Data Template: Medical Claims Data

Field

Data Type

Description

340B ID*

Alpha/Numeric

The unique identification number provided by HRSA to the 340B covered entity.

Claim Number*

Alpha/Numeric

The unique claim number identifying the claim.

Claim Line Number*

Alpha/Numeric

Identifies an individual line number on a claim. Line numbers distinguish distinct services that are submitted on the same claim.

Date of Service*

Standard date formats

Date on which the medication was administered to the patient.

HCPCS Code

Alpha/Numeric

The five digit HCPCS code corresponding to the medication administered. For drugs billed using a non-specific or miscellaneous HCPCS code (e.g., A9270, J3490), please leave this field blank.

HCPCS Code Modifier

Alpha/Numeric

Modifier to the HCPCS code. Up to four modifier codes may be entered for the same claim line.

Health Plan Name*

Alpha/Numeric

Name of the patient's primary health insurance plan. Examples include Medicare Part B, MediCal, Aetna POS, etc. If the patient is uninsured or a cash payer, mark “CASH” in this field. If no health plan information is recorded, mark “NONE” in this field.

Health Plan ID*

Alpha/Numeric

The identifier code of the patient's primary health insurance plan. If the patient is uninsured or a cash payer, mark “CASH” in this field. If no health plan information is recorded, mark “NONE” in this field.

NDC-11*

Numeric – 11 digits

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

Rendering Physician ID*

Numeric – 10 digits

The NPI of the healthcare provider who rendered or supervised the care reported on the claim.

Quantity*

Numeric

The quantity of medication administered to the patient. If a specific (non-miscellaneous) HCPCS code with CMS-defined billing units is reported, quantity must reflect the CMS-defined billable units for that HCPCS code. If no HCPCS code is reported, quantity must reflect standardized billing units as defined by NCPDP for the NDC-11.

Unit of Measure

Alpha/Numeric

Either HCPCS code or UOM is required. If no specific (non-miscellaneous) HCPCS code is reported, UOM must be reported, and it must be consistent with standardized billing units as defined by NCPDP for the NDC-11.

Service Provider ID*

Numeric – 10 digits

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.