Lookup Report the value that defines the Drug Source PC 62 11/8/12 Table - int[1] availability of the pharmaceutical. All 98% A2 Source Indicator Integer EXAMPLE: 1 = Multi-source brand Indicator Value Description 1 Multi-source brand 2 brand with generic equivalent 3 Single source brand Single source brand with generic 4 equivalent 5 Unknown Do not populate with any data. Required PC 63 Filler 2/2017 text Filler char[0] Filler All 100% A0 to be NULL. The Billing Billing Report the Federal Tax ID of the Billing Provider's Provider Provider here. Do not use hyphen or PC 64 11/8/12 Numeric ID Tax char[9] Federal Tax All 90% C Tax ID alpha prefix.Reminder: Must not be an Identification Number SSN. 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
PC 62 Source Indicator 11/8/12 Lookup Table - Integer int[1] Drug Source Indicator Report the value that defines the availability of the pharmaceutical. EXAMPLE: 1 = Multi-source brand All 98% A2 Value Description 1 Multi-source brand 2 brand with generic equivalent 3 Single source brand 4 Single source brand with generic equivalent 5 Unknown PC 63 Filler 2/2017 text Filler char[0] Filler Do not populate with any data. Required to be NULL. All 100% A0 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.Reminder: Must not be an SSN. 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
v6-apcd-pharmacy-claim-file-submission-guide-FINAL.docx