Collection of Drug Event Data from Contracted Part D Providers For Payments (CMS-10174)

HDR
FIELD NO.

FIELD NAME

NCPDP FIELD

POSITION

PICTURE

LENGTH

NCPDP, CMS OR PDFS DEFINED

DEFINITION / VALUES

1

RECORD ID

1-3

X(3)

3

PDFS

"HDR"

2

SUBMITTER ID

4-9

X(6)

6

CMS

Unique ID assigned by CMS.

3

FILE ID

10 - 19

X(10)

10

PDFS

4

TRANS DATE

20 - 27

9(8)

8

PDFS

Unique ID provided by Submitter.
Same ID cannot be used within 12
months.
Date of file transmission to PDFS.

5

PROD TEST CERT IND

28 - 31

X(4)

4

PDFS

PROD, TEST, or CERT

6

FILLER

32 - 512

X(481)

481

N/A

SPACES

BHD
FIELD NO.

FIELD NAME

NCPDP FIELD

POSITION

PICTURE

LENGTH

NCPDP, CMS OR PDFS DEFINED

DEFINITION / VALUES

1

RECORD ID

1-3

X(3)

3

PDFS

"BHD"

2

SEQUENCE NO

4 - 10

9(7)

7

PDFS

Must start with 0000001

3
4
5

CONTRACT NO
PBP ID
FILLER

11 - 15
16 - 18
19 - 512

X(5)
X(3)
X(494)

5
3
494

CMS
CMS
N/A

 Assigned by CMS
 Assigned by CMS
SPACES

DET

FIELD NO.
1
2
3
4

FIELD NAME
RECORD ID
SEQUENCE NO
CLAIM CONTROL NUMBER
Medicare beneficiary
identifier

NCPDP FIELD

POSITION
1-3
4 - 10
11 - 50
51 - 70

PICTURE
X(3)
9(7)
X(40)
X(20)

302-C2
304-C4

71 - 90
91 - 98

X(20)
9(8)

20
8

NCPDP
NCPDP

7

CARDHOLDER ID
PATIENT DATE OF BIRTH
(DOB)
PATIENT GENDER CODE

305-C5

99 - 99

9(1)

1

NCPDP

8
9

DATE OF SERVICE (DOS)
PAID DATE

401-D1

100 - 107
108 - 115

9(8)
9(8)

8
8

NCPDP
CMS

10

PRESCRIPTION SERVICE
REFERENCE NO

402-D2

116 - 127

9(12)

12

NCPDP

11
12

FILLER
PRODUCT SERVICE ID

128 - 129
130 - 148

X(2)
X(19)

2
19

N/A
NCPDP

5
6

407-D7 or 489TE

LENGTH
3
7
40
20

NCPDP, CMS OR PDFS DEFINED
PDFS
PDFS
CMS
CMS

DEFINITION / VALUES
"DET"
Must start with 0000001
 Optional Field
Medicare Health Insurance Claim Number (HICN) or Railroad
Retirement Board (RRB) number or Medicare Beneficiary
Identifier (MBI).
Plan identification of the enrollee. Assigned by plan.
CCYYMMDD
Optional Field
1=M
2=F
Unspecified or unknown values are not accepted
CCYYMMDD
CCYYMMDD. The date the plan paid the pharmacy for the
prescription drug. Mandatory for Fallback plans. Optional for
all other plans.
The field length of 12 will be implemented in DDPS on
January 1, 2011 in anticipation of the implementation of the
NCPDP D.0 standard in 2012 . Field will be right justified and
filled with 5 leading zeroes. Applies to all PDEs submitted
January 1, 2011 and after.
SPACES
Submit 11 digit NDC only. Fill the first 11 positions, no spaces
or hyphens, followed by 8 spaces. Format is
MMMMMDDDDPP. DDPS will reject the following billing
codes for compounded legend and/or scheduled drugs:
99999999999, 99999999992, 99999999993, 99999999994,
99999999995, and 99999999996

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13

RECORD ID
SERVICE PROVIDER ID
QUALIFIER

202-B2

1-3
149 - 150

X(3)
X(2)

3
2

PDFS
NCPDP

"DET"
The type of pharmacy provider identifier used in field 14.
01 = National Provider Identifier (NPI)
06 = UPIN
07 = NCPDP Provider ID
08 = State License
11 = Federal Tax Number
99 = Other (Reported Gap Discount must = 0)
Mandatory for standard format. For standard format, valid
values are 01 - NPI or 07 - NCPDP Provider ID.
For non-standard format any of the above values are
acceptable.

14

SERVICE PROVIDER ID

201-B1

151 - 165

X(15)

15

NCPDP

When Plans report Service Provider ID Qualifier = “99” Other, populate Service Provider ID with the default value
“PAPERCLAIM” defined for TrOOP Facilitation Contract.
When Plans report Federal Tax Number (TIN), use the
following format: ex: 999999999 (do not report embedded
dashes).

15
16

FILL NUMBER
DISPENSING STATUS

403-D3
343-HD

166 - 167
168 - 168

9(2)
X(1)

2
1

NCPDP
NCPDP

Values = 0 - 99.
On PDEs with DOS on or after January 1, 2011, must be blank.
On PDEs with DOS prior to January 1, 2011, valid values are:
Blank = Not Specified
P = Partial Fill
C = Completion of Partial Fill

17

COMPOUND CODE

406-D6

169 - 169

9(1)

1

NCPDP

0=Not specified
1=Not a Compound
2=Compound

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18

RECORD ID
DISPENSE AS WRITTEN (DAW) 408-D8
PRODUCT SELECTION CODE

1-3
170 - 170

X(3)
X(1)

3
1

PDFS
NCPDP

"DET"
0=No Product Selection Indicated
1=Substitution Not Allowed by Prescriber
2=Substitution Allowed - Patient Requested Product
Dispensed
3=Substitution Allowed - Pharmacist Selected Product
Dispensed
4=Substitution Allowed - Generic Drug Not in Stock
5=Substitution Allowed - Brand Drug Dispensed as Generic
6=Override
7=Substitution Not Allowed - Brand Drug Mandated by Law
8=Substitution Allowed Generic Drug Not Available in
Marketplace
9=Other

19

QUANTITY DISPENSED

442-E7

171 - 180

9(7)V999

10

NCPDP

20
21
22

FILLER
DAYS SUPPLY
PRESCRIBER ID QUALIFIER

405-D5
466-EZ

181 - 182
183 - 185
186 - 187

X(2)
9(3)
X(2)

2
3
2

N/A
NCPDP
NCPDP

Number of Units, Grams, Milliliters, other. If compounded
item, total of all ingredients will be supplied as Quantity
Dispensed.
SPACES
0 – 999
The type of prescriber identifier used in field 23.
Prior to January 1, 2013:
01 = National Provider Identifier (NPI)
06 = UPIN
08 = State License Number
12 = Drug Enforcement Administration (DEA) number
Mandatory for standard format.
Mandatory for Non-Standard Format with DOS => 1/1/2012
For DOS <1/1/2012, Optional when Non-Standard Format
Code = "B", "C", "P", or "X" but must be valid value if present.
As of January 1, 2013, 01 = NPI is mandatory for all formats

23

PRESCRIBER ID

411-DB

188 - 202

X(15)

15

NCPDP

Mandatory

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24

RECORD ID
DRUG COVERAGE STATUS
CODE

1-3
203 - 203

X(3)
X(1)

3
1

PDFS
CMS

25

ADJUSTMENT DELETION
CODE

204 - 204

X(1)

1

CMS

26

NON- STANDARD FORMAT
CODE

205 - 205

X(1)

1

CMS

27

PRICING EXCEPTION CODE

206 - 206

X(1)

1

 CMS

28

CATASTROPHIC COVERAGE
CODE

207 - 207

X(1)

1

CMS

"DET"
Coverage status of the drug under Part D and/or the PBP.
C = Covered
E = Supplemental drugs (reported by Enhanced Alternative
plans only)
O = Over-the-counter drugs
A = Adjustment
D = Deletion
Blank = Original PDE
Format of claims originating in a non-standard format.
B = Beneficiary submitted claim
C = COB claim
P = Paper claim from provider
X = X12 837
Blank = NCPDP electronic format
M= Medicare as Secondary Payer
O = Out-of-network pharmacy (Medicare is Primary)
Blank = In-network pharmacy (Medicare is Primary)
Optional for PDEs with DOS January 1, 2011 and forward.
Mandatory on PDEs with DOS prior to January 1, 2011. Valid
values are:
A = Attachment Point met on this event
C = Above Attachment Point
Blank = Attachment Point not met

29

INGREDIENT COST PAID

506-F6

208 - 215

S9(6)V99

8

NCPDP

Amount the pharmacy is paid for the drug itself. Dispensing
fees or other costs are not included in this amount.

30

DISPENSING FEE PAID

507-F7

216 - 223

S9(6)V99

8

NCPDP

Amount the pharmacy is paid for dispensing the medication.
The fee may be negotiated with pharmacies at the plan or
PBM level. Additional fees may be charged for
compounding/mixing multiple drugs. Do not include
administrative fees. Vaccine Administration Fee reported in
Field 41.

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31

RECORD ID
TOTAL AMOUNT ATTRIBUTED
TO SALES TAX

1-3
224 - 231

X(3)
S9(6)V99

3
8

PDFS
CMS

"DET"
Depending on jurisdiction, sales tax may be calculated in
different ways or distributed in multiple NCPDP fields. Plans
will report the total sales tax for the PDE regardless of how
the tax is calculated or reported at point-of-sale.

32

GROSS DRUG COST BELOW
OUT- OF-POCKET THRESHOLD
(GDCB)

232 - 239

S9(6)V99

8

CMS

Reports covered drug cost at or below the out of pocket
threshold. Any remaining portion of covered drug cost is
reported in GDCA. Covered drug cost is the sum of Ingredient
Cost Paid + Dispensing Fee Paid + Total Amount Attributed to
Sales Tax + Vaccine Administration Fee.
For DOS prior to January 1, 2011, when the Catastrophic
Coverage Code = blank, this field equals the sum of Ingredient
Cost Paid + Dispensing Fee Paid + Total Amount Attributed to
Sales Tax + Vaccine Administration Fee. When the
Catastrophic Coverage Code = 'A', this field equals the portion
of Ingredient Cost Paid + Dispensing Fee Paid + Total Amount
Attributed to Sales Tax + Vaccine Administration Fee falling at
or below the OOP threshold. Any remaining portion is
reported in GDCA. This amount increments the Total Gross
Covered Drug Cost Accumulator amount.

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33

RECORD ID
GROSS DRUG COST ABOVE
OUT-OF-POCKET THRESHOLD
(GDCA)

1-3
240 - 247

X(3)
S9(6)V99

3
8

PDFS
CMS

"DET"
Reports covered drug cost above the out of pocket threshold.
Any remaining portion of covered drug cost is reported in
GDCB. Covered drug cost is the sum of Ingredient Cost Paid +
Dispensing Fee Paid + Total Amount Attributed to Sales Tax +
Vaccine Administration Fee.
For DOS prior to January 1, 2011, when the Catastrophic
Coverage Code = 'C', this field equals the sum of Ingredient
Cost Paid + Dispensing Fee Paid + Total Amount Attributed to
Sales Tax + Vaccine Administration Fee above the OOP
threshold. When the Catastrophic Coverage Code = 'A', this
field equals the portion of Ingredient Cost Paid + Dispensing
Fee Paid + Total Amount Attributed to Sales Tax + Vaccine
Administration Fee falling above the OOP threshold. Any
remaining portion is reported in GDCB. This amount
increments the Total Gross Covered Drug Cost Accumulator
amount.

34

PATIENT PAY AMOUNT

35

505-F5

248 - 255

S9(6)V99

8

NCPDP

OTHER TROOP AMOUNT

256 - 263

S9(6)V99

8

CMS

36

LOW INCOME COST SHARING
SUBSIDYAMOUNT (LICS)

264 - 271

S9(6)V99

8

CMS

37

PATIENT LIABILITY
REDUCTION DUE TO OTHER
PAYER AMOUNT (PLRO)

272 - 279

S9(6)V99

8

CMS

Payments made by the beneficiary or by family or friends at
point of sale. This amount increments the True Out-of-Pocket
Accumulator amount.
Other health insurance payments by TrOOP-eligible other
payers (e.g. SPAPs). This field records all third party payments
that contribute to a beneficiary's TrOOP except LICS, Patient
Pay Amount, and Reported Gap Discount. This amount
increments the True Out-of-Pocket Accumulator amount.
Amount the plan advanced at point-of-sale due to a
beneficiary's LI status. This amount increments the True Outof-Pocket Accumulator amount.
Amounts by which patient liability is reduced due to payment
by other payers that are not TrOOP-eligible and do not
participate in Part D. Examples of non-TrOOP-eligible payers:
group health plans, governmental programs (e.g. VA,
TRICARE), Workers' Compensation, Auto/No-Fault/Liability
Insurances.

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38

RECORD ID
COVERED D PLAN PAID
AMOUNT (CPP)

1-3
280 - 287

X(3)
S9(6)V99

3
8

PDFS
CMS

"DET"
The net Medicare covered amount which the plan has paid
for a Part D covered drug under the Basic benefit. Amounts
paid for supplemental drugs, supplemental cost-sharing and
Over-the-Counter drugs are excluded from this field.

39

NON COVERED PLAN PAID
AMOUNT (NPP)

288 - 295

S9(6)V99

8

CMS

The amount of plan payment for enhanced alternative
benefits (cost sharing fill-in and/or non-Part D drugs). This
dollar amount is excluded from risk corridor calculations.

40

ESTIMATED REBATE AT POS

296 - 303

S9(6)V99

8

CMS

The estimated amount of rebate that the plan sponsor has
elected to apply to the negotiated price as a reduction in the
drug price made available to the beneficiary at the point of
sale.  This estimate should reflect the rebate amount that the
plan sponsor reasonably expects to receive from a
pharmaceutical manufacturer or other entity.

41

VACCINE ADMINISTRATION
FEE

304 - 311

S9(6)V99

8

CMS

42

PRESCRIPTION ORIGIN CODE 419-DJ

312 - 312

X(1)

1

NCPDP

The amount reported by a pharmacy, physician, or provider
to cover the cost of administering a vaccine, excluding the
ingredient cost and dispensing fee.
Required on PDEs with DOS January 1, 2010 and forward.
Valid values are:
“1” = Written
“2” = Telephone
“3” = Electronic
“4” = Facsimile
"5" = Pharmacy
On PDEs with DOS prior to January 1, 2010, “0” = Not
Specified and blank are also allowed.

43

DATE ORIGINAL CLAIM
RECEIVED

313 - 320

9(8)

8

CMS

44

CLAIM ADJUDICATION BEGAN
TIMESTAMP

321 - 346

X(26)

26

CMS

Date sponsor received original claim. Required on PDEs with
DOS January 1, 2011 and forward. On PDEs with DOS prior to
January 1, 2011, must be blank or zeros. Required for all LI
NET PDEs submitted January 1, 2011 and after, regardless of
DOS.
Date and time sponsor began adjudicating the claim in
Greenwich Mean Time. Required on PDEs with DOS January
1, 2011 and forward. On PDEs with DOS prior to January 1,
2011, must be blank or zeros.

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45

RECORD ID
TOTAL GROSS COVERED
DRUG COST ACCUMULATOR

1-3
347 - 355

X(3)
S9(7)V99

3
9

PDFS
CMS

"DET"
Sum of beneficiary's covered drug costs for the benefit year
known immediately prior to adjudicating the claim. Required
on PDEs with DOS January 1, 2011 and forward. On PDEs
with DOS prior to January 1, 2011, must be blank or zeros.

46

TRUE OUT-OF-POCKET
ACCUMULATOR

356 - 363

S9(6)V99

8

CMS

BRAND/GENERIC CODE

364 - 364

X(1)

1

CMS

Sum of beneficiary's incurred costs (Patient Pay Amount, LICS,
Other TrOOP Amount, Reported Gap Discount) for the benefit
year known immediately prior to adjudicating the claim.
Required on PDEs with DOS January 1, 2011 and forward. On
PDEs with DOS prior to January 1, 2011, must be blank or
zeros.
Plan reported value indicating whether the plan adjudicated
the claim as a brand or generic drug.

47

B - Brand
G - Generic

48

BEGINNING BENEFIT PHASE

365 - 365

X(1)

1

CMS

Required on PDEs with DOS January 1, 2011 and forward. On
PDEs with DOS prior to January 1, 2011, must be blank.
Applies to covered drugs only.
Plan-defined benefit phase in effect immediately prior to the
time the sponsor began adjudicating the individual claim
being reported.
D - Deductible
N - Initial Coverage Period
G - Coverage Gap
C - Catastrophic
Required on PDEs with DOS January 1, 2011 and forward. On
PDEs with DOS prior to January 1, 2011, must be blank.
Applies to covered drugs only.

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49

RECORD ID
ENDING BENEFIT PHASE

1-3
366 - 366

X(3)
X(1)

3
1

PDFS
CMS

"DET"
Plan-defined benefit phase in effect upon the sponsor
completing adjudication of the individual claim being
reported.
D - Deductible
N - Initial Coverage Period
G - Coverage Gap
C - Catastrophic

50

REPORTED GAP DISCOUNT

367 - 374

S9(6)V99

8

CMS

Required on PDEs with DOS January 1, 2011 and forward. On
PDEs with DOS prior to January 1, 2011, must be blank.
Applies to covered drugs only.
The reported amount that sponsor advanced at point of sale
for the Gap Discount for applicable drugs.
Required on PDEs with DOS January 1, 2011 and forward.
On PDEs with DOS prior to January 1, 2011 must be blank or
zeros. This amount increments the True Out-of-Pocket
Accumulator amount.

51

TIER

375 - 375

X(1)

1

CMS

Formulary tier in which the sponsor adjudicated the claim.
Values = 1-6 or space.
Required on PDEs with DOS January 1, 2011 and forward.
On PDEs with DOS prior to January 1, 2011, must be blank.
Applies to covered drugs only.

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52

RECORD ID
FORMULARY CODE

1-3
376 - 376

X(3)
X(1)

3
1

PDFS
CMS

"DET"
Indicates if the drug is on the plan's formulary.
F - Formulary
N - Non-Formulary
Required on PDEs with DOS January 1, 2011 and forward.
On PDEs with DOS prior to January 1, 2011, must be blank.
Applies to covered drugs only.

53

OAP Indicator

377 - 377

X(1)

1

CMS

This is a placeholder field related to Prescriber ID editing.
Field should be blank until further notice.
Note: This replaced Gap Discount Plan Override Code on
5/15/2016.

54

Pharmacy Service Type

378 - 379

X(2)

2

CMS

Required on PDEs with DOS February 28, 2013 and forward.
Valid values are:
01 – Community/Retail Pharmacy Services
02 – Compounding Pharmacy Services
03 – Home Infusion Therapy Provider Services
04 – Institutional Pharmacy Services
05 – Long Term Care Pharmacy Services
06 – Mail Order Pharmacy Services
07 – Managed Care Organization Pharmacy Services
08 – Specialty Care Pharmacy Services
99 - Other
For DOS on or before February 27, 2013, can be spaces or any
of the valid values listed above.
For COB PDEs, can be spaces or any of the valid values listed
above.

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55

RECORD ID
Patient Residence

1-3
380 - 381

X(3)
X(2)

3
2

PDFS
CMS

"DET"
Required on PDEs with DOS February 28, 2013 and forward.
Valid values are:
00 – Not specified, other patient residence not identified
below
01 – Home
03 – Nursing Facility
04 – Assisted Living Facility
06 – Group Home
09 – Intermediate Care Facility/Mentally Retarded
11 – Hospice
For DOS on or before February 27, 2013, can be spaces or any
of the valid values listed above.
For COB PDEs, can be spaces or any of the valid values listed
above.

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56

RECORD ID
Submission Clarification Code

1-3
382 - 383

X(3)
X(2)

3
2

PDFS
CMS

"DET"
For PDEs with DOS February 28, 2013 and forward IF Patient
Residence is "03", valid values are:
Spaces
16 – Long Term Care (LTC) emergency box or automated
dispensing machine
21 – LTC dispensing, 14 days or less not applicable
22 – LTC dispensing, 7 day supply
23 – LTC dispensing, 4 day supply
24 – LTC dispensing, 3 day supply
25 – LTC dispensing, 2 day supply
26 – LTC dispensing, 1 day supply
27 – LTC dispensing, 4 day, then 3 day supply
28 – LTC dispensing, 2 day, then 2 day, then 3 day supply
29 – LTC dispensing, daily during the week then multiple days
for weekend
30 – LTC dispensing, per shift
31 – LTC dispensing, per med pass
32 – LTC dispensing, PRN on demand
33 – LTC dispensing, other 7 day or less cycle
34 – LTC dispensing, 14 day supply
35 – LTC dispensing, other 8-14 day dispensing not listed
above
36 – LTC dispensing, outside short cycle, determined to be
Medicare Part D after originally submitted to another payer
For all other cases, field must be spaces .

57

Adjustment Reason Code
Qualifier

384 - 384

X(1)

1

CMS

The type of Adjustment Reason Code used in field 58:
2 - CMS Audit
3 - CMS Identified Overpayment (CIO)
4 - CGDP Dispute or Appeal
9 - Other
BLANK - Not Applicable
The Adjustment Reason Code Qualifier of ‘1’ has been
removed from the list of valid values for PDEs for all dates of
service submitted on or after 11/13/2016.

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58

RECORD ID
Adjustment Reason Code

1-3
385 - 396

X(3)
X(12)

3
12

PDFS
CMS

"DET"
This code will assist CMS to track the reason for an
adjustment or deletion. Accepted values are dependent
upon the qualifier submitted in field 57
Where qualifier... Accepted value is:
2
'OFM', 'RAC', or 'MEDIC' *
3
‘CIO’ *
4
‘DISPUTE’ or 'APPEAL' *
9
For future use at CMS' direction
BLANK
BLANK

59

Type of Fill Code

397 - 397

X(1)

1

CMS

60

FILLER

398 - 512

X(115)

115

CMS

This is a placeholder field related to Prescriber ID editing.
Field should be blank until further notice.
SPACES

Notes:
For any field that references NCPDP values, please refer to the appropriate NCPDP specification to ensure compliance.
All dollar fields are mandatory. If the field is not applicable, report a default value of zeroes. Since the field is a signed field, plans must utilize the appropriate overpunch signs as specified in the NCPDP Telecommunications
Standard, Version 5.1.

BTR
FIELD NO.

FIELD NAME

NCPDP FIELD

POSITION

PICTURE

1
2

RECORD ID
SEQUENCE NO

1-3
4 - 10

X(3)
9(7)

3
4
5
6

CONTRACT NO
PBP ID
DET RECORD TOTAL
FILLER

11 - 15
16 - 18
19 - 25
26 -512

X(5)
X(3)
9(7)
X(487)

LENGTH

NCPDP, CMS OR PDFS DEFINED

DEFINITION / VALUES

3
7

PDFS
PDFS

5
3
7
487

CMS
CMS
CMS
CMS

"BTR"
Must match BHD. Must start
with 0000001.
Must match BHD
Must match BHD
Total count of DET records
SPACES

TLR
FIELD NO.
1
2
3
4
5
6

FIELD NAME
RECORD ID
SUBMITTER ID
FILE ID
TLR BHD RECORD TOTAL
TLR DET RECORD TOTAL
FILLER

NCPDP FIELD

POSITION

PICTURE

1-3
4-9
10 - 19
20 - 28
29 - 37
38 -512

X(3)
X(6)
X(10)
9(9)
9(9)
X(475)

LENGTH
3
6
10
9
9
475

NCPDP, CMS OR PDFS DEFINED

DEFINITION / VALUES

PDFS
CMS
PDFS
CMS
CMS
CMS

"TLR"
Must match HDR
Must match HDR
Total count of BHD records
Total count of DET records
SPACES

Note:
Maximum number of detail records per file is 3 million records. If one file contains multiple batches, maximum record count applies to the
cumulative total across all batches.

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