Do not populate with any data. Required PC 79 Filler 2/2017 text Filler char[0] Filler All 100% A0 to be NULL. Do not populate with any data. Required PC 80 Filler 2/2017 text Filler char[0] Filler All 100% A0 to be NULL. Do not populate with any data. Required PC 81 Filler 2/2017 text Filler char[0] Filler All 100% A0 to be NULL. Do not populate with any data. Required PC 82 Filler 2/2017 text Filler char[0] Filler All 100% A0 to be NULL. Do not populate with any data. Required PC 83 Filler 2/2017 text Filler char[0] Filler All 100% A0 to be NULL. Carrier Report the identifier the carrier / submitter Specific uses internally to uniquely identify the Member's PC 84 Unique 11/8/12 Text ID Link to ME107 member. Used to validate Unique All 100% A0 Unique ID Member Member ID and link back to Member ID Eligibility (ME107). 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). Do not populate with any data. Required PC 86 Filler 2/2017 text Filler char[0] Filler All 100% A0 to be NULL. Lookup Claim Line Report the code that defines the claim Claim Line PC 87 11/8/12 Table - tlkpClaimLineType char[1] Activity Type line 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 Control Number (PC004) that was originally sent in a prior filing that this line corresponds to. When reported, Former Previous Claim this data cannot equal its own PC004. PC 88 Claim 12/1/10 Text ID Claim Number All 0% B Number Use of Claim Number” to version “Former Number claims can only be used if approved by the APCD. Contact the APCD for conditions of use.
PC 79 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 80 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 81 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 82 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 83 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 84 Carrier Specific Unique Member ID 11/8/12 Text ID Link to ME107 Member's Unique ID Report the identifier the carrier / submitter uses internally to uniquely identify the member. Used to validate Unique Member ID and link back to Member Eligibility (ME107). All 100% A0 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 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 PC 87 Claim Line Type 11/8/12 Lookup Table - Text tlkpClaimLineType char[1] Claim Line Activity Type Code Report the code that defines the claim 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 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
v6-apcd-pharmacy-claim-file-submission-guide-FINAL.docx