340B ID*

The HRSA assigned parent 340B ID of the entity that purchased the administered medication at the 340B price.

Alpha-Numeric ID that may contain dashes. Always starts with with 2 or 3 letters

Claim Number*

The claim number as assigned by the healthcare provider.

Alpha Numeric (A/N)

Date of Service (DOS)*

Date on which the medication was administered to the patient.

Standard Date Formats

HCPCS Code

The five digit HCPCS code for separately payable medications. This value may not exist for medications that are reimbursed as part of procedure (e.g. a blood thinner used as part of an outpatient procedure).

Alpha Numeric (A/N)

HCPCS Code Modifier

Modifier code associated with a separately payable medication with its own 5 digit HCPCS code. This field can be used to indicate that the units are associated with drug wastage and are not duplicative of those units administered to the patient.

Alpha Numeric (A/N)

Health Plan Name*

Name of the patient's health insurance plan. Examples include Medicare Part B, MediCal, Aetna POS, etc.

Alpha Numeric (A/N)

Health Plan ID*

The identifier code of the patient's health insurance plan as assigned by the health insurer.

Alpha Numeric (A/N)

Health Plan ID Qualifier

The qualifier for the patient's health insurance plan ID.

Alpha Numeric (A/N)

Product Service ID (NDC-11)*

The NDC-11 of the medication administered to the patient.

Numeric, 11 digits, may contain up to 4 leading zeros

Physician / Prescriber ID*

The NPI of the physician that administered the medication to the patient.

Numeric, 10 digits, never starts with a leading zero

Quantity*

The quantity - as measured in billable units - of medication administered to the patient.

Numeric, can contain decimals

Service Provider ID*

The NPI of the healthcare entity where the patient received the medication administration. For example, this could be the NPI of a hospital outpatient surgery center or the NPI of an outpatient infusion center.

Numeric, 10 digits, never starts with a leading zero