Data Layouts and Formats

Transcription

1 Data Layouts and Formats Pharmacy, Dental, and Provider Files March 13, 2008 INSTITUTE FOR CHILD HEALTH POLICY 1 ENCOUNTERS SUBMISSION GUIDELINES 03/13//2008

2 Table of Contents 1. INTRODUCTION 3 2. GENERAL REQUIREMENTS 3 3. DENTAL CLAIMS FILE LAYOUT 4 4. PHARMACY CLAIMS FILE LAYOUT 5 5. PROVIDER FILE 6 6. REVISIONS 6 INSTITUTE FOR CHILD HEALTH POLICY 2

3 1. INTRODUCTION This document describes the data layouts and formats for receiving the following data files: Dental claims data data related to dental claims Pharmacy claims data data related to prescription information Provider data data related to physicians and other health care providers 2. GENERAL REQUIREMENTS 2.1 Data Extraction For this encounter system, ICHP requires the MCOs to submit all paid and denied claims data. Pending claims should not be included in the submission. Our expectation is that we will get quarterly claims file submissions which will cover claims adjudicated in the prior quarter. 2.2 Data Submission We accept encounter data 24 hours a day, 7 days a week, 365 days a year, except during brief, preannounced system maintenance periods. The file naming convention for these files will be Identifier< Dental, Provider, Pharmacy> Plan Name/Code YYYYMM where YYYYMM is the submission year and month. 2.3 Data Element Formatting 1. Date formats are always formatted YYYYMMDD(8). 2. Numeric values are always right-justified, zero filled. 3. Alphanumeric values are always left-justified, blank filled and uppercase. 4. Each file should be delivered in a fixed-length ASCII format with no field labels and no binary data. 5. All null fields must contain blanks/spaces 6. For dollar amounts, we always assume a whole dollar amount unless a decimal is provided. If a portion of your data has decimal values, we will add appropriate fill values (e.g. 00 cents) for each of the values. Examples: 125 = $ = $ = -$ All dental and pharmacy files must end with a Trailer record containing the Trailer Identifier< FHK>, Total # of Records, Total Paid Dollars on the File, Paid Month Start Date and Paid Month Thru Date INSTITUTE FOR CHILD HEALTH POLICY 3

4 3. DENTAL CLAIMS FILE LAYOUT FIELD Name SIZE TYPE VALUE DESCRIPTION Record Type 1 AN D Record Type Recipient ID 12 AN Enrollee s ID Number Plan ID 5 AN Program name or ID Billing Provider -Number 12 AN Unique Provider ID Number ( Program ID for the provider) Billing Provider NPI 10 AN Billing Provider Taxonomy 10 AN Taxonomy Code Billing Provider Tax ID 9 N Provider s TAX ID Treating Provider -Number 12 AN Treating Provider Unique Provider ID Treating Provider Specialty 2 AN D1 - Endodontia/D2 - Oral and maxillofacial surgery/d3 - General dentistry/d4 - Orthodontia/D5 - Pediatric dentistry/d6 - Periodontia/D7 - Public health dentistry/d8 - Other Treating Provider NPI 10 AN Treating Provider Taxonomy 10 AN Taxonomy Code Treating Provider Tax ID 9 AN Provider s TAX ID Claim Number 25 AN Claim Number Line Item 7 N Adjudication Status 1 AN P,A,C, D Status as paid, adjusted, Capitated or denied Procedure Date 8 AN YYYYMMDD Date of Service Tooth number or letter 2 AN 1-32 or A-T Tooth number or letter B (buccal), D (distal), F (facial), I (incisal), L (lingual), M (mesial), O (occlusal) Tooth Surface 5 A Procedure Code 6 AN CPT code Amount Billed 9 N UCR fee Tooth surface appropriate for Procedure code billed Amount Paid 12 N Amount paid for the line item on the claim related to the above referenced care Place of Treatment 1 AN O,I (O=Office; I=Inpatient Hosp) Place where dental services were delivered Date Claim received 8 AN YYYYMMDD Not Required. Date received by processing contractor Paid Date 8 AN YYYYMMDD Date Paid or Denied Line Item EOB 3 AN Explanation code for each line item processed relating to how the claim was adjudicated Not Required.Explanation of Benefits code INSTITUTE FOR CHILD HEALTH POLICY 4

5 4. PHARMACY CLAIMS FILE LAYOUT Field Name Data Type Size Definition Claim Number Numeric 40 The claim number Claim Status AN 1 Indicates the status of a CLAIM submitted by a pharmacy: P - Payable or Paid R - Original claim reversed D- Denied A-Adjusted Recipient ID AN 12 Unique identifier assigned to the member Patient Last Name AN 30 Last Name of the client Patient First Name AN 30 First name Date of Birth AN 8 Patient DOB (yyyymmdd) Sex Code AN 1 U=Not specified M=Male F=Female Client_ Category (Eligibility AN 2 Not Required. The eligibility category of the member. Category) This field will be blank if information not available Plan ID AN 5 Program name or ID Pharmacy Number AN 8 The ID number for the Pharmacy Pharmacy Name AN 30 Name of pharmacy Pharmacy Street Address AN 30 Address of pharmacy Pharmacy City AN 20 City of pharmacy Pharmacy State AN 2 State of pharmacy Pharmacy Zip AN 10 Zip code of pharmacy Prescriber Number AN 12 Healthplan assigned or program assigned ID of the prescriber. Prescriber NPI AN 10 NPI of the provider Prescriber Last Name AN 30 Last name of prescribing physician Prescriber First Name AN 30 First name of prescribing physician RX Fill Date AN 8 Dispensing date of RX (YYYYMMDD) Authorize Refill AN 1 Number of refills authorized by prescriber NDC Number AN 11 National Drug Code Label Name AN 50 NDC description and the drug strength Source Type AN 1 S - Single Source, G - Generic, B - Branded Generic, I - Innovator DEA Code AN Non-Controlled, 1 - Research Only, 2 - Most Abused, 3 - Less Abused, 4 - Potential Abuse, 5 - Controlled Sale Legend Indicator AN 1 L - Legend, N - OTC RX Days Supply AN 3 Estimated number of days prescription will last RX Quantity N 6 Number of metric units of medication dispensed Unit Type AN 3 Units dispensed; Primary Values EA=each, ML=milliliter; GM=gram Additional Allowed Values AM=Ampule, APO=Apothecary, CP=Capsule, INT=International Unit, KT=Kit, MG=Milligram, OZ=Ounces, SP=SP, TB=Tablet, TP=TP, UN=Unit, VL=Vial RX Submit Amount Numeric 12 Amount billed from pharmacy Amount Paid Numeric 12 Amount Paid Patient Amount Due Numeric 12 Correct copay for member Drug Cost Numeric 12 Calculated cost of drug Recipient Location AN 2 00=Not Specified 01=Home 02=Inter Care 03=Nursing Home 04=Long Term/Extended Care 05=Rest Home 06=Boarding Home 07=Skilled Care Facility 08=Subacute Care Facility 09=Acute Care Facility 10=Outpatient 11=Hospice Not a required field for Vendor Drug Therapeutic Class AN 3 Paid date YYYYMMDD(8) 8 INSTITUTE FOR CHILD HEALTH POLICY 5

6 5. PROVIDER FILE NAME TYPE SIZE VALUE Description of Values Transaction Type AN 1 Blank a,c,d a = Add;c = Change/Edit; d = Delete; Blank = existing member, no change Period - current month N 6 yyyymm Plan ID AN 5 Program name or ID Provider ID (Provider Number) AN 12 Healthplan assigned or program assigned ID for the provider NPI number AN 10 National Provider ID Taxonomy code AN 10 Provider last name AN 24 Provider s first name AN 14 Address attn AN 24 Address line 1 AN 24 Address line 2 AN 24 Address line 3 AN 24 City AN 12 State AN 2 Zip N 10 Telephone AN 12 format: Practice type AN 2 01, 02 Group Practice=01, Individual Practice=02 Panel size N 2 Number of clients assigned to the provider County code N 3 Primary Care Provider AN 1 Y/N Yes or No Provider s License Number AN 7 Provider s Tax ID AN 9 Credentialed AN 1 Is Provider Credentialed Y/N? 6. REVISIONS 02/08/2008 : Added NPI and Taxonomy information on the Dental, Pharmacy, and Provider files. Changed Specialty Code to PCP Y/N on the provider file. Added Plan ID field to Dental, Pharmacy, and Provider files 03/13/2008 : Changed the Date of Birth field on the pharmacy layout from AN(10) to AN(8). Changed the Recipient ID on the pharmacy layout from AN(9) to AN(12). Changed the RX Fill Date field on the pharmacy layout from AN(10) to AN(8). Changed Claim Status in pharmacy file from AN(2) to AN(1). Changed Amount in dental file from N(9) to N(12) INSTITUTE FOR CHILD HEALTH POLICY 6