WC Workers' Compensation ZZ Other Payer Payer Claim Report the Unique identifier within the Claim PC 4 6/24/10 Text ID Claim Number Control payer's system that applies to the entire All 100% A0 Control Identification claim. Number Report the line number for this service within the claim. Start with 1 and Line Incremental PC 5 11/8/12 Integer ID Count varchar[4] increment by 1 for each additional line. All 100% A0 Counter Line Counter Do not start with 0, include alphas or special characters. Report the version number of this claim Claim Service service line. The version number begins Version PC 6 7/6/10 Integer Counter varchar[4] Line Version with 0 and is incremented by 1 for each All 100% A0 Number Number subsequent version of that service line. No alpha or special characters. Insured Report the number that defines the Group or / Policy insured group or policy. Do not report the PC 7 6/24/10 Text ID Group All 98% A2 Policy Number number that uniquely identifies the Number subscriber or member. Do not populate with any data. Required PC 8 Filler 2/2017 text Filler char[0] Filler All 100% A0 to be NULL. Report the Plan assigned contract Plan number. Do not include values in this Specific Contract element that will distinguish one member PC 9 6/24/10 Text ID Contract All 98% A2 Contract Number of the family from another. This should Number be the contract or certificate number for the subscriber and all of the dependents. Member Suffix or Contract Report the unique number / identifier of PC 10 6/24/10 Text ID Sequence All 98% A2 Sequence Sequence the member within the contract. Number Number Do not populate with any data. Required PC 11 Filler 2/2017 text Filler char[0] Filler All 100% A0 to be NULL. Patient to Individual Lookup Report the value that defines the Patient's Subscriber PC 12 6/24/10 Table - char[2] relationship to the Subscriber. All 85% B Relationship Code Text EXAMPLE: 20 = Self / Employee Code Value Description 01 Spouse
WC Workers' Compensation ZZ Other PC 4 Payer Claim Control Number 6/24/10 Text ID Claim Number Payer Claim Control Identification Report the Unique identifier within the payer's system that applies to the entire claim. All 100% A0 PC 5 Line Counter 11/8/12 Integer ID Count varchar[4] Incremental Line Counter Report the line number for this service within the claim. Start with 1 and increment by 1 for each additional line. Do not start with 0, include alphas or special characters. All 100% A0 PC 6 Version Number 7/6/10 Integer Counter varchar[4] Claim Service Line Version Number Report the version number of this claim service line. The version number begins with 0 and is incremented by 1 for each subsequent version of that service line. No alpha or special characters. All 100% A0 PC 7 Insured Group or Policy Number 6/24/10 Text ID Group / Policy Number Report the number that defines the insured group or policy. Do not report the number that uniquely identifies the subscriber or member. All 98% A2 PC 8 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 9 Plan Specific Contract Number 6/24/10 Text ID Contract Contract Number Report the Plan assigned contract number. Do not include values in this element that will distinguish one member of the family from another. This should be the contract or certificate number for the subscriber and all of the dependents. All 98% A2 PC 10 Member Suffix or Sequence Number 6/24/10 Text ID Sequence Contract Sequence Number Report the unique number / identifier of the member within the contract. All 98% A2 PC 11 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 12 Individual Code 6/24/10 Lookup Table - Text char[2] Patient to Subscriber Relationship Code Report the value that defines the Patient's relationship to the Subscriber. EXAMPLE: 20 = Self / Employee All 85% B Value Description 01 Spouse
v6-apcd-pharmacy-claim-file-submission-guide-FINAL.docx