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. |