Code of Maine Rules
90 - INDEPENDENT AGENCIES
590 - MAINE HEALTH DATA ORGANIZATION
Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS
Appendix 590-243-E-1 - Maine Health Data Organization Pharmacy Claims File Specifications

Data Element #

Data Element Name

Date Effective

Type

Maximum Length

Description/Codes/Sources

PC001

Submitter

1/1/2003

Text

8

MHDO-assigned identifier of payor submitting claims data. Do not leave blank.

PC002

Payor

7/1/2012

Text

8

MHDO-assigned code of the insurer/underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage. Do not leave blank.

PC003

Insurance Type/Product Code

1/1/2003

Text

2

Code identifying the type of insurance policy within a specific insurance program. Refer to Appendix A 16 Medicare Part C MD Medicare Part D SP Supplemental Policy

PC004

Payor Claim Control Number

1/1/2003

Text

35

Must apply to the entire claim and be unique within the payor's system. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC005

Line Counter

4/1/2004

Number

4

Line number for this service The line counter begins with 1 and is incremented by 1 for each additional service line of a claim. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC006

Insured Group or Policy Number

1/1/2003

Text

30

Group or policy number - not the number that uniquely identifies the Subscriber Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC007

Subscriber Social Security Number

1/1/2003

Text

9

Subscriber's social security number Leave blank if unavailable. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC008

Plan Specific Contract Number

1/1/2003

Text

80

Plan-assigned contract number Leave blank if contract number = subscriber's social security number. Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC009

Member Suffix or Sequence Number

1/1/2003

Text

20

Uniquely numbers the member within the contract Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC010

Member Identification Code

1/1/2003

Text

50

Member's social security number

Leave blank if unavailable

Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC011

Individual Relationship Code

1/1/2003

Text

2

Member's relationship to insured

Refer to Appendix A

Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC012

Member Gender

1/1/2003

Number

1

Refer to Appendix A

Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC013

Member Date of Birth

1/1/2003

Text

8

CCYYMMDD

Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC014

Member City Name

4/1/2004

Text

30

City name of member

Refer to Appendix A

Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC015

Member State or Province

4/1/2004

Text

2

As defined by the US Postal Service and Canada Post Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC016

Member ZIP Code

1/1/2003

Text

11

ZIP Code of member - may include non-US codes Do not include dash Refer to Appendix A Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC017

Date Service Approved (AP Date)

1/1/2003

Text

8

CCYYMMDD

The value 'CCYY0101', where CCYY is the year in which the service was approved, shall be used when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = 'Y'.

PC018

Pharmacy Number

1/1/2003

Text

30

Payor-assigned pharmacy number Not required if PC021 is populated.

PC019

Pharmacy Tax ID Number

1/1/2003

Text

10

Federal taxpayer's identification number

PC020

Pharmacy Name

1/1/2003

Text

100

Name of pharmacy

PC021

National Provider ID - Pharmacy Provider

4/1/2004

Text

20

National Provider ID for Pharmacy

This data element pertains to the entity or individual directly providing the service.

Refer to Appendix A

PC022

Pharmacy Location City

4/1/2004

Text

30

City name of pharmacy - preferably pharmacy location Refer to Appendix A

PC023

Pharmacy Location State

4/1/2004

Text

2

As defined by the US Postal Service and Canada Post Refer to Appendix A

PC024

Pharmacy ZIP Code

1/1/2003

Text

11

ZIP Code of pharmacy - may include non-US codes Do not include dash.

Refer to Appendix A

PC024A

Pharmacy Country Code

1/1/2010

Text

30

Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A.

PC025

Claim Status

1/1/2003

Text

2

Refer to Appendix A

PC026

Drug Code

1/1/2003

Text

11

NDC Code

Refer to Appendix A

PC027

Drug Name

1/1/2003

Text

80

Text name of drug

PC028

New Prescription or Refill

1/1/2003

Text

2

00 New prescription 01-99 Number of refill

PC029

Generic Drug Indicator

1/1/2003

Text

1

N No, branded drug Y Yes, generic drug

PC030

Dispense as Written Code

1/1/2003

Text

1

Refer to Appendix A

PC031

Compound Drug Indicator

4/1/2004

Text

1

N Non-compound drug

U Non-specified drug compound

Y Compound drug

PC032

Date Prescription Filled

1/1/2003

Text

8

CCYYMMDD

The value 'CCYY0101', where CCYY is the year in which the service was approved, shall be used when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of MC333 = 'Y'.

PC033

Quantity Dispensed

1/1/2003

Number

10

Number of metric units of medication dispensed. Code decimal point.

PC034

Days' Supply

1/1/2003

Number

3

Estimated number of days the prescription will last

PC035

Charge Amount

1/1/2003

Number

10

Do not code decimal point. Two decimal places implied.

PC036

Paid Amount

1/1/2003

Number

10

Includes all health plan payments and excludes all member payments. Do not deduct POS rebate amount, if applicable. Do not include Pharmacy Benefits Manager Compensation.

Do not code decimal point. Two decimal places implied.

PC037

Ingredient Cost/List Price

1/1/2003

Number

10

Cost of the drug dispensed

Do not code decimal point. Two decimal places implied.

PC038

Postage Amount Claimed

4/1/2004

Number

10

Do not code decimal point. Two decimal places implied.

PC039

Dispensing Fee

1/1/2003

Number

10

Do not code decimal point. Two decimal places implied.

PC040

Co-pay Amount

1/1/2003

Number

10

The preset, fixed dollar amount for which the individual is responsible. Do not deduct POS rebate amount, if applicable.

Do not code decimal point. Two decimal places implied.

PC041

Coinsurance Amount

1/1/2003

Number

10

The dollar amount an individual is responsible for - not the percentage. Do not deduct POS rebate amount, if applicable.

Do not code decimal point. Two decimal places implied.

PC042

Deductible Amount

1/1/2003

Number

10

Do not deduct POS rebate amount, if applicable.

Do not code decimal point. Two decimal places implied.

PC043

Patient Pay Amount

1/1/2013

Number

10

Amount that is calculated by the payor and returned to the pharmacy as the total amount to be paid by the patient to the pharmacy. $0 is acceptable; if "data not available" leave blank.

Do not include decimal point. Two decimal places implied.

PC044

Prescribing Physician First Name

7/1/2006

Text

40

Physician first name Optional if PC047 is filled.

PC045

Prescribing Physician Middle Name

7/1/2006

Text

25

Physician middle name or initial Optional if PC047 is filled.

PC046

Prescribing Physician Last Name

7/1/2006

Text

60

Physician last name. Optional if PC047 is filled.

PC047

Prescribing Physician DEA

7/1/2006

Text

20

DEA for prescribing physician

PC048

Prescribing Physician NPI

10/1/2014

Text

20

NPI for prescribing physician Refer to Appendix A

PC101

Subscriber Last Name

1/1/2010

Text

60

The subscriber last name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC102

Subscriber First Name

1/1/2010

Text

35

The subscriber first name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC103

Subscriber Middle Name

1/1/2010

Text

25

The subscriber middle name or initial Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC104

Member Last Name

1/1/2010

Text

60

The member last name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC105

Member First Name

1/1/2010

Text

35

The member first name Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC106

Member Middle Name

1/1/2010

Text

25

The member middle name or initial Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC107

Member Address Line 1

2/1/2019

Text

55

Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC108

Member Address Line 2

2/1/2019

Text

55

Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC109

Member Country Code

2/1/2019

Text

2

Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A.

Shall be left blank when the payor indicates the record contains 42 CFR Part 2 SUD-related data by setting the value of PC113 = 'Y'.

PC110

In-Plan Network Indicator

2/1/2021

Text

1

Use this field to specify if services from the requested Pharmacy Provider were provided within the health plan network. Valid values are: N=No; Y=Yes.

PC111

Placeholder

2/1/2025

N/A

0

Leave blank. Payment Arrangement Type Indicator retired

PC112

Member Age

2/1/2025

Text

3

Member's calculated age as of the service date. Round to the nearest integer. For ages GREATER THAN EQUAL TO 90, indicate '90'.

PC113

Substance Use Disorder (SUD) Indicator

2/1/2025

Text

1

Indicates whether a record contains 42 CFR Part 2 SUD-related data or not. Valid values are:

N = Record does not contain 42 CFR Part 2 SUD-related data. Send all available values of all requested fields.

Y = Record contains 42 CFR Part 2 SUD-related data. The following fields shall be left blank: PC004-PC016; and PC101-PC109.

PC114

Total POS Rebate Amount

2/1/2025

Number

10

The total dollar amount of all reductions to amounts paid by the health plan or an individual member resulting from POS (point-of-sale) rebates. The total POS rebate amount should be reported in full and should not be deducted from either plan paid or member copay, deductible, or coinsurance amounts. Do not code decimal point. Two decimal places implied.

PC115

Member POS Rebate Amount

2/1/2025

Number

10

The dollar amount of all reductions to amounts paid by an individual member resulting from POS rebates. The member POS rebate amount should not be deducted from member copay, deductible, or coinsurance amounts. Do not code decimal point. Two decimal places implied.

PC116

PBM Compensation Amount

2/1/2025

Number

10

The value of payments made by the payor to its pharmacy benefits manager that is not paid to the pharmacy The pharmacy benefits manager compensation amount should not be included in the plan paid amount. PBM compensation does not include any compensation paid by a manufacturer, developer, or labeler for the performance of services.

Do not code decimal point. Two decimal places implied.

PC899

Record Type

1/1/2003

Text

2

PC

To ensure the security of personally identifiable information and personal health information that is submitted to the MHDO Data Warehouse and to reduce file transmission times, MHDO requires submitters to compress and encrypt all files before uploading to the warehouse. This file-level encryption will ensure the confidentiality of all data that are submitted to the warehouse, not just individual fields.