Procella Standard Claims Extract Fields V4.6

Written By:

Sathish

Last Edited:

2025-02-182025-02-18

Tagged:

File Format: Procella system exports the data in Tab-delimited CSV File

Export File Naming Format: <ExportDate>_<ExportTime>_<ID>_<PbmID>_CLAIM_EXTRACTION_<FromDate>_<ToDate>.csv

Example: 230922_000142_7989_CCAPBM_CLAIM_EXTRACTION_20230921_20230921.csv

FIELD #	EXTRACT FIELD NAME	DESCRIPTION	CODES/Values
1	DataFileType	Extract Format	CESTD_V04.6
2	BIN	Card Issuer ID or Bank ID Number used for network routing.
3	Processor_Control_Number	Number assigned by the processor.
4	Filler_01	For Future Use
5	Filler_02	For Future Use
6	Filler_03	For Future Use
7	Filler_04	For Future Use
8	File_Type	Code identifying whether the file contained is test or production data.	P - Production
9	Record_Indicator	Action to be taken on record	0 - New Record 1 - Overwrite Existing 2 - Delete Existing Record
10	Transaction_Response_Status	Code indicating the status of the transaction.	A - Approved D - Duplicate of Paid P - Paid R - Rejected S - Duplicate of Approved
11	Claim_Status_Code	The end status of the claim.	0 - Reject 1 - Paid 2 - Reversal 3 - Denied 4 - Duplicate of Approved
12	Claim_Type_Code	The type of claim processed	1 - POS Claim 2 – DMR
13	Transaction_Code	Code identifying the type of transaction.	B1 - Billing Transaction B2 - Reversal Transaction
14	Response_Status		A - Approved D - Duplicate of Paid P - Paid R - Rejected S - Duplicate of Approved
15	Provider Network	The Name of the Provider Network used for processing
16	Cardholder_ID	The Cardholder ID assigned to the family
17	Member_Last_Name	The Member Last Name
18	Member_First_Name	The Member First Name
19	Submitted_Date_Of_Birth_Member	The Submitted Date of Birth of the Member
20	Gender_Code	The Submitted Gender Code of the Member	U - Unknown M - Male F - Female
21	Submitted_Person_Code	The Submitted Person Code for the Member
22	Filler_06	For Future Use
23	Group_ID_Adjudicated	Group ID used for Adjudication
24	Group_ID_Submitted	Group ID submitted on the claim
25	Other_Coverage_Code	The Other Coverage Code as submitted for the Member
26	Provider_ID_Qualifier	Code qualifying the Service Provider ID	01 - NPI 02 - Blue Cross ID 03 - Blue Shield ID 04 - Medicare ID 05 - Medicaid ID 06 - UPIN 07 - NCPDP ID 08 - State License ID 09 - Tricare ID 10 - HIN 11 - Federal Tax ID 12 - DEA 13 - State Issued ID 14 - Plan Specific 15 - HCIdea ID
27	Provider_ID	The Service Provider ID of the dispensing provider.
28	Filler_07	For Future Use
29	Provider_Name	The name of the Provider
30	Provider_Address1	The Street Address of the provider
31	Provider_Address2	The Street Address of the provider
32	Provider_City	The City of the provider
33	Provider_State	The State of the Provider
34	Provider_Zip	The Zip Code of the Provider
35	Prescriber_Id_Qualifier	The Prescriber ID Qualifier	01 - NPI 02 - Blue Cross ID 03 - Blue Shield ID 04 - Medicare ID 05 - Medicaid ID 06 - UPIN 07 - NCPDP ID 08 - State License ID 09 - Tricare ID 10 - HIN 11 - Federal Tax ID 12 - DEA 13 - State Issued ID 14 - Plan Specific 15 - HCIdea ID
36	Prescriber_Id	The Submitted Prescriber ID
37	Prescriber_Last_Name	Prescriber Last Name
38	Prescriber_First_Name	Prescriber First Name
39	Service_Reference_Number_Qualifier	Indicates the type of billing submitted.	1 - Rx Billing
40	Service_Reference_Number	Reference number assigned by the provider for the dispensed drug/product and/or service provided.
41	Product_Service_Id_Qualifier	Code qualifying the value in 'Product/Service ID' (407-D7).	03 - National Drug Code
42	Product_Service_Id	ID of the product dispensed or service provided.
43	Date_Service	The date of service of the claim. Also known as the date the Provider filled the prescription for the member.
44	Date_Adjudication	The date the claim was processed adjusted to Eastern Time Zone
45	Time_Adjudicated	The UTC Time the claim was adjudicated
46	Date_Adjudication_UTC	The date the claim was processed based on Coordinated Univeral Time/Zulu
47	Quantity_Dispensed	The metric quantity dispensed for the claim.
48	Fill_Number	The code indicating whether the prescription is an original or a refill.
49	Days_Supply	Estimated number of days the prescription will last.
50	Date_Rx_Written	The date the Prescription was written by the Prescriber.
51	DAW_PSC_Code	Dispense As Written, Product Service Selection Code	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 not in Stock 5 - Substitution Allowed, Brand dispensed as Generic 6 - Override 7 - Substitution not allowed, Brand Mandated by law. 8 - Substitution Allowed, Generic Drug not available in Marketplace 9 - Substitution Allowed by Prescriber, Plan Requested Brand
52	Number_Refills_Authorized	Number of refills authorized by the prescriber.
53	Unit_Of_Measure	The Strength Unit of Measure (SUM), when combined with the Strength, represents the dosage strength as provided by the manufacturer.
54	Compound_Code	Code indicating whether or not the prescription is a compound.	1 - Not a Compound 2 - Compound
55	Reject_Code_1	NCPDP Standard Reject Code, first code	See NCPDP Reject Code listing
56	Reject_Code_2	NCPDP Standard Reject Code, second code	See NCPDP Reject Code listing
57	Reject_Code_3	NCPDP Standard Reject Code, third code	See NCPDP Reject Code listing
58	Reject_Code_4	NCPDP Standard Reject Code, forth code	See NCPDP Reject Code listing
59	Reject_Code_5	NCPDP Standard Reject Code, fifth code	See NCPDP Reject Code listing
60	Drug_Name	The Drug Name for the dispensed product
61	Generic_Name	The Generic Name of the drug dispensed
62	Multi_Source_Code	The Multi-Source Code identifies drug products as either single- or multiple-source original drug products or a generic copy of the standard drug product.	N - Single Source Product M - Single-Source, co-licensed product O - Multi-source, originator product Y - Multi Source Product
63	Maintenance_Drug_Indicator	The Maintenance Drug Code indicates whether or not the drug is considered a maintenance drug.	0 - Undetermined 1 - Not a Maintenance Drug 2 - Maintenance Drug
64	Third_Party_Restriction_Code	The Third-Party Restriction Code can be used by Third Party Administrators (TPAs) for identifying drug products for formulary exclusion (such as oral contraceptives) or inclusion (for example, vitamins).	1 - Insulin 2 - Oral Contraceptives 3 - Surgical Supply/Medical Device/Ostomy 4 - Blood Component 5 - Diagnostic Agent 6 - General Anesthetic 7 - Fertility Drugs 8 - Anorexic, Anti-obesity 9 - Multiple Vitamin A - Used for HIV Infection B - Bulk Chemicals C - Cosmetic Alteration Drugs D - Antidepressants F - Multiple Vitamin with Fluoride G - Growth Hormones/Biosynthetic Hormones H - Hypnotics/Sedatives I - Multiple Vitamin with Iron J - Digital Therapy K - Non Oral Systemic Contraceptives L - Contraceptives Other M - Immunosuppressants P - Antipsychotics S - Smoking Deterrents T - Antianxiety Agents V - Impotence and (HSDD) Agents
65	DEA_Class_Code	The DEA Class Code identifies federally controlled substances classified by the Drug Enforcement Administration (DEA).	1 - No accepted Medical use 2 - High Abuse, Severe Dependence liability 3 - Moderate dependence Liability 4 - Limited abuse Potential 5 - Limited abuse Potential, small amounts
66	Rx_Otc_Indicator_Code	The RX-OTC Indicator Code indicates federal prescription (Rx) or Over-the-Counter (OTC) status.	O - OTC, Single Source P - OTC, Multiple Source R - Rx, Single Source S - Rx, Multiple Source
67	Generic_Product_Indicator	The Medispan Generic Product Identifier (GPI) categorizes drug products by a hierarchical therapeutic classification scheme.
68	Formulary_Status_Code	The Status code for the drug dispensed on the Formulary	1 - No Formulary on plan 2 - Formulary, Open 3 - Formulary, Closed 4 - Non-Formulary
69	Formulary_Compliance_Code	The compliance code for the drug on the Formulary. This reflects the Formulary and Preferred Drug status of the product dispensed.	F - Formulary, No Preferred Drug FP - Formulary, Preferred Drug FN - Formulary, Non-Preferred Drug NF - Non-Formulary, No Preferred Drug NP - Non-Formulary, Preferred Drug NN - Non-Formulary, Non-Preferred Drug 1X - No Formulary, No Preferred Drug 1P - No Formulary, Preferred Drug 1N - No Formulary, Non-Preferred Drug
70	Preferred_Drug_Status_Code	The Preferred Drug Tier for the dispensed drug.	NP - Non-Preferred Drug XP - No Preferred Drugs P1 - Preferred Drug Tier 1 P2 - Preferred Drug Tier 2 P3 - Preferred Drug Tier 3 P4 - Preferred Drug Tier 4 P5 - Preferred Drug Tier 5 P6 - Preferred Drug Tier 6 P7 - Preferred Drug Tier 7 P8 - Preferred Drug Tier 8 P9 - Preferred Drug Tier 9
71	Usual_And_Customary	Amount charged cash customers for the prescription exclusive of sales tax or other amounts claimed.
72	Gross_Amount_Due	The Submitted Gross Amount Due value as submitted by the provider.
73	Filler_10	For Future Use
74	Ingredient_Cost_Paid	The contracted ingredient cost paid to the Provider
75	Dispensing_Fee_Paid_Provider	The dispensing fee paid to the Provider
76	Amount_Attributed_To_Tax	Amount to be collected that is attributable to tax.
77	Patient_Pay_Amount	The total amount the Patient Pays towards the claim.
78	Amount_Of_Copay	Amount to be collected from the patient that is due to a per prescription coinsurance/copay.
79	Basis_Of_Cost	The cost basis used for the reimbursement determination	1 - SBM Ingredient 2 - AWP 3 - Ingr Reduced to AWP less X% 4 - U&C 5 - Paid Lower of U&C/Contract 6 - MAC Pricing Ingredient Cost Paid 7 - MAC Pricing Ingredietn reduced to MAC 8 - Contract Price 9 - Acquisition Price 10 - Average Sales Price 11 - Average Manufacturer Price 12 - 340B/Disproportionate Share Pricing 13 - Wholesale Acquisition Price 14 - Ohter Payer-Patient Responsibility Amount 15 - Patient Pay Amount 16 - Coupon Payment 17 - Special Patient Reimbursement 18 - Direct Price 19 - State Fee Schedule 20 - National Average Drug Acquisition Cost 21 - State Average Acquisition Cost 22 - Ingredient Cost Paid based on Submitted Basis of Cost of Free Product
80	Brand_Class	The Brand Class of the drug
81	Brand_Name_Code	The Brand Name Code indicates the type of name used in the Drug Name	T - Trademarked Name B - Branded Generic Name G - Generic Name
82	AWP_Total_Cost	The Total AWP before discount for the quantity dispensed.
83	Net_Amount_Due	The Net Amount Due (Total Rx Cost less Patient Pay)
84	Transaction_Id_Cross_Reference	The Procella Internal Transaction ID of the referenced claim. This is typically null, present only when the claim has been reversed. The Transaction ID Cross Reference on a REVERSED claim will be the Transaction ID of the associated PAID claim. The Transaction ID Cross Reference on a PAID claim will be the Transaction ID of the associated REVERSED claim.
85	Transaction_Id	The Procella Internal Unique Transaction ID assigned to the claim
86	SBM_Authorization_Number	Number submitted by the provider to identify the prior authorization.
87	Program_Admin_Fee_Amount	The final amount of the applied Program Administration Fee that is the member responsibility.
88	Program_Admin_Fee_Status	Indicates if the Program Admin Fee was a full fee or a partial fee.
89	Brand_Class_Final	The Brand class of the drug after processing rules.
90	Plan_ID	The Plan ID used for claim processing.
91	Plan_Name	The Name of the Plan.

Procella Standard Claims Extract Fields V4.6

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