Download the medical claims data template here:
View the field list for medical claims data below
Field | Data Type | Description |
Health Plan Name* | Alphanumeric | Name 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. |
Health Plan ID* | Alphanumeric | 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. |
Health Plan ID Qualifier | Alphanumeric | The qualifier for the patient's health insurance plan ID. |
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. |
NDC-11* | Numeric (11 Digits) | The 11-digit National Drug Code which indicates the manufacturer, product, and commercial package size. |
Quantity* | Numeric | The quantity of medication administered to the patient. Quantity must reflect standardized billing units as defined by NCPDP for the NDC-11. |
Unit of Measure* | Alphanumeric | UOM must be consistent with the standardized billing unit as defined by NCPDP for the NDC-11. |
Date of Service* | Date | Date on which the medication was 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. |
Claim Number* | Alphanumeric | A unique identifier for a prescription and claim processor. This value should align with the Patient Control Number or Claim Submission ID, as set within provider systems and included on EDI 837 transmissions to payers (Form 1500 Box 26 or Claim 1450 Box 3). |
Claim Line Number* | Numeric | Identifies an individual line number on a claim. Line numbers distinguish services that are submitted on the same claim. Wastage Claims or undispensed units submitted should include a separate claim line number from the dispensed units. |
340B ID* | Alphanumeric | HRSA assigned identifier of the 340B covered entity that designated the administration as 340B. |
*Indicates a required field
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