Copy of PDE Inbound File Layout Final_20250101.xlsx

Collection of Prescription Drug Data from MA-PD, PDP and Fallout Plans/Sponsors for Medicare Part D Payments (CMS-10174) - IRA

Copy of PDE Inbound File Layout Final_20250101.xlsx

OMB: 0938-0982

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Overview

HDR
BHD
DET
BTR
TLR


Sheet 1: 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 Unique ID provided by Submitter. Same ID cannot be used within 12 months.
4 TRANS DATE
20 - 27 9(8) 8 PDFS Date of file transmission to PDFS.
5 PROD TEST CERT IND
28 - 31 X(4) 4 PDFS PROD, TEST, or CERT
6 FILLER
32 - 1000 X(969) 969 N/A SPACES

Sheet 2: 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 CONTRACT NO
11 - 15 X(5) 5 CMS Assigned by CMS
4 PBP ID
16 - 18 X(3) 3 CMS Assigned by CMS
5 FILLER
19 - 1000 X(982) 982 N/A SPACES

Sheet 3: DET

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 "DET"
2 SEQUENCE NO
4 - 10 9(7) 7 PDFS Must start with 0000001
3 CLAIM CONTROL NUMBER
11 - 50 X(40) 40 CMS A number assigned by the plan to identify the prescription drug event. This is an optional field.
*non-numeric values should be left justified.
4 MEDICARE BENEFICIARY IDENTIFIER
51 - 70 X(20) 20 CMS Medicare Health Insurance Claim Number (HICN) or Railroad Retirement Board (RRB) number or Medicare Beneficiary Identifier (MBI).
5 CARDHOLDER ID 302-C2 71 - 90 X(20) 20 NCPDP Plan identification of the enrollee. Assigned by plan.
*non-numeric values should be left justified.
6 PATIENT DATE OF BIRTH (DOB) 304-C4 91 - 98 9(8) 8 NCPDP Optional field.
If populated, the format is CCYYMMDD.
7 PATIENT GENDER CODE 305-C5 99 - 99 9(1) 1 NCPDP Valid values are:
1 = M
2 = F
8 DATE OF SERVICE (DOS) 401-D1 100 - 107 9(8) 8 NCPDP CCYYMMDD
9 PAID DATE
108 - 115 9(8) 8 CMS The date the plan paid the pharmacy for the prescription drug.
Mandatory for Fallback plans.
Optional for all other plans. If populated, the format is CCYYMMDD.
10 PRESCRIPTION SERVICE REFERENCE NO 402-D2 116 - 127 9(12) 12 NCPDP Applies to all PDEs with a DOS >= 01/01/2011.
Field is right justified and filled with 5 leading zeros.
11 PRODUCT SERVICE ID 407-D7 or
489- TE
128 - 167 X(40) 40 NCPDP Submit 11 digit NDC only. Fill the first 11 positions, no spaces or hyphens, followed by 29 spaces. Format is MMMMMDDDDPP. DDPS will reject the following billing codes for compounded legend and/or scheduled drugs with a value of:
99999999999, 99999999992, 99999999993, 99999999994, 99999999995, or 99999999996.
12 FILLER
168 - 197 X(30) 30 CMS SPACES
13 SERVICE PROVIDER ID QUALIFIER 202-B2 198 - 199 X(2) 2 NCPDP The type of pharmacy provider identifier used in field 14. Valid values are:
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 or 07.
For non-standard format any of the above values are acceptable.
14 SERVICE PROVIDER ID 201-B1 200 - 214 X(15) 15 NCPDP When Plans report Service Provider ID Qualifier = 99, populate Service Provider ID with the default value PAPERCLAIM defined for the TrOOP Facilitation Contract. When Plans report Federal Tax Number (TIN), use the following format: ex: 999999999 (do not report embedded dashes).
* non-numeric values should be left justified.
15 FILL NUMBER 403-D3 215 - 216 9(2) 2 NCPDP Valid values are:
0–99
If unavailable, use zero.
16 DISPENSING STATUS 343-HD 217 - 217 X(1) 1 NCPDP On PDEs with a DOS >= 01/01/2011, must be a SPACE.
On PDEs with a DOS < 01/01/2011, valid values are:
SPACE = Not Specified
P = Partial Fill
C = Completion of Partial Fill
17 COMPOUND CODE 406-D6 218 - 218 9(1) 1 NCPDP Valid values are:
0 = Not specified
1 = Not a Compound
2 = Compound
18 DISPENSE AS WRITTEN (DAW) PRODUCT SELECTION CODE 408-D8 219 - 219 X(1) 1 NCPDP Valid values are:
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 ORIGINALLY PRESCRIBED QUANTITY 446-EB 220 - 229 9(7)V999 10 NCPDP Required for PDEs with a DOS >= 01/01/2025. For Schedule II drugs that are reported as standard, electronically-submitted PDEs, this field must contain the originally prescribed quantity. Must be zero for DOS < 01/01/2025, or for non-Schedule II PDEs.
20 QUANTITY DISPENSED 442-E7 230 - 239 9(7)V999 10 NCPDP Number of Units, Grams, Milliliters, other. If compounded item, total of all ingredients will be supplied as Quantity Dispensed; report quantity in the unit form of the final state of the resulting compound.
21 FILLER
240 - 242 X(3) 3 CMS SPACES
22 DAYS SUPPLY 405-D5 243 - 245 9(3) 3 NCPDP Valid values are:
0 - 999
23 PRESCRIBER ID QUALIFIER 466-EZ 246 - 247 X(2) 2 NCPDP The type of prescriber identifier used in field 24.

For PDEs with a DOS >= 01/01/2013, the value of 01 is mandatory for all formats.

For PDEs with a DOS < 01/01/2013, valid values are:
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 for PDEs with a DOS >= 01/01/2012

For PDEs with a DOS < 01/01/2012, optional when the Non-Standard Format Code = B, C, P, or X, but must be a valid value if present.
24 PRESCRIBER ID 411-DB 248 - 282 X(35) 35 NCPDP Mandatory
* non-numeric values should be left justified.
25 DRUG COVERAGE STATUS CODE
283 - 283 X(1) 1 CMS Coverage status of the drug under Part D and/or the PBP. Valid values are:
C = Covered
E = Supplemental drugs (reported by Enhanced Alternative plans only)
O = Over-the-counter drugs
26 ADJUSTMENT DELETION CODE
284 - 284 X(1) 1 CMS Valid values are:
A = Adjustment
D = Deletion
SPACE = Original PDE
27 NON- STANDARD FORMAT CODE
285 - 285 X(1) 1 CMS Format of claims originating in a non-standard format. Valid values are:
A = Medicaid subrogation claim
B = Beneficiary submitted claim
C = COB claim
P = Paper claim from provider
X = X12 837
SPACE = NCPDP electronic format
28 PRICING EXCEPTION CODE
286 - 286 X(1) 1 CMS Valid Values are:
M= Medicare as Secondary
Payer
O = Out-of-network pharmacy (Medicare is Primary)
SPACE = In-network pharmacy (Medicare is Primary)
29 PART D MODEL INDICATOR
287 - 288 X(2) 2 CMS Plan reported value indicating the Part D Model type applied to the PDE. Valid values are:
01 = Value-based Insurance Design (VBID) Model
07 = Part D Senior Savings (PDSS) Model
SPACES = No Part D Model applied

For PDSS model eligible PDEs submitted by Plans participating in the PDSS Model, this field is required to be populated with 07 on PDEs with a DOS >= 01/01/2022.

For VBID model eligible PDEs submitted by Plans participating in a VBID Model, this field is required to be populated with 01 on PDEs with a DOS >= 01/01/2023. This field is optional for VBID eligible PDEs with a DOS < 01/01/2023.

Applies to covered drugs only.

For non-model PDEs submitted by Plans participating in a Part D Model, and for PDEs submitted by Plans that are not participating in a Part D Model, this field must contain SPACES.
30 FILLER
289 - 314 X(26) 26 CMS SPACES
31 CATASTROPHIC COVERAGE CODE
315 - 315 X(1) 1 CMS Optional for PDEs with a DOS >= 01/01/2011. Mandatory on PDEs with a DOS < 01/01/2011. Valid values are:
A = Attachment Point met on this event
C = Above Attachment Point
SPACE = Attachment Point not met
32 INGREDIENT COST PAID 506-F6 316 - 326 S9(9)V99 11 NCPDP Amount the pharmacy is paid for the drug itself. Dispensing fees or other costs are not included in this amount.
33 DISPENSING FEE PAID 507-F7 327 - 337 S9(9)V99 11 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 or Additional Dispensing Fee is reported in Field 37.
34 TOTAL AMOUNT ATTRIBUTED TO SALES TAX
338 - 348 S9(9)V99 11 CMS 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.
35 ESTIMATED REMUNERATION AT POS AMOUNT (ERPOSA)
349 - 359 S9(9)V99 11 CMS For PDEs with a DOS >= 01/01/2025, this field contains the estimated amount of remuneration that are not pharmacy price concessions that the plan sponsor is required to apply, or 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 (POS). This estimate includes the rebate or other price concession amount that the plan sponsor expects to receive from a pharmaceutical manufacturer or other non-pharmacy entity and has elected to apply to the negotiated price. This estimate does not include pharmacy price concessions applied at the point of sale, which must be reported in the “Pharmacy Price Concessions at POS” field.

For PDEs with a DOS >= 01/01/2024 and a DOS <= 12/31/2024, this estimate must reflect the maximum amount of any contingent payments or adjustments that the plan sponsor might receive from a network pharmacy that would serve to decrease the total amount that the plan sponsor pays for the drug, i.e., all pharmacy price concessions. This estimate must also reflect the rebate or other price concession amount that the plan sponsor expects to receive from a pharmaceutical manufacturer or other non-pharmacy entity and has elected to apply to the negotiated price.

For PDEs with a DOS < 01/01/2024, this field must contain the estimated amount of rebates and/or other price concessions that the plan sponsor is required to apply, or has elected to apply, to the negotiated price as a reduction in the drug price made available to the beneficiary at the POS.

When there is no rebate or price concession made available to the beneficiary at the POS, this field may be zero dollars. This field must contain a positive dollar amount; the field may never be negative.
36 PHARMACY PRICE CONCESSIONS AT POS
360 - 370 S9(9)V99 11 CMS For PDEs with a DOS >= 01/01/2025, this field must contain the maximum amount of any contingent payments or adjustments that the plan sponsor might receive from a network pharmacy that would serve to decrease the total amount that the plan sponsor pays for the drug, i.e., all pharmacy price concessions. All other estimated remuneration applied at the POS must be reported in the “Estimated Remuneration at POS Amount (ERPOSA)” field. This field must contain a positive dollar amount, or zero dollars when there is no price concession applied at the POS; the field may never be negative. For PDEs with a DOS < 01/01/2025, this field must be zero.
37 VACCINE ADMINISTRATION FEE OR ADDITIONAL DISPENSING FEE
371 - 381 S9(9)V99 11 CMS Amount the plan paid the pharmacy for administering a vaccination. For PDEs with a DOS >= 01/01/2008, a value must be reported when there is a vaccine administration fee or additional Emergency Use Authorization (EUA) dispensing fee charged. For PDEs with a DOS < 01/01/2008, this field must be zero. This field may also include amounts of additional dispensing fees paid for EUA oral antiviral drugs procured by the U.S. Government, over and above what was reported in the “Dispensing Fee Paid” field.
38 FILLER
382 - 436 X(55) 55 CMS SPACES
39 GROSS DRUG COST BELOW OUT-OF-POCKET THRESHOLD (GDCB)
437 - 447 S9(9)V99 11 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 or Additional Dispensing Fee.
For PDEs with a DOS < 01/01/2011, when the Catastrophic Coverage Code = SPACE, this field equals the sum of Ingredient Cost Paid + Dispensing Fee Paid + Total Amount Attributed to Sales Tax + Vaccine Administration Fee or Additional Dispensing 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 or Additional Dispensing 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.
40 GROSS DRUG COST ABOVE OUT-OF-POCKET THRESHOLD (GDCA)
448 - 458 S9(9)V99 11 CMS 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 or Additional Dispensing Fee.
For PDEs with a DOS < 01/01/2011, 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 or Additional Dispensing 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 or Additional Dispensing Fee falling above the OOP threshold. Any remaining portion is reported in GDCB. This amount increments the Total Gross Covered Drug Cost Accumulator amount.
41 PATIENT PAY AMOUNT 505-F5 459 - 469 S9(9)V99 11 NCPDP Payments made by the beneficiary or by family or friends at point of sale. This amount increments the True Out-of-Pocket (TrOOP) Accumulator amount.
42 OTHER TROOP AMOUNT
470 - 480 S9(9)V99 11 CMS 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 the Reported Gap Discount (for PDEs with a DOS < 01/01/2025) or Manufacturer Discount (for PDEs with a DOS >= 01/01/2025). This amount increments the True Out-of-Pocket Accumulator amount. For PDEs with a DOS >= 01/01/2023 and DOS <= 12/31/2023, this field may contain the Inflation Reduction Act Subsidy Amount (IRASA). When this field contains IRASA, the Other TrOOP Amount Indicator field must be reported with a value of S or B.
43 LOW INCOME COST SHARING SUBSIDY AMOUNT (LICS)
481 - 491 S9(9)V99 11 CMS Amount the plan advanced at point-of-sale due to a beneficiary's LI status. This amount increments the True Out-of-Pocket Accumulator amount.
44 PATIENT LIABILITY REDUCTION DUE TO OTHER PAYER AMOUNT (PLRO)
492 - 502 S9(9)V99 11 CMS Amount by which patient liability is reduced due to payment by other payers that are not TrOOP-eligible and do not participate in Part D.
45 COVERED D PLAN PAID AMOUNT (CPP)
503 - 513 S9(9)V99 11 CMS 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.
46 NON COVERED PLAN PAID AMOUNT (NPP)
514 - 524 S9(9)V99 11 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.
47 GOVERNMENT PAY SUBSIDY
525 - 535 S9(9)V99 11 CMS Required for PDEs with a DOS >= 01/01/2025, the government pay selected drug subsidy amount. On PDEs with a DOS < 01/01/2025, must be zero.
48 REPORTED MANUFACTURER DISCOUNT
536 - 546 S9(9)V99 11 CMS Required for PDEs with a DOS >= 01/01/2025. The reported amount that the plan sponsor advanced at point of sale for the Manufacturer Discount for applicable drugs. On PDEs with a DOS < 01/01/2025, must be zero. This amount will not increment the True Out-of-Pocket Accumulator amount.
49 REPORTED GAP DISCOUNT
547 - 557 S9(9)V99 11 CMS The reported amount that the plan sponsor advanced at point of sale for the Gap Discount for applicable drugs. Required on PDEs with a DOS >= 01/01/2011 and a DOS <= 12/31/2024. On PDEs with a DOS < 01/01/2011 or PDEs with a DOS >= 01/01/2025, must be zero. This amount increments the True Out-of-Pocket Accumulator amount.
50 FILLER
558 - 623 X(66) 66 CMS SPACES
51 TOTAL GROSS COVERED DRUG COST ACCUMULATOR
624 - 634 S9(9)V99 11 CMS Sum of the beneficiary's covered drug costs for the benefit year known immediately prior to adjudicating the claim. Required on PDEs with a DOS >= 01/01/2011. On PDEs with a DOS < 01/01/2011, must be zero.
52 FILLER
635 - 636 X(2) 2 CMS SPACES
53 TRUE OUT-OF-POCKET ACCUMULATOR
637 - 647 S9(9)V99 11 CMS Sum of the beneficiary's incurred costs for the benefit year known immediately prior to adjudicating the claim. Required on PDEs with a DOS >= 01/01/2011. On PDEs with a DOS < 01/01/2011, must be zero.
54 FILLER
648 -649 X(2) 2 CMS SPACES
55 DEDUCTIBLE ACCUMULATOR
650 - 660 S9(9)V99 11 CMS Sum of the beneficiary's deductible amount for the benefit year known immediately prior to adjudicating the claim. Required for PDEs with a DOS >= 01/01/2025. On PDEs with a DOS < 01/01/2025, must be zero.
56 OTHER TROOP AMOUNT INDICATOR
661 - 661 X(1) 1 CMS This code is used for PDEs with a DOS >= 01/01/2023 and a DOS <= 12/31/2023, when the Other TrOOP Amount includes Inflation Reduction Act Subsidy Amount (IRASA) dollars for benefit year 2023.

Valid values are:
B = indicates the amount reported in Other TrOOP field contains both IRASA and non-IRASA Other TrOOP amounts.
S = indicates the amount reported in Other TrOOP field contains only IRASA Other TrOOP amount.
SPACE = indicates amount reported in Other TrOOP field contains only non-IRASA Other TrOOP amount, if any; and for PDEs with a DOS < 01/01/2023 or for PDEs with a DOS >= 01/01/2024.
57 BEGINNING BENEFIT PHASE
662 - 662 X(1) 1 CMS Required on PDEs with a DOS >= 01/01/2011 and a DOS <= 12/31/2024. Plan-defined benefit phase in effect immediately prior to the time the sponsor began adjudicating the individual claim being reported. Valid values are:
D = Deductible
N = Initial Coverage Period
G = Coverage Gap
C = Catastrophic
For PDEs with a DOS < 01/01/2011, must be SPACE. For PDEs with a DOS >= 01/01/2025, the value of G no longer applies, and will not be accepted. Applies to covered drugs only.
58 ENDING BENEFIT PHASE
663 - 663 X(1) 1 CMS Required on PDEs with a DOS >= 01/01/2011 and a DOS <= 12/31/2024. Plan-defined benefit phase in effect upon the sponsor completing adjudication of the individual claim being reported. Valid values are:
D = Deductible
N = Initial Coverage Period
G = Coverage Gap
C = Catastrophic
For PDEs with a DOS < 01/01/2011, must be SPACE. For PDEs with a DOS >= 01/01/2025, the value of G no longer applies, and will not be accepted. Applies to covered drugs only.
59 PRESCRIPTION ORIGIN CODE 419-DJ 664 - 664 X(1) 1 NCPDP Valid values are:
1 = Written
2 = Telephone
3 = Electronic
4 = Facsimile
5 = Pharmacy
0 = Not Specified
SPACE = Unknown

For PDEs with a DOS >= 01/01/2010, only the values of 1, 2, 3, 4 or 5 are valid for the following scenarios:
1. PDEs that are standard claims (excluding Medicaid Subrogation) and Fill Number = 00
2. PACE claims with non-standard format code not in X, B, P or C and Fill Number = 00
60 DATE ORIGINAL CLAIM RECEIVED
665 - 672 9(8) 8 CMS Date sponsor received original claim. Required on PDEs with a DOS >= 01/01/2011. On PDEs with a DOS < 01/01/2011, must be zero. Required for all LI NET PDEs submitted on and after 01/01/2011, regardless of the DOS.
61 CLAIM ADJUDICATION BEGAN TIMESTAMP
673 - 698 X(26) 26 CMS Date and time sponsor began adjudicating the claim in Greenwich Mean Time. Required on PDEs with a DOS >= 01/01/2011. On PDEs with a DOS < 01/01/2011, must be SPACES or zero.
62 BRAND/GENERIC CODE
699 - 699 X(1) 1 CMS Plan reported value indicating whether the plan adjudicated the claim as a brand or generic drug. Valid values are:
B = Brand
G = Generic
Required on PDEs with a DOS >= 01/01/2011. On PDEs with a DOS < 01/01/2011, must be a SPACE. Applies to covered drugs only.
63 TIER
700 - 700 X(1) 1 CMS Formulary tier in which the sponsor adjudicated the claim. Required on PDEs with a DOS >= 01/01/2011.

On PDEs with a DOS >= 01/01/2022, values must be 1-7 or a SPACE.

On PDEs with a DOS >= 01/01/2011 and DOS <= 12/31/2021, values must be 1-6 or a SPACE.

On PDEs with a DOS < 01/01/2011, must be a SPACE.

Applies to covered drugs only.
64 FORMULARY CODE
701 - 701 X(1) 1 CMS Indicates if the drug is on the plan's formulary. Valid values are:
F = Formulary
N = Non-Formulary
Required on PDEs with a DOS >= 01/01/2011. On PDEs with a DOS < 01/01/2011, must be a SPACE. Applies to covered drugs only.
65 PHARMACY SERVICE TYPE 147-U7 702 - 703 X(2) 2 NCPDP Required on PDEs with a DOS >= 02/28/2013. 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 PDEs with a DOS < 02/28/2013, valid values are SPACES or any of the valid values listed above.

For COB PDEs, valid values are SPACES or any of the valid values listed above.
66 PATIENT RESIDENCE 384-4X 704 - 705 X(2) 2 NCPDP Required on PDEs with a DOS >= 02/28/2013. 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/Intellectual Disability
11 = Hospice

For DOS < 02/28/2013, valid values are SPACES or any of the valid values listed above.

For COB PDEs, valid values are SPACES or any of the valid values listed above.
67 SUBMISSION TYPE CODE 1 D17-K8 706 - 707 X(2) 2 NCPDP Optional on PDEs with a DOS >= 01/01/2025. Used to identify specific types of claims with the following valid values:
SPACES
AA = 340B Claims
AB = Split Billing
AD = Nominal Price
AF = Synchronization Fill
AG = Trial Fill
For PDES with a DOS < 01/01/2025, must be SPACES.
68 SUBMISSION TYPE CODE 2 D17-K8 708 - 709 X(2) 2 NCPDP Optional on PDEs with a DOS >= 01/01/2025. Used to identify specific types of claims with the following valid values:
SPACES
AA = 340B Claims
AB = Split Billing
AD = Nominal Price
AF = Synchronization Fill
AG = Trial Fill
For PDES with a DOS < 01/01/2025, must be SPACES.
69 SUBMISSION TYPE CODE 3 D17-K8 710 - 711 X(2) 2 NCPDP Optional on PDEs with a DOS >= 01/01/2025. Used to identify specific types of claims with the following valid values:
SPACES
AA = 340B Claims
AB = Split Billing
AD = Nominal Price
AF = Synchronization Fill
AG = Trial Fill
For PDES with a DOS < 01/01/2025, must be SPACES.
70 SUBMISSION TYPE CODE 4 D17-K8 712 - 713 X(2) 2 NCPDP Optional on PDEs with a DOS >= 01/01/2025. Used to identify specific types of claims with the following valid values:
SPACES
AA = 340B Claims
AB = Split Billing
AD = Nominal Price
AF = Synchronization Fill
AG = Trial Fill
For PDES with a DOS < 01/01/2025, must be SPACES.
71 SUBMISSION TYPE CODE 5 D17-K8 714 - 715 X(2) 2 NCPDP Optional on PDEs with a DOS >= 01/01/2025. Used to identify specific types of claims with the following valid values:
SPACES
AA = 340B Claims
AB = Split Billing
AD = Nominal Price
AF = Synchronization Fill
AG = Trial Fill
For PDES with a DOS < 01/01/2025, must be SPACES.
72 SUBMISSION CLARIFICATION CODE 1 420-DK 716 - 718 X(3) 3 NCPDP For PDEs with a DOS >= 01/01/2025, any numeric value or SPACES may be reported in this field; if an LTC-related value is reported, Patient Residence must be 03.

For PDEs with a DOS >= 02/28/2013 and DOS <= 12/31/2024, if Patient Residence = 03, the valid values are:
SPACES
16 = Long Term Care (LTC) emergency box (kit) or automated dispensing machine
21 = LTC dispensing: 14 days or less not applicable
22 = LTC dispensing: 7 days
23 = LTC dispensing: 4 days
24 = LTC dispensing: 3 days
25 = LTC dispensing: 2 days
26 = LTC dispensing: 1 day
27 = LTC dispensing: 4-3 days
28 = LTC dispensing: 2-2-3 days
29 = LTC dispensing: daily and 3-day weekend
30 = LTC dispensing: Per shift dispensing
31 = LTC dispensing: Per med pass dispensing
32 = LTC dispensing: PRN on demand
33 = LTC dispensing: 7 day or less cycle not otherwise represented
34 = LTC dispensing: 14 days dispensing
35 = LTC dispensing: 8–14 day dispensing method not listed above
36 = LTC dispensing: dispensed outside short cycle, determined to be Medicare Part D after originally submitted to another payer

For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence Code not equal to 03, must be SPACES. For PDEs with a DOS < 02/28/2013, must be SPACES.
73 SUBMISSION CLARIFICATION CODE 2 420-DK 719 - 721 X(3) 3 NCPDP For PDEs with a DOS >= 01/01/2025, any numeric value or SPACES may be reported in this field; if an LTC-related value is reported, Patient Residence must be 03.

For PDEs with a DOS >= 02/28/2013 and DOS <= 12/31/2024, if Patient Residence = 03, the valid values are:
SPACES
16 = Long Term Care (LTC) emergency box (kit) or automated dispensing machine
21 = LTC dispensing: 14 days or less not applicable
22 = LTC dispensing: 7 days
23 = LTC dispensing: 4 days
24 = LTC dispensing: 3 days
25 = LTC dispensing: 2 days
26 = LTC dispensing: 1 day
27 = LTC dispensing: 4-3 days
28 = LTC dispensing: 2-2-3 days
29 = LTC dispensing: daily and 3-day weekend
30 = LTC dispensing: Per shift dispensing
31 = LTC dispensing: Per med pass dispensing
32 = LTC dispensing: PRN on demand
33 = LTC dispensing: 7 day or less cycle not otherwise represented
34 = LTC dispensing: 14 days dispensing
35 = LTC dispensing: 8–14 day dispensing method not listed above
36 = LTC dispensing: dispensed outside short cycle, determined to be Medicare Part D after originally submitted to another payer

For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence Code not equal to 03, must be SPACES. For PDEs with a DOS < 02/28/2013, must be SPACES.
74 SUBMISSION CLARIFICATION CODE 3 420-DK 722 - 724 X(3) 3 NCPDP For PDEs with a DOS >= 01/01/2025, any numeric value or SPACES may be reported in this field; if an LTC-related value is reported, Patient Residence must be 03.

For PDEs with a DOS >= 02/28/2013 and DOS <= 12/31/2024, if Patient Residence = 03, the valid values are:
SPACES
16 = Long Term Care (LTC) emergency box (kit) or automated dispensing machine
21 = LTC dispensing: 14 days or less not applicable
22 = LTC dispensing: 7 days
23 = LTC dispensing: 4 days
24 = LTC dispensing: 3 days
25 = LTC dispensing: 2 days
26 = LTC dispensing: 1 day
27 = LTC dispensing: 4-3 days
28 = LTC dispensing: 2-2-3 days
29 = LTC dispensing: daily and 3-day weekend
30 = LTC dispensing: Per shift dispensing
31 = LTC dispensing: Per med pass dispensing
32 = LTC dispensing: PRN on demand
33 = LTC dispensing: 7 day or less cycle not otherwise represented
34 = LTC dispensing: 14 days dispensing
35 = LTC dispensing: 8–14 day dispensing method not listed above
36 = LTC dispensing: dispensed outside short cycle, determined to be Medicare Part D after originally submitted to another payer

For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence Code not equal to 03, must be SPACES. For PDEs with a DOS < 02/28/2013, must be SPACES.
75 SUBMISSION CLARIFICATION CODE 4 420-DK 725 - 727 X(3) 3 NCPDP For PDEs with a DOS >= 01/01/2025, any numeric value or SPACES may be reported in this field; if an LTC-related value is reported, Patient Residence must be 03.

For PDEs with a DOS >= 02/28/2013 and DOS <= 12/31/2024, if Patient Residence = 03, the valid values are:
SPACES
16 = Long Term Care (LTC) emergency box (kit) or automated dispensing machine
21 = LTC dispensing: 14 days or less not applicable
22 = LTC dispensing: 7 days
23 = LTC dispensing: 4 days
24 = LTC dispensing: 3 days
25 = LTC dispensing: 2 days
26 = LTC dispensing: 1 day
27 = LTC dispensing: 4-3 days
28 = LTC dispensing: 2-2-3 days
29 = LTC dispensing: daily and 3-day weekend
30 = LTC dispensing: Per shift dispensing
31 = LTC dispensing: Per med pass dispensing
32 = LTC dispensing: PRN on demand
33 = LTC dispensing: 7 day or less cycle not otherwise represented
34 = LTC dispensing: 14 days dispensing
35 = LTC dispensing: 8–14 day dispensing method not listed above
36 = LTC dispensing: dispensed outside short cycle, determined to be Medicare Part D after originally submitted to another payer

For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence Code not equal to 03, must be SPACES. For PDEs with a DOS < 02/28/2013, must be SPACES.
76 SUBMISSION CLARIFICATION CODE 5 420-DK 728 - 730 X(3) 3 NCPDP For PDEs with a DOS >= 01/01/2025, any numeric value or SPACES may be reported in this field; if an LTC-related value is reported, Patient Residence must be 03.

For PDEs with a DOS >= 02/28/2013 and DOS <= 12/31/2024, if Patient Residence = 03, the valid values are:
SPACES
16 = Long Term Care (LTC) emergency box (kit) or automated dispensing machine
21 = LTC dispensing: 14 days or less not applicable
22 = LTC dispensing: 7 days
23 = LTC dispensing: 4 days
24 = LTC dispensing: 3 days
25 = LTC dispensing: 2 days
26 = LTC dispensing: 1 day
27 = LTC dispensing: 4-3 days
28 = LTC dispensing: 2-2-3 days
29 = LTC dispensing: daily and 3-day weekend
30 = LTC dispensing: Per shift dispensing
31 = LTC dispensing: Per med pass dispensing
32 = LTC dispensing: PRN on demand
33 = LTC dispensing: 7 day or less cycle not otherwise represented
34 = LTC dispensing: 14 days dispensing
35 = LTC dispensing: 8–14 day dispensing method not listed above
36 = LTC dispensing: dispensed outside short cycle, determined to be Medicare Part D after originally submitted to another payer

For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence Code not equal to 03, must be SPACES. For PDEs with a DOS < 02/28/2013, must be SPACES.
77 LTPAC DISPENSE FREQUENCY C91-KK 731 - 732 X(2) 2 NCPDP For PDEs with a DOS >= 01/01/2025, used for long-term and post-acute care short-cycle (LTPAC) dispensing. Valid values are:
SPACES
1 = Medication dispensed in a day-supply increment equal to the billed days supply (for example: medication dispensed for a 30-day supply and billed for a 30-day supply).
2 = 7 days - dispenses medication in 7-day supplies. 
3 = 4 days - dispenses medication in 4-day supplies. 
4 = 3 days - dispenses medication in 3-day supplies.
5 = 2 days - dispenses medication in 2-day supplies.
6 = 1 day - dispenses medication in 1-day supplies.
7 = 4-3 days - dispenses medication in 4-day, then 3-day supplies. 
8 = 2-2-3 days - dispenses medication in 2-day, then 2-day, then 3-day supplies.
9 = Daily and 3-day weekend - dispensed daily during the week and combines multiple days dispensing for weekends.
10 = Per shift dispensing (multiple med passes).
11 = Per med pass dispensing.
12 = PRN on demand.
13 = 7-day or less cycle not otherwise represented.
14 = 14 days dispensing - dispenses medication in 14-day supplies.
15 = 8–14-Day dispensing cycle not otherwise represented.

For PDEs with a DOS < 01/01/2025, must be SPACES.
78 ADJUSTMENT REASON CODE QUALIFIER
733 - 733 X(1) 1 CMS For PDEs with a DOS >= 11/13/2016 and a DOS <= 12/31/2024, the type of Adjustment Reason Code used in field 79. Valid values are:
2 = CMS Audit
3 = CMS Identified Overpayment (CIO)
4 = CGDP Dispute or Appeal
9 = Other
SPACE = Not Applicable

The Adjustment Reason Code Qualifier of 1 has been removed from the list of valid values for PDEs with a DOS >= 11/13/2016, and will not be accepted.

The Adjustment Reason Code Qualifiers of 3, 4, and 9 have been removed from the list of valid values for PDEs with a DOS >= 01/01/2025, and will not be accepted.
79 ADJUSTMENT REASON CODE
734 - 745 X(12) 12 CMS For PDEs with a DOS >= 11/13/2016 and a DOS <= 12/31/2024, this code will assist CMS to track the reason for an adjustment or deletion. Accepted values are dependent upon the adjustment reason code qualifier submitted in field 78. Valid values are:

If the qualifier = 2, the valid value is: OFM, RAC, or MEDIC
If the qualifier = 3, the valid value is: CIO
If the qualifier = 4, the valid value is: DISPUTE or APPEAL
If the qualifier = 9, the valid value is: For future use at CMS' direction
If the qualifier = SPACES, the valid value is: SPACES

* Non-numeric values should be left justified

The Adjustment Reason Code Qualifier of 1 has been removed from the list of valid values for PDEs with a DOS >= 11/13/2016, and will not be accepted.

The Adjustment Reason Codes of CIO, DISPUTE or APPEAL, and For Future use at CMS' direction have been removed from the list of valid values for PDEs with a DOS >= 01/01/2025, and will not be accepted.
80 FILLER
746 - 1000 X(255) 255 CMS SPACES








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 zeros. Since the field is a signed field, plans must utilize the appropriate overpunch signs as specified in the current NCPDP Telecommunications Standard.

Sheet 4: BTR

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 "BTR"
2 SEQUENCE NO
4 - 10 9(7) 7 PDFS Must match BHD. Must start with 0000001.
3 CONTRACT NO
11 - 15 X(5) 5 CMS Must match BHD
4 PBP ID
16 - 18 X(3) 3 CMS Must match BHD
5 DET RECORD TOTAL
19 - 25 9(7) 7 CMS Total count of DET records
6 FILLER
26 -1000 X(975) 975 CMS SPACES

Sheet 5: TLR

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 "TLR"
2 SUBMITTER ID
4 - 9 X(6) 6 CMS Must match HDR
3 FILE ID
10 - 19 X(10) 10 PDFS Must match HDR
4 TLR BHD RECORD TOTAL
20 - 28 9(9) 9 CMS Total count of BHD records
5 TLR DET RECORD TOTAL
29 - 37 9(9) 9 CMS Total count of DET records
6 FILLER
38 -1000 X(963) 963 CMS SPACES








Note:






Maximum number of detail records per file is TBD, and will be communicated in future guidance. If one file contains multiple batches, maximum record count applies to the cumulative total across all batches.








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