The Billing Billing Provider's Report the Federal Tax ID of the Billing Provider PC 64 11/8/12 Numeric ID Tax char[9] Federal Tax Provider here. Do not use hyphen or All 90% C Tax ID Identification alpha prefix. Number Number (FTIN) Report the date that appears on the check and/or remit and/or explanation of Full Century Year benefits and corresponds to any and all Paid date of the PC 65 Paid Date 6/24/10 Date - Month Day - int[8] types of payment in CCYYMMDD Format. All 99% A0 claim line Integer CCYYMMDD This can be the same date as Processed Date. EXAMPLE: Claims paid in full, partial or zero paid Date Full Century Year Date Report the date that was written on the PC 66 11/8/12 Date - Month Day - int[8] prescription was prescription or called-in by the physician's All 98% B Written Integer CCYYMMDD prescribed office in CCYYMMDD Format. Report the amount that another carrier / insurer is liable for after submitting payer Amount due has processed this claim line. Report 0 if Required of from a there is no COB / TPL amount. Do not when PC 67 11/8/12 Integer Currency Secondary code decimal or round up / down to whole PC025 = 98% A2 Carrier when dollars, code zero cents (00) when 19, 20 or Liability known applicable. EXAMPLE: 150.00 is 21 Amount reported as 15000; 150.70 is reported as 15070 Report the amount that a prior payer has paid for this claim line. Indicates the submitting Payer is 'secondary' to the prior payer. Only report 0 if the Prior Required Other Amount paid by Payer paid 0 towards this claim line, else when Insurance PC 68 11/8/12 Integer Currency a Primary / Prior do not report any value here. Do not PC025 = 98% A2 Paid Carrier code decimal or round up / down to whole 02, 03, 20, Amount dollars, code zero cents (00) when or 21 applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070
PC 64 Billing Provider Tax ID Number 11/8/12 Numeric ID Tax char[9] The Billing Provider's Federal Tax Identification Number (FTIN) Report the Federal Tax ID of the Billing Provider here. Do not use hyphen or alpha prefix. All 90% C PC 65 Paid Date 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Paid date of the claim line Report the date that appears on the check and/or remit and/or explanation of benefits and corresponds to any and all types of payment in CCYYMMDD Format. This can be the same date as Processed Date. EXAMPLE: Claims paid in full, partial or zero paid All 99% A0 PC 66 Date Written 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Date prescription was prescribed Report the date that was written on the prescription or called-in by the physician's office in CCYYMMDD Format. All 98% B PC 67 of Liability Amount 11/8/12 Integer Currency Amount due from a Secondary Carrier when known Report the amount that another carrier / insurer is liable for after submitting payer has processed this claim line. Report 0 if there is no COB / TPL amount. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when PC025 = 19, 20 or 21 98% A2 PC 68 Other Insurance Paid Amount 11/8/12 Integer Currency Amount paid by a Primary / Prior Carrier Report the amount that a prior payer has paid for this claim line. Indicates the submitting Payer is 'secondary' to the prior payer. Only report 0 if the Prior Payer paid 0 towards this claim line, else do not report any value here. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when PC025 = 02, 03, 20, or 21 98% A2
v5-apcd-pharmacy-claim-file-submission-guide-FINAL.docx