PDE-Inbound-File-Layout-Final-20250101_Q4-2023.xlsx

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Overview

HDR
BHD
DET
BTR
TLR

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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, TS1K, CERT, or CT1K
6	FILLER	—	32 - 1000	X(969)	969	N/A	SPACES

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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

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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 (For DOS < 01/01/2025, Reported Gap Discount must = 0; for DOS >= 01/01/2025, Manufacturer 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	FILLER	—	217 - 217	X(1)	1	CMS	SPACE
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 Schedule II drugs that are reported as standard, electronically-submitted PDEs with a DOS >= 01/01/2025. 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 and a DOS <= 12/31/2023. 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	MEDICARE PRESCRIPTION PAYMENT PLAN INDICATOR	—	289 - 289	X(1)	1	CMS	Required for PDEs with a DOS >= 01/01/2025 that are included in the Medicare Prescription Payment Plan. Valid values are: Y = PDE is included in the Medicare Prescription Payment Plan SPACE = PDE is not included in the Medicare Prescription Payment Plan For DOS < 01/01/2025, this field must contain a SPACE.
31	FILLER	—	290 - 314	X(25)	25	CMS	SPACES
32	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
33	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.
34	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 38.
35	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.
36	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.
37	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.
38	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.
39	FILLER	—	382 - 436	X(55)	55	CMS	SPACES
40	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.
41	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.
42	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.
43	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). 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.
44	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.
45	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.
46	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.
47	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.
48	SELECTED DRUG SUBSIDY	—	525 - 535	S9(9)V99	11	CMS	Required for PDEs with a DOS >= 01/01/2026. The reported subsidy amount that the plan sponsor advanced at point of sale for a Selected Drug in the Initial Coverage Period. This field must contain a positive dollar amount, or zero dollars when there is no Selected Drug subsidy applied at the POS; the field may never be negative. On PDEs with a DOS < 01/01/2026, must be zero. This amount will not increment the True Out-of-Pocket Accumulator amount.
49	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.
50	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.
51	FILLER	—	558 - 623	X(66)	66	CMS	SPACES
52	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.
53	FILLER	—	635 - 636	X(2)	2	CMS	SPACES
54	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.
55	FILLER	—	648 -660	X(13)	13	CMS	SPACES
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 or Medicaid Subrogation 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 or Medicaid Subrogation 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 NCPDP 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 * Values should be left justified with trailing spaces. For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence 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 NCPDP 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 * Values should be left justified with trailing spaces. For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence 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 NCPDP 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 * Values should be left justified with trailing spaces. For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence 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 NCPDP 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 * Values should be left justified with trailing spaces. For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence 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 NCPDP 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 * Values should be left justified with trailing spaces. For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence 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	Optional on 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. * Values should be left justified with trailing spaces. 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
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 zeros. Since the field is a signed field, plans must utilize the appropriate overpunch signs as specified in the current NCPDP Telecommunications Standard.

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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

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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
Notes: - 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. - According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0982. The time required to complete this information collection is estimated to average two (2) hours per one million (1,000,000) transactions or 0.0074 seconds per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.