E4
441E6
528FS
Action
Addition
Deletion
Modification
Changedefinition
Changedefinition
3.
UniversalClaimFormandWorkersCompensation/Property&CasualtyForm
AppendixorFieldName
CompoundIngredientProductName
DateofBilling
DocumentControlNumber
GenericAvailable
JurisdictionalField(15)
JurisdictionalState
PayToPhoneNumber
WorkersCompensation/PropertyAndCasualtyIndicator
BasisofCostDetermination
BINNumber
CardholderFirstName
CardholderID
Field
Number
686
689
589
682
687
688
683
685
588
423DN
11A1
312CC
32C2
Action
Addition
X
X
X
X
X
X
X
X
X
Deletion
Modification
Add:ZandWtoStandardFormatsColumninDataDictionary
Add:ZtoStandardFormatsColumninDataDictionary
- 231 April215
DATA DICTIONARY
CardholderLastName
CarrierAddress
CarrierLocationCity
CarrierName
CarrierZipCode
Claim/ReferenceID
CompoundDispensingUnitFormIndicator
CompoundIngredientBasisofCostDetermination
CompoundProductID
DateofBirth
Field
Number
313CD
871D
891F
811G
8111H
8131J
435DZ
451EG
45EF
49UE
447EC
449EE
448ED
489TE
488RE
34C4
DateofInjury
434DY
DateofService
41D1
414DE
AppendixorFieldName
Action
Addition
Deletion
Modification
Add:WtoStandardFormatsColumninDataDictionary
AddtotheCommentsColumnoftheDataDictionary:
WhenusedontheUCFandWorkersCompensation/Property&CasualtyForms,theformatis:
MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
WhenusedontheWorkersCompensation/Property&CasualtyForm,theformatis:
MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
- 232 April215
DATA DICTIONARY
DaysSupply
DelayReasonCode
DiagnosisCode
DispenseasWritten(DAW)/ProductSelectionCode
DUR/PPSLevelofEffort
EmployerCityAddress
EmployerContactName
EmployerName
EmployerPhoneNumber
EmployerZip/PostalCode
FillNumber
GrossAmountDue
GroupID
NetAmountDue
OtherCoverageCode
OtherPayerDate
Field
Number
45D5
357NV
424DO
492WE
48D8
412DC
4748E
317CH
321CL
315CF
32CK
318CI
316CG
319CJ
43D3
481HA
43DU
31C1
49D9
48H9
281
38C8
431DV
443E8
OtherPayerID
OtherPayerRejectCode
PatientCityAddress
PatientFirstName
PatientGenderCode
PatientID
PatientIDQualifier
PatientLastName
PatientPhoneNumber
347C
3396C
352NQ
4726E
323CN
31CA
35C5
332CY
331CX
311CB
433DX
326CQ
AppendixorFieldName
Action
Addition
Deletion
Modification
MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
Add:ZandWtoStandard FormatsColumninDataDictionary
- 233 April215
DATA DICTIONARY
AppendixorFieldName
PayToCityAddress
PayToID
PayToName
PayToQualifier
PayToStreetAddress
PayToState/ProvinceAddress
PayToZip/PostalZone
PersonCode
PharmacyAddress
PharmacyLocationCity
PharmacyName
PharmacyTelephoneNumber
PharmacyZIPCode
PlaceofService
PlanName
PrescriberFirstName
PrescriberID
PrescriberLastName
PrescriberPhoneNumber
ProductDescription
Product/ServiceID
ProductStrength
ProviderID
Field
Number
36C6
324.CO
322CM
325CP
122TW
119TT
12TU
118TW
121TV
123TX
124TY
482GE
33C3
8295L
8315N
8326F
8335P
8345Q
8355R
37C7
696
3662M
3642J
411DB
466EZ
427DR
498PM
3672N
3652K
3682P
42D2
455EM
462EV
461EU
459ER
14A4
612
47D7
436E1
6124
44E5
444E9
Action
Addition
Deletion
Modification
Add: WtoStandardFormatsColumninDataDictionary
- 234 April215
DATA DICTIONARY
AppendixorFieldName
ProviderIDQualifier
QuantityDispensed
ResultofServiceCode
ServiceProviderID
UnitofMeasure
UsualandCustomaryCharge
Field
Number
465EY
442E7
439E4
441E6
995E2
21B1
22B2
42DK
628
426DQ
Action
Addition
Deletion
X
X
Modification
DD.
APRIL29
1.
AppendixorFieldName
InvoicedDate
OutOfPocketRemainingAmount
NumberOfGenericManufacturers
TotalGrossAmountDue
TotalPatientPayAmount
Field
Number
69ZG
691ZH
692ZJ
693
694
Action
Addition
X
X
X
X
X
Deletion
Modification
Add:AtoStandardFormatsColumninDataDictionary
2.
EE.
JUNE29
1.
AppendixorFieldName
PurchaserRelationshipCode
Field
Number
A22YR
A23YS
Action
Addition
X
X
Deletion
- 235 April215
Modification
DATA DICTIONARY
AppendixorFieldName
PrescriberAlternateIDQualifier
PrescriberAlternateID
PrescriberAlternateIDAssociatedState/ProvinceAddress
Field
Number
A24ZK
A25ZM
A26ZP
A27ZQ
Action
Addition
X
X
X
X
X
X
Deletion
Modification
2.
PriorAuthorizationStandardImplementationGuideVersion1Release
AppendixorFieldName
BenefitAmount
BenefitAmountTimePeriod
BenefitAmountType
ClaimOrigination
CompoundIndicator
Copay/CoinsuranceOverrideType
CopayConjunctionSequence
DaysSupplyUsedtoDate
DispenseAsWritten(DAW)Difference
DosagePerDay
Fills/RefillsUsedToDate
PrescriberOverrideType
PriorAuthorizationCreateDate
PriorAuthorizationNumberofFillsAuthorized
PriorAuthorizationReasonCode
PriorAuthorizationUpdateDate
ReceiverName
ServiceProviderOverrideType
SubgroupID
AlternateIDNumber
BatchNumber
CardholderID
ClientName
CreationDate
Field
Number
A
A1
A2
A3
A4
A5
A6
A7
A8
A9
A1
A11
A12
A13
A14
A15
A16
A17
A18
A19
A2
A21
526FQ
724ST
865C
32C2
65NB
88K2
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
Modification
Add:XtoStandardFormatsColumninDataDictionary
Add:XtoStandard FormatsColumninDataDictionary
Add:XtoStandard FormatsColumninDataDictionary
- 236 April215
DATA DICTIONARY
CreationTime
DateOfBirth
DaysSupply
DrugType
Field
Number
88K3
34C4
45D5
425DP
FileType
FirstName
GroupID
LastName
MiddleInitial
PatientGenderCode
PatientID
PatientIDQualifier
72MC
717SX
31C1
716SY
718SZ
35C5
332CY
331CX
PatientFirstName
PatientLastName
PersonCode
PrescriberID
PreviousDateOfFill
PriorAuthorizationEffectiveDate
PriorAuthorizationExpirationDate
PriorAuthorizationNumberOfRefillsAuthorized
ProductCode
31CA
311CB
36C6
33C3
411DB
466EZ
42D2
455EM
53FU
498PS
498PT
498PY
498PW
462EV
498RA
498PX
6118
6119
Product/ServiceID
RecordType
47D7
436E1
614
SenderName
ServiceProviderID
626SD
21B1
AppendixorFieldName
Action
Addition
Deletion
Modification
AddtoexistingValue:=NotSpecified(WhenusedinthePriorAuthorizationTransfer
Standard=Specificbutnotlimited;alllegendandOTC's)
Add:XtoStandardFormatsColumninDataDictionaryandtoExternalCodeList
AddValues:7=MedicareHIC# TheidentificationofpersonassignedbyMedicare.
8=EmployerAssignedIDTheidentificationofapersonassignedbytheemployer.
9=Payer/PBMAssignedIDTheidentificationofapersonassignedbythepayerorpharmacy
benefitmanager.
Add:XtoStandardFormatsColumninData Dictionary
AddValue:V=Allproductsused=Representsallvalidproductsregardlessoftype
AddValues:PE=PriorAuthorizationTransferHeader,PJ=PriorAuthorizationTransferDetail,
PKPriorAuthorizationTransferTrailer
- 237 April215
DATA DICTIONARY
AppendixorFieldName
TelephoneNumber
TotalRecordCount
Field
Number
22B2
732TB
619
12A2
Action
Addition
Deletion
X
X
Modification
3.
NoDataDictionarychangesweremadeforVersion1.8.ForVersion1.9,seeupdatestoAppendixJSCRIPTDATAELEMENTSofthisdocumentnoted.
4.
PostAdjudicationStandardImplementationGuideVersion2Release1andVersion
Field
Number
513FD
514FE
HealthCareReimbursementAccountAmountRemaining
264
128UC
OutofPocketRemainingAmount
691ZH
AppendixorFieldName
Action
Addition
Deletion
Addition
Deletion
Modification
CommentsColumn:Add Note:ForthefixedformatPostAdjudicationStandardifthisfield is
notapplicable,thefieldshouldcontain9999999I
CommentsColumn:Add Note:Forthefixed formatPostAdjudicationStandardifthisfield is
5.
UniversalClaimForm
AppendixorFieldName
Field
Number
419DJ
Action
Modification
FF.
OCTOBER29
1.
FinancialInformationReportingStandardImplementationGuideVersion1Release1
AppendixorFieldName
Field
Number
Action
Addition
Deletion
- 238 April215
Modification
DATA DICTIONARY
AppendixorFieldName
Action
Field
Number
Addition
Deletion
Field
Number
Addition
Deletion
X
Modification
2.
DataDictionary
AppendixorFieldName
Action
AppendicesAAlphabeticCrossReference,COldFieldNameCross
ReferenceinVersion5.,DNewFieldNameCrossReferencein
Version5.,andEDeletedDataElementsNotSupportedinVersion
5.
AppendixBNumericCrossReference
AppendixFVersion1.RejectCodesforPaymentTape
AppendixGVersion2.RejectCodesforPaymentTape
AppendixHVersion3.and4.RejectCodesforPaymentTape
AppendixITelecommunicationPhasesWithFlowCharts
AppendixJSCRIPTDataElements
AppendixKPublicationModifications
Modification
RenamedtoAppendixANumericCrossReference
RenamedtoAppendixBVersion1.RejectCodesforPaymentTape
RenamedtoAppendixCVersion2.RejectCodesforPaymentTape
RenamedtoAppendixDVersion3.and4.RejectCodesforPaymentTape
RenamedtoAppendixETelecommunicationPhasesWithFlowCharts
RenamedtoAppendixFSCRIPTDataElements
RenamedtoAppendixGPublicationModifications
GG.
JANUARY21
1.
FinancialInformationReportingStandardImplementationGuideVersion1Release2
AppendixorFieldName
CMSPartDContractID
AppendixANumericCrossReference
SeeECLPublicationofJanuary21forAddedFieldValues
Field
Number
A33ZX
A34ZY
Action
Addition
X
X
Deletion
Modification
2.
AppendixorFieldName
PrescriberSpecialty
SeeECLPublicationofJanuary21forAddedFieldValues
Field
Number
621RY
Action
Addition
Deletion
Modification
FieldSize:From3to1
- 239 April215
DATA DICTIONARY
HH.
MARCH21
1.
AppendixorFieldName
AdjudicatedPaymentType
ReportedPaymentType
ReleasedDate
ReleasedTime
CompoundPreparationTime
TotalAmountPaid
AppendixANUMERICCROSSREFERENCE
SeeECLPublicationofMarch21forAddedFieldValues
Field
Number
A28ZR
A29ZS
A3ZT
A31ZU
A32ZW
45EF
3632H
459ER
59F9
Action
Addition
X
X
X
X
X
Deletion
Modification
Format=Increasedfrom2to15
Values :ReferencedECLforCMSlink
Values :ReferencedECLforCMSlink
Comments:AddedPrescriptionResponseFormulaandServiceResponseFormula
2.
SeeupdatestoAppendixFSCRIPTDATAELEMENTSofthisdocumentnoted.
II.
JUNE21
1.
AppendixorFieldName
CMSPartDContractID
COBPrimaryPayerAllowedAmount
COBSecondaryPayerAllowedAmount
CopayWaiverAmount
MemberSubmittedClaimRejectCode
ProcedureCode
SpecialtyClaimIndicator
Field
Number
A33ZX
227
233
A39
A34ZY
A38
285
298
459ER
A37
Action
Addition
Deletion
X
X
Modification
Deletedforthisversionandgreater
X
X
X
DeletedMedicarefromfieldname
DeletedAforusebythisversionandgreater
X
Added/DeletedFieldsasShownAbove
- 240 April215
DATA DICTIONARY
2.
SeeupdatestoAppendixFSCRIPTDATAELEMENTSofthisdocumentnoted.
JJ.
SEPTEMBER21
1.
AppendixorFieldName
PatientCountryCode
SeeECLPublicationofSeptember21forAddedFieldValues
Field
Number
A431K
Action
Addition
X
Deletion
Modification
Added FieldasShownAbove
2.
AppendixorFieldName
OriginalDispensedQuantity
Field
Number
A44ZL
Action
Addition
X
Deletion
Modification
AddedFieldasShownAbove
3.
DataDictionary
AppendixorFieldName
SectionIIntroduction
Format
PayloadType
TransactionStandard
SeeECLPublicationofSeptember21forAddedFieldValues
Field
Number
A42
A4
A41
Action
Addition
Deletion
Modification
Add:K=ConnectivityStandardtoStandardFormatsKeytable
X
X
X
KK.
DECEMBER21
1.
AppendixorFieldName
VeterinaryUseIndicator
Field
Number
A451R
Action
Addition
X
Deletion
- 241 April215
Modification
DATA DICTIONARY
AppendixorFieldName
Field
Number
Action
Addition
Deletion
SeeECLPublicationofDecember21forAddedFieldValues
Modification
2.
ManufacturerRebateStandardVersion5Release
AppendixorFieldName
DosageFormIDCode
InterestAmount
TotalRemittance
Field
Number
6134
6189
6214
Action
Addition
Deletion
X
X
X
Modification
LowLightedFieldsDeleted Above
3.
FormularyandBenefitStandardVersion3Release
AppendixorFieldName
TextMessageType
ClassID
SubclassID
ClassName
SubclassName
ClassificationID
4.
Field
Number
A461S
92BQ
975JP
94BS
977JR
95BT
Action
Addition
X
Deletion
Modification
X
X
X
X
X
AddedFieldasShownAboveandLowLightedFieldsDeletedAbove
SpecializedImplementationGuideVersion21121
ThefollowingXMLelementswereincorporatedintothemainbodyoftheDataDictionary.
Field
AppendixorFieldName
Number
Addition
AcknowledgementID
X
AdditionalTraceNumber
X
AddressLine1
X
AddressLine2
X
AddressTypeQualifier
X
AllergyDrugProductCodedQualifier
X
AnticipatedReturnDate
AttachmentData
AttachmentSource
X
X
Bed
Action
Deletion
Modification
NewField
NewField
- 242 April215
DATA DICTIONARY
AppendixorFieldName
BodyType
BusinessName
CardholderID
CensusEffectiveDate
City
ClinicName
CommunicationTypeNumber
Created
DatatypesVersion
DateOfBirth
DateValidated
DaysSupply
DeliveredID
Description
DescriptionCode
DrugProductCoded
DrugProductCodedQualifier
ECLVersion
EffectiveDate
Field
Number
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
Modification
NewField
NewField
NewField
NewField
Ethnicity
NewField
ExpirationDate
NewField
FacilityName
FacilityUnit
FirstName
FrequencyOfEncountersApprovedCode
X
X
X
X
X
NewField
FrequencyOfEncountersApprovedCodeQualifier
NewField
FrequencyOfEncountersApprovedText
NewField
From
Gender
GroupID
GroupName
LanguageNameCode
LastFillDate
LastName
MailboxID
MessageID
X
X
X
X
X
X
X
X
MessageRequestCode
MiddleInitial
X
- 243 April215
DATA DICTIONARY
AppendixorFieldName
MIMEType
Field
Number
Action
Addition
X
MTMPayerCaseIdentifier
NewPassword
NoKnownAllergies
Nonce
Note
X
X
X
OldPassword
Password
X
X
PayerIdentification
PayerName
PersonCode
X
X
X
X
X
PharmacyIdentification
PharmacySpecialty
X
X
PlaceLocationQualifier
Prefix
PregnancyIndicator
PrescriberIdentification
PrescriberOrderNumber
X
X
X
PrescriberSpecialty
ProblemNameCode
ProblemNameCodeQualifier
ProblemNameCodeText
ProductCode
X
X
X
X
X
X
ProductQualifierCode
ProviderIdentification
ProviderSpecialty
Race
X
X
ReactionCoded
ReasonCode
RelatesToMessageID
RequestReferenceNumber
ResidenceCode
X
X
ReturnReceipt
Room
RxReferenceNumber
X
X
SecondaryIdentification
Deletion
Modification
NewField
NewField
NewField
- 244 April215
DATA DICTIONARY
AppendixorFieldName
SentTime
Field
Number
Action
Addition
X
X
X
X
SeverityCoded
Smoker
SNOMEDAdverseEventCode
SNOMEDAdverseEventText
SourceOfInformation
State
X
X
Deletion
Modification
StatusCode
StructuresVersion
Suffix
SupervisorIdentification
SupervisorSpecialty
TargetedTypeOfServiceCode
NewField
TargetedTypeOfServiceCodeQualifier
NewField
TargetedTypeOfServiceFreeText
NewField
TargetedTypeOfServiceText
NewField
TertiaryIdentification
TertiaryIdentifier
Text
TextMessage
NewField
TimeZoneDifferenceQuantity
TimeZoneIdentifier
To
TotalNumberOfEncountersApproved
NewField
TransactionDomain
NewField
TransactionErrorCode
TransactionVersion
TransportVersion
NewField
TypeOfServiceCode
NewField
TypeOfServiceCodeQualifier
NewField
TypeOfServiceFreeText
NewField
TypeOfServiceText
NewField
Username
VerifyStatusCode
WrittenDate
ZipCode
X
X
X
NewField
- 245 April215
DATA DICTIONARY
AppendixorFieldName
Field
Number
Action
Addition
Deletion
Modification
5.
ThefollowingXMLelementswereincorporatedintothemainbodyoftheDataDictionary.
Field
AppendixorFieldName
Number
Addition
AcknowledgementID
AcknowledgementReason
AdditionalRefillsAuthorized
AdditionalTraceNumber
AddressLine1
AddressLine2
Bed
BodyMetricQualifier
BodyMetricValue
BodyType
BusinessName
CalculatedDoseUnitOfMeasureCode
CalculatedDoseUnitOfMeasureCodeQualifier
CalculatedDoseUnitOfMeasureText
CardholderID
ChangeOfPrescriptionStatusCode
ChangeReasonText
City
ClinicName
Action
Deletion
Modification
NewField
X
528FS
RemovedusebySCRIPT,listedasseparatefield
X
CoAgentCode
CoAgentQualifier
CompoundCode
X
- 246 April215
DATA DICTIONARY
AppendixorFieldName
ComopundIngredientItemDescription
Consent
Field
Number
Action
Addition
X
Deletion
Modification
Created
DatatypesVersion
DateOfBirth
DateValidated
DaysSupply
DEAScheduleCode
DeliveredOnDate
DeliveredID
Description
DescriptionCode
Directions
DoNotFill
DoseFormCode
DoseFormText
DoseQuantity
DoseRangeModifier
DosingBasisUnitofMeasureCodeQualifier
DrugAdminReasonCode
DrugAdminReasonText
DrugDBCode
DrugDBCodeQualifier
DrugDescription
DurationText
NewField
- 247 April215
DATA DICTIONARY
AppendixorFieldName
DurationTextCode
Field
Number
Action
Addition
X
ECLVersion
EffectiveDate
EndDate
ExpirationDate
FacilityName
FacilityUnit
FillNumber
FinalCompoundPharmaceuticalDosageForm
FinalRouteOfAdministrationCode
FinalRouteOfAdministrationCodeText
FirstName
FMTVersion
FollowUpRequest
FrequencyUnitsCode
FrequencyUnitsText
From
Gender
GroupID
X
X
GroupName
IndicationText
IndicationTextCode
IndicationValueText
IndicationValueUnit
IndicationValueUnitOfMeasureCode
IndicationValueUnitOfMeasureCodeQualifier
IndicationValueUnitOfMeasureText
IntervalUnitsCode
Deletion
Modification
NewField
- 248 April215
DATA DICTIONARY
AppendixorFieldName
IntervalUnitsText
Field
Number
Action
Addition
X
LanguageNameCode
LastFillDate
LastName
X
X
MailboxID
MaximumDoseRestrictionVariableDurationModifier
MaximumDoseRestrictionVariableUnitsCode
MaximumDoseRestrictionVariableUnitsCodeQualifier
MaximumDoseRestrictionVariableNumericValue
MeasurementUnitCode
MeasurementValue
MessageID
MessageRequestCode
MiddleInitial
X
X
MultipleRouteOfAdminstrationModifier
MultipleSigModifier
MultipleSiteOfAdministrationTimingModifier
NeededNoLaterThanDate
NewPassword
Nonce
Note
X
X
NumberOfRefills
ObservationDate
X
X
OldPassword
OrderCaptureMethod
Password
X
X
PayerIdentification
X
X
Deletion
- 249 April215
Modification
DATA DICTIONARY
AppendixorFieldName
PayerName
Field
Number
Action
Addition
X
PBMMemberID
PeriodEnd
PersonCode
PharmacyIdentification
PharmacyRequestedRefills
X
X
PharmacySpecialty
Prefix
PrescriberIdentification
PrescriberOrderNumber
X
X
PrescriberSpecialty
PrimaryDiagnosisCodeQualifierCode
X
X
X
PrimaryDiagnosisValue
PriorAuthorizationCodeValue
PriorAuthorizationCodeValueQualifier
ProductCode
ProductQualifierCode
ProhibitRefillRequest
ProviderIdentification
ProviderSpecialty
QuantityCodeListQualifier.
X
X
QuantityValue
QuantityUnitOfMeasureCode
RateOfAdministration
ReasonCode
ReasonForSubstitutionCodeUsed
RefillsRemaining
RelatesToMessageID
RequestReferenceNumber
ResumeDateTime
X
X
ReturnReceipt
Deletion
Modification
NewField
NewField
- 250 April215
DATA DICTIONARY
AppendixorFieldName
Room
Field
Number
Action
Addition
X
X
RxReferenceNumber
SecondaryDiagnosisCodeQualifierCode
SecondaryDiagnosisValue
SecondaryIdentification
SentTime
X
X
X
X
ServiceReasonCode
ServiceResultCode
ServiceTypeCoded
SigFreeText
SiteOfAdministrationCode
SNOMEDVersion
SoldDate
SourceDescription
SourceQualifier
StartDate
X
X
State
StatusCode
StopIndicator
StrengthForm
StrengthUnitOfMeasure
StrengthValue
StructuresVersion
SubstitutionCode
Suffix
SupervisorIdentification
SupervisorSpecialty
SuspendDateTime
TertiaryIdentification
Deletion
Modification
NewField
- 251 April215
DATA DICTIONARY
AppendixorFieldName
Field
Number
TertiaryIdentifier
Action
Addition
X
TextMessage
TimePeriodBasisCode
TimePeriodBasisText
To
Deletion
Modification
TransactionDomain
TransactionErrorCode
TransactionVersion
NewField
TransportVersion
NewField
Username
VehicleName
VehicleNameCode
VehicleQuantity
VerifyStatusCode
WrittenDate
ZipCode
X
X
6.
NewField
DeletedSCRIPTuseofFieldasShownAbove
DataDictionary
AppendixorFieldName
Field
Number
Action
Addition
AppendixBVERSION1.REJECTCODESFORPAYMENTTAPE
Deletion
X
AppendixCVERSION2.REJECTCODESFORPAYMENTTAPE
AppendixDVERSION3.and4.REJECTCODESFORPAYMENT
TAPE
AppendixFSCRIPTDATAELEMENTS
AppendixGPUBLICATIONMODIFICATIONS
AppendixDTELECOMMUNICATIONPHASESWITHFLOWCHARTS
AppendixBDATADICTIONARYFIELDSUSEDFORSCRIPTTOTHE
MODELDRIVENSCHEMAS
I.INTRODUCTION
Modification
X
RenamedtoAppendixDPUBLICATIONMODIFICATIONS
RenamedtoAppendixC TELECOMMUNICATIONPHASESWITHFLOWCHARTS
X
AddedverbiageforXMLfieldnamingconvention andformats.AddedQ=Specialized
ImplementationGuidetotheSTANDARDFORMATSKEYTable.
- 252 April215
DATA DICTIONARY
AppendixorFieldName
LL.
Field
Number
Action
Addition
Deletion
Modification
APRIL211
1.
AppendixorFieldName
MedicareDrugCoverageCode
SeeECLPublicationofApril211forAddedFieldValues
Field
Number
A73
Action
Addition
X
Deletion
Modification
2.
DataDictionary
AppendixorFieldName
Introduction
BenefitAmount
Field
Number
Action
Addition
Deletion
A
A3
A4
A7
Modification
CorrectedexampleforN=UnsignedNumericunderFieldFormat Values
CorrectedFormatExampletoremovesign
MM. JULY211
1.
MedicalRebateDataSubmissionStandardImplementationGuideVersion1Release
AppendixorFieldName
AllowedAmount
BilledAmount
JCode
JCodeModifier1
JCodeModifier2
JCodeModifier3
JCodeModifier4
MedicalRebateVersionReleaseNumber
PlanReimbursedAmount
QuarterlyMemberIndicator
AdjudicationDate
Field
Number
A74
A75
A76
A77
A78
A79
A8
A81
A82
A83
578
Action
Addition
X
X
X
X
X
X
X
X
X
X
Deletion
Modification
MedicalRebateDataSubmission StandardaddedtotheStandardFormatcolumn
- 253 April215
DATA DICTIONARY
AppendixorFieldName
ClaimNumber
ContractingOrganization(PMO)ContractNumber
ContractingOrganization(PMO)IDCode
ContractingOrganization(PMO)IDQualifier
DataLevel
DataProviderIDCode
DataProviderIDQualifier
DataProviderName
DateOfService
DiagnosisCode
EncryptedPatientIDCode
FillNumber
FormularyCode
GrandTotalQuantity
GrandTotalRequestedAmount
LineNumber
Manufacturer(PICO)ContractNumber
Manufacturer(PICO)IDCode
Manufacturer(PICO)IDQualifier
PlaceofService
PlanIDCode
PlanIDQualifier
PlanName
PrescriberID
PrescriptionType
ProductDescription
Product/ServiceID
RebatePeriodEndDate
RebatePeriodStartDate
RecordPurposeIndicator
RecordType
ReimbursementDate
RequestedRebateAmount
Field
Number
6168
665
666
671
643
6131
6132
6137
6133
41D1
424DO
492WE
6135
784
43D3
674
6141
6142
6143
647
648
672
65
6144
37C7
694
695
696
411DB
466EZ
42D2
455EM
6149
612
47D7
436E1
639
638
6153
614
6154
6155
Action
Addition
Deletion
Modification
MedicalRebateDataSubmission StandardaddedtotheStandardFormat column
MedicalRebateDataSubmission Standardadded totheStandardFormatcolumn
- 254 April215
DATA DICTIONARY
AppendixorFieldName
Segment1
Segment2
Segment3
Segment4
Segment5
Segment6
SegmentQualifier1
SegmentQualifier2
SegmentQualifier3
SegmentQualifier4
SegmentQualifier5
SegmentQualifier6
ServiceProviderID
SubmitCode
TherapeuticClassDescription
TotalQuantity
TotalRecordCount
TransmissionDate
UnitOfMeasure
SeeECLPublicationofJuly211forAddedFieldValues
2.
Field
Number
638XK
639XL
64XM
641XN
642XP
643XQ
644XR
644XS
644XT
644XU
644XV
644XW
21B1
22B2
586YP
6136
6125
6126
6127
6139
619
611
628
Action
Addition
Deletion
Modification
ManufacturerRebateUtilization,Plan,Formulary,MarketBasket,andReconciliationFlatFileStandardImplementationGuide
Version5Release1
AppendixorFieldName
FormularyStartDate
FormularyTerminationDate
PlanEligibilityStartDate
PlanEligibilityTerminationDate
AdjudicatorIDCode
AdjudicatorIDQualifier
AdjudicatorName
CalculationMultiplier
Dependents
Enrollees
Field
Number
A84
A85
A86
A87
657
658
659
662
668
67
Action
Addition
X
X
X
X
Deletion
X
X
X
X
X
X
- 255 April215
Modification
DATA DICTIONARY
AppendixorFieldName
HierarchicalLevelTerminology
MailOrderIDCode
MailOrderIDQualifier
MailOrderName
MembershipCalculationMultiplier
MembershipDependents
MembershipEnrollees
NumberofMarketProductRecords
OriginatorIDCode
OriginatorName
PlanAffiliationParentPlanID
PlanAffiliationParentPlanIDQualifier
PlanDegreeManaged
PlanTotalAdjudicatorsRecords
PlanTotalFormularyBenefitDesignRecords
PlanTotalMailOrderRecords
PlanTypeService
Total#ofMarketBasketRecords
Field
Number
679
68
681
6111
682
684
685
616
6166
6167
691
692
693
697
698
619
622
6169
Action
Addition
Deletion
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Modification
AddedandRemovedFieldsasShownAbove
3.
AppendixorFieldName
AdditionalMessageIndicator
ClinicalInfoFormatsRequested
ClinicalInfoTypesRequested
DateOfService
MessageToFollowMessageIdentifier
MTMActionCode
MTMActionCodeQualifier
MTMActionFreeText
MTMActionText
NoKnown
ReasonForMTMServiceCode
ReasonForMTMServiceCodeQualifier
ReasonForMTMServiceFreeText
ReasonForMTMServiceText
ResultOfActionCode
ResultOfActionCodeQualifier
Field
Number
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
- 256 April215
Modification
DATA DICTIONARY
AppendixorFieldName
Field
Number
ResultOfActionFreeText
ResultOfActionText
TemplateID
Version
Consent
4.
Action
Addition
X
X
X
X
Deletion
Modification
SpecializedStandardaddedtotheStandardFormatcolumn
AppendixorFieldName
Field
Number
SplitScript
DaysSupply
5.
Action
Addition
X
Deletion
Modification
Formatchange
AppendixorFieldName
AuditRequestType
AuditControlIdentification
AuditSponsor
RequestedResponseDate
EstimatedArrivalTimeDescription
EntityEmail
EntityFaxNumber
AuditRangeQualifier
AuditRangeStart
AuditRangeEnd
AuditElementType1
AuditElementType2
AuditElementType3
AuditElementType4
AuditElementType5
BillingSequence
DiscrepancyCode1
Field
Number
A47
A48
A49
A5
A51
A52
A53
A54
A55
A56
A57
A58
A59
A6
A61
A62
A63
A64
A65
A66
A67
A68
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
- 257 April215
Modification
DATA DICTIONARY
DiscrepancyCode2
DiscrepancyCode3
DiscrepancyMessage
DiscrepancyAmount
RecordType
TransmissionDate
ServiceProviderID
RecordCount
Field
Number
A69
A7
A71
A72
614
611
886
21B1
22B2
751M9
BINNumber
GroupID
FillNumber
AuthorizationNumber
DateOfService
TotalAmountPaid
ReceiverID
ClaimSequenceNumber
Message
EntityAddressLine1
11A1
14A4
31C1
42D2
455EM
43D3
53F3
41D1
59F9
88K7
219
54F4
776
EntityAddressLine2
777
EntityCity
778
EntityContactName
779
EntityName
78
EntityState
SubmissionNumber
TransmissionType
782
783
784
879N2
986KJ
888
12A2
88K6
AppendixorFieldName
Action
Addition
X
X
X
X
Deletion
Modification
AuditTransactionStandardaddedtotheStandardFormatcolumn
AuditTransactionStandardaddedtotheStandardFormatcolumnandaddedseparatefield
definitionforAuditTransaction
AuditTransactionStandardaddedtotheStandard Formatcolumn
AuditTransactionStandardaddedtotheStandardFormatcolumnandremovedWorkers
Compensationformdefinition.
- 258 April215
DATA DICTIONARY
6.
ConnectivityOperatingRuleVersion1.
AppendixorFieldName
PayloadType
TransactionStandard
Format
PayloadEnvelopeVersion
Payload
PayloadEnvelopeReferenceID
7.
Field
Number
A4
A41
A42
Action
Addition
Deletion
X
Modification
ConnectivityStandardchangedtoOperatingRules.ThisfieldisnotusedinOperatingRules.
DeletedfieldIDofA41;Changedfielddefinitionandcomments
DeletedfieldIDofA42;Changedfielddefinitionanddeletedcomments
X
X
X
RemovedFieldandFieldIDasShownAbove
AppendixorFieldName
Action
Field
Number
Addition
Deletion
Field
Number
Addition
Deletion
Modification
8.
DataDictionary
AppendixorFieldName
IntroductionStandardFormatsKey
519FJ
452EH
Action
Modification
Values:AddedEandJ;ChangedKtoOperatingRules
Addedfieldthatwaspreviouslydeleted.SunsettedfieldforspecificuseinPostAdjudication
Version2.
Addedfieldthatwaspreviouslydeleted.SunsettedfieldforspecificuseinPostAdjudication
Version2.
NN.
OCTOBER211
1.
AppendixorFieldName
ClaimProcessedCode
EncryptedSocialSecurityNumber
InsuranceType/ProductCode
LineCounter
MiddleName
TypeOfFile
Field
Number
A88
A89
A9
A91
A92
A93
A94
Action
Addition
X
X
X
X
X
X
X
Deletion
- 259 April215
Modification
DATA DICTIONARY
AppendixorFieldName
AdjudicationDate
FormularySelection
Selection
AmountofCoinsurance
AmountOfCopay
CardholderID
CheckDate
City
CompoundCode
CreationDate
DateOfBirth
DateOfService
DaysSupply
DispensingFeePaid
DrugType
EligibilityGroupID
FirstName
GrossAmountDue
IngredientCostPaid
IncentiveAmountPaid
LastName
Message
MiddleInitial
NetAmountDue
OtherAmountPaid
Field
Number
578
517FH
137UP
571NZ
519FJ
134UK
136UN
Action
Addition
Deletion
Modification
UniformHealthcarePayerData StandardaddedtotheStandardFormatcolumn
135UM
133UJ
523FN
52FK
5724U
518FI
32C2
216
728SU
46D6
88K2
34C4
41D1
45D5
48D8
57F7
425DP
246
247
254
717SX
558AW
43DU
129UD
56F6
521FL
993A7
716SY
54F4
718SZ
281
565J4
564J3
- 260 April215
DATA DICTIONARY
AppendixorFieldName
PatientGenderCode
PatientID
PatientPayAmount
PayerID
PersonCode
PharmacyName
PrescriberID
Product/ServiceID
Product/ServiceName
QuantityDispensed
RecordStatusCode
RecordType
ServiceProviderID
State
TotalRecords
Zip/PostalCode
Field
Number
35C5
332CY
55F5
569J8
559AX
33C3
8335P
411DB
466EZ
47D7
436E1
397
562J1
442E7
399
614
615
616
879N2
21B1
22B2
729TA
978JS
12A2
73TC
Action
Addition
Deletion
Modification
2.
AppendixorFieldName
ApplicationID
ContactPerson
GrossRetireeCost
LimitReduction
QualifiedCoveredRetireeHICN
QualifiedCoveredRetireeSSN
ThresholdReduction
UniqueBenefitOptionIdentifier
CreationDate
Field
Number
A95
A96
A97
A98
A99
B1
B2
B3
88K2
Action
Addition
X
X
X
X
X
X
X
X
Deletion
Modification
RetireeDrugSubsidy StandardaddedtotheStandardFormatcolumn
- 261 April215
DATA DICTIONARY
AppendixorFieldName
CreationTime
DateOfBirth
FirstName
LastName
MiddleInitial
RecordType
SenderID
TelephoneNumber
TotalRecordCount
Field
Number
88K3
34C4
717SX
716SY
718SZ
614
88K1
879N2
732TB
619
12A2
Action
Addition
Deletion
Modification
3.
AppendixorFieldName
MACPrice
4.
Field
Number
29
21
211
253
271
12A2
Action
Addition
Deletion
Modification
VersionupdatedinECL
AppendixorFieldName
5.
Field
Number
12A2
Action
Addition
Deletion
Modification
VersionupdatedinECL
AppendixorFieldName
6.
Field
Number
12A2
Action
Addition
Deletion
Modification
VersionupdatedinECL
DataDictionary
AppendixorFieldName
Field
- 262 April215
Action
DATA DICTIONARY
Number
Addition
Deletion
IntroductionStandardFormatsKey
Modification
Values:AddedLandY
OO.
JANUARY212
1.
AppendixorFieldName
NextAvailableFillDate
2.
Field
Number
B4BT
Action
Addition
X
Deletion
Modification
VersionupdatedinECL
12A2
AppendixorFieldName
MultipleSiteOfAdministrationTimingModifier
PP.
Field
Number
Action
Addition
Deletion
12A2
Modification
NameofFieldcorrectedtoMultipleSiteOfAdministrationModifier
VersionupdatedinECL
APRIL212
1.
AppendixorFieldName
FieldFormats
2.
Field
Number
Action
Addition
Deletion
X
Modification
Allxsd:stringwerereplacedwithan
VersionupdatedinECL
12A2
AppendixorFieldName
PharmacistIdentification
TypeOfServiceGroupSetting
FieldFormats
Field
Number
Action
Addition
X
X
Deletion
Modification
X
12A2
VersionupdatedinECL
- 263 April215
DATA DICTIONARY
QQ.
JULY212
1.
DataDictionary
AppendixorFieldName
CompoundIngredientProductCode
CompoundIngredientProductCodeQualifier
RR.
Field
Number
Action
Addition
X
X
Deletion
Addition
Deletion
Modification
VersionupdatedinECL forPostAdjudicationVersion3.1
12A2
OCTOBER212
1.
DataDictionary
AppendixorFieldName
Field
Number
Action
Introduction
AdditionalMessageIndicator
ProhibitRefillRequest
ExternalCodeList(ECL)
SS.
Modification
CorrectedBooleanCodevaluesfromTrue/FalsetoYes/No
RemovedSeeECL
Format:fromBooleanCodetoxsd:boolean;removedSeeECL
SeeECLpublicationofOctober212foradditionofvaluesandrejectcodes.
JANUARY213
1.
AppendixorFieldName
AdministrationIndicator
AdministrationTimingClarifyingFreeText
AdministrationTimingEventCode
AdministrationTimingEventQualifier
AdministrationTimingEventText
AdministrationTimingModifierCode
AdministrationTimingModifierQualifier
AdministrationTimingModifierText
AdministrationTimingNumericValue
BeeperNumber
BeeperExtension
BeeperSupportsSMS
ClarifyingFreeText
DoseAmountText
DoseAmountTextCode
Field
Number
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
- 264 April215
Modification
DATA DICTIONARY
AppendixorFieldName
DoseAmountTextQualifier
DoseClarifyingFreeText
DoseCalculationClarifyingFreeText
DurationClarifyingFreeText
ElectronicMail
FaxNumber
FaxExtension
FaxSupportsSMS
HomeTelephoneNumber
HomeTelephoneExtension
HomeTelephoneSupportsSMS
IndicationClarifyingFreeText
IndicationValueCode
IndicationValueQualifier
InstructionIndicator
MaximumDoseRestrictionClarifyingFreeText
MaximumDoseRestrictionFormCode
MaximumDoseRestrictionFormQualifier
MaximumDoseRestrictionFormText
OtherTelephoneExtension
OtherTelephoneNumber
OtherTelephoneSupportsSMS
PrimaryTelephoneExtension
PrimaryTelephoneNumber
PrimaryTelephoneSupportsSMS
RouteOfAdministrationClarifyingFreeText
SiteOfAdministrationClarifyingFreeText
StopIndicatorText
StopIndicatorTextCode
StopIndicatorTextQualifier
TimingClarifyingFreeText
TriggerText
TriggerTextCode
TriggerTextQualifier
VehicleClarifyingFreeText
VehiclePrepositionCode
VehiclePrepositionQualifier
VehiclePrepositionText
WorkTelephoneExtension
WorkTelephoneNumber
WorkTelephoneSupportsSMS
AddressLine1
Field
Number
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
Modification
FormatChange
- 265 April215
DATA DICTIONARY
AppendixorFieldName
AddressLine2
BodyMetricValue
CalculatedDoseUnitOfMeasureCode
CalculatedDoseUnitOfMeasureCodeQualifier
CalculatedDoseUnitOfMeasureText
ClinicName
DoseFormCode
DoseFormText
DoseRangeModifier
DosingBasisUnitOfMeasureCode
DosingBasisUnitOfMeasureCodeQualifier
DosingBasisUnitOfMeasureText
DurationTextCode
DurationText
FacilityName
FMTVersion
FrequencyUnitsCode
FrequencyUnitsText
GroupName
IndicationTextCode
Field
Number
Action
Addition
Deletion
Modification
FormatChange
Namechangeto:AdministrationTimingUnitsCode; FormatChange
Namechangeto:AdministrationTimingUnitsQualifier:
Namechangeto:AdministrationTimingUnitsText:FormatChange
FormataddedtoCommentsColumn
DefinitionChange;FormatChange
Namechangeto:CalculatedDoseUnitOfMeasureQualifier
FormatChange
X
X
FormatChange
NameChangetoDoseDeliveryMethodQualifier
FormatChange
FormatChange
Namechangeto:DoseDeliveryMethodModifierQualifier
Namechangeto:DoseFormQualifier
FormatChange
Namechangeto:DosingBasisNumeric
NameChangeto:DosingBasisUnitOfMeasureQualifier
FormatChange
FormatChange
FormatChange
NameChangeto:DurationTextQualifier
FormatChange
FormatChange
FormatChange
Namechangeto:FrequencyUnitsQualifier
FormatChange
FormatChange
Namechangeto:IndicationPrecursorQualifier
FormatChange
Namechangeto:IndicationCode;FormatChange
Namechangeto:IndicationQualifier
- 266 April215
DATA DICTIONARY
AppendixorFieldName
Field
Number
Action
IndicationText
IndicationValueText
IndicationValueUnitOfMeasureCode
IndicationValueUnitOfMeasureCodeQualifier
IndicationValueUnitOfMeasureText
IntervalUnitsCode
IntervalUnitsText
Modification
Namechangeto:IndicationValueUnitOfMeasureQualifier
FormatChange
FormatChange
Namechangeto:IntervalUnitsQualifier
FormatChange
Namechangeto:MaximumDoseRestrictionUnitsQualifier
MaximumDoseRestrictionVariableNumericValue
Namechangeto:MaximumDoseRestrictionDurationValue;DefinitionChange
MaximumDoseRestrictionVariableUnitsCode
Namechangeto:MaximumDoseRestrictionDurationUnitsCode;DefinitionChange;Format
Change
Namechangeto:MaximumDoseRestrictionDurationUnitsQualifier
MaximumDoseRestrictionVariableUnitsCodeQualifier
Addition
Deletion
MultipleSigModifier
Namechangeto:MaximumDoseRestrictionDurationUnitsText;DefinitionChange;Format
Change
NameChangeto:MultipleInstructionModifier;DefinitionChange,FormatChange
PayerName
SigFreeText
SiteOfAdministrationCode
SNOMEDVersion
TimePeriodBasisCode
TimePeriodBasisText
VehicleName
NameChangeto:VariableAdministrationTimingModifier;DefinitionChange;FormatChange
FormatChange
FormatChange
Namechangeto:RateUnitOfMeasureQualifier
DefinitionChange;Format Change
NameChangeto:RouteOfAdministrationQualifier
Namechangeto:SigText;DefinitionChange;FormatChange
Namechangeto:SiteOfAdministrationQualifier
FormatChange
FormatChange
Namechangeto:TimePeriodBasisQualifier
FormatChange
FormatChange
Namechangeto:Vehicle;DefinitionChange;FormatChange
VehicleNameCode
Namechangeto:VehicleCode;DefinaitonChange;FormatChange
Namechangeto:VehicleQualifier
- 267 April215
DATA DICTIONARY
AppendixorFieldName
Directions
FinalRouteOfAdministrationCode
FinalRouteOfAdministrationCodeText
MaximumDoseRestrictionVariableDurationModifier
MultipleRouteOfAdminstrationModifier
MultipleSiteOfAdministrationModifier
StopIndicator
2.
Field
Number
Action
Addition
Deletion
X
X
X
X
X
X
X
X
X
X
12A2
Modification
Namechangeto:VehicleUnitOfMeasureQualifier
SunsetofDataElement
SunsetofDataElement
SunsetofDataElement
SunsetofDataElement
SunsetofDataElement
SunsetofDataElement
SunsetofDataElement
SunsetofDataElement
SunsetofDataElement
SunsetofDataElement
VersionupdatedinECL
SeeECLpublicationofJanuary213forupdatesofvalues
AppendixorFieldName
CoAgentCodeDescription
CompoundQuantityCodeListQualifier
CompoundQuantityValue
PrimaryDiagnosisCodeDescription
QuantityValue
SecondaryDiagnosisCodeDescription
3.
Field
Number
Action
Addition
X
X
X
X
Deletion
Modification
Comments:Addedformat
X
12A2
VersionupdatedinECL
AppendixorFieldName
AddressLine1
AddressLine2
FirstName
PharmacyName
Field
Number
726SR
727SS
717SX
8335P
B18A
12A2
Action
Addition
Deletion
Modification
FormatChange
FormatChange
FormatChange
FormatChange
X
VersionupdatedinECL
- 268 April215
DATA DICTIONARY
4.
AppendixorFieldName
5.
Field
Number
448ED
12A2
Action
Addition
Deletion
Modification
FormatChange
VersionupdatedinECL
AppendixorFieldName
EntityContactFirstName
EntityContactLastName
EntityTelephoneNumberExtension
EntityAddressLine1
EntityAddressLine2
EntityContactName
EntityName
6.
Field
Number
B5
B6
B7
776
777
779
78
12A2
Action
Addition
X
X
X
Deletion
Modification
FormatChange
FormatChange
SunsetofDataElement
FormatChange
VersionupdatedinECL
AppendixorFieldName
SourceName
7.
Field
Number
972JK
12A2
Action
Addition
Deletion
Modification
VersionupdatedinECL
Version6Release
AppendixorFieldName
AddressLine1
AddressLine2
DataProviderName
PlanName
Field
Number
726SR
727SS
643
6133
6115
65
696
613
Action
Addition
Deletion
Modification
FormatChange
FormatChange
FormatChange
Format Change
FormatChange
FormatChange
FormatChange
VersionupdatedinECL
- 269 April215
DATA DICTIONARY
AppendixorFieldName
Field
Number
Action
Addition
Deletion
8.
Modification
AppendixorFieldName
PatientFirstName
PatientLastName
9.
Field
Number
B87A
B97B
322CM
31CA
311CB
12A2
Action
Addition
X
X
Deletion
Modification
SunsetDataElementforthisStandard
AddedforusebythisStandard;Commentaddedregardingfieldsize
AddedforusebythisStandard;Commentaddedregardingfieldsize
VersionupdatedinECL
MedicalRebatesDataSubmissionStandardImplementationGuideVersion2Release
AppendixorFieldName
DataProviderName
PlanName
MedicalRebatesVersionReleaseNumber
10.
Field
Number
643
6133
65
696
A81
Action
Addition
Deletion
Modification
FormatChange
FormatChange
FormatChange
FormatChange
VersionupdatedinECL
SeeECLpublicationofJanuary 213forupdatesofvalues
PrescriptionFileTransferStandardImplementationGuideVersion3Release
AppendixorFieldName
AddressLine1
AddressLine2
ClientName
DestinationName
FacilityName
FirstName
LastName
PharmacyName
ProcessorName
SenderName
Field
Number
726SR
727SS
65NB
8185F
3853Q
717SX
716SY
8335P
8395V
626SD
B18A
12A2
Action
Addition
Deletion
Modification
FormatChange
FormatChange
FormatChange
FormatChange
FormatChange
FormatChange
FormatChange
FormatChange
FormatChange
FormatChange
X
VersionupdatedinECL
- 270 April215
DATA DICTIONARY
AppendixorFieldName
Field
Number
Action
Addition
Deletion
11.
Modification
SeeECLpublication ofJanuary213forupdatesofvalues
PriorAuthorizationTransferStandardImplementationGuideVersion2Release
AppendixorFieldName
ClientName
FirstName
LastName
PatientFirstName
PatientLastName
ReceiverName
SenderName
12.
Field
Number
65NB
717SX
716SY
31CA
311CB
A19
626SD
B18A
12A2
Action
Addition
Deletion
Modification
FormatChange
FormatChange
FormatChange
AddedforusebythisStandard
FormatChange
FormatChange
X
VersionupdatedinECL
AppendixorFieldName
ContactPerson
ContactPersonFirstName
ContactPersonLastName
FirstName
13.
Field
Number
A96
B11
B12
717SX
B18A
12A2
Action
Addition
Deletion
X
Modification
X
X
FormatChange
X
VersionupdatedinECL
AppendixorFieldName
AddressLine1
AddressLine2
BeeperNumber
BeeperExtension
BeeperSupportsSMS
ClinicName
Field
Number
Action
Addition
Deletion
Modification
FormatChange
FormatChange
X
X
X
FormatChange
X
X
- 271 April215
DATA DICTIONARY
AppendixorFieldName
ElectronicMail
FacilityName
FaxNumber
FaxExtension
FaxSupportsSMS
GroupName
HomeTelephoneNumber
HomeTelephoneExtension
HomeTelephoneSupportsSMS
OtherTelephoneExtension
OtherTelephoneNumber
OtherTelephoneSupportsSMS
PayerName
PrimaryTelephoneExtension
PrimaryTelephoneNumber
PrimaryTelephoneSupportsSMS
WorkTelephoneExtension
WorkTelephoneNumber
WorkTelephoneSupportsSMS
14.
Field
Number
Action
Addition
X
Deletion
Modification
FormatChange
X
X
X
FormatChange
X
X
X
X
X
X
FormatChange
X
X
X
X
X
X
12A2
VersionupdatedinECL
TelecommunicationStandardImplementationGuideVersionERelease
AppendixorFieldName
EmployerContactFirstName
EmployerContactLastName
EmployerTelephoneNumberExtension
HelpDeskTelephoneNumberExtension
OtherPayerHelpDeskTelephoneNumberExtension
PrescriberTelephoneNumberExtension
Field
Number
B137D
B148B
B158D
B167G
B177H
B187J
B197K
B27M
B217N
B227P
B237Q
B87A
B97B
B247R
B257S
B267T
Action
Addition
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Deletion
- 272 April215
Modification
DATA DICTIONARY
AppendixorFieldName
AuthorizedRepresentativeStreetAddress
CardholderFirstName
CardholderLastName
EmployerPhoneNumber
EmployerContactName
FacilityName
FacilityStreetAddress
HelpDeskPhoneNumber
HelpDeskPhoneNumberQualifer
OtherPayerHelpDeskPhoneNumber
PatientFirstName
PatientLastName
PatientPhoneNumber
PayToName
PayToStreetAddress
PrescriberFirstName
PrescriberLastName
PrescriberPhoneNumber
PrimaryCareProviderLastName
PurchaserFirstName
PurchaserLastName
PurchaserStreetAddress
ServiceProviderName
ServiceProviderStreetAddress
15.
Field
Number
B277U
B287V
B297W
B37X
B317Y
B327Z
498PE
498PF
498PG
312CC
313CD
316CG
32CK
321CL
3853Q
3863U
558F
5497F
127UB
322CM
31CA
311CB
326CQ
12TU
121TV
3642J
427DR
3652K
498PM
474E
596YZ
597Y
598Y1
583YK
584YM
12A2
Action
Addition
X
X
X
X
X
X
X
X
Deletion
Modification
X
Commentaddedregardingfieldsize
SunsetofDataElementforthisStandard
Namechangeto:EmployerTelephoneNumber
SunsetofDataElementforthisStandard
FormatChange
X
Namechangeto:HelpDeskTelephoneNumber
Namechangeto:HelpDeskTelephoneNumberQualifer
Namechangeto:OtherPayerHelpDeskTelephoneNumber
Namechangeto:PatientTelephoneNumber
FormatChange
FormatChange
FormatChange
Namechangeto:PrescriberTelephoneNumber
FormatChange
FormatChange
FormatChange
X
FormatChange
X
VersionupdatedinECL
AppendixorFieldName
Field
Number
Action
Addition
Deletion
- 273 April215
Modification
DATA DICTIONARY
AppendixorFieldName
16.
Field
Number
448ED
12A2
Action
Addition
Deletion
Modification
FormatChange
VersionupdatedinECL
AppendixorFieldName
PharmacyName
Field
Number
8335P
12A2
Action
Addition
Deletion
Addition
Deletion
Modification
FormatChange
VersionupdatedinECL
TT.
APRIL213
1.
DataDictionary
AppendixorFieldName
Introduction
2.
Field
Number
Action
12A2
Modification
ModifiedRulesforDemographicFields
VersionupdatedinECL
SeeECLpublicationofApril 213forupdates ofvalues
AppendixorFieldName
ProfessionalServiceFeeContracted/ReimbursementAmount
PayToZip/PostalZone
PrescriberAlternateIDAssociatedState/ProvinceAddress
Field
Number
B336G
498PJ
498PK
318CI
319CJ
3873V
A22YR
324CO
325CP
123TX
124TY
A27ZQ
A24ZK
3672N
Action
Addition
x
Deletion
Modification
Definition:modified
Name,Definition,Comments:modified;Examples:added
Definition:modified;Comments:deleted
Definition:modified
Definition:modified
Name,Definiton,Comments:modified;Examples:added
Definition:modified
Definition:modified
Definition:modified
Definition:modified
- 274 April215
DATA DICTIONARY
AppendixorFieldName
AuthorizedRepresentativeCountryCode
EmployerCountryCode
FacilityCountryCode
PatientIDAssociatedCountryCode
PaytoCountryCode
PrescriberAlternateIDAssociatedCountryCode
PrescriberIDAssociatedCountryCode
PrescriberCountryCode
PurchaserIDAssociatedCountryCode
3.
Field
Number
675Y3
593YW
676Y4
A93
586YP
587YQ
4748
B341U
B351V
B371X
B381Y
B391Z
B43A
B413B
B423C
B433D
12A2
Action
Addition
Deletion
Modification
Name,Definition:modified
Definition,Comments:modified
Added2digitIDtofieldnumber
Definition,Comments:modified
Comments:MovedtoECL
x
x
x
x
x
x
x
x
x
VersionupdatedinECL
SeeECLpublicationofApril213forupdatesofvalues
WorkersCompensation/Property&CasualtyUniversalClaimForm
AppendixorFieldName
CarrierZipCode
PayToZip/PostalZone
PharmacyZipCode
4.
Field
Number
811G
8131J
318CI
319CJ
324CO
325CP
123TX
124TY
8326F
8355R
3672N
4748
12A2
Action
Addition
Deletion
Modification
Name:modified
Name,Definition:modified;Comments,Examples:added
Definition:modified
Definition:modified
Comments:MovedtoECL
VersionupdatedinECL
AuditTransactionStandardImplementationGuideVersion2Release1
AppendixorFieldName
Field
- 275 April215
Action
DATA DICTIONARY
EntityState
EntityCountryCode
5.
Number
782
784
B361W
12A2
Addition
Deletion
Modification
Definition:modified;Comments,Examples:added
x
VersionupdatedinECL
MedicalRebatesDataSubmissionStandardImplementationGuideVersion2Release1
AppendixorFieldName
EntityCountryCode
6.
Field
Number
784
A93
586YP
B361W
12A2
Action
Addition
Deletion
Modification
Definition:modified;Comments,Examples:added
x
VersionupdatedinECL
AppendixorFieldName
PatientCountryCode
State
Zip/PostalCode
EntityCountryCode
7.
Field
Number
A431K
A93
729TA
73TC
4748
B361W
12A2
Action
Addition
x
x
Deletion
Modification
Definition:modified;Comments:added
Comments:MovedtoECL
x
VersionupdatedinECL
UniversalClaimForm
AppendixorFieldName
PharmacyZipCode
8.
Field
Number
8326F
4748
8355R
12A2
Action
Addition
Deletion
Modification
Comments:MovedtoECL
VersionupdatedinECL
UniformHealthcarePayerDataStandardImplementationGuideVersion2Release1
- 276 April215
DATA DICTIONARY
AppendixorFieldName
State
Zip/PostalCode
EntityCountryCode
9.
Field
Number
A93
729TA
73TC
B361W
12A2
Action
Addition
x
Deletion
Modification
x
VersionupdatedinECL
AppendixorFieldName
State
PostalCode
10.
Field
Number
Action
Addition
Deletion
Modification
Name,Definition,Format:modified
x
12A2
VersionupdatedinECL
AppendixorFieldName
State
PostalCode
11.
Field
Number
Action
Addition
Deletion
Modification
Name,Definition,Format:modified
x
12A2
VersionupdatedinECL
PrescriptionFileTransferStandardImplementationGuideVersion3Release1
AppendixorFieldName
State
Zip/PostalCode
EntityCountryCode
Field
Number
729TA
73TC
B361W
12A2
Action
Addition
Deletion
Modification
x
VersionupdatedinECL
UU.
JULY213
1.
AppendixorFieldName
Field
- 277 April215
Action
DATA DICTIONARY
Number
AuthorizationNumber
CacluatedPrescriptionSellingPrice
CFOrderID
ChildResistantPackage
Coating
Color
Counsel
CounselNotes
DiscountAmount
DrugShape
Flavor
Imprint1
Imprint2
IngredientCost
LabelCode
LabelGraphicCode
LabelPriority
LabelText
LotExpiration
LotNumber
MailOrder
ManufacturerName
Markings
MonographText
PatientPayAmount
PrescriptionSellPrice
Priority
RxBarcode
RxRefillMessage
ShippingAmount
ShippingMethod
ShipToteIdentification
SubstitutedBrandDrug
SubstitutionMessage
TechnicianInitials
TotalAmountBrandPenalty
TotalNumberPackages
TotalNumberVials
ToteBarcode
UnitOfUse
PayerIdentification
12A2
Addition
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Deletion
Modification
FieldSizeincreasedto8
VersionupdatedinECL
- 278 April215
DATA DICTIONARY
AppendixorFieldName
Field
Number
Action
Addition
Deletion
2.
Modification
SeeECLpublicationofJuly 213forupdatesofvalues
AppendixorFieldName
AdditionalFreeText
AdditionalFreeTextIndicator
Answer
AnswerValue
AppealCaseID
AttachmentControlNumber
CancelReasonCode
ChoiceID
ChoiceText
ClosedReasonCode
CodedReferenceCode
CodedReferenceDescription
CodedReferenceQualifier
CodedSystemVersion
ComparisonOperator
ComparisonValue
DeadlineForReply
DefaultNextQuestionID
DeniedForCancelReasonCode
IsDateTimeRequired
IsEAppealSupported
IsFreeText
IsNumeric
IsPatientNotified
LowerBoundComparisonOperator
LowerBoundComparisonValue
NextQuestionID
NumberOfCycles
OtherReason
PACaseID
PANote
PAReferenceID
PAStructuresVersion
PharmacyType
PrescriberProvidedAnswer
PrescriberProvidedNumericAnswer
Field
Number
Action
Addition
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Deletion
- 279 April215
Modification
DATA DICTIONARY
AppendixorFieldName
QuestionID
QuestionLevel
QuestionSetComment
QuestionSetDescription
QuestionSetID
QuestionSetTitle
QuestionText
SeeTransactionLevelAttachmentControlNumber
SelectMultiple
SequenceNumber
UpperBoundComparisonOperator
UpperBoundComparisonValue
CouponNumber
PriorAuthorizationCodeValue
PriorAuthorizationCodeValueQualifier
PayerIdentification
3.
Field
Number
Action
Addition
x
x
x
x
x
x
x
x
x
x
x
x
x
Deletion
Modification
FieldNamechangedtoPriorAuthorization
x
FieldSizeincreasedto8
VersionupdatedinECL
SeeECLpublicationofJuly 213forupdatesofvalues
12A2
Version6Release1
AppendixorFieldName
4.
Field
Number
419DJ
613
Action
Addition
Deletion
Modification
VersionupdatedinECL
DataDictionary
AppendixorFieldName
Field
Number
Action
Addition
AppendixC
AppendixDPublicationModifications
Deletion
x
Modification
RenamedtoAppendixC
VV.
OCTOBER213
1.
AppendixorFieldName
Field
Number
Action
Addition
Deletion
- 280 April215
Modification
DATA DICTIONARY
AppendixorFieldName
2.
Field
Number
Action
Addition
Deletion
12A2
Modification
Valueadded.
VersionupdatedinECL
SeeECLpublicationofOctober 213forupdatesofvalues
AppendixorFieldName
DigitalSignatureIndicator
DigitalSignatureVersion
DigestValue
LOINCVersion
ObservationNotes
SignatureValue
UCUMVersion
UnitOfMeasure
VitalSign
X59Data
MeasurementUnitCode
MeasurementValue
3.
Field
Number
Action
Addition
x
x
x
x
x
x
x
x
x
x
x
Deletion
Modification
x
x
x
DeletedComments
VersionupdatedinECL
SeeECLpublicationofOctober 213forupdatesofvalues
12A2
FormularyandBenefitStandardImplementationGuideVersion4Release1
AppendixorFieldName
ClassIDStepDrug
Field
Number
93BR
67V9
663V2
667V6
669V8
668V7
657T5
658T6
659T7
66T8
662V1
Action
Addition
Deletion
x
x
x
x
x
x
x
x
x
x
x
- 281 April215
Modification
DATA DICTIONARY
AppendixorFieldName
RelativeCost
RelativeCostLimit
SubclassIDStepDrug
AppendixA
4.
Field
Number
661T9
666V5
664V3
665V4
966JC
967JD
976JQ
Action
Addition
Deletion
x
x
x
x
x
x
x
Modification
Deletedfieldsshownabove
VersionupdatedinECL
12A2
AppendixorFieldName
5.
Field
Number
12A2
Action
Addition
Deletion
Modification
VersionupdatedinECL
AppendixorFieldName
IntermediaryIDCount
IntermediaryIDTypeCode
IntermediaryIDTypeEntity
IntermediaryIDQualifier
IntermediaryID
IntermediaryIDState/ProvinceAddress
IntermediaryIDRelationshipCode
IntermediaryMessage
ResponseIntermediaryAuthorizationCount
ResponseIntermediaryAuthorizationTypeID
ResponseIntermediaryAuthorizationID
IntermediaryIDCountryCode
IntermediaryAuthorizationID
AppendixA
Field
Number
B448G
B458H
B468J
B478K
B488M
B498N
B58P
B518Q
B528R
B538S
B548T
B558U
464EX
463EW
12A2
Action
Addition
x
x
x
x
x
x
x
x
x
x
x
x
Deletion
Modification
x
x
Deletedandadded fields as shownabove
VersionupdatedinECL
SeeECLpublicationofOctober213forupdatesofvalues
- 282 April215
DATA DICTIONARY
WW. JANUARY214
1.
AppendixorFieldName
2.
Action
Field
Number
12A2
Addition
Deletion
Field
Number
984JY
Addition
Deletion
Modification
VersionupdatedinECL
SeeECLpublicationofJanuary 214 forupdates
DataDictionary
AppendixorFieldName
TransmissionTime
3.
Action
Modification
Correctedformatfrom6to8
Version7Release
AppendixorFieldName
BrandedGenericCoPayConfidential
BrandedProductCoPayAmount
CostIndexPointHighValue
CostIndexPointLowValue
DollarSignRating
FormularyManagerPersonName
FormularyNonFormularyCoPayConfidential
FormularyProductCoPayAmount
FormularyProductCoPayConfidential
GenericProductCoPayAmount
NonFormularyProductCoPayAmount
ProductDosageForm
ProductFormularyStatusCode
ProductGenericName
ProductStrength
TherapeuticUseCode
TherapeuticUseDescription
AppendixA
Field
Number
66
661
6112
6113
6114
6115
6116
676
677
6117
678
69
6121
6122
6123
6124
6128
6129
613
Action
Addition
Deletion
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Modification
ForuseintheRebateStandard
ForuseintheRebate Standard
Deletedfieldsasshownabove
VersionupdatedinECL
- 283 April215
DATA DICTIONARY
XX.
APRIL214
1.
UniformStandardImplementationGuideVersion22
FieldNumber
879N2
12A2
AppendixorFieldName
Action
Addition
Deletion
2.
Modification
Revisedsizefrom8to1
VersionupdatedinECL. SeeECLpublicationofApril214forupdates
FieldNumber
215
12A2
AppendixorFieldName
Action
Addition
Deletion
CarrierNumber
3.
Modification
Revisedsizefrom9 to1
VersionupdatedinECL.SeeECLpublicationofApril214forupdates
Version7Release1
FieldNumber
613
AppendixorFieldName
Action
Addition
Deletion
4.
Modification
VersionupdatedinECL.SeeECLpublicationofApril214forupdateofvalues.
FieldNumber
B563E
B573F
B583G
B593H
B63J
B613K
314CE
12A2
AppendixorFieldName
LastKnownBINNumber
LastKnownProcessorControlNumber
LastKnownGroupID
LastKnownCardholderID
YearofLastPaidClaim
MonthofLastPaidClaim
HomePlan
AppendixA
5.
Action
Addition
X
X
X
X
X
X
Deletion
Modification
Sunsetoffield
Deletedandaddedfieldsasshownabove
VersionupdatedinECL
SeeECLpublicationofApril 214forupdates
FieldNumber
AppendixorFieldName
Action
Addition
Deletion
- 284 April215
Modification
DATA DICTIONARY
FieldNumber
12A2
AppendixorFieldName
Action
Addition
CancelReasonCode
ClosedReasonCode
DeniedForCancelReasonCode
6.
Deletion
X
X
X
Modification
Sunsetoffield
Sunsetoffield
Sunsetoffield
VersionupdatedinECL
SeeECLpublicationof April 214forupdates
AuditTransactionStandardImplementationGuideVersion3
FieldNumber
5486F
252
436E1
47D7
466EZ
411DB
42DK
51F1
112AN
511FB
12A2
AppendixorFieldName
Action
Addition
Deletion
ApprovedMessageCode
FederalDEASchedule
Product/ServiceID
PrescriberID
RejectCode
AppendixA
7.
Modification
AddedforusebyVersion3oftheAuditTransactionStandard
AddedforusebyVersion3of theAuditTransactionStandard
VersionupdatedinECL
SeeECLpublicationof April 214forupdates
MedicalRebateDataSubmissionStandardImplementationGuideVersion2Release2
FieldNumber
A81
AppendixorFieldName
Action
Addition
Deletion
MedicalRebatesVersionReleaseNumber
8.
Modification
VersionupdatedinECL.SeeECLpublicationofApril214forupdateofvalues.
FieldNumber
12A2
AppendixorFieldName
Action
Addition
Deletion
Modification
VersionupdatedinECL
SeeECLpublicationofApril214forupdates
- 285 April215
DATA DICTIONARY
YY.
JULY214
1.
DataDictionary
FieldNumber
498PK
8131J
319CJ
784
325CP
124TY
8355R
676Y4
587YQ
Action
AppendixorFieldName
Addition
Deletion
FrontMatter
AuthorizedRepresentativeZip/PostalCode
CarrierZip/PostalCode
EmployerZip/PostalCode
PatientZip/PostalCode
PayToZip/PostalCode
PharmacyZip/PostalCode
2.
Modification
AddedFormatLimitations/Requirements
Definitionclarified
Definitionclarified
Definitionclarified
Definitionclarified
Definitionclarified
Definitionclarified
Definitionclarified
Definitionclarified
Definitionclarified
FieldNumber
12A2
Action
AppendixorFieldName
Addition
X
X
X
X
X
X
OfficeOfPharmacyAffairsID
PrescriptionPreviouslyFilled
TransferRequest
RxFillIndicator
RxFillConfirmIndicator
TransferType
3.
Deletion
Modification
VersionupdatedinECL
SeeECLpublicationofJuly 214forupdates
FieldNumber
12A2
Action
AppendixorFieldName
Addition
X
X
X
Species
DeliveryRequest
DeliveryLocation
4.
Deletion
Modification
VersionupdatedinECL
SeeECLpublicationofJuly214forupdates
AppendixorFieldName
Field
- 286 April215
Action
DATA DICTIONARY
Number
FillNumber
DrugProductCoded
DrugProductCodedQualifier
5.
Addition
Deletion
x
x
12A2
Modification
AddedforuseinSpecializedStandardandaddedComments
Incorrectlylistedasseparateelement.See AllergyDrugProductCodedQualifier
Incorrectlylistedasseparateelement.See AllergyDrugProductCodedQualifier
VersionupdatedinECL
SeeECLpublicationofJuly214forupdatesofvalues
PrescriptionTransferStandardImplementationGuideVersion33
AppendixorFieldName
Field
Number
12A2
Action
Addition
Deletion
Modification
VersionupdatedinECL
SeeECLpublicationofJuly214forupdatesofvalues
ZZ.
OCTOBER214
1.
FieldNumber
B621M
B631N
B641P
B653M
B663N
914B5
12A2
AppendixorFieldName
AlternativesGroupID
AlternativesListType
StepMedicationsGroupID
MinimumDrugsPerStepGroup
MaximumDrugsPerStepGroup
AppendixA
2.
Action
Addition
X
X
X
X
X
Deletion
Modification
Sunsetoffield
Deletedandaddedfieldsasshownabove
VersionupdatedinECL
SeeECLpublicationofOctober 214forupdates
FieldNumber
12A2
AppendixorFieldName
TestingFrequency
TestingFrequencyNotes
SupplyIndicator
DateOfLastOfficeVisit
InsulinDependent
HasAutomatedInsulinDevice
RelatesToMessageID
Action
Addition
X
X
X
X
X
X
Deletion
Modification
Definitionmodified
VersionupdatedinECL
- 287 April215
DATA DICTIONARY
FieldNumber
AppendixorFieldName
Action
Addition
Deletion
3.
Modification
FieldNumber
394MW
12A2
394MW
AppendixorFieldName
Action
Addition
Deletion
BenefitStageAmount
4.
Modification
Definitionmodified
VersionupdatedinECL
FieldNumber
394MW
12A2
394MW
AppendixorFieldName
Action
Addition
Deletion
BenefitStageAmount
Modification
Definitionmodified
VersionupdatedinECL
AAA. JANUARY215
1.
FieldNumber
12A2
AppendixorFieldName
Action
Addition
Deletion
2.
Modification
VersionupdatedinECL
BenefitIntegrationStandardImplementationGuideVersion1
FieldNumber
AppendixorFieldName
711
ActionCode
24
571NZ
134UK
523FN
518FI
865C
761
AmountOfCopay
BatchNumber
Action
Addition
Deletion
Modification
ReinstatefieldforusebyVersion1oftheBenefitIntegrationStandard.Fieldpreviouslyused
bytheMemberEnrollmentStandard(M)
AddedforusebyVersion1oftheBenefitIntegrationStandard
- 288 April215
DATA DICTIONARY
FieldNumber
759
212
686
32C2
313CD
215
222
24U1
88K2
88K3
34C4
41D1
45D5
48D8
785SV
72MC
257
43DU
31C1
266
267
269
54F4
718SZ
31CA
35C5
332CY
311CB
55F5
36C6
324CO
33C3
47D7
436E1
397
442E7
88K7
751M9
614
511FB
AppendixorFieldName
BenefitType
CardholderID
CardholderLastName
CarrierNumber
ClientPassThrough
ContractNumber
CreationDate
CreationTime
DateOfBirth
DateOfService
DaysSupply
FamilyIDNumber
FileType
FormularyStatus
GrossAmountDue
GroupID
InNetworkIndicator
InsuranceCode
InvoicedAmount
Message
MiddleInitial
PatientFirstName
PatientGenderCode
PatientID
PatientLastName
PatientPayAmount
PersonCode
Product/ServiceID
Product/ServiceName
QuantityDispensed
ReceiverID
RecordCount
RecordType
RejectCode
Action
Addition
Deletion
Modification
Added forusebyVersion1oftheBenefitIntegrationStandard
AddedforusebyVersion1oftheBenefitIntegration Standard
- 289 April215
DATA DICTIONARY
FieldNumber
88K1
21B1
22B2
888
6125
6126
59F9
896
897
112AN
611
986KJ
984JY
88K6
12A2
B67
B68
B69
B7
B71
B72
B73
B74
B75
B76
B77
B78
B79
B8
B81
B82
B83
B84
B85
AppendixorFieldName
SenderID
ServiceProviderID
SubmissionNumber
TotalAmountPaid
TransactionID
TransmissionDate
TransmissionTime
TransmissionType
AccumulatorActionCode
AccumulatorAppliedAmount
AccumulatorBalanceBenefitType
AccumulatorBalanceQualifier
AccumulatorBalanceCount
AccumulatorBenefitPeriodAmount
AccumulatorChangeSourceCode
AccumulatorNetworkIndicator
AccumulatorReferenceTimeStamp
AccumulatorRemainingBalance
AccumulatorSpecificCategoryType
DocumentReferenceIdentifierQualifier
OptionalDataIndicator
PenaltyAmount
ProcessorRoutingIdentification
RecordLength
SenderReferenceNumber
TransmissionID
AppendixA
Action
Addition
Deletion
Modification
AddedforusebyVersion1oftheBenefitIntegrationStandardandVersionaddedinECL
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
x
addedfieldsasshownabove
BBB. APRIL215
1.
- 290 April215
DATA DICTIONARY
FieldNumber
12A2
AppendixorFieldName
Action
Addition
Deletion
NoKnownAllergies
2.
Modification
FieldFormat:FromBooleanCodeTox(1)
VersionupdatedinECL
SeeECLpublicationofApril 215 forupdates
FieldNumber
12A2
AppendixorFieldName
NoKnownAllergies
Action
Addition
Deletion
Modification
FieldFormat:FromBooleanCodeTox(1)
VersionupdatedinECL
SeeECLpublicationofApril 215 forupdates
- 291 April215

Data Dictionary 201504

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AppendixANUMERICCROSSREFERENCEFORDATAELEMENTSWITHNUMERICIDENTIFIERS .......................................................................................................................... 166

IV.AppendixBCROSSREFERENCEOFFIELDSUSEDINNCPDPSCRIPTTOTHEMODELDRIVENSCHEMAS .................................................................................................................... 183

A transmitted value of 25.4 when applied to a monetary use represents

Code identifying the coverage

ForT,A,V,W,X :Comments: QualifiedbyPatientId

Comments: WhenusedforUSZIPCode Thisleft

Used to request return receipt. If

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