Procella HelpdeskProcella Claim System User Manual Claims History Load v1.03
Claims History Load
The Claims History Load process is designed to capture historical claims data, typically supporting a client transition. This process is not adjudicating a set of claims, it is simply posting the data as provided into the Procella database. These claims are primarily net paid claims, but reversals are supported.
What claim history loads do
The claim history load is a capture of claims information. It supports plan edits, such as criteria and edits that look back in a member’s profile as well as population of pharmacy accumulators.
What claim history loads do not do
Claim history loads do not re-adjudicate claims.
The history loads do not:
- Support denied or rejected claims
- validate coverage
- enforce prior authorization
- Not the system of record for historical claims.
Instructions
- The claims history batch file is a delimited text file.
- The delimiter supported is pipe delimited.
- ALL FIELD DATA is to be provided in capital letters
- The file should have an header row
- The file naming format is *_CLAIMHISTORY_*.txt Example test_CLAIMHISTORY_group1.txt
- In the all the Dollar amount field, please do not include dollar $ sign , comma separator in the amounts
Claim History Format
| # | Field | R/O/S | Field Format / Valid values | Comments |
| 1 | FILLER | R | Was PBM ID which will be taken from the load process. | |
| 2 | PLAN ID | R | The PLAN ID in the Procella system the claim will be associated with. | |
| 3 | GROUP ID | R | The Group ID in the Procella system the claim will be associated with. | |
| 4 | CLAIM TYPE | R | 1 – POS 2 - DMR | |
| 5 | DATE OF SERVICE | R | YYYYMMDD | |
| 6 | ADJUDICATION DATE | R | YYYY-MM-DD HH:MM:SS Ex: 2019-11-31 00:00:00 | Space is valid between the date and time segments |
| 7 | CLAIM STATUS | R | 1 - Paid 2 - Reversal | Denied and rejected claims are not supported for claims history loads. |
| 8 | EXTERNAL TRANSACTION ID | R | Unique transaction ID for this claim. | |
| 9 | EXTERNAL TRANSACTION CROSS REFERENCE ID | S | Unique transaction ID of the reversal claim if this record is a paid claim. If this is a reversal claim, this ID is the transaction ID of the paid claim. | |
| 10 | NETWORK CLASSIFICATION | O | 0 - In Network 1 - Out of Network | Is the claim considered in network or out of network. |
| 11 | SOURCE OF NETWORK | O | 0 - Network Assignment 1 - Reporting Network | Default to 0 – Network Assignment unless directed otherwise. |
| 12 | NETWORK TYPE | O | 0 - Mail 3 - Retail 90 4 - All | |
| 13 | EXTERNAL PRESCRIBER ID | R | The Service Prescriber/Physician ID as submitted on the claim | |
| 14 | EXTERNAL PRESCRIBER QUALIFIER ID | O | 01 - National Provider Identifier (NPI) 02 - Blue Cross 03 - Blue Shield 04 - Medicare 05 - Medicaid 06 - UPIN (Unique Physician/ Practitioner Identification Number) 08 - State License 09 - TRICARE 10 - Health Industry Number 11 - Federal Tax ID 12 - Drug Enforcement Administration (DEA) Number 13 - State Issued 14 - Plan Specific 15 - HCIdea 16 - Combat Methamphatamine Epidemic Act (CMEA) Certificate ID 17 - Foreign Prescriber Identifier 18 - No Prescriber Required 99 - Other | The qualifier for the Service Prescriber ID submitted on the claim. Note : It is recommended to provide this value, but if not provided - Our logic assigns either 01 or 12 based on the starting value of the external prescriber ID
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| 15 | EXTERNAL SERVICE PROVIDER ID | R | The Pharmacy/Provider Service ID of the submitting provider. | |
| 16 | EXTERNAL SERVICE PROVIDER ID QUALIFIER | O | 01 - National Provider Identifier (NPI) 02 - Blue Cross 03 - Blue Shield 04 - Medicare 05 - Medicaid 06 - UPIN (Unique Physician/ Practitioner Identification Number) 08 - State License 09 - TRICARE 10 - Health Industry Number 11 - Federal Tax ID 12 - Drug Enforcement Administration (DEA) Number 13 - State Issued 14 - Plan Specific 15 - HCIdea 16 - Combat Methamphatamine Epidemic Act (CMEA) Certificate ID 17 - Foreign Prescriber Identifier 18 - No Prescriber Required 99 - Other | The qualifier for the External Pharmacy/Provider Service Provider ID submitted on the claim. Note : It is recommended to provide this value, but if not provided - Our logic assigns 01 by default |
| 17 | RX SERVICE REFERENCE NUMBER | R | The prescription number for the claim | |
| 18 | RX SERVICE REFERENCE NUMBER QUALIFIER | R | 1 - Rx | The qualifier for the Rx Service Reference Number |
| 19 | DRUG NAME | O | Only 30 Characters allowed | |
| 20 | DRUG PRODUCT SERVICE ID | R | The NDC code of the drug dispensed | |
| 21 | DRUG PRODUCT SERVICE ID QUALIFIER | R | 03 - NDC | 03 is the code for NDCs. |
| 22 | FILLER | O | (Drug Record Number) This is the individual drug index and is related to compounds. This is to be removed from this layout. | |
| 23 | BRAND CLASS | R | BSS - Brand Single-Source BMS - Brand Multi-Source GSS - Generic Single-Source GMS - Generic Multi-Source | The brand class associated with the drug dispensed.
Note: We can just accept B or G and default to one of the above if needed. |
| 24 | COMPOUND CODE | R | 0 – Not Specified 1 – Not a Compound 2 - Compound | |
| 25 | DAW CODE | R | 0 - No Product Selection Indicated 1 - Substitution Not Allowed By Prescriber 2 - Substitution Allowed but Patient Requested Product Dispensed 3 - Substitution Allowed but Pharmacist Selected Product Dispensed 4 - Substitution Allowed but Generic Drug Not in Stock 5 - Substitution Allowed but Brand Drug Dispensed as Generic 6 - Override 7 - Substitution Not Allowed but Brand Drug Mandated by Law 8 - Substitution Allowed but Generic Not Available in Marketplace 9 - Substitution Allowed By Prescriber but Plan Requested Brand | The dispense as written code as submitted on the claim. |
| 26 | FILLER | O | New/Refill Code | |
| 27 | PRIOR AUTH SUBMITTED | O | The Prior Authorization number as submitted on the claim | |
| 28 | REFILLS AUTHORIZED | R | 0 – No Refills Authorized 1-99 – Authorized Refill Number | The number of refills authorized for the written prescription. |
| 29 | AUTHORIZATION TYPE CODE SUBMITTED | O | 0 – Not Specified 1 – Prior Authorization 2 – Medical Certification 3 – EPSDT 4 – Exemption from Copay/Coins 5 – Exemption from Rx 6 – Family Planning Indicator 7 – TANF 8 – Payer Defined Exemption 9 - Emergency Preparedness | This is Prior Authorization Type Code as submitted on the claim. |
| 30 | CARDHOLDER ID | R | The Cardholder ID for the Member. | |
| 31 | PERSON CODE | R | The Person Code for the Member/Patient. | |
| 32 | RELATIONSHIP CODE | R | 1 - Cardholder 2 - Spouse 3 - Child 4 - Other 5 - Student 6 - Disabled Dependent 7 - Adult Dependent | The Relationship Code for the Member/Patient. |
| 33 | FIRST NAME | R | Member First Name Note : This should exactly match the FN of the Member in procella system | |
| 34 | LAST NAME | R | Member Last Name Note : This should exactly match the LN of the Member in procella system | |
| 35 | DATE OF BIRTH | R | YYYYMMDD | Member Date of Birth |
| 36 | GENDER | R | M = Male F = Female U = Unknown | Member Gender |
| 37 | FILL NUMBER | R | 0 – Original Dispensing 1-99 Refill Number | The Fill number of the claim dispensed. |
| 38 | OTHER COVERAGE CODE | S | 0 - Not Specified by Patient 1 - No other coverage 2 - Other coverage exists-payment collected 3 - Other Coverage Billed 4 - Other coverage exists-payment not collected 5-7 - No longer Supported 8 - Claim is billing for patient financial responsibility | The Other Coverage Code as submitted on the claim. |
| 39 | OTHER PAYER COVERAGE TYPE | S | 01 Primary - First 02 Secondary - Second 03 Tertiary - Third 04 Quaternary - Fourth 05 Quinary - Fifth 06 Senary - Sixth 07 Septenary - Seventh 08 Octonary - Eighth 09 Nonary - Ninth | The Other Payer Coverage Type code as submitted on the claim. |
| 40 | INCENTIVE AMOUNT PLAN | S | For reversals, this field is a negative value. | |
| 41 | INCENTIVE AMOUNT MEMBER | S | For reversals, this field is a negative value. | |
| 42 | AMOUNT PROGRAM ADMIN FEE PLAN | S | For reversals, this field is a negative value. | |
| 43 | AMOUNT PROGRAM ADMIN FEE | S | For reversals, this field is a negative value. | |
| 44 | AMOUNT PLAN SALES TAX | S | For reversals, this field is a negative value. | |
| 45 | AMONT PROFESSIONAL SERVICE FEE PAID | S | For reversals, this field is a negative value. | |
| 46 | OTHER AMOUNT PLAN | S | For reversals, this field is a negative value. | |
| 47 | OTHER AMOUNT MEMBER | S | For reversals, this field is a negative value. | |
| 48 | PLAN PAY AMOUNT | R | The Net Amount (Cost less member paid) the Plan/Client is responsible for. For reversals, this field is a negative value. | |
| 49 | PATIENT PAY AMOUNT | R | The total financial responsibility of the Member For reversals, this field is a negative value. | |
| 50 | AMOUNT EXCEEDING PERIODIC BENEFIT MAX | S | For reversals, this field is a negative value. | |
| 51 | AMOUNT ATTRIBUTED PROCESSOR FEE | S | For reversals, this field is a negative value. | |
| 52 | AMOUNT ATTRIBUTED SALES TAX | S | For reversals, this field is a negative value. | |
| 53 | AMOUNT ATTRIBUTED PRODUCT BRAND DRUG | S | DAW Penalty amount. For reversals, this field is a negative value. | |
| 54 | AMOUNT HEALTH PLAN FUNDED ASSISTANCE | S | For reversals, this field is a negative value. | |
| 55 | AMOUNT APPLIED PERIODIC DEDUCTIBLE | S | The amount attributed to deductible for this claim. For reversals, this field is a negative value. | |
| 56 | AMOUNT ATTRIBUTABLE COINSURANCE/COPAY | R | For reversals, this field is a negative value. | |
| 57 | DAYS SUPPLY AMOUNT | R | The Days Supply as submitted on the claim. For reversals, this field is a negative value. | |
| 58 | QUANTITY AMOUNT | R | This would be the individual ingredient quantity amount. For reversals, this field is a negative value. | |
| 59 | FILLER | For future use. | ||
| 60 | CALCULATED INGREDIENT COST | O | For reversals, this field is a negative value. Note : It is recommended to provide this value. If not provided, we will automatically update as PLAN PAY AMOUNT (# 48) + PATIENT PAY AMOUNT (# 49). | |
| 61 | CALCULATED DISPENSING FEE | O | For reversals, this field is a negative value. Note : It is recommended to provide this value. If not provided, we will automatically take it as $0.00 | |
| 62 | CALCULATED OTHER AMOUNT CLAIMED/PAID | S | For reversals, this field is a negative value. | |
| 63 | SUBMITTED FLAT TAX AMOUNT | S | For reversals, this field is a negative value. | |
| 64 | CALCULATED PERCENT TAX | S | For reversals, this field is a negative value. | |
| 65 | SUBMITTED PERCENT SALES TAX RATE | S | The sales tax rate as submitted on the claim. | |
| 66 | USUAL & CUSTOMARY | O | For reversals, this field is a negative value. Note : It is recommended to provide this value. If not provided, we will automatically update as PLAN PAY AMOUNT (# 48) + PATIENT PAY AMOUNT (# 49). | |
| 67 | GROSS AMOUNT DUE | R | For reversals, this field is a negative value. Note : It is recommended to provide this value. If not provided, we will automatically update as PLAN PAY AMOUNT (# 48) + PATIENT PAY AMOUNT (# 49). | |
| 68 | DATE RX WRITTEN | O | YYYYMMDD | The Date the prescription was written as submitted on the claim. Note : It is recommended to provide this value. If not provided, we will use Date of Service (#5) |
| 69 | CARDHOLDER FIRST NAME | O | The First Name of the Cardholder Note : When not provided, we check If the Relationship code (#32) is cardholder, if Yes – then we copy Member first name (#33) as Cardholder First Name | |
| 70 | CARDHOLDER LAST NAME | O | The Last Name of the Cardholder Note : When not provided, we check If the Relationship code (#32) is cardholder, if Yes – then we copy Member Last name (#34) as Cardholder Last Name. | |
| 71 | PRESCRIPTION ORIGIN CODE | O | 0 - Not Known 1 - Written 2 - Telephone 3 - Electronic 4 - Facsimile 5 - Pharmacy | We will take 0 as default value if not provided. |
| 72 | PRESCRIBER FIRST NAME | O | ||
| 73 | PRESCRIBER LAST NAME | O | ||
| 74 | BIN | R | ||
| 75 | PCN | O | ||
| 76 | SUBMITTED INGR COST | O | From Provider. For reversals, this field is a negative value. | |
| 77 | SUBMITTED DISP FEE | O | From Provider. For reversals, this field is a negative value. | |
| 78 | BASIS OF REIMBURSEMENT | O | 01 - Ingredient Cost Paid as Submitted 02 - Ingredient Cost Reduced to AWP Pricing 03 - Ingredient Cost Reduced to AWP X% Pricing 04 - U & C 05 - Paid Lower Ingredient Cost Plus Fees Vs. U & C 06 - MAC Pricing Ingredient Cost Paid 07 - MAC Pricing Ingredient Cost Reduced to MAC 08 - Contract Pricing 09 - Acquisition Pricing 10 - ASP (Average Sales Price) 11 - AMP (Average Manufacturer Price) 12 - 340B/Disproportionate Share/Public Health Service Pricing 13 - WAC (Wholesale Acquisition Cost) 14 - Other Payer-Patient Responsibility Amount 15 - Patient Pay Amount 16 - Coupon Payment 17 - Special Patient Reimbursement 18 - Direct Price (DP) 19 - State Fee Schedule (SFS) Reimbursement 20 - National Average Drug Acquisition Cost (NADAC) 21 - State Average Acquisition Cost (AAC) 22 - Ingredient Cost paid based on submitted Basis of Cost Free Product 23 - Reimbursement based on contracted or state fee schedule rate for Original Manufacturer Product ID for the packaged drug 24 - Federal Upper Limit | |
| 79 | PROVIDER INGR COST | O | Provider paid ingredient amount. For reversals, this field is a negative value. | |
| 80 | PROVIDER DISP FEE | O | Provider paid ingredient amount. For reversals, this field is a negative value. |