PDE Outbound File Layout

Status: Original and derived artifacts are available for this document.

Download: xlsx | pdf | html

FIELD NO.
1
2
3
4
5
6
7
8
9

FIELD NAME
RECORD ID
SUBMITTER ID
FILE ID
TRANS DATE
PROD TEST CERT IND
DDPS SYSTEM DATE
DDPS SYSTEM TIME
DDPS REPORT ID

POSITION
1-3
4-9
10-19
20-27
28-31
32-39
40-45
46-50

PICTURE
X(3)
X(6)
X(10)
9(8)
X(4)
9(8)
9(6)
X(5)

LENGTH
3
6
10
8
4
8
6
5

FILLER

51-1000

X(950)

950

DEFINITION / VALUES
"HDR"
Unique ID assigned by CMS.
Unique ID provided by Submitter.
Date of file transmission to PDFS.
PROD, TEST, TS1K, CERT, or CT1K
CCYYMMDD = DDPS file creation date
HHMMSS = DDPS file creation time
DDPS report identifier (Always '01').
Field is right-padded with spaces.
SPACES

FIELD NO.
1
2
3
4

FIELD NAME
RECORD ID
SEQUENCE NO
CONTRACT NO
PBP ID

POSITION
1-3
4-10
11-15
16-18

PICTURE
X(3)
9(7)
X(5)
X(3)

LENGTH
3
7
5
3

5
6
7

DDPS SYSTEM DATE
DDPS SYSTEM TIME
DDPS REPORT ID

19-26
27-32
33-37

9(8)
9(6)
X(5)

8
6
5

8

FILLER

38-1000

X(963)

963

DEFINITION / VALUES
"BHD"
Must start with 0000001
Contract Number from submitted batch
Plan Benefit Package (PBP) ID from
submitted batch
CCYYMMDD = DDPS file creation date
HHMMSS = DDPS file creation time
DDPS report identifier (Always '01'). Field
is right-padded with spaces.
SPACES

FIELD NO.

FIELD NAME

POSITION

PICTURE

LENGTH

1
2

RECORD ID
SEQUENCE NO

1-3
4 - 10

X(3)
9(7)

3
7

3

CLAIM CONTROL NUMBER

11 - 50

X(40)

40

4

MEDICARE BENEFICIARY
IDENTIFIER

51 - 70

X(20)

20

5

CARDHOLDER ID

71 - 90

X(20)

20

6

PATIENT DATE OF BIRTH
(DOB)

91 - 98

9(8)

8

7

PATIENT GENDER CODE

99 - 99

9(1)

1

8

DATE OF SERVICE (DOS)

100 - 107

9(8)

8

9

PAID DATE

108 - 115

9(8)

8

10

PRESCRIPTION SERVICE
REFERENCE NO

116 - 127

9(12)

12

11

PRODUCT SERVICE ID

128 - 167

X(40)

40

12

FILLER

168 - 197

X(30)

30

13

SERVICE PROVIDER ID
QUALIFIER

198 - 199

X(2)

2

14

SERVICE PROVIDER ID

200 - 214

X(15)

15

15

FILL NUMBER

215 - 216

9(2)

2

16

FILLER

217 - 217

X(1)

1

17

COMPOUND CODE

218 - 218

9(1)

1

18

DISPENSE AS WRITTEN (DAW)
PRODUCT SELECTION CODE

219 - 219

X(1)

1

19

ORIGINALLY PRESCRIBED
QUANTITY

220 - 229

9(7)V999

10

20

QUANTITY DISPENSED

230 - 239

9(7)V999

10

21

FILLER

240 - 242

X(3)

3

22

DAYS SUPPLY

243 - 245

9(3)

3

23

PRESCRIBER ID QUALIFIER

246 - 247

X(2)

2

24

PRESCRIBER ID

248 - 282

X(35)

35

25

DRUG COVERAGE STATUS
CODE

283 - 283

X(1)

1

26

ADJUSTMENT DELETION CODE

284 - 284

X(1)

1

27

NON- STANDARD FORMAT
CODE

285 - 285

X(1)

1

28

PRICING EXCEPTION CODE

286 - 286

X(1)

1

29

PART D MODEL INDICATOR

287 - 288

X(2)

2

30

MEDICARE PRESCRIPTION
PAYMENT PLAN INDICATOR

289 - 289

X(1)

1

31

FILLER

290 - 314

X(25)

25

32

CATASTROPHIC COVERAGE
CODE

315 - 315

X(1)

1

33

INGREDIENT COST PAID

316 - 326

S9(9)V99

11

34

DISPENSING FEE PAID

327 - 337

S9(9)V99

11

35

TOTAL AMOUNT ATTRIBUTED
TO SALES TAX

338 - 348

S9(9)V99

11

36

ESTIMATED REMUNERATION
AT POS AMOUNT (ERPOSA)

349 - 359

S9(9)V99

11

37

PHARMACY PRICE
CONCESSIONS AT POS

360 - 370

S9(9)V99

11

38

VACCINE ADMINISTRATION
FEE OR ADDITIONAL
DISPENSING FEE

371 - 381

S9(9)V99

11

39

FILLER

382 - 436

X(55)

55

40

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

437 - 447

S9(9)V99

11

41

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

448 - 458

S9(9)V99

11

42

PATIENT PAY AMOUNT

459 - 469

S9(9)V99

11

43

OTHER TROOP AMOUNT

470 - 480

S9(9)V99

11

44

LOW INCOME COST SHARING
SUBSIDY AMOUNT (LICS)

481 - 491

S9(9)V99

11

492 - 502

S9(9)V99

11

503 - 513

S9(9)V99

11

514 - 524

S9(9)V99

11

45
46
47

PATIENT LIABILITY REDUCTION
DUE TO OTHER PAYER
AMOUNT (PLRO)
COVERED D PLAN PAID
AMOUNT (CPP)
NON COVERED PLAN PAID
AMOUNT (NPP)

48

SELECTED DRUG SUBSIDY

525 - 535

S9(9)V99

11

49

REPORTED MANUFACTURER
DISCOUNT

536 - 546

S9(9)V99

11

50

REPORTED GAP DISCOUNT

547 - 557

S9(9)V99

11

51

FILLER
TOTAL GROSS COVERED DRUG
COST ACCUMULATOR

558 - 623

X(66)

66

624 - 634

S9(9)V99

11

FILLER
TRUE OUT-OF-POCKET
ACCUMULATOR
FILLER

635 - 636

X(2)

2

637 - 647

S9(9)V99

11

648 -660

X(13)

13

52
53
54
55

56

OTHER TROOP AMOUNT
INDICATOR

661 - 661

X(1)

1

57

BEGINNING BENEFIT PHASE

662 - 662

X(1)

1

58

ENDING BENEFIT PHASE

663 - 663

X(1)

1

59

PRESCRIPTION ORIGIN CODE

664 - 664

X(1)

1

665 - 672

9(8)

8

673 - 698

X(26)

26

60
61

DATE ORIGINAL CLAIM
RECEIVED
CLAIM ADJUDICATION BEGAN
TIMESTAMP

62

BRAND/GENERIC CODE

699 - 699

X(1)

1

63

TIER

700 - 700

X(1)

1

64

FORMULARY CODE

701 - 701

X(1)

1

65

PHARMACY SERVICE TYPE

702 - 703

X(2)

2

66

PATIENT RESIDENCE

704 - 705

X(2)

2

67

SUBMISSION TYPE CODE 1

706 - 707

X(2)

2

68

SUBMISSION TYPE CODE 2

708 - 709

X(2)

2

69

SUBMISSION TYPE CODE 3

710 - 711

X(2)

2

70

SUBMISSION TYPE CODE 4

712 - 713

X(2)

2

71

SUBMISSION TYPE CODE 5

714 - 715

X(2)

2

72

SUBMISSION CLARIFICATION
CODE 1

716 - 718

X(3)

3

73

SUBMISSION CLARIFICATION
CODE 2

719 - 721

X(3)

3

74

SUBMISSION CLARIFICATION
CODE 3

722 - 724

X(3)

3

75

SUBMISSION CLARIFICATION
CODE 4

725 - 727

X(3)

3

76

SUBMISSION CLARIFICATION
CODE 5

728 - 730

X(3)

3

77

LTPAC DISPENSE FREQUENCY

731 - 732

X(2)

2

78

ADJUSTMENT REASON CODE
QUALIFIER

733 - 733

X(1)

1

79

ADJUSTMENT REASON CODE

734 - 745

X(12)

12

80

FILLER
CMS CALCULATED GAP
DISCOUNT
CMS CALCULATED
MANUFACTURER DISCOUNT
APPLICABLE DISCOUNT
PERCENTAGE FOR SPECIFIED
SMALL MANUFACTURER
DRUGS

746 - 829

X(84)

84

830 - 840

S9(9)V99

11

841 - 851

S9(9)V99

11

852 - 853

X(2)

2

84

APPLICABLE DISCOUNT
PERCENTAGE FOR SPECIFIED
MANUFACTURER DRUGS
DISPENSED TO LIS
BENEFICIARIES

854 - 855

X(2)

2

85

FILLER

856 - 895

X(40)

40

86

ALTERNATE SERVICE
PROVIDER ID QUALIFIER

896 - 897

X(2)

2

87

ALTERNATE SERVICE
PROVIDER ID

898 - 912

X(15)

15

81
82

83

90

ORIGINAL SUBMITTING
CONTRACT
CORRECTED MEDICARE
BENEFICIARY IDENTIFIER
P2P CONTRACT OF RECORD

91

PBP OF RECORD

943 - 945

X(3)

3

92
93
94
95
96
97
98
99
100
101
102
103
104

ERROR COUNT
ERROR 1
ERROR 2
ERROR 3
ERROR 4
ERROR 5
ERROR 6
ERROR 7
ERROR 8
ERROR 9
ERROR 10
EXCLUSION REASON CODE
FILLER

946 - 947
948 - 950
951 - 953
954 - 956
957 - 959
960 - 962
963 - 965
966 - 968
969 - 971
972 - 974
975 - 977
978 - 980
981 - 1000

9(2)
X(3)
X(3)
X(3)
X(3)
X(3)
X(3)
X(3)
X(3)
X(3)
X(3)
X(3)
X(20)

2
3
3
3
3
3
3
3
3
3
3
3
20

88
89

913 - 917

X(5)

5

918 - 937

X(20)

20

938 - 942

X(5)

5

DEFINITION / VALUES

"ACC", "REJ", or "INF"
Must start with 0000001
A number assigned by the plan to identify the prescription drug event. This is an optional field.
*non-numeric values should be left justified.
Medicare Health Insurance Claim Number (HICN) or Railroad Retirement Board (RRB) number or Medicare Beneficiary Identifi

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
reject the following billing codes for compounded legend and/or scheduled drugs with a value of:
99999999999, 99999999992, 99999999993, 99999999994, 99999999995, or 99999999996.

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 =
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
Facilitation Contract. When Plans report Federal Tax Number (TIN), use the following format: ex: 999999999 (do not report em
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
contain the originally prescribed quantity. Must be zero for DOS < 01/01/2025, or for non-Schedule II PDEs.

Number of Units, Grams, Milliliters, other. If compounded item, total of all ingredients will be supplied as Quantity Dispensed;
quantity in the unit form of the final state of the resulting compound.
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 p
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
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
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 participa
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 le
fees may be charged for compounding/mixing multiple drugs. Do not include administrative fees. Vaccine Administration Fee o
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 repo
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 co
the plan sponsor is required to apply, or has elected to apply, to the negotiated price as a reduction in the drug price made ava
beneficiary at the point of sale (POS). This estimate includes the rebate or other price concession amount that the plan sponso
receive from a pharmaceutical manufacturer or other non-pharmacy entity and has elected to apply to the negotiated price. T
does not include pharmacy price concessions applied at the point of sale, which must be reported in the “Pharmacy Price Conc
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 conting
or adjustments that the plan sponsor might receive from a network pharmacy that would serve to decrease the total amount t
sponsor pays for the drug, i.e., all pharmacy price concessions. This estimate must also reflect the rebate or other price conces
that the plan sponsor expects to receive from a pharmaceutical manufacturer or other non-pharmacy entity and has elected to
negotiated price.

For PDEs with a DOS < 01/01/2024, this field must contain the estimated amount of rebates and/or other price concessions th
sponsor is required to apply, or has elected to apply, to the negotiated price as a reduction in the drug price made available to
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 fi
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
sponsor might receive from a network pharmacy that would serve to decrease the total amount that the plan sponsor pays for
all pharmacy price concessions. All other estimated remuneration applied at the POS must be reported in the “Estimated Rem
POS Amount (ERPOSA)” field. This field must contain a positive dollar amount, or zero dollars when there is no price concessio
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 repo
there is a vaccine administration fee or additional Emergency Use Authorization (EUA) dispensing fee charged. For PDEs with a
01/01/2008, this field must be zero. This field may also include amounts of additional dispensing fees paid for EUA oral antivira
procured by the U.S. Government, over and above what was reported in the “Dispensing Fee Paid” field.
SPACES
Reports covered drug cost at or below the out of pocket threshold. Any remaining portion of covered drug cost is reported in
Covered drug cost is the sum of Ingredient Cost Paid + Dispensing Fee Paid + Total Amount Attributed to Sales Tax + Vaccine A
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 Cos
Dispensing Fee Paid + Total Amount Attributed to Sales Tax + Vaccine Administration Fee or Additional Dispensing Fee. When
Catastrophic Coverage Code = A, this field equals the portion of Ingredient Cost Paid + Dispensing Fee Paid + Total Amount Att
Tax + Vaccine Administration Fee or Additional Dispensing Fee falling at or below the OOP threshold. Any remaining portion is
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
drug cost is the sum of Ingredient Cost Paid + Dispensing Fee Paid + Total Amount Attributed to Sales Tax + Vaccine Administra
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
Fee Paid + Total Amount Attributed to Sales Tax + Vaccine Administration Fee or Additional Dispensing Fee above the OOP thre
the Catastrophic Coverage Code = A, this field equals the portion of Ingredient Cost Paid + Dispensing Fee Paid + Total Amount
Sales Tax + Vaccine Administration Fee or Additional Dispensing Fee falling above the OOP threshold. Any remaining portion is
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 (TrO
Accumulator amount.

Other health insurance payments by TrOOP-eligible other payers (e.g., SPAPs). This field records all third-party payments that
a beneficiary’s TrOOP except LICS, Patient Pay Amount, and the Reported Gap Discount (for PDEs with a DOS < 01/01/2025)
increments the True Out-of-Pocket Accumulator amount. For PDEs with a DOS >= 01/01/2023 and DOS <= 12/31/2023, this fie
the Inflation Reduction Act Subsidy Amount (IRASA). When this field contains IRASA, the Other TrOOP Amount Indicator field m
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 Ac
amount.

Amount by which patient liability is reduced due to payment by other payers that are not TrOOP-eligible and do not participat

The net Medicare covered amount which the plan has paid for a Part D covered drug under the Basic benefit. Amounts paid fo
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 amoun
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
Drug in the Initial Coverage Period. This field must contain a positive dollar amount, or zero dollars when there is no Selecte
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
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 M
Discount for applicable drugs. On PDEs with a DOS < 01/01/2025, must be zero. This amount will not increment the True Out-o
Accumulator amount.
The reported amount that the plan sponsor advanced at point of sale for the Gap Discount for applicable drugs. Required on P
>= 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
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
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 PD
>= 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 Infla
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 w
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
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
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
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
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 b
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. O
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 o
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 o

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
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 pa
* 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 SPACE
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
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 pa
* 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 SPACE
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
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 pa
* 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 SPACE
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
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 pa
* 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 SPACE
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
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 pa
* 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 SPACE
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 va
SPACES
1 = Medication dispensed in a day-supply increment equal to the billed days supply (for example: medication dispensed for a 3
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 valu
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
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 >= 0
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
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
be accepted.

The Adjustment Reason Codes of CIO, DISPUTE or APPEAL, and For Future use at CMS' direction have been removed from the
values for PDEs with a DOS >= 01/01/2025, and will not be accepted.
SPACES
For PDEs with a DOS >= 01/01/2011 and a DOS <= 12/31/2024, the Gap Discount Amount calculated by CMS during on-line PD
on data reported in the PDE.
For PDEs with a DOS >= 01/01/2025, the Manufacturer Discount Amount calculated by CMS during on-line PDE editing based o
reported on the PDE.
For PDEs with a DOS >= 01/01/2025, the phased-in Manufacturer Discount percentage that applies for the benefit year of the
specified small manufacturer drugs, as provided by the statute.

For PDEs with a DOS >= 01/01/2025, the phased-in Manufacturer Discount percentage that applies for the benefit year of the
specified manufacturer drugs dispensed to Low Income Subsidy (LIS) eligible beneficiaries, as provided by the statute.

SPACES
The Alternate Service Provider ID Qualifier cross-referenced by CMS to the Service Provider ID submitted on the PDE. Valid val
01 = NPI (if the Service Provider ID Qualifier submitted on PDE = 07)
07 = NCPDP Provider ID (if the Service Provider ID Qualifier submitted on PDE = 01)
The Alternate Service Provider ID cross-referenced by CMS to the Service Provider ID submitted on the PDE. Corresponds to th
Service Provider ID Qualifier.

Contract that submitted the previously accepted PDE (in conjunction with edit 784).

Populated with Medicare Beneficiary Identifier (MBI) if HICN was received on PDE submission file or the beneficiary MBI has ch
according to CMS records.
Contract of Record for accepted P2P PDEs
PBP of Record assigned by CMS during P2P Update Process. Returned only when the PBP of Record changes from the time the
processed and accepted by CMS.
Count of errors encountered during processing
First error encountered during processing
Second error encountered during processing
Third error encountered during processing
Fourth error encountered during processing
Fifth error encountered during processing
Sixth error encountered during processing
Seventh error encountered during processing
Eighth error encountered during processing
Ninth error encountered during processing
Tenth error encountered during processing
Subcategory reject code for an NDC Error Code of 738 identified in Errors 1-10.
SPACES

FIELD NO.
1
2
3
4
5
6

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

POSITION
1-3
4-9
10-19
20-28
29-37
38-46

PICTURE
X(3)
X(6)
X(10)
9(9)
9(9)
9(9)

LENGTH
3
6
10
9
9
9

7

TLR DET INFORMATIONAL RECORD TOTAL

47-55

9(9)

9

8

TLR DET REJECTED RECORD TOTAL

56-64

9(9)

9

9

FILLER

65-1000

X(936)

936

DEFINITION / VALUES
"TLR"
Must match HDR
Must match HDR
Total count of BHD records
Total count of DET records
Total count of ACC records as
determined by DDPS processing
Total count of INF records as
determined by DDPS processing
Total count of REJ records as
determined by DDPS processing
SPACES

FIELD NO.
1
2

FIELD NAME
RECORD ID
SEQUENCE NO

POSITION
1-3
4-10

PICTURE
X(3)
9(7)

LENGTH
3
7

3
4
5
6

CONTRACT NO
PBP ID
DET RECORD TOTAL
DET ACCEPTED RECORD TOTAL

11-15
16-18
19-25
26-32

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

5
3
7
7

7

DET INFORMATIONAL RECORD TOTAL

33-39

9(7)

7

8

DET REJECTED RECORD TOTAL

40-46

9(7)

7

9

FILLER

47-1000

X(954)

954

DEFINITION / VALUES
"BTR"
Must match BHD. Must start
with 0000001.
Must match BHD
Must match BHD
Total count of DET records
Total count of ACC records as
determined by DDPS processing
Total count of INF records as
determined by DDPS processing
Total count of REJ records as
determined by DDPS processing
SPACES