Carrier Report the identifier the carrier / submitter Specific uses internally to uniquely identify the Subscriber's PC 85 Unique 11/8/12 Text ID Link to ME117 subscriber. Used to validate Unique All 100% A0 Unique ID Subscriber Member ID and link back to Member ID Eligibility (ME117) Report the address of member which may Secondary Member include apartment number or suite, or Street Address PC 86 Street 11/8/12 Text Address 2 Member other secondary information besides the All 0% B of the Address 2 street. Used to validate Unique Member Member/Patient ID. Lookup Claim Line Report the code that defines the line Line PC 87 11/8/12 Table - tlkpClaimLineType char[1] Activity Type status in terms of adjudication. All 98% A2 Type Text Code EXAMPLE: O = Original Code Description O Original V Void R Replacement B Back Out A Amendment Report the Claim Control Number (PC004) that was originally sent in a prior filing that this line corresponds to. When Former Previous Claim reported, this data cannot equal its own PC 88 Claim 12/1/10 Text ID Claim Number All 0% B Number PC004. Use of Claim Number” “Former Number to version claims can only be used if approved by the APCD. Contact the APCD for conditions of use. Indicator - Lookup Report the value that defines the element. Medicare Medicare PC 89 11/8/12 Table - tlkpFlagIndicators int[1] EXAMPLE: 1 = Yes, Medicare paid for All 100% A0 Indicator Payment Integer part or all of services Applied Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable Lookup Report the value that defines the element. Required Pregnancy Indicator - PC 90 Table - tlkpFlagIndicators int[1] EXAMPLE: 1 = Yes, the patient is when 98% A2 Indicator Pregnancy Integer pregnant PC012=F
PC 85 Carrier Specific Unique Subscriber ID 11/8/12 Text ID Link to ME117 Subscriber's Unique ID Report the identifier the carrier / submitter uses internally to uniquely identify the subscriber. Used to validate Unique Member ID and link back to Member Eligibility (ME117) All 100% A0 PC 86 Member Street Address 2 11/8/12 Text Address 2 Member Secondary Street Address of the Member/Patient Report the address of member which may include apartment number or suite, or other secondary information besides the street. Used to validate Unique Member ID. All 0% B PC 87 Line Type 11/8/12 Lookup Table - Text tlkpClaimLineType char[1] Claim Line Activity Type Code Report the code that defines the line status in terms of adjudication. EXAMPLE: O = Original All 98% A2 Code Description O Original V Void R Replacement B Back Out A Amendment PC 88 Former Claim Number 12/1/10 Text ID Claim Number Previous Claim Number Report the Claim Control Number (PC004) that was originally sent in a prior filing that this line corresponds to. When reported, this data cannot equal its own PC004. Use of “Former Claim Number” to version claims can only be used if approved by the APCD. Contact the APCD for conditions of use. All 0% B PC 89 Medicare Indicator 11/8/12 Lookup Table - Integer tlkpFlagIndicators int[1] Indicator - Medicare Payment Applied Report the value that defines the element. EXAMPLE: 1 = Yes, Medicare paid for part or all of services All 100% A0 Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PC 90 Pregnancy Indicator Lookup Table - Integer tlkpFlagIndicators int[1] Indicator - Pregnancy Report the value that defines the element. EXAMPLE: 1 = Yes, the patient is pregnant Required when PC012=F 98% A2
v5-apcd-pharmacy-claim-file-submission-guide-FINAL.docx