PROCELLA HEALTH

Claim Processing System

Provider Load Format Manual

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Copyright 2023 by Procella Processing Platform LLC.

Table of Contents

Provider Loads

Data File Types

File Processing Actions

Data Layouts

  Primary Provider

  Provider Alias

  Provider Services

  Provider Contacts/Demographics

  Provider E-Prescribe

  Provider Group

  Provider Group Membership

Codes and References

  Dispensing Class Code

  Provider Type Code

  Deactivation Code

  Reinstatement Code

  Hours of Operation

  Provider Services Codes

  ePrescribing Service Level Codes

  Address/Contact Type

Data File Formatting

File Naming

Provider Loads

The Provider Loads manual will provide the layout for loading Provider/Pharmacy data into the Procella processing system.  Various data elements for the Provider load are available to load.  There are 2 required data files, Primary Provider and Provider Alias.  Below is the full list of loads currently supported:

Data File Types

There are multiple files associated with the loading of the Providers into the System.  Only one data file, Primary Provider, is required.  Below are the files supported for importing Provider Data.

• Primary Provider: This data set includes the critical elements of the Provider necessary for standard claims processing.  This file contains the base Service Provider IDs, the physical location of the Provider, Primary contact information and similar information.
• Provider Alias:  This data set includes the additional Service Provider ID's associated with the Provider.  This may include State License and Medicaid ID's.
• Provider Services:  This data set reflects the basic services available by the Provider.
• Provider Contact:  This data set includes the specific contact information for the Provider.
• Provider Demographics:  This data set provides the demographic and contact information for the Provider.
• Provider ePrescribe:  This data set reflects the ePrescribing capabilities of the Provider.
• Provider Group:  This is the Chain/Relationship level reflected in typical NCPDP nomenclature.  A Provider Group is simply a grouping of Providers, typically used for Provider Networks.  The Provider Group record is the general information for the Group.
• Provider Group Membership:  This reflects the individual providers that are associated with a Provider Group.

File Processing Actions

For all types of files provided, the following actions will occur.

• All record adds, changes, terminations, failures, rejections, suspensions, etc will be provided on an appropriate report for UX review by the Client.
• All data file records will be compared against the ACTIVE records in the Provider Group and the Provider Group Membership
• if the Provider Group ID provided on the data file is not found in the Provider Group record, all records associated the Provider Group ID in the data file will be treated as a failure, no Provider Group record found.
• if the Provider record submitted on the data file is not a registered Provider within the Provider table in the database, the record will be treated as a failure.
• if a Provider is present twice within the same Provider Group using the same Service Provider ID/Service Provider ID Qualifier, both records will be consider failed due to duplicate record.  
• if a Provider is present twice within the same Provider Group using two separate Service Provider ID/Service Provider ID Qualifier (which identify the same Provider), both records will be considered failed as duplicate provider record. 
• If the Begin Date of the Provider Group record in the data file is before the Begin Date of the Provider Group record in the database, reject the record with the error, invalid record effective date (Begin Date is before Provider Group Begin Date).
• If the Begin Date of the Provider Membership record is after the Provider Group End Date, reject the record as invalid record Begin Date (Begin Date is after Provider Group End Date).
• If the Provider Membership record End Date is before the Provider Membership Begin Date, reject the record as invalid record End Date (End Date is before Begin Date).

Data Layouts

The following are the various data layouts for each type of file.  Do not use commas in the Legal Business Name or Name fields.

 

Primary Provider

Data File Reference:  PROVIDER_PRIMARY

Field #	Field Name	File Column Name	Format	Size	REQ/ OPT	Description
1	Action Code	ActionCode	A/N	1	R	“A” = Add “D” = Terminate “C” = Change
2	Processor Provider ID	ProcessorProviderID	A/N	20	R	This is the PBM's Internal Service Provider ID.  While this may be a standard industry identifier, it will be mapped to a non-industry Qualifier Code.  This ID will be needed for loading the ancillary data specific to this Provider.
3	NCPDP Provider ID	NCPDPProvId	A/N	7	R	The NCPDP number of the provider.
4	Legal Business Name	LegalBusinessName	A/N	60	O	The legal name of the entity, as it appears on the official federal tax ID document provided by the IRS.
5	Name	Name	A/N	60	R	The DBA (Doing Business As) name of the provider.
6	Doctor’s Name	DoctorName	A/N	60	S	The name of the doctor dispensing at the alternate dispensing site.
7	Store Number	StoreNumber	A/N	10	S	The store number (usually assigned by parent company) associated with the provider.
8	Physical Location Address 1	PhysicalAddress1	A/N	55	R	The physical location of the store and first line of the address.
9	Physical Location Address 2	PhysicalAddress2	A/N	55	O	The physical location and second address line.
10	Physical Location City	PhysicalCity	A/N	30	R	Physical location city of provider.
11	Physical Location State Code	PhysicalState	A/N	2	R	The two-digit state code.
12	Physical Location Zip Code	PhysicalZip	A/N	9	R	This field identifies the 5 or 9-digit zip code of the provider, less dash marks.
13	Physical Location Phone Number	PhysicalPhoneNumber	A/N	10	O	The physical site phone number.
14	Physical Location Extension	PhysicalExtension	A/N	5	O	The physical site phone extension.
15	Physical Location FAX	PhysicalFax	A/N	10	O	The physical site FAX number.
16	Physical Location E-Mail Address	PhysicalEmail	A/N	50	O	E-mail address of pharmacy.
17	Physical Location Cross Street or Directions	CrossStreets	A/N	50	O	Text stating cross street or directions for physical location of provider.
18	Physical Location County/Parish	LocationCountyParish	A/N	5	O	Code for County or Parish (FIPS-Federal Information Processing Standards). The County FIPS code is a 5-digit numeric field containing a unique numeric identification assigned to that county by the US government. The County FIPS code field and the County Name field identify the “most prevalent” county for the 5-digit ZIP code listed in a given record. Codes can be viewed at http://www.itl.nist.gov/fipspubs/co-codes/states.txt.
19	Physical Location MSA	LocationMSA	A/N	4	O	The MSA field contains the Metropolitan Statistical Area code, if any, in which some or all of the ZIP code lies. The MSA is a 4-digit FIPS code assigned by the White House’s Office of Management and Budget.
20	Physical Location PMSA	LocationPMSA	A/N	4	O	The PMSA field contains the Primary Metropolitan Statistical Area code, if any, in which some or all of the ZIP code lies. The PMSA is a 4-digit FIPS code assigned by the White House’s Office of Management and Budget. More info on these two fields is available at http://www.itl.nist.gov/fipspubs/fip8-6-0.htm
21	Physical Location 24 Hour Operation Flag	Physical24hr	A/N	1	O	This field indicates whether this provider operates 24 hours a day. “Y” = Yes “N” = No See “Appendix D. Hours of Operation”.
22	Physical Location Provider Hours	PhysicalHourOper	A/N	35	O	Operating hours in seven segments (DOOCC). D = Day of the Week (Sunday = 1, Saturday = 7) OO = Open (9am = 09) CC = Close (9:30pm = 46) Additional information on the times is provided below.
23	Physical Location Congressional Voting District	VotingDistrict	A/N	4	O	Congressional voting district code.
24	Physical Location Language Code 1	LanguageCode1	A/N	2	O	Language Spoken Code (ISO 639-1 codes). See section “Appendix B. ISO 639-1 Language Codes” for list of values.
25	Physical Location Language Code 2	LanguageCode2	A/N	2	O	Language Spoken Code (ISO 639-1 codes). See section “Appendix B. ISO 639-1 Language Codes” for list of values.
26	Physical Location Language Code 3	LanguageCode3	A/N	2	O	Language Spoken Code (ISO 639-1 codes). See section “Appendix B. ISO 639-1 Language Codes” for list of values.
27	Physical Location Language Code 4	LanguageCode4	A/N	2	O	Language Spoken Code (ISO 639-1 codes). See section “Appendix B. ISO 639-1 Language Codes” for list of values.
28	Physical Location Language Code 5	LanguageCode5	A/N	2	O	Language Spoken Code (ISO 639-1 codes). See section “Appendix B. ISO 639-1 Language Codes” for list of values.
29	Physical Location Store Open Date	StoreOpen	D	8	O	Date of store opening. Zeroes if unknown.
30	Physical Location Store Closure Date	StoreClosure	D	8	O	Last business day of the site. This is a through date.  Store is considered closed on the day after the Physical Location Store Closure Date. Zeroes if not closed.
31	Mailing Address 1	MailAddress1	A/N	55	O	The first line of the mailing address.
32	Mailing Address 2	MailAddress2	A/N	55	O	The second line of the mailing address.
33	Mailing Address City	MailCity	A/N	30	O	The mailing address city.
34	Mailing Address State Code	MailState	A/N	2	O	The mailing address two-digit state code.
35	Mailing Address ZIP Code	MailZip	A/N	9	O	This field identifies the 5- or 9-digit zip code of the mailing address, less dash marks.  SPLIT ZIP
36	Contact Last Name	ContactLast	A/N	35	O	Last name of primary contact person.
37	Contact First Name	ContactFirst	A/N	35	O	First name of primary contact person.
38	Contact Middle Initial	ContactMI	A/N	1	O	Middle initial of primary contact person.
39	Contact Title	ContactTitle	A/N	30	O	Title of primary contact person.
40	Contact Phone Number	ContactTelephone	A/N	10	O	The provider’s phone number including area code.
41	Contact Extension	ContactExt	A/N	5	O	The site phone extension.
42	Contact E-mail Address	ContactEmail	A/N	50	O	E-mail address of contact.
43	Dispenser Class Code	DispClassCode	A/N	2	O	The class code associated with this provider.
44	Primary Provider Type Code	PrimProvTypeCode	A/N	2	O	This field contains the provider’s Provider type code.  Blanks are not allowed.
45	Secondary Provider Type Code	SecProvTypeCode	A/N	2	O	This field contains the provider’s Provider type code. blanks = none/not specified or not applicable in this field (provider does not specify a secondary type)
46	Tertiary Provider Type Code	TertProvTypeCode	A/N	2	O	This field contains the provider’s dispenser type code. blanks = none/not specified or not applicable in this field (provider does not specify a tertiary type)
47	Medicare Provider (supplier) ID	MCareProvId	A/N	10	O	The National Supplier Clearinghouse (NSC) is the organizational entity contracted by the Centers for Medicare & Medicaid Services (CMS) to issue Medicare billing privileges to suppliers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) and to maintain a supplier file that contains information collected via the CMS 855S enrollment form.
48	National Provider ID (NPI)	NPI	A/N	10	O	The standard unique health identifier for health care providers to use in filing and processing health care claims and other transactions. At the pharmacy or alternate dispensing site level.
49	DEA Registration ID	DEA	A/N	12	O	This field contains the Drug Enforcement Administration (DEA) Number of the provider. Formerly called the Federal License Number on this file.
50	DEA Expiration Date	DeaExp	D	8	O	The date the Drug Enforcement Administration (DEA) requires the federal license be renewed by. See section “DEA Expiration Dates” for more information.
51	Federal Tax ID Number	FederalTaxID	A/N	15	O	This field contains the Federal Tax ID number of the provider. Also known as EIN or TIN.
52	State Income Tax ID Number	StateTaxID	A/N	15	O	This field contains the State Income Tax ID of the provider.
53	Deactivation Code	DeactivationCode	A/N	2	S	Code representing the reason for deactivation of the record.
54	Reinstatement Code	ReInstatementCode	A/N	2	S	Code representing the reason for reactivation of the record.
55	Reinstatement Date	ReInstatementDate	D	8	S	Date the reinstatement of the record occurs.
56	Begin Date	BeginDate	D	8	R	The date (CCYYMMDD) which the Service Provider record is effective.
57	End Date	EndDate	D	8	R	The through date (CCYYMMDD) which the Service Provider record is effective.

Provider Alias

 Data File Reference:  PROVIDER_ALIAS

Field #	Field Name	File Column Name	Format	Size	REQ/OPT	Description
1	Action Code	ActionCode	A/N	1	R	“A” = Add “D” = Terminate “C” = Change
2	Processor Provider ID	ProcessorProviderId	A/N	20	R	This is the PBM's Internal Service Provider ID and is the same as is registered in the Primary Provider data source.
3	Service Provider ID	ServiceProviderId	A/N	20	R	This is the Service Provider ID you are registering in the system for the Provider.
4	Service Provider ID Qualifier	ServiceProviderIdQual	A/N	2	R	These should be listed in the Standard NCPDP Service Provider ID Qualifier
5	Service Provider ID State	ServiceProviderIdState	A/N	2	S	The State which the Service Provider ID is registered/licensed.  This will be left blank for Service Provider ID's that are NOT State specific.
6	Deactivation Code	DeactivationCode	A/N	2	S	The cause for deactivation of the Service Provider ID
7	Reactivation Code	ReactivationCode	A/N	2	S	The reason for re-activation of Service Provider ID
8	Begin Date	BeginDate	D	8	R	The date (CCYYMMDD) which the Alias ID is available.
9	End Date	EndDate	D	8	R	The through date (CCYYMMDD) which the Alias ID is available.

 

 Provider Services

 Data File Reference:  PROVIDER_SERVICE

Field #	Field Name	File Column Name	Format	Size	REQ/OPT	Description
1	Action Code	ActionCode	A/N	1	R	“A” = Add “D” = Terminate  “C” = Change
2	Processor Provider ID	ProcessorProviderId	A/N	20	R	This is the PBM's Internal Service Provider ID and is the same as is registered in the Primary Provider data source.
3	Accepts ePrescriptions Indicator	AcceptsePrescriptionsIndicator	A/N	1	O	(Y)es or (N)o indicator that provider accepts electronic prescriptions (computer to computer). Blank field = unreported.
4	Accepts ePrescriptions Code	AcceptsePrescriptionCode	A/N	2	O	The code indicating the level of ePrescribing services offered. See Services Table Codes
5	Delivery Service Indicator	DeliveryServiceIndicator	A/N	1	O	(Y)es or (N)o indicator that provider offers some level of delivery service. Blank field = unreported.
6	Delivery Service Code	DeliveryServiceCode	A/N	2	O	The code indicating the level of delivery services offered. See Services Table Codes
7	Compounding Service Indicator	CompoundingServiceIndicator	A/N	1	O	(Y)es or (N)o indicator that provider offers some level of compounding service. Blank field = unreported.
8	Compounding Service Code	CompoundingServiceCode	A/N	2	O	The code indicating the level of compounding services offered. See Services Table Codes
9	Drive-Up Window Indicator	DriveUpWindowIndicator	A/N	1	O	(Y)es or (N)o indicator that site has a drive-up window. Blank field = unreported.
10	Drive-Up Window Code	DriveUpWindowCode	A/N	2	O	The code indicating the level of drive-up window services offered. See Services Table Codes
11	Durable Medical Equipment Indicator	DMEIndicator	A/N	1	O	(Y)es or (N)o indicator that provider offers some level of durable medical equipment. Blank field = unreported.
12	Durable Medical Equipment Code	DMECode	A/N	2	O	The code indicating the level of durable medical equipment services offered. See Services Table Codes
13	Walk-In Clinic Indicator	WalkInClinicIndicator	A/N	1	O	(Y)es or (N)o indicator that provider offers some level of walk-in clinical services. Blank field = unreported.
14	Walk-In Clinic Code	WalkInClinicCode	A/N	2	O	The code indicating the level of walk-in clinical services offered. See Services Table Codes
15	24-Hour Emergency Service Indicator	T24HRERServiceIndicator	A/N	1	O	(Y)es or (N)o indicator that provider offers some level of 24-hour emergency service. Blank field = unreported.
16	24-Hour Emergency Service Code	T24HRERServiceCode	A/N	2	O	The code indicating the level of 24-hour services offered. See Services Table Codes
17	Multi-Dose Compliance Packaging Indicator	MultiDoseComplianceIndicator	A/N	1	O	(Y)es or (N)o indicator that provider offers some level of multi-dose compliance packaging. Blank field = unreported.
18	Multi-Dose Compliance Packaging Code	MultiDoseComplianceCode	A/N	2	O	The code indicating the level of multi-dose compliance packaging services offered. See Services Table Codes
19	Immunizations Provided Indicator	ImmunizationIndicator	A/N	1	O	(Y)es or (N)o indicator that provider offers some level immunizations on-site. Blank field = unreported.
20	Immunizations Provided Code	ImmunizationCode	A/N	2	O	The code indicating the level of immunizations services offered. See Services Table Codes
21	Handicapped Accessible Indicator	HandicappedAccessibleIndicator	A/N	1	O	(Y)es or (N)o indicator that site is handicapped accessible. Blank field = unreported.
22	Handicapped Accessible Code	HandicappedAccessibleCode	A/N	2	O	The code indicating the level of handicapped accessible services offered. See Services Table Codes
23	340B Status Indicator	T340bStatusIndicator	A/N	1	O	(Y)es or (N)o indicator that site offers some level of 340B service. Blank field = unreported.
24	340B Status Code	T340bStatusCode	A/N	2	O	The code indicating the level of 340B services offered. See Services Table Codes
25	Closed Door Facility Indicator	ClosedDoorFacilityIndicator	A/N	1	O	(Y)es or (N)o indicator that site is a closed-door facility. Blank field = unreported.
26	Closed Door Facility Status Code	ClosedDoorFacilityCode	A/N	2	O	The code indicating the service level of the site’s closed-door facility. See Services Table Codes
27	Begin Date	BeginDate	D	8	R	The date (CCYYMMDD) which the Service Provider Service record is effective.
28	End Date	EndDate	D	8	R	The through date (CCYYMMDD) which the Service Provider Service record is effective.

 

Provider Contacts/Demographics

Data File Reference:  PROVIDER_CONTACT

Field #	Field Name	File Column Name	Format	Size	REQ/OPT	Description
1	Action Code	ActionCode	A/N	1	R	“A” = Add “D” = Terminate “C” = Change
2	Processor Provider ID	ProcessorProviderId	A/N	20	R	This is the PBM's Internal Service Provider ID.
3	Address Type	AddressType	A/N	4	R	This is the code reflecting the type of demographic record being provided:  Business, Accounts Payable, Accounts Receivable, etc Use 16 as default.
4	Address 1	Address1	A/N	55	R	The first address line where checks are sent.
5	Address 2	Address2	A/N	55	O	The second address line for payment address.
6	City	City	A/N	30	R	Location city.
7	State Code	State	A/N	2	R	The two-digit state code.
8	Zip Code	ZipCode	A/N	9	R	This field identifies the 5 or 9-digit zip code of the address, less dash marks.
9	FAX Number	Fax	A/N	10	O	The facsimile machine telephone line number.
10	Contact Type	ContactType	A/N	4	O	The type of Contact.  Use 16 as default.
11	Contact First Name	ContactFirstName	A/N	35	O	Contact Person First Name.
12	Contact MI	ContactMI	A/N	1	O	Contact Person middle initial
13	Contact Last Name	ContactLastName	A/N	35	O	Contact Person Last Name
14	Contact Title	ContactTitle	A/N	30	O	Title of the primary contact person.
15	Contact Phone	ContactPhone	A/N	10	O	Telephone Number for the contact person
16	Contact Extension	ContactExt	A/N	5	O	Telephone Extension
17	E-Mail Address	EmailAddress	A/N	50	O	E-mail address for contact person.
18	Begin Date	BeginDate	D	8	R	The date (CCYYMMDD) which the Service Provider Demographic record is effective.
19	End Date	EndDate	D	8	R	The through date (CCYYMMDD) which the Service Provider Demographic record is effective.

  

Provider E-Prescribe

Data File Reference:  PROVIDER_EPRESCRIBE

Field #	Field Name	File Column Name	Format	Size	REQ/OPT	Description
1	Action Code	ActionCode	A/N	1	R	“A” = Add “D” = Terminate “C” = Change
2	Processor Provider ID	ProcessorProviderId	A/N	20	R	This is the PBM's Internal Service Provider ID.
3	ePrescribing Network Identifier	ePrescribNetworkId	A/N	3	R	NCPDP Network Identifier Codes. See section “Appendix F. NCPDP Network Identifier Codes” for list of values. SSX - Surescripts
4	ePrescribing Service Level Codes	ePrescribServLevelCodes	A/N	100	R	ePrescribing Service Level Codes are three-digit codes separated by a COLON delimiter.  A pharmacy must have at least one Service Level Code to have a record in this file. This field can reflect up to 25 service level codes. Updates will be a complete replace in the update process.
5	Begin Date	BeginDate	D	8	R	The date (CCYYMMDD) which the Service Provider ePrescribe record is effective.
6	End Date	EndDate	D	8	R	The through date (CCYYMMDD) which the Service Provider ePrescribe record is effective.

Provider Group

Data File Reference:  PROVIDER_GROUP

Field #	Field Name	File Column Name	Format	Size	REQ/OPT	Description
1	Action Code	ActionCode	A/N	1	R	“A” = Add “D” = Terminate  “C” = Change
2	Provider Group ID	ProviderGroupId	A/N	6	R	The identifier assigned to represent the relationship associated with the provider.
3	Provider Group Type	ProviderGroupType	A/N	2	R	Type of Group 01=Chain 02=Franchise 03=Purchasing Buying Group 04=Third Party Reconciliation Entity 05=Third Party Contracting Group
4	Name	ProviderGroupName	A/N	35	R	The name of the Provider Group.
5	Address 1	ProviderGroupAddress1	A/N	55	R	The first address line.
6	Address 2	ProviderGroupAddress2	A/N	55		The second address line.
7	City	ProviderGroupCity	A/N	30	R	Location city.
8	State Code	ProviderGroupState	A/N	2	R	The two-digit state code.
9	Zip Code	ProviderGroupZip	N	9	R	This field identifies the 5- or 9-digit zip code of the relationship, less dash marks.
10	Phone Number	ProviderGroupTelephone	N	10	O	The telephone number.
11	Extension	ProviderGroupExt	A/N	5	O	The telephone number extension.
12	FAX Number	ProviderGroupFax	N	10	O	The facsimile machine telephone line number.
13	Provider Group NPI	ProviderGroupNPI	A/N	10	O	The standard unique health identifier for health care providers to use in filing and processing health care claims and other transactions. An Organizational, Type 2, NPI assigned to the relationship entity.
14	Provider Group Federal Tax ID	ProviderGroupFedTaxId	A/N	15	O	The Federal Tax ID, also known as EIN or TIN, assigned to the Relationship entity.
15	Contact Name	ProviderGroupContactName	A/N	30	O	The name of the primary contact person.
16	Contact Title	ProviderGroupContactTitle	A/N	30	O	Title of the primary contact person.
17	E-mail Address	ProviderGroupContactEmail	A/N	50	O	The email address of the primary contact person.
18	Contractual Contact Name	ProviderGroupContractName	A/N	30	O	The name of the contact in charge of contracts.
19	Contractual Contact Title	ProviderGroupContractTitle	A/N	30	O	The title of the contact in charge of contracts.
20	Contractual Contact E-Mail	ProviderGroupContractEmail	A/N	50	O	The E-mail address of the contact in charge of contracts.
21	Operational Contact Name	ProviderGroupOpsName	A/N	30	O	The name of the contact in charge of operations.
22	Operational Contact Title	ProviderGroupOpsTitle	A/N	30	O	The title of the contact in charge of operations.
23	Operational Contact E-Mail	ProviderGroupOpsEmail	A/N	50	O	The E-mail address of the contact in charge of operations.
24	Technical Contact Name	ProviderGroupTechName	A/N	30	O	The name of the contact in charge of technical support.
25	Technical Contact Title	ProviderGroupTechTitle	A/N	30	O	The title of the contact in charge of technical support.
26	Technical Contact E-Mail	ProviderGroupTechEmail	A/N	50	O	The E-mail address of the contact in charge of technical support.
27	Audit Contact Name	ProviderGroupAuditName	A/N	30	O	The name of the contact in charge of audits.
28	Audit Contact Title	ProviderGroupAuditTitle	A/N	30	O	The title of the contact in charge of audits.
29	Audit Contact E-Mail	ProviderGroupAuditEmail	A/N	50	O	The E-mail of the contact in charge of audits.
30	NCPDP Chain Code	NCPDPChainCode	A/N	6	O	The NCPDP assigned Chain/relationship code
32	Begin Date	BeginDate	D	8	O	The date (CCYYMMDD) which the Service Provider record is effective. Defaults to today's date when empty.
33	End Date	EndDate	D	8	O	The through date (CCYYMMDD) which the Service Provider record is effective. Defaults to end of time (9999-12-31) when empty.

 

Provider Group Membership

 Data File Reference:  PROVIDER_GROUPMEMBERSHIP

Field #	Field Name	File Column Name	Format	Size	REQ/OPT	Description
1	Action Code	ActionCode	A/N	1	R	“A” = Add “D” = Terminate  “C” = Change
2	Provider Group ID	ProviderGroupId	A/N	6	R	This is the Provider Group ID registered in the system.  It may reflect a Chain/Relationship, a grouping of pharmacies based on type (Specialty) or other grouping as needed by the PBM for their business needs.
3	Service Provider ID	ServiceProviderId	A/N	20	R	The Service Provider ID of the Provider to be associated to the Provider Group ID
4	Service Provider ID Qualifier	ServiceProviderIDQual	A/N	2	R	The Qualifier representing the Service Provider ID of the Provider to be associated to the Provider Group ID
5	BeginDate	BeginDate	D	8	O	The date (CCYYMMDD) which the Service Provider record is effective. Defaults to today's date when empty.
6	EndDate	EndDate	D	8	O	The through date (CCYYMMDD) which the Service Provider record is effective. Defaults to end of time (9999-12-31) when empty.

Codes and References

We have provided the NCPDP industry codes utilized in the various formats.

Dispensing Class Code

Based on the NCPDP codes, the following are currently available for use in the Provider Primary Load.

Code	Value	Definition
01	Independent Pharmacy	One – three (1-3) pharmacies under common ownership.
02	Chain Pharmacy	A pharmacy that is part of a group of four (4) or more pharmacies under common ownership. Pharmacies may or may not share the same Federal Tax ID number.
05	Franchise Pharmacy	An independently owned pharmacy that has signed a franchise agreement with a franchisor wherein the franchisee receives services such as training, marketing, and other support from the franchisor in exchange for a franchise fee to the franchisor. A franchisee often includes the franchisor’s name as part of the store name.
06	Government Pharmacy	A pharmacy under the jurisdiction of federal, state, county or city government or the Indian Health Service. This includes military pharmacies within or outside the United States.
07	Alternate Dispensing Site (e.g. physician office, emergency department, urgent care centers, rural health facilities, etc)	A pharmacy or dispensing site that does not fit into the four classes above. This includes mail service Pharmacies, institutional and hospital pharmacies, most clinic pharmacies and non-pharmacy dispensing sites.

Provider Type Code

Based on the NCPDP codes, the following are currently available for use in the Provider Primary Load.

Code	Value	Taxonomy2	Taxonomy Definition
01	Community/ Retail Pharmacy	3336C0003X	A pharmacy where pharmacists store, prepare, and dispense medicinal preparations and/or prescriptions for a local patient population in accordance with federal and state law; counsel patients and caregivers (sometimes independent of the dispensing process); administer vaccinations; and provide other professional services associated with pharmaceutical care such as health screenings, consultative services with other health care providers, collaborative practice, disease state management, and education classes.
04	Long Term Care Pharmacy	3336L0003X	A pharmacy that dispenses medicinal preparations delivered to patients residing within an intermediate or skilled nursing facility, including intermediate care facilities for mentally retarded, hospice, assisted living facilities, group homes, and other forms of congregate living arrangements.
05	Mail Order Pharmacy	3336M0002X	A pharmacy where pharmacists compound or dispense prescriptions or other medications in accordance with federal and state law, using common carriers to deliver the medications to patient or their caregivers. Mail order pharmacies counsel patients and caregivers (sometimes independent of the dispensing process) through telephone or email contact and provide other professional services associated with pharmaceutical care appropriate to the setting. Mail order pharmacies are licensed as a Mail Order Pharmacy in the state where they are located and may also be licensed or registered as nonresident pharmacies in other states.
06	Home Infusion Therapy Provider	3336H0001X	Pharmacy-based, decentralized patient care organization with expertise in USP 797-compliant sterile drug compounding that provides care to patients with acute or chronic conditions generally pertaining to parenteral administration of drugs, biologics and nutritional formulae administered through catheters and/or needles in home and alternate sites.  Extensive professional pharmacy services, care coordination, infusion nursing services, supplies and equipment are provided to optimize efficacy and compliance.
07	Non- Pharmacy Dispensing Site	332900000X	A site other than a pharmacy that dispenses medicinal preparations under the supervision of a physician to patients for self-administration. (e.g. physician offices, ER, Urgent Care Centers, Rural Health Facilities, etc.
08	Indian Health Service/Tribal /Urban Indian Health (I/T/U) Pharmacy	332800000X	An Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy means a pharmacy operated by the Indian Health Service, an Indian tribe or tribal organization, or an urban Indian organization, all of which are defined in Section 4 of the Indian Health Care Improvement Act, 25 U.S.C. 1603.
09	Department of Veterans Affairs (VA) Pharmacy	332100000X	Department of Veterans Affairs (VA) Pharmacy means any place under VA jurisdiction where drugs are dispensed and Pharmaceutical Care is provided to enrolled Veterans, by licensed pharmacists.  The Pharmacy is reviewed by JCAHO, utilizes the VA hospital’s DEA number, and has a designated NCPDP number. VA facility pharmacies include Inpatient (Institutional), Outpatient, Consolidated Mail Outpatient Pharmacies, Research, Addiction Treatment Centers, Long Term Care and Community Based Outpatient Clinics Pharmacies.  The VA Pharmacy Benefits Management – Strategic Healthcare Group has oversight for professional and practice activities of VA Pharmacies. Each pharmacy is under the direct supervision of a U.S. or U.S. territory licensed pharmacist, and has staffing to meet its designated scope of service.
11	Institutional Pharmacy	3336I0012X	A pharmacy in a hospital (inpatient) or institution used by pharmacists for the compounding and delivery of medicinal preparations to be administered to the patient by nursing or other authorized personnel. Institutional Pharmacies also counsel patients and caregivers; administer vaccinations; and provide other professional services associated with pharmaceutical care such as health screenings, consultative services with other health care providers, collaborative practice, disease state management, and education classes.
12	Managed Care Organization Pharmacy	3336M0003X	A pharmacy owned by a managed care organization (MCO) used by pharmacists for the compounding and dispensing of medicinal preparations to that MCO’s covered Providers only.
13	DME	332B00000X	A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient’s use in the home and that are usable for an extended period of time.
14	Clinic Pharmacy	3336C0002X	A pharmacy in a clinic, emergency room or hospital (outpatient) that dispenses medications to patients for self-administration under the supervision of a pharmacist.
15	Specialty Pharmacy	3336S0011X	A pharmacy that dispenses generally low volume and high cost medicinal preparations to patients who are undergoing intensive therapies for illnesses that are generally chronic, complex and potentially life threatening. Often these therapies require specialized delivery and administration.
16	Nuclear Pharmacy	3336N0007X	A pharmacy dedicated to the compounding and dispensing of radioactive materials for use in nuclear imaging and nuclear medical procedures.
17	Military/U.S. Coast   Guard Pharmacy	332000000X	A Department of Defense (DoD) or U.S. Coast Guard entity whose primary function is to store, prepare and dispense pharmaceuticals and other associated items to Uniformed Services beneficiaries. These pharmacies may be associated with a DoD or U.S. Coast Guard clinic, DoD Hospital, or freestanding. Usually associated with outpatient services.
18	Compounding Pharmacy	3336C0004X	A pharmacy that specializes in the preparation of components into a drug preparation as the result of a Practitioner’s Prescription Drug Order or initiative based on the Practitioner/Patient/Pharmacist relationship in the course of professional practice. A compounding pharmacy utilizes specialized equipment and specially designed facilities necessary to meet the legal and quality requirements of its scope of compounding practice.
19	Oxygen Equipment
20	Nursing Facility Supplies
21	Customized Equipment
22	Dialysis Equipment
23	Parenteral and Enteral Nutrition

Deactivation Code

Deactivation Code	Description
01	Pharmacy is Closing
02	Pharmacy is changing ownership and the buyer requires a new NCPDPD Provider ID for the location
03	Deactivation request (the number is being deactivated for a reason other than explicit values already defined)

Reinstatement Code

Reinstatement Code	Description
01	Change of Ownership was cancelled or delayed
02	Deactivation was in error
03	Temporarily closed due to remodeling
04	Temporarily closed due to natural disaster

Hours of Operation

To encourage adoption, we use the NCPDP method of identifying hours of operation.

 

Provider Services Codes

Reference Field	Code	Description
ePrescriptions	01	Site does not accept NCPDP SCRIPT Transactions
	02	Site accepts NCPDP SCRIPT Transactions
Delivery Service	03	Site does not offer prescription delivery service
	04	Site offers prescription delivery service for a fee
	05	Site offers free prescription delivery service
Compounding Services	06	Site does not offer prescription compounding service
	07	Site offers basic non-sterile compounding services
	08	Site offers complex non-sterile compounding services
	09	Site offers low-medium complexity sterile compounding services
	10	Site offers high complexity sterile compounding services
Drive Up Window	11	Site does not have a drive-up window for prescriptions
	12	Site has one or more drive-up windows for prescriptions
DME Durable Medical Equipment	13	Site does not offer durable medical equipment (DME)
	14	Site provides off-the-shelf non-custom DME but is not accredited
	15	Site provides a full range of DME including custom items but is not accredited
	16	Site is accredited to provide DME limited to pharmaceuticals and diabetic testing supplies
	17	Site is accredited to provide DME limited to off-the-shelf non-custom products and pharmaceuticals
	18	Site is accredited to provide a full range of DME including custom items and pharmaceuticals
Walk In Clinic	19	Site does not have on-site walk-in clinic
	20	Site has on-site affiliate walk-in clinic offering limited services staffed by mid-level practitioner(s)
	21	Site has on-site affiliate walk-in clinic offering limited services staffed by licensed physician(s)
	22	Site has on-site affiliate emergency room
24-Hour Emergency Services	23	Site does not offer 24 hour emergency service
	24	Site offers 24 hour emergency access to a pharmacist via remote call center or equivalent
	25	Site offers 24 hour emergency access to a local pharmacist via telephone, pager or electronic means
	26	Site offers 24 hour emergency access to a pharmacist with access to the location
	27	Site offers 24 hour emergency service

ePrescribing Service Level Codes

ePrescribing Service Level Code	Name	Description
NEW	New Prescription Request	This transaction is a request for a new prescription and is sent from the prescriber to the pharmacy.
REF	Refill Request/Refill Response	Refill Request is used by a pharmacy to request a refill of a prescriber. Refill Response is sent from the prescriber to the pharmacy and indicates whether the refill request has been accepted or denied.
CHG	Prescription Change Request/Prescription Change Response	Prescription Change Request is a transaction sent from a pharmacy to a prescriber to request a change on a new prescription.  Prescription Change Response is a transaction sent from the prescriber to the pharmacy in response to a request for a change of a new prescription or “fillable” prescription.
FILL	Prescription Fill Status Notification	This transaction is sent from the pharmacy to the prescriber to notify the prescriber of the dispensing status of a prescription.
CAN	Cancel Prescription Request/Cancel Prescription Response	Cancel Prescription Request is a transaction sent from the prescriber to a pharmacy requesting a previously sent prescription not be filled. Cancel Prescription Response is a transaction sent from the pharmacy to the prescriber to acknowledge the cancel request.
RSP	Resupply	This transaction is used to send a refill request from a facility to a pharmacy.
CEN	Census Update	Request by the facility in a long-term care environment to notify the pharmacy about census events.

Address/Contact Type

00 - General/Other	10- Eligibility
01 - Account Management	11 - Executive
02 - Accounting	12 - Finance
03 - Audit	13 - Human Resources
04 - Authorized Official	14 - Legal
05 - Non-Authorized Official	15 - Pharmacist in Charge
06 - Billing	16 - Primary
07 - Clinician	17 - Secondary
08 - Contracting	18 - Technical
09 - Data Management	19 - Sales

Data File Formatting

At this time, the data file formats will include a header row.  Fields will be pipe delimited.

File Naming

It is important to name each file precisely.  As noted by each table layout, there was a Data File Reference.  This reference is part of the output file naming convention.

All Provider file names will follow the format below.

1. PBMCODE:  The PBM Code is the processor’s code in the system.  This will be provided by the processor.
2. PROVIDER:  This indicates the type of data load that is being submitted.  This is a fixed element. 
3. PROVIDERTYPE:  This is the type of provider data in the file.  The types are as follows:
   • ALIAS
   • CONTACT
   • EPRESCRIBE
   • GROUP
   • GROUPMEMBERSHIP
   • PRIMARY
   • SERVICE
4. FILEDATE:  The File Date Time is the date and time the file is created.  The format of the element is CCYYMMHHMMSS.  The time element is important and should reflect valid values.  If more than 1 file for the same basis of cost code is submitted, the File Date Time data will be used to process the oldest file first.
5. NUMOFRECORDS:  This is the number of records in the data file INCLUDING the header record.  This file name value is validated against the total records in the file.

The image below is a sample of Provider Files.

*** Some general description information on the provider data is referenced from the NCPDP provider data.  While we do not require the use of the NCPDP provider files, we do recommend their service.  We have provided language as many are using the NCPDP data files for their source.  The National Council on Prescription Drug Programs (NCPDP) is the leading organization for creating and promoting standards in the Pharmacy industry.