Data Submission Template (Pharmaceutical and Institutional))

Appendix B Sample Data Elements Pharmaceutical
TTP Default Formats For Professional Claims

Missing Values: It is preferred for missing / null values to be left blank.
No special characters, n/a, word "Null", multiple blank spaces, etc.
If this is not possible please discuss with TPP prior to test file submission.

Seq
1

Data Type Format
VARCHAR(40)

Expected Values

Professional Data Elements
Payer Name

Data Element Description
Name of entity providing source data.

2

File Type

The type of file being reported (i.e. Professional,
Institutional; Pharmacy, Dental).

VARCHAR(2)

Professional=P
Institutional-I
Pharmacy =RX
Dental=D

3

Line of Business

Classification of insurance type.

VARCHAR(40)

e.g., Medicare, Medicaid, Private

4

Claim Number

5
6
7

Claim Line Number
Member ID
Member SSN

A unique number assigned by the payment system that
identifies a claim
Line number on the claim.
A unique identification number for the member.
Member's social security number (full 9 or none).

8

Member Sex

The sex of the member.

9
12
10
11

Member Date of Birth
Member DOD
Member State
Member Zip Code
Rendering Provider Legal Business
Name

13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38

Member’s date of birth.
Member’s date of death.
Member’s state.
Member’s zip code.
Official name of the rendering provider organization; if
individual, in format LAST SUFFIX, FIRST MIDDLE.
Name provider renders services under or is known to
Rendering Provider Doing Business
public by for organizations; if individual, in format LAST
As Name
SUFFIX, FIRST MIDDLE
The NPI for the provider who treated the member (as
Rendering Provider NPI
opposed to the provider “billing” for the service).
Taxpayer identification number for provider who treated
Rendering Provider TIN
the member.
Rendering Provider EIN
The EIN for the provider who treated the member.
The taxonomy code for the provider who treated the
Rendering Provider Taxonomy
member (as opposed to the provider “billing” for the
service).
Code that describes the area of specialty for the provider
Rendering Provider Specialty
treating the member.
Rendering Provider Practice
US address line 1 for the provider rendering service.
Address Line 1
Rendering Provider Practice
US address line 2 for the provider rendering service.
Address Line 2
Rendering Provider Practice City
US city for the provider rendering service.
Rendering Provider Practice State US state for the provider rendering service.
Rendering Provider Practice Zip
USPS zip code for the provider rendering service.
Billing Provider Legal Business
Official name of billing provider organization; if
Name
individual, in format LAST SUFFIX, FIRST MIDDLE.
Name billing provider is known to public by for
Billing Provider Doing Business As
organizations; if individual, in format LAST SUFFIX, FIRST
Name
MIDDLE.
Federal Tax Number
Billing provider taxpayer identification number.
Billing Provider Address Line 1
US address line 1 for the billing provider.
Billing Provider Address Line 2
US address line 2 for the billing provider.
Billing Provider City
US city for billing provider.
Billing Provider State
US state for the billing provider.
Billing Provider Zip
USPS zip code for the billing provider.
Referring Provider Legal Business
Official name of referring provider organization; if
Name
individual, in format LAST SUFFIX, FIRST MIDDLE.
Name referring provider provides services under or is
Referring Provider Doing Business
known to public by for organizations or if individual, in
As Name
format LAST SUFFIX, FIRST MIDDLE
Referring Provider NPI
NPI of referring provider.
Referring Provider TIN
Referring taxpayer identification number.
Referring Provider EIN
The EIN for the provider who referred the member.
Referring Provider Practice Address
US address line 1 for the referring provider.
Line 1

VARCHAR(20)
INTEGER(3)
VARCHAR(20)
varchar(9)
CHAR(1)
DATE
DATE
CHAR(2)
varchar(5)

1, 2, 3, …

Male= M
Female=F
Unidentified=U
MM/DD/YYYY
MM/DD/YYYY
State abbreviation.
5 digit zip code

VARCHAR(100)
VARCHAR(100)
INTEGER(10)
INTEGER(10)
INTEGER(10)
VARCHAR(10)
VARCHAR(8)

Please provide your specialty
code definitions.

VARCHAR(100)
VARCHAR(50)
VARCHAR(50)
CHAR(2)
varchar(5)

State abbreviation.

VARCHAR(60)
VARCHAR(60)
varchar(10)
VARCHAR(60)
VARCHAR(20)
VARCHAR(25)
CHAR(2)
varchar(5)
VARCHAR(100)
VARCHAR(100)
INTEGER(10)
INTEGER(10)
INTEGER(10)
VARCHAR(100)

State abbreviation.

Seq

40
41
42

Professional Data Elements
Referring Provider Practice Address
Line 2
Referring Provider Practice City
Referring Provider Practice State
Referring Provider Practice Zip

43

Service/Procedure Code

44

Service/Procedure Code Modifier

45

Modifier (2)

The 2nd modifier for the service code on this claim record.
Modifier can be used to enhance the Service Code.

VARCHAR(2)

46

Modifier (3)

The 3rd modifier for the service code on this claim record.
Modifier can be used to enhance the Service Code.

VARCHAR(2)

47

Modifier (4)

The 4th modifier for the service code on this claim record.
Modifier can be used to enhance the Service Code.

VARCHAR(2)

48

Total Units/Quantity of Service

The number of units of service received by the recipient or
units dispensed as shown on the claim record.

Decimal(5,0)

49
50
51
52
53
54

Diagnosis Code 1
Diagnosis Code 2
Diagnosis Code 3
Diagnosis Code 4
Diagnosis Type Code
Place of Service

55

Beginning Date of Service

56

Ending Date of Service

57

Type of Service

58

Charged Amount

The total charge on the claim line.

DECIMAL (8,2)

59

Amount Paid

The total amount paid on the claim line.

DECIMAL (8,2)

60

COB Amount

Coordination of benefits amounts paid.

DECIMAL (8,2)

61

Claim Submission Date

62

Payment Adjudication Date

63

Adjustment Indicator

64
65
66
67
68
69
70
71
72
73

Billing Provider NPI
Allowed Amount
Diagnosis Code 5
Diagnosis Code 6
Diagnosis Code 7
Diagnosis Code 8
Diagnosis Code 9
Diagnosis Code 10
Diagnosis Code 11
Diagnosis Code 12

Date the claim line was submitted for payment.
The date on which the payment status of the claim was
paid.
Code indicating the type of adjustment record claim
represented (i.e. original claim, void, resubmittal, credit
adjustment, debit adjustment, gross adjustment).
NPI for the billing provider.
Amount allowed by the payer on the claim line.
Fifth ICD-10-CM codes that appear on the claim.
Sixth ICD-10-CM codes that appear on the claim.
Seventh ICD-10-CM codes that appear on the claim.
Eighth ICD-10-CM codes that appear on the claim.
Ninth ICD-10-CM codes that appear on the claim.
Tenth ICD-10-CM codes that appear on the claim.
Eleventh ICD-10-CM codes that appear on the claim.
Twelfth ICD-10-CM codes that appear on the claim.

39

Data Element Description

Data Type Format

US Address line 2 for the referring provider.

VARCHAR(50)

US city for the referring provider.
US state for the referring provider.
USPS zip code for the referring provider.
The code per CPT, HCPCS or NDC used to indicate the
service performed on the Beginning Date Of Service by
Claim Line Number.
The modifier for the service code by claim line number.
Modifier can be used to enhance the Service Code.

VARCHAR(50)
CHAR(2)
varchar(5)

The primary ICD-10 code found on the claim.
Second ICD-10-CM code found on the claim.
Third ICD-10 -CM codes that appear on the claim.
Fourth ICD-10-CM codes that appear on the claim.
Indicates if diagnosis code is ICD9-CM or ICD-10-CM.
Code indicating where the service was performed.
The first date of services received during an encounter
with a provider on the claim line.
The last date of services received during an encounter
with a provider on the claim line.
A code indicating the type of service being billed (if
available-i.e. Transportation Services; Hospice, PCS etc.
represented by a code).

Expected Values

State abbreviation.

VARCHAR(11)
VARCHAR(2)

VARCHAR(8)
VARCHAR(8)
VARCHAR(8)
VARCHAR(8)
VARCHAR(8)
VARCHAR(8)

Normally integer. If fractional
values, insert decimal point.

ICD9-CM or ICD10-CM

DATE

MM/DD/YYYY

DATE

MM/DD/YYYY

VARCHAR(8)

Please provide code definitions.

DATE

Assumes right two digits are
cents value
Assumes right two digits are
cents value.
Assumes right two digits are
cents value.
MM/DD/YYYY

DATE

MM/DD/YYYY

VARCHAR(40)
INTEGER(10)
DECIMAL (8,2)
VARCHAR(8)
VARCHAR(8)
VARCHAR(8)
VARCHAR(8)
VARCHAR(8)
VARCHAR(8)
VARCHAR(8)
VARCHAR(8)

Please provide code definitions.