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