Pharmacy Claims Submission Requirements

Field

Data Type

Description

Date of Service*

Date

The date on which the prescription was filled by the dispensing pharmacy.

Date Prescribed*

Date

The date on which the prescription was written by the prescribing healthcare provider.

Rx Number*

Numeric

The native (unmodified) prescription number for the prescription as generated by the pharmacy.

Fill Number*

Numeric (0-99)

Indicates the number of times the prescription has been filled as of the current fill. For example, a value of "0" indicates that the prescription has not been filled previously and the current fill is the first one. The first refill would have a value of "1".

NDC-11*

Numeric (11 Digits)

The 11-digit National Drug Code (NDC) identifying the manufacturer, drug product, and package size of the medication dispensed.

Quantity Dispensed*

Numeric

Number of units dispensed to the patient. Appropriate Units of Measure for each product will be provided within the NDC list.

Prescriber ID*

Numeric (10 Digits)

National provider identifier (NPI) of the healthcare provider that wrote the prescription.

Service Provider ID*

Numeric (10 Digits), no leading zeros

NPI of the pharmacy that dispensed the prescription.

340B ID*

Alphanumeric, may contain dashes – starts with 2 or 3 letters

HRSA assigned identifier of the 340B covered entity that designated the dispense as 340B. If the 340B ID contains a suffix, this must be included.

Rx BIN*

Numeric (6 Digits)

Prescription Drug Bank Identification Number for the primary payer. Enables pharmacies to electronically transmit data to the appropriate PBM for processing and reimbursement. If a patient is uninsured or a cash payer, mark "999999" in this field.

Rx PCN*

Alphanumeric

Processor Control Number for the primary payer. Identifier used to determine which processor will handle a prescription drug claim. If a patient is uninsured or a cash payer, mark "CASH" in this field. If there is no PCN, mark "NONE" in this field.