Drug Rebate Claims File Extract
Field Data Type Start End Length Description
CLIENT_ID NUMBER 1 4 4 Default to 0016 (for GA)
FILLER_1 CHAR 5 5 1 Blank
ICN CHAR 6 25 20 Number assigned to a claim processed in the system. This number is used for control purposes.  The ICN is broken down as follows:  Region Code (2 characters), Year (2 characters), Julian Date (3 characters), Batch Number (3 characters) and Claim Sequence (3 characters).
FILLER_2 CHAR 26 26 1 Blank
LINE_NUMBER NUMBER 27 30 4 The detail line number on the claim where the Jcode was found.
FILLER_3 CHAR 31 31 1 Blank
CDE_CLM_TXN CHAR 32 32 1 Code indicating if the claims is Original "O", Adjustment Replacement "A", Adjustment Void "V" or Adjustment Backout "B"
FILLER_4 CHAR 33 33 1 Blank
YRQTR CHAR 34 38 5 The year and quarter in which claim was paid or year and quarter of original claim when matching voids. The format CCYYQ. Calculate the quarter based on calendar year: If month= 1,2,3, quarter = 1. If month = 4,5,6, quarter = 2. If month = 7,8,9, quarter would be 3. If month = 10,11,12, quarter would be 4.
FILLER_5 CHAR 39 39 1 Blank
NDC CHAR 40 50 11 National Drug Code
FILLER_6 CHAR 51 51 1 Blank
UNITS_SIGN CHAR 52 52 1 + or "-"
UNITS_BEG NUMBER 53 61 9 Number of units paid before decimal points. Units are HCPC Units.
UNITS_DECIMAL CHAR 62 62 1 Decimal Point"."
UNITS_END NUMBER 63 65 3 Number of units paid after decimal points. Units are HCPC Units.
FILLER_7 CHAR 66 66 1 Blank
PAID_AMT_SIGN CHAR 67 67 1 + or "-"
PAID_AMT_BEG NUMBER 68 76 9 Paid amount dollars before decimal point
PAID_AMT_DECIMAL CHAR 77 77 1 Decimal Point"."
PAID_AMT_END NUMBER 78 79 2 Paid amount dollars after decimal point
FILLER_8 CHAR 80 80 1 Blank
BILLED_AMT_SIGN CHAR 81 81 1 + or "-"
BILLED_AMT_BEG NUMBER 82 90 9 Billed amount dollars before decimal point
BILLED_AMT_DECIMAL CHAR 91 91 1 Decimal Point"."
BILLED_AMT_END NUMBER 92 93 2 Billed amount dollars after decimal point
FILLER_9 CHAR 94 94 1 Blank
PRESC_PROVIDER CHAR 95 109 15 Medicaid ID (MCD) of the  payee provider.
FILLER_10 CHAR 110 110 1 Blank
PHARMACY_PROVIDER CHAR 111 125 15 Medicaid ID (MCD) for the pharmacy billing provider. 
FILLER_11 CHAR 126 126 1 Blank
DOS CHAR 127 136 10 Date of service -  format MM/DD/CCYY
FILLER_12 CHAR 137 137 1 Blank
MEMBER_ID CHAR 138 152 15 The member's Medicaid Id
FILLER_13 CHAR 153 153 1 Blank
RX_NUMBER CHAR 154 163 10 Script number if available.  Default to blanks, does not exist on an Inst or Prof claims.
FILLER_14 CHAR 164 164 1 Blank
PROCEDURE_CODE CHAR 165 171 7 Procedure code (Jcode) for medical claims
FILLER_15 CHAR 172 172 1 Blank
TPL_AMT_SIGN CHAR 173 173 1 + or "-"
TPL_AMT_BEG NUMBER 174 182 9 Third Party Liability  amount dollars before decimal point. Medicare payment amount plus the TPL payment amount equal the Drug Rebate Third Pary Liability Amount.
TPL_AMT_DECIMAL CHAR 183 183 1 Decimal Point"."
TPL_AMT_END NUMBER 184 185 2 Third Party Liability amount dollars after decimal point. Medicare payment amount plus the TPL payment amount equal the Drug Rebate Third Pary Liability Amount.
FILLER_16 CHAR 186 186 1 Blank
CO_PAY_SIGN CHAR 187 187 1 + or "-"
CO_PAY_AMT_BEG NUMBER 188 196 9 Co-pay amount dollars before decimal point
CO_PAY_AMT_DECIMAL CHAR 197 197 1 Decimal Point"."
CO_PAY_AMT_END NUMBER 198 199 2 Co-pay amount dollars after decimal point
FILLER_17 CHAR 200 200 1 Blank
PAID_DATE CHAR 201 210 10 Date the Jcode was paid, format: MM/DD/CCYY
FILLER_18 CHAR 211 211 1 Blank
RECEIVED DATE CHAR 212 221 10 Date the claim was received, format: MM/DD/CCYY
FILLER_19 CHAR 222 222 1 Blank
DAW CHAR 223 223 1 Dispense as written indicator - default is 0
FILLER_20 CHAR 224 224 1 Blank
COMPOUND CHAR 225 225 1 Compound indicator - default is "N"
FILLER_21 CHAR 226 226 1 Blank
EXCLUSION_REASON CHAR 227 227 1 Exclusion Reason - default is blank
FILLER_22 CHAR 228 228 1 Blank
DAYS_SUPPLY NUMBER 229 232 4 Days supply - default is 0
FILLER_23 CHAR 233 233 1 Blank
CLAIM_SOURCE CHAR 234 236 3 For physician and UB claims default to JCD
FILLER_24 CHAR 237 237 1 Blank
DISP_FEE_BEG NUMBER 238 240 3 Dispensing fee amt before decimal, default to 0.
DISP_FEE_DECIMAL CHAR 241 241 1 Decimal Point"."
DISP_FEE_END NUMBER 242 243 2 Dispensing fee amt after decimal, default to 0.
FILLER_25 CHAR 244 244 1 Blank
REFILL_CODE CHAR 245 246 2 Refill indicator - default is blank
FILLER_26 CHAR 247 247 1 Blank
CYCLE_QTR CHAR 248 252 5 Year and quarter when claim was paid. Should reflect quarter of paid date -format CCYYQ.
Calculate the quarter based on calendar year: If month= 1,2,3, quarter = 1. If month = 4,5,6, quarter = 2. If month = 7,8,9, quarter would be 3. If month = 10,11,12, quarter would be 4.
FILLER_27 CHAR 253 253 1 Blank
PROGRAM_TYPE CHAR 254 256 3 Indicates which rebate program this claim belongs to - default to GAH.
FILLER_28 CHAR 257 257 1 Blank
RPT_FUND_GROUP CHAR 258 272 15 Reporting fund group
FILLER_29 CHAR 273 273 1 Blank
FUND_CODE CHAR 274 277 4 Indicates a Professional Crossover or Outpatient Crossoer Claim
Values:
B - Professional Crossover
C - Outpatient Crossover
Blank
FILLER_30 CHAR 278 278 1 Blank
TOWN_CODE CHAR 279 282 4 Town code - default value is blanks
FILLER_31 CHAR 283 283 1 Blank
LOCATION_CODE CHAR 284 285 2 Location code - default value is blanks
FILLER_32 CHAR 286 286 1 Blank
ORIGINAL_PROVIDER CHAR 287 301 15 Blank
FILLER_33 CHAR 302 302 1 Blank
MODIFIER_1 CHAR 303 304 2 First Procedure Code Modifier
FILLER_34 CHAR 305 305 1 Blank
MODIFIER_2 CHAR 306 307 2 Second Procedure Code Modifier
FILLER_35 CHAR 308 308 1 Blank
MODIFIER_3 CHAR 309 310 2 Third Procedure Code Modifier
FILLER_36 CHAR 311 311 1 Blank
MODIFIER_4 CHAR 312 313 2 Fourth Procedure Code Modifier
FILLER_37 CHAR 314 314 1 Blank
FORMER ICN CHAR 315 327 13 The Interchange ICN number for the previous paid claim.
FILLER_38 CHAR 328 328 1 Blank
TCN CHAR 329 348 20 The TC number assoicated to the former converted former ICN  OR the TCN assoicated to the converted ICN.
FILLER_END_CHARACTER CHAR 349 349 1 Default to new line character.