Report the amount that defines a preset, amount for this claim line service that the patient is responsible to pay. Report Amount of 0 if no Copay applies. Do not code Copay member/patient PC 42 6/24/10 Integer Currency decimal or round up / down to whole All 99% A1 Amount is responsible to dollars code zero cents (00) when pay applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Report the amount that defines a calculated percentage amount for this claim line service that the patient is Amount of responsible to pay. Report 0 if no coinsurance Coinsurance applies. Do not code PC 43 6/24/10 Integer Currency member/patient All 99% A1 Amount decimal or round up / down to whole is responsible to dollars code zero cents (00) when pay applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Report the amount that defines a preset, fixed amount for this claim line service Amount of that the patient is responsible to pay. deductible Report 0 if no Deductible applies to Deductible member/patient PC 44 6/24/10 Integer Currency service. Do not code decimal or round up All 99% A1 Amount is responsible to / down to whole dollars code zero cents pay on the claim (00) when applicable. EXAMPLE: line 150.00 is reported as 15000; 150.70 is reported as 15070 Report the number of the prescribing Prescribing provider here. This value in this element PC 45 11/8/12 Text ID Link to PV002 Provider All 98% A0 must have corresponding Provider ID ProviderID Number (PV002) in the Provider File. First name of Name First Report the name of the prescribing PC 46 Physician 6/24/10 Text Prescribing All 50% B Provider physician here. First Physician Name
PC 42 Copay Amount 6/24/10 Integer Currency Amount of member/patient is responsible to pay Report the amount that defines a preset, amount for this claim line service that the patient is responsible to pay. Report 0 if no Copay applies. 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 All 99% A1 PC 43 Amount 6/24/10 Integer Currency Amount of coinsurance member/patient is responsible to pay Report the amount that defines a calculated percentage amount for this claim line service that the patient is responsible to pay. Report 0 if no Coinsurance applies. 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 All 99% A1 PC 44 Deductible Amount 6/24/10 Integer Currency Amount of deductible member/patient is responsible to pay on the claim line Report the amount that defines a preset, fixed amount for this claim line service that the patient is responsible to pay. Report 0 if no Deductible applies to service. 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 All 99% A1 PC 45 ProviderID 11/8/12 Text ID Link to PV002 Prescribing Provider Number Report the number of the prescribing provider here. This value in this element must have corresponding Provider ID (PV002) in the Provider File. All 98% A0 PC 46 Physician First Name 6/24/10 Text Name First Provider First name of Prescribing Physician Report the name of the prescribing physician here. All 50% B
v6-apcd-pharmacy-claim-file-submission-guide-Redline-.docx