Document
PDE Inbound File Layout
ICR 202609-0938-018 · OMB 0938-0982 · Object 173305200.
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| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | PDE Inbound File Layout |
| Subject | PDE Inbound File Layout |
| Keywords | PDE, Layout |
| Author | CMS - GDIT |
| Last Modified By | Calc |
| File Modified | 2023-10-23 |
| File Created | 2026-10-03 |
| Conversion State | complete |
Extracted Text
HDR FIELD NO. FIELD NAME 1 RECORD ID 2 SUBMITTER ID 3 FILE ID 4 5 6 TRANS DATE PROD TEST CERT IND FILLER NCPDP FIELD — — — — — — POSITION 1-3 PICTURE X(3) LENGTH 3 NCPDP, CMS OR PDFS DEFINED PDFS DEFINITION / VALUES 4-9 X(6) 6 CMS Unique ID assigned by CMS. 10 - 19 X(10) 10 PDFS 20 - 27 28 - 31 32 - 1000 9(8) X(4) X(969) 8 4 969 PDFS PDFS N/A Unique ID provided by Submitter. Same ID cannot be used within 12 months. Date of file transmission to PDFS. PROD, TEST, TS1K, CERT, or CT1K SPACES "HDR" BHD FIELD NO. FIELD NAME 1 RECORD ID 2 SEQUENCE NO 3 4 5 CONTRACT NO PBP ID FILLER NCPDP FIELD POSITION PICTURE LENGTH NCPDP, CMS OR PDFS DEFINED — 1-3 X(3) 3 PDFS — 4 - 10 9(7) 7 PDFS — — — 11 - 15 16 - 18 19 - 1000 X(5) X(3) X(982) 5 3 982 CMS CMS N/A DEFINITION / VALUES "BHD" Must start with 0000001 Assigned by CMS Assigned by CMS SPACES DET FIELD NO. 1 2 FIELD NAME RECORD ID SEQUENCE NO NCPDP FIELD — — — POSITION 1-3 4 - 10 11 - 50 PICTURE X(3) 9(7) X(40) LENGTH 3 7 40 NCPDP, CMS OR DEFINITION / VALUES PDFS DEFINED PDFS "DET" PDFS Must start with 0000001 A number assigned by the plan to identify the prescription drug event. This is an optional field. CMS *non-numeric values should be left justified. 3 CLAIM CONTROL NUMBER 4 MEDICARE BENEFICIARY IDENTIFIER 5 CARDHOLDER ID 6 PATIENT DATE OF BIRTH (DOB) 304-C4 91 - 98 9(8) 8 NCPDP 7 PATIENT GENDER CODE 305-C5 99 - 99 9(1) 1 NCPDP — 51 - 70 X(20) 20 CMS 302-C2 71 - 90 X(20) 20 NCPDP 8 DATE OF SERVICE (DOS) 9 PAID DATE 10 PRESCRIPTION SERVICE REFERENCE NO 402-D2 116 - 127 9(12) 12 NCPDP 11 PRODUCT SERVICE ID 407-D7 or 489- TE 128 - 167 X(40) 40 NCPDP 12 FILLER — 168 - 197 X(30) 30 CMS 13 SERVICE PROVIDER ID QUALIFIER 401-D1 202-B2 100 - 107 198 - 199 X(2) 2 NCPDP 14 200 - 214 X(15) 108 - 115 9(8) 9(8) 8 8 NCPDP CMS 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. *non-numeric values should be left justified. Optional field. If populated, the format is CCYYMMDD. Valid values are: 1=M 2=F CCYYMMDD 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. Applies to all PDEs with a DOS >= 01/01/2011. Field is right justified and filled with 5 leading zeros. 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. SERVICE PROVIDER ID 201-B1 15 NCPDP 15 FILL NUMBER 403-D3 215 - 216 9(2) 2 NCPDP 16 FILLER — 217 - 217 X(1) 1 CMS 17 COMPOUND CODE 406-D6 218 - 218 1 NCPDP 18 DISPENSE AS WRITTEN (DAW) PRODUCT SELECTION CODE 408-D8 219 - 219 1 NCPDP 19 ORIGINALLY PRESCRIBED QUANTITY 446-EB 220 - 229 9(7)V999 10 NCPDP SPACES 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. 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. Valid values are: 0 – 99 If unavailable, use zero. SPACE Valid values are: 0 = Not specified 1 = Not a Compound 2 = Compound 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 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. 9(1) X(1) 21 FILLER — 240 - 242 X(3) 3 CMS 22 DAYS SUPPLY 405-D5 243 - 245 9(3) 3 NCPDP 23 PRESCRIBER ID QUALIFIER 466-EZ 246 - 247 X(2) 2 NCPDP 24 PRESCRIBER ID 411-DB 248 - 282 X(35) 35 NCPDP 25 DRUG COVERAGE STATUS CODE — 283 - 283 X(1) 1 CMS 26 ADJUSTMENT DELETION CODE — 284 - 284 X(1) 1 CMS 27 NON- STANDARD FORMAT CODE — 285 - 285 X(1) 1 CMS 28 PRICING EXCEPTION CODE — 286 - 286 X(1) 1 CMS 29 PART D MODEL INDICATOR — 287 - 288 X(2) 2 CMS 30 MEDICARE PRESCRIPTION PAYMENT PLAN INDICATOR — CMS SPACES Valid values are: 0 - 999 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. Mandatory * non-numeric values should be left justified. 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 Valid values are: A = Adjustment D = Deletion SPACE = Original PDE 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 Valid Values are: M= Medicare as Secondary Payer O = Out-of-network pharmacy (Medicare is Primary) SPACE = In-network pharmacy (Medicare is Primary) 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. 289 - 289 X(1) 1 31 FILLER — 290 - 314 X(25) 25 CMS 32 CATASTROPHIC COVERAGE CODE — 315 - 315 X(1) 1 CMS 33 INGREDIENT COST PAID 506-F6 316 - 326 S9(9)V99 11 NCPDP 34 DISPENSING FEE PAID 507-F7 327 - 337 S9(9)V99 11 NCPDP 35 TOTAL AMOUNT ATTRIBUTED TO SALES TAX — 338 - 348 S9(9)V99 11 CMS 36 ESTIMATED REMUNERATION AT POS AMOUNT (ERPOSA) — 349 - 359 S9(9)V99 11 CMS 37 PHARMACY PRICE CONCESSIONS AT POS — 360 - 370 S9(9)V99 11 CMS 38 VACCINE ADMINISTRATION FEE OR ADDITIONAL DISPENSING FEE — 371 - 381 S9(9)V99 11 CMS 39 FILLER — 382 - 436 X(55) 55 CMS 40 GROSS DRUG COST BELOW OUT-OF-POCKET THRESHOLD (GDCB) — 437 - 447 S9(9)V99 11 CMS 41 GROSS DRUG COST ABOVE OUT-OF-POCKET THRESHOLD (GDCA) — 448 - 458 S9(9)V99 11 CMS 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. 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. SPACES 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 Amount the pharmacy is paid for the drug itself. Dispensing fees or other costs are not included in this amount. 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. 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. 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. 42 PATIENT PAY AMOUNT 505-F5 459 - 469 S9(9)V99 11 NCPDP 43 OTHER TROOP AMOUNT — 470 - 480 S9(9)V99 11 CMS 44 LOW INCOME COST SHARING SUBSIDY AMOUNT (LICS) — 481 - 491 S9(9)V99 11 CMS PATIENT LIABILITY REDUCTION DUE TO OTHER PAYER AMOUNT (PLRO) — 492 - 502 S9(9)V99 11 CMS 45 46 47 COVERED D PLAN PAID AMOUNT (CPP) NON COVERED PLAN PAID AMOUNT (NPP) 503 - 513 S9(9)V99 11 CMS 514 - 524 S9(9)V99 11 CMS 525 - 535 S9(9)V99 11 CMS 536 - 546 S9(9)V99 11 CMS 50 REPORTED GAP DISCOUNT — 547 - 557 S9(9)V99 11 CMS 51 SELECTED DRUG SUBSIDY — REPORTED MANUFACTURER DISCOUNT FILLER — — 558 - 623 X(66) 66 CMS TOTAL GROSS COVERED DRUG COST ACCUMULATOR — FILLER TRUE OUT-OF-POCKET ACCUMULATOR FILLER — 635 - 636 X(2) 2 CMS — 637 - 647 S9(9)V99 11 CMS — 648 -660 X(13) 13 CMS 56 OTHER TROOP AMOUNT INDICATOR — 661 - 661 X(1) 1 CMS 57 BEGINNING BENEFIT PHASE — 662 - 662 X(1) 1 CMS 58 ENDING BENEFIT PHASE — 663 - 663 X(1) 1 CMS 59 PRESCRIPTION ORIGIN CODE 419-DJ 664 - 664 — 52 53 55 624 - 634 S9(9)V99 CMS 1 NCPDP 665 - 672 9(8) 8 CMS — 673 - 698 X(26) 26 CMS BRAND/GENERIC CODE — 699 - 699 X(1) 1 CMS 63 TIER — 700 - 700 X(1) 1 CMS 64 FORMULARY CODE — 701 - 701 X(1) 1 CMS 65 PHARMACY SERVICE TYPE 147-U7 702 - 703 X(2) 2 NCPDP 66 PATIENT RESIDENCE 384-4X 704 - 705 X(2) 2 NCPDP 67 SUBMISSION TYPE CODE 1 D17-K8 706 - 707 X(2) 2 NCPDP 68 SUBMISSION TYPE CODE 2 D17-K8 708 - 709 X(2) 2 NCPDP 69 SUBMISSION TYPE CODE 3 D17-K8 710 - 711 X(2) 2 NCPDP 70 SUBMISSION TYPE CODE 4 D17-K8 712 - 713 X(2) 2 NCPDP 71 SUBMISSION TYPE CODE 5 D17-K8 714 - 715 X(2) 2 NCPDP 72 SUBMISSION CLARIFICATION CODE 1 420-DK 716 - 718 X(3) 3 NCPDP 73 SUBMISSION CLARIFICATION CODE 2 420-DK 719 - 721 X(3) 3 NCPDP 61 DATE ORIGINAL CLAIM RECEIVED CLAIM ADJUDICATION BEGAN TIMESTAMP X(1) 11 62 60 SPACES 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. 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. 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. 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. 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. 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. — — 48 49 54 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. 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. 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. 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. 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. 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. 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. 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. SPACES 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. SPACES 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. SPACES 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. 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. 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. 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 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 74 SUBMISSION CLARIFICATION CODE 3 420-DK 722 - 724 X(3) 3 NCPDP 75 SUBMISSION CLARIFICATION CODE 4 420-DK 725 - 727 X(3) 3 NCPDP 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. 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. 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. 76 SUBMISSION CLARIFICATION CODE 5 420-DK 728 - 730 X(3) 3 NCPDP 77 LTPAC DISPENSE FREQUENCY C91-KK 731 - 732 X(2) 2 NCPDP 78 ADJUSTMENT REASON CODE QUALIFIER — 733 - 733 X(1) 1 CMS 79 ADJUSTMENT REASON CODE — 734 - 745 X(12) 12 CMS 80 FILLER — 746 - 1000 X(255) 255 CMS 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. 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. 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. 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. 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. BTR FIELD NO. FIELD NAME 1 RECORD ID 2 SEQUENCE NO 3 4 5 6 CONTRACT NO PBP ID DET RECORD TOTAL FILLER NCPDP FIELD — — — — — — POSITION 1-3 PICTURE X(3) LENGTH 3 NCPDP, CMS OR PDFS DEFINED PDFS 4 - 10 9(7) 7 PDFS 11 - 15 16 - 18 19 - 25 26 -1000 X(5) X(3) 9(7) X(975) 5 3 7 975 CMS CMS CMS CMS DEFINITION / VALUES "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 1-3 4-9 10 - 19 20 - 28 29 - 37 38 -1000 PICTURE X(3) X(6) X(10) 9(9) 9(9) X(963) LENGTH 3 6 10 9 9 963 NCPDP, CMS OR PDFS DEFINED PDFS CMS PDFS CMS CMS CMS DEFINITION / VALUES "TLR" Must match HDR Must match HDR Total count of BHD records Total count of DET records 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.