NCPDP Data Dictionary 201607

DATA DICTIONARY
This document provides the data element definitions that have been defined and approved by the Maintenance and Control Work Group.
The definitions support the various file and telecommunications formats that have been approved by the NCPDP membership.
July 2016
National Council for Prescription Drug Programs

9240 East Raintree Drive
Scottsdale, AZ 85260
Phone: (480) 477-1000

Fax: (480) 767-1042
e-mail: ncpdp@ncpdp.org
Data Dictionary
COPYRIGHT (©) National Council for Prescription Drug Programs, Inc.
2016
This work is owned by National Council for Prescription Drug Programs, Inc., 9240 E. Raintree Drive, Scottsdale, AZ 85260, (480) 477-1000, ncpdp@ncpdp.org, and protected by the copyright laws of the
United States. 17 U.S.C. §101, et. seq. Permission is given to Council members to copy and use the work or any part thereof in connection with the business purposes of the Council members.
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Inc., at any time. The National Council for Prescription Drugs Programs, Inc. is not responsible for any errors or damage as a result of the use of the work.
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codes requiring confidentiality of this information and should utilize the standards accordingly.
NOTICE: In addition, this NCPDP Standard contains certain data fields and elements that may be completed by users with the proprietary information of third parties. The use and distribution of third
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Published by:
Publication Dates
Copyright © June 1999 NCPDP Copyright @ October 2005 NCPDP Copyright @ January 2012
Copyright © August 1999 NCPDP Copyright @ June 2006 NCPDP Copyright @ April 2012
Copyright © September 1999 NCPDP Copyright @ September 2006 NCPDP Copyright @ July 2012
Copyright © June 2000 NCPDP Copyright @ October 2006 NCPDP Copyright @ October 2012
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Copyright @ October 2004 NCPDP Copyright @ December 2010 Copyright @ April 2016
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DATA DICTIONARY
TABLE OF CONTENTS
I. INTRODUCTION..................................................................................................................................................................................................................................................... 8
II. DATA ELEMENTS ................................................................................................................................................................................................................................................... 4
III. Appendix A - NUMERIC CROSS REFERENCE FOR DATA ELEMENTS WITH NUMERIC IDENTIFIERS .......................................................................................................................... 179
IV. Appendix B – CROSS REFERENCE OF FIELDS USED IN NCPDP SCRIPT TO THE MODEL-DRIVEN SCHEMAS .................................................................................................................... 196
VI. Appendix C – PUBLICATION MODIFICATIONS............................................................................................................................................................................................................ 200
A. SEPTEMBER 1999 200
1. Telecommunication Standard Version 5 Release 1 200
B. JUNE 2000 200
2. Enrollment Standard Version 2 Release 0 201
3. Payment Tape Format Version 3 Release 0 203
4. Manufacturer Rebate Utilization, Plan, Formulary, and Market Basket Flat File Format Version 02 Release 01 205
6, Batch Standard Version1 Release 1 205
C. SEPTEMBER 2000 205
D. NOVEMBER 2000 206
E. MAY 2001 206
1. SCRIPT Standard Version 3 Release 1 206
F. AUGUST 2001 206
G. JANUARY 2002 206
3. Manufacturer Rebate Standard Version 03.01 207
4. Payment Reconciliation Standard Version 4 Release 0 208
5. Data Dictionary Modifications 209
H. JUNE 2002 209
I. DECEMBER 2002 209
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Copyrighted Materials - See Copyright Statement for Allowed Use
DATA DICTIONARY
1. Manufacturer Rebate Standard Version 03 Release 02 209
J. FEBRUARY 2003 210
K. AUGUST 2003 210
L. OCTOBER 2003 210
M. NOVEMBER 2003 211
1. Manufacturer Rebate Standard Version 03 Release 02 – New publication date of November 2003 211
N. MAY 2004 211
O. AUGUST 2004 211
1. Telecommunication Standard Version A.0 211
P. OCTOBER 2004 212
2. Telecommunication Standard Version A.1 212
Q. JANUARY 2005 212
1. SCRIPT Standard Versions 7.0 and 7.1 212
R. MAY 2005 212
1. Telecommunication Standard Version B.0 212
S. JULY 2005 212
1. Telecommunication Standard Version C.0 212
2. SCRIPT Standard Versions 8.0 213
T. OCTOBER 2005 213
2. Formulary & Benefit Standard Version 1.0 214
3. SCRIPT Standard Versions 8.1 and 9.0 217
U. JUNE 2006 217
V. SEPTEMBER 2006 217
1. Post Adjudication Standard Version 1.0 217
W. OCTOBER 2006 225
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1. SCRIPT Standard Version 10.0 225
X. JANUARY 2007 225
Y. APRIL 2007 225
Z. JULY 2007 230
1. Telecommunication Version D Release 0 230
2. Medicaid Subrogation Implementation Guide Version 3 Release 0 236
3. SCRIPT Standard Implementation Guide Version 10 Release 1 and Version 10 Release 2 237
AA. JANUARY 2008 237
1. Financial Information Reporting Standard Implementation Guide Version 1 Release 0 237
2. Post Adjudication Standard Implementation Guide Version 2 Release 0 238
3. Prescription Transfer Standard Implementation Guide Version 1 Release 0 239
4. SCRIPT Standard Implementation Guide Version10 Release 3 242
BB. JUNE 2008 242
1. Formulary and Benefit Standard Implementation Guide Version 2 Release 0 242
2. SCRIPT Standard Implementation Guides Version10 Release 4 and Version 10 Release 5 243
CC. OCTOBER 2008 243
1. Telecommunication Standard Implementation Guide Version D Release 1 243
2. SCRIPT Standard Implementation Guides Version10 Release 6 244
3. Universal Claim Form and Workers’ Compensation/Property & Casualty Form 244
DD. APRIL 2009 248
2. SCRIPT Standard Implementation Guide Version 10 Release 7 248
EE. JUNE 2009 248
2. Prior Authorization Standard Implementation Guide Version 1 Release 0 249
3. SCRIPT Standard Implementation Guide Version 10 Release 8 and Version 10 Release 9 251
4. Post Adjudication Standard Implementation Guide Version 2 Release 1 and Version 251
5. Universal Claim Form 251
FF. OCTOBER 2009 251
2. Data Dictionary 252
GG. JANUARY 2010 252
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HH. MARCH 2010 252
II. JUNE 2010 253
JJ. SEPTEMBER 2010 254
KK. DECEMBER 2010 254
3. Formulary and Benefit Standard Version 3 Release 0 255
4. Specialized Implementation Guide Version 2010121 255
5. SCRIPT Standard Implementation Guide Version 2010121 258
LL. APRIL 2011 265
MM. JULY 2011 266
1. Medical Rebate Data Submission Standard Implementation Guide Version 01 Release 00 266
2. Manufacturer Rebate Utilization, Plan, Formulary, Market Basket, and Reconciliation Flat File Standard Implementation Guide Version 05 Release 01 268
3. Specialized Standard Implementation Guide Version 2011071 269
5. Audit Transaction Standard Implementation Guide Version 1 Release 0 270
6. Connectivity Operating Rule Version 1.0 271
NN. OCTOBER 2011 272
1. Uniform Healthcare Payer Data Standard Implementation Guide Version 1 Release 0 272
2. Retiree Drug Subsidy Standard Implementation Guide Version 1 Release 0 274
OO. JANUARY 2012 275
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PP. APRIL 2012 276
QQ. JULY 2012 276
RR. OCTOBER 2012 277
SS. JANUARY 2013 277
8. Medicaid Subrogation Implementation Guide Version 4 Release 0 282
9. Medical Rebates Data Submission Standard Implementation Guide Version 02 Release 00 283
10. Prescription File Transfer Standard Implementation Guide Version 3 Release 0 283
11. Prior Authorization Transfer Standard Implementation Guide Version 2 Release 0 283
12. Retiree Drug Subsidy Standard Implementation Guide Version 2 Release 0 284
14. Telecommunication Standard Implementation Guide Version E Release 0 285
TT. APRIL 2013 287
3. Workers’ Compensation/Property & Casualty Universal Claim Form 288
5. Medical Rebates Data Submission Standard Implementation Guide Version 02 Release 01 288
7. Universal Claim Form 289
11. Prescription File Transfer Standard Implementation Guide Version 3 Release 1 290
UU. JULY 2013 290
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1. Specilaized Implementation Guide Version 2013071 290
VV. OCTOBER 2013 293
1. Specilaized Implementation Guide Version 2013101 293
WW. JANUARY 2014 295
XX. APRIL 2014 296
1. Uniform Standard Implementation Guide Version 22 296
2. Post Adjudication Standard Implementation Guide Version 43 296
4. Telecommunication Standard Implementation Guide Version E5 297
6. Audit Transaction Standard Implementation Guide Version 30 297
7. Medical Rebate Data Submission Standard Implementation Guide Version 02 Release 02 298
YY. JULY 2014 298
5. Prescription Transfer Standard Implementation Guide Version 33 299
ZZ. OCTOBER 2014 299
1. Formulary and Benefit Standard Implementation Guide Version 42 299
AAA. JANUARY 2015 301
2. Benefit Integration Standard Implementation Guide Version 10 301
BBB. APRIL 2015 303
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DATA DICTIONARY
CCC. JULY 2015 303
DDD. OCTOBER 2015 306
2. Health Care Identification Card – Pharmacy and/or Combination ID Card Implementation Guide Version 4.3 306
EEE. JANUARY 2016 306
2. Batch Implementation Guide Version 13 307
FFF. APRIL 2016 307
GGG. JULY 2016 309
2. Prescription Transfer Standard Implementation Guide Version 34 310
4. Audit Transaction Standard Implementation Guide Version 31 310
5. Prior Authorization Transfer Standard Implementation Guide Version 21 310
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DATA DICTIONARY
I. INTRODUCTION
Presented in this document are the data element definitions that have been defined and approved by the Maintenance and Control (MC) Work Group of the National Council for
Prescription Drug Programs (NCPDP). The definitions support the various file and telecommunication formats that have been approved by the NCPDP membership.
The data element definitions should be used by all persons who want to know when, where and how specific data elements are used in the approved file formats. The NCPDP
Standards Matrix document is an important reference for use. It contains a high-level overview of the latest version/release and/or the most commonly used of the standards
and implementation guides, as well as NCPDP’s Data Dictionary and External Code List. This document provides version/release/publication reference charts for approved and
draft NCPDP standards/implementation guides.
The External Code List (ECL) contains values for data elements within the NCPDP Standards. All Data Elements whose values reside in the ECL will have an indicator of “See ECL” in
the Values Column of this document. Please refer to the appropriate ECL publication.
Note: Data elements within the Claims Billing Tape Format, Diskette Billing Format, Claim Payment Tape Format, and Member Enrollment Standard have been excluded from the
ECL, with infrequent exceptions, since these standards are not presently maintained or updated. The few exceptions would be for those data elements that have shared code lists
with data elements included in the ECL for the maintained NCPDP Standards.
Various appendices provide lists of reject (and adjustment) codes. In addition, a cross-reference for Field Name changes has been provided. Reject Codes for the
Telecommunication Standard are listed in the External Code List (ECL) document.
NOTE: APPENDIX C PUBLICATION MODIFICATIONS PROVIDES A LISTING OF ALL APPROVED DATA ELEMENT CHANGES FOR ALL NCPDP STANDARDS. THE UPDATES INCLUDE
ALL MODIFICATIONS MADE SINCE THE LAST QUARTERLY PUBLICATION OF THE DATA DICTIONARY AND APPEAR IN BOLD PRINT.
Changes or additions to the NCPDP Data Dictionary and/or External Code List should be submitted on a Data Element Request Form (DERF). The process for submitting, reviewing,
approving and implementing data element changes is described in this document. For a copy of the most current DERF form please contact the Council office or see
www.ncpdp.org. Refer to the DERF for instructions on completing and submitting the form.
The MC Maintenance and Control Work Group meets quarterly at the Joint Technical Work Group Meetings to consider requests for the addition and/or modification of data
elements. Additions and modifications that have been approved by the membership at large will be published quarterly. NCPDP pledges its commitment to maintain, modify,
enhance and disseminate information pertaining to the Data Dictionary consistent with the goals of the organization and its membership.
STANDARD FORMATS KEY (THROUGHOUT DOCUMENT)
A = Post Adjudication Standard I = Benefit Integration Standard

B = Batch Standard J = Medical Rebate Data Q = Specialized Implementation
E = Audit Transaction Standard Submission Standard Guide
F = Formulary & Benefit Standard K = Operating Rules R = Manufacturer Rebate Standard
G = Medicaid Subrogation L = Retiree Drug Subsidy S = SCRIPT Standard
H = Health Care ID Card N = Financial Information Reporting T = Telecommunication Standard
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U = Billing Unit Standard Compensation/Property & Y = Uniform Healthcare Payer Data
V = Prescription Transfer Standard Casualty Universal Claim Form Standard
W = Workers’ X = Prior Authorization Transfer Z = Universal Claim Form
FIELD and NAME of FIELD

The approval of the model-generated schemas for SCRIPT and Specialized Implementation Guide has introduced XML fields. The XML elements are listed in the main body of the
Data Dictionary. Note the XML elements do not support Field Numbers and the naming convention includes no spaces in the Field Name.
FIELD FORMAT VALUES

The following field format values are supported.
"N" = Unsigned Numeric, always right justified, zero filled and when used for dollar fields, have default values of zeros.
Example: 9(7)v999 represents 9999999.999
"D" = Signed Numeric, sign is internal and trailing (see section Internal Representation of Overpunch Signs), zero always positive, always right justified, zero filled dollar-
cents amount with 2 positions to the right of the implied decimal point, all other positions to the left of the implied decimal point and when used for dollar fields, have
default values of zeros.
Example: "D" fields of length 8 represent $$$$$$cc
"A/N" = Alpha/Numeric, upper case when alpha, always left justified, space filled, upper case, printable characters and default values of spaces
Example: X(14) represents “1234ABC44bbbbb“
“NX” = Numeric Extended, are always right justified and zero filled, with the right most position reserved for the sign. The field must be blank when not reported. The
symbol “b” indicates a “blank” or a “positive” value. The symbol “-“ indicates a negative value. Zeros represent a valid numeric value and do not mean “null”. All decimals
are implied not explicit.
Example: 9999v99- represents a negative 9999.99
9999v99b represents a positive 9999.99
“R” = Numeric 0-9 with decimal point

For numeric values that have a varying number of decimal positions, a decimal data element may contain an explicit decimal point and is used. This data element type is
represented as “R.”
The decimal point always appears if it is at any place other than the right most position. If the value is an integer (decimal point at the right most position), the decimal
point should be omitted. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus sign (+) should not be transmitted.
Leading zeros should be suppressed unless necessary to satisfy a minimum length requirement. Trailing zeros following the decimal point should be suppressed unless
necessary to indicate precision. The use of triad separators (for example, the commas in 1,000,000, 000,000) is prohibited. The length of a decimal type data element
does not include the decimal point. A value of 12345.67 is valid in a field defined with a maximum length of 7.
Example: A transmitted value of 12.34 represents a decimal value of 12.34.

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DATA DICTIONARY
A transmitted value of 25.4 when applied to a monetary use represents
$25.40.
There are certain data fields that allow an explicit decimal point in the Alpha/Numeric representation. See Implementation Guide for decimal discussion for specific data
elements.
The following field format values are supported in XML.
an = a sequence of characters, alphanumeric that must have at least 1 nonblank character, no constraint to length of the content (“string”). When length is constrained,
is shown as x(#) such as x(15), x(140).
n = numeric in the allowable values that must be sent with at least one valid value. Shown as 9(18), 9(2).
xsd:boolean = the type of an expression with two possible values, "True" and "False".
xsd:BooleanCode = NCPDP-defined backwards compatible type of expression with two possible values, “Y” and “N”.
xsd:datetime - Format = CCYY-MM-DDTHH:MM:SS
xsd:date - Format = CCYY-MM-DD
Format Limitations/Requirements
If a field requires explicit format limitations/requirements, it will be specified in this document. For example, Employer ID (333-CZ) has explicit format requirements.
Rules for Demographic Fields

The following rules apply to the creation of demographic fields used by all NCPDP standards. Exceptions when granted are noted in the comments of the field (i.e., compatibility
issues with external standards).
Organizational Names
Field Length is 70 (x70)
Individual Names
Separate fields must be created for first name, middle name (if required) and last name. Field Length of first name and last name is 35.
Street Address
Field Length is 40 (x40)
Address Line 1 and Address Line 2 are created.
City
Current range: 18-35 characters
All new city fields are 35 characters.
State/Province Address
All state/province codes are 2 characters
Field naming convention is “State/Province Address”
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DATA DICTIONARY
Country Code
All codes are 2 characters
Zip/Postal Codes
All codes are 15 characters
Field naming convention is “Zip/Postal Code”
Telephone Number
Field Length is 10 (9(10))
Separate field must be created for Extension with a length of 8 (9(8))
Fax numbers are not included in this rule.
INTERNAL REPRESENTATION OF OVERPUNCH SIGNS
UNITS SIGNED POSITIVE SIGNED NEGATIVE

Digit Graphics Oct Dec Hex Graphics Oct Dec Hex
0 { 173 123 7B } 175 125 7D
1 A 101 65 41 J 112 74 4A
2 B 102 66 42 K 113 75 4B
3 C 103 67 43 L 114 76 4C
4 D 104 68 44 M 115 77 4D
5 E 105 69 45 N 116 78 4E
6 F 106 70 46 O 117 79 4F
7 G 107 71 47 P 120 80 50
8 H 110 72 48 Q 121 81 51
9 I 111 73 49 R 122 82 52
NOTE: If you are not implementing Telecommunication Version 5.0 or higher, please refer to the appropriate data dictionary version and ECL publication to ensure the
appropriate field length, definitions and values are applied.
Any questions regarding the content or the intent of the information presented herein should be addressed to the Council office:

9240 East Raintree Drive
Scottsdale, AZ 85260
Phone (480) 477-1000
Fax (480) 767-1042
email ncpdp@ncpdp.org
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July 2016
DATA DICTIONARY
II. DATA ELEMENTS
FIELD NAME OF FIELD DEFINITION OF FIELD FIELD STANDARD FIELD VALUES COMMENTS / EXAMPLES
FORMAT FORMATS LENGTH
900-BN Absolute Row The absolute row or line number 9(10) F 10

Number in the file that contains the error.
601-86 Accepted Quantity Total quantity accepted for 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
payment. or
Note:
9(11)v999-
b = Space
- = Negative sign
512-FC Accumulated Amount in dollars met by the s9(6)v99 T,A 8 Format=s$$$$$$cc

Deductible Amount patient/family in a deductible
plan. Examples: The deductible amount on the patient’s
plan is $100.00. The patient purchases two
prescriptions, one for $15.00 and another for
$35.00. The accumulated deductible at that point
would be $50.00. This field would reflect: 500{.
653-S4 Accumulated Gross The accumulated cost incurred s9(6)v99 N 8 Format=s$$$$$$cc

Covered Drug Cost by the plan for covered Part D
Amount drugs including amounts paid by Example: If the amount is $5.50 this field would
or on behalf of an enrollee and reflect: 55{.
including certain dispensing fees,
but not including administrative
costs.
652-S3 Accumulated The accumulated cost for s9(6)v99 N 8 Format=s$$$$$$cc

Patient True Out Of covered Part D drugs incurred by
Pocket Amount a patient that are applicable Example: If the amount is $5.50 this field would
towards the out-of-pocket limit reflect: 55{.
set by the Centers for Medicare
and Medicaid Services (CMS).
B67 Accumulator Action Describes the accumulator x(2) I 2 See ECL

Code event/action that is requested by
the sender and the action to be
taken by the receiver.
B68 Accumulator Amount applied to the 9(8)v99 I 10 Format=$$$$$$$$cc

Applied Amount associated accumulator. Negative dollar designation is handled with the use
of the Action Code (711) field
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B69 Accumulator Code representing family or x(1) I 1 See ECL

Balance Benefit individual benefit.
Type
B70 Accumulator Identifies the type of x(2) I 2 See ECL

Balance Qualifier accumulator balance being
reported.
B71 Accumulator The number of accumulator 9(2) I 2

Balance Count balance groupings to follow.
B72 Accumulator Benefit The total accrued amount for the 9(8)v99 I 10 Format=$$$$$$$$cc
Period Amount benefit period. A benefit year is Negative dollar designation is handled with the use
normally known as YTD or (year of the Action Code (711) field
to date) amount.
B73 Accumulator Code indicating the activity that x(1) I 1 See ECL
Change Source Code caused the accumulator change.
655-S6 Accumulator Month Identifies the accumulator month 9(2) N 2 See ECL
based on date of service of
claims activity.
656-S7 Accumulator Month Count of Accumulator Month 9(2) N 2

Count (655-S6) occurrences.
B74 Accumulator Indicates the type of x(1) I 1 See ECL

Network Indicator accumulation based on network
contracting status.
B75 Accumulator The date and time the x(26) I 26 Format: CCYY-MM-DD-HH.MM.SS.mmmmmm
Reference Time accumulator was adjusted by the
Stamp sender of the record.
B76 Accumulator Amount remaining for the 9(8)v99 I 10 Format=$$$$$$$$cc

Remaining Balance associated accumulator within Negative dollar designation is handled with the use
the benefit period. of the Action Code (711) field
B77 Accumulator Identifies the accumulator x(2) I 2 See ECL

Specific Category specific condition/disease.
Type
650-S1 Accumulator Year Identifies the accumulator year. 9(4) N 4 Format=CCYY

CC=Century
YY=Year
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DATA DICTIONARY
AcknowledgementI Responder control reference x(35) S, Q 35

D This field may be used as a trace
number between trading
partners. For Resupply – In the
LTC environment this is the
prescription number assigned by
the facility.
AcknowledgementR Additional textual information x(100) S 100

eason regarding intervention and/or
acknowledgment associated with
a DUE conflict.
711 Action Code Processing action requested. x(1) I 1 See ECL
369-2Q Additional Unique identifier for the data x(3) T 3 See ECL
Documentation being submitted.
Type ID
AdditionalFreeText Free text x(2000) S 2000
AdditionalFreeTextI Indicates if the prescriber is x(2) S 2 See ECL

ndicator allowed to supply additional free
text with their answer to the
question.
AdditionalMessageI Designates if a subsequent xsd:boolean Q

ndicator transaction will be sent.
526-FQ Additional Message Free text message. x(1)-x(40) T 40

Information --------------- ------------- -------------
x(100) - F,N 100 -
-------------- --------------- ------------
x(200) V,X 200
131-UG Additional Message Indicates continuity of the text x(1) T 1 See ECL
Information found in the current repetition of
Continuity Additional Message Information
(526-FQ) with the text found in
the next repetition that follows.
130-UF Additional Message Count of the Additional Message 9(2) T 2

Information Count Information (526-FQ)
occurrences that follow.
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DATA DICTIONARY
132-UH Additional Message Format qualifier of the Additional x(2) T 2 See ECL Comments: Qualifies Additional Message
Information Message Information (526-FQ) Information (526-FQ).
Qualifier that follows. Each value may
occur only once per transaction
and values must be ordered
sequentially (numeric characters
precede alpha characters, i.e., 0-
9, A-Z).
AdditionalRefillsAut Number of additional refills 9(2) S 2

horized authorized.
AdditionalTraceNum Trace number between trading x(3) S, Q 3

ber partners.
603-MY Address Count Count of address occurrences. 9(1) V 1 Comments: For Prescription Transfer, fields
included in the set/logical grouping are: Address
Qualifier (604-NA), Effective Date (609-NG),
Address Line 1 (726-SR), Address Line 2 (727-SS),
City (728-SU), State/Province Address (729-TA),
Zip/Postal Code (730-TC).
AddressLine1 First line of address information. x(40) S,Q 40
726-SR Address Line 1 First line of address information. x(40) A,R,V 40 Comments: For Prescription Transfer, qualified by
ADDRESS QUALIFIER (604-NA)
AddressLine2 Second line of address x(40) S,Q 40

information.
727-SS Address Line 2 Second line of address x(40) A,R,V 40 Comments: Second line of street address. Used only
information. if first line will not accommodate a complete
address.
604-NA Address Qualifier Qualifier of the address. 9(2) V 2 See ECL

Qualifies the To or From.
AddressTypeQualifie an S,Q See ECL
r
The type of prescription benefit
A28-ZR Adjudicated plan that adjudicated and paid 9(2) T 2 See ECL
Payment Type the primary amount of the
prescription as reported by the
plan in a response.
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DATA DICTIONARY
578 Adjudication Date Date the claim or adjustment is 9(8) A,R,J,Y 8 Format=CCYYMMDD
processed.
CC=Century
YY=Year
MM=Month
DD=Day
203 Adjudication Time Time the claim or adjustment is 9(6) A,R 6 Format=HHMMSS
processed.
HH=Hours
MM=Minutes
SS=Seconds
601-71 Adjusted Quantity A correction between the Total 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
Quantity (601-39) submitted and or
the ‘Accepted Quantity’ (601-86). 9(11)v999- Note:
b = Space
- = Negative sign
601-70 Adjusted Rebate Per The dollar difference between 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
Unit the Rebate Per Unit Amount 9b
(601-52) and the Paid Per Unit or Note:
Amount (601-95). 9(5)v99999
b = Space
9-
- = Negative sign
601-72 Adjusted Variance The Total Quantity (601-39) 9(9)v99b or R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
Difference times the Adjusted Rebate Per 9(9)v99-
Unit (601-70) amount. Note:
b = Space
- = Negative sign
204 Adjustment Reason Reason for adjustment x(3) A 3 For A:

Code __________ _________ _________ _____________________________________
Comments: Codes defined by processor.
x(1) I 1 See ECL
205 Adjustment Type Type of adjustment. x(1) A 1 See ECL
AdministrationIndic Indicates the action to be taken an S See ECL

ator on the Administration fields.
AdministrationTimin Used to add clarity to the x(255) S 255

gClarifyingFreeText administration timing for
elements that cannot be
codified.
AdministrationTimin The code representing the an S Qualified by AdministrationTimingEventQualifier.

gEventCode AdministrationTimingEventText.
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DATA DICTIONARY
AdministrationTimin Qualifier to identify the code an S See ECL

gEventQualifier system being used.
AdministrationTimin The textual representation of an S

gEventText AdministrationTimingEventCode.
AdministrationTimin The code representing the an S Qualified by

gModifierCode AdministrationTimingModifierTe AdministrationTimingModifierQualifier.
xt.

gModifierQualifier system being used.
AdministrationTimin The textual representation of the an S

gModifierText AdministrationTimingModifierCo
de. Used to clarify or specify
when the medication is to be
administered relative to the
actual timing event.
AdministrationTimin The numeric value for the 9(18) S 18

gNumericValue administration event, such as 30
(minutes).
AdministrationTimin The code representing the an S Qualified by AdministrationTimingUnitsQualifier.

gUnitsCode AdministrationTimingUnitsText.

gUnitsQualifier system being used.
AdministrationTimin The textual representation of an S

gUnitsText AdministrationTimingUnitsCode.
206 Administrative Fee Administrative fee charge per s9(2)v99 A 4 Format=s$$cc

Amount claim.
Example: If the amount is $5.50 this field would
reflect: 55{.
207 Administrative Fee Indicates how the transaction x(1) A 1 See ECL
Effect Indicator should be counted for
administrative fee
determination.
208 Age Calculated from Date of Birth 9(3) A 3 Format=YYY

(304-C4).
Y=Year
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DATA DICTIONARY
an
AllergyDrugProduct The code list used to identify the Q See ECL
CodedQualifier drug product to which the
patient is allergic.
A74 Allowed Amount Allowable charges for covered 9(9)v99b J 12 The amount of the patient co-pay or deductible is
services based on the specially not deducted from this amount.
negotiated fee between the or 9(9)v99-
provider and MCO. Format=$$$$$$$$$ccb or $$$$$$$$$cc-
b = Space
- = Negative sign
AlternateContactRel Alternate contact relationship to 9(2) S,Q 2 See ECL

ationship the patient.
330-CW Alternate ID Person identifier to be used for x(20) T 20

controlled product reporting.
Identifier may be that of the
patient or the person picking up
the prescription as required by
the governing body.
724-ST Alternate ID Alternate ID number assigned to x(20) V,X 20 Comments: Alternate ID number identifying
Number the cardholder or family member.
member.
B62-1M Alternatives Group ID assigned by payer to match x(40) F 40

ID the Formulary Alternatives
Triggers record.
901-BP Alternatives ID ID for the alternative list. x(10) F 10
B63-1N Alternatives List Indicates the type of Alternatives x(2) F 2 See ECL
Type List.
- 10 -
July 2016
DATA DICTIONARY
517-FH Amount Applied To Amount to be collected from a s9(6)v99 T,A 8 For T,A: Format=s$$$$$$cc
Periodic Deductible patient that is included in Patient _______ _________ _______
Pay Amount (505-F5) that is Examples: A patient has a $50.00 deductible to
applied to a periodic deductible. 9(6)v99 Y 8 meet. The patient’s first prescription costs $95.00.
or The amount applied to the periodic deductible
-9(5)v99 would reflect $50.00. This field would reflect: 500{.
A patient has a $100.00 deductible to meet. The
patient has previously met $80.00 of the
deductible. The next prescription purchased costs
$42.00. The amount applied to the periodic
deductible would reflect $20.00. This field would
reflect: 200{.
For Y:
Format=$$$$$$cc or -$$$$$cc
Note:
- = Negative sign
This minus (-) sign occupies a position, so the
dollars that can be supported are one digit less than
a positive dollar amount.
See important information in the Uniform
Healthcare Payer Data Standard for dollar field
usage.
137-UP Amount Attributed Amount to be collected from the s9(6)v99 T,A 8 For T,A: Format = s$$$$$$cc
to Coverage Gap patient that is included in Patient
Pay Amount (505-F5) that is due _______ _________ _______ Example: If the amount is $5.50 this field would
to the patient being in the reflect: 55{.
9(6)v99 Y 8
coverage gap (for example or
Medicare Part D Coverage Gap For Y:
-9(5)v99 Format=$$$$$$cc or -$$$$$cc
(donut hole)). A coverage gap is
defined as the period or amount Note:
during which the previous - = Negative sign
coverage ends and before an This minus (-) sign occupies a position, so the
additional coverage begins. dollars that can be supported are one digit less than
usage.
- 11 -
July 2016
DATA DICTIONARY
571-NZ Amount Attributed Amount to be collected from the s9(6)v99 T,A 8 For T,A: Format = s$$$$$$cc
to Processor Fee patient that is included in Patient
to the processing fee imposed by reflect: 55{.
9(6)v99 Y 8
the processor. or For Y:
-9(5)v99 Format=$$$$$$cc or -$$$$$cc
__________ __________ _________ Note:
- = Negative sign
9(8)v99 I 10
usage.
For I: Format=$$$$$$$$cc
This field does not support negative dollar
amounts.
519-FJ Amount Attributed Amount to be collected from the s9(6)v99 A 8 For A: Format = s$$$$$$cc
To Product Selection patient that is included in Patient _______ _________ ________ 0
Pay Amount (505-F5) that is due For Y:
to the patient’s selection of drug 9(6)v99 Y 8 Format=$$$$$$cc or -$$$$$cc
product. or Note:
-9(5)v99 - = Negative sign
usage.
- 12 -
July 2016
DATA DICTIONARY
134-UK Amount Attributed Amount to be collected from the s9(6)v99 T,A 8 For T,A: Format = s$$$$$$cc
to Product Selection patient that is included in Patient
/ Brand Drug Pay Amount (505-F5) that is due _______ _________ _______ Example: If the amount is $5.50 this field would
to the patient’s selection of a reflect: 55{.
9(6)v99 Y 8
brand product. or For Y:
9(5)v99 Format=$$$$$$cc or -$$$$$cc
__________ __________ _________ Note:
- = Negative sign
9(8)v99 I 10
usage.
amounts.
136-UN Amount Attributed Amount to be collected from the s9(6)v99 T,A 8 For T,A: Format = s$$$$$$cc
/ Brand Non- Pay Amount (505-F5) that is due _______ _________ _______ Example: If the amount is $5.50 this field would
Preferred Formulary to the patient’s selection of a reflect: 55{.
9(6)v99 Y 8
Selection Brand Non-Preferred Formulary or
product. For Y:
-9(5)v99 Format=$$$$$$cc or -$$$$$cc
Note:
- = Negative sign
usage.
135-UM Amount Attributed Amount to be collected from the s9(6)v99 T,A 8 For T,A: Format = s$$$$$$cc
/ Non-Preferred Pay Amount (505-F5) that is due _______ _________ _______ Example: If the amount is $5.50 this field would
Formulary Selection to the patient’s selection of a reflect: 55{.
9(6)v99 Y 8
Non-Preferred Formulary or
product. For Y:
-9(5)v99 Format=$$$$$$cc or -$$$$$cc
Note:
- = Negative sign
usage.
- 13 -
July 2016
DATA DICTIONARY
133-UJ Amount Attributed Amount to be collected from the s9(6)v99 T,A 8 For T,A: Format = s$$$$$$cc
to Provider patient that is included in Patient
Network Selection Pay Amount (505-F5) that is due _______ _________ _______ Example: If the amount is $5.50 this field would
to the patient’s provider network reflect: 55{.
9(6)v99 Y 8
selection. or For Y:
-9(5)v99 Format=$$$$$$cc or -$$$$$cc
Note:
- = Negative sign
usage.
523-FN Amount Attributed Amount to be collected from the s9(6)v99 T,A 8 For T,A: Format = s$$$$$$cc
To Sales Tax patient that is included in Patient
Pay Amount (505-F5) that is due _______ _________ _______ Examples: The patient may be required to pay some
to sales tax paid. portion of the sales tax on a prescription. If the
9(6)v99 Y 8 patient pays 1.5% of the sales tax on a $50.00
or prescription, this field would reflect: 7E.
-9(5)v99
__________ __________ _________ For Y:
9(8)v99 I 10 Note:
- = Negative sign
usage.
amounts.
- 14 -
July 2016
DATA DICTIONARY
520-FK Amount Exceeding Amount to be collected from the s9(6)v99 T,A 8 For T,A: Format = s$$$$$$cc
Periodic Benefit patient that is included in Patient
Maximum Pay Amount (505-F5) that is due _______ _________ _______ Examples: The patient is allowed a specific benefit
to the patient exceeding a amount. When the maximum benefit amount is
9(6)v99 Y 8 exceeded, the remainder of the prescription price is
periodic benefit maximum. or added to the amount the patient pays in field 505-
-9(5)v99 F5. If the amount exceeded is $32.56, this field
would reflect: 325F.
For Y:
Note:
- = Negative sign
usage.
Amount of
572-4U Coinsurance Amount to be collected from the s9(6)v99 T,A 8 For T,A: Format = s$$$$$$cc
patient that is included in Patient
_______ _________ _______ Example: If the amount is $5.50 this field would
Pay Amount (5∅5-F5) that is due
reflect: 55{.
to a per prescription 9(6)v99 Y 8
coinsurance. or For Y:
-9(5)v99 Format=$$$$$$cc or -$$$$$cc
Note:
- =Negative sign

usage.
- 15 -
July 2016
DATA DICTIONARY
Amount to be collected from the
518-FI Amount Of Copay patient that is included in Patient s9(6)v99 T,A 8 For T,A: Format = s$$$$$$cc
to a per prescription copay. reflect: 55{.
9(6)v99 Y 8
or For Y:
-9(5)v99 Format=$$$$$$cc or -$$$$$cc
__________ __________ _________ Note:
- = Negative sign
9(8)v99 I 10 This minus (-) sign occupies a position, so the
usage.
amounts.
601-73 Amount Paid This Dollar amount paid with this 9(9)v99b or R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
Transaction transaction. 9(9)v99-
Note:
b = Space -
= Negative sign
Answer Value for the answer. x(2000) S 2000
AnswerValue Coded reference value for the x(255) S 255

answer.
Date Format=CCYY-MM-DD
AnticipatedDischarg Indicates expected date of xsd:date or S CC=Century
eDate patient's discharge from facility. xsd:datetim YY=Year
e MM=Month
DD=Day
Example: 2010-10-01
DateTime Format= CCYY-MM-DDTHH:MM:SS

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
- 16 -
July 2016
DATA DICTIONARY
AnticipatedReturnD The date on which the patient is xsd:date Q CC=Century
ate expected to return to the care YY=Year
facility. MM=Month
DD=Day
Example: 2010-10-01
AppealCaseID ID assigned by the payer to x(35) S 35

identify the specific appeal
request.
A95 Application ID Application ID assigned by CMS 9(10) L 10

to the Plan Sponsor applying for
the Retiree Drug Subsidy.
See ECL
548-6F Approved Message Message code, on an approved x(3) T,E 3
Code claim/service, communicating
the need for an additional follow-
up.
547-5F Approved Message Count of the Approved Message 9(1) T 1

Code Count Code (548-6F) occurrences.
Associated
457-EP Prescription/Service Date of the Associated 9(8) T,A 8 Format=CCYYMMDD
Date Prescription/Service Reference
Number (456-EN). CC=Century
YY=Year
MM=Month
DD=Day
582-X0 Associated Related Fill Number to which the 9(2) T 2

Prescription/Service claim/service is associated.
Fill Number
580-XY Associated Related Service Provider ID to x(15) T 15 Comments: Qualified by Associated

Prescription/Service which the claim/service is Prescription/Service Provider ID Qualifier (579-XX).
Provider ID associated.
579-XX Associated Code qualifying the Associated x(2) T 2 See ECL Comments: Qualifies Associated
Prescription/Service Prescription/Service Provider ID Prescription/Service Provider ID (580-XY).
Provider ID Qualifier (580-XY) to which the
claim/service is related.
456-EN Associated Related Prescription/Service 9(12) T,A 12 Comment: Qualified by Associated

Prescription/ Reference Number (402-D2) to Prescription/Service Reference Number Qualifier
Service Reference which the service is associated. (581-XZ).
Number
- 17 -
July 2016
DATA DICTIONARY
581-XZ Associated Code qualifying the Associated x(2) T 2 See ECL Comments: Qualifies Associated
Prescription/Service Prescription/Service Reference Prescription/Service Reference Number (456-EN).
Reference Number Number ID (456-EN) to which the
Qualifier claim/service is related.
AttachmentControl Indicates the control number of an S

Number the attachment.
AttachmentData The actual attachment. xsd:base64 Q

Binary
AttachmentSource The source of the attachment. an Q
A48 Audit Control Internal identification assigned x(30) E 30

Identification by the audit entity to identify this
transaction.
A62 Audit Element Indicates status of the Audit x(2) E 2 See ECL
Response 1 Element Type.
A57 Audit Element Type Indicates type of information for x(2) E 2 See ECL
1 associated Prescription/Service
Reference Number(s).
- 18 -
July 2016
DATA DICTIONARY
A56 Audit Range End Indicates the ending of the audit x(19) E 19
range of data.
A54 Audit Range Indicates the type of range being 9(2) E 2 See ECL
Qualifier requested.
A55 Audit Range Start Indicates the beginning of the x(19) E 19

audit range of data.
A47 Audit Request Type Type of audit being requested. x(2) E 2 See ECL
A49 Audit Sponsor Payer, Plan Sponsor or PBM who x(30) E 30

is requesting the audit be
performed.
AuthorizationNumb See Authorization Number (503– an Q

er F3)
503-F3 Authorization Number assigned by the x(20) T,A,N,E 20

Number processor to identify an
authorized transaction.
498-PH Authorized Free-form text for city name. x(20) T 20

Representative City
Address
B34-1U Authorized Code of the country. x(2) T 2 See ECL

Representative
Country Code
498-PE Authorized First name of the patient’s x(35) T 35

Representative First authorized representative.
Name
498-PF Authorized Last name of the patient’s x(35) T 35

Representative Last authorized representative.
Name
498-PJ Authorized State/Province Code of the x(2) T 2 See ECL

Representative authorized representative.
State/Province
Address
- 19 -
July 2016
DATA DICTIONARY
B13-7D Authorized Free-form text for address line 1 x(40) T 40

Representative information.
Street Address Line
1
B14-8B Authorized Free-form text for address line 2 x(40) T 40

Representative information.
Street Address Line
2
498-PK Authorized Code defining international x(15) T 15 Comments: When used for US ZIP Code - This left-
Representative postal code of authorized justified field contains the five-digit zip code, and
Zip/Postal Code representative, excluding may include the four-digit expanded zip code in
punctuation. which the patient's authorized representative is
located.
Examples: If the zip code is 98765-4321, this field

would reflect: 987654321.
If the zip code is 98765, this field would reflect:
98765 left justified.
When used for Canadian Postal Code – This left

justified field contains the three-digit forward
sortation area (FSA) followed by a space, then
followed by a Local Delivery Unit. (Format A0A
0A0, where A is a letter and 0 is a digit, with a space
separating the third and fourth characters.)
Examples:
A0E 3B0
A1L 2T8
AvailabilityEndDate Indicates the date after which xsd:date or Q CC=Century
the payer is no longer available xsd:datetim YY=Year
to the resident. e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
- 20 -
July 2016
DATA DICTIONARY
AvailabilityStartDate Indicates the date the payer xsd:date or Q CC=Century
becomes available to the xsd:datetim YY=Year
resident. e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
209 Average Cost Per Average Cost Per Quantity as s9(5)v9999 A 9 Format=s$$$$$cccc
Quantity Unit Price defined by processor.
reflect: 5500{.
210 Average Generic Average Generic Price per unit as s9(5)v9999 A 9 Format=s$$$$$cccc
Unit Price defined by processor.
reflect: 5500{.
211 Average Wholesale Average Wholesale Price per unit s9(5)v9999 A 9 Format=s$$$$$cccc
Unit Price for the drug as defined by
processor. Example: If the amount is $5.5000 this field would
reflect: 5500{.
See ECL
573-4V Basis of Calculation - Code indicating how the x(2) T, A 2
Coinsurance Coinsurance reimbursement
amount was calculated for
Patient Pay Amount (505-F5).
Code indicating how the Copay See ECL
347-HJ Basis Of Calculation- reimbursement amount was x(2) T,A 2
Copay calculated for Patient Pay
Amount (505-F5).
See ECL
346-HH Basis Of Calculation- Code indicating how the x(2) T,A 2
Dispensing Fee reimbursement amount was
calculated for Dispensing Fee
Paid (507-F7).
- 21 -
July 2016
DATA DICTIONARY
See ECL
348-HK Basis Of Calculation- Code indicating how the x(2) T,A 2
Flat Sales Tax reimbursement amount was
calculated for Flat Sales Tax
Amount Paid (558-AW).
See ECL
349-HM Basis Of Calculation- Code indicating how the x(2) T,A 2
Percentage Sales reimbursement amount was
Tax calculated for Percentage Sales
Tax Amount Paid (559-AX).
See ECL
423-DN Basis Of Cost Code indicating the method by x(2) T,Z,W 2
Determination which Ingredient Cost Submitted
(409-D9) was calculated.
See ECL
522-FM Basis Of Code identifying how the 9(2) T,A 2
Reimbursement reimbursement amount was
Determination calculated for Ingredient Cost
Paid (506-F6).
See ECL
498-PD Basis Of Request Code describing the reason for x(2) T 2 Comments: Used by processor to determine
prior authorization request. appropriate modules and editing for the prior
authorization transaction.
806-5C Batch Number This number is assigned by the 9(7) B 7 For B:

processor/sender. _________
A,V,X,I Format=CCYYDDD
For A,V,X,I:
CC=Century
A number generated by the YY=Year
sender to uniquely identify this DDD=Julian date
batch from others, especially
when multiple batches may be Examples: 2002252=September 9, 2002
sent in one day.
For A,V,X,I:
Format=9999999
Example: A batch number of 4113 would be
0004113 or 4113
Bed The bed of the patient. x(10) S,Q 10
671-W1 Bed The bed of the patient. x(10) V 10
BeeperExtension Extension of the beeper number. 9(8) S,Q 8
- 22 -
July 2016
DATA DICTIONARY
BeeperNumber
Beeper number of the entity. 9(10) S,Q 10 Format=AAAEEENNNN
AAA=Area Code
EEE=Exchange Code
NNNN=Number
BeeperSupportsSMS Indication the number accepts xsd:Boolean S,Q See ECL

text messages. Code
A00 Benefit Amount Represents the amount of the 9(7)v99 X 9 Format=$$$$$$$cc

overridden amount to be applied
in place of the standard plan
benefit.
A01 Benefit Amount Defines how the Benefit Amount 9(1) X 1 See ECL
Time Period Type override is to be applied
during a time period and
corresponds to the plan’s benefit
accrual period.
A02 Benefit Amount Represents which of the benefit 9(1) X 1 See ECL
Type accumulation types is being
overridden and also has an
option to override all benefit
amounts. This amount is usually
set to an amount outside of the
normal plan benefit coverage
level.
A03 Benefit Amount Indicates the aggregated amount 9(7)v99 X 9 Format=$$$$$$$cc

Used To-Date of benefit used to date against a
previously approved override
amount.
Format=CCYYMMDD
761 Benefit Effective Effective date of the benefit. 9(8) I 8
Date CC=Century
YY=Year
MM=Month
DD=Day
757-U6 Benefit ID Assigned by processor to identify x(15) A,T 15 Comments: Note: For Part D, used to identify the
a set of parameters, benefits, or PBP (Plan Benefit Package) Number.
coverage criteria used to
adjudicate a claim.
- 23 -
July 2016
DATA DICTIONARY
394-MW Benefit Stage The amount of claim allocated to s9(6)v99 T,A 8 Format=s$$$$$$cc
Amount the Medicare Part D benefit
stage, allocated to other Example: If the amount is $5.50 this field would
Medicare benefit, or paid by an reflect: 55{.
alternative benefit coordinated
with or by the responding
Medicare Part D payer as
identified by the Benefit Stage
Qualifier (393-MV).
Comments: Fields included in the set/logical
392-MU Benefit Stage Count Count of Benefit Stage Amount 9(1) T 1 grouping are:
(394-MW) occurrences. Benefit Stage Qualifier (393-MV)
Benefit Stage Amount (394-MW)
Comments: Qualifies Benefit Stage Amount (392-
393-MV Benefit Stage Code qualifying the Benefit Stage x(2) T,R,A 2 See ECL MW).
Qualifier Amount (394-MW).
759 Benefit Termination Date benefit will terminate. 9(8) I 8 Format=CCYYMMDD

Date (Coverage continues through
midnight of date submitted). CC=Century
YY=Year
MM=Month
DD=Day
212 Benefit Type Indicates the type of acceptable x(1) A,I 1 See ECL
claims for the group based on
the benefit setup.
A75 Billed Amount Total reasonable and customary 9(9)v99b J 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
fee providers charge to provide
the type of service received. or 9(9)v99- b = Space
- = Negative sign
213 Billing Cycle End Cycle end date. 9(8) A 8 Format=CCYYMMDD

Date
CC=Century
YY=Year
MM=Month
DD=Day
117-TR Billing Entity Type A code that identifies the entity 9(2) T 2 See ECL
Indicator submitting the billing
transaction.
A67 Billing Sequence Code Identifying the billing x(2) E 2 See ECL
sequence of the claim.
- 24 -
July 2016
DATA DICTIONARY
Comments: Each processor will need to have an IIN
101-A1 BIN Number Card Issuer ID or Bank ID Number 9(6) T,N,Z,E 6 (formerly BIN) assigned by:
used for network routing. American National Standards Institute
25 West 43rd Street
New York, NY 10036
(212) 642-4900
or a Processor Number assigned by:
9240 E Raintree Dr
Scottsdale, AZ 85260-7518
Phone: (480) 477-1000
Fax: (480) 767-1042 Contact:
NCPDP Provider Services
http://www.ncpdp.org
See ECL
BodyMetricQualifier Qualifier to identify the body an S
metric being used (either weight
or surface area).
Qualified by BodyMetricQualifier.
BodyMetricValue Expresses the value of the body 9(18) S 18
metric.
Format=9(15)v9(3)
See ECL
BodyType The XML transaction types. an S, Q
See ECL
686 Brand/Generic Denotes brand or generic drug x(1) W,I 1
Indicator dispensed.
BusinessName Name of the business. x(70) S,Q 70
CalculatedDoseNum Expresses the numeric value of 9(18) S 18

eric the calculated dose.
CalculatedDoseUnit Code representing the an S Qualified by

OfMeasureCode CalculatedDoseUnitOfMeasureTe CalculatedDoseUnitOfMeasureQualifier.
xt.
CalculatedDoseUnit Qualifier to identify the code an S See ECL

OfMeasureQualifier system being used.
CalculatedDoseUnit The textual representation of the an S

OfMeasureText CalculatedDoseUnitOfMeasureCo
de.
- 25 -
July 2016
DATA DICTIONARY
CalculatedPrescripti Calculated selling price for the an Q Format=s$$$$$$$$.cc to the length of the dollar
onSellingPrice prescription. Could be Usual and amount exchanged.
Customary or Gross Amount Due.
If negative, the – is used. If positive, no sign is used
and does not occupy a position.
- = Negative sign
. = Decimal point
Example: If the amount is a positive $5.50 this field
would reflect: 5.50
Example: If the amount is a negative $5.50 this field
would reflect: -5.50
214 Cardholder Date Of Date of Birth of Member. 9(8) A 8 Format=CCYYMMDD

Birth CC=Century
YY=Year
MM=Month
DD=Day
312-CC Cardholder First Individual first name. x(12) T,Z 12 Examples: JOHN
Name --------------- --------------- -------------
x(35) V 35 Note: Field size for the Telecommunication
Standard does not conform to the demographic
rules to remain compatible with PDF-417 ID Card
size limit.
CardholderID Insurance ID assigned to the x(35) S,Q 35

cardholder or identification
number used by the plan.
302-C2 Cardholder ID Insurance ID assigned to the x(20) T,A,N,Z,V,X,I 20 Size of 128 is used in Uniform Healthcare Payer
cardholder or identification _______ _________ _______ Data Standard for possible encrypted data.
number used by the plan.
x(128) Y 128
313-CD Cardholder Last Individual last name. x(15) T,Z 15 Examples: SMITH
Name --------------- -------------- -------------
x(35) V,I 35 Note: Field size for the Telecommunication
Standard does not conform to the demographic
rules to remain compatible with PDF-417 ID Card
size limit.
B94 Cardholder Type Code to identify the type of X(2) H 2 See ECL
Code cardholder for which the health
care ID card is issued.
A36 Card Purpose Code Code to identify the reason the x(1) H 1 See ECL
Health Care card is issued.
- 26 -
July 2016
DATA DICTIONARY
807-1D Carrier Address Address of the carrier. x(25) W 25
327-CR Carrier ID Carrier code assigned in Worker’s x(10) T 10

Compensation Program.
809-1F Carrier Location City This field identifies the name of x(18) W 18
the city in which the carrier is
located.
810-1G Carrier Location State of the carrier. x(2) W 2 See ECL

State/Province
Address
811-1H Carrier Name Name of the carrier. x(25) W 25
215 Carrier Number Account number assigned during x(10) A,I 10

installation.
813-1J Carrier Zip/Postal Code defining international x(15) W 15 Comments:

Code postal code of the carrier,
excluding punctuation. When used for US ZIP Code - This left-justified field
contains the five-digit zip code, and may include the
four-digit expanded zip code.

followed by a Local Delivery Unit. (Format A0A 0A0,
where A is a letter and 0 is a digit, with a space
Examples:
A0E 3B0
A1L 2T8
CensusEffectiveDate The date that census event was xsd:date Q CC=Century
effective.
YY=Year
MM=Month
DD=Day
Example: 2010-10-01
- 27 -
July 2016
DATA DICTIONARY
CFOrderID Unique Identifier assigned by the an Q

pharmacy for the prescription
fulfillment order.
600-63 Change Date Identifies the date the change is 9(8) R 8 Format=CCYYMMDD
effective.
CC=Century
YY=Year
MM=Month
DD=Day
See ECL
600-64 Change Identifier Identifies type of change being x(1) R, F 1
made.
ChangeOfPrescriptio Used in the CancelRx message an S See ECL

nStatusCode when the prescriber wishes
to notify the pharmacy to no
longer continue dispensing
any open refills on an
active prescription or to cancel a
prescription that has not yet
been dispensed.
ChangeReasonText Explanation of the reason for the x(260) S 260

change request.
216 Check Date Member Claims - Actual member 9(8) A,Y 8 Format=CCYYMMDD
check date. Nonmember Claims -
Pharmacy check date. CC=Century
YY=Year
MM=Month
DD=Day
ChildResistantPacka Indicator the prescription xsd:Boolean Q See ECL

ge requires child resistant Code
packaging.
ChoiceID ID assigned by the payer to x(35) S 35

identify the answer choice for a
question.
ChoiceText Answer choice text. x(2000) S 2000
City Free-form text for city name. x(35) S,Q 35
728-SU City Free-form text for city name. x(20) _____ R,V 20
x(30) _________ ________
A,Y 30
- 28 -
July 2016
DATA DICTIONARY
A04 Claim Cost Ceiling Represents either the specific 9(7)v99 X 9 Format=$$$$$$$cc
Override Amount copay Gross Amount Due or the
Gross Amount Due Ceiling that
the prior authorization is
overriding.
217 Claim Date Received Date paper claim was received in 9(8) A 8 Format=CCYYMMDD
In The Mail the mail.
CC=Century
YY=Year
MM=Month
DD=Day
218 Claim Media Type Claim submission type code. x(1) A 1 See ECL
601-68 Claim Number A unique identifier for a x(20) R,J 20

prescription and claim processor
A05 Claim Origination From the plan's perspective, the 9(1) X 1 See ECL
method/system/application by
which the payer received the
claim.
A88 Claim Processed Code defining which perspective x(2) Y 2 See ECL
Code in the possible coordination of
benefits flow the payer reflected
when adjudicating the claim.
435-DZ Claim/Reference ID Identifies the claim number x(30) T,A,W 30

assigned by Worker’s
Compensation Program.
219 Claim Sequence Indicates the sequence of this 9(5) A,E 5

Number claim within the set of claims
submitted.
ClarifyingFreeText Used to add clarity for the entire x(255) S 255

structured Sig for elements that
cannot be codified within the
specific sections.
220 Client Assigned The location of the member x(20) A 20

Location Code within the Client's Company from
Client eligibility when submitted
by the client.
221 Client Formulary Indicates that client has a x(1) A 1 See ECL
Flag formulary.
- 29 -
July 2016
DATA DICTIONARY
605-NB Client Name Name of client. x(70) V,X 70
222 Client Pass Through Information from client eligibility x(200) A 200
when submitted by the client. _______ ________ _______
x(50) I 50
223 Client Pricing Basis Code indicating the method by x(2) A 2 See ECL
Of Cost which ingredient cost submitted
is calculated based on client
pricing.
224 Client Specific Data Trading partners mutually agreed x(50) A 50

upon specific data defined by
client.
ClinicalInfoFormatsR Types of clinical information an Q See ECL

equested formats the sender can handle.
493-XE Clinical Information Counter number of clinical 9(1) T 1 Comments: Fields in the logical set/grouping may
Counter information measurement include:
set/logical grouping.
Measurement Date (494-ZE)
Measurement Time (495-H1)
Measurement Dimension (496-H2)
Measurement Unit (497-H3)
Measurement Value (499-H4)
See ECL
ClinicalInformation Qualifies how the an S
Qualifier PrimaryDiagnosis was obtained.
See ECL
ClinicalInfoTypesRe Requested patient clinical an Q
quested information types.
See ECL
ClinicalSignificanceC Code identifying the significance an S
ode or severity level of a clinical
event as contained in the
originating database.
See ECL
528-FS Clinical Significance Code identifying the significance x(1) T 1
Code or severity level of a clinical
event as contained in the
originating database.
- 30 -
July 2016
DATA DICTIONARY
CMS Low Income Free-form text that provides the Format= If yes or no is supported, the field contains
138-UQ Cost Sharing (LICS) low-income subsidy copay level x(20) T 20 Y or N.
Level for a Part D patient.
Format= If dollar ranges supported, the format is
$nn/$nn/$nn where the literal “$” is used, then the
dollar amount, then the literal “/” to separate
ranges. If only one dollar amount is supported, the
format is $nn. The dollar amount is variable, such as
n, nn, nnn.
Format= If percentage is supported, the format is
nn%/nn%/nn% where the literal “%” is used, then
the percentage amount, then the literal “/” to
separate ranges. If only one percentage is
supported, the format is nn%. The percentage
amount is variable, such as n, nn, nnn. An individual
percentage amount must not be larger than nnn
(100).
Examples:
Y
N
y=yes
n=no
$0
$2/$5
$1/$3
15%
10%/25%/50%
CMS Part D Contract Designation assigned by CMS Format= ANNNN
A33-ZX ID that identifies a specific x(5) N,A 5
Medicare Part D sponsor.
CMS Part D Defined
997-G2 Indicates that the patient resides x(1) T,A 1 See ECL
Qualified Facility
in a facility that qualifies for the
CMS Part D benefit.
Qualified by CoAgentQualifier.
CoAgentCode Identifies the co-existing agent an S
contributing to the DUR event
(drug or disease conflicting with When CoAgentCode is used, the CoAgentQualifier
the prescribed drug or prompting must be present.
pharmacist professional service).
CoAgentCodeDescri The textual representation of an S

ption CoAgentCode.
CoAgentQualifier Code qualifying the value in an S See ECL When CoAgentQualifier is sent, the CoAgentCode
CoAgentCode. must be present.
Coating Drug coating from a drug imprint an Q

database.
- 31 -
July 2016
DATA DICTIONARY
225 COB Carrier Submit The amount submitted by the s9(6)v99 A 8 Format=s$$$$$$cc
Amount COB carrier.
reflect: 55{.
226 COB Primary Claim For secondary coordination of x(1) A 1 See ECL
Type benefits claims. Indicates the
claim type of the primary claim.
Amount paid by primary payer
228 COB Primary Payer s9(6)v99 A 8 Format=s$$$$$$cc
for product or service.
Amount Paid Example: If the amount is $5.50 this field would
reflect: 55{.
229 COB Primary Payer Coinsurance amount according s9(6)v99 A 8 Format=s$$$$$$cc

Coinsurance to primary payer for product or
service.
reflect: 55{.
230 COB Primary Payer Co-pay amount according to s9(6)v99 A 8 Format=s$$$$$$cc

Copay primary payer for product or
service.
reflect: 55{.
231 COB Primary Payer Deductible amount according to s9(6)v99 A 8 Format=s$$$$$$cc

Deductible primary payer for product or
service.
reflect: 55{.
232 COB Primary Payer ID assigned to primary payer. x(10) A 10

ID
234 COB Secondary Amount paid by secondary payer s9(6)v99 A 8 Format=s$$$$$$cc

Payer Amount Paid for product or service.
reflect: 55{.
235 COB Secondary Coinsurance amount according s9(6)v99 A 8 Format=s$$$$$$cc

Payer Coinsurance to secondary payer for product
or service.
reflect: 55{.
236 COB Secondary Co-pay amount according to s9(6)v99 A 8 Format=s$$$$$$cc

Payer Copay secondary payer for product or
service.
reflect: 55{.
237 COB Secondary s9(6)v99 A 8 Format=s$$$$$$cc

Payer Deductible Deductible amount according to
secondary payer for product or Example: If the amount is $5.50 this field would
service. reflect: 55{.
238 COB Secondary ID assigned to secondary payer. x(10) A 10

Payer ID
- 32 -
July 2016
DATA DICTIONARY
CodedReferenceCod The code from the source. an S Comments: Qualified by CodedReferenceQualifier.

e
CodedReferenceDes The textual representation of the an S

cription CodedReferenceCode.
CodedReferenceQu Qualifier to identify the code an S See ECL

alifier system being used.
CodedSystemVersio The version of the code system an S

n used.
Color Drug color from a drug imprint an Q

database.
239 Communication For Mail Service Claims Only - x(2) A 2 See ECL
Type Indicator Identifies the type of
communication used by either
prescriber or patient to initiate
the request for the fill.
ComparisonOperato Code that conveys the an S See ECL

r relationship between the
answered value to a question
and a defined boundary.
ComparisonValue Value for the boundary of the 9(18) S 18

comparison.
CompoundCode Code indicating whether or not an S See ECL

the prescription is a compound.
406-D6 Compound Code Code indicating whether or not 9(1) T,A,R,V,Y 1 See ECL
the prescription is a compound.
451-EG Compound NCPDP standard product billing 9(1) T,Z,W 1 See ECL
Dispensing Unit codes.
Form Indicator
450-EF Compound Dosage Dosage form of the complete x(15) T,Z,W 15 See ECL
Form Description compound mixture.
Code
A06 Compound Indicator Code indicating if the prior 9(1) X 1 See ECL
authorization applies to
compounded products only.
- 33 -
July 2016
DATA DICTIONARY
490-UE Compound Code indicating the method by x(2) T,A,Z,W 2 See ECL
Ingredient Basis of which the drug cost of an
Cost Determination ingredient used in a compound
was calculated.
For Telecommunication:
447-EC Compound Count of compound product IDs 9(2) T,A,Z,W 2 Comments: Fields included in the set/logical
Ingredient (both active and inactive) in the grouping are:
Component Count compound mixture submitted. Compound Product ID Qualifier (488-RE)
Compound Product ID (489-TE)
Compound Ingredient Basis of Cost Determination
(490-UE)
Compound Ingredient Quantity (448-ED)
Compound Ingredient Drug Cost (449-EE)
Compound Ingredient Modifier Code Count (362-
2G)Compound Ingredient Modifier Code (363-2H)
449-EE Compound Ingredient cost for the metric s9(6)v99 T,A,Z,W 8 Format=s$$$$$$cc
Ingredient Drug decimal quantity of the product
Cost included in the compound Example: If the amount is $5.50 this field would
mixture indicated in Compound reflect: 55{
Ingredient Quantity (Field 448-
ED).
CompoundIngredien Name of drug. x(105) S 105 See also DrugDescription.

tItemDescription
363-2H Compound Identifies special circumstances x(2) T 2 See ECL

Ingredient Modifier related to the
Code dispensing/payment of the
product as identified in the
Compound Product ID (489-TE).
362-2G Compound Code indicating the number of 9(2) T 2

Ingredient Modifier Compound Ingredient Modifier
Code Count Code (363-2H)
CompoundIngredien Code identifying the compound an S

tProductCode ingredient product being
reported.
CompoundIngredien The code list defining the an S See ECL

tProductCodeQualifi CompoundIngredientProductCod
er e.
689 Compound Description of the ingredient x(30) Z,W 30

Ingredient Product being submitted.
Name
- 34 -
July 2016
DATA DICTIONARY
448-ED Compound Amount expressed in metric 9(7)v99999 T,A,Z,W 14 Format=9999999.9999999

Ingredient Quantity decimal units of the product 99
included in the compound
mixture.
A32-ZW Compound Measurement in minutes for the 9(4) T 4 Format= MMMM

Preparation Time preparation of the compound. M = Minute
Comment: 30 seconds and above, round to the next
minute. 29 seconds and below, round down.
489-TE Compound Product Product identification of an x(19) T,A,Z,W 19 Comments: Qualified by Compound Product ID
ID ingredient used in a compound. Qualifier (488-RE).
488-RE Compound Product Code qualifying the type of x(2) T,A,Z,W 2 See ECL Comments: Qualifies Compound Product ID (489-
ID Qualifier product dispensed. TE).
CompoundQuantity Qualifies an S See ECL

CodeListQualifier CompoundQuantityValue.
CompoundQuantity Amount expressed in metric 9(14) S 14 Qualified by CompoundQuantityCodeListQualifier.

Value decimal units of the product
included in the compound
mixture.
452-EH Compound Route of Code for the route of 9(2) A 2 See ECL
Administration administration of the complete
compound mixture.
996-G1 Compound Type Clarifies the type of compound. x(2) T,A 2 See ECL
Consent Patient Consent Indicator. an S,Q See ECL
B11 Contact Person First First Name of contact person. x(35) L 35

Name
B12 Contact Person Last Last name of contact person. x(35) L 35

Name
600-65 Contracting Contract number assigned by the x(15) R,J 15

Organization (PMO) contracting organization.
Contract Number
600-66 Contracting ID code assigned by the x(17) R,J 17

Organization (PMO) contracting organization.
ID Code
- 35 -
July 2016
DATA DICTIONARY
See ECL
600-71 Contracting Indicates the type of data being x(2) R,J 2
Organization (PMO) submitted in the Contracting
ID Qualifier Organization (PMO) ID Code
(600-66) field.
601-64 Contracting The market basket name or code x(17) R 17

Organization (PMO) being submitted to PICO to
Market Basket Code identify market basket being
submitted.
600-43 Contracting The name of the contracting x(70) R,J 70

Organization (PMO) organization.
Name
600-67 Contracting The total number of lives (the 9(9)b R 10 Format=999999999b or 999999999-
Organization (PMO) sum of enrollees and dependents or
Total Lives Covered or the product of enrollees and 9(9)- Note
calculation multiplier) covered by b = space
the contracting organization. - = negative sign
240-U1 Contract Number Account number assigned during x(8) A, T 8

installation for segments of ________ ________ _________
business.
x(15) I 15
337-4C Coordination of Count of other payment 9(1) T 1 Comments: Fields included in the set/logical
Benefits/Other occurrences. grouping are:
Payments Count
Other Payer Coverage Type (338-5C)
Other Payer ID Qualifier (339-6C)
Other Payer ID (340-7C)
Other Payer Date (443-E8)
Other Payer Amount Paid (431-DV)
Other Payer-Patient Responsibility Amount
Qualifier (351-NP)
Other Payer-Patient Responsibility Amount (352-
NQ)
Other Payer Amount Paid Count (341-HB)
Other Payer Amount Paid Qualifier (342-HC)
Benefit Stage Count (392-MU)
Benefit Stage Qualifier (393-MV)
Benefit Stage Amount (394-MW)
Other Payer-Patient Responsibility Amount Count
(353-NR)
or if rejected
Other Payer Reject Count (471-5E) and Other Payer
Reject Code (472-6E)
- 36 -
July 2016
DATA DICTIONARY
A07 Copay/Coinsurance Represents either the specific 9(7)v99 X 9 Format=$$$$$$$cc

Override Amount copay dollar amount or
coinsurance rate that is defined
in the prior authorization and is
qualified by the
Copay/Coinsurance Override
Type (A08).
A08 Copay/Coinsurance Indicator used to represent 9(1) X 1 See ECL

Override Type whether or not the override is
defined as a flat dollar amount or
as a percentage, and is usually
outside of the normal plan
benefit coverage level.
Percentage may be considered a
coinsurance amount.
A09 Copay Conjunction The sequence in which a multi- 9(1) X 1

Sequence tiered copay structure should be
applied.
906-BU Copay ID The membership population to x(40) F 40

which the copay rule applies.
907-BV Copay List ID ID for the benefit copay list. x(10) F 10 Comments: Qualified by Copay List Type (908-BW).
Comments: Qualifies Copay List ID (907-BV).

908-BW Copay List Type Code identifying the type of x(2) F 2 See ECL
copay being conveyed.
241 Copay Modifier ID Unique drug list ID that is x(10) A 10

coordinated for use with the
clients copay set-up. Processor
defined codes.
909-BX Copay Tier This medication’s Tier; an 9(2) F 2

indication of the cost to the
patient. Lower values represent
lower cost to the patient (e.g.,
Tier 1 is less costly to the patient
than Tier 2)
Format=s$$$$$$cc
A39 Copay Waiver Dollar amount funded by third s9(6)v99 A 8
Amount party for a copay waiver program Example: If the amount is $5.50 this field would
where a client funds a portion of reflect: 55{
their copay amount if they select
a certain drug.
- 37 -
July 2016
DATA DICTIONARY
242 Cost Difference Difference between client s9(6)v99 A 8 Format=s$$$$$$cc

Amount contracted amount and the
pharmacy or member submitted Example: If the amount is $5.50 this field would
amount. reflect: 55{
Counsel Indicator the patient has xsd:Boolean Q See ECL

requested counseling for the Code
medication.
CounselNotes Counseling text to be printed on an Q

the documentation provided to
the patient.
CouponNumber Identifies the promotion number x(35) S 35

or sample.
486-ME Coupon Number Unique serial number assigned to x(15) T 15

the prescription coupons.
See ECL
485-KE Coupon Type Code indicating the type of x(2) T 2
coupon being used.
487-NE Coupon Value Value of the coupon. s9(6)v99 T 8 Format=s$$$$$$cc

Amount
Examples: If the coupon value amount is $10.00,
this field would reflect: 100{.
910-BY Coverage ID The membership population to x(40) F 40

which the coverage rule applies.
Comments: Qualified by Coverage List Type (912-
911-BZ Coverage List ID ID for the coverage rule. x(10) F 10 B3).
912-B3 Coverage List Type Code identifying the type of x(2) F 2 See ECL Comments: Qualifies Coverage List ID (911-BZ).
coverage rule being conveyed.
Created Element in UsernameToken for xsd:datetim S,Q CC=Century
the creation of the transaction. e YY=Year
SOAP.
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
- 38 -
July 2016
DATA DICTIONARY
880-K2 Creation Date Date the file was created. 9(8) B,A,V,X,Y,L,I 8 Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
880-K3 Creation Time Time the file was created. 9(4) B,A,V,X,L,I 4 Format= HHMM
HH=Hour
MM=Minute
601-80 Current Amount The cumulative dollar amount of 9(9)v99b or R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
Paid To Date rebates paid to date. 9(9)v99-
Note:
b = Space
-= Negative sign
601-81 Current Rebate Per The current rebate per unit 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
Unit amount after adjustment. 9b or
Note:
9(5)v99999
b = Space
9-
-= Negative sign
CurrentTreatmentC Current treatment cycle 9(2 ) S 2

ycleNumber represented by this prescription.
601-82 Current Units The cumulative number of units 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
Disputed To Date in dispute. or
Note:
9(11)v999-
b = Space
-= Negative sign
601-83 Current Units Paid The cumulative number of units 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
To Date paid to date. or
Note:
9(11)v999-
b = Space
-= Negative sign
601-84 Current Units To The cumulative number of units 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
Date submitted for rebate calculation. or
Note:
9(11)v999-
b = Space
-= Negative sign
See ECL
532-FW Database Indicator Code identifying the source of x(1) T, A 1
drug information used for DUR
processing or to define the
database used for identifying the
product.
- 39 -
July 2016
DATA DICTIONARY
913-B4 Data In Error Copy of the bad data x(100) F 100
See ECL
601-31 Data Level The level of data being x(2) R,J 2
submitted.
601-32 Data Provider ID Code assigned to identify the x(17) R,J 17

Code data provider.
See ECL
601-37 Data Provider ID Identifies the type of data being x(2) R,J 2
Qualifier submitted in the Data Provider ID
Code (601-32) field.
601-33 Data Provider Name Name of the data provider. x(70) R,J 70
DatatypesVersion Element defines which NCPDP an S,Q See ECL

datatypes schema is being used.
Format=MMDDCCYY
589 Date of Billing Date the invoice was created. 9(8) W 8
Used only by those entities MM=Month
creating the paper invoice and DD=Day
submitting for payment. CC=Century
YY=Year
DateOfBirth Date of birth of patient. xsd:date or S,Q CC=Century
xsd:datetim YY=Year
e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
- 40 -
July 2016
DATA DICTIONARY
304-C4 Date Of Birth Date of birth of patient. 9(8) T,A,Z,V,W,X, 8 Format=CCYYMMDD

Y,L,I
CC=Century
YY=Year
MM=Month
DD=Day
Examples: If a patient was born on July 27, 1970,

this field would reflect: 19700727.
When used on the UCF and Workers

Compensation/Property & Casualty Forms, the
Format =MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
000
434-DY Date Of Injury Date on which the injury 9(8) T,A,W 8 Format=CCYYMMDD
occurred.
CC=Century
YY=Year
MM=Month
DD=Day
Examples: If injury occurred on July 1, 1999, field

When used on the Workers

Compensation/Property & Casualty Form, the
Format =MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year00
- 41 -
July 2016
DATA DICTIONARY
DateOfLastOfficeVisi Date of the last office visit for xsd:date or S CC=Century
t this diagnosis. xsd:datetim YY=Year
e MM=Month
DD=Day
Example: 2010-10-01
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
DateOfService See Date of Service (401-D1) xsd:datetim Q DateTime Format= CCYY-MM-DDTHH:MM:SS

e CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
401-D1 Date Of Service Identifies date the prescription 9(8) R,T,A,Z,V, 8 Format=CCYYMMDD
was filled or professional service W,J,E,Y,I
rendered or subsequent payer CC=Century
began coverage following Part A YY=Year
expiration in a long-term care MM=Month
setting only. DD=Day
Examples: If the prescription was dispensed on

April 22, 2000, this field would reflect 20000422.

Format =MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year0000000
- 42 -
July 2016
DATA DICTIONARY
414-DE Date Prescription Date prescription was written. 9(8) T,A,Z,V,W 8 Format=CCYYMMDD
Written
CC=Century
YY=Year
MM=Month
DD=Day
Examples: For a prescription written on August 1,

1999, field would reflect: 19990801.

Format =MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year00
DateRecertified The date when the prescriber xsd:date or S CC=Century
recertifies the medication order. xsd:datetim YY=Year
e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
- 43 -
July 2016
DATA DICTIONARY
Format= CCYYMMDDhhmmssmss (Format of date
654-S5 DateTime Date and time of the item from x(17) N 17 time where CC = Two-digit Century, YY = Two-digit
the originator, expressed in Year, MM = Two-digit month (01 through 12), DD =
Coordinated Universal Time Two-digit day of month (01 through 31), hh = Two-
(UTC). digit Hour (00 through 23), mm = Two-digit minutes
(00 through 59), ss = Two-digit second (00 through
59), mss = Three-digit millisecond (000 through
999))
If granularity is not desired, the appropriate
subsequent digits must not be sent. For example, if
month, day, and year is only to be transmitted, the
field would contain 20091122.
The granularity must be expressed completely for
the digits expressed. If month, day, year, hours, and
seconds are to be transmitted, the field would
contain 200911221533. It is incorrect to express
this example without both digits of seconds (33).
DateValidated The date when material xsd:date or S,Q CC=Century
obligations were verified. xsd:datetim YY=Year
e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
DaysSupply Estimated number of days the 9(3) S,Q 3

prescription will last.
Examples: The prescription is estimated to last 30
405-D5 Days Supply Estimated number of days the 9(3) R,T,A,V,Z,W 3 days. This field would reflect: 30
prescription will last. ,X,Y,I
- 44 -
July 2016
DATA DICTIONARY
345-HG Days Supply Days supply for metric decimal 9(3) T,A 3
Intended To Be quantity of medication that
Dispensed would be dispensed on original
dispensing if inventory were
available. Used in association
with a P or C in Dispensing Status
(343-HD).
B91-3W Days Supply Limit Maximum days supply allowed 9(3) T 3

Per Specific Time over the designated time period.
Period
B90-3T Days Supply Limit Count of days supply limit per 9(1) T 1
Per Specific Time specific time period.
Period Count
B92-3X Days Supply Limit This is an informational field to 9(5) T 5

Time Period convey the maximum days
supply over a set number of days
for this medication.
988-MB Days Supply Per The days’ supply associated with 9(3) F 3
Copay the stated copay terms.
A10 Days Supply Used to Accumulated authorized amount 9(3) X 3

Date of days supply used to date.
DeadlineForReply Expiration date of the case. xsd:date or S CC=Century
xsd:datetim
YY=Year
e
MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
DEAScheduleCode Value defining the DEA schedule an S See ECL
of the medication.
- 45 -
July 2016
DATA DICTIONARY
DefaultNextQuestio Indicates the next QuestionID x(35) S 35

nID that should be answered
regardless of the answer
provided to this question or END.
357-NV Delay Reason Code Code to specify the reason that 9(2) T,Z,W 2 See ECL
submission of the transactions
has been delayed.
DeliveredID Initiator reference identifier. x(35) S, Q 35
DeliveredOnDate Date or date and time xsd:date or S CC=Century
prescription was received at xsd:datetim
YY=Year
facility. e
MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
DeliveryLocation If patient specifies a delivery, this an S See ECL
is the location for the delivery.
DeliveryRequest Indicator of whether patient an S See ECL

requests delivery of prescription.
Description Text an S, Q
DescriptionCode Reject codes used by responder an S, Q See ECL

who takes responsibility for
transaction.
818-5F Destination Name The destination name to whom x(70) V 70

the file is being sent.
424-DO Diagnosis Code Code identifying the diagnosis of x(15) R,T,F,A,Z,J 15 Comments: Qualified by a Diagnosis Code Qualifier
the patient. (492-WE). The format must adhere to the owner’s
code set rules and formats.
- 46 -
July 2016
DATA DICTIONARY
491-VE Diagnosis Code Count of diagnosis occurrences. 9(1) T 1 Comments: Fields included in the set/logical
Count grouping are:
Diagnosis Code Qualifier (492-WE)
Diagnosis Code (424-DO)
See ECL
492-WE Diagnosis Code Code qualifying the Diagnosis x(2) T,F,A,Z,J 2
Qualifier Code (424-DO).
DigestMethod Defines the Hashing method to X(10) S 10 See ECL

be used.
DigitalSignatureIndi True/False indicating the xsd:boolean S

cator prescription has been digitally
signed.
DigitalSignatureVers Element defines which digitial an S See ECL

ion signature version is being used.
DigestValue Used to confirm that all fields x(35) S 35

have been included in the digital
signature. Apply a SHA1 HASH
and base64Encode the result.
DigestValue is composed of fields
concatenated together and then
encoded.
The DigestValue is the result of a
SHA-1 Hash, which is always 160
bits or 20 bytes.
For example, the diluent order may be for 1L
DiluentAmountValu Indicates the amount of diluent 9(3 ) S 3
normal saline, but the amount used when
e (which will have a separate
administering the medication is 10 mL.
order) to be used for
administration.
DiluentAmountQua Concepts of the intended or an S See ECL

ntityUnitOfMeasure actual diluent amount unit of
Code measure.
DirectAddress The direct project address of the x(254) S,Q 254
entity.
Format= CCYYMMDD
607-ND Discontinue Date Date on or after which the 9(8) V 8
CC=Century
prescription is no longer fillable.
YY=Year
MM=Month
DD=Day
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July 2016
DATA DICTIONARY
606-NC Discontinue Date Code qualifying Discontinue Date x(1) V 1 See ECL
Qualifier (607-ND).
DiscountAmount Amount of discount that was an Q Format=s$$$$$$$$.cc to the length of the dollar
applied to the prescription. amount exchanged.
- = Negative sign
. = Decimal point
would reflect: 5.50
A72 Discrepancy The financial value that the 9(6)v(2) E 8

Amount pharmacy will be charged back
due to the results of the audit.
A68 Discrepancy Code 1 The reason/findings for the x(5) E 5 See ECL
Charge Back Amount.
Charge Back Amount.
Charge Back Amount.
A71 Discrepancy Free Text additional information x(200) E 200

Message to further define the discrepancy
found.
A11 Dispense As Written Indicator to determine where the 9(1) X 1 See ECL
(DAW) Difference cost differential of the DAW
difference should be shifted.
408-D8 Dispense As Written Code indicating whether or not x(1) R,T,A,V,Z,W 1 See ECL See SubstitutionCode for SCRIPT Standard
(DAW)/ Product the prescriber’s instructions ,Y,I
Selection Code regarding generic substitution
were followed.
DispensedPackageM Indicate the methods by which an S See ECL

ethod treatment was dispensed.
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July 2016
DATA DICTIONARY
149-U9 Dispensing Fee Informational field used when s9(6)99 T 8 Format=s$$$$$$cc

Contracted/ Other Payer-Patient
Reimbursable Responsibility Amount (352-NQ) Example: If the amount is $5.50 this field would
Amount or Patient Pay Amount (505-F5) reflect: 55{
is used for reimbursement.
Amount is equal to contracted or
reimbursable dispensing fee for
product being dispensed.
507-F7 Dispensing Fee Paid Dispensing fee paid included in s9(6)v99 T,A 8 For T,A: Format=s$$$$$$cc
the Total Amount Paid (509-F9).
_______ _________ _______ For T: Examples: If the dispensing fee paid is $3.50,
9(6)v99 Y 8
or For Y:
-9(5)v99 Format=$$$$$$cc or -$$$$$cc
Note:
- = Negative sign
usage.
412-DC Dispensing Fee Dispensing fee submitted by the s9(6)v99 T,Z,W 8 Format=s$$$$$$cc
Submitted pharmacy. This amount is
included in the Gross Amount Examples: If the pharmacy submitted a $5.62
Due (430-DU). dispensing fee, this field would reflect: 56B.
DispensingRequestC Code conveying a pharmacy an Q See ECL

ode dispensing action associated with
a Census event.
343-HD Dispensing Status Code indicating the quantity x(1) T,A,R 1 See ECL
dispensed is a partial fill or the
completion of a partial fill. Used
only in situations where
inventory shortages do not allow
the full quantity to be dispensed.
601-85 Disputed Quantity The number of units that are in 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
question or the difference or
Note:
between the Total Quantity (601- 9(11)v999-
b = Space
39) and the Accepted Quantity
-= Negative sign
(601-86).
- 49 -
July 2016
DATA DICTIONARY
682 Document Control Internal number used by the x(20) Z, W 20

Number payer or processor to further
identify the claim for imaging
purposes - Document archival,
retrieval and storage.
B78 Document The reference number assigned x(15) I 15

Reference Identifier by the provider for the service.
B79 Document Code qualifying the value in x(2) I 2 See ECL

Reference Identifier Document Reference Identifier
Qualifier (B78).
DoNotFill Used for medications ordered by an S See ECL

a prescriber but not requiring
dispensing at this time, but may
be required for administration
and may be available for drug-to-
drug interactions.
243 Dosage Form Code Dosage form code for product x(4) A 4 Values are Trading Partner Defined
identified.
A12 Dosage Per Day The dosage per day that is 9(7)v999 X 10 Format= 9999999v999
approved by the prior
authorization and is usually over
or under the normal plan limits
or clinical guidelines.
DoseAmountText The textual representation of the an S

Dose Amount when dose amount
cannot expressed as a unit of
measure.
DoseAmountTextCo The code representing the an S Qualified by DoseAmountTextQualifier.

de DoseAmountText.
DoseAmountTextQu Qualifier to identify the code an S See ECL

DoseCalculationClari Used to add clarity to the dose x(255) S 255

fyingFreeText calculation for elements that
cannot be codified.
DoseClarifyingFreeT Used to add clarity to the dose x(255) S 255

ext for elements that cannot be
codified.
- 50 -
July 2016
DATA DICTIONARY
DoseDeliveryMetho The code representing the an S Qualified by DoseDeliveryMethodQualifier.

dCode DoseDeliveryMethodText.
DoseDeliveryMetho The code representing the an S Qualified by DoseDeliveryMethodModifierQualifier

dModifierCode DoseDeliveryMethodModifierTex
t.
Qualifier to identify the code
DoseDeliveryMetho system being used. an S See ECL
dModifierQualifier
The textual representation of the
DoseDeliveryMetho DoseDeliveryMethodModifierCo an S
dModifierText de.
Modifies the method in which
the dose is delivered. Ancillary
information needed to better
understand the delivery method.
DoseDeliveryMetho Qualifier to identify the code an S See ECL

dQualifier system being used.
DoseDeliveryMetho The textual representation of the an S

dText DoseDeliveryMethod. This is the
method in which the dose is
delivered (describes how the
dose is administered/consumed).
DoseUnitOfMeasure The code representing the an S Qualified by DoseUnitOfMeasureQualifier.

Code DoseUnitOfMeasureText .
Comment: FMT Term from NCI for
DoseUnitOfMeasureQualifier
A terminology subset for NCPDP that contains
concepts that qualify the strength and strength unit
of measure associated with the prescribed product
(e.g. Tablet, Inhaler, Patch, Ointment, Suppository,
Capsule, Drop Solution, Cream, etc).
DoseUnitOfMeasure Qualifier to identify the code an S See ECL

Qualifier system being used.
DoseUnitOfMeasure The textual representation of the an S

Text DoseUnitOfMeasureCode.
DoseQuantity The numeric expression of the 9(18) S 18

dose.
- 51 -
July 2016
DATA DICTIONARY
DoseRangeModifier Used to signify that the Sig an S See ECL

contains more than one dose in a
range or option.
DosingBasisNumeric Expresses the numeric value of 9(18) S 18

the dosing basis.
DosingBasisRangeM Used to signify that the Sig an S See ECL

odifier contains more than one dose
which represent a dose range
(TO) or contains a dose option
(OR).
DosingBasisUnitOfM The code representing the an S Qualified by DosingBasisUnitOfMeasureQualifier.

easureCode DosingBasisUnitofMeasureText.
DosingBasisUnitOfM Qualifier to identify the code an S See ECL

easureQualifier system being used.
DosingBasisUnitOfM The textual representation of the an S

easureText DosingBasisUnitOfMeasureCode.
DrugAdminReasonC Code identifying the reason for an S See ECL

ode the message.
DrugAdminReasonT Additional textual information x(100) S 100

ext regarding the message.
244 Drug Category Code The drug category to which a x(1) A 1 Values are Trading Partner Defined
specified drug belongs. Each drug
category code is associated with
a specific drug category.
DrugCoverageStatus Code identifying the coverage x(2) S 2 See ECL

Code status of the prescribed drug.
DrugDBCode Code value to define the an S Qualified by DrugDBCodeQualifier.

reference number GPI, GCN Seq
#, GFC, DDID, SmartKey, GM,
Multum MMDC, Multum Drug ID,
etc.
DrugDBCodeQualifie Qualifies DrugDBCode. an S See ECL

r
DrugDescription Name of drug. x(105) S 105 See also CompoundIngredientItemDescription.
- 52 -
July 2016
DATA DICTIONARY
516-FG Drug Description Name of drug. x(30) R 30

-------------- ------------- -------------
x(60) V 60
915-B6 Drug Reference Identifier for the drug from x(35) F 35 Comments: Qualified by Drug Reference Qualifier
Number proprietary drug sources. (916-B7).
917-B8 Drug Reference Identifier for the alternative drug x(35) F 35 Comments: Qualified by Drug Reference Qualifier-
Number -Alternative from proprietary drug sources. Alternative (918-B9).
919-CS Drug Reference Identifier for the drug from x(35) F 35 Comments: Qualified by Drug Reference Qualifier-
Number-Source proprietary drug sources. Source (920-CT).
921-CU Drug Reference Identifier for the drug from x(35) F 35 Comments: Qualified by Drug Reference Qualifier-
Number-Step Drug proprietary drug sources that is Step Drug (922-CV).
recommended to be tried first.
916-B7 Drug Reference Code value that identifies the x(3) F 3 See ECL Comments: Qualifies Drug Reference Number (915-
Qualifier source and type for the Drug B6).
Reference Number.
918-B9 Drug Reference Code value that identifies the x(3) F 3 See ECL Comments: Qualifies Drug Reference Number-
Qualifier-Alternative source and type for the Drug Alternative (918-B9).
Reference Number-Alternative.
920-CT Drug Reference Code value that identifies the x(3) F 3 See ECL Code qualifying the value in Drug Reference
Qualifier-Source source and type for the Drug Number-Source (919-CS).
Reference Number-Source.
922-CV Drug Reference Code value that identifies the x(3) F 3 See ECL Code qualifying the value in Drug Reference
Qualifier-Step Drug source and type for the Drug Number-Step Drug (921-CU).
Reference Number-Step Drug.
DrugShape Drug shape text from a drug an Q

imprint database.
425-DP Drug Type Code to indicate the type of drug 9(1) A,X,Y 1
dispensed. See ECL
570-NS DUR Additional Text Descriptive information that x(100) T 100

further defines the referenced
DUR alert.
DurationClarifyingFr Used to add clarity to the x(255) S 255

eeText duration for elements that
cannot be codified.
- 53 -
July 2016
DATA DICTIONARY
DurationNumericVal The numeric duration units. 9(18) S 18

ue
DurationText The textual representation of an S

DurationUnitsCode.
DurationTextCode The code representing the an S Qualified by DurationTextQualifier.

DurationUnitsText.
DurationTextQualifi Qualifier to identify the code an S See ECL

er system being used.
476-H6 DUR Co-Agent ID Identifies the co-existing agent x(19) T,A 19 Comments: Qualified by DUR Co-Agent ID Qualifier
contributing to the DUR event (475-J9).
(drug or disease conflicting with
the prescribed drug or prompting
pharmacist professional service).
475-J9 DUR Co-Agent ID Code qualifying the value in DUR x(2) T,A 2 See ECL
Qualifier Co-Agent ID (476-H6).
544-FY DUR Free Text Text that provides additional x(30) T 30 Comments: Response data may provide:
Message detail regarding a DUR conflict. -drug names involved in an interaction
-reported disease contraindication
-other applicable DUR information
473-7E DUR/PPS Code Counter number for each 9(1) T 1 Comments: Fields included in the set/logical
Counter DUR/PPS set/logical grouping. grouping are:
Reason of Service Code (439-E4)
Professional Service Code (440-E5)
Result of Service Code (441-E6)
DUR/PPS Level of Effort (474-8E)
DUR Co-Agent ID Qualifier (475-J9)
DUR Co-Agent ID (476-H6)
See ECL
474-8E DUR/PPS Level Of Code indicating the level of effort 9(2) T,A,Z,W 2
Effort as determined by the complexity
of decision-making or resources
utilized by a pharmacist to
perform a professional service.
- 54 -
July 2016
DATA DICTIONARY
567-J6 DUR/PPS Response Counter number for each 9(1) T 1 Comments: Fields included in the set/logical
Code Counter DUR/PPS response set/logical grouping are:
grouping.
Reason for Service Code (439-E4)
Clinical Significance Code (528-FS)
Other Pharmacy Indicator (529-FT)
Previous Date of Fill (530-FU)
Quantity of Previous Fill (531-FV)
Database Indicator (532-FW)
Other Prescriber Indicator (533-FX)
DUR Free Text Message (544-FY)
DUR Additional Text (570-NS)
608-NF Easy Open Cap Code indicating patient requires x(1) V 1 See ECL
Indicator use of easy open cap or not.
ECLVersion Element defines which NCPDP an S,Q See ECL

external code list schema is being
used.
EffectiveDate The beginning date or date and xsd:date or S,Q CC=Century
time. xsd:datetim YY=Year
e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
Format=CCYYMMDD
609-NG Effective Date Date the information was valid. 9(8) V 8 CC=Century
YY=Year
MM=Month
DD=Day
ElectronicMail The electronic mail address of x(80) S,Q 80

the entity.
- 55 -
July 2016
DATA DICTIONARY
See ECL
309-C9 Eligibility Code indicating that the 9(1) T,A 1 Examples: The patient has become a student but
Clarification Code pharmacy is clarifying eligibility eligibility has not yet been updated. The pharmacy
for a patient. can indicate 3 so that the carrier may override
eligibility for this patient.
245 Eligibility COB Coordination of Benefits code as x(1) A 1 See ECL

Indicator provided on Client eligibility.
246 Eligibility Group ID Identifier of the group that x(15) A,Y 15

determines eligibility parameters
for the member when submitted
by the client.
247 Eligibility/Patient Individual Relationship Code. 9(2) A,Y 2 See ECL

Relationship Code Code indicating the relationship
between two individuals or
entities.
248 Eligible Coverage Coverage Level Code. Code x(3) A 3 See ECL
Code indicating the level of coverage
being provided for the insured.
See ECL
600-69 Eligible Plan Indicates whether or not the plan x(1) R 1
is eligible for rebates.
317-CH Employer City Free-form text for city name. x(20) T,W 20 Examples: CHICAGO
Address
B17-7H Employer Contact First name of the employer’s x(35) T 35

First Name primary contact.
B18-7J Employer Contact Last name of the employer’s x(35) T 35

Last Name primary contact.
321-CL Employer Contact Employer primary contact. x(30) W 30 Examples: JOHN SMITH
Name
B35-1V Employer Country Code of the country. x(2) T 2 See ECL

Code
- 56 -
July 2016
DATA DICTIONARY
Comments: The Internal Revenue Service,
333-CZ Employer ID ID assigned to employer. x(15) T 15 Department of the Treasury, assigns the Employer
ID. The format of this field is nine-digits with a
hyphen, as in 00-0000000. The hyphen must be
transmitted as part of the Employer ID Number.
Information on the Employer ID may be found at
http://www.irs.ustreas.gov/.
315-CF Employer Name Complete name of employer. x(30) T,W 30 Examples: GENERAL MOTORS CORPORATION
318-CI Employer State/Province Code of the x(2) T,W 2 See ECL

State/Province employer.
Address
316-CG Employer Street Free-form text for address x(30) W 30 Examples: 123 MAIN STREET
Address information.
B15-8D Employer Street Free-form text for address line1 x(40) T 40

Address Line 1 information.
B16-7G Employer Street Free-form text for address line 2 x(40) T 40

320-CK Employer Ten-digit phone number of 9(10) T,W 10 Format=AAAEEENNNN

Telephone Number employer.
AAA=Area Code
EEE=Exchange Code
NNNN=Number
Examples: A phone number of 212-555-1212 would
reflect: 2125551212.
B19-7K Employer Extension of the telephone 9(8) T 8 Format = 99999999

Telephone Number number.
Extension
- 57 -
July 2016
DATA DICTIONARY
319-CJ Employer Zip/Postal Code defining international x(15) T,W 15 Comments: When used for US ZIP Code - This left-
Code postal code of the employer, justified field contains the five-digit zip code and
excluding punctuation. may include the four-digit expanded zip code in
which the employer is located.

Examples:
A0E 3B0
A1L 2T8
601-35 Encrypted Patient ID Encrypted patient ID. x(17) R,J 17

Code
A89 Encrypted Social Social Security Number which x(128) Y 128

Security Number has been encrypted.
EndDate The final date or date and time. xsd:date or S CC=Century
xsd:datetim YY=Year
e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
776 Entity Address Line First line of the address of the x(40) E 40
1 entity indicated.
- 58 -
July 2016
DATA DICTIONARY
777 Entity Address Line Second line of the address of the X(40) E 40
2 entity indicated.
778 Entity City City in which the entity indicated x(20) E 20

is located.
B05 Entity Contact First First name of contact within the x(35) E 35
Name entity indicated.
B06 Entity Contact Last Last name of contact within the x(35) E 35
Name entity indicated.
B36-1W Entity Country Code Code of the country. x(2) E,J,V,Y, A 2 See ECL
A52 Entity Email Email address of the entity x(80) E 80

indicated.
A53 Entity Fax Number Fax Number of the entity 9(10) E 10

indicated.
780 Entity Name Complete name of the entity x(70) E 70

indicated.
782 Entity State/Province Code of the x(2) E 2 See ECL

State/Province entity.
Address
783 Entity Telephone Telephone number of the entity 9(10) E 10 Format=AAAEEENNNN

Number indicated.
AAA=Area Code
EEE=Exchange Code
NNNN=Number
B07 Entity Telephone Extension of the telephone 9(8) E 8 Format = 99999999

Number Extension number.
- 59 -
July 2016
DATA DICTIONARY
784 Entity Zip/Postal Code defining international x(15) R,J,E 15 Comments:

Code postal code of the entity
indicated, excluding punctuation. When used for US ZIP Code - This left-justified field

Examples:
A0E 3B0
A1L 2T8
Estimated earliest time auditor
A51 Estimated Arrival will arrive for audit at the x(30) E 30
Time Description pharmacy using pharmacy local
time.
The amount, not included in the
577-G3 Estimated Generic Total Amount Paid (509-F9), that s9(6)v99 T 8 Format=s$$$$$$cc
Savings the patient would have saved if Example: If the amount is $5.50 this field would
they had chosen the generic drug reflect: 55{
instead of the brand drug.
The cultural heritage of the

Ethnicity entity. an Q See ECL
249 Excess Copay Amount of the copay that s9(6)v99 A 8 Format=s$$$$$$cc

Amount exceeds the approved amount
for this claim. Example: If the amount is $5.50 this field would
reflect: 55{
- 60 -
July 2016
DATA DICTIONARY
ExpirationDate The final date or date and time. xsd:date or S,Q CC=Century
xsd:datetim YY=Year
e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
Format= CCYYMMDD
610-NH Expiration Date Date on which coverage is no 9(8) V 8 CC=Century
longer effective. YY=Year
MM=Month
DD=Day
ExpiringPACaseID ID assigned by the payer to x(35) S 35

identify the existing expiring
case.
Format= CCYYMMDD
923-DD Extract Date Date the file was extracted from 9(8) F 8 CC=Century
the internal source system. YY=Year
MM=Month
DD=Day
388-5J Facility City Address Free-form text for facility city x(20) T 20
name.
B37-1X Facility Country Code of the country. x(2) T 2 See ECL

Code
336-8C Facility ID ID assigned to the patient’s x(10) T,A 10

clinic/host party. --------------- --------------- ------------
x(35) V 35
FacilityIdentification Identification of the facility. x(35) S, Q 35 See ECL
FacilityName Name identifying the location of x(70) S, Q 70

the service rendered.
- 61 -
July 2016
DATA DICTIONARY
Note: This is not the name of the dispensing
385-3Q Facility Name Name identifying the location of x(70) T,V 70 pharmacy.
the service rendered.
387-3V Facility State/Province Code of the x(2) T 2 See ECL

State/Province facility.
Address
B20-7M Facility Street Free-form text for Facility x(40) T 40

Address Line 1 address line 1 information.
B21-7N Facility Street Free-form text for Facility x(40) T 40

FacilityUnit The unit of the patient. x(35) S,Q 35
672-W2 Facility Unit The unit of the patient. x(35) V 35
389-6D Facility Zip/Postal Code defining international x(15) T 15

Zone postal zone excluding
punctuation and blanks.
785-SV Family ID Number ID number that represents that x(20) V,I 20 Comments: Used to link families when unique ID
family. numbers are assigned to each member.
FaxExtension Extension of the fax number. 9(8) S,Q 8 Format = 99999999
FaxNumber Fax number of the entity. 9(10) S,Q 10 Format=AAAEEENNNN

AAA=Area Code
EEE=Exchange Code
NNNN=Number
FaxSupportsSMS Indication the number accepts xsd:Boolean S,Q See ECL

text messages. Code
250 FDA Drug Efficacy A one-position field which marks x(1) A 1 See ECL
Code a particular drug as being
declared less than effective by
the Food and Drug
Administration.
252 Federal DEA The controlled substance x(1) A,E 1 See ECL
Schedule schedule as defined by the Drug
Enforcement Administration.
251 Federal Upper Limit Indicates if a Federal Upper Limit x(1) A 1 See ECL
Indicator exists for the drug.
- 62 -
July 2016
DATA DICTIONARY
253 Federal Upper Limit Federal Upper Limit Unit Price as s9(5)v9999 A 9 Format=s$$$$$cccc
Unit Price defined by processor.
reflect: 5500{
611-NJ File Structure Type Indicates type of structure of 9(1) V 1 See ECL
record supported.
702-MC File Type Code identifying whether the file x(1) B,F,A,V,X,I 1 See ECL
contained is test or production
data.
FillNumber The code indicating whether the 9(2) S,Q 2 See ECL This field must always be two significant digits (e.g.
prescription is an original or a 01, 02, 08, 14, 99).
refill.
403-D3 Fill Number The code indicating whether the 9(2) T,A,R,V,Z,W 2 See ECL
prescription is an original or a ,J,E
refill.
254 Fill Number Code identifying whether the 9(2) A,Y 2 See ECL
Calculated prescription is an original (00) or
by refill number (01-99) as
calculated by system based on
historical claims data. This field
represents the Fill Number as
calculated (not submitted by
pharmacy).
A13 Fills/Refills Used To- Indicates the number of fills or 9(2) X 2

Date refills used to date by a patient
against an existing Annual Fill or
Annual Refill override.
FinalCompoundPhar Drug form, in a code. Dosage an S See ECL

maceuticalDosageFo form code. Pharmaceutical
rm Dosage Form.
FinancialGuarantorR Code indicating the relationship x(2) Q 2 See ECL

elationship between the financial guarantor
and the patient.
924-DH First Copay Term First Copay term (flat copay x(1) F 1 See ECL
amount or percent copay) to be
considered.
FirstName First name. x(35) S,Q 35
- 63 -
July 2016
DATA DICTIONARY
x(35) A,L,V,X 35
717-SX First Name First name. _______ _________ _______ Size of 128 is used in Uniform Healthcare Payer
Data Standard for possible encrypted data.
x(128) Y 128
Format=$$$$$$$.cc
925-ES Flat Copay Amount Fixed copay amount. R(10) F 10
Comments: No dollar sign. Decimal required if value
includes cents. The length includes the decimal
point. Currency: USD
558-AW Flat Sales Tax Flat sales tax paid which is s9(6)v99 T,A 8 For T and A: Format=s$$$$$$cc
Amount Paid included in the Total Amount
Paid (509-F9). _______ _________ _______ Examples: If the flat sales tax paid is $2.60, this field
would reflect: 26{.
9(6)v99 Y 8
or For Y:
-9(5)v99 Format=$$$$$$cc or -$$$$$cc
Note:
- = Negative sign
usage.
481-HA Flat Sales Tax Flat sales tax submitted for s9(6)v99 T,Z,W 8 Format=s$$$$$$cc
Amount Submitted prescription. This amount is
included in the Gross Amount Comments: The submission of sales tax is governed
Due (430-DU). by regulatory agencies (state, local, parish, etc). If
the sales tax reported is a flat rate, then it is a fixed
amount for a certain dollar value (for example for
$xxx it is a certain amount). For example, for $100
the flat rate is $1.99. This flat rate is then reported
in Flat Sales Tax Amount Submitted (481-HA).
Examples: If the flat sales tax amount submitted is
$3.08, this field would reflect: 30H.
Flavor Drug flavor from a drug imprint an Q
database.
FlavoringRequested Indicates the prescriber is x(1) S 1 See ECL
requesting flavoring be added to
the prescribed product.
FMTVersion The version of FMT (Federal an S Comment: Governed by NCI Thesaurus.
Medication Terminologies) from
NCI being used for NCPDP Drug
StrengthForm Terminology.
- 64 -
July 2016
DATA DICTIONARY
FollowUpRequest Indicator to allow pharmacies to 9(1) S 1 See ECL
tell prescribers that this is a
follow-up Refill Request or
Change Request transaction. The
field is not sent on an original
request.
Format Code identifying the type of an K See ECL
standard syntax exchange
included within a payload
envelope.
600-73 Formulary Benefit Identifies the type of formulary x(4) R 4 See ECL
Design Type benefit design utilized by the
plan.
600-74 Formulary Code Code assigned by PMO to x(17) R,J 17

identify the formulary used.
255 Formulary Code Indicates how the Formulary x(1) A 1

Type Benefit is set up. As defined by
processor.
600-75 Formulary Description of the formulary x(30) R 30

Description used by the PMO.
256 Formulary File ID Identifies the formulary ID used x(15) A 15

during adjudication of the claim.
926-FF Formulary ID ID for the formulary list x(10) F,T 10
989-MF Formulary Name Name for the formulary list x(35) F 35
A84 Formulary Start Represents the date on which 9(8) R 8 Format=CCYYMMDD

Date the formulary became effective. CC=Century
YY=Year
MM=Month
DD=Day
927-FP Formulary Status Status of the drug within the x(2) F 2 See ECL Comments: The higher the number for the
formulary. preferred level, the more preferred the drug.
257 Formulary Status Indicates the Formulary status of x(1) A,I 1 See ECL
the Drug.
- 65 -
July 2016
DATA DICTIONARY
A85 Formulary Represents the date on which 9(8) R 8 Format=CCYYMMDD

Termination Date the formulary was terminated. CC=Century
YY=Year
MM=Month
DD=Day
FrequencyOfEncoun The code expressed as a unit of an Q Qualified by

tersApprovedCode time for FrequencyOfEncountersApprovedCodeQualifier.
TotalNumberEncountersApprove
d.
FrequencyOfEncoun Qualifier to identify the code an Q See ECL

tersApprovedCodeQ system being used for
ualifier FrequencyOfEncountersApprove
dCode.
FrequencyOfEncoun Textual representation of an Q

tersApprovedText TotalNumberOfEncountersAppro
ved per unit of time
(FrequencyOfEncountersApprove
dCode).
FrequencyNumericV The numeric interval for the 9(18) S 18

alue event. Used to define a
frequency of administration.
FrequencyUnitsCod The code representing the an S Qualified by FrequencyUnitsQualifier.

e FrequencyUnitsText.
FrequencyUnitsQual Qualifier to identify the code an S See ECL

ifier system being used.
FrequencyUnitsText The textual representation of an S

FrequencyUnitsCode.
From The identification number of the an S, Q Qualified by AddressTypeQualifier.

sender.
Gender Code identifying the gender of an S,Q See ECL

the individual.
721-MD Gender Code Code identifying the gender of x(1) F 1 See ECL
the individual. _________ _________
9(1) A
687 Generic Available Denotes availability of a generic x(1) W 1 See ECL

product in the store/facility
when brand was dispensed.
- 66 -
July 2016
DATA DICTIONARY
126-UA Generic Equivalent Identifies the generic equivalent x(19) T 19 Comments: Qualified by Generic Equivalent Product
Product ID of the brand product dispensed. ID Qualifier (125-TZ).
125-TZ Generic Equivalent Code qualifying the Generic X(2) T 2 See ECL Comments: Qualifies Generic Equivalent Product ID
Product ID Qualifier Equivalent Product ID (126-UA). (126-UA).
260 Generic Indicator Distinguishes if product priced as x(1) A 1

Generic or Branded product: As
defined by processor.
261 Generic Name Generic name of the product x(30) A 30

identified in Product/Service
Name.
GestationalAge Gestational age at birth (number 9(2) S,Q 2

of weeks).
601-87 Grand Total The sum of the Accepted 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
Accepted Quantity Quantity (601-86) fields or
Note:
submitted within the RD record 9(11)v999-
b = Space
type.
- = Negative sign
601-88 Grand Total Paid The sum of the Paid Rebate 9(9)v99b R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
Amount Amount (601-96) fields or
submitted within the RS record 9(9)v99- Note:
type OR the sum of the Paid b = Space
Amount 1 (175-WH), Paid - = Negative sign
Amount 2 (176-WJ), Paid Amount
3 (177-WK), Paid Amount 4 (178-
WL), and Paid Amount 5 (179-
WM) fields submitted within the
RD record type.
601-41 Grand Total The sum of the Total Quantity 9(11)v999b R,J 15 Format=$$$$$$$$$$$cccb or $$$$$$$$$$$ccc-
Quantity (601-39) fields submitted within or
the UD record type. 9(11)v999- If detail records contain this field, the total is
required on the trailer record.
Note
b = Space
- = Negative Sign
- 67 -
July 2016
DATA DICTIONARY
601-42 Grand Total The sum of the Requested 9(9)v99b R,J 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
Requested Amount Rebate Amount (601-55) fields or
submitted within the UD record 9(9)v99- If detail records contain this field, the total is required
type. on the trailer record.
Note
b = Space
- = Negative Sign
430-DU Gross Amount Due Total price claimed from all s9(6)v99 T,A,Z,W 8 For T,A,Z,W: Format=s$$$$$$cc
sources. For prescription claim
request, field represents a sum _______ _________ _______ Examples: If the gross amount due is $14.95, this
of Ingredient Cost Submitted field would reflect: 149E.
9(6)v99 Y 8
(409-D9), Dispensing Fee or For Y:
Submitted (412-DC), Flat Sales -9(5)v99 Format=$$$$$$cc or -$$$$$cc
Tax Amount Submitted (481-HA), __________ Note:
__________ _________
Percentage Sales Tax Amount - = Negative sign
Submitted (482-GE), Incentive 9(8)v99 I 10 This minus (-) sign occupies a position, so the
Amount Submitted (438-E3), dollars that can be supported are one digit less than
Other Amount Claimed (480-H9). a positive dollar amount.
For service claim request, field
represents a sum of Professional See important information in the Uniform
Services Fee Submitted (477-BE), Healthcare Payer Data Standard for dollar field
Flat Sales Tax Amount Submitted usage.
(481-HA), Percentage Sales Tax For I: Format=$$$$$$$$cc
Amount Submitted (482-GE), This field does not support negative dollar
Other Amount Claimed (480-H9). amounts.
A97 Gross Retiree Cost Total of all Gross Retiree Costs 9(10)v99 L 12 Format=$$$$$$$$$$cc
for the retiree that is valid for
Subsidy Billing. Gross Retiree Cost = The sum of ingredient cost +
dispensing fee + tax for Medicare D covered drugs
included by the other vendor in subsidy billing.
(Note: This cost does not support a sign.)
GroupID ID assigned to the cardholder x(35) S,Q 35

group or employer group.
R,T,A,N,V,Z,
301-C1 Group ID ID assigned to the cardholder x(15) X,E,I 15
group or employer group.
GroupName Name of group being submitted. x(70) S,Q 70
HasAutomatedInsuli This flag identifies that the xsd:Boolean S See ECL

nDevice patient has an automated insulin Code
device.
- 68 -
July 2016
DATA DICTIONARY
501-F1 Header Response Code indicating the status of the x(1) T,N,E 1 See ECL
Status transmission.
A35 Health Care ID Card Codes that enable card issuers to x(2) H 2 See ECL
Qualifier Code include information such as
effective dates of benefit
coverage, cardholder address,
dependent names and person
codes, gender codes, dates of
birth, etc. and support full
implementation of machine-
readable information on
Healthcare ID Cards.
263 Health Care Client-defined benefit that s9(6)v99 A 8 Format=s$$$$$$cc

Reimbursement provides funds to patients that
Account Amount can be used to offset Out of Example: If the amount is $5.50 this field would
Applied Pocket expenses. reflect: 55{
Note: For the fixed format Post Adjudication

264 Health Care Client-defined benefit that s9(6)v99 A 8 Standard if this field is not applicable, the field
Reimbursement provides funds to patients that should contain 9999999I
Account Amount can be used to offset Out of
Remaining Pocket expenses. Format=s$$$$$$cc
reflect: 55{
- 69 -
July 2016
DATA DICTIONARY
For T,A: Comments: This field will be returned on a
129-UD Health Plan-funded The amount from the health s9(6)v99 T,A 8 PAID (P) or Duplicate Paid (D) transaction when a
Assistance Amount plan-funded assistance account patient meets the plan-funded assistance criteria.
for the patient that was applied _______ _________ _______
to reduce Patient Pay Amount 9(6)v99 Y 8 Format=s$$$$$$cc
(505-F5). This amount is used in or
Healthcare Reimbursement Example: If the amount is $5.50 this field would
-9(5)v99 reflect: 55{
Account (HRA) benefits only. This
field is always a negative amount
or zero. Health Plan-funded Assistance Amount is part of
the patient pay amount calculation and is used to
report back to the provider and patient the portion
of Patient Pay Amount (505-F5) that was reduced
due to this plan-funded assistance. In this
transaction, the patient pays the value reported in
Patient Pay Amount (505-F5) however without this
field; the patient would have been required to pay
a higher dollar amount. NOTE: There is no credit
card transaction involved in this type of Patient
Spending Assistance, as in a Flexible Spending
Account (FSA).
For Y:
Note:
- = Negative sign
usage.
550-8F Help Desk Phone number of the help desk. x(10) T 10 Format=AAAEEENNNN
Telephone Number
AAA=Area Code
EEE=Exchange Code
NNNN=Number
Comments: Qualified by ‘Help Desk Telephone
Number Qualifier’ (549-7F).
reflect: 2125551212.
B22-7P Help Desk Extension of the telephone 9(8) T 8 Format = 99999999

Extension
549-7F Help Desk Code qualifying the phone x(2) T 2 See ECL
Telephone Number number in the Help Desk
Qualifier Telephone Number (550-8F).
- 70 -
July 2016
DATA DICTIONARY
265 Hold Harmless Amount payable to member s9(6)v99 A 8 Format=s$$$$$$cc

Amount when paper claims amount
exceeds Pharmacy Network Example: If the amount is $5.50 this field would
Reimbursement. reflect: 55{
Home Extension of the home telephone 9(8) S,Q 8 Format = 99999999

TelephoneExtension number.
HomeTelephoneNu Home telephone number of the 9(10) S,Q 10 Format=AAAEEENNNN

mber entity. AAA=Area Code
EEE=Exchange Code
NNNN=Number
HomeTelephoneSup Indication the number accepts xsd:Boolean S,Q See ECL

portsSMS text messages. Code
HospiceIndicator Indicates patient's hospice 9(2) S,Q 2 See ECL

status.
673-W3 Hours Of Indicates the specific time(s) x(70) V 70 Comments: Times should be expressed in the
Administration when the prescribed medication facility’s local time, using twenty-four hour military
is to be administered. time format. Multiple times should be separated
with a comma delimiter, e.g.: 0900,1700
representing 9:00 AM and 5:00 PM facility local
time.
Imprint1 Imprint1 on drug from a drug an Q

imprint database.
Imprint2 Imprint2 on drug from a drug an Q

imprint database.
612-NK Inactive Prescription Indicates that the prescription is x(1) V 1 See ECL Comments: The active prescription may or may not
Indicator considered inactive and is be refillable based upon other factors.
therefore no longer fillable.
- 71 -
July 2016
DATA DICTIONARY
521-FL Incentive Amount Amount represents the s9(6)v99 T,A 8 For T,A: Format=s$$$$$$cc
Paid contractually agreed upon
incentive fee paid for specific _______ _________ _______ Examples: If the incentive amount paid is $4.55, this
services rendered. Amount is field would reflect: 45E.
9(6)v99 Y 8
included in the Total Amount or For Y:
Paid (509-F9). -9(5)v99 Format=$$$$$$cc or -$$$$$cc
Note:
- = Negative sign
usage.
438-E3 Incentive Amount Amount represents a fee that is s9(6)v99 T 8 Format=s$$$$$$cc

Submitted submitted by the pharmacy for
contractually agreed upon Examples: If the incentive amount submitted is
services. This amount is included $4.50, this field would reflect: 45{.
in the Gross Amount Due (430-
DU).
IndicationClarifyingF Used to add clarity to the x(255) S 255

reeText indication for elements that
cannot be codified.
IndicationCode The code representing the an S Qualified by IndicationQualifier.

IndicationText.
IndicationPrecursor The code representing the an S Qualified by IndicationPrecursorQualifier.

Code IndicationPrecursorText.
IndicationPrecursor Qualifier to identify the code an S See ECL

IndicationPrecursor The textual representation of the an S

Text IndicationPrecursorCode.
IndicationQualifier Qualifier to identify the code an S See ECL

system being used.
IndicationText The textual representation of the an S

IndicationText.
IndicationValueCod The code representing the an S Qualified by IndicationValueQualifier.

e IndicationValueText.
- 72 -
July 2016
DATA DICTIONARY
IndicationValueQual
ifier Qualifier to identify the code an S See ECL
system being used.
IndicationValueText The textual representation of the an S

IndicationValueCode.
IndicationValueUnit The numeric expression of a 9(18) S 18

value when it applies to an
Indication.
IndicationValueUnit The code representing the an S Qualified by

OfMeasureCode IndicationValueUnitOfMeasureTe IndicationValueUnitOfMeasureQualifier.
xt.
IndicationValueUnit Qualifier to identify the code an S See ECL

OfMeasureQualifier system being used.
IndicationValueUnit The textual representation of the an S

OfMeasureText IndicationValueUnitOfMeasureC
ode.
IndicationVariableM Used to express when there is an S See ECL

odifier more than one Indication as to
whether all the indications must
apply (AND) or if any of the
indications can apply (OR).
IngredientCost Ingredient cost of the medication an Q Format=s$$$$$$$$.cc to the length of the dollar
dispensed. amount exchanged.
- = Negative sign
. = Decimal point
would reflect: 5.50
- 73 -
July 2016
DATA DICTIONARY
148-U8 Ingredient Cost Informational field used when s9(6)99 T 8 Format=s$$$$$$cc

Contracted/ Other Payer-Patient
Reimbursable Responsibility Amount (352-NQ) Example: If the amount is $5.50 this field would
Amount or Patient Pay Amount (505-F5) reflect: 55{
is used for reimbursement.
Amount is equal to contracted or
reimbursable amount for
product being dispensed.
506-F6 Ingredient Cost Paid Drug ingredient cost paid s9(6)v99 T,A 8 For T,A: Format=s$$$$$$cc
included in the Total Amount
Paid (509-F9). _______ _________ _______ Examples: If the ingredient cost paid is $150.00, this
field would reflect: 1500{.
9(6)v99 Y 8
or For Y:
-9(5)v99 Format=$$$$$$cc or -$$$$$cc
Note:
- = Negative sign
usage.
409-D9 Ingredient Cost Submitted product component s9(6)v99 T,A,Z,W 8 Format=s$$$$$$cc

Submitted cost of the dispensed
prescription. This amount is Comments: This field can be further defined by
included in the Gross Amount using the Basis of Cost Determination Field 423-DN.
Due (430-DU). Examples: If the ingredient cost submitted is
$65.00, this field would reflect: 650{.
InjuryRelated The type of injury related to the an S See ECL

prescription.
Indicates if the pharmacy
266 In Network Indicator dispensing the prescription is x(1) A 1 See ECL
considered in network. ----------------
Indicates if the Health Care I

Service Provider is considered in
network.
InstructionIndicator Indicates the action to be taken an S See ECL

on the Instruction fields.
InsulinDependent Flag to identify if the patient is xsd:Boolean S See ECL

Insulin dependent. Code
- 74 -
July 2016
DATA DICTIONARY
267 Insurance Code Special group/member data as x(20) A,I 20

supplied on eligibility record
when supplied by the client.
A90 Insurance The insurance type or product x(6) Y 6 See ECL

Type/Product Code code for the type of insurance
coverage of the individual.
B48-8M Intermediary ID Intermediary ID assigned to the x(20) T 20

type entity.
B44-8G Intermediary ID Count of Intermediary ID Type 9(1) T 1

Count Code (B45-8H), Intermediary
Type Entity (B46-8J),
Intermediary ID Qualifier (B47-
8K), Intermediary ID (B48-8M),
Intermediary ID State/Province
Address (B49-8N) and
Intermediary ID Relationship
Code (B50-8P) occurrences.
B55-8U Intermediary ID The associated Postal country x(2) T 2 See ECL

Country Code code of the associated
Intermediary ID.
B47-8K Intermediary ID Code qualifying the Intermediary x(2) T 2 See ECL

Qualifier ID (B48-8M).
B50-8P Intermediary ID Code indicating the relationship 9(1) T 1 See ECL

Relationship Code to the patient.
B49-8N Intermediary ID The postal state code x(2) T 2 See ECL

State/Province abbreviation that is used in
Address conjunction with the
Intermediary ID Qualifier and the
Intermediary ID fields to identify
what state the identification is
from.
See ECL
B45-8H Intermediary ID Type Code identifying the type of x(2) T 2
Code Intermediary ID (B48-8M).
See ECL
B46-8J Intermediary ID Type Code Identifying the type of x(2) T 2
Entity entity associated with the
Intermediary ID (B48-8M).
B51-8Q Intermediary Free-form message. x(1)-x(200) T 200

Message
- 75 -
July 2016
DATA DICTIONARY
993-A7 Internal Control Number assigned by the x(30) T,Y 30

Number processor to identify an
adjudicated claim when supplied
in payer-to-payer coordination of
benefits only.
268 Internal Mail Order Field designating the internal x(15) A 15
(Prescription/Servic prescription number assigned by
e) Reference pharmacies.
Number
IntervalNumericValu The numeric time between 9(18) S 18

e events. Used to define an
Interval of administration.
IntervalUnitsCode The code representing the an S Qualified by IntervalUnitsQualifier.

IntervalUnitsText.
See ECL
IntervalUnitsQualifi Qualifier to identify the code an S
er system being used.
IntervalUnitsText The textual representation of an S

IntervalUnitsCode.
269 Invoiced Amount Amount invoiced for this s9(9)v99 A 11 For A: Format=s$$$$$$$$$cc
transaction. Determined by _________ ________ ________
processor. Example: If the amount is $5.50 this field would
9(8)V99 I 10 reflect: 55{
amounts.
150-VF Invoiced Amount 1 The dollar amount requested for 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
this specific calculation type. 9b Note
or b = Space
9(5)v99999 - = Negative Sign
9-
151-VG Invoiced Amount 2 The dollar amount requested for 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or b = Space
9-
152-VH Invoiced Amount 3 The dollar amount requested for 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or b = Space
9-
- 76 -
July 2016
DATA DICTIONARY
153-VJ Invoiced Amount 4 The dollar amount requested for 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or b = Space
9-
154-VK Invoiced Amount 5 The dollar amount requested for 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or b = Space
9-
690-ZG Invoiced Date The date this claim was included
on an invoice. x(8) A 8 Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
155-VL Invoiced Per Unit The calculation amount at a per 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
Amount 1 unit level. 9b
or Note
9(5)v99999 b = Space
9- - = Negative Sign
156-VM Invoiced Per Unit The calculation amount at a per 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or Note
9(5)v99999 b = Space
157-VN Invoiced Per Unit The calculation amount at a per 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or Note
9(5)v99999 b = Space
158-VP Invoiced Per Unit The calculation amount at a per 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or Note
9(5)v99999 b = Space
159-VQ Invoiced Per Unit The calculation amount at a per 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or Note
9(5)v99999 b = Space
160-VR Invoice Price 1 The price used for the 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
calculation. 9b
or Note
9(5)v99999 b = Space
- 77 -
July 2016
DATA DICTIONARY
161-VS Invoice Price 2 The price used for the 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
calculation. 9b
or Note
9(5)v99999 b = Space
162-VT Invoice Price 3 The price used for the 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
calculation. 9b
or Note
9(5)v99999 b = Space
163-VU Invoice Price 4 The price used for the 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-Note
calculation. 9b b = Space
or - = Negative Sign
9(5)v99999
9-
164-VV Invoice Price 5 The price used for the 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-Note
calculation. 9b b = Space
or - = Negative Sign
9(5)v99999
9-
165-VW Invoice Rate 1 The rate used for the calculation. 9(3)v99999 R 9 Format=999v99999b or 999v99999-
b
or
Note
9(3)v99999-
b = Space
- = Negative Sign
166-VX Invoice Rate 2 The rate used for the calculation. 9(3)v99999 R 9 Format=999v99999b or 999v99999-
b or
9(3)v99999-
Note
b = Space
- = Negative Sign
167-VY Invoice Rate 3 The rate used for the calculation. 9(3)v99999 R 9 Format=999v99999b or 999v99999-
b
or
Note
9(3)v99999-
b = Space
- = Negative Sign
168-VZ Invoice Rate 4 The rate used for the calculation. 9(3)v99999 R 9 Format=999v99999b or 999v99999-
b
or
Note
9(3)v99999-
b = Space
- = Negative Sign
169-WA Invoice Rate 5 The rate used for the calculation. 9(3)v99999 R 9 Format=999v99999b or 999v99999-
b
or
Note
9(3)v99999-
b = Space
- = Negative Sign
170-WB Invoice Type 1 Description of transaction type. x(3) R 3 See ECL
- 78 -
July 2016
DATA DICTIONARY
171-WC Invoice Type 2 Description of transaction type. x(3) R 3 See ECL
172-WD Invoice Type 3 Description of transaction type. x(3) R 3 See ECL
173-WF Invoice Type 4 Description of transaction type. x(3) R 3 See ECL
174-WG Invoice Type 5 Description of transaction type. x(3) R 3 See ECL
IsDateTimeRequired Indicates whether datetime xsd:Boolean S See ECL

format is required for date Code
answer.
IsEAppealSupported Indicates if payer supports xsd:Boolean S See ECL

electronic appeals submission. Code
IsFreeText Indicates if the answer to the xsd:Boolean S See ECL

question is free text. Code
IsNumeric Indicates if the answer to the xsd:Boolean S See ECL

question is numeric. Code
IsPatientNotified Indicates if the prescriber has xsd:Boolean S See ECL

notified the patient that the Code
prescriber has requested the PA
Request be cancelled.
See ECL
IVAccessCatheterTip The code representing the an S
Code IVAccessCatheterTipType. It is
the intended specific structure of
the catheter tip for the specific
device used for central or midline
IV access.
IVAccessCatheterTip Description of the catheter tip. an S

Description
IVAccessCatheterTip The textual representation of an S

Text IVAccessCatheterTipTypeCode.
See ECL
IVAccessDeviceType The code representing the an S
Code IVAccessDeviceType.
IVAccessDeviceType Description of device type. an S Example: Implanted port, PICC, tunneled, non-
Description tunneled
IVAccessDeviceType The textual representation of an S

Text IVAccessDeviceCode.
- 79 -
July 2016
DATA DICTIONARY
See ECL
IVAccessTypeCode The code representing the an S
IVAccessType.
IVAccessTypeText The textual representation of an S

IVAccessTypeCode.
See ECL
IVInfusionTypeCode The code representing the an S
IVInfusionType. It is the intended
type of IV infusion.
IVInfusionTypeDescr Description of the infusion type. an S Example: Continuous, intermittent, TOTAL

iption Perenteral Nutrition (TPN), PARTIAL Perenteral
Nutrition (PPN), maintenance
IVInfusionTypeText The textual representation of an S

IVInfusionTypeCode.
A76 J Code A subset of the HCPCS Level II x(6) J 6 See below for a list of codes:
code set with a high-order value
of J that has been used to http://www.cms.hhs.gov/hcpcsreleasecodesets/an
identify certain drugs and other hcpcs/list.asp
items.
A77 J Code Modifier 1 Code specifying drug and other x(2) J 2

items.

items.

items.

items.
688 Jurisdictional Field Text field with constraints. x(30) W 30

(1-5)
See ECL
683 Jurisdictional State Postal State Abbreviation x(2) W 2
identifying the state which has
jurisdiction over the payment of
benefits and medical claims for
the injured worker. Typically, the
Jurisdictional State is the state
where the worker was injured.
- 80 -
July 2016
DATA DICTIONARY
LabelCode Code associated with the an Q,S

warning label to be included on
the prescription vial.
613-NM Label Directions Prescription label directions. x(200) V 200
LabelGraphicCode Graphic code associated with the an Q,S

LabelPriority Priority associated with the 9(1) Q,S 1

LabelText Text associated with the warning an Q,S

to be included on the
prescription vial.
See ECL
LanguageNameCode The language the patient best x(3) S,Q 3
understands and communicates
with (read, write, speak).
LastFillDate Last demand (last fill) date or xsd:date or S,Q CC=Century
date and time. xsd:datetim YY=Year
e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
B56-3E Last Known BIN Last known Card Issuer ID or 9(6) T 6 Comments: See BIN Number (101-A1).
Number Bank ID Number used for
network routing used on a
previous claim.
- 81 -
July 2016
DATA DICTIONARY
B59-3H Last Known Last known insurance ID assigned x(20) T 20

Cardholder ID to the cardholder or
identification number used by
the plan used on a previous
claim.
B58-3G Last Known Group Last known ID assigned to the x(15) T 15

ID cardholder group or employer
group used on a previous claim.
B57-3F Last Known Last known number assigned by x(10) T 10

Processor Control the processor used on a previous
Number claim.
LastName Last name. x(35) S, Q 35

x(35) A,L,V,X 35
716-SY Last Name Last name. Size of 128 is used in Uniform Healthcare Payer
_______ _________ _______
Data Standard for possible encrypted data.
x(128) Y 128
Qualified by Length of Need Qualifier (371-2S).
370-2R Length of Need Length of time the physician 9(3) T 3
expects the patient to require
use of the ordered item.
Qualifies Length of Need (370-2R).
371-2S Length of Need Code qualifying the length of 9(2) T 2 See ECL Note: If value is 6, length of need would be 1.
Qualifier need.
See ECL
418-DI Level Of Service Coding indicating the type of 9(2) T,A 2
service the provider rendered.
Total limit reduction applicable
A98 Limit Reduction 9(10)v99 L 12 Format=$$$$$$$$$$cc
to the retiree’s Gross Retiree
Cost. (Note: This cost does not support a sign.)
A91 Line Counter Line number for this service. The 9(4) Y 4
line counter begins with 1 and is
incremented by 1 for each
additional service line.
601-43 Line Number Unique number that identifies x(11) R,J 11

the record.
270 Line Of Business Line of Business Code from Client x(6) A 6

Code eligibility or as defined by trading
partner agreement.
- 82 -
July 2016
DATA DICTIONARY
928-FR List Action Indicates whether this is a x(1) F 1 See ECL

replacement list, list updates or a
list delete.
929-FZ List Effective Date Date the list goes into effect. 9(8) F 8 Format= CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
B93-3Y List Expiration Date Date the list is no longer in 9(8) F 8 Format = CCYYMMDD
effect. CC=Century
YY=Year
MM=Month
DD=Day
930-F2 Load Status Code explaining the status of the x(2) F 2 See ECL
load.
LOINCVersion The version of Logical an S

Observation Identifier Names
and Codes (LOINC) being used.
LotExpiration The expiration date associated xsd:date or Q,S CC=Century
with a specific lot number of a xsd:datetim YY=Year
medication. e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
LotNumber Number assigned by the an Q,S
manufacturer to a batch of
medications for tracking.
LowerBoundCompar Code that conveys the an S See ECL

isonOperator relationship between the
and a defined lower boundary.
- 83 -
July 2016
DATA DICTIONARY
LowerBoundCompar Value for the lower boundary of 9(18) S 18

isonValue the comparison.
271 MAC Price Indicates the unit maximum s9(5)v9(4) A 9 Format=s$$$$$cccc

allowable cost price for the
product/service as defined by Example: If the amount is $5.5000 this field would
the processor. reflect: 5500{
272 MAC Reduced Indicates if a claim payment was x(1) A 1 See ECL
Indicator reduced due to a MAC
(Maximum Allowable Cost)
program.
MailboxID Identification of the mailbox. x(35) S,Q 35
MailOrder Indicator that Central Fill Order is xsd:Boolean Q See ECL

to be shipped somewhere other Code
than requesting pharmacy.
273 Maintenance Drug Indicates if the drug is a x(1) A 1 See ECL

Indicator maintenance drug under the
client's benefit plan.
ManufacturerName Name of the manufacturer. an Q,S
600-47 Manufacturer Contract number assigned by the x(15) R,J 15

(PICO) Contract manufacturer.
Number
600-48 Manufacturer Code assigned to identify the x(17) R,J 17

(PICO) ID Code manufacturer.
See ECL
600-72 Manufacturer Indicates the type of data being x(2) R,J 2
(PICO) ID Qualifier submitted in the Manufacturer
(PICO) ID Code (600-48) field.
601-65 Manufacturer This is the name or code for the x(17) R 17

(PICO) Market market basket being submitted
Basket Code to the PMO.
600-50 Manufacturer Name of the manufacturer. x(70) R,J 70

(PICO) Name
601-63 Market Basket Description of market basket x(30) R 30

Description being submitted.
- 84 -
July 2016
DATA DICTIONARY
601-62 Market Basket Start The effective date of the market 9(8) R 8 Format=CCYYMMDD
Date basket.
CC=Century
YY=Year
MM=Month
DD=Day
601-61 Market Basket The termination date of the 9(8) R 8 Format=CCYYMMDD

Termination Date market basket.
CC=Century
YY=Year
MM=Month
DD=Day
Markings Drug marking text from a drug an Q

imprint database.
932-GA Maximum Age Maximum age at which the drug 9(3) F 3 Comments: Qualified by Maximum Age Qualifier
is covered (inclusive). (931-F8)
931-F8 Maximum Age Code qualifying the maximum x(1) F 1 See ECL Comments: Qualifies Maximum Age (932-GA)
Qualifier age.
Comments: Qualified by Maximum Amount
933-GB Maximum Amount Maximum amount for a quantity R(10) F 10 Qualifier (934-GC).
limit.
If Maximum Amount Qualifier = DL (Dollar
Amount), Format= 9999999.99 If dollar amount, no
dollar sign. Decimal required if value includes cents.
Currency: USD The length includes the decimal
point. For all other values of Maximum Amount
Qualifier, Format= 9999999999 with no implicit or
explicit decimal point.
934-GC Maximum Amount This field qualifies the amount in x(2) F 2 See ECL Comments: Qualifies Maximum Amount (933-GB).
Qualifier the Maximum Amount (933-GB).
935-GF Maximum Amount Type of time period associated x(2) F 2 See ECL
Time Period with the overall Maximum
Amount Qualifier (934-GC).
937-GH Maximum Amount Ending date of Specific Date 9(8) F 8 Format= CCYYMMDD
Time Period End Range.
CC=Century
Date
YY=Year
MM=Month
DD=Day
- 85 -
July 2016
DATA DICTIONARY
936-GG Maximum Amount Starting date of Specific Date 9(8) F 8 Format= CCYYMMDD
Time Period Start Range.
CC=Century
Date
YY=Year
MM=Month
DD=Day
938-GJ Maximum Amount Number of units associated with 9(4) F 4 Format= 9999
Time Period Units the overall Maximum Amount
Time Period (935-GF).
939-GK Maximum Copay Maximum total copay to be paid R(10) F 10 Format=$$$$$$$.cc

by the patient.
940-GM Maximum Copay Provides the range within which 9(2) F 2

Tier the Copay Tier is stated. The
highest Copay Tier within that
range.
MaximumDoseRestr Used to add clarity to the x(255) S 255

ictionClarifyingFreeT maximum dose restriction for
ext elements that cannot be
codified.
MaximumDoseRestr The code represented by the an S Qualified by

ictionDurationUnits MaximumDoseRestrictionDuratio MaximumDoseRestrictionUnitsQualifier
Code nUnitsText.
MaximumDoseRestr Qualifier to identify the code an S See ECL

ictionDurationUnits system being used.
Qualifier
MaximumDoseRestr The textual representation of the an S

ictionDurationUnits MaximumDoseRestrictionDuratio
Text nUnitsCode.
MaximumDoseRestr The numeric representation of 9(18) S 18

ictionDurationValue the maximum dose restriction
duration.
MaximumDoseRestr The code representing the an S Qualified by

ictionFormCode MaximumDoseRestrictionFormT MaximumDoseRestrictionFormQualifier.
ext.
- 86 -
July 2016
DATA DICTIONARY

ictionFormQualifier system being used.
MaximumDoseRestr The textual representation of the x(255) S 255

ictionFormText MaximumDoseRestrictionFormC
ode.
MaximumDoseRestr Defines a MaximumDose, so that 9(18) S 18

ictionNumericValue the Sig can represent the
concept, Not to exceed _____.
Expression of a Dose Maximum
involves placing the core dose
value in this field and the units
and variables in the fields that
follow.
MaximumDoseRestr The code representing the an S Qualified by MaximumDoseRestrictionQualifier.

ictionUnitsCode MaximumDoseRestrictionUnitsTe
xt.

ictionUnitsQualifier system being used.
MaximumDoseRestr The textual representation of the an S

ictionUnitsText MaximumDoseRestrictionUnitsC
ode.
B66-3N Maximum Drugs Per This is the maximum number of 9(2) F 2

Step Group drugs that may be tried in the
step group. Not used for
alternatives.
494-ZE Measurement Date Date clinical information was 9(8) T 8 Format=CCYYMMDD

collected or measured.
CC=Century
YY=Year
MM=Month
DD=Day
496-H2 Measurement Code indicating the clinical x(2) T 2 See ECL

Dimension domain of the observed value in
Measurement Value (499-H4).
MeasurementDurati
onClarifyingFreeTex Used to add clarity to the x(255) S 255
t duration for elements that
cannot be codified.
- 87 -
July 2016
DATA DICTIONARY
MeasurementDurati The numeric duration units. 9(18) S 18

onNumericValue
MeasurementDurati The textual representation of an S

onText MeasurementDurationUnitsCode
.
MeasurementDurati The code representing the an S Qualified by MeasurementDurationTextQualifier.

onTextCode MeasurementDurationUnitsText.
MeasurementDurati Qualifier to identify the code an S See ECL

onTextQualifier system being used.
MeasurementDurati The textual representation of the an S

onTriggerText MeasurementDurationTriggerTex
tCode. The event that indicates
the completion of the duration of
use or reason to stop.
MeasurementDurati The code representing the an S Qualified by

onTriggerTextCode MeasurementDurationTriggerTex MeasurementDurationTriggerTextQualifier.
t.
MeasurementDurati Qualifier to identify the code an S See ECL

onTriggerTextQualifi system being used
er
MeasurementFrequ The numeric interval for the 9(18) S 18

encyNumericValue event. Used to define a
frequency of administration.
MeasurementFrequ The code representing the an S Qualified by MeasurementFrequencyUnitsQualifier.

encyUnitsCode MeasurementFrequencyUnitsTex
t.
MeasurementFrequ Qualifier to identify the code an S See ECL

encyUnitsQualifier system being used.
MeasurementFrequ The textual representation of an S

encyUnitsText MeasurementFrequencyUnitsCo
de.
MeasurementInterv The numeric time between 9(18) S 18

alNumericValue events. Used to define an
Interval of administration.
- 88 -
July 2016
DATA DICTIONARY
MeasurementInterv The code representing the an S Qualified by MeasurementIntervalUnitsQualifier.

alUnitsCode MeasurementIntervalUnitsText.
MeasurementInterv Qualifier to identify the code an S See ECL

alUnitsQualifier system being used.
MeasurementInterv The textual representation of an S

alUnitsText MeasurementIntervalUnitsCode.
495-H1 Measurement Time Time clinical information was 9(4) T 4 Format= HHMM
collected or measured.
HH=Hour
MM=Minute
Examples: Reported in military time. Two o’clock
P.M. = 1400.
MeasurementTimin Used to add clarity to the x(255) S 255

gClarifyingFreeText titration measurement timing for
elements that cannot be
codified.
MeasurementTimin The code representing the an S Qualified by MeasurementTimingEventQualifier.

gEventCode MeasurementTimingEventText.
MeasurementTimin Qualifier to identify the code an S See ECL

gEventQualifier system being used.
MeasurementTimin The textual representation of an S

gEventText MeasurementTimingEventCode.
MeasurementTimin The code representing the an S Qualified by MeasurementTimingModifierQualifier.

gModifierCode MeasurementTimingModifierTex
t.
MeasurmentTiming Qualifier to identify the code an S See ECL

ModifierQualifier system being used.
MeasurementTimin The textual representation of the an S

gModifierText MeasurementTimingModifierCod
e. Used to clarify or specify when
the clinical information is to be
evaluated relative to the actual
timing event.
- 89 -
July 2016
DATA DICTIONARY
MeasurementTimin The numeric value for the 9(18) S 18

gNumericValue measurement event, such as 30
(minutes).
MeasurementTimin The code representing the an S Qualified by MeasurementTimingUnitsQualifier.

gUnitsCode MeasurementTimingUnitsText.
MeasurementTimin Qualifier to identify the code an S See ECL

gUnitsQualifier system being used.
MeasurementTimin The textual representation of an S

gUnitsText MeasurementTimingUnitsCode.
497-H3 Measurement Unit Code indicating the metric or x(2) T 2 See ECL
English units used with the
clinical information.
MeasurementValue Actual value of clinical 9(18) S 18

information.
499-H4 Measurement Value Actual value of clinical x(15) T 15 Comments: Blood pressure entered in XXX/YYY
information. format in which XXX=systolic, /=divider, and YYY is
diastolic. Temperature entered in XXX.X format
always including decimal point.
116-N6 Medicaid Agency Number assigned by processor to x(15) T,G 15

Number identify the individual Medicaid
Agency or representative.
115-N5 Medicaid ID A unique member identification x(20) T,G 20
Number number assigned by the
Medicaid Agency.
360-2B Medicaid Indicator Two character State Postal Code x(2) T 2 See ECL
indicating the state where
Medicaid coverage exists.
113-N3 Medicaid Paid Amount paid by the Medicaid s9(6)V99 T,G 8
Amount Agency. Format=s$$$$$$cc
reflect: 55{
A81 Medical Rebate Version and release number of x(5) J 5 See ECL
Version Release standard being submitted
Number
- 90 -
July 2016
DATA DICTIONARY
114-N4 Medicaid Claim number assigned by the x(20) T,G 20

Subrogation Internal Medicaid Agency.
Control
Number/Transactio
n Control Number
(ICN/TCN)
Code to indicate if the claim was

A73 Medicare Drug processed under the Part D Drug x(2) A 2 See ECL
Coverage Code Benefit, the Part B Drug Benefit,
or does not apply.
139-UR Medicare Part D Code indicating the position of 9(2) T, 2 See ECL
Coverage Code Medicare Part D in the billing
order.
A34-ZY Medicare Part D Identifier assigned by CMS of a 9(3) N,A 3

Plan Benefit particular plan benefit package
Package (PBP) (Benefit Category) within a
Medicare Part D contract.
274 Medicare Plan Code This represents if the member is x(1) A 1 See ECL
eligible for Medicare coverage as
provided in eligibility data.
275 Medicare Recovery Field to indicate if days supply on x(1) A 1 See ECL
Dispensing Indicator prescription was reduced due to
plan limits.
276 Medicare Recovery Field to indicate if Medicare was x(1) A 1 See ECL
Indicator billed in order to recover funds
for current or previous claims
billed to the client.
359-2A Medigap ID Patient’s ID assigned by the x(20) T 20

Medigap Insurer.
See ECL
600-83 Membership Count Further specifies the x(1) R 1
Qualifier membership period qualifier in
order to calculate the data
submitted in the Membership
Total Count (600-88) field.
See ECL
600-86 Membership Period Identifies the period of time for x(1) R 1
Qualifier which the membership counts
cover.
- 91 -
July 2016
DATA DICTIONARY
600-87 Membership The first day of the membership 9(8) R 8 Format=CCYYMMDD

Reporting Period reporting period.
Start Date CC=Century
YY=Year
MM=Month
DD=Day
600-88 Membership Total The total number of persons 9(9)b R 10 Format=999999999b or 999999999-
Count covered (the sum of enrollees or 9(9)-
and dependents or the product Note
of enrollees and the calculation b = Space
multiplier). - = Negative Sign
600-89 Membership Type Identifies the type of x(1) R 1 See ECL

Qualifier membership being reported.
277 Member Submit Ingredient Cost as submitted by s9(6)v99 A 8 Format=s$$$$$$cc

Amount member (Paper claims only).
reflect: 55{
278 Member Submitted Indicates the date the member 9(8) A 8 Format= CCYYMMDD
Claim Payment submitted claim became CC=Century
Release Date payable, which could differ from YY=Year
the check date. MM=Month
DD=Day
279 Member Submitted A one-position field indicating x(1) A 1 See ECL

Claim Program Code the type of member submitted
claim program used to process
this claim.
A38 Member Submitted For member submitted claims; a X(3) A 3

Claim Reject Code processor-specified list.
For all standards but Benefit Integration and
504-F4 Message Free-form message. x(1)-x(200) B,T,N,E 200 Uniform Healthcare Payer Data: Comments:
_______ _________ ________ Variable length is from 1-200 characters.
x(80) Y,I 80
- 92 -
July 2016
DATA DICTIONARY
MessageID Trace number. A unique x(35) S, Q 35

reference identifier for the
transmission, generated from the
sender of the request and the
sender of the response. When
generated from the sender, it is
then echoed back in the
response message in the field
RelatesToMessageID. The value
in this field must be present in
RelatesToMessageID on
subsequent transactions (such as
RefillRequest, CancelRx, etc) to
tie back to an original
transmission.
941-GN Message-Long Text message. x(200) F 200
MessageRequestCo To clarify a transaction. an S,Q See ECL

de
942-GP Message-Short Text message. x(100) F 100
MessageToFollowM The specific message identifier x(35) Q 35

essageIdentifier that may be sent in the response
to provide the original requester
linkage from the original request
to this response.
MiddleInitial Individual middle initial. x(35) S,Q 35
718-SZ Middle Initial Individual middle initial. x(1) A,V,X,L,I 1 Size of 128 is used in Uniform Healthcare Payer
_______ _________ _______ Data Standard for possible encrypted data.
x(128) Y 128
A92 Middle Name Middle name of individual. x(25) Y 25
MIMEType Defines the content nature of the an Q See ECL

AttachmentData. It is an Internet
standard defined in RFC 2045,
RFC 2046, RFC 2047, RFC 4288,
RFC 4289 and RFC 2049.
944-GR Minimum Age Minimum age at which the drug 9(3) F 3 Comments: Qualified by Minimum Age Qualifier
is covered (inclusive). (943-GQ)
- 93 -
July 2016
DATA DICTIONARY
943-GQ Minimum Age Code qualifying the Minimum x(1) F 1 See ECL Comments: Qualifies Minimum Age (944-GR)
Qualifier Age (944-GR).
945-GS Minimum Copay Minimum total copay to be paid R(10) F 10 Format=$$$$$$$.cc

by the patient.
B65-3M Minimum Drugs Per This is the minimum number of 9(2) F 2

Step Group drugs that must be tried in the
step group. Thisnumber may
range between zero (group
optional) to N where N is less
than or equal to the Number of
Drugs to Try (951-GY). Not used
for alternatives.
MonographText Monograph Text to be printed an Q

with the Central Fill order.
B61-3K Month of Last Paid Identifies the month used on a 9(2) T 2 Format=MM MM=Month
Claim previous claim.
Format CCYYMMDD
614-NW Most Recent Date Date of the most recent fill. 9(8) V 8
Filled CC=Century
YY=Year
MM=Month
DD=Day
MTMActionCode Code representing the reason for an Q Qualified by MTMActionCodeQualifier.

the service.
MTMActionCodeQu Qualifier to identify the code an Q See ECL

alifier system being used for
MTMActionCode.
MTMActionFreeText Free Text field to be used only if an Q

reason identified does not have a
code list (MTMActionCode).
MTMActionText Textual representation of an Q

MTMActionCode.
- 94 -
July 2016
DATA DICTIONARY
MTMPayerCaseIden Unique identifier assigned by the an Q

tifier payer to this case.
MTMPayerCaseIdentifier is
subservient to the patient
identifier. (A patient may have
multiple cases, distinguished by
multiple case identifiers.)
MultipleInstruction Used to express when there is an S See ECL

Modifier more than one Sig as to whether
all the Sigs must apply (AND) or if
any of the Sigs can apply (OR) or
if the Sigs are sequential (THEN),
in the sequence defined by the
occurrence of the Instruction.
MultipleVehicleMod Denotes if for an instance of an S See ECL

ifier more than one vehicle if all
vehicles are used together (AND),
or if each of the listed vehicles is
an option (OR). (TO) is used if the
VehicleUnitOfMeasure provides
for a range.
280 Name Suffix Individual name suffix. x(10) A 10
390-BM Narrative Message Free-form text. x(200) T 200

NeededNoLaterTha For the facility to relay to the xsd:datetim S CC=Century
nDate long term care pharmacy the e YY=Year
timeframe when medication is MM=Month
needed for delivery. DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
NeededNoLaterTha Free text additional instructions. x(70) S 70

nReason
- 95 -
July 2016
DATA DICTIONARY
For A and Y:
281 Net Amount Due Net amount paid to provider by s9(6)v99 A,Z,W 8 For A,Z,W: Format=s$$$$$$cc
the payer or net amount due _______ _________ _______ Example: If the amount is $5.50 this field would
from the client to the payer, reflect: 55{For Y:
determined by trading partner 9(6)v99 Y 8 Format=$$$$$$cc or -$$$$$cc
agreement. or Note:
-9(5)v99 -= Negative sign
For Z and W:
Net amount due from the payer This minus (-) sign occupies a position, so the
or their agent to the payee. dollars that can be supported are one digit less than
usage.
545-2F Network Field defined by the processor. It x(10) T,A 10

Reimbursement ID identifies the network, for the
covered member, used to
calculate the reimbursement to
the pharmacy.
NewPassword Contains the new password. an S,Q
B04-BT Next Available Fill Date on which this prescription 9(8) T 8 Format=CCYYMMDD
Date will have passed the plan's CC=Century
minimum consumption YY=Year
requirements and may be MM=Month
considered for a standard refill. DD=Day
Format=CCYYMMDD
140-US Next Medicare Part Future date Part D coverage 9(8) T 8 CC=Century
D Effective Date begins for the patient. YY=Year
MM=Month
DD=Day
Format=CCYYMMDD
141-UT Next Medicare Part Future date Part D coverage ends 9(8) T 8 CC=Century
D Termination Date for the patient. YY=Year
MM=Month
DD=Day
NextQuestionID Indicates the next QuestionID x(35) S 35 See ECL

that should be answered if this
answer choice is selected or END.
NoKnown Indicates if the sender does not an Q See ECL

know of any specific categories
of information for this patient.
- 96 -
July 2016
DATA DICTIONARY
NoKnownAllergies Indicates if the sender does not x(1) Q 1 See ECL

know of any specific allergies for
this patient.
Nonce Element in UsernameToken. n/a S, Q

SOAP.
948-GV Non-Listed Brand Tells the receiver how to treat x(2) F 2 See ECL Comments: The higher the number for the
Over The Counter non-listed branded over the preferred level, the more preferred the drug is.
Formulary Status counter drugs.
949-GW Non-Listed Generic Tells the receiver how to treat x(2) F 2 See ECL Comments: The higher the number for the
Over The Counter non-listed generic over the preferred level, the more preferred the drug is.
Formulary Status counter drugs.
946-GT Non-Listed Tells the receiver how to treat x(2) F 2 See ECL Comments: The higher the number for the
Prescription Brand non-listed prescription branded preferred level, the more preferred the drug is.
Formulary Status drugs.
947-GU Non-Listed Tells the receiver how to treat x(2) F 2 See ECL Comments: The higher the number for the
Prescription Generic non-listed prescription generic preferred level, the more preferred the drug is.
Formulary Status drugs.
950-GX Non-Listed Supplies Tells the receiver how to treat x(2) F 2 See ECL Comments: The higher the number for the
Formulary Status non-listed supplies. preferred level, the more preferred the drug is.
282 Non-POS Claim Used for bypassing system edits x(1) A 1 See ECL
Override Code for non-Point of Sale (POS) claims
and/or modifying pricing logic.
Note Free text. x(210) S, Q 210
NumberOfCycles Number of cycles authorized. 9(3) S 3
NumberOfCyclesPla Number of treatment cycles 9(2) S 2

nned planned.
951-GY Number of Drugs To The number of drugs to try 9(2) F 2

Try within a class, subclass, or
pharmacological class.
616-PU Number Of Fills Number of fills authorized by the 9(2) V 2 See RefillsRemaining.
Remaining prescriber that have not yet been
dispensed.
- 97 -
July 2016
DATA DICTIONARY
615-NY Number Of Fills To Number of times this 9(2) V 2

Date prescription has been filled to
date.
692-ZJ Number Of Generic Number of manufacturers that 9(3) A 3

Manufacturers produce this generic drug
provided by drug compendium.
NumberOfLumens Indicates the number of lumens an S

in the IV access line that will be
used for administering the
medication.
NumberOfPackages Number of separate packages of 9(2) S,Q 2

Dispensed medication for administration in
different locations or by different
caregivers (each package
contains an equal portion of the
total quantity that has been
dispensed). If it is not sent it is
implied it is 1, otherwise send
actual number that was
dispensed.
NumberOfPackages Number of separate packages of 9(2) S,Q 2

ToBeDispensed medication for administration in
different locations or by different
caregivers (each package
contains an equal portion of the
total quantity to be dispensed). If
it is not sent it is implied it is 1,
otherwise send desired number.
NumberOfRefills The refill quantity of the 9(2) S 2

prescription.
415-DF Number of Refills Number of refills authorized by 9(2) T,A,V 2 See ECL
Authorized the prescriber.
601-59 Numerator Indicator Product is part of numerator and x(1) R 1 See ECL
denominator of market share
calculation.
- 98 -
July 2016
DATA DICTIONARY
ObservationDate The date or date and time on xsd:date or S CC=Century
which the observation was xsd:datetim YY=Year
made. e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
ObservationNotes Free text of the observation. x(140) S 140

Information is found at
OfficeOfPharmacyAf Health Resources and Services x(15) S 15
http://opanet.hrsa.gov/opa/CESearch.aspx
fairsID Administration (HRSA) Office of
Pharmacy Affairs (OPA)
Identification Code associated
with the eligibility of this
prescription for drugs purchased
pursuant to rights under Section
340B of the Public Health Service
Act of 1992.
OldPassword Contains the old password. an S,Q
B80 Optional Data Indicator that optional financial x(1) I 1 See ECL
Indicator amounts are present.
OrderCaptureMetho Code conveying the method by an S See ECL

d which the order was defined by
the prescriber and captured in
the prescribing system.
601-92 Original Amount The first dollar amount invoiced. 9(9)v99b R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
Invoiced or
9(9)v99- Note:
b = Space
-= Negative sign
- 99 -
July 2016
DATA DICTIONARY
283 Original Claim The date the pharmacy 9(8) A 8 Format= CCYYMMDD
Received Date submitted the claim
electronically for a paper claim- CC=Century
matching program. YY=Year
MM=Month
DD=Day
617-RQ Original Dispensed Date of the first fill for the 9(8) V 8 Format= CCYYMMDD
Date prescription.
CC=Century
YY=Year
MM=Month
DD=Day
A44-ZL Original Dispensed Product initially dispensed 9(7)v999 V 10 Format=9999999v999

Quantity amount expressed in metric
decimal units.
445-EA Originally Prescribed Code of the initially prescribed x(19) T.V 19 Comments: Qualified by ‘Originally Prescribed
Product/Service product or service. Product/Service Code Qualifier’ (453-EJ).
Code
453-EJ Originally Prescribed Code qualifying the value in x(2) T,V 2 See ECL
Product/Service ID Originally Prescribed
Qualifier Product/Service Code (445-EA).
446-EB Originally Prescribed Product initially prescribed 9(7)v999 T 10 Format=9999999v999

Quantity amount expressed in metric
decimal units.
601-93 Original Rebate Per The original amount per unit. 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
Unit 9b
or Note:
9(5)v99999 b = Space
9- -= Negative sign
601-94 Original Units The number of units originally 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
Invoiced invoiced. or
9(11)v999- Note:
b = Space
-= Negative sign
- 100 -
July 2016
DATA DICTIONARY
480-H9 Other Amount Amount representing the s9(6)v99 T,Z,W 8 Format=s$$$$$$cc

Claimed Submitted additional incurred costs for a
dispensed prescription or Comments: Qualified by Other Amount Claimed
service. Submitted Qualifier (479-H8).
Examples: If the other amount claimed submitted is
$12.55, this field would reflect: 125E.
478-H7 Other Amount Count of other amount claimed 9(1) T 1 Comments: Fields included in the set/logical
Claimed Submitted submitted occurrences. grouping are:
Count
Other Amount Claimed Submitted Qualifier (479-
H8)
Other Amount Claim Submitted (480-H9)
479-H8 Other Amount Code identifying the additional x(2) T 2 See ECL
Claimed Submitted incurred cost claimed in Other
Qualifier Amount Claimed Submitted (480-
H9).
565-J4 Other Amount Paid Amount paid for additional costs s9(6)v99 T,A 8 For T,A: Format=s$$$$$$cc
claimed in Other Amount
_______ _________ _______ Example: If the amount is $5.50 this field would
Claimed Submitted (480-H9).
reflect: 55{
9(6)v99 Y 8
or Comments: Qualified by Other Amount Paid
-9(5)v99 Qualifier (564-J3).
For Y:
Note:
-= Negative sign
usage.
563-J2 Other Amount Paid Count of the other amount paid 9(1) T 1 Comments: Fields included in the set/logical
Count occurrences. grouping are:
Other Amount Paid Qualifie’ (564-J3)
Other Amount Paid (565-J4)
564-J3 Other Amount Paid Code clarifying the value in the x(2) T,A,Y 2 See ECL
Qualifier Other Amount Paid (565-J4).
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July 2016
DATA DICTIONARY
308-C8 Other Coverage Code indicating whether or not 9(2) T,A,R,Z,W 2 See ECL
Code the patient has other insurance
coverage.
431-DV Other Payer Amount of any payment known s9(6)v99 T,Z,W 8 Format=s$$$$$$cc
Amount Paid by the pharmacy from other
sources. Examples: If the other payer amount paid is $32.56,
this field would reflect: 325F.
341-HB Other Payer Count of the payer amount paid 9(1) T 1

Amount Paid Count occurrences.
342-HC Other Payer Code qualifying the Other Payer x(2) T 2 See ECL
Amount Paid Amount Paid (431-DV).
Qualifier
566-J5 Other Payer Total amount recognized by the s9(6)v99 T,A 8 Format=s$$$$$$cc
Amount Recognized processor of any payment from
another source. Examples: If the other payer amount recognized is
$5.27. This field would reflect: 52G.
Format=CCYYMMDD
144-UX Other Payer Benefit Other Payer’s effective date of 9(8) T 8 CC=Century
Effective Date the patient’s benefit. YY=Year
MM=Month
DD=Day
Format=CCYYMMDD
145-UY Other Payer Benefit Other Payer’s termination date 9(8) T 8 CC=Century
Termination Date of the patient’s benefit. YY=Year
MM=Month
DD=Day
990-MG Other Payer BIN The secondary, tertiary, etc. card 9(6) T 6
Number issuer or bank ID number used
for network routing.
356-NU Other Payer Cardholder ID for this member x(20) T 20

Cardholder ID that is associated with the Payer
noted.
338-5C Other Payer Code identifying the type of x(2) T 2 See ECL
Coverage Type ‘Other Payer ID’ (340-7C).
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July 2016
DATA DICTIONARY
443-E8 Other Payer Date Payment or denial date of the 9(8) T,Z,W 8 Format=CCYYMMDD
claim submitted to the other
payer. Used for coordination of CC=Century
benefits. YY=Year
MM=Month
DD=Day
Examples: If the primary payer denial date was

August 1, 1999, this field would reflect: 19990801.

Format =MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
00
992-MJ Other Payer Group ID assigned to the cardholder x(15) T 15

ID group or employer group by the
secondary, tertiary, etc. payer.
127-UB Other Payer Help Phone number of the other x(10) T 10 Format=AAAEEENNNN
Desk Telephone payer’s help desk.
Number AAA=Area Code
EEE=Exchange Code
NNNN=Number

reflect: 2125551212.
B23-7Q Other Payer Help Extension of the telephone 9(8) T 8 Format = 99999999
Desk Telephone number.
Number Extension
340-7C Other Payer ID ID assigned to the payer. x(10) T,V,Z,W 10 Comments: Qualified by Other Payer ID Qualifier
(339-6C).
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July 2016
DATA DICTIONARY
355-NT Other Payer ID Count of other payers with 9(1) T,V 1 Comments:
Count payment responsibility. Other Payer Coverage Type (338-5C)
Other Payer ID Qualifier (339-6C)
Other Payer ID (340-7C)
Other Payer Processor Control Number (991-MH)
Other Payer Cardholder ID (356-NU)
Other Payer Group ID (992-MJ)
Other Payer Person Code (142-UV)
Other Payer Help Desk Phone Number (127-UB)
Other Payer-Patient Relationship Code (143-UW)
Other Payer Benefit Effective Date (144-UX)
Other Payer Benefit Termination Date (145-UY)
339-6C Other Payer ID Code qualifying the Other Payer x(2) T,V,Z,W 2 See ECL
Qualifier ID (340-7C).
143-UW Other Payer-Patient Code assigned by the other payer 9(1) T 1 See ECL
Relationship Code to indicate the relationship of
patient to cardholder.
352-NQ Other Payer-Patient The patient’s cost share from a s9(8)v99 T,A,Z,W 10 Format=s$$$$$$$$cc
Responsibility previous payer.
Amount Example: If the amount is $5.50 this field would
reflect: 55{
353-NR Other Payer-Patient Count of Other Payer-Patient 9(2) T 2

Responsibility Responsibility Amount (352-NQ)
Amount Count and Other Payer-Patient
Responsibility Amount Qualifier
(351-NP) occurrences.
351-NP Other Payer-Patient Code qualifying the Other Payer- x(2) T,A 2 See ECL Comments: This field is submitted by the
Responsibility Patient Responsibility Amount pharmacist for the purpose of qualifying the entry
Amount Qualifier (352-NQ). in the Other Payer-Patient Responsibility Amount
field.
142-UV Other Payer Person Code assigned by the other payer x(3) T 3
Code to a specific person within a
family.
991-MH Other Payer A number that uniquely x(10) T,V 10

Processor Control identifies the secondary, tertiary,
Number etc. payer to the processor.
472-6E Other Payer Reject The error encountered by the x(3) T,Z,W 3
Code previous Other Payer in Reject
Code (511-FB).
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July 2016
DATA DICTIONARY
471-5E Other Payer Reject Count of Other Payer Reject 9(2) T 2 Comments: Number of reject codes identified by
Count Code (472-6E) occurrences. the previous Other Payer in Reject Count (510-FA).
529-FT Other Pharmacy Code indicating the pharmacy 9(1) T 1 See ECL
Indicator responsible for the previous
event involved in the DUR
conflict.
533-FX Other Prescriber Code comparing the prescriber of 9(1) T 1 See ECL
Indicator the current prescription to the
prescriber of the previously filled
conflicting prescription.
OtherTelephoneExt Extension of the other telephone 9(8) S,Q 8 Format = 99999999

ension number.
OtherTelephoneNu Other telephone number of the 9(10) S,Q 10 Format=AAAEEENNNN

mber entity. AAA=Area Code
EEE=Exchange Code
NNNN=Number
OtherTelephoneSup Indication the number accepts xsd:Boolean S,Q See ECL

284 Out Of Pocket Apply Amount applied to out of pocket s9(6)v99 A 8 Format=s$$$$$$cc
Amount expense.
reflect: 55{
691-ZH Out Of Pocket Dollars remaining until patient is s9(6)v99 A 8 Standard if this field is not applicable, the field
Remaining Amount totally in benefit paying no out of should contain 9999999I
pocket expenses.
Format=s$$$$$$cc
reflect: 55{
953-HP Out of Pocket Range If the copay varies according to R(10) F 10 Format=$$$$$$$.cc
End the patient’s out of pocket, this is
the upper range value. Comments: No dollar sign. Decimal required if value
includes cents. Currency: USD - The length includes
the decimal point.
Blank indicates no upper limit to range.
952-GZ Out of Pocket Range If the copay varies according to R(10) F 10 Format=$$$$$$$.cc
Start the patient’s out of pocket, this is
the lower range value. Comments: No dollar sign. Decimal required if value
includes cents. Currency: USD - The length includes
the decimal point.
- 105 -
July 2016
DATA DICTIONARY
PACaseID ID assigned by the payer to x(35) S 35
identify the specific case.
633-SN Package Acquisition The per-package acquisition cost s9(6)v99 V 8
Cost of the product. Format s$$$$$$cc
reflect: 55{
175-WH Paid Amount 1 The amount paid for this specific 9(9)v99b R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
calculation type. or
9(9)v99-
Note
b = Space
- = Negative Sign
176-WJ Paid Amount 2 The amount paid for this specific 9(9)v99b R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
calculation type. or Note
9(9)v99- b = Space
- = Negative Sign
177-WK Paid Amount 3 The amount paid for this specific 9(9)v99b R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
9(9)v99-
Note
b = Space
- = Negative Sign
178-WL Paid Amount 4 The amount paid for this specific 9(9)v99b R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
9(9)v99-
Note
b = Space
- = Negative Sign
179-WM Paid Amount 5 The amount paid for this specific 9(9)v99b R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
9(9)v99-
Note
b = Space
- = Negative Sign
180-WN Paid Base Price 1 The price used in the paid 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
amount calculations. 9b
or
Note
9(5)v99999
b = Space
9-
- = Negative Sign
181-WP Paid Base Price 2 The price used in the paid 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or
Note
9(5)v99999
b = Space
9-
- = Negative Sign
182-WQ Paid Base Price 3 The price used in the paid 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or
Note
9(5)v99999
b = Space
9-
- = Negative Sign
- 106 -
July 2016
DATA DICTIONARY
183-WR Paid Base Price 4 The price used in the paid 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or
Note
9(5)v99999
b = Space
9-
- = Negative Sign
184-WS Paid Base Price 5 The price used in the paid 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or
Note
9(5)v99999
b = Space
9-
- = Negative Sign
601-95 Paid Per Unit The amount per unit that is paid. 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
Amount 9b
or Note:
9(5)v99999 b = Space
9- -= Negative sign
185-WT Paid Per Unit The amount paid calculated at a 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
Amount 1 per unit level. 9b
or
Note
9(5)v99999
b = Space
9-
- = Negative Sign
186-WU Paid Per Unit The amount paid calculated at a 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or
Note
9(5)v99999
b = Space
9-
- = Negative Sign
187-WV Paid Per Unit The amount paid calculated at a 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or
Note
9(5)v99999
b = Space
9-
- = Negative Sign
188-WW Paid Per Unit The amount paid calculated at a 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or
Note
9(5)v99999
b = Space
9-
- = Negative Sign
189-WX Paid Per Unit The amount paid calculated at a 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
or
Note
9(5)v99999
b = Space
9-
- = Negative Sign
190-WY Paid Quantity 1 The quantity accepted for 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
payment processing. or
9(11)v999-
Note
b = Space
- = Negative Sign
- 107 -
July 2016
DATA DICTIONARY
191-WZ Paid Quantity 2 The quantity accepted for 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
9(11)v999-
Note
b = Space
- = Negative Sign
192-XA Paid Quantity 3 The quantity accepted for 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
9(11)v999-
Note
b = Space
- = Negative Sign
193-XB Paid Quantity 4 The quantity accepted for 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
9(11)v999-
Note
b = Space
- = Negative Sign
194-XC Paid Quantity 5 The quantity accepted for 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
9(11)v999-
Note
b = Space
- = Negative Sign
195-XD Paid Rate 1 The rate used to calculate the 9(3)v99999 R 9 Format=$$$cccccb or $$$ccccc-
paid amount. b
or
Note
9(3)v99999-
b = Space
- = Negative Sign
196-XF Paid Rate 2 The rate used to calculate the 9(3)v99999 R 9 Format=$$$cccccb or $$$ccccc-
paid amount. b
or
Note
9(3)v99999-
b = Space
- = Negative Sign
197-XG Paid Rate 3 The rate used to calculate the 9(3)v99999 R 9 Format=$$$cccccb or $$$ccccc-
paid amount. b
or
Note
9(3)v99999-
b = Space
- = Negative Sign
198-XH Paid Rate 4 The rate used to calculate the 9(3)v99999 R 9 Format=$$$cccccb or $$$ccccc-
paid amount. b
or
Note
9(3)v99999-
b = Space
- = Negative Sign
199-XJ Paid Rate 5 The rate used to calculate the 9(3)v99999 R 9 Format=$$$cccccb or $$$ccccc-
paid amount. b
or
Note
9(3)v99999-
b = Space
- = Negative Sign
- 108 -
July 2016
DATA DICTIONARY
601-96 Paid Rebate Amount The total rebate amount paid 9(9)v99b R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
within the RS record type for the or
reported product. 9(9)v99- Note:
b = Space
- = Negative sign
PANote Free text. x(2000) S 2000

Element which indicates the
PAPriorityIndicator priority of the requested prior an S See ECL
authorization.
Identification of the PA
PAProcessorIdentific processor. an S See ECL
ation
Identifier established by the
PAReferenceID prescribing system sending a x(35) S 35
PAInitiationRequest in the
solicited model or PARequest in
the unsolicited model to initiate
the process to request prior
authorization. The identifier
must be echoed in any
subsequent prior authorization
transactions related to that
request for prior authorization
(including prior authorization
appeal and cancel transactions).
The identifier must be unique per
prescribing system.
Password Element in UsernameToken for n/a S, Q

the user’s password. SOAP.
391-MT Patient Assignment Code to indicate a patient’s x(1) T 1 See ECL Note: Currently used by providers of Medicare Part
Indicator (Direct choice on assignment of benefits. B
Member
Reimbursement
Indicator)
323-CN Patient City Address Free-form text for city name. x(20) T,W 20 Examples: CHICAGO
A43-1K Patient Country The country of the patient’s x(2) T,A 2 See ECL
Code permanent residence.
350-HN Patient E-Mail The E-Mail address of the patient x(80) T,V 80 Examples: JSMITH@NCPDP.ORG
Address (member).
- 109 -
July 2016
DATA DICTIONARY
310-CA Patient First Name Individual first name. x(12) T,Z,W,G 12 Examples: JOHN
__________ __________ _________
Note: Field size for the Telecommunication and
x(35) V,X 35 Medicaid Subrogation Standards does not conform
_________ __________ _________ to the demographic rules to remain compatible
with PDF-417 ID Card size limit.
x(25) I 25
285 Patient Formulary Credit the patient receives on s9(6)v99 A 8 Format=s$$$$$$cc

Rebate Amount this claim from the drug
manufacturer. Example: If the amount is $5.50 this field would
reflect: 55{
305-C5 Patient Gender Code indicating the gender of the 9(1) T,A,V,Z,W,X, 1 See ECL
Code individual. Y,I
For T,A,V,W,X :Comments: Qualified by Patient ID
332-CY Patient ID ID assigned to the patient. x(20) T,A,V,W,X,I 20 Qualifier (331-CX)
_______ _________ _______
x(128) Y 128 For A: See Post Adjudication Implementation Guide
for restriction on use of field in different records.
B38-1Y Patient ID Code of the country. x(2) T 2 See ECL

Associated Country
Code
A22-YR Patient ID State/Province Code associated x(2) T 2 See ECL

Associated with the Patient ID Qualifier
State/Province (331-CX) and the Patient ID (332-
Address CY).
PatientIdentification Identification of the patient. x(35) S,Q 35 See ECL
331-CX Patient ID Qualifier Code qualifying the Patient ID x(2) T, A,V,W,X 2 See ECL
(332-CY).
618-RR Patient ID Qualifier Count of patient ID occurrences 9(1) V 1 Comments: For Prescription Transfer, fields
Count included in the set/logical grouping are: Patient ID
Qualifier (331-CX), Patient ID (332-CY).
311-CB Patient Last Name Individual last name. x(15) T,Z,W,G 15 Examples: SMITH
-------------- --------------- -------------
x(35) V, X,I 35 Note: Field size for the Telecommunication and
Medicaid Subrogation Standards does not conform
to the demographic rules to remain compatible
with PDF-417 ID Card size limit.
- 110 -
July 2016
DATA DICTIONARY
601-44 Patient Liability Amount of patient’s out-of- 9(11)b R,J 12 For Manufacturer Rebate Standard:
Amount pocket cost. or 9(11)- Format=$$$$$$$$$$$b or $$$$$$$$$$$-
--------------- ---------------
s9(10)v99 V Note
b = Space
- = Negative Sign
For Prescription Transfer Standard:
Format=s$$$$$$$$$$cc
433-DX Patient Paid Amount the pharmacy received s9(6)v99 T,Z,W 8 Comments: This field is not used in coordination of
Amount Submitted from the patient for the benefit transactions to pass patient liability
prescription dispensed. information to a downstream payer. See Other
Payer-Patient Responsibility Amount (352-NQ)
Format=s$$$$$$cc
Examples: If the patient paid amount submitted is
PatientPayAmount See Patient Pay Amount Number an Q Format=s$$$$$$$$.cc to the length of the dollar
(505–F5) amount exchanged.
- = Negative sign
. = Decimal point
would reflect: 5.50
- 111 -
July 2016
DATA DICTIONARY
505-F5 Patient Pay Amount Amount that is calculated by the s9(6)v99 T,A 8 For T,A: Format=s$$$$$$cc
processor and returned to the
pharmacy as the TOTAL amount _______ _________ _______ Example: If the amount is $5.50 this field would
to be paid by the patient to the reflect: 55{
9(6)v99 Y 8
pharmacy; the patient’s total or Examples: If the patient pay amount is $56.96, this
cost share, including -9(5)v99 field would reflect: 569F.
copayments, amounts applied to __________ __________ _________ For Y:
deductible, over maximum
amounts, penalties, etc. 9(8)v99 I 10 Format=$$$$$$cc or -$$$$$cc
Note:
- = Negative sign
usage.
amounts.
PatientRelationship Code indicating relationship of an S,Q See ECL

Code patient to cardholder.
See ECL
306-C6 Patient Relationship Code indicating relationship of 9(1) T,A,V,Z,X,I 1
Code patient to cardholder.
See ECL
384-4X Patient Residence Code identifying the patient’s 9(2) T,A,V 2 See ResidenceCode.
place of residence.
575-EQ Patient Sales Tax Patient sales tax responsibility. s9(6)v99 T 8 Format=s$$$$$$cc
Amount This field is not a component of
the Patient Pay Amount (505-F5) Example: If the amount is $5.50 this field would
formula. reflect: 55{
286 Patient Spend Down Claim dollars applied to patient's s9(6)v99 A 8 Format=s$$$$$$cc
Amount spend down account (example
Flexible Spending Account). Example: If the amount is $5.50 this field would
reflect: 55{
324-CO Patient State/Province Code of the x(2) T,W,I 2 See ECL

State/Province patient.
Address
322-CM Patient Street Free-form text for address x(30) W 30 Examples: 123 MAIN STREET
Address information.
- 112 -
July 2016
DATA DICTIONARY
B08-7A Patient Street Free-form text for address line 1 x(40) T,G 40
B09-7B Patient Street Free-form text for address line 2 x(40) T,G 40
326-CQ Patient Telephone Phone number of patient. 9(10) T,W 10 Format=AAAEEENNNN

Number
AAA=Area Code
EEE=Exchange
NNNN=Number
Examples: If the phone number is (313) 555-1212,
this field would reflect: 3135551212.
325-CP Patient Zip/Postal Code defining international x(15) T,W 15 Comments: When used for US ZIP Code - This left-
Code postal code of the patient, justified field contains the five-digit zip code, and
which the patient is located.
Examples:
A0E 3B0
A1L 2T8
569-J8 Payer ID ID of the payer. x(10) T,V,Y 10 Comments: Qualified by Payer ID Qualifier (568-J7).
PayerIdentification Identification of the payer. x(80) S,Q 80 See ECL
568-J7 Payer ID Qualifier Code indicating the type of payer x(2) T,V 2 See ECL Comments: Qualifies Payer ID (569-J8).
ID.
PayerName Name of the payer. x(70) S, Q 70

PayerResponsibility Indicates the insurance type. an S, Q See ECL
Code
PayerType Identifies the type of payer. x(2) Q 2 See ECL
- 113 -
July 2016
DATA DICTIONARY
For example – an NCPDP Telecommunication D.0
Payload The transaction or file in a an K Claim Billing transaction, or a Batch 1.2 file, or ASC
transmission. X12 270 Health Care Eligibility Benefit Inquiry
transaction, version 005010X279A1.
Note: contains a boolean attribute of whether
Payload is Base64encoded (true or false).
PayloadEnvelopeVer Code uniquely identifying the an K See ECL Format: CCYYMM

sion version of the payload envelope.
PayloadEnvelopeRef Identifier established by the x(50) K 50

erenceID sender that must be echoed back
on the response.
PaymentType Type of payment received for the 9(5) S 5 See ECL

prescription fill as recorded by a
state Prescription Drug
Monitoring Program (PDMP).
287 Payment/Reference Identifies ID assigned by sender x(30) A 30

ID to reference individual pharmacy
and member reimbursement.
Check or EFT trace number.
288 Payroll Class A field defined by the client x(1) A 1 See ECL
indicating the payroll class of the
member.
122-TW Pay To City Address City of the entity to receive x(20) T,W 20
payment for claim.
B39-1Z Pay to Country Code Code of the country. x(2) T 2 See ECL
119-TT Pay To ID Identifying number of the entity x(15) T,W 15 Comments: Qualified by Pay To Qualifier (118-TS).
to receive payment for claim.
x(20) W 20
120-TU Pay To Name Name of the entity to receive --------------- --------------- -------------
payment for claim. x(70) T 70
Format=AAAEEENNNN
685 Pay To Phone Telephone number of the payee. 9(10) W 10
Number AAA=Area Code
EEE=Exchange Code
NNNN=Number
Examples: A phone number of 212-555-1212

is entered as: 2125551212.
- 114 -
July 2016
DATA DICTIONARY
118-TS Pay To Qualifier Code qualifying the Pay To ID x(2) T,W 2 See ECL Comments: Qualifies Pay To ID (119-TT).
(119-TT).
123-TX Pay to State/ State/Province Code of the x(2) T,W 2 See ECL
Province Address payee.
121-TV Pay To Street Street address of the entity to x(30) W 30

Address receive payment for claim.
B24-7R Pay To Street Line 1 of street address of the x(40) T 40

Address Line 1 entity to receive payment for
claim.
B25-7S Pay To Street Line 2 of street address of the x(40) T 40

Address Line 2 entity to receive payment for
claim.
124-TY Pay To Zip/Postal Code defining international x(15) T,W 15 Comments:

Code postal code of the Pay To entity,
excluding punctuation. When used for US ZIP Code - This left-justified field

Examples:
A0E 3B0
A1L 2T8
PBMMemberID Payer assigned Unique Member x(80) S 80

ID.
Format=$$$$$$$$cc
B81 Penalty Amount Non-reimbursable amount 9(8)v99 I 10
incurred by patient based on This field does not support negative dollar
benefit parameters. amounts.
- 115 -
July 2016
DATA DICTIONARY
559-AX Percentage Sales Amount of percentage sales tax s9(6)v99 T,A 8 For T,A: Format=s$$$$$$cc
Tax Amount Paid paid which is included in the
Total Amount Paid (509-F9). _______ _________ _______ Examples: If the percentage sales tax paid is $3.62,
this field would reflect: 36B.
9(6)v99 Y 8
or For Y:
-9(5)v99 Format=$$$$$$cc or -$$$$$cc
Note:
- = Negative sign
usage.
482-GE Percentage Sales Percentage sales tax submitted. s9(6)v99 T,Z,W 8 Format=s$$$$$$cc
Tax Amount
Submitted Comments: The submission of sales tax is governed
by regulatory agencies (state, local, parish, etc).
Examples: If the percentage sales tax amount
submitted is $4.47, this field would reflect: 44G.
See ECL
561-AZ Percentage Sales Code indicating the percentage x(2) T,A 2
Tax Basis Paid sales tax paid basis.
See ECL
484-JE Percentage Sales Code indicating the basis for x(2) T 2 Comments:. The submission of sales tax is governed
Tax Basis Submitted percentage sales tax. by regulatory agencies (state, local, parish, etc).
560-AY Percentage Sales Percentage sales tax rate used to s9(3)v9999 T,A 7 Format=s999v9999
Tax Rate Paid calculate Percentage Sales Tax
Amount Paid (559-AX).
483-HE Percentage Sales Percentage sales tax rate used to s9(3)v9999 T 7 Comments: The submission of sales tax is governed
Tax Rate Submitted calculate Percentage Sales Tax by regulatory agencies (state, local, parish, etc).
Amount Submitted (482-GE).
Format=s999v9999
Comments: Percentage expressed as a decimal

954-HQ Percent Copay Rate Percentage copay rate. R(10) F 10
(e.g., 0.0 through 1.0 represents 0% through 100%)
The length includes the decimal point.
- 116 -
July 2016
DATA DICTIONARY
PeriodEnd The date or date and time that xsd:date or S CC=Century
the referenced period expires. xsd:datetim YY=Year
e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
PersonCode Code assigned to a specific x(3) S, Q 3

person within a family.
R,T,A,N,V,Z,
303-C3 Person Code Code assigned to a specific x(3) X,Y,I 3 Enrollment Standard Examples:
person within a family.
Examples:
001=Cardholder
002=Spouse
003-999=Dependents and Others (including second
spouses, etc.)
PharmacistIdentifica Identification of the pharmacist. x(35) Q See ECL

tion
636-TD Pharmacist Initials The initials of the pharmacist. x(3) V 3
829-5L Pharmacy Address The street address for a x(20) Z,W 20

pharmacy.
289 Pharmacy Class Indicates class of the pharmacy. x(1) A 1 Comments: Qualified by Pharmacy Class Code
Code Qualifier (150).
See ECL
150 Pharmacy Class Code qualifying the Pharmacy x(1) A 1 Comments: Qualifies Pharmacy Class Code (289).
Code Qualifier Class Code (289).
Comments: Qualified by Pharmacy Dispenser Type
290 Pharmacy Dispenser Type of pharmacy dispensing x(2) A 2 Qualifier (146).
Type product.
See ECL
146 Pharmacy Dispenser Code qualifying the Pharmacy x(1) A 1 Comments: Qualifies Pharmacy Dispenser Type
Type Qualifier Dispenser Type (290). (290).
- 117 -
July 2016
DATA DICTIONARY
PharmacyIdentificati Identification of the pharmacy. x(35) S, Q See ECL

on
831-5N Pharmacy Location City of pharmacy. x(18) Z,W 18

City
833-5P Pharmacy Name Name of pharmacy. x(20) Z,W 20

_________ _________ ________
x(70) A,Y,V 70
PharmacyRequested Number of refills the pharmacy is 9(2) S 2

Refills requesting.
147-U7 Pharmacy Service The type of service being 9(2) T,R 2 See ECL
Type performed by a pharmacy when
different contractual terms exist
between a payer and the
pharmacy, or when benefits are
based upon the type of service
performed.
PharmacySpecialty Specialty of pharmacy. x(10) S,Q 10 See ECL
832-6F Pharmacy State/Province Code of x(2) Z,W 2 See ECL

State/Province pharmacy.
Address
834-5Q Pharmacy Telephone number of pharmacy. 9(10) Z,W 10 Format=AAAEEENNNN

Telephone Number
AAA=Area Code
EEE-Exchange Code
NNNN=Number
PharmacyToTitrateD An indicator the pharmacy is to xsd:Boolean S See ECL

ose titrate the dose, frequency, etc. Code
at the request of the prescriber
in response to lab results.
PharmacyType See Pharmacy Type (955–HR) x(1) S 1 See ECL
955–HR Pharmacy Type Type of Pharmacy. x(1) F 1 See ECL
- 118 -
July 2016
DATA DICTIONARY
835-5R Pharmacy Zip/Postal Code defining international x(9) Z,W 9 Comments: When used for US ZIP Code - This left-
Code postal code of the pharmacy, justified field contains the five-digit zip code, and
which the pharmacy is located.

Examples:
A0E 3B0
A1L 2T8
Note: Size of this field has not been modified to the
standard x(15) because it is used in the Universal
Claim Forms for which size can be determined by
font.
307-C7 Place of Service Code identifying the place where 9(2) T,A,Z,J 2
a drug or service is dispensed or See ECL
administered.
291 Plan Benefit Code Determines the method by which x(2) A 2

Insulin and OTC claims are paid.
Defined by processor.
292 Plan Cutback Indicates the type of cutback, if x(1) A 1 See ECL
Reason Code any, imposed by plan.
A86 Plan Eligibility Start Represents the later of either, 9(8) R 8 Format=CCYYMMDD
Date the date the Plan established a CC=Century
relationship with the PMO, or YY=Year
the date the Plan became eligible MM=Month
under the PMO's contract with DD=Day
the PICO.
- 119 -
July 2016
DATA DICTIONARY
A87 Plan Eligibility Represents the earlier of either, 9(8) R 8 Format=CCYYMMDD

Termination Date the date the Plan severed their CC=Century
relationship with the PMO, or YY=Year
the date the Plan no longer was MM=Month
eligible under the PMO's contract DD=Day
with the PICO.
524-FO Plan ID Assigned by the processor to x(8) T 8

identify a set of parameters,
benefit, or coverage criteria used
to adjudicate a claim.
600-94 Plan ID Code ID assigned to identify the plan. x(17) R,J 17
600-95 Plan ID Qualifier Identifies the type of data being x(1) R,J 1 See ECL
submitted in the Plan ID Code
(600-94) field.
x(30) Z 30
600-96 Plan Name The name of the plan. --------------- --------------- -------------
x(70) R,J 70
A82 Plan Reimbursed Total amount the MCO pays to 9(9)v99b J 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
Amount the provider (after removing the b = Space
co-pay or deductible from the or 9(9)v99- -=Negative sign
Allowable cost).
574-2Y Plan Sales Tax Plan sales tax responsibility. This s9(6)v99 T 8 Format=s$$$$$$cc
Amount field is not a component of the
Patient Pay Amount (505-F5) Example: If the amount is $5.50 this field would
formula. reflect: 55{
601-01 Plan Type Identifies the type of plan. x(4) R,A 4 See ECL
PositionInOrderGro Indicates the position of the 9(2) S,Q 2 Example: 1 of X where “X” is to total number of
up medication order within the orders in the group.
group.
- 120 -
July 2016
DATA DICTIONARY
PostalCode Code defining international an S, Q Comments:

postal code excluding
punctuation. PostalCode must be mailable in the country.
When used for US ZIP Code - This left-justified field

Examples:
A0E 3B0
A1L 2T8
956-HS Preference Level If there are multiple alternatives 9(2) F 2 See ECL Comments: A higher number indicates more
for a given Source drug, this is preferred.
the payer’s order of preference
(a higher number equals greater
preference).
293 Preferred Indicates the preferred x(10) A 10

Alternative File ID alternative file ID number used
to determine processing.
555-AT Preferred Product Amount of patient’s copay/cost- s9(6)v99 T 8 Format=s$$$$$$cc

Cost Share Incentive share incentive for preferred
product. Examples: If the preferred product copay is $6.00
551-9F Preferred Product Count of preferred product 9(1) T 1 Comments: Fields included in the set/logical
Count occurrences. grouping are:
Preferred Product ID Qualifier (552-AP)
Preferred Product ID (553-AR)
Preferred Product Incentive (554-AS)
Preferred Product Cost Share Incentive (555-AT)
Preferred Product Description (556-AU)
- 121 -
July 2016
DATA DICTIONARY
556-AU Preferred Product Free text message. x(40) T 40

Description
553-AR Preferred Product Alternate product recommended x(19) T 19 Comments: Qualified by Preferred Product ID
ID by the plan. Qualifier (552-AP).
552-AP Preferred Product Code qualifying the type of x(2) T 2 See ECL
ID Qualifier product ID submitted in
Preferred Product ID (553-AR).
554-AS Preferred Product Amount of pharmacy incentive s9(6)v99 T 8 Format=s$$$$$$cc

Incentive available for substitution of
preferred product. Examples: If the preferred product incentive is
Prefix Prefix of the name. x(10) S,Q 10
PregnancyIndicator Code indicating the patient as xsd:Boolean Q See ECL

pregnant or non-pregnant. Code
335-2C Pregnancy Indicator Code indicating the patient as x(1) T,V 1 See ECL
pregnant or non-pregnant.
294 Prescribed Days Indicates the original days supply 9(3) A 3

Supply of the prescription. Applies to
internal Mail Service only.
619-RW Prescribed Product The name of the drug or x(60) V 60

Description compound prescribed.
A26-ZP Prescriber Alternate An alternate ID assigned to the x(15) T 15

ID prescriber.
B40-3A Prescriber Alternate Code of the country. x(2) T 2 See ECL

ID Associated
Country Code
A27-ZQ Prescriber Alternate State/Province Code associated x(2) T 2 See ECL

ID Associated with the Prescriber Alternate ID
State/Province Qualifier (A25-ZM) and the
Address Prescriber Alternate ID (A26-ZP).
A25-ZM Prescriber Alternate A code qualifying the Prescriber x(2) T 2 See ECL
ID Qualifier Alternate ID (A26-ZP).
- 122 -
July 2016
DATA DICTIONARY
295 Prescriber Indicates a provider’s x(2) A 2 See ECL

Certification Status certification in the health plan
program.
PrescriberCheckedR Identifies if the prescribing x(2) S 2 See ECL

EMS system has performed an inquiry
to the REMS Administrator in
order to verify the REMS
component of the prescription.
366-2M Prescriber City Free-form text for prescriber city x(20) T,W 20
Address name.
2
B42-3C Prescriber Country Code of the country. x(2) T See ECL
Code
x(12) W 12
364-2J Prescriber First Individual first name. --------------- --------------- -------------
Name x(35) T 35
Regarding the Telecommunication Standard:
411-DB Prescriber ID ID assigned to the prescriber. x(15) T,A,R,V,Z,W 15
,X,J,Y,E Comments: Qualified by Prescriber ID Qualifier
(466-EZ) for the Telecommunications Standard.
B41-3B Prescriber ID Code of the country. x(2) T 2 See ECL

Associated Country
Code
A24-ZK Prescriber ID State/Province Code associated x(2) T 2 See ECL

Associated with the Prescriber ID Qualifier
State/Province (466-EZ) and the Prescriber ID
Address (411-DB).
620-RX Prescriber ID Count Count of prescriber ID 9(2) V 2 Comments: For Prescription Transfer, fields
occurrences. included in the set/logical grouping are: Prescriber
ID Qualifier (466-EZ), Prescriber ID (411-DB).
PrescriberIdentificat Identification of the prescriber. x(35) S,Q See ECL

ion
466-EZ Prescriber ID Code qualifying the Prescriber ID x(2) T,A,R,V,Z,W 2 See ECL
Qualifier (411-DB). ,X,J,Y,E
x(15) Z,W 15
427-DR Prescriber Last Individual last name. --------------- --------------- ------------- Examples: BROWN
Name x35 T 35
- 123 -
July 2016
DATA DICTIONARY
PrescriberOrderGro Unique ID assigned by the X(35) S,Q 35

upNumber prescriber to link multiple
medication orders together.
PrescriberOrderNu This is the reference number x(35) S,Q 35 Note: Some vendors carry through life of
mber assigned by the prescribing prescription; others change per prescription order.
system.
See ECL
A14 Prescriber Override The override’s inclusion or 9(1) X 1
Type exclusion parameters as it
applies to the prescriber network
for a plan.
PrescriberProvidedA Free text answer provided by x(2000) S 2000

nswer prescriber.
PrescriberProvidedN Numeric answer provided by 9(18) S 18

umericAnswer prescriber.
PrescriberSpecialty Specialty of prescriber. x(10) S,Q 10 See ECL
621-RY Prescriber Specialty Specialty of prescriber. x(10) V 10 See ECL
622-RZ Prescriber Specialty Count of specialty occurrences. 9(1) V 1 Comments: For Prescription Transfer, fields
Count included in the set/logical grouping are: Prescriber
Specialty (621-RY).
367-2N Prescriber State/Province Code of the x(2) T,W 2 See ECL

State/Province prescriber.
Address
365-2K Prescriber Street Free-form text for prescriber x(30) W 30

Address address information.
B27-7U Prescriber Street Free-form text for prescriber x(40) T 40

B28-7V Prescriber Street Free-form text for prescriber x(40) T 40

Format = CCYYMMDD
372-2T Prescriber/Supplier The date the form was 9(8) T 8
Date Signed completed and signed by the CC=Century
ordering physician. YY=Year
MM=Month
DD=Day
- 124 -
July 2016
DATA DICTIONARY
296 Prescriber The taxonomy is defined as a x(10) A 10 See ECL

Taxonomy Code classification scheme that
codifies provider type and
provider area of specialization.
498-PM Prescriber Ten-digit phone number of the 9(10) T,W 10 Format=AAAEEENNNN

Telephone Number prescriber.
AAA=Area Code
EEE=Exchange Code
NNNN=Number
Examples: This field would reflect the telephone
number of (414) 555-1212 as 4145551212.
B26-7T Prescriber Extension of the telephone 9(8) T 8 Format = 99999999

Extension
368-2P Prescriber Code defining international x(15) T,W 15

Zip/Postal Zone postal zone excluding
PrescriptionDelivery The method through which the an S,Q 1 See ECL

Method original electronically created
transaction was delivered to its
intended recipient. The presence
of this value will confirm to the
original sender the delivery
method ultimately employed to
successfully deliver the
transaction to its intended
recipient; clarity in ultimate
delivery method will assist with
any troubleshooting or
transaction tracing that may take
place.
419-DJ Prescription Origin Code indicating the origin of the 9(1) T,A,W,Z,R 1
Code prescription. See ECL
297 Prescription Over The indicator that specifies this x(1) A 1 See ECL
The Counter prescription is a federal/legend
Indicator (RX prescription only) or
nonprescription drug (OTC).
PrescriptionPrevious Indicates whether the xsd:Boolean S See ECL

lyFilled prescription has been previously Code
filled.
- 125 -
July 2016
DATA DICTIONARY
PrescriptionSellPrice The total amount paid by all an Q Format=s$$$$$$$$.cc to the length of the dollar
plans involved or cash amount exchanged.
prescription selling price.
- = Negative sign
. = Decimal point
would reflect: 5.50
402-D2 Prescription/Service Reference number assigned by 9(12) T,A,R,V,Z,W 12 For all but Prescription Transfer Standard:
Reference Number the provider for the dispensed ,X,J,E
drug/product and/or service Qualified by Prescription/Service Reference
provided. Number Qualifier (455-EM).
Prescription/Service
455-EM Reference Number Indicates the type of billing x(1) R,T,A,X,J,E, 1 See ECL Comments: Qualifies Prescription/Service
Qualifier submitted. W,Z Reference Number (402-D2).
601-49 Prescription Type Identifies the prescription as 9(1)b R,J 2 See ECL
either a new/refill, an adjusted or 9(1)-
prescription or a reversal.
530-FU Previous Date of Fill Date prescription was previously 9(8) T,X 8 Format=CCYYMMDD
filled.
CC=Century
YY=Year
MM=Month
DD=Day
Examples: If the prescription was previously filled
on August 1, 1999, this field would reflect:
19990801.
421-DL Primary Care ID assigned to the primary care x(15) T,A 15 Comments: Qualified by Primary Care Provider ID
Provider ID provider. Used when the patient Qualifier (468-2E).
is referred to a secondary care
provider.
468-2E Primary Care Code qualifying the Primary Care x(2) T,A 2 See ECL
Provider ID Qualifier Provider ID (421-DL).
470-4E Primary Care Individual last name. x(35) T 35

Provider Last Name
- 126 -
July 2016
DATA DICTIONARY
PrimaryDiagnosisCo The textual representation of an S

deDescription PrimaryDiagnosisCode.
PrimaryDiagnosisCo Qualifies the code list used for an S See ECL

deQualifierCode the PrimaryDiagnosis.
PrimaryDiagnosisVal Code for the primary diagnosis. an S Qualified by PrimaryDiagnosisCodeQualifierCode.

ue
602-01 Prior Amount Paid The cumulative dollar amount of 9(9)v99b R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
previously paid rebates. or
9(9)v99- Note:
b = Space
-= Negative sign
PrimaryTelephoneE Extension of the preferred 9(8) S,Q 8 Format = 99999999

xtension telephone number.
Format=AAAEEENNNN
PrimaryTelephoneN Preferred telephone number of 9(10) S,Q 10 AAA=Area Code
umber the entity. EEE=Exchange Code
NNNN=Number
PrimaryTelephoneS Indication the number accepts xsd:Boolean S,Q See ECL

upportsSMS text messages. Code
PriorAuthorization Identifies the prior authorization. x(35) S 35
A15 Prior Authorization The date the prior authorization 9(8) X 8 Format=CCYYMMDD
Create Date record was created in sender’s
system. CC=Century
YY=Year
MM=Month
DD=Day
498-RB Prior Authorization Amount authorized in the prior s9(6)v99 T 8 Format= s$$$$$$cc
Dollars Authorized authorization.
Example: If the amount is $5.50, this field would
reflect: 55{
498-PS Prior Authorization Date the prior authorization 9(8) T,X 8 Format=CCYYMMDD
Effective Date became effective.
CC=Century
YY=Year
MM=Month
DD=Day
Comments: Provided by the processor to the
pharmacy to indicate the date on which the prior
authorization became effective.
- 127 -
July 2016
DATA DICTIONARY
498-PT Prior Authorization Date the prior authorization 9(8) T,X 8 Format=CCYYMMDD
Expiration Date ends.
CC=Century
YY=Year
MM=Month
DD=Day
authorization approval expires.
498-PY Prior Authorization Unique number identifying the 9(11) T 11 Comments: Provided to the pharmacy by the
Number-Assigned prior authorization assigned by processor to be used by the pharmacy for billing,
the processor. and if applicable, reversal purposes.
________________ __________________________ __________ _________ _________
Prior Authorization Unique ID identifying the prior
ID Assigned X(35) A,X 35
authorization assigned by the
processor.
A16 Prior Authorization The number of fills allowed to be 9(2) X 2

Number of Fills covered by the prior
Authorized authorization and is usually over
or under the normal plan
limitations.
498-PW Prior Authorization Number of refills authorized by 9(2) T,X 2

Number Of Refills the prior authorization.
Authorized
462-EV Prior Authorization Number submitted by the 9(11) T,Z,W 11

Number Submitted provider to identify the prior
authorization.
________________ __________________________ __________ __________ _________
Prior Authorization ID submitted by the provider to
ID Submitted X(35) A,V,X 35
identify the prior authorization.
498-PR Prior Authorization Date the prior authorization 9(8) T 8 Format=CCYYMMDD

Processed Date request was processed.
CC=Century
YY=Year
MM=Month
DD=Day
authorization transaction was processed.
- 128 -
July 2016
DATA DICTIONARY
498-RA Prior Authorization Amount authorized expressed in 9(7)v999 T,X 10 Format=9999999v999

Quantity metric decimal units.
Comments: Provided to the pharmacy by the
processor to convey the number of units
authorized.
498-PX Prior Authorization Accumulated authorized amount 9(7)v999 T,X 10 Format=9999999v999

Quantity expressed in metric decimal
Accumulated units. Comments: Provided to the pharmacy by the
processor to determine quantity remaining for
billing.
See ECL
A17 Prior Authorization Code clarifying the explanation 9(3) X 3
Reason Code of the plan benefit override
classification.
PriorAuthorizationSt The status of the prescription’s x(1) S 1 See ECL

atus prior authorization as known by
the sender.
498-PP Prior Authorization Free text message. x(1)-x(500) T 1-500 Comments: Could be used, if applicable, to supply
Supporting information not already included in NCPDP data
Documentation fields that may be required to process a prior
authorization transaction.
461-EU Prior Authorization Code clarifying the Prior 9(2) T,A,Z,W 2 See ECL
Type Code Authorization Number Submitte’
(462-EV) or benefit/plan (See ECL for Emergency Disaster
exemption. Standard Values)
A18 Prior Authorization The date the prior authorization 9(8) X 8 Format=CCYYMMDD
Update Date record was last updated in the
sender’s system. CC=Century
YY=Year
MM=Month
DD=Day
Priority Priority associated with the an Q

Central Fill Order.
- 129 -
July 2016
DATA DICTIONARY
PiorPeriodCorrectio Indicates the end date for which xsd:date or Q CC=Century
nEndDate the payer information is being xsd:datetim YY=Year
restated. e MM=Month
DD=Day
Example: 2010-10-01
DateTime Format= CCYY-MM-DD

THHDDTHH:MM:SS
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
PriorPeriodCorrectio Indicates the start date for which xsd:date or Q CC=Century
nStartDate the payer information is being xsd:datetim YY=Year
restated. e MM=Month
DD=Day
Example: 2010-10-01
DateTime Format= CCYY-MM-DD

THHDDTHH:MM:SS
CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
PriorPeriodCorrectio Free text indicating the reason an Q

nType for the prior period payer
correction.
602-02 Prior Units Disputed The number of units in dispute. 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
or
9(11)v999- Note:
b = Space
-= Negative sign
- 130 -
July 2016
DATA DICTIONARY
602-03 Prior Units Paid The number of units previously 9(11)v999b R 15 Format=99999999999v999b or 99999999999v999-
paid. or
9(11)v999- Note:
b = Space
-= Negative sign
ProblemNameCode Code of problem. an Q Qualified by ProblemNameCodeQualifier.
ProblemNameCode Qualifies ProblemNameCode. an Q See ECL

Qualifier
ProblemNameCode Text of problem. an Q

Text
ProblemTypeCode Code identifying the type of an Q See ECL

problem.
459-ER Procedure Modifier Identifies special circumstances x(2) T,Z,W 2 See ECL
Code related to the performance of
the service.
458-SE Procedure Modifier Count of the Procedure Modifier 9(2) T 2

Code Count Code (459-ER) occurrences.
104-A4 Processor Control Number assigned by the x(10) T,N,V,Z,E 10

Number processor.
299 Processor Defined Code clarifying the Prior 9(2) A 2 See ECL
Prior Authorization Number.
Authorization
Reason Code
839-5V Processor Name Name of the processor. x(70) V 70
395 Processor Payment Provides additional information x(2) A 2 See ECL

Clarification Code of the status of the payment of
the claim.
B82 Processor Routing Used to trigger the process at the x(200) I 200
Identification host system.
396 Processor Specific Trading partners mutually agreed x(50) A 50

Data upon specific data defined by
processor.
ProductCode Code identifying the product an S,Q Qualified by ProductQualifierCode.

being reported.
- 131 -
July 2016
DATA DICTIONARY
601-18 Product Code Code identifying the product x(17) A,X 17 Comments: Qualified by Product Code Qualifier
being reported. (601-19).
601-19 Product Code Identifies the type of data being x(1) A,X 1 See ECL
Qualifier submitted in the Product Code
(601-18) field.
601-58 Product Daily A value that the units would be 9(2)v99b R 5 Format=99v99b or 99v99-
Consumption divided by to convert to days of or
Note:
therapy, canister, etc. for the 9(2)v99-
b=Space
calculation of market share.
-=Negative Sign
601-20 Product Description Description of product being x(30) R,V,Z,W,J 30

submitted.
601-21 Product Dosage The dosage form of the reported x(30) V 30

Form product.
957-HT Product Name- User-recognizable health plan x(35) F 35

Health Plan product name.
ProductQualifierCod The code list defining the an S,Q See ECL

e ProductCode.
407-D7 Product/Service ID ID of the product dispensed or x(19) T,F,A,R,V,Z, 19 Format=MMMMMDDDDPP

service provided. W,X,J,Y,E,I
MMMMM=Manufacturer's Assigned Number
DDDD=Drug ID
PP=Package Size
Comments: Qualified by Product/Service ID
Qualifier (436-E1) If Product Service ID Qualifier
(436-E1) is 03=NDC
958-HU Product/Service ID- ID of the preferred alternative x(19) F 19

Alternative drug.
436-E1 Product/Service ID Code qualifying the value in x(2) T,F,A,R,V,Z, 2 See ECL
Qualifier Product/Service ID (407-D7). W,X,J,Y,E,I
959-HV Product/Service ID Code qualifying the value in x(2) F 2 See ECL

Qualifier- Product/Service ID-Alternative.
Alternative
963-HZ Product/Service ID Code qualifying the value in x(2) F 2 See ECL

Qualifier-Source Product/Service ID-Source.
- 132 -
July 2016
DATA DICTIONARY
961-HX Product/Service ID Code qualifying the value in x(2) F 2 See ECL

Qualifier-Step Drug Product/Service ID-Step Drug.
962-HY Product/Service ID- Identifier for the drug for which x(19) F 19
Source the alternative is given.
960-HW Product/Service ID- Identifier for the drug that is x(19) F 19

Step Drug recommended to be tried first.
397 Product/Service Product or Service Description or x(30) A,I 30

Name Product Label Name. _______ _________ _______
(80) Y 80
601-24 Product Strength The strength of the product. x(15) A,V,W 15
964-JA Product Type Code to indicate the type of x(1) F 1 See ECL
product.
ProfessionalService Code identifying intervention an S See ECL

Code performed when a conflict has
been detected.
440-E5 Professional Service Code identifying pharmacist x(2) T,A,Z,W 2 See ECL Examples: If the pharmacist spoke with the patient
Code intervention when a conflict code as a result of a conflict code being transmitted on a
has been identified or service has prescription, the field would reflect P0.
been rendered.
B33-6G Professional Service Informational field used with s9(6)v99 T 8 Format=s$$$$$$cc

Fee service billings when Other
Contracted/Reimbu Payer-Patient Responsibility Example: If the amount is $5.50 this field would
rsement Amount Amount (352-NQ) or Patient Pay reflect: 55{.
Amount (505-F5) is used for
reimbursement. Amount is equal
to contracted or reimbursable
amount for service being
rendered.
- 133 -
July 2016
DATA DICTIONARY
562-J1 Professional Service Amount representing the s9(6)v99 T,A 8 For T,A: Format=s$$$$$$cc
Fee Paid contractually agreed upon fee for
professional services rendered. _______ _________ _______ Examples: If the professional service fee paid is
This amount is included in the $5.50 this field would reflect: 55{.
9(6)v99 Y 8
Total Amount Paid (509-F9). or For Y:
-9(5)v99 Format=$$$$$$cc or -$$$$$cc
Note:
- = Negative sign
usage.
477-BE Professional Service Amount submitted by the s9(6)v99 T 8 Format=s$$$$$$cc

Fee Submitted provider for professional services
rendered. Examples: If the Professional Service Fee Submitted
is $7.00, this field would reflect: 70{.
ProhibitRefillReques Allows the prescriber to indicate xsd:boolean S

t to the pharmacy that the
pharmacy should never request
refills for this specific
prescription by any technique.
ProphylacticOrEpiso Indicates if treatment is for an S See ECL

dic Prophylactic and/or episodic
needs.
361-2D Provider Accept Code indicating whether the x(1) T 1 See ECL
Assignment provider accepts assignment.
Indicator
444-E9 Provider ID Unique ID assigned to the person x(15) T,Z 15 Comments: Qualified by Provider ID Qualifier (465-
responsible for the dispensing of EY).
the prescription or provision of
the service.
ProviderIdentificati Identification of the provider. x(35) S, Q See ECL

on
465-EY Provider ID Qualifier Code qualifying the Provider ID x(2) T,Z 2 See ECL
(444-E9).
See ECL
ProviderSpecialty Specialty of provider. x(10) S,Q 10
- 134 -
July 2016
DATA DICTIONARY
599-Y2 Purchaser City The City name associated to the x(20) T 20 Examples: CHICAGO
Address address of the purchaser of the
product/service.
See ECL
677-Y5 Purchaser Country The associated Postal country x(2) T 2
Code code of the purchaser of the
product/service.
Format= CCYYMMDD
594-YX Purchaser Date of The Date of Birth of the 9(8) T 8
Birth purchaser of the product/service. CC=Century
YY=Year
MM=Month
DD=Day
596-YZ Purchaser First The First Name of the purchaser x(35) T 35

Name of the product/service.
See ECL
595-YY Purchaser Gender The Gender of the purchaser of 9(1) T 1
Code the product/service.
592-YV Purchaser ID The ID number used to identify x(20) T 20 Comments: Qualified by Purchaser ID Qualifier
the purchaser of the (591-YU).
product/service.
B43-3D Purchaser ID Code of the country. x(2) T 2 See ECL

Associated Country
Code
593-YW Purchaser ID State/Postal Code associated x(2) T 2 See ECL

Associated with the Purchaser ID Qualifier
State/Province Code (591-YU) and Purchaser ID (592-
YV).
591-YU Purchaser ID Code indicating the type of ID 9(2) T 2 See ECL Comments: Qualifies Purchaser ID (592-YV).
Qualifier used in the Purchaser ID field.
597-Y0 Purchaser Last The Last Name of the purchaser x(35) T 35

Name of the product/service.
A23-YS Purchaser Code indicating the relationship x(2) T 2 See ECL

Relationship Code from purchaser to patient.
See ECL
675-Y3 Purchaser State/Province Code of the x(2) T 2
State/Province purchaser.
Address
- 135 -
July 2016
DATA DICTIONARY
B29-7W Purchaser Street Free-form text for address line 1 x(40) T 40

B30-7X Purchaser Street Free-form text for address line 2 x(40) T 40

Comments: When used for US ZIP Code - This left-
676-Y4 Purchaser Code defining international x(15) T 15 justified field contains the five-digit zip code and
Zip/Postal Code postal code of the purchaser of may include the four-digit expanded zip code.
the product/service, excluding
punctuation. Examples: If the zip code is 98765-4321, this field

Examples:
A0E 3B0
A1L 2T8
A99 Qualified Covered HIC # for each covered individual x(11) L 11

Retiree HICN whom the RDS Plan Sponsor is
seeking the subsidy.
B01 Qualified Covered Social Security Number for each x(9) L 9

Retiree SSN covered individual whom the
RDS Plan Sponsor is seeking the
subsidy.
QuantityCodeListQu Qualifies QuantityValue. an S See ECL

alifier
442-E7 Quantity Dispensed Quantity dispensed expressed in 9(7)v999 T,A,V,Z,W,Y, 10 Format=9999999v999

metric decimal units. I
623-SA Quantity Dispensed Total number of metric decimal 9(7)v999 V 10

To Date units that have been dispensed Format=9999999v999
to this point.
- 136 -
July 2016
DATA DICTIONARY
344-HF Quantity Intended Metric decimal quantity of 9(7)V999 T,A 10 Format=9999999v999

To Be Dispensed medication that would be
dispensed on original filling if
inventory were available. Used in
association with a P or C in
Dispensing Status (343-HD).
B88-3R Quantity Limit Per Maximum quantity allowed over 9(7)v999 T 10 Format=9999999v999
Specific Time Period the designated time period.
B87-3P Quantity Limit Per Count of quantity limit per 9(1) T 1

Specific Time Period specific time period.
Count
B89-3S Quantity Limit Time Number of days to which the 9(5) T 5

Period maximum quantity is allowed.
531-FV Quantity Of Amount expressed in metric 9(7)v999 T 10 Format=9999999v999

Previous Fill decimal units of the conflicting
agent that was previously filled.
460-ET Quantity Prescribed Amount expressed in metric 9(7)v999 T,A,V 10 Format=9999999v999

decimal units.
QuantityUnitOfMea Concepts of the intended or an S See ECL

sureCode actual dispensed quantity unit of
measure (e.g., 1 Pack, 1 Inhaler,
17 grams, 30 tablets, 473 ML, 3
Eaches). Upon billing, this data is
translated to Milliliters, Grams,
for Eaches.
QuantityValue The total quantity of a single 9(11) S 11 Qualified by QuantityCodeListQualifier.

prescription filled e.g. the count
of tablets or number of
grams.The
compound final quantity.
A83 Quarterly Member Number indicating the number of x(2) J 2 See ECL
Indicator times a member is billed in the
billing period.
383-4K Question Alphanumeric response to a x(30) T 30

Alphanumeric question (part of the question
Response information).
- 137 -
July 2016
DATA DICTIONARY
9(8)
380-4G Question Date Date response to a question T 8 Format=CCYYMMDD
Response (part of the question
information). CC=Century
YY=Year
MM=Month
DD=Day
Format=s$$$$$$$$$cc
381-4H Question Dollar Dollar Amount response to a s9(9)v99 T 11
Amount Response question (part of the question
information). Example: If the amount is $5.50 this field would
reflect: 55{
QuestionID ID assigned by the payer to x(35) S 35

identify the question.
QuestionLevel Indicates that all questions with x(35) S 35

this ID are related.
382-4J Question Numeric Numeric response to a question 9(11) T 11

information).
378-4B Question Identifies the question x(3) T 3 Comments: Values to be determined by Trading
Number/Letter number/letter that the question Partner Agreement
response applies to (part of the
question information).
377-2Z Question Count of Question 9(2) T 2 Fields included in the set/logical grouping are:
Number/Letter Number/Letter occurrences. Question Number/Letter (378-4B), Question
Count Percent Response (379-4D), Question Date
Response (380-4G), Question Dollar Amount
Response (381-4H), Question Numeric Response
(382-4J), Question Alphanumeric Response (383-
4K)
379-4D Question Percent Percent response to a question 9(3)v99 T 5 Examples: 25.75% = 02575 or 0.5% = 0005
information).
QuestionSetComme Comments from the provider x(2000) S 2000

nt answering the question set.
QuestionSetDescrip Descriptive information about x(2000) S 2000

tion the question set.
QuestionSetID ID assigned by the payer to x(70) S 70

identify the question set.
QuestionSetTitle Title of the question set. x(70) S 70
- 138 -
July 2016
DATA DICTIONARY
QuestionText Text of the question. x(2000) S 2000
Race The biological descent of the an Q See ECL Code includes a check digit.
entity.
RateOfAdministrati The amount of time for a single x(11) S 11

on dose to be administered.
RateUnitOfMeasure The code representing the an S Qualified by RateUnitOfMeasureQualifier

Code RateUnitOfMeasureText.
See ECL
RateUnitOfMeasure Qualifier to identify the code an S
RateUnitOfMeasure The textual representation of an S

Text RateUnitOfMeasureCode for the
period of time in which the dose
is to be administered.
ReactionCoded Patient reaction to the problem an Q See ECL

reported.
ReasonCode Codes used in response x(3) S,Q 3 See ECL

messages by the ultimate
receiver.
ReasonForMTMServ Code representing the reason for an Q,S Qualified by ReasonForMTMServiceCodeQualifier.

iceCode the service.
ReasonForMTMServ Qualifier to identify the code an Q,S See ECL

iceCodeQualifier system being used for
ReasonForMTMServiceCode.
ReasonForMTMServ Free Text field to be used only if an Q,S

iceFreeText reason identified does not have a
code list
(ReasonForMTMServiceCode).
ReasonForMTMServ Textual representation of an Q,S

iceText ReasonForMTMServiceCode.
439-E4 Reason For Service Code identifying the type of x(2) T,A,Z,W 2 See ECL
Code utilization conflict detected by
the prescriber or the pharmacist
or the reason for the
pharmacist’s professional
service.
- 139 -
July 2016
DATA DICTIONARY
ReasonForSubstituti Restricted text for submitter to an S See ECL

onCodeUsed define their clarification basis for
Substitution code applied.
601-50 Rebate Batch Unique number identifying the x(15) R 15 Comments: Can be invoice number.
Number batch being submitted.
601-51 Rebate Days Supply Days supply of the product being 9(3)b R 4 Format=999b or 999-
reported. or 9(3)-
Note
b = Space
- = Negative Sign
601-52 Rebate Per Unit Amount per unit being 9(5)v99999 R 12 Format=$$$$$ccccccb or $$$$$cccccc-
Amount submitted. 9b
or Note
9(5)v99999 b = Space
600-39 Rebate Period End Last day of the rebate period. 9(8) R,J 8 Format=CCYYMMDD
Date
CC=Century
YY=Year
MM=Month
DD=Day
600-38 Rebate Period Start First day of the rebate period. 9(8) R,J 8 Format=CCYYMMDD
Date
CC=Century
YY=Year
MM=Month
DD=Day
601-03 Rebate Version Version and release number of x(5) R 5 See ECL Format=VV.RR
Release Number standard being submitted.
VV=Version
RR=Release
x(24) B,A,V,E 24
880-K7 Receiver ID An identification number of the --------------- --------------- -------------
endpoint receiver of the data file. x(30) F,I 30
A19 Receiver Name Business name of entity receiving x(70) X 70

the information.
602-08 Reconciliation Error Description of the R99 Reason x(30) R 30

Description Code.
- 140 -
July 2016
DATA DICTIONARY
B98-34 Reconciliation ID A unique identifier assigned by X(30) T 30

the processor for the transaction
response statuses of
Paid/Duplicate of Paid,
Capture/Duplicate of Capture, or
Approved/Duplicate of Approved
that provides a means to identify
that transaction should any
subsequent transaction or other
associated activity occur.
602-09 Reconciliation Line Unique number that identifies x(11) R 11

Number the record.
602-10 Reconciliation This code indicates the reason x(3) R 3 See ECL
Reason Code for the dispute.
602-11 Reconciliation Indicates how the line is being x(1) R 1 See ECL
Status Code adjudicated.
602-12 Reconciliation Unique number identifying the x(9) R 9

Transmission whole transmission.
Control Number
Batch Standard:
751-M9 Record Count For Batch Standard: Includes the 9(10) B,F,V,E,I 10
total number of records in the
batch, including the header and Comments: Data trailer segment record count =
trailer records. total number of enrollment segments in the
processor set.
For Formulary & Benefit
Standard: The count of the detail
records between the subordinate File trailer segment record count = total number of
header and the trailer records. enrollment segments in the entire file.
Record Count does not include
the subordinate header and
trailer records, or the file header
or trailer records.
For Prescription Transfer
Standard: Includes the total
number of records within the
grouped records header and
trailer, including the header and
trailer in the count.
For Audit and Benefit
Integration Standards: Total
number of detail records
included in transmission
- 141 -
July 2016
DATA DICTIONARY
624-SB Record Delimiter This field is used to delimit the x(1) V 1 Comments: For Prescription Transfer, Carriage
end of the data record. Return (CR) = Hex 0D
398 Record Indicator Action to be taken on the record. x(1) A 1 See ECL
B83 Record Length Length of the file. 9(5) I 5
601-53 Record Purpose Identifies the purpose of the x(1) R,J 1 See ECL
Indicator record being submitted.
399 Record Status Code Identifies the transaction status x(1) A,Y 1 See ECL
as assigned by the processor.
R, A,V,X,J, See ECL
601-04 Record Type Type of record being submitted. x(2) E,Y,L,I 2
-------------- --------------- -------------
x(3) F 3
RefillsRemaining The number of refills remaining 9(2) S 2 See Number Of Fills Remaining (616-PU).
in the prescription.
601-47 Reimbursement The amount that the plan 9(9)v99b R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
Amount reimburses the pharmacy. or 9(9)v99-
Note
b = Space
- = Negative Sign
601-54 Reimbursement Date provider was reimbursed 9(8) R,J 8 Format=CCYYMMDD

Date for product being reported.
CC=Century
YY=Year
MM=Month
DD=Day
601-48 Reimbursement Identifies the content of the data x(2) R 2 See ECL
Qualifier submitted in the Reimbursement
Amount (601-47) field.
x(3) T,A,N,V,E,I 3
511-FB Reject Code Code indicating the error -------------- --------------- ------------- See ECL
encountered. x(4) F 4
510-FA Reject Count Count of Reject Code (511-FB) 9(2) B,T,N 2 Comments: Fields included in the set/logical
occurrences. grouping are:
Reject Code (511-FB)
Reject Field Occurrence Indicator (546-4F)
- 142 -
July 2016
DATA DICTIONARY
546-4F Reject Field Identifies the counter number or 9(2) T 2

Occurrence occurrence of the field that is
Indicator being rejected. Used to indicate
rejects for repeating fields.
878 Reject Override Indicates the reason for paying a x(1) A 1 See ECL
Code claim when override is used.
RelatesToMessageI Used in the conversation x(35) S,Q 35

D (message string) to link the
current message to the most
recent message you received
from your trading partner. In
RelatesToMessageID use the
latest MessageID in the
conversation (message string)
you received from your trading
partner that was not a utility
message (for example, not a
GetMessage, Status, Verify or
Error).
A30-ZT Released Date Identifies the date the 9(8) T 8 Format=CCYYMMDD

prescription was relinquished
CC=Century
from the dispensing facility to
YY=Year
the patient or purchaser.
MM=Month
DD=Day
Example: A date of July 27, 2009 would be:
20090727.
A31-ZU Released Time Indicates the time the 9(6) T 6 Format=HHMMSS

prescription was relinquished Example: (Reported in Military Time)
from the dispensing facility to Two O’Clock P.M. = 140000
the patient or purchaser. This is
the local time that corresponds
with the Released Date (A30-ZT)
514-FE Remaining Benefit Amount remaining in a s9(6)v99 T,A 8 Format=s$$$$$$cc

Amount patient/family plan with a
periodic maximum benefit. Example: If the amount is $5.50 this field would
reflect: 55{
Note: 0000000{ (No benefit remaining)
Standard if this field is not applicable, the field
should contain 9999999I
- 143 -
July 2016
DATA DICTIONARY
513-FD Remaining Amount not met by the s9(6)v99 T,A 8 Format=s$$$$$$cc

Deductible Amount patient/family in the deductible
plan. Examples: The patient has $50.00 deductible. The
patient pays $20.00 for a prescription. The
remaining deductible is $30.00, and this field would
reflect: 300{.

625-SC Remaining Quantity Quantity not yet dispensed. 9(7)V999 V 10 Format=9999999v999
REMSAuthorization Number assigned by the REMS an S

Number Administrator to identify an
authorized transaction.
REMSCaseID ID assigned by the REMS x(20) S 20

Administrator to identify the
specific case.
REMSNote Free text. x(2000) S 2000
REMSPatientRiskCat Identifies the risk of adverse an S See ECL

egory event based on variables of the
patient.
REMSReferenceID Assigned by the prescribing x(35) S 35

system on the initial transaction
and is used as a tracking
identifier on all request and
response REMS transactions to
tieback related REMS
transactions.
A29-ZS Reported Payment The type of prescription benefit 9(2) T 2 See ECL
Type plan that adjudicated and paid
for the prescription.
- 144 -
July 2016
DATA DICTIONARY
601-05 Reporting Period For Post Adjudication and 9(8) R,A 8 Format=CCYYMMDD
End Date Uniform Healthcare Payer Data: _______ _________ _______
The last day of the period being CC=Century
reported in the file. 9(6) Y 6 YY=Year
MM=Month
For Manufacturer Rebates: The DD=Day
last day of the period being
reported in the plan flat file.
For Uniform Healthcare Payer Data Standard,
Format=CCYYMM
CC=Century
YY=Year
MM=Month
601-06 Reporting Period For Post Adjudication and 9(8) R,A 8 Format=CCYYMMDD
Start Date Uniform Healthcare Payer Data: _______ _________ _______
The first day of the period being CC=Century
reported in the file. 9(6) Y 6 YY=Year
MM=Month
For Manufacturer Rebate: The DD=Day
first day of the period being
For Uniform Healthcare Payer Data Standard,
reported in the plan flat file.
Format=CCYYMM
CC=Century
YY=Year
MM=Month
ReportURL URL where an additional report an S 1000

with the SCOREValue can be
requested.
601-55 Requested Rebate The total rebate being requested 9(9)v99b R,J 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
Amount for the reported product. or 9(9)v99-
Note
b = Space
- = Negative Sign
A50 Requested Date associated with the 9(8) E 8 Format: CCYYMMDD

Response Date Transmission File Type (986-KJ). For Desk Top Audits: the due date for the initial
audit request, the end of an appeal period or an
appeal hearing date as defined by the auditing
entity.
For In-Store Audits: the date of the store visit by an

auditor, the end of an appeal period, or an appeal
hearing date.
- 145 -
July 2016
DATA DICTIONARY
374-2V Request Period The beginning date of need. 9(8) T 8 Format = CCYYMMDD
Begin Date
CC=Century
YY=Year
MM=Month
DD=Day
498-PB Request Period Beginning date for a prior 9(8) T 8 Format=CCYYMMDD

Date-Begin authorization request.
CC=Century
YY=Year
MM=Month
DD=Day
Comments: Used by processor to determine
starting date of a prior authorization request.
498-PC Request Period Ending date for a prior 9(8) T 8 Format=CCYYMMDD

Date-End authorization request.
CC=Century
YY=Year
MM=Month
DD=Day
Comments: Used by processor to determine the
ending date for a prior authorization request.
375-2W Request Period The effective date of the revision 9(8) T 8 Format = CCYYMMDD
Recert/Revised Date or re-certification provided by
the certifying physician. CC=Century
YY=Year
MM=Month
DD=Day
RequestReferenceN The receiver's identification x(35) S,Q 35

umber number for the transaction being
returned. Used in GetMessage
transaction.
373-2U Request Status Code identifying type of request. x(1) T 1

See ECL
498-PA Request Type Code identifying type of prior x(1) T 1 Comments: Used by processor to distinguish reason
authorization request. See ECL for prior authorization request.
ResidenceCode Code identifying the patient’s 9(2) Q 2 See ECL See Patient Residence (384-4X).
place of residence.
968-JF Resource Link Type Identifies the type of coverage x(2) F 2 See ECL
information contained at the URL
contained in URL (987-MA).
- 146 -
July 2016
DATA DICTIONARY
B52-8R Response Count of Response Intermediary 9(1) T 1

Intermediary Authorization Type ID (B53-8S),
Authorization Count Response Intermediary
Authorization Type ID and
Intermediary Message.
B54-8T Response Value indicating intermediary x(20) T (20)

Intermediary authorization.
Authorization ID
B53-8S Response Value indicating the 9(2) T 2 See ECL

Intermediary authorization type from
Authorization Type intermediary processing.
ID
ResponsibilityEndDa Indicates the last day of a period xsd:date or Q CC=Century
te of responsibility that began on xsd:datetim YY=Year
the ResponsibilityStartDate. e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
ResponsibilityStartD Indicates the date on which the xsd:date or Q CC=Century
ate payer becomes responsible for xsd:datetim YY=Year
the resident’s facility costs. e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
- 147 -
July 2016
DATA DICTIONARY
ResultOfActionCode Code representing the result of an Q Qualified by ResultOfActionCodeQualifier.

the action.
ResultOfActionCode Qualifier to identify the code an Q See ECL

Qualifier system being used for
ResultOfActionCode.
ResultOfActionFree Free Text field to be used only if an Q

Text result identified does not have a
code list (ResultOfActionCode).
ResultOfActionText Textual representation of an Q

ResultOfActionCode.
441-E6 Result of Service Action taken by a pharmacist or x(2) T,A,Z,W 2 See ECL
Code prescriber in response to a
conflict or the result of a
pharmacist’s professional
service.
ResumeDateTime The date and time at which xsd:datetim S CC=Century
administration of a medication is e YY=Year
resumed after being suspended. MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
Used to request return receipt. If
ReturnReceipt this field is submitted with 1 in the x(3) S, Q 3 See ECL
request, a Verify transaction is to be
sent from the recipient at same
time.
602-13 Revised Invoice The Original Rebate Per Unit 9(9)v99b R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
Amount (601-93) is different than the or
Current Rebate Per Unit (601- 9(9)v99- Note:
81). The dollar amount of the b = Space
Current Units times the Current - = Negative sign
Rebate Per Unit.
Room The room of the patient. x(10) S,Q 10
674-W4 Room The room of the patient. x(10) V 10
- 148 -
July 2016
DATA DICTIONARY
995-E2 Route of This is an override to the default x(11) T,A,Z,W 11 See ECL
Administration route referenced for the product.
For a multi-ingredient
compound, it is the route of the
complete compound mixture.
RouteOfAdministrat Used to add clarity to the route x(255) S 255

ionClarifyingFreeTex of administration for elements
t that cannot be codified.
RouteOfAdministrat The code representing the an S,Q Qualified by RouteOfAdministrationQualifier.

ionCode RouteOfAdministrationText.
RouteOfAdministrat Qualifier to identify the code an S,Q See ECL

ionQualifier system being used.
RouteOfAdministrat The textual representation of the an S,Q

ionText RouteOfAdministrationCode.
RxBarcode Barcode representation of an Q

prescription as designated by
pharmacy.
RxFillConfirmIndicat Indicates the transferred to xsd:Boolean S See ECL

or pharmacy supports Fill Status Code
messages.
RxFillIndicator Indicates the type of fill status an S See ECL

transactions the prescriber
would like to receive for this
patient/medication.
969-JG RxNorm Code ID from RxNorm database. x(15) F 15 Comments: Qualified by RxNorm Qualifier (970-JH).
970-JH RxNorm Qualifier Code qualifying the RxNorm code x(3) F 3 See ECL
submitted in RxNorm Code (969-
JG).
RxReferenceNumbe The prescription number x(35) S, Q 35

r assigned by the pharmacy
system.
RxReferenceOrderG Unique ID assigned by the X(35) S,Q 35

roupNumber pharmacy to link multiple
medication orders together.
RxRefillMessage Number of refills remaining and an Q

expiration date of prescription.
- 149 -
July 2016
DATA DICTIONARY
681-ZF Sales Transaction ID A reference identifier assigned to x(80) T 80

the sale transaction as assigned
by the merchant.
454-EK Scheduled The serial number of the x(12) T 12

Prescription ID prescription blank/form.
Number
ScoreName Descriptive name of score.
an S 255
ScoreSource Indicates the product or
organization generating the an S 255
associated score and report.
ScoreValue Value of score.
an S 10
SecondaryDiagnosis The textual representation of
CodeDescription SecondaryDiagnosisCode. an S
SecondaryDiagnosis Qualifies the code list used for an S See ECL

CodeQualifierCode the SecondaryDiagnosis.
SecondaryDiagnosis Code for the secondary an S Qualified by SeconaryDiagnosisCodeQualifierCode.

Value diagnosis.
SecondaryIdentifica For Sender - Password. This field x(35) S, Q 35

tion is used for the sender's password
to the recipient's system.
For Receiver - May be used as a
secondary identification of the
recipient. Or May be used to
identify the switch.
971-JJ Section Column In Column number that contains 9(2) F 2

Error the error
SeeTransactionLevel Indicates to see attachment at an S

AttachmentControl the transaction level instead of
Number an attachment at a completed
answer level and provides the
control number.
638-XK Segment 1 The business segmentation of x(20) R,J 20

rebates to permit one file to go
to each manufacturer.
639-XL Segment 2 The business segmentation of x(20) R,J 20

- 150 -
July 2016
DATA DICTIONARY
640-XM Segment 3 The business segmentation of x(20) R,J 20

641-XN Segment 4 The business segmentation of x(20) R,J 20

642-XP Segment 5 The business segmentation of x(20) R,J 20

643-XQ Segment 6 The business segmentation of x(20) R,J 20

111-AM Segment Identifies the segment in the x(2) T,N 2 See ECL
Identification request and/or response.
701 Segment Identifier Unique record type required on x(2) B 2

Enrollment/Batch Transaction See ECL
Standard.
644-XR Segment Qualifier 1 Indicates for the Segment Field x(2) R,J 2 See ECL
the definition of how the rebates
are stratified in the batch
number.
645-XS Segment Qualifier 2 Indicates for the Segment Field x(2) R,J 2 See ECL
number.
646-XT Segment Qualifier 3 Indicates for the Segment Field x(2) R,J 2 See ECL
number.
647-XU Segment Qualifier 4 Indicates for the Segment Field x(2) R,J 2 See ECL
number.
648-XV Segment Qualifier 5 Indicates for the Segment Field x(2) R,J 2 See ECL
number.
649-XW Segment Qualifier 6 Indicates for the Segment Field x(2) R,J 2 See ECL
number.
- 151 -
July 2016
DATA DICTIONARY
SelectMultiple Indicates if multiple choices can xsd:Boolean S See ECL

be selected to answer the Code
question.
SelfAdministrationA Indicates if patient is allowed to xsd:boolean S

llowed self-administer medication.
679-Y9 Seller ID The identification of the person x(70) T 70

responsible for dispensing the
prescription or provision of the
service.
See ECL
680-ZB Seller ID Qualifier Code indicating the type of ID 9(2) T 2
used in the Seller Identification
(679-Y9).
590-YT Seller Initials The initials of the person x(3) T 3

responsible for dispensing the
prescription or provision of
service.
880-K1 Sender ID An identification number x(24) B 24

assigned to the sender of the
data by the processor/receiver of ------------ --------------- ------------
the data. x(30) F,I 30
------------ ------------- ------------
x(6) L 6
626-SD Sender Name Business name of entity sending x(70) V,X 70

the information.
973-JM Sender Participant Trading Partner Defined - x(10) F 10

Password Password for the Source
Participant.
B84 Sender Reference A reference number assigned by x(30) I 30

Number the sender that is to be echoed
back in the response.
- 152 -
July 2016
DATA DICTIONARY
SenderSoftwareDev The text field that identifies the x(35) S,Q 35

eloper entity responsible for the
software that generated the
transaction. The developer may
be a software vendor or, if the
software was developed in-
house, the developer is the
entity actually sending the
transaction (e.g., a chain). The
value transmitted is determined
by the
SenderSoftwareDeveloper.
SenderSoftwarePro The text field that identifies the x(35) S,Q 35

duct software developer’s product, as
determined by the software
developer.
The text field that identifies the
SenderSoftwareVer version and release of the x(35) S,Q 35
sionRelease software product, as determined
by the software developer.
This is not to be used to block
transactions.
879-N2 Sending Entity Party creating the data enclosed x(24) A,V,L 24
Identifier or the entity for whom the data _______ ,E________ _______
is being enclosed.
x(10) Y 10
627-SF Sending Pharmacy ID of sending pharmacy. x(35) V 35

ID
SentTime The date of the transmission. xsd:datetim S,Q CC=Century
e YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
SequenceNumber Sequence number to indicate the 9(3) S 3

order answer choices should be
displayed to the prescriber.
- 153 -
July 2016
DATA DICTIONARY
886 Service Provider Processor specific ID assigned to x(7) A,E 7

Chain Code a chain by processor.
585-YN Service Provider The city name of the address of x(20) T 20 Examples: CHICAGO
City Address the service provider.
A93-1T Service Provider Indicates the country of the x(2) Y,T,J,A 2 See ECL
Country Code provider.
887 Service Provider Indicates the county of the x(3) A 3 Comments: Trading partner defined.
County Code pharmacy.
201-B1 Service Provider ID ID assigned to a pharmacy or x(15) R,T,A,V,Z,W 15 Comments: If NCPDP Provider Identification
provider. ,X,J,E,Y,I Number or Dispensing Physician ID Number
assigned by NCPDP, this is the following format:
Format= SSNNNNC
SS=State code (see ECL)
NNNN=Number assigned to specific pharmacy or
dispensing physician within the state
C=Check digit with the remaining positions blank.
The check digit is calculated as follows: If the
number is 123456
1+3+5 = 9 (sum the 1st, 3rd, & 5th digits)
+(2+4+6)x2 = 24 (2 times the sum of 2nd, 4th, & 6th
digits)
33 (the units digit is the check
digit)
The check digit is 3, giving the full number 1234563.
Qualified by ‘Service Provider ID Qualifier’ (202-B2).
202-B2 Service Provider ID Code qualifying the Service x(2) T,A,R,V,Z,W 2 See ECL
Qualifier Provider ID (201-B1). ,X,J,E,Y,I
Example: XYZ GROCERY MART
583-YK Service Provider The name of the service provider x(70) T 70
Name business associated to the
service provider ID (201-B1).
See ECL
A20 Service Provider The override’s inclusion or 9(1) X 1
Override Type exclusion parameters as it
applies to the pharmacy network
for a plan.
- 154 -
July 2016
DATA DICTIONARY
See ECL
586-YP Service Provider State/Province Code of the x(2) T,J 2
State/Province Code service provider
Address
B31-7Y Service Provider Line 1 of the street address of x(40) T 40

Street Address Line the service provider.
1
B32-7Z Service Provider Line 2 of the street address of x(40) T 40

Street Address Line the service provider.
2
Comments:
587-YQ Service Provider Code defining international x(15) T 15 When used for US ZIP Code - This left-justified field
Zip/Postal Code postal code of the service contains the five-digit zip code and may include the
provider, excluding punctuation. four-digit expanded zip code.

Examples:
A0E 3B0
A1L 2T8
ServiceReasonCode Code identifying the type of conflict an S See ECL When ServiceReasonCode is sent from the prescriber to
detected. the pharmacist, the ServiceResultCode is mandatory.
When the ServiceReasonCode is sent from the
pharmacist to the prescriber, the ServiceResultCode
is conditional.
ServiceResultCode Action taken in response to a an S See ECL

conflict.
- 155 -
July 2016
DATA DICTIONARY
ServiceTypeCoded Medication list contains all x(3) S 3 See ECL

current medication orders as of
the current date and time of the
response, for the patient
indicated. Current status is
determined by the point of care
responder. Current is medication
orders which have not been
discontinued.
SeverityCoded Severity of the patient’s reaction an Q See ECL

to the problem reported.
ShippingAmount Amount of shipping cost that was an Q Format=s$$$$$$$$.cc to the length of the dollar
applied to the prescription. amount exchanged.
- = Negative sign
. = Decimal point
would reflect: 5.50
ShippingMethod Text indicating the shipping an Q

method for the order.
ShipToteIdentificati Unique number assigned by the an Q

on Central Fill Facility for the
shipping tote.
SignatureValue DigestValue that has been signed an S

with a Private Key, base64
encode the results.
SigText SigText contains either 1) an S

completely free text with no
corresponding codified content
OR 2) a generated structured
English version of the structured
sig content that follows the sig
grammar in the XML. The SigText
should have no more and no less
then what is in the structured Sig
content.
- 156 -
July 2016
DATA DICTIONARY
SiteOfAdministratio Used to add clarity to the site of x(255) S 255

nClarifyingFreeText administration for elements that
cannot be codified.
SiteOfAdministratio The code representing the an S Qualified by SiteOfAdministrationQualifier

nCode SiteOfAdministrationText.
SiteOfAdministratio Qualifier to identify the code an S See ECL

nQualifier system being used.
SiteOfAdministratio The textual representation of an S

nText SiteOfAdministrationCode. It is
the site of administration.
334-1C Smoker/Non- Code indicating the patient as a x(1) T,V 1 See ECL
Smoker Code smoker or non-smoker.
SNOMEDAdverseEv Type of product and intolerance. an Q See ECL.

entCode
SNOMEDAdverseEv Text of the an Q

entText SNOMEDAdverseEventCode.
SNOMEDVersion The version of The Systematized an S Comment: Governed by SNOMED.

Nomenclature of Human and
Veterinary Medicine (SNOMED)
being used.
110-AK Software Vendor/ ID assigned by the switch or x(10) T,N 10

Certification ID processor to identify the
software source.
- 157 -
July 2016
DATA DICTIONARY
SoldDate The date or date and time the xsd:datetim S CC=Century
product was sold. e or YY=Year
xsd:date MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
SourceDescription Name of the medication history x(35) S 35 Qualified by SourceQualifier.

source.
972-JK Source Name Name of Source supplying the x(70) F 70

formulary - Formulary Source
SourceOfInformatio Sender indicates where the x(1) Q 1 See ECL

n sender received the allergy
information if known.
SourceQualifier Qualifies the SourceDescription. x(3) S 3 See ECL
429-DT Special Packaging Code indicating the type of 9(1) T,A 1 See ECL
Indicator dispensing dose.
A37 Specialty Claim Indicates whether a claim was x(1) A 1 See ECL
Indicator filled by a specialty pharmacy or
a specialty drug.
SpecificAdministrati Indicates the specific Brand of an S

onBrand the PICC line used for central IV
access.
SpecificAdministrati Indicates the size (gauge) of the 9(2) S 2

onGauge needle or catheter being used for
medication administration, i.e.
14, 18, 20.
- 158 -
July 2016
DATA DICTIONARY
SpecificAdministrati Indicates the size (length) of the an S

onLength PICC line used for central IV
access.
SpecificAdministrati Indicates the type of pump used an S

onPump for the IV administration
128-UC Spending Account The balance from the patient’s s9(6)v99 T,A 8 Format= s$$$$$$cc
Amount Remaining spending account after this
transaction was applied. Example: If the amount is $5.50 this field would
reflect: 55{
Species A basic biological classification an S See ECL

containing individuals that
resemble one another and may
interbreed.
SplitScript Two prescriptions for the same x(1) S 1 See ECL

medication that are sent to two
different entities for fulfillment.
StartDate The beginning date or date and xsd:date or S CC=Century
time. xsd:datetim YY=Year
e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
- 159 -
July 2016
DATA DICTIONARY
601-07 Start Date The first day of eligibility. 9(8) R 8 Format=CCYYMMDD

CC=Century
YY=Year
MM=Month
DD=Day
StateProvince The State/Province Code of the X(2) S,Q 2 See ECL

address.
729-TA State/Province The State/Province Code of the x(2) R,A,V,Y 2 See ECL
Address address.
StatusCode Codes used to relay successful or an S,Q See ECL

rejected communications.
B64-1P Step Medications ID assigned by payer to match x(40) F 40

Group ID the Coverage Information Detail -
Step Medications (SM) Triggers
record.
974-JN Step Order The suggested order in which the x(1) F 1 See ECL
step medication is to be tried.
StopIndicatorText The textual representation of the x(255) S 255

StopIndicatorTextCode. The
event that indicates the
completion of the duration of
use or reason to stop.
StopIndicatorTextCo The code representing the an S Qualified by StopIndicatorTextQualifier.

de StopIndicatorText.
StopIndicatorTextQ Qualifier to identify the code an S See ECL

ualifier system being used.
- 160 -
July 2016
DATA DICTIONARY
StrengthForm Concepts that qualify the an S See ECL

strength and strength unit of
measure associated with the
prescribed product (e.g.,
Amoxicillin 250 mg Tablet,
Allbuterol HFA 17 grams Inhaler,
Cefaclor 250 MG/5ML
Suspension, Fentanyl 12 mcg/hr
Patch, Epinephrine 0.3 mg
[implied per dose] Auto-Injector,
Timolol 0.25% Ophthalmic Drops,
Sprintec 28 Day Pack,
Hydrocortisone 1% Ointment).
StrengthUnitOfMea Concepts of dosage form an S See ECL

sure strength (e.g., 250 mg, 250
MG/5ML), a delivery rate (e.g.,
12 mcg/hr, a dosage form
concentration (e.g., 0.05%, 1%),
the dosage released from a single
delivery device actuation (e.g.,
90 mcg [implied as per
inhalation], 5 grams), the days
supply or quantity in a package
(e.g., 28 day, 60 grams).
StrengthValue Drug strength. x(70) S 70
StructuresVersion Element defines which NCPDP an S,Q See ECL

structures schema is being used.
A21 Subgroup ID Further definition of client x(15) X 15

population divisions. Further
defines Group ID (301-C1).
420-DK Submission Code indicating that the 9(2) T,Z,W 2 See ECL Examples: Since the patient will be out of state for
Clarification Code pharmacist is clarifying the the next three months, they have requested a
submission. _________ __________ _________ _________ three-month supply of their medication. This
9(3) A,E 3 See ECL situation can cause the claim to reject, because it
was refilled too soon. By indicating an 03, the
processor is made aware of the situation, and can
properly adjudicate the claim.
354-NX Submission Count of the Submission 9(1) T 1

Clarification Code Clarification Code (420-DK)
Count occurrences.
- 161 -
July 2016
DATA DICTIONARY
888 Submission Number Indicates the number of times a x(2) A,E 2 See ECL
data set has been resent. _________ __________ _________
9(4) I 4
601-36 Submit Code The code on the file defining the x(2) R,J 2 See ECL
type of submission for the entire
batch (identified by the batch
number). Indicates the action to
perform on the submitted file.
SubstanceLevelCod The code representing the an S,Q

e SubstanceLevelText.
SubstanceLevelQual Qualifier to identify the an S,Q See ECL

ifier SubstanceLevelCode.
SubstanceLevelText The textual representation of the an S,Q

Code or the SubstanceLevelCode.
SubstanceTypeCode The code representing the an S,Q

SubstanceTypeText.
SubstanceTypeQuali Qualifier to identify the code an S,Q See ECL

fier system being used.
SubstanceTypeText The textual representation of the an S,Q

SubstanceTypeCode.
SubstitutedBrandDr Name of the brand medication an Q

ug that the dispensed medication
was substituted.
SubstitutionCode Code indicating whether or not an S See ECL

the prescriber’s instructions
regarding generic substitution
were followed.
SubstitutionMessag Substitution message to be an Q

e printed on the prescription label.
Suffix Name suffix. x(10) S, Q 10
SupervisorIdentifica Identification of the supervisor. x(35) S,Q See ECL

tion
SupervisorSpecialty Specialty of supervisor. x(10) S,Q See ECL
- 162 -
July 2016
DATA DICTIONARY
SupplyIndicator Identifies that the prescription is xsd:Boolean S See ECL

for a Diabetic Supply and Code
additional information
supporting the rationale behind
the prescription and the patient
condition and review should be
included in the prescription.
376-2X Supporting Free text message. x(65) T 65

Documentation
SuspendDateTime The date and time at which xsd:datetim S CC=Century
administration of a medication is e YY=Year
suspended. MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
TargetedTypeOfSer Code representing the targeted an Q,S Qualified by TargetedTypeOfServiceCodeQualifier.

viceCode service.
TargetedTypeOfSer Qualifier to identify the code an Q,S See ECL

viceCodeQualifier system being used for
TargetedTypeOfServiceCode.
TargetedTypeOfSer Free Text field to be used only if an Q,S

viceFreeText targeted service identified does
not have a code list
(TargetedTypeOfServiceCode).
TargetedTypeOfSer Textual representation of an Q,S

viceText TargetedTypeOfServiceCode.
557-AV Tax Exempt Code indicating the payer and/or x(1) T,A 1 See ECL
Indicator the patient is exempt from taxes.
TechnicianInitials Initials of the Technician an Q

performing the order entry of
the prescription.
637-TF Technician Initials The initials of the pharmacy x(3) V 3

technician.
- 163 -
July 2016
DATA DICTIONARY
732-TB Telephone Number Telephone number. 9(10) A,V,X,L 10 Format=AAAEEENNNN

AAA=Area Code
EEE=Exchange Code
NNNN=Number
628-SG Telephone Number Count of phone number 9(1) V 1 Comments: Fields included in the set/logical
Count occurrences. grouping for Prescription Transfer are: Telephone
Number Qualifier (629-SH), Effective Date (609-
NG). Telephone Number (732-TB)
B10-8A Telephone Number Extension of the telephone 9(8) A,V,X,L 8 Format = 99999999
Extension number.
629-SH Telephone Number Code qualifying the type of X(2) V 2 See ECL For Prescription Transfer, qualifies Telephone
Qualifier telephone number. Number (732-TB).
TemplateID A unique identifier for the x(35) Q 35

template used.
713 Termination Date Date that group or member’s 9(8) R 8 Format=CCYYMMDD

participation in this group will
terminate. Coverage continues CC=Century
through midnight of the YY=Year
termination date. MM=Month
DD=Day
TertiaryIdentificatio Used as a tertiary identification x(35) S,Q 35

n of the recipient.
TertiaryIdentifier Used as a tertiary identifier, x(3) S,Q 3

based on trading partner
agreements or need of the
originating system.
TestingFrequency Identifies the maximum number 9(2) S 2

of times per day the patient is to
test their blood glucose levels.
TestingFrequencyN This is a notes field and is x(210) S 210

otes expected to be a long hand
explanation by the prescriber to
support the testing frequency.
TestMessage Indicates whether the 9(1) S,Q 1 See ECL

transaction is test or live.
- 164 -
July 2016
DATA DICTIONARY
Text The textual representation of the an Q

code.
880-K4 Text Indicator This field is used to identify the x(1) B,V 1 Comments:
beginning and ending of the data For Batch
record. Start of text (STX)=Hex 02
End of text (ETX)=Hex 03
For Prescription Transfer
Line Feed (LF) = Hex 0A
A46-1S Text Message Type Identifies the type of coverage x(2) F 2 See ECL
information contained at the URL
contained in URL (987-MA).
889 Therapeutic An eight position field x(8) A 8

Chapter representing the therapeutic
chapter; from formulary file as
defined by processor.
601-25 Therapeutic Class Code assigned to product being x(17) R,A,J,I 17 Comments: Qualified by Therapeutic Class Code
Code reported. Qualifier (601-26).
601-26 Therapeutic Class Identifies type of data being x(1) R,A,J,I 1 See ECL
Code Qualifier submitted in the Therapeutic
Class Code (601-25) field.
601-27 Therapeutic Class A text description of the x(30) R,J 30

Description Therapeutic Class Code (601-25)
field.
Total threshold reduction
B02 Threshold applicable to the retiree’s Gross 9(10)v99 L 12 Format=$$$$$$$$$$cc
Reduction Retiree Cost. (Note: This cost does not support a sign.)
678-Y6 Time of Service The time at which the service is 9(6) T 6 Format=HHMMSS
performed as local time that will
correspond with the actual date HH=Hours
of service. MM=Minutes
SS=Seconds
TimePeriodBasisCod The code representing the an S Qualified by TimePeriodBasisQualifier.

e TimePeriodBasisText.
See ECL
TimePeriodBasisQu Qualifier to identify the code an S
- 165 -
July 2016
DATA DICTIONARY
TimePeriodBasisTex The textual representation of the an S

t TimePeriodBasisCode. Expresses
the time unit of measure for the
calculated dose.
The time zone difference
TimeZoneDifference quantity is HHMM offset from an Q
Quantity the Coordinated Universal Time
(UTC).
TimeZoneIdentifier Defines the time zone used by an Q See ECL

the sender.
TimingClarifyingFre Used to add clarity to the Timing x(255) S 255

eText for elements that cannot be
codified.
TitrationDoseMaxim The value representing the 9(18) S 18

umValue bottom of the range that is
acceptable for the desired clinical
effect of the medication.
TitrationDoseMeasu Free text of the titration dose x(255) S 255 Example: 30 minutes before third dose.
rementNotes measurement.
TitrationDoseMeasu Actual value of clinical 9(18) S 18 Measurement provided at time of prescription

rementValue information.
TitrationoDoseMeas The code representing the an S

urementValueUnitO TitrationDoseMeasurementValue
fMeasureCode UnitOfMeasureText.
TitrationDoseMeasu Physical condition identifier. an S Qualifies the TitrationDoseMeasurementValue.

rementVitalSign See ECL
TitrationDoseMinim The value representing the 9(18) S 18

umMeasurementVa bottom of the range that is
lue acceptable for the desired clinical
effect of the medication.
To The identification number of the an S, Q Qualified by AddressTypeQualifier.

receiver.
- 166 -
July 2016
DATA DICTIONARY
TotalAmountBrandP The total amount of penalty by an Q Format=s$$$$$$$$.cc to the length of the dollar
enalty all plans involved for the amount exchanged.
selection of a brand name drug.
- = Negative sign
. = Decimal point
would reflect: 5.50
S9(6)v99 T, E 8
509-F9 Total Amount Paid Total amount to be paid by the _________ _________ _________ For T and E: Comments: Format=s$$$$$$cc
claims processor (i.e. pharmacy
receivable). Represents a sum of I Example: If the amount is $5.50 this field would
S9(8)v99 10 reflect: 55{
Ingredient Cost Pai’ (506-F6),
Dispensing Fee Paid (507-F7), Prescription Response Formula:
Flat Sales Tax Amount Paid (558- Ingredient Cost Paid (506-F6)
AW), Percentage Sales Tax + Dispensing Fee Paid (507-F7)
Amount Paid (559-AX), Incentive + Incentive Amount Paid (521-FL)
Amount Paid (521-FL), + Other Amount Paid (565-J4)
Professional Service Fee Paid + Flat Sales Tax Amount Paid (558-AW)
(562-J1), Other Amount Paid + Percentage Sales Tax Amount Paid (559-AX)
(565-J4), less Patient Pay Amount - Patient Pay Amount (505-F5)
(505-F5) and Other Payer - Other Payer Amount Recognized (566-J5)
Amount Recognized (566-J5).
= Total Amount Paid (509-F9)
Service Response Formula:

Professional Service Fee Paid (562-J1)
+ Flat Sales Tax Amount Paid (558-AW)
+ Percentage Sales Tax Amount Paid (559-AX)
+ Other Amount Paid (565-J4)
- Patient Pay Amount (505-F5)
- Other Payer Amount Recognized (566-J5)
= Total Amount Paid (509-F9)
amounts.
894 Total Amount Paid Total amount of the prescription s9(6)v99 A 8 Format=s$$$$$$cc
By All Sources regardless of party responsible
for payment. Example: If the amount is $5.50 this field would
reflect: 55{
- 167 -
July 2016
DATA DICTIONARY
TotalCountforOrder Indicates the total number of 9(2) S,Q 2

Group medication orders within the
group.
979-JT Total Errors Total number of errors for entire 9(10) F 8

file. Some rows could have more
than one error.
693 Total Gross Amount Total sum of the gross amount s9(10)v99 A 12 Format=s$$$$$$$$$$cc
Due due fields on the claim level.
reflect: 55{
895 Total Net Amount Summarization of Net Amount s9(10)v99 A 12 Format=s$$$$$$$$$$cc

Due Due (281).
reflect: 55{
TotalNumberOfEnc Number of encounters approved 9(4) Q 4

ountersApproved for this TypeOfServiceCode
within the EffectiveDate and
ExpirationDate.
601-30 Total Number of Total number of FO records in 9(9)b R 10 Format=999999999b or 999999999-

Formularies the submission. or 9(9)-
Note
b = Space
- = Negative Sign
601-08 Total Number Of Total number of PD records in 9(9)b R 10 Format=999999999b or 999999999-

Plans the submission. or 9(9)-
Note
b = Space
- = Negative Sign
601-40 Total Number Of Value is total net number of 9(7)b R 8 Format=9999999b or 9999999-
Prescriptions prescriptions. or 9(7)-
For summary-level records only
Note
b = Space
- = Negative Sign
630-SJ Total Number Of Total number of Prescription 9(8) V 8 For Prescription Transfer, record count of segment
Sending And Detail information. RX (Prescription Detail Record) records, including
Receiving Pharmacy the corresponding SR (Sending & Receiving
Records Pharmacy Record) and ST (Sending & Receiving
Pharmacy Total Record) records.
TotalNumberPackag The total number of packages 9(3) Q 3

es included in the Central Fill Order.
- 168 -
July 2016
DATA DICTIONARY
TotalNumberVials The total number of prescription 9(3) Q 3

vials included in the Central Fill
Order.
694 Total Patient Pay Total sum of the patient pay s9(10)v99 A 12 Format=s$$$$$$$$$$cc
Amount amount fields on the claim level.
reflect: 55{
601-39 Total Quantity Total quantity being submitted. 9(11)v999b R,J 15 Format=99999999999v999b or 99999999999v999-
or
9(11)v999- Note
b = Space
- = Negative Sign
9(10)b R,J 11
601-09 Total Record Count Total number of records being or 9(10)- For Rebates:
submitted, including header and ________ -------------- _______
trailer. Format=9999999999b or 9999999999-
9(10) A,V,X,L 10
Note
b = Space
- = Negative Sign
For Post Adjudication:
Comments: Include header and trailer in count.
For other standards:
Format=9999999999
978-JS Total Records Total Records Processed. 9(10) F,Y 10 Comments: Do not include the file header and
trailer in this count. Total Records in file minus 2.
980-JU Total Rows In Error Number of rows in file that have 9(10) F 10
errors.
ToteBarcode Barcode representation for the an Q

shipping tote.
103-A3 Transaction Code Code identifying the type of x(2) T,N 2 See ECL
transaction.
109-A9 Transaction Count Count of transactions in the x(1) T,N 1 Comments: A transaction count of greater than one
transmission. See ECL is not allowed in Telecommunication Standard or
Financial Information Reporting Standard.
TransactionDomain Element defines which NCPDP an S,Q See ECL

business domain schema is being
used.
- 169 -
July 2016
DATA DICTIONARY
TransactionErrorCo Codes used to relay successful or an S,Q See ECL

de rejected communications.
896 Transaction ID Internally assigned unique claim x(30) A,I 30

ID by the payer.
Transaction
651-S2 Identifier The unique value assigned by the x(21) N 21
Facilitator that relates the
Inquiry, Exchange(s), and Update
transactions to each other.
897 Transaction ID Cross For adjustments, ID associated x(30) A,I 30

Reference with original claim.
880-K5 Transaction A reference number assigned by x(30) T,B 30 Comments: To be assigned by provider.
Reference Number the provider to each of the data
records in the batch or real-time
transactions. The purpose of this
number is to facilitate the
process of matching the
transaction response to the
transaction. The transaction
reference number assigned
should be returned in the
response.
112-AN Transaction Code indicating the status of the x(1) T,N,E,I 1 See ECL
Response Status transaction.
TransactionStandar Code identifying the type of an K See ECL Comments: If a code value other than stated is
d standard included within a submitted, the WSDL contains the specific SOAP
payload envelope. fault.
TransactionVersion Element defines the version of an S,Q See ECL

the TransactionDomain schema
is being used.
631-SK Transfer Flag Indicates previous transfer x(1) V 1 See ECL Comments: Value is from sending pharmacy's
history of the prescription. perspective. Indicates whether prescription has
been transferred or not.
TransferRequest Indicates the prescriptions an S See ECL

requested to be transferred.
TransferType Indicates whether the requesting an S See ECL

or source pharmacy.
- 170 -
July 2016
DATA DICTIONARY
632-SM Transfer Type Indicates file content. x(1) V 1 See ECL
981-JV Transmission Action Indicates whether this is a x(1) F,A 1 See ECL
replacement file, file updates or
a file delete.
601-56 Transmission Unique number identifying the x(9) R 9

Control Number whole transmission. --------------- --------------- -------------
x(10) F 10
601-10 Transmission Date Date the file was created. 9(8) R,F,J,E,I 8 Format=CCYYMMDD
CC=Century
YY=Year
MM=Month
DD=Day
Format= CCYYMMDD
982-JW Transmission Date- Date original incoming file was 9(8) F 8
Originating created.
CC=Century
YY=Year
MM=Month
DD=Day
986-KJ Transmission File Identifier of the file type. x(3) F,E 3 See ECL
Type _________ __________ _________
x(2) I 2
B85 Transmission ID Unique identifier for the x(50) I 50

transmission.
983-JX Transmission Transmission number of the x(10) F 10

Number-Originating original incoming file processed.
984-JY Transmission Time Time the file was created. 9(8) F,I 8 Format= HHMMSSDD
985-JZ Transmission Time- Time original incoming file was 9(8) F 8 Format= HHMMSSDD
Originating created.
880-K6 Transmission Type A value to define the type of x(1) B,E,I 1 See ECL
transmission being sent.
TransportVersion Element defines which NCPDP an S,Q See ECL

transport schema is being used.
- 171 -
July 2016
DATA DICTIONARY
TreatmentIndicator Indicates if the order is new, an S,Q See ECL

continuation of treatment or a
restart of treatment.
TriggerText The textual representation of the an S

TriggerTextCode. The event that
indicates the completion of the
duration of use or reason to stop.
TriggerTextCode The code representing the an S Qualified by TriggerTextQualifier.

TriggerText.
TriggerTextQualifier Qualifier to identify the code an S See ECL

system being used.
A94 Type Of File The type of Uniform Healthcare x(2) Y 2 See ECL
Payer Data Standard Record.
TypeOfServiceCode Code representing the service. an Q,S Qualified by TypeOfServiceCodeQualifier.
TypeOfServiceCode Qualifier to identify the code an Q,S See ECL

Qualifier system being used for
TypeOfServiceCode.
TypeOfServiceFreeT Free Text field to be used only if an Q,S

ext service identified does not have a
code list (TypeOfServiceCode).
Clarifies whether the
TypeOfServiceGrou TypeOfService is to be conducted an Q,S See ECL
pSetting in a group setting.
TypeOfServiceText Textual representation of an Q,S

TypeOfServiceCode.
UCUMVersion The version of The Unified Code an S

for Units of Measure (UCUM)
being used.
B03 Unique Benefit Retiree Drug Subsidy Plan x(20) L 20

Option Identifier Sponsor-assigned ID to identify a
specific benefit design.
634-SP Unique Record ID assigned that makes this x(30) V 30 Qualified by Unique Record Identifier Qualifier
Identifier record unique. (635-SQ).
- 172 -
July 2016
DATA DICTIONARY
635-SQ Unique Record Code qualifying Unique Record x(2) V 2 See ECL Qualifies Unique Record Identifier (634-SP)
Identifier Qualifier Identifier (634-SP).
UnitOfMeasure A division of quantity accepted as an S See ECL

a standard of measurement.
600-28 Unit Of Measure NCPDP standard product billing x(2) R,T,A,W,J,U 2 See ECL
codes.
UnitOfUse Indicates the product requires xsd:Boolean Q See ECL

special quantity consideration. Code
UpperBoundCompa Code that conveys the an S See ECL

risonOperator relationship between the
and a defined upper boundary.
UpperBoundCompa Value for the upper boundary of 9(18) S 18

risonValue the comparison.
UrgencyIndicatorCo Element which indicates the an S See ECL

de sender’s urgency of the
associated message.
987-MA URL The web page address. x(255) F,T 255
898 User Benefit ID Member’s benefit ID based upon x(10) A 10

User Group Number from
Eligibility when submitted by
Client.
899 User Coverage ID Member’s coverage ID based x(10) A 10

upon User Group Number
submitted by Client on eligibility
data.
Username Element in UsernameToken for n/a S, Q

the user. SOAP.
426-DQ Usual and Amount charged cash customers s9(6)v99 T,A,W,Z 8 Format=s$$$$$$cc
Customary Charge for the prescription exclusive of
sales tax or other amounts Examples: If the usual and customary charge is
claimed. $32.56, this field would reflect: 325F.
- 173 -
July 2016
DATA DICTIONARY
VariableAdministrati Used to express when there is an S See ECL

onTimingModifier more than one time as to
whether the times are all
required to be used (AND) or if
any of the times can be used
(OR). (TO) is used if the
Administration Timing provides
for a range.
See ECL
VariableFrequency Used to express when there is an S
Modifier more than one Frequency as to
whether the frequencies are all
any of the frequencies can be
used (OR/TO).
See ECL
VariableIntervalMo Used to express when there is an S
difier more than one Interval as to
whether the intervals are all
any of the intervals can be used
(OR/TO).
See ECL
VariableMeasureme Used to express when there is an S
ntFrequencyModifie more than one Measurement
r Frequency as to whether the
frequencies are all required to be
used (AND) or if any of the
frequencies can be used
(OR/TO).
See ECL
ntIntervalModifier more than one Interval as to
whether the intervals are all
any of the intervals can be used
(OR/TO).
See ECL
ntTimingModifier more than one time as to
whether the times are all
any of the times can be used
(OR). (TO) is used if the
Measurement Timing provides
for a range.
Vehicle The textual representation of an S
- 174 -
July 2016
DATA DICTIONARY
VehicleCode.
VehicleClarifyingFre Used to add clarity to the vehicle x(255) S 255

eText for elements that cannot be
codified.
VehicleCode The code representing the an S Qualified by VehicleQualifier

VehicleText.
VehiclePrepositionC The code representing the an S Qualified by VehiclePrepositionQualifier.

ode VehiclePrepositionText.
VehiclePrepositionQ Qualifier to identify the code an S See ECL

ualifier system being used.
VehiclePrepositionT The textual representation of the x(255) S 255

ext VehiclePrepositionCode.
See ECL
VehicleQualifier Qualifier to identify the code an S
system being used.
VehicleQuantity A volume, expressed in a value. 9(18) S 18
VehicleUnitOfMeas The code representing the an S Qualified by VehicleUnitOfMeasureQualifier.

ureCode VehicleUnitOfMeasureText.
See ECL
VehicleUnitOfMeas Qualifier to identify the code an S
ureQualifier system being used.
VehicleUnitOfMeas The textual representation of an S

ureText VehicleUnitOfMeasureCode.
See ECL
VerifyStatusCode Codes used to relay successful or an S, Q
rejected communications.
Version A version for the Continuity of x(35) Q 35

Care Record (CCR) supported.
A, B, T, F,G, See ECL
102-A2 Version/Release Code uniquely identifying the x(2) N,V,X,E,Y,L,I 2
Number transmission syntax and
corresponding Data Dictionary.
Veterinary Use
A45-1R Indicator To indicate that the prescription x(1) T 1 See ECL
was dispensed for use on
something other than human.
- 175 -
July 2016
DATA DICTIONARY
VitalSign Physical condition identifier. an S See ECL Qualifies the Measurement value.
602-15 Withheld Invoice The Disputed Quantity (601-85) 9(9)v99b R 12 Format=$$$$$$$$$ccb or $$$$$$$$$cc-
Amount times the Paid Per Unit Amount or
(601-95). 9(9)v99- Note:
b = Space
- = Negative sign
x(2)
588 Workers Code identifying whether the W 2 See ECL
Compensation/Prop submission is for Workers'
erty And Casualty Compensation or Property &
Indicator Casualty.
WorkTelephoneExte Extension of the work telephone 9(8) S,Q 8 Format = 99999999

nsion number.
Format=AAAEEENNNN
WorkTelephoneNu Work telephone number of the 9(10) S,Q 10 AAA=Area Code
mber entity. EEE=Exchange Code
NNNN=Number
WorkTelephoneSup Indication the number accepts xsd:Boolean S,Q See ECL

Comment: Decimals allowed. The length of the data

WoundDepth Depth of the wound in x(6) S 6 element includes the decimal point.
centimeters.
WoundLateralityCo Code representing the laterality an S See ECL

de associated with the wound
location.
WoundLateralityTex Textual representation of the an S

t laterality associated with the
wound location. If
WoundLateralityCode is present
this must be the textual
representation of the code.
WoundLength Length of the wound in x(6) S 6 element includes the decimal point.
centimeters.
WoundLocationCod Code representing the location of an S See ECL

e the wound on the body.
- 176 -
July 2016
DATA DICTIONARY
WoundLocationText Textual representation of the an S

location of the wound on the
body. If WoundLocationCode is
present this must be the textual
representation of the code.
WoundWidth Width of the wound in x(6) S 6 element includes the decimal point.
centimeters.
WrittenDate Date or date and time issued. xsd:date or S CC=Century
xsd:datetim YY=Year
e MM=Month
DD=Day
Example: 2010-10-01

CC=Century
YY=Year
MM=Month
DD=Day
T=T
HH=Hour
MM=Minute
SS=Second
Example: 2010-10-01T08:15:22
X509Data Base64 encoded raw bytes of the an S

X509 certificate (which contains
the Public Key). Used by the
receiver to validate the digital
signature.
B60-3J Year of Last Paid Identifies the year used on a 9(4) T 4 Format=CCYY CC=Century YY=Year
Claim previous claim.
ZipCode Code defining international an S,Q

postal zone excluding
- 177 -
July 2016
DATA DICTIONARY
730-TC Zip/Postal Code Code defining international x(15) R,A,V,Y 15 Comments:

postal code excluding
punctuation. When used for US ZIP Code - This left-justified field

Examples:
A0E 3B0
A1L 2T8
- 178 -
July 2016
DATA DICTIONARY
III. Appendix A - NUMERIC CROSS REFERENCE FOR DATA ELEMENTS WITH NUMERIC IDENTIFIERS
(Fields in lowlight have been deleted but are maintained in the numeric cross reference table for historic purposes)
NUMERIC CROSS REFERENCE NUMERIC CROSS REFERENCE
Field Name Of Field Standard Field Name Of Field Standard

Formats Formats
101-A1 BIN Number T,N,Z,E 130-UF Additional Message Information Count T

102-A2 Version/Release Number B,T,F,A,N,V,X,E,Y,L,G, 131-UG Additional Message Information Continuity T
I
132-UH Additional Message Information Qualifier T
103-A3 Transaction Code T,N
133-UJ Amount Attributed to Provider Network Selection T,Y,A
104-A4 Processor Control Number T,N,V,Z,E
134-UK Amount Attributed to Product Selection / Brand Drug T,Y,I,A
109-A9 Transaction Count T,N
135-UM Amount Attributed to Product Selection / Non-Preferred T,Y,A
110-AK Software Vendor/Certification ID T,N Formulary Selection
111-AM Segment Identification T,N 136-UN Amount Attributed to Product Selection / Brand Non- T,Y,A
Preferred Formulary Selection
112-AN Transaction Response Status T,N,E,I
137-UP Amount Attributed to Coverage Gap T,Y,A
113-N3 Medicaid Paid Amount T,G
138-UQ CMS Low Income Cost Sharing (LICS) Level T
114-N4 Medicaid Subrogation Internal Control T,G
Number/Transaction Control Number (ICN/TCN) 139-UR Medicare Part D Coverage Code T
115-N5 Medicaid ID Number T,G 140-US Next Medicare Part D Effective Date T
116-N6 Medicaid Agency Number T,G 141-UT Next Medicare Part D Termination Date T
117-TR Billing Entity Type Indicator T 142-UV Other Payer Person Code T
118-TS Pay To Qualifier T,W 143-UW Other Payer Patient Relationship Code T
119-TT Pay To ID T,W 144-UX Other Payer Benefit Effective Date T
120-TU Pay To Name T,W 145-UY Other Payer Benefit Termination Date T
121-TV Pay To Street Address T,W 146 Pharmacy Dispenser Type Qualifier A
122-TW Pay To City Address T,W 147-U7 Pharmacy Service Type T,R
123-TX Pay to State/ Province Address T,W 148-U8 Ingredient Cost Contracted/ Reimbursable Amount T
124-TY Pay To Zip/Postal Zone T,W 149-U9 Dispensing Fee Contracted/ Reimbursable Amount T
125-TZ Generic Equivalent Product ID Qualifier T 150 Pharmacy Class Code Qualifier A
126-UA Generic Equivalent Product ID T 150-VF Invoiced Amount 1 R
127-UB Other Payer Help Desk Telephone Number T 151-VG Invoiced Amount 2 R
128-UC Spending Account Amount Remaining T,A 152-VH Invoiced Amount 3 R
129-UD Health Plan-funded Assistance Amount T,Y,A 153-VJ Invoiced Amount 4 R
- 179 -
July 2016
DATA DICTIONARY

Formats Formats
154-VK Invoiced Amount 5 R 184-WS Paid Base Price 5 R

155-VL Invoiced Per Unit Amount 1 R 185-WT Paid Per Unit Amount 1 R
156-VM Invoiced Per Unit Amount 2 R 186-WU Paid Per Unit Amount 2 R
157-VN Invoiced Per Unit Amount 3 R 187-WV Paid Per Unit Amount 3 R
158-VP Invoiced Per Unit Amount 4 R 188-WW Paid Per Unit Amount 4 R
159-VQ Invoiced Per Unit Amount 5 R 189-WX Paid Per Unit Amount 5 R
160-VR Invoice Price 1 R 190-WY Paid Quantity 1 R
161-VS Invoice Price 2 R 191-WZ Paid Quantity 2 R
162-VT Invoice Price 3 R 192-XA Paid Quantity 3 R
163-VU Invoice Price 4 R 193-XB Paid Quantity 4 R
164-VV Invoice Price 5 R 194-XC Paid Quantity 5 R
165-VW Invoice Rate 1 R 195-XD Paid Rate 1 R
166-VX Invoice Rate 2 R 196-XF Paid Rate 2 R
167-VY Invoice Rate 3 R 197-XG Paid Rate 3 R
168-VZ Invoice Rate 4 R 198-XH Paid Rate 4 R
169-WA Invoice Rate 5 R 199-XJ Paid Rate 5 R
170-WB Invoice Type 1 R 201-B1 Service Provider ID T,A,R,V,Z,W,X ,J,E,Y,I
171-WC Invoice Type 2 R 202-B2 Service Provider ID Qualifier T,A,R,V,Z,W,X,J,E,Y,I
172-WD Invoice Type 3 R 203 Adjudication Time A,R
173-WF Invoice Type 4 R 204 Adjustment Reason Code A,I
174-WG Invoice Type 5 R 205 Adjustment Type A
175-WH Paid Amount 1 R 206 Administrative Fee Amount A
176-WJ Paid Amount 2 R 207 Administrative Fee Effect Indicator A
177-WK Paid Amount 3 R 208 Age A
178-WL Paid Amount 4 R 209 Average Cost Per Quantity Unit Price A
179-WM Paid Amount 5 R 210 Average Generic Unit Price A
180-WN Paid Base Price 1 R 211 Average Wholesale Unit Price A
181-WP Paid Base Price 2 R 212 Benefit Type A,I
182-WQ Paid Base Price 3 R 213 Billing Cycle End Date A
183-WR Paid Base Price 4 R 214 Cardholder Date of Birth A
- 180 -
July 2016
DATA DICTIONARY

Formats Formats
215 Carrier Number A,I 247 Eligibility/Patient Relationship Code A,Y

216 Check Date A,Y 248 Eligible Coverage Code A
217 Claim Date Received In The Mail A 249 Excess Copay Amount A
218 Claim Media Type A 250 FDA Drug Efficacy Code A
219 Claim Sequence Number A,E 251 Federal Upper Limit Indicator A
220 Client Assigned Location Code A 252 Federal DEA Schedule A,E
221 Client Formulary Flag A 253 Federal Upper Limit Unit Price A
222 Client Pass Through A,I 254 Fill Number Calculated A,Y
223 Client Pricing Basis Of Cost A 255 Formulary Code Type A
224 Client Specific Data A 256 Formulary File ID A
225 COB Carrier Submit Amount A 257 Formulary Status A,I
226 COB Primary Claim Type A 260 Generic Indicator A
228 COB Primary Payer Amount Paid A 261 Generic Name A
229 COB Primary Payer Coinsurance A 263 Health Care Reimbursement Account Amount Applied A
230 COB Primary Payer Copay A 264 Health Care Reimbursement Account Amount Applied A
Remaining
231 COB Primary Payer Deductible A
265 Hold Harmless Amount A
232 COB Primary Payer ID A
266 In Network Indicator A,I
234 COB Secondary Payer Amount Paid A
267 Insurance Code A,I
235 COB Secondary Payer Coinsurance A
268 Internal Mail Order (Prescription/Service) Reference A
236 COB Secondary Payer Copay A Number
237 COB Secondary Payer Deductible A
269 Invoiced Amount A,I
238 COB Secondary Payer ID A
270 Line Of Business Code A
239 Communication Type Indicator A 271 MAC Price A
240-U1 Contract Number A,T,I 272 MAC Reduced Indicator A
241 Copay Modifier ID A
273 Maintenance Drug Indicator A
242 Cost Difference Amount A 274 Medicare Plan Code A
243 Dosage Form Code A 275 Medicare Recovery Dispensing Indicator A
244 Drug Category Code A
276 Medicare Recovery Indicator A
245 Eligibility COB Indicator A
277 Member Submit Amount A
246 Eligibility Group ID A,Y
- 181 -
July 2016
DATA DICTIONARY

Formats Formats
278 Member Submitted Claim Payment Release Date A 310-CA Patient First Name T,V,Z,W,X,G,I
279 Member Submitted Claim Program Code A 311-CB Patient Last Name T,V,Z,W,X,I,G
280 Name Suffix A 312-CC Cardholder First Name T,V,Z
281 Net Amount Due A,Z,W,Y 313-CD Cardholder Last Name T,V,Z,I
282 Non-POS Claim Override Code A 314-CE Home Plan T
283 Original Claim Received Date A 315-CF Employer Name T,W
284 Out Of Pocket Apply Amount A 316-CG Employer Street Address W
285 Patient Medicare Formulary Rebate Amount A 317-CH Employer City Address T,W
286 Patient Spend Down Amount A 318-CI Employer State/Province Address T,W
287 Payment/Reference ID A 319-CJ Employer Zip/Postal Zone T,W
288 Payroll Class A 320-CK Employer Telephone Number T,W
289 Pharmacy Class Code A 321-CL Employer Contact Name T,W
290 Pharmacy Dispenser Type A 322-CM Patient Street Address T,W
291 Plan Benefit Code A 323-CN Patient City Address T,W
292 Plan Cutback Reason Code A 324-CO Patient State/Province Address T,W,I
293 Preferred Alternative File ID A 325-CP Patient Zip/Postal Zone T,W
294 Prescribed Days Supply A 326-CQ Patient Phone Number T,W
295 Prescriber Certification Status A 327-CR Carrier ID T
296 Prescriber Taxonomy Code A 330-CW Alternate ID T
297 Prescription Over The Counter Indicator A 331-CX Patient ID Qualifier T,A,V,W,X
299 Processor Defined Prior Authorization Reason Code A 332-CY Patient ID T,A,V,W,X,Y,I
301-C1 Group ID R,T,A,N,V,Z,X,E,I 333-CZ Employer ID T
302-C2 Cardholder ID T,A,N,V,Z,X,Y,I 334-1C Smoker/Non-Smoker Code T,V
303-C3 Person Code R,T,A,N,V,Z,X,Y,I 335-2C Pregnancy Indicator T,V
304-C4 Date Of Birth T,A,V,Z,W,X,Y,L,I 336-8C Facility ID T,A,V
305-C5 Patient Gender Code T,A,V,Z,W,X,Y,I 337-4C Coordination Of Benefits/Other Payments Count T
306-C6 Patient Relationship Code T,A,V,Z,X,I 338-5C Other Payer Coverage Type T
307-C7 Place of Service T,Z,J,A 339-6C Other Payer ID Qualifier T,V,Z,W
308-C8 Other Coverage Code T,A,R,Z,W 340-7C Other Payer ID T,V,Z,W
309-C9 Eligibility Clarification Code T,A 341-HB Other Payer Amount Paid Count T
- 182 -
July 2016
DATA DICTIONARY

Formats Formats
342-HC Other Payer Amount Paid Qualifier T 373-2U Request Status T

343-HD Dispensing Status T,A,R 374-2V Request Period Begin Date T
344-HF Quantity Intended To Be Dispensed T,A 375-2W Request Period Recert/Revised Date T
345-HG Days Supply Intended To Be Dispensed T,A 376-2X Supporting Documentation T
346-HH Basis of Calculation-Dispensing Fee T,A 377-2Z Question Number/Letter Count T
347-HJ Basis of Calculation-Copay T,A 378-4B Question Number/Letter T
348-HK Basis of Calculation-Flat Sales Tax T,A 379-4D Question Percent Response T
349-HM Basis Of Calculation-Percentage Sales Tax T,A 380-4G Question Date Response T
350-HN Patient E-Mail Address T,V 381-4H Question Dollar Amount Response T
351-NP Other Payer-Patient Responsibility Amount Qualifier T,A 382-4J Question Numeric Response T
352-NQ Other Payer-Patient Responsibility Amount T,A,Z,W 383-4K Question Alphanumeric Response T
353-NR Other Payer-Patient Responsibility Amount Count T 384-4X Patient Residence T,V,A
354-NX Submission Clarification Code Count T 385-3Q Facility Name T,V
355-NT Other Payer ID Count T,V 387-3V Facility State/Province Address T
356-NU Other Payer Cardholder ID T 388-5J Facility City Address T
357-NV Delay Reason Code T,Z,W 389-6D Facility Zip/Postal Zone T
359-2A Medigap ID T 390-BM Narrative Message T
360-2B Medicaid Indicator T 391-MT Patient Assignment Indicator (Direct Member T
Reimbursement Indicator)
361-2D Provider Accept Assignment Indicator T
392-MU Benefit Stage Count T
362-2G Compound Ingredient Modifier Code Count T
393-MV Benefit Stage Qualifier T,R,A
363-2H Compound Ingredient Modifier Code T
394-MW Benefit Stage Amount T,A
364-2J Prescriber First Name T,W
395 Processor Payment Clarification Code A
365-2K Prescriber Street Address T,W
Prescriber City Address 396 Processor Specific Data A
366-2M T,W
Prescriber State/ Province Address 397 Product/Service Name A,Y,I
367-2N T,W
398 Record Indicator A
368-2P Prescriber Zip/Postal Zone T,W
399 Record Status Code A,Y
369-2Q Additional Documentation Type ID T
401-D1 Date Of Service R,T,A,V,Z,W,J,E,Y,I
370-2R Length of Need T
402-D2 Prescription/Service Reference Number R,T,A,V,Z,W,X,J,E
371-2S Length of Need Qualifier T
403-D3 Fill Number T,A,R,V,Z,W,J,E
372-2T Prescriber/Supplier Date Signed T
- 183 -
July 2016
DATA DICTIONARY

Formats Formats
405-D5 Days Supply R,T,A,V,Z,W,X,Y,I 441-E6 Result Of Service Code T,A,Z,W

406-D6 Compound Code T,A,R,V,Y 442-E7 Quantity Dispensed T,A,V,Z,W,Y,I
407-D7 Product/Service ID T,F,A,R,V,Z,W,X,J,Y,E, 443-E8 Other Payer Date T,Z,W
I
444-E9 Provider ID T,Z
408-D8 Dispense As Written (DAW)/Product Selection Code R,T,A,V,Z,W,Y,I
445-EA Originally Prescribed Product/Service Code T,V
409-D9 Ingredient Cost Submitted T,A,Z,W
446-EB Originally Prescribed Quantity T
411-DB Prescriber ID R,T,A,V,Z,W,X, J,Y ,E
447-EC Compound Ingredient Component Count T,Z,W,A
412-DC Dispensing Fee Submitted T,Z,W
448-ED Compound Ingredient Quantity T,A,Z,W
414-DE Date Prescription Written T,A,V,Z,W
449-EE Compound Ingredient Drug Cost T,A,Z,W
415-DF Number Of Refills Authorized T,A,V
450-EF Compound Dosage Form Description Code T,Z,W
418-DI Level Of Service T,A
451-EG Compound Dispensing Unit Form Indicator T,Z,W
419-DJ Prescription Origin Code T,A,R,W,Z
452-EH Compound Route of Administration A
420-DK Submission Clarification Code T,A,Z,W,E
453-EJ Originally Prescribed Product/Service ID Qualifier T,V
421-DL Primary Care Provider ID T,A
454-EK Scheduled Prescription ID Number T
423-DN Basis Of Cost Determination T,Z,W
455-EM Prescription/Service Reference Number Qualifier T,A,R,Z,W,X,J,E
424-DO Diagnosis Code R,T,F,A,Z,J
456-EN Associated Prescription/Service Reference Number T,A
425-DP Drug Type A,X,Y
457-EP Associated Prescription/Service Date T,A
426-DQ Usual And Customary Charge T,A,Z,W
458-SE Procedure Modifier Code Count T
427-DR Prescriber Last Name T,Z,W
459-ER Procedure Modifier Code T,Z,W
429-DT Special Packaging Indicator T,A
460-ET Quantity Prescribed T,A,V
430-DU Gross Amount Due T,A,Z,W,Y,I
461-EU Prior Authorization Type Code T,A,Z,W
431-DV Other Payer Amount Paid T,Z,W
462-EV Prior Authorization Number Submitted T,Z,W
433-DX Patient Paid Amount Submitted T,Z,W
462-EV Prior Authorization ID Submitted A,V,X
434-DY Date Of Injury T,A,W
463-EW Intermediary Authorization Type ID T
435-DZ Claim/Reference ID T,A,W
464-EX Intermediary Authorization ID T
436-E1 Product/Service ID Qualifier T,F,A,R,V,Z,W,X,J,Y
,E,I 465-EY Provider ID Qualifier T,Z
438-E3 Incentive Amount Submitted T 466-EZ Prescriber ID Qualifier T,A,R,V,Z,W,X,J,Y,E

468-2E Primary Care Provider ID Qualifier T,A
439-E4 Reason For Service Code T,A,Z,W
470-4E Primary Care Provider Last Name T
440-E5 Professional Service Code T,A,Z,W
471-5E Other Payer Reject Count T
- 184 -
July 2016
DATA DICTIONARY

Formats Formats
472-6E Other Payer Reject Code T,Z,W 498-PE Authorized Representative First Name T
473-7E DUR/PPS Code Counter T 498-PF Authorized Representative Last Name T
474-8E DUR/PPS Level Of Effort T,A,Z,W 498-PH Authorized Representative City Address T
475-J9 DUR Co-Agent ID Qualifier T,A 498-PJ Authorized Representative State/Province Address T
476-H6 DUR Co-Agent ID T,A 498-PK Authorized Representative Zip/Postal Zone T
477-BE Professional Service Fee Submitted T,A 498-PM Prescriber Telephone Number T,W
478-H7 Other Amount Claimed Submitted Count T 498-PP Prior Authorization Supporting Documentation T
479-H8 Other Amount Claimed Submitted Qualifier T 498-PR Prior Authorization Processed Date T
480-H9 Other Amount Claimed Submitted T,Z,W 498-PS Prior Authorization Effective Date T,X
481-HA Flat Sales Tax Amount Submitted T,Z,W 498-PT Prior Authorization Expiration Date T,X
482-GE Percentage Sales Tax Amount Submitted T,Z,W 498-PW Prior Authorization Number Of Refills Authorized T,X
483-HE Percentage Sales Tax Rate Submitted T 498-PX Prior Authorization Quantity Accumulated T,X
484-JE Percentage Sales Tax Basis Submitted T 498-PY Prior Authorization Number-Assigned T
485-KE Coupon Type T 498-PY Prior Authorization ID Assigned X,A
486-ME Coupon Number T 498-RA Prior Authorization Quantity T,X
487-NE Coupon Value Amount T 498-RB Prior Authorization Dollars Authorized T
488-RE Compound Product ID Qualifier T,A,Z,W 499-H4 Measurement Value T
489-TE Compound Product ID T,A,Z,W 501-F1 Header Response Status T,N,E
490-UE Compound Ingredient Basis Of Cost Determination T,A,Z,W 503-F3 Authorization Number T,A,N,E
491-VE Diagnosis Code Count T 504-F4 Message B,T,N,E,Y,I
492-WE Diagnosis Code Qualifier T,F,A,Z,J 505-F5 Patient Pay Amount T,A,Y,I
493-XE Clinical Information Counter T 506-F6 Ingredient Cost Paid T,A,Y
494-ZE Measurement Date T 507-F7 Dispensing Fee Paid T,A,Y
495-H1 Measurement Time T 509-F9 Total Amount Paid T,E,I
496-H2 Measurement Dimension T 510-FA Reject Count B,T,N
497-H3 Measurement Unit T 511-FB Reject Code T,F,A,N,V,E,I
498-PA Request Type T 512-FC Accumulated Deductible Amount T,A
498-PB Request Period Date-Begin T 513-FD Remaining Deductible Amount T,A
498-PC Request Period Date-End T 514-FE Remaining Benefit Amount T,A
498-PD Basis Of Request T 516-FG Drug Description R,V
- 185 -
July 2016
DATA DICTIONARY

Formats Formats
517-FH Amount Applied To Periodic Deductible T,A,Y 559-AX Percentage Sales Tax Amount Paid T,A,Y
518-FI Amount Of Copay/Coinsurance T,A,Y,I 560-AY Percentage Sales Tax Rate Paid T,A
519-FJ Amount Attributed To Product Selection A,Y 561-AZ Percentage Sales Tax Basis Paid T,A
520-FK Amount Exceeding Periodic Benefit Maximum T,A,Y 562-J1 Professional Service Fee Paid T,A,Y
521-FL Incentive Amount Paid T,A,Y 563-J2 Other Amount Paid Count T
522-FM Basis Of Reimbursement Determination T,A 564-J3 Other Amount Paid Qualifier T,A,Y
523-FN Amount Attributed To Sales Tax T,A,Y,I 565-J4 Other Amount Paid T,A,Y
524-FO Plan ID T 566-J5 Other Payer Amount Recognized T,A
526-FQ Additional Message Information T,F,N,V,X 567-J6 DUR/PPS Response Code Counter T
528-FS Clinical Significance Code T 568-J7 Payer ID Qualifier T,V
529-FT Other Pharmacy Indicator T 569-J8 Payer ID T,V,Y
530-FU Previous Date Of Fill T,X 570-NS DUR Additional Text T
531-FV Quantity Of Previous Fill T 571-NZ Amount Attributed to Processor Fee T,A,Y,I
532-FW Database Indicator T,A 572-4U Amount of Coinsurance T,A,Y
533-FX Other Prescriber Indicator T 573-4V Basis of Calculation – Coinsurance T,A
544-FY DUR Free Text Message T 574-2Y Plan Sales Tax Amount T
545-2F Network Reimbursement ID T,A 575-EQ Patient Sales Tax Amount T
546-4F Reject Field Occurrence Indicator T 577-G3 Estimated Generic Savings T
547-5F Approved Message Code Count T 578 Adjudication Date A,R,J,Y
548-6F Approved Message Code T,E 579-XX Associated Prescription/Service Provider ID Qualifier T
549-7F Help Desk Telephone Number Qualifier T 580-XY Associated Prescription/Service Provider ID T
550-8F Help Desk Telephone Number T 581-XZ Associated Prescription/Service Reference Number T
Qualifier
551-9F Preferred Product Count T
582-X0 Associated Prescription/Service Fill Number T
552-AP Preferred Product ID Qualifier T
583-YK Service Provider Name T
553-AR Preferred Product ID T
585-YN Service Provider City Address T
554-AS Preferred Product Incentive T
586-YP Service Provider State/Province Code Address T,J
555-AT Preferred Product Copay Incentive T
587-YQ Service Provider Zip/Postal Code T
556-AU Preferred Product Description T
588 Workers' Compensation/Property And Casualty Indicator W
557-AV Tax Exempt Indicator T,A
589 Date of Billing W
558-AW Flat Sales Tax Amount Paid T,A,Y
- 186 -
July 2016
DATA DICTIONARY

Formats Formats
590-YT Seller Initials T 600-71 Contracting Organization (PMO) ID Qualifier R,J

591-YU Purchaser ID Qualifier T 600-72 Manufacturer (PICO) ID Qualifier R,J
592-YV Purchaser ID T 600-73 Formulary Benefit Design Type R
593-YW Purchaser ID Associated State/Province Code T 600-74 Formulary Code R,J
594-YX Purchaser Date of Birth T 600-75 Formulary Description R
595-YY Purchaser Gender Code T 600-76 Formulary Non-Formulary Co-Pay Confidential R
596-YZ Purchaser First Name T 600-77 Formulary Product Co-Pay Amount R
597-Y0 Purchaser Last Name T 600-78 Generic Product Co-Pay Amount R
599-Y2 Purchaser City Address T 00
600-28 Unit Of Measure R,T,A,W,J 000
600-38 Rebate Period Start Date R,J 00
600-39 Rebate Period End Date R,J 00
600-43 Contracting Organization (PMO) Name R,J 600-83 Membership Count Qualifier R
600-47 Manufacturer (PICO) Contract Number RJ 00
600-48 Manufacturer (PICO) ID Code R,J 00
600-50 Manufacturer (PICO) Name R,J 600-86 Membership Period Qualifier R
00 600-87 Membership Reporting Period Start Date R
00 600-88 Membership Total Count R
00 600-89 Membership Type Qualifier R
600-60 Branded Generic Co-Pay Confidential R 600-90 Non-Formulary Product Co-Pay Amount R
600-61 Branded Product Co-Pay Amount R 00
00 00
600-63 Change Date R 00
600-64 Change Identifier R,F 600-94 Plan ID Code R,J
600-65 Contracting Organization (PMO) Contract Number R,J 600-95 Plan ID Qualifier R,J
600-66 Contracting Organization (PMO) ID Code R,J 600-96 Plan Name R,Z,J
600-67 Contracting Organization (PMO) Total Lives Covered R 00
00 00
600-69 Eligible Plan R 00
000 601-01 Plan Type R,A
- 187 -
July 2016
DATA DICTIONARY

Formats Formats
00 601-32 Data Provider ID Code R,J

601-03 Rebate Version Release Number R 601-33 Data Provider Name R,J
601-04 Record Type R,F,A,V,X,J,E,Y,L,I 0
601-05 Reporting Period End Date R,A,Y 601-35 Encrypted Patient ID Code R,J
601-06 Reporting Period Start Date R,A,Y 601-36 Submit Code R,J
601-07 Start Date R 601-37 Data Provider ID Qualifier R,J
601-08 Total Number Of Plans R 601-39 Total Quantity R,J
601-09 Total Record Count R,A,V,X,J,L 601-40 Total Number Of Prescriptions R
601-10 Transmission Date R,F,J,E,I 601-41 Grand Total Quantity R,J
0 601-42 Grand Total Requested Amount R,J
601-12 Cost Index Point High Value R 601-43 Line Number R,J
601-13 Cost Index Point Low Value R 601-44 Patient Liability Amount R,V,J
601-14 Dollar Sign Rating R 601-47 Reimbursement Amount R
601-15 Formulary Manager Company Name R 601-48 Reimbursement Qualifier R
601-16 Formulary Manager Person Name R 601-49 Prescription Type R,J
601-17 Formulary Product Co-Pay Confidential R 601-50 Rebate Batch Number R
601-18 Product Code A,X 601-51 Rebate Days Supply R
601-19 Product Code Qualifier A,X 601-52 Rebate Per Unit Amount R
601-20 Product Description R,V,Z,W,J 601-53 Record Purpose Indicator R,J
601-21 Product Dosage Form R,V 601-54 Reimbursement Date R,J
601-22 Product Formulary Status Code R 601-55 Requested Rebate Amount R,J
601-23 Product Generic Name R 601-56 Transmission Control Number R,F
601-24 Product Strength R,A,V,W 601-58 Product Daily Consumption R
601-25 Therapeutic Class Code R,A,J,I 601-59 Numerator Indicator R
601-26 Therapeutic Class Code Qualifier R,A,J,I 00
601-27 Therapeutic Class Description R,J 601-61 Market Basket Termination Date R
601-28 Therapeutic Use Code R 601-62 Market Basket Start Date R
601-29 Therapeutic Use Description R 601-63 Market Basket Description R
601-30 Total Number Of Formularies R 601-64 Contracting Organization (PMO) Market Basket Code R
601-31 Data Level R,J 601-65 Manufacturer (PICO) Market Basket Code R
- 188 -
July 2016
DATA DICTIONARY

Formats Formats
0 602-12 Reconciliation Transmission Control Number R

0 602-13 Revised Invoice Amount R
601-68 Claim Number R,J 0
0 602-15 Withheld Invoice Amount R
601-70 Adjusted Rebate Per Unit R 603-MY Address Count V
601-71 Adjusted Quantity R 604-NA Address Qualifier V
601-72 Adjusted Variance Difference R 605-NB Client Name V,X
601-73 Amount Paid This Transaction R 606-NC Discontinue Date Qualifier V
601-80 Current Amount Paid To Date R 607-ND Discontinue Date V
601-81 Current Rebate Per Unit R 608-NF Easy Open Cap Indicator V
601-82 Current Units Disputed To Date R 609-NG Effective Date V
601-83 Current Units Paid To Date R 610-NH Expiration Date V
601-84 Current Units To Date R 611-NJ File Structure Type V
601-85 Disputed Quantity R 612-NK Inactive Prescription Indicator V
601-86 Accepted Quantity R 613-NM Label Directions V
601-87 Grand Total Accepted Quantity R 614-NW Most Recent Date Filled V
601-88 Grand Total Paid Amount R 615-NY Number Of Fills To Date V
0 616-PU Number Of Fills Remaining V
601-92 Original Amount Invoiced R 617-RQ Original Dispensed Date V
601-93 Original Rebate Per Unit R 618-RR Patient ID Qualifier Count V
601-94 Original Units Invoiced R 619-RW Prescribed Product Description V
601-95 Paid Per Unit Amount R 620-RX Prescriber ID Count V
601-96 Paid Rebate Amount R 621-RY Prescriber Specialty V
602-01 Prior Amount Paid R 622-RZ Prescriber Specialty Count V
602-02 Prior Units Disputed R 623-SA Quantity Dispensed To Date V
602-03 Prior Units Paid R 624-SB Record Delimiter V
602-08 Reconciliation Error Description R 625-SC Remaining Quantity V
602-09 Reconciliation Line Number R 626-SD Sender Name V,X
602-10 Reconciliation Reason Code R 627-SF Sending Pharmacy ID V
602-11 Reconciliation Status Code R 628-SG Telephone Number Count V
- 189 -
July 2016
DATA DICTIONARY

Formats Formats
629-SH Telephone Number Qualifier V 658-T6 Prior Authorization Form Title F

630-SJ Total Number Of Sending And Receiving Pharmacy V 659-T7 Prior Authorization Question Code F
Records
660-T8 Prior Authorization Question Code Qualifier F
631-SK Transfer Flag V
661-T9 Prior Authorization Question Sequence F
632-SM Transfer Type V
662-V1 Prior Authorization Question Number F
633-SN Package Acquisition Cost V
663-V2 Prior Authorization Applicability F
634-SP Unique Record Identifier V
664-V3 Prior Authorization Required Question F
635-SQ Unique Record Identifier Qualifier V
665-V4 Prior Authorization Response Type F
636-TD Pharmacist Initials V
666-V5 Prior Authorization Question Text F
637-TF Technician Initials V
667-V6 Prior Authorization Basis Question Sequence Number F
638-XK Segment 1 R,J
668-V7 Prior Authorization Comparison Type F
639-XL Segment 2 R,J
669-V8 Prior Authorization Basis Value F
640-XM Segment 3 R,J
670-V9 Prior Authorization Answer Value F
641-XN Segment 4 R,J
671-W1 Bed V
642-XP Segment 5 R,J
672-W2 Facility Unit V
643-XQ Segment 6 R,J
673-W3 Hours Of Administration V
644-XR Segment Qualifier 1 R,J
674-W4 Room V
645-XS Segment Qualifier 2 R,J
675-Y3 Purchaser State/Province Address T
646-XT Segment Qualifier 3 R,J
676-Y4 Purchaser Zip/Postal Code T
647-XU Segment Qualifier 4 R,J
677-Y5 Purchaser Country Code T
648-XV Segment Qualifier 5 R,J
678-Y6 Time of Service T
649-XW Segment Qualifier 6 R,J
679-Y9 Seller ID T
650-S1 Accumulator Year N
680-ZB Seller ID Qualifier T
651-S2 Transaction Identifier N
681-ZF Sales Transaction ID T
652-S3 Accumulated Patient True Out Of Pocket Amount N
682 Document Control Number Z,W
653-S4 Accumulated Gross Covered Drug Cost Amount N
683 Jurisdictional State W
654-S5 DateTime N
685 Pay To Phone Number W
655-S6 Accumulator Month N
686 Brand/Generic Indicator W,I
656-S7 Accumulator Month Count N
687 Generic Available W
657-T5 Prior Authorization Form ID F
688 Jurisdictional Field (1-5) W
- 190 -
July 2016
DATA DICTIONARY

Formats Formats
689 Compound Ingredient Product Name Z,W 783 Entity Telephone Number E
690-ZG Invoiced Date A 784 Entity Zip/Postal Code R,J,E
691-ZH Out Of Pocket Remaining Amount A 785-SV Family ID Number V,I
692-ZJ Number Of Generic Manufacturers A 806-5C Batch Number B,A,V,X,I
693 Total Gross Amount Due A 807-1D Carrier Address W
694 Total Patient Pay Amount A 809-1F Carrier Location City W
701 Segment Identifier B 810-1G Carrier Location State/Province Address W
702-MC File Type A,B,F,V,X,I 811-1H Carrier Name W
711 Action Code I 813-1J Carrier Zip/Postal Code W
713 Termination Date R 818-5F Destination Name V
716-SY Last Name A,V,X,Y,L 829-5L Pharmacy Address Z,W
717-SX First Name A,V,X,Y,L 831-5N Pharmacy Location City Z,W
718-SZ Middle Initial A,V,X,Y,L,I 832-6F Pharmacy State/Province Address Z,W
721-MD Gender Code F,A 833-5P Pharmacy Name A,V,Z,W,Y
724-ST Alternate ID Number V,X 834-5Q Pharmacy Telephone Number Z,W
726-SR Address Line 1 R,A,V 835-5R Pharmacy Zip/Postal Code Z,W
727-SS Address Line 2 R,A,V 839-5V Processor Name V
728-SU City R,A,V,Y 878 Reject Override Code A
729-TA State/Province Address R,A,V,Y 879-N2 Sending Entity Identifier A,V,E,Y,L
730-TC Zip/Postal Code R,A,V,Y 880-K1 Sender ID B,F,L,I
732-TB Telephone Number A,V,X,L 880-K2 Creation Date B,A,V,X,Y,L,I
751-M9 Record Count B,F,V,E,I 880-K3 Creation Time B,A,V,X,L,I
757-U6 Benefit ID A,T 880-K4 Text Indicator B,V
759 Benefit Termination Date I 880-K5 Transaction Reference Number B,T
761 Benefit Effective Date I 880-K6 Transmission Type B,E,I
776 Entity Address Line 1 E 880-K7 Receiver ID B,F,A,V,E,I
777 Entity Address Line 2 E 886 Service Provider Chain Code A,E
778 Entity City E 887 Service Provider County Code A
780 Entity Name E 888 Submission Number A,E,I
782 Entity State/Province Address E 889 Therapeutic Chapter A
- 191 -
July 2016
DATA DICTIONARY

Formats Formats
894 Total Amount Paid By All Sources A 927-FP Formulary Status F

895 Total Net Amount Due A 928-FR List Action F
896 Transaction ID A,I 929-FZ List Effective Date F
897 Transaction ID Cross Reference A,I 930-F2 Load Status F
898 User Benefit ID A 931-F8 Maximum Age Qualifier F
899 User Coverage ID A 932-GA Maximum Age F
900-BN Absolute Row Number F 933-GB Maximum Amount F
901-BP Alternatives ID F 934-GC Maximum Amount Qualifier F
903-BR Class ID ---Step Drug F 935-GF Maximum Amount Time Period F
906-BU Copay ID F 936-GG Maximum Amount Time Period Start Date F
907-BV Copay List ID F 937-GH Maximum Amount Time Period End Date F
908-BW Copay List Type F 938-GJ Maximum Amount Time Period Units F
909-BX Copay Tier F 939-GK Maximum Copay F
910-BY Coverage ID F 940-GM Maximum Copay Tier F
911-BZ Coverage List ID F 941-GN Message - Long F
912-B3 Coverage List Type F 942-GP Message -Short F
913-B4 Data In Error F 943-GQ Minimum Age Qualifier F
914-B5 Drug Qualifier-Step Drug F 944-GR Minimum Age F
915-B6 Drug Reference Number F 945-GS Minimum Copay F
916-B7 Drug Reference Qualifier F 946-GT Non-Listed Prescription Brand Formulary Status F
917-B8 Drug Reference Number -Alternative F 947-GU Non-listed Prescription Generic Formulary Status F
918-B9 Drug Reference Qualifier -Alternative F 948-GV Non-listed Brand Over The Counter Formulary Status F
919-CS Drug Reference Number -Source F 949-GW Non-listed Generic Over The Counter Formulary Status F
920-CT Drug Reference Qualifier -Source F 950-GX Non-listed Supplies Formulary Status F
921-CU Drug Reference Number -Step Drug F 951-GY Number of Drugs To Try F
922-CV Drug Reference Qualifier -Step Drug F 952-GZ Out of Pocket Range Start F
923-DD Extract Date F 953-HP Out of Pocket Range End F
924-DH First Copay Term F 954-HQ Percent Copay Rate F
925-ES Flat Copay Amount F 955–HR Pharmacy Type F
926-FF Formulary ID F,T 956-HS Preference Level F
- 192 -
July 2016
DATA DICTIONARY

Formats Formats
957-HT Product Name -Health Plan F 990-MG Other Payer BIN Number T
958-HU Product/Service ID - Alternative F 991-MH Other Payer Processor Control Number T,V
959-HV Product/Service ID Qualifier - Alternative F 992-MJ Other Payer Group ID T
960-HW Product/Service ID - Step Drug F 993-A7 Internal Control Number T,Y
961-HX Product/Service ID Qualifier -Step Drug F 995-E2 Route of Administration T,Z,W,A
962-HY Product/Service ID - Source F 996-G1 Compound Type T
963-HZ Product/Service ID Qualifier -Source F 997-G2 CMS Part D Defined Qualified Facility T
964-JA Product Type F A00 Benefit Amount X
966-JC Relative Cost F A01 Benefit Amount Time Period X
967-JD Relative Cost Limit F A02 Benefit Amount Type X
968-JF Resource Link Type F A03 Benefit Amount Used To-Date X
969-JG RxNorm Code F A04 Claim Cost Ceiling Override Amount X
970-JH RxNorm Qualifier F A05 Claim Origination X
971-JJ Section Column In Error F A06 Compound Indicator X
972-JK Source Name F A07 Copay/Coinsurance Override Amount X
973-JM Sender Participant Password F A08 Copay/Coinsurance Override Type X
974-JN Step Order F A09 Copay Conjunction Sequence X
976-JQ Subclass ID- Step Drug F A10 Days Supply Used to Date X
978-JS Total Records F,Y A11 Dispense As Written (DAW) Difference X
979-JT Total Errors F A12 Dosage Per Day X
980-JU Total Rows In Error F A13 Fills/Refills Used To-Date X
981-JV Transmission Action F,A A14 Prescriber Override Type X
982-JW Transmission Date - Originating F A15 Prior Authorization Create Date X
983-JX Transmission Number - Originating F A16 Prior Authorization Number of Fills Authorized X
984-JY Transmission Time F,i A17 Prior Authorization Reason Code X
985-JZ Transmission Time - Originating F A18 Prior Authorization Update Date X
986-KJ Transmission File Type F,E,I A19 Receiver Name X
987-MA URL F,T A20 Service Provider Override Type X
988-MB Days Supply Per Copay F A21 Subgroup ID X
989-MF Formulary Name F A22-YR Patient ID Associated State/Province Address T
- 193 -
July 2016
DATA DICTIONARY

Formats Formats
A23-YS Purchaser Relationship Code T A55 Audit Range Start E

A24-ZK Prescriber ID Associated State/Province Address T A56 Audit Range End E
A25-ZM Prescriber Alternate ID Qualifier T A57 Audit Element Type 1 E
A26-ZP Prescriber Alternate ID T A58 Audit Element Type 2 E
A27-ZQ Prescriber Alternate ID Associated State/ Province T A59 Audit Element Type 3 E
Address
A60 Audit Element Type 4 E
A28-ZR Adjudicated Payment Type T
A61 Audit Element Type 5 E
A29-ZS Reported Payment Type T
A62 Audit Element Response 1 E
A30-ZT Released Date T
A31-ZU Released Time T
A32-ZW Compound Preparation Time T
A33-ZX CMS Part D Contract ID N
A34-ZY Medicare Part D Plan Benefit Package (PBP) N
A67 Billing Sequence E
A35 Health Care ID Card Qualifier Code H
A68 Discrepancy Code 1 E
A36 Card Purpose Code H
A37 Specialty Claim Indicator A
A38 Member Submitted Claim Reject Code A
A71 Discrepancy Message E
A39 Copay Waiver Amount A
A72 Discrepancy Amount E
A43-1K Patient Country Code T
A73 Medicare Drug Coverage Code A
A44-ZL Original Dispensed Quantity V
A74 Allowed Amount J
A45-1R Veterinary Use Indicator T
A75 Billed Amount J
A46-1S Text Message Type F
A76 J Code J
A47 Audit Request Type E
A77 J Code Modifier 1 J
A48 Audit Control Identification E
A49 Audit Sponsor E
A50 Requested Response Date E
A51 Estimated Arrival Time Description E
A81 Medical Rebate Version Release Number J
A52 Entity Email E
A82 Plan Reimbursed Amount J
A53 Entity Fax Number E
A83 Quarterly Member Indicator J
A54 Audit Range Qualifier E
A84 Formulary Start Date R
- 194 -
July 2016
DATA DICTIONARY

Formats Formats
A85 Formulary Termination Date R B17-7H Employer Contact First Name T

A86 Plan Eligibility Start Date R B18-7J Employer Contact Last Name T
A87 Plan Eligibility Termination Date R B19-7K Employer Telephone Number Extension T
A88 Claim Processed Code Y B20-7M Facility Street Address Line 1 T
A89 Encrypted Social Security Number Y B21-7N Facility Street Address Line 2 T
A90 Insurance Type/Product Code Y B22-7P Help Desk Telephone Number Extension T
A91 Line Counter Y B23-7Q Other Payer Help Desk Telephone Number Extension T
A92 Middle Name Y B24-7R Pay To Street Address Line 1 T
A93-1T Service Provider Country Code Y,T,J,A B25-7S Pay To Street Address Line 2 T
A94 Type Of File Y B26-7T Prescriber Telephone Number Extension T
A95 Application ID L B27-7U Prescriber Street Address Line 1 T
A97 Gross Retiree Cost L B28-7V Prescriber Street Address Line 2 T
A98 Limit Reduction L B29-7W Purchaser Street Address Line 1 T
A99 Qualified Covered Retiree HICN L B30-7X Purchaser Street Address Line 2 T
B01 Qualified Covered Retiree SSN L B31-7Y Service Provider Street Address Line 1 T
B02 Threshold Reduction L B32-7Z Service Provider Street Address Line 2 T
B03 Unique Benefit Option Identifier L B33-6G Professional Service Fee Contracted/Reimbursement T
Amount
B04 Next Available Fill Date T
B34-1U Authorized Representative Country Code T
B05 Entity Contact First Name E
B35-1V Employer Country Code T
B06 Entity Contact Last Name E
B36-1W Entity Country Code E,J,V,Y,A
B07 Entity Telephone Number Extension E
B37-1X Facility Country Code T
B08-7A Patient Street Address Line 1 T,G
B38-1Y Patient ID Associated Country Code T
B09-7B Patient Street Address Line 2 T,G
B39-1Z Pay to Country Code T
B10-8A Telephone Number Extension A,V,X,L
B40-3A Prescriber Alternate ID Associated Country Code T
B11 Contact Person First Name L
B41-3B Prescriber ID Associated Country Code T
B12 Contact Person Last Name L
B42-3C Prescriber Country Code T
B13-7D Authorized Representative Street Address Line 1 T
B43-3D Purchaser ID Associated Country Code T
B14-8B Authorized Representative Street Address Line 2 T
B44-8G Intermediary ID Count T
B15-8D Employer Street Address Line 1 T
B16-7G Employer Street Address Line 2 T
- 195 -
July 2016
DATA DICTIONARY

Formats Formats
B45-8H Intermediary ID Type Code T B70 Accumulator Balance Qualifier I

B46-8J Intermediary ID Type Entity T B71 Accumulator Balance Count I
B47-8K Intermediary ID Qualifier T B72 Accumulator Benefit Period Amount I
B48-8M Intermediary ID T B73 Accumulator Change Source Code I
B49-8N Intermediary ID State/Province Address T B74 Accumulator Network Indicator I
B50-8P Intermediary ID Relationship Code T B75 Accumulator Reference Time Stamp I
B51-8Q Intermediary Message T B76 Accumulator Remaining Balance I
B52-8R Response Intermediary Authorization Count T B77 Accumulator Specific Category Type I
B53-8S Response Intermediary Authorization Type ID T B78 Document Reference Identifier I
B54-8T Response Intermediary Authorization ID T B79 Document Reference Identifier Qualifier I
B55-8U Intermediary ID Country Code T B80 Optional Data Indicator I
B56-3E Last Known BIN Number T B81 Penalty Amount I
B57-3F Last Known Processor Control Number T B82 Processor Routing Identification I
B58-3G Last Known Group ID T B83 Record Length I
B59-3H Last Known Cardholder ID T B84 Sender Reference Number I
B60-3J Year of Last Paid Claim T B85 Transmission ID I
B61-3K Month of Last Paid Claim T B87-3P Quantity Limit Per Specific Time Period Count T
B62-1M Alternatives Group ID F B88-3R Quantity Limit Per Specific Time Period T
B63-1N Alternatives List Type F B89-3S Quantity Limit Time Period T
B64-1P Step Medications Group ID F B90-3T Days Supply Limit Per Specific Time Period Count T
B65-3M Minimum Drugs Per Step Group F B91-3W Days Supply Limit Per Specific Time Period T
B66-3N Maximum Drugs Per Step Group F B92-3X Days Supply Limit Time Period T
B67 Accumulator Action Code I B93-3Y List Expiration Date F
B68 Accumulator Applied Amount I B94 Cardholder Type Code H
B69 Accumulator Balance Benefit Type I B98 Reconciliation ID T
IV. Appendix B – CROSS REFERENCE OF FIELDS USED IN NCPDP SCRIPT TO THE MODEL-DRIVEN SCHEMAS
This cross-reference table contains fields used in previous versions of NCPDP SCRIPT Standard that used four-digit field identifiers (Old Field ID). The fields are cross-
referenced to the XML name in current versions of NCPDP SCRIPT.
- 196 -
July 2016
DATA DICTIONARY
Old Field EDI Field Name New Field Name Old Field EDI Field Name New Field Name
ID ID
7944 Administration Timing Code AdministrationTimingCode ADMINISTRATION COMPOSITE
7943 Administration Timing Code Qualifier AdministrationTimingCodeQualifier 4711 Condition/Response, coded - Patient Consent Consent
7942 Administration Timing Text AdministrationTimingText Indicator
S036 ADVERSE EVENT DATE COMPOSITE EffectiveDate 3229 Country Sub-entity Identification State
S037 ADVERSE EVENT TYPE COMPOSITE AdverseEvent 2005 Date/Time/Period Qualifier (X12 DE 432) Date Elements
7890 Bed Bed Became explicit elements – e.g.,
7919 Body Metric Qualifier BodyMetricQualifier SoldDate
ExpirationDate
7920 Body Metric Value BodyMetricValue WrittenDate, etc.
0326 Message Function BodyType 7996 DEA Schedule - NCPDP DEA Schedule DEAScheduleCode
Became explicit elements for XML Terminology
Transaction Types, e.g.
8013 Dispensing Request Code DispensingRequestCode
NewRx
7892 Do Not Fill/Profile Flag DoNotFill
RefillRequest
7878 Dosage Directions
RefillResponse
RxChangeRequest 7879 Dosage Identification Not defined
RxChangeResponse S025 DOSE COMPOSITE Dose
CancelRx 7925 Dose Basis Range Modifier DosingBasisRangeModifier
Census S026 DOSE CALCULATION COMPOSITE DoseCalculation
RxHistoryRequest 7903 Dose Composite Indicator DoseCompositeIndicator
7921 Calculated Dose Numeric CalculatedDoseNumeric 7906 Dose Delivery Method Code DoseDeliveryMethodCode
7924 Calculated Dose Unit of Measure Code CalculatedDoseUnitofMeasureCode 7905 Dose Delivery Method Code Qualifier DoseDeliveryMethodCodeQualifier
7923 Calculated Dose Unit of Measure Code CalculatedDoseUnitOfMeasureCodeQualifi 7909 Dose Delivery Method Modifier Code DoseDeliveryMethodModifierCode
Qualifier er 7908 Dose Delivery Method Modifier Code Qualifier DoseDeliveryMethodModifierCodeQualifier
7922 Calculated Dose Unit of Measure Text CalculatedDoseUnitofMeasureText 7907 Dose Delivery Method Modifier Text DoseDeliveryMethodModifierText
7893 Change of Prescription Status Flag ChangeOfPrescriptionStatusCode 7904 Dose Delivery Method Text DoseDeliveryMethodText
6810 Clinical Information Qualifier ClinicalInformationQualifier 7913 Dose Form Code DoseFormCode
1131 Code List Qualifier – Diagnosis Code Qualifier PrimaryDiagnosisCodeQualifierCode 7912 Dose Form Code Qualifier DoseFormCodeQualifier
(Primary) 7911 Dose Form Text DoseFormText
1131 Code List Qualifier – Diagnosis Code Qualifier SecondaryDiagnosisCodeQualifierCode 7910 Dose Quantity DoseQuantity
(Secondary)
7914 Dose Range Modifier DoseRangeModifier
1131 Code List Qualifier – Quantity Qualifier (X12 QuantityCodeListQualifier
7915 Dosing Basis Numeric Value DosingBasisNumericValue
DE 673)
7925 Dosing Basis Range Modifier Dosing Basis Range Modifier
1131 Code List Qualifier – Response Code ReasonCode
7918 Dosing Basis Unit of Measure Code DosingBasisUnitofMeasureCode
1131 Code List Qualifier – Reject Code DescriptionCode
7917 Dosing Basis Unit of Measure Code Qualifier DosingBasisUnitOfMeasureCodeQualifier
1131 Code List Qualifier –Communication Number CommunicationTypeQualifier
7916 Dosing Basis Unit of Measure Text DosingBasisUnitofMeasureText
(X12 DE 365)
7885 Drug Coverage Status Code DrugCoverageStatusCode
3055 Code List Responsibility Agency Became explicit elements, e.g.,
S038 DRUG - PRODUCT CODED COMPOSITE DrugCodedType
ProductCodeQualifier
S018 DRUG USE EVALUATION COMPOSITE DrugUseEvaluationType
CompoundProductCodeQualifier
Allergy/DrugProductCoded/CodeListQualifi 7998 DUE Acknowledgement Reason AcknowledgementReason
er 7997 DUE Clinical Significance Code ClinicalSignificanceCode
S023 CODE SYSTEM COMPOSITE (Sig) CodeSystem 7883 DUE Co-Agent ID CoAgentID
8003 Compound Code CompoundCode 7884 DUE Co-Agent ID Qualifier CoAgentQualifier
7881 DUE Professional Service Code ProfessionalServiceCode
I017 COMPOUND INGREDIENT COMPOSITE CompoundIngredient 7880 DUE Reason For Service Code ServiceReasonCode
8005 Compound Ingredient Item Description CompoundIngredientItemDescription 7882 DUE Result Of Service Code ServiceResultCode
S044 COMPOUNDED PRESCRIPTION ROUTE OF RouteOfAdministration S031 DURATION COMPOSITE Duration
- 197 -
July 2016
DATA DICTIONARY
ID ID
7963 Duration Numeric Value DurationNumericValue 7969 Maximum Dose Restriction Code Qualifier MaximumDoseRestrictionCodeQualifier
7964 Duration Text DurationText 7967 Maximum Dose Restriction Numeric Value MaximumDoseRestrictionNumericValue
7966 Duration Text Code DurationTextCode 7970 Maximum Dose Restriction Units Code MaximumDoseRestrictionUnitsCode
7965 Duration Text Code Qualifier DurationTextCodeQualifier 7968 Maximum Dose Restriction Units Text MaximumDoseRestrictionUnitsText
7888 Facility Unit FacilityUnit 7975 Maximum Dose Restriction Variable Duration MaximumDoseRestrictionVariableDuration
7897 Fill Number FillNumber Modifier Modifier
8004 Final Compound Pharmaceutical Dosage Form FinalCompoundPharmaceuticalDosageF 7971 Maximum Dose Restriction Variable Numeric MaximumDoseRestrictionVariableNumeric
- NCPDP Drug StrengthForm Terminology orm Value Value
- NCPDP Drug StrengthForm 7974 Maximum Dose Restriction Variable Units MaximumDoseRestrictionVariableUnitsCod
Terminology Code e
7901 FMT Version FMTVersion 7973 Maximum Dose Restriction Variable Units MaximumDoseRestrictionVariableUnitsCod
8017 Follow-Up Request FollowUpRequest Code Qualifier eQualifier
7953 Frequency Numeric Value FrequencyNumericValue 7972 Maximum Dose Restriction Variable Units Text MaximumDoseRestrictionVariableUnitsText
7956 Frequency Units Code FrequencyUnitsCode 7887 Measurement Data Qualifier MeasurementDataQualifier
7955 Frequency Units Code Qualifier FrequencyUnitsCodeQualifier 6311 Measurement Dimension, coded (Values MeasurementDimension
7954 Frequency Units Text FrequencyUnitsText when referencing X12 DE 738)
S034 INDICATION COMPOSITE Indication 7995 Measurement Unit Code MeasurementUnitCode
7978 Indication Precursor Code IndicationPrecursorCode - NCPDP MeasurementUnitCode Terminology - NCPDP MeasurementUnitCode
7977 Indication Precursor Code Qualifier IndicationPrecursorCodeQualifier Terminology
7976 Indication Precursor Text IndicationPrecursorText 4343 Message Function, coded MessageRequestCode
7979 Indication Text IndicationText 7945 Multiple Administration Timing Modifier MultipleAdministrationTimingModifier
7981 Indication Text Code IndicationTextCode 7937 Multiple Route of Administration Modifier MultipleRouteOfAdministrationModifier
7980 Indication Text Code Qualifier IndicationTextCodeQualifier 7899 Multiple Sig Modifier MultipleSigModifier
7982 Indication Value Text IndicationValueText 7941 Multiple Site of Administration Timing MultipleSiteOfAdministrationTimingModifi
7983 Indication Value Unit IndicationValueUnit Modifier er
7986 Indication Value Unit of Measure Code IndicationValueUnitofMeasureCode 7933 Multiple Vehicle Modifier MultipleVehicleModifier
7985 Indication Value Unit of Measure Code IndicationValueUnitOfMeasureCodeQualifi 1006 Needed No Later Than NeededNoLaterThan
Qualifier er 7894 Needed No Later Than Reason NeededNoLaterThanReason
7984 Indication Value Unit of Measure Text IndicationValueUnitofMeasureText 7999 No Known Allergies NoKnownAllergies
7987 Indication Variable Modifier IndicationVariableModifier 8015 Order Capture Method OrderCaptureMethod
9701 Individual Relationship, coded PatientRelationshipCode S043 OTHER COMPOUND INFORMATION OtherCompoundInformationType
7958 Interval Numeric Value IntervalNumericValue COMPOSITE
7961 Interval Units Code IntervalUnitsCode 7886 Patient Identifier Became explicit elements, e.g.
7960 Interval Units Code Qualifier IntervalUnitsCodeQualifier MedicalRecordIdentificationNumber
7959 Interval Units Text IntervalUnitsText Commercial
7009 Item Description Identification CompoundIngredientItemDescription IndividualPolicyNumber
MedicareNumber
8001 Item Description Long Item DescriptionLong
MedicaidNumber
7992 Item Form Code DrugStrengthForm
8014 Payer Responsibility Code PayerResponsibilityCode
- NCPDP Drug StrengthForm Terminology - NCPDP Drug StrengthForm
Terminology 8016 Person Code PersonCode
7994 Potency Unit Code QuantityUnitOfMeasureCode
8009 Item Quantity Value
- NCPDP QuantityUnitOfMeasure Terminology - NCPDP QuantityUnitOfMeasure
7993 Item Strength Code StrengthUnitOfMeasure
Note: The actual CODE values are not used in Terminology
- NCPDP Drug StrengthUnitOfMeasure - NCPDP Drug StrengthUnitOfMeasure
XML standards.
Terminology Terminology
8002 Prescription Delivery Method PrescriptionDeliveryMethod
3453 Language Name Code LanguageNameCode
7891 Prior Authorization Status PriorAuthorizationStatus
S033 MAXIMUM DOSE RESTRICTION COMPOSITE MaximumDoseRestriction
S042 PROBLEM NAME CODED COMPOSITE ProblemNameCoded
7969 Maximum Dose Restriction Code MaximumDoseRestrictionCode
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DATA DICTIONARY
ID ID
(DiagnosisGeneral) S040 SEVERITY CODED COMPOSITE SeverityCoded
S041 PROBLEM TYPE COMPOSITE ProblemType S024 SIG FREE TEXT STRING COMPOSITE FreeText
(DiagnosisGeneral)
4705 Provider Coded Explicit Provider Name Types, e.g. 7989 Sig Free Text SigFreeText
MandatoryPrescriberType- 7902 Sig Free Text String Indicator SigFreeTextStringIndicator
MandatoryPharmacyType 7898 Sig Sequence Position Number SigSequencePositionNumber
SupervisorType MandatoryFacilityType S030 Sig TIMING COMPOSITE Timing
7990 Provider Specialty code Specialty 7940 Site of Administration Code SiteofAdministrationCode
(replacing 4707 - Provider Specialty, coded 7939 Site of Administration Code Qualifier SiteOfAdministrationCodeQualifier
(X12 DE 1222) S029 SITE OF ADMINISTRATION COMPOSITE SiteOfAdministration
7946 Rate of Administration RateofAdministration 7938 Site of Administration Text SiteOfAdministrationText
7949 Rate Unit of Measure Code RateUnitOfMeasureCode 7900 SNOMED Version SNOMEDVersion
7948 Rate Unit of Measure Code Qualifier RateUnitOfMeasureCodeQualifier 1007 Source HistorySourceType
7947 Rate Unit of Measure Text RateUnitOfMeasureText 7991 Source Code List SourceCodeList - NCICode
S039 REACTION CODED COMPOSITE ReactionCoded Note: The actual CODE (AA, AB, etc) values
8011 Reason Code (REQ Segment) DrugAdminReasonCode are not used in XML standards.
8012 Reason Text DrugAdminReasonText 7896 Source Description SourceDescription
1153 Reference Qualifier– Generic Database, Prior DrugDBCodeQualifier 8000 Source of Information SourceOfInformation
Authorization 7895 Source Qualifier SourceQualifier
1153 Reference Qualifier (X12 DE 128)(IDs) Identification Elements 9015 Status Type, coded StatusCode,
Note: PriorAuthorizationQualifier uses the CODE Became explicit elements, e.g. TransactionErrorCode,
values. PatientIdentification, VerifyStatusCode
PayerIdentification, S035 STOP COMPOSITE Stop
FacilityIdentification, 7988 Stop Indicator - SIG Segment StopIndicator
PharmacyIdentification,
0035 Test Indicator TestMessage
PrescriberIdentification,
7952 Time Period Basis Code TimePeriodBasisCode
SupervisorIdentification,
7951 Time Period Basis Code Qualifier TimePeriodBasisCodeQualifier
ProviderIdentification,
PriorAuthorizationQualifier. 7950 Time Period Basis Text TimePeriodBasisText
8010 Refill Quantity RefillsRemaining 2029 Time Zone Identifier TimeZoneIdentifier
S022 REPEATING Sig COMPOSITE RepeatingSIG 7957 Variable Frequency Modifier VariableFrequencyModifier
7889 Room Room 7962 Variable Interval Modifier VariableIntervalModifier
S028 ROUTE OF ADMINISTRATION COMPOSITE RouteOfAdministration S027 VEHICLE COMPOSITE Vehicle
7936 Route of Administration Code RouteOfAdministrationCode 7926 Vehicle Name VehicleName
7935 Route of Administration Code Qualifier RouteOfAdministrationCodeQualifier 7928 Vehicle Name Code VehicleNameCode
7934 Route of Administration Text RouteOfAdministrationText 7927 Vehicle Name Code Qualifier VehicleNameCodeQualifier
7701 Service Type, coded ServiceTypeCoded 7929 Vehicle Quantity VehicleQuantity
S045 SENDER SOFTWARE COMPOSITE SenderSoftwareType 7932 Vehicle Unit of Measure Code VehicleUnitOfMeasureCode
7931 Vehicle Unit of Measure Code Qualifier VehicleUnitOfMeasureCodeQualifier
8006 Sender Software Developer SenderSoftwareDeveloper 7930 Vehicle Unit of Measure Text VehicleUnitOfMeasureText
8007 Sender Software Product SenderSoftwareProduct
8008 Sender Software Version Release SenderSoftwareVersionRelease
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DATA DICTIONARY
VI. Appendix C – PUBLICATION MODIFICATIONS
A. SEPTEMBER 1999
1. Telecommunication Standard Version 5 Release 1

The following code values were approved for inclusion in the Data Dictionary.
Field 439-E4 – Reason for Service Code

CD=Chronic Disease Management
LK=Lock In Recipient
PH=Preventive Health Care
RE=Suspected Environmental Risk
SC=Suboptimal Compliance
Field 441-E6 – Result of Service Code

3K=Instructions Understood
3N=Medication Administered
Field 102-A2 - Version/Release Number

51=Version 5.1
B. JUNE 2000

The following code values were approved for inclusion in the Data Dictionary.
Field 496-H2 – Measurement Dimension
18=Cholesterol
19=Low Density Lipoprotein (LDL)
20=High Density Lipoprotein (HDL)
21=Triglycerides (TG)
22=Bone Mineral Density (BMD T-Score)
23=Prothrombin Time (PT)
24=Hemoglobin (Hb; Hgb)
25=Hematocrit (Hct)
26=White Blood Cell Count (WBC)
27=Red Blood Cell Count (RBC)
28=Heart Rate
29=Absolute Neutrophil Count (ANC)
30=Activated Partial Thromboplastin Time (APTT)
31=CD4 Count
32=Partial Thromboplastin Time (PTT)
33=T-Cell Count
34=INR-International Normalized Ratio
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DATA DICTIONARY
Field 497-H3 Measurement Unit
19=Ratio
20=SI Units
21=Millimoles (mmol/l)
22=Seconds
23=Grams per deciliter (g/dl)
24=Cells per cubic millimeter (cells/cu mm)
25=1,000,000 cells per cubic millimeter (million cells/cu mm)
26=Standard deviation
27=Beats per minute
The following are data elements that were approved for inclusion in the Data Dictionary.
Field Action
Field Name
Number Addition Deletion Modification
Patient E-Mail Address 350-HN X
Version/Release Number 102-A2 Added value: 52=Version 5.2
2. Enrollment Standard Version 2 Release 0

Field Action
Field Name
Action Code 711 Update values: removed P=Purge; C=Change; added S=Suspend
Alternate Benefit ID 753 X
Alternate Enrollment Verification Code 754 X
Alternate Financial Verification Code 755 X
Alternate Group Number 756 X
Alternate ID Number 724 Field length expanded from 18 to 20
Benefit Effective Date 761 X
Benefit ID 757 X
Benefit Qualifier 758 X
Benefit Termination Date 759 X
Billing Level Indicator 760 X
Card Production Indicator 762 X
Cardholder ID 302-C2 Field name change: Cardholder ID Number to Cardholder ID, definition, field length expanded
from 18 to 20
Carrier ID 327-CR Field name change: Carrier ID Number to Carrier ID, definition
Case Manager 763 X
Claim/Reference ID 435-DZ Field name change: Claim/Reference ID Number to Claim/Reference ID, field length expanded
from 14 to 30, definition
Client ID Code 600-01 X
Client ID Code Qualifier 600-02 X
Copay Calculation Code 764 X
Copay Dollar Amount 765 X
Copay Effective Date 766 X
Copay Percentage Amount 767 X
Copay Qualifier 768 X
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DATA DICTIONARY
Field Action
Field Name
Copay Termination Date 769 X
Covered Through Qualifier 770 X
Data Category 703 Update values: added C=Combo Group & Member; G=Group Only, definition
Date Of Injury 434-DY X
Dependent Adult Coverage Indicator 749 Definition
Dependent Adult Covered Through Age 750 Field name change: Dependent Adult Covered Thru Age to Dependent Adult Covered Through
Age
Dependent Coverage Indicator 743 Definition
Dependent Covered Through Age 744 Field name change: Dependent Covered Thru Age to Dependent Covered Through Age
Dependent Covered Through Date 885 X
Diagnosis Code 424-DO X
Diagnosis Code Qualifier 492-WE X
Disabled Dependent Coverage Indicator 747 Definition
DUR Type Indicator 771 X
Early Refill Percentage 772 X
Effective Date 712 Definition
Eligibility Type 773 X
Employer ID 333-CZ X
Enrollment Relationship Code 715 Definition
Enrollment Tax Exempt Indicator 774 X
Enrollment Version/Release Number 775 Field name change: Version/Release Number to Enrollment Version/Release Number, deleted
value 10=1994 Version 1.0 Format, add value 20= 1999 Version 2.0 Format
Entity Address Line 1 776 X
Entity Address Line 2 777 X
Entity City 778 X
Entity Contact Name 779 X
Entity Name 780 X
Entity Segment Qualifier 781 X
Entity State 782 X
Entity Telephone Number 783 X
Entity Zip/Postal Code 784 X
Family ID Number 785 X Field length expanded from 18 to 20
File Type 702 Definition
First Name 717 Definition
Gender Code 721 Definition, update value: Blank=Unknown; 1=Male; 2=Female
Group Name 786 X
Group ID 301-C1 Field name change: Group Number to Group ID
Group Sequence Number 787 X
Hierarchy Level Name 788 X
Hierarchy Level Number 789 X
ID Card Reason Code 790 X Field name change: ID Card Code to ID Card Reason Code
Industry Classification Code 791 X
Maximum Copay Amount 792 X
Member Sequence Number 710 Field name change: Sequence Number to Member Sequence Number
Minimum Copay Amount 793 X
Number of ID Cards 794 X
Original Effective Date 714 Definition
Originator Name 706 Definition, Field length expanded from 20 to 30
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DATA DICTIONARY
Field Action
Field Name
Other Coverage Code 308-C8 Field length expanded from 1 to 2, update values: added 05=Managed care plan denial;
06=Other coverage denied-not participating provider; 07=Other coverage exists-not in effect
on DOS; 08=Claim is billing for copay
Plan ID Extension 733 Definition
Pregnancy Indicator 335-2C X
Prescriber ID 411-DB X
Prescriber ID Qualifier 466-EZ X
Primary Care Provider ID 421-DL Field length reduced from 18 to 15
Primary Care Provider ID Qualifier 468-2E X
Primary Care Provider Termination Date 795 X
Primary Pharmacy Effective Date 739 Definition
Primary Pharmacy ID Qualifier 496 X
Prior Approval Amount 797 X
Processor Indicator 707 Definition, update values: M=Maintenance/Changes Only; T=Full File with Terms
Relationship Coverage Effective Date 740 Definition
Report Level Indicator 798 X
Segment Identifier 701 Update values, added: 11 Group Demographics; 12 Group Benefits; 13 Group Copay; 18 Group
Copay Processor Defined; 19 Group Benefits Processor Defined; 42 Member Benefits; 43
Member Copays; 48 Member Copay Processor Defined; 49 Member Benefits Processor
Defined; 50 Workers Compensation; 51 Workers Compensation Demographics; 59 Workers
Compensation Processor Defined; 89 Group Processor Defined
Significant Other Coverage Indicator 799 X
Smoker/Non-Smoker Code 334-1C X
Spouse Coverage Indicator 742 Definition
Student Coverage Indicator 745 Definition
Student Covered Through Age 746 Field name change: Student Covered Thru Age to Student Covered Through Age
Student Covered Through Date 884 X
Telephone Number 732 X
Version/Release Number 102-A2 X Replaced by Enrollment Version/Release Number
Workers Compensation Effective Date 881 X
Workers Compensation Original Effective Date 882 X
Workers Compensation Termination Date 883 X
Zip/Postal Code 730 Field name change: Zip Code to Zip/Postal Code, definition, field length expanded from 9 to 15
3. Payment Tape Format Version 3 Release 0

While the new standard remains a 368-byte record, the field positions will no longer be the same as they were in the previous Payment Reconciliation Standard v3.0. The data element names and field lengths in this revised
standard were updated to be compliant with Telecommunications Version 5. In addition, date fields were updated to be Y2K compliant, and new fields have been added. These changes have caused the field positions in all
of the record types to be adjusted.
Field Action
Field Name
Amount Billed 804-5B Field length expanded from 6 to 8
Amount Paid 876-FB Field length expanded from 6 to 8
Amount Adjusted 872-3Z Field length expanded from 6 to 8
Amount Rejected 805-1C Field length expanded from 6 to 8
Authorization Number 503-F3 X
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DATA DICTIONARY
Field Action
Field Name
Balance Forward 880-KC X
Bank Account 880-KK X
Bank Routing ID 880-KH X
Basis Of Reimbursement Determination 522-FM X
Batch Amount 880-KR X
Batch Number 806-5C Field length expanded from 5 to 7
Carrier Zip Code 813-1J Field length expanded from 9 to 15
Check Amount 880-KS X
Check Number 880-KG X
Claim Count 814-50 Field length expanded from 5 to 8
Claim Transmission Fee 880-KF X
Co-Pay Amount 817-5E X
Dispensing Fee Paid 507-F7 Field length expanded from 6 to 8
Dollars Billed 822-5H Field length expanded from 8 to 10
Dollars Paid 873-4A Field length expanded from 8 to 10
Dollars Adjusted 821-1M Field length expanded from 8 to 10
Dollars Rejected 824-1N Field length expanded from 8 to 10
Fund Destination Name 880-K8 X
Fund Destination ID 880-K9 X
Group ID 301-C1 X
Incentive Amount Paid 521-FL X
Ingredient Cost Billed 827-10 Field length expanded from 6 to 8
Ingredient Cost Paid 506-F6 Field length expanded from 6 to 8
Message 504-F4 X
Non-Claim Adjustment Dollars 880-KQ X
Non-Claim Transmission Fee Dollars 880-KP X
Open Balance 880-KT X
Other Amount Paid 565-J4 X
Patient Pay Amount 505-F5 X Replaced Co-Pay Amount (817-5E)
Payment Cycle Start Date 880-KA X
Payment Cycle End Date 880-KB X
Pending Claim Count 880-KM X
Pharmacy Count 830-5M Field length expanded from 4 to 5
Prescription/Service Reference Number Qualifier 455-EM X
Primary Care Provider ID 421-DL X
Professional Service Fee Paid 562-J1 X
Rejected Claim Count 880-KN X
Sales Tax 410-DA X Field length expanded from 6 to 8
Total Batch Amount 880-U2 X
Total Claim Count 880-KU X
Total Dollars Adjusted 880-KY X
Total Dollars Billed 880-KW X
Total Dollars Paid 880-KX X
Total Dollars Rejected 880-KZ X
Total Non-Claim Adjustment Dollars 880-U5 X
Total Non-Claim Transmission Fee Dollars 880-U4 X
Total Pending Claim Count 880-KV X
Total Rejected Claim Count 880-U3 X
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DATA DICTIONARY
Field Action
Field Name
Transaction Type 880-KD X
Version/Release Number 102-A2 Update values: added 30=1999
4. Manufacturer Rebate Utilization, Plan, Formulary, and Market Basket Flat File Format Version 02 Release 01
Field Action
Field Name
Claim Number 601-68 X
Contracting Organization (PMO) Market Basket Code 601-64 X
Manufacturer (PICO) Market Basket Code 601-65 X
Market Basket Description 601-63 X
Market Basket Start Date 601-62 X
Market Basket Termination Date 601-61 X
Number of Market Product Records 601-60 X
Numerator Indicator 601-59 X
Originator ID Code 601-66 X
Originator Name 601-67 X
Product Daily Consumption 601-58 X
Record Type 601-04 Update values: added MB=Market Basket Record, MP=Market Product Record
Total Number Of Market Basket Records 601-69 X

Field Action
Field Name
Unit Dose Indicator 429-DT Update value: 4=Custom Packaging
6, Batch Standard Version1 Release 1

Batch 1.1 added to Version/Release Number (102-A2).
C. SEPTEMBER 2000

Field Action
Field Name
Basis of Cost Determination 423-DN Update value: 08=Disproportionate Share Pricing/Public Health Service
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DATA DICTIONARY
D. NOVEMBER 2000

Field Action
Field Name
Clinical Significance Code 528-FS Update value: 9 = Undetermined
Other Payer-Patient Responsibility Amount Qualifier 351-NP X
Other Payer-Patient Responsibility Amount 352-NQ X
Other Payer-Patient Responsibility Amount Count 353-NR X
E. MAY 2001
1. SCRIPT Standard Version 3 Release 1

Data elements that have been created by NCPDP for usage in the SCRIPT Standard have been incorporated into Appendix J SCRIPT Data Elements of this document.
The following were approved modifications to the Data Dictionary.
Field Action
Appendix or Field Name
DUR Co-Agent ID Qualifier 475-J9 Add: “S” to Standard Formats Column in Data Dictionary
Reason for Service Code 439-E4 Add: “S” to Standard Formats Column in Data Dictionary
Professional Service Code 440-E5 Add: “S” to Standard Formats Column in Data Dictionary
Result of Service Code 441-E6 Add: “S” to Standard Formats Column in Data Dictionary
F. AUGUST 2001

Field Action
Field Name
DUR Additional Text 570-NS X
G. JANUARY 2002

Field Action
Field Name
Associated Prescription/Service Reference Number 456-EN Field Length Expanded from 7 to 9
Prescription/Service Reference Number 402-D2 Field Length Expanded from 7 to 9
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DATA DICTIONARY
Field Action
Field Name
Database Indicator 532-FW Value Change ‘3’ to Micromedex/Medical Economics
Diagnosis Code Qualifier 492-WE Value Change ‘06’ to First DataBank MDDB Product Line
Other Payer Cardholder ID 356-NU X
Other Payer ID 340-7C Comments Add RESPONSE STATUS SEGMENT
Other Payer ID Count 355-NT X
Other Payer ID Qualifier 339-6C Comments Add RESPONSE STATUS SEGMENT
Prior Authorization Type Code 461-EU Definition Change to Code clarifying the Prior Authorization Number Submitted (462-EV) or
benefit/plan exemption.
Product Code Qualifier 601-19 Values Change ‘1’ to First DataBank Generic Code Number (GCN), ‘2’ to First DataBank Generic
Product Identifier (GPI), ‘4’ to First DataBank Drug Descriptor Identifier (DDID)
Submission Clarification Code 420 -DK Value Add ‘10’-Meets Plan Limitations-The pharmacy certifies that the transaction is in
compliance with the program’s policies and rules that are specific to the particular product
being billed.
Submission Clarification Code Count 354-NX X Reject Code Add NX-M/I Submission Clarification Code Count
Therapeutic Class Code Qualifier 601-26 Values Change ‘1’ to First DataBank Generic Code Number (GCN), ‘2’ to First DataBank Generic
Product Identifier (GPI), ‘4’ to First DataBank Drug Descriptor Identifier (DDID)
Intermediary Authorization Type ID 463-EW Comments Add: Usage Change—‘Check Implementation Guide when value = 99’
Appendix K- PRODUCT/SERVICE QUALIFIER updated with the following value change:

NOTE: Product/Service Qualifier Codes were moved to the ECL.
Value Definition
14 First DataBank Generic Product Identifier (GPI)

15 First DataBank Generic Code Number (GCN)
16 Micromedex/Medical Economics Generic Formulation Code (GFC)
17 First DataBank Drug Descriptor Identifier (DDID)
19 Micromedex/Medical Economics Generic Master (GM)
22 First DataBank MDDB Product Line Diagnosis Code (Note: MDDB is not an acronym)
3. Manufacturer Rebate Standard Version 03.01

Field Action
Field Name
Adjusted Quantity 601-71 X
Adjusted Rebate Per Unit 601-70 X
Adjusted Variance Difference 601-72 X
Amount Paid This Transaction 601-73 X
Baseline 601-77 X
Baseline Description 601-78 X
Baseline Qualifier 601-79 X
Base Price 601-74 X
Base Price Description 601-75 X
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DATA DICTIONARY
Field Action
Field Name
Base Price Type 601-76 X
Current Amount Paid To Date 601-80 X
Current Rebate Per Unit 601-81 X
Current Units Disputed To Date 601-82 X
Current Units Paid To Date 601-83 X
Current Units To Date 601-84 X
Disputed Quantity 601-85 X
FF Accepted Metric Decimal Quantity 601-86 X
Grand Total Accepted Metric Decimal Quantity 601-87 X
Grand Total Paid Rebate Amount 601-88 X
Interest Amount 601-89 X
Level Achieved 601-90 X
Number of Rebate Type Records 601-91 X
Original Amount Invoiced 601-92 X
Original Rebate Per Unit 601-93 X
Original Units Invoiced 601-94 X
Paid Per Unit Amount 601-95 X
Paid Rebate Amount 601-96 X
Performance 601-97 X
Performance Description 601-98 X
Performance Qualifier 601-99 X
Prior Amount Paid 602-01 X
Prior Units Disputed 602-02 X
Prior Units Paid 602-03 X
Rebate Rate 602-04 X
Rebate Type 602-05 X
Rebate Type Description 602-06 X
Rebate Variance Amount 602-07 X
Reconciliation Error Description 602-08 X
Reconciliation Line Number 602-09 X
Reconciliation Reason Code 602-10 X
Reconciliation Status Code 602-11 X
Reconciliation Transmission Control Number 602-12 X
Record Type 601-04 Values Add ‘RD’-Reconciliation Detail Record, ‘RT’-Rebate Type Record
Revised Invoice Amount 602-13 X
Total Remittance 602-14 X
Withheld Invoice Amount 602-15 X
4. Payment Reconciliation Standard Version 4 Release 0

Field Action
Field Name
Amount Paid 876-FB X Use Total Amount Paid (509-F9)
Fund Destination ID 880-K9 Format Change from x(25) to 9(10)
Fund Destination Name 880-K8 Format Change from 9(10) to x(25)
Transaction Type 880-KD Definition Add: Defines the status of the billed transaction.
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DATA DICTIONARY
5. Data Dictionary Modifications

Field Action
Appendix J- United States and Canadian Province Postal Service Values Add: ‘NT’ Northwest Territories, ‘NU’ Nunavut, ‘YT’ Yukon Value Change ‘QC’ Quebec.
Abbreviations Note: This table was moved to the ECL.
Prior Authorization/Medical Certification Code and Number 416-DG Value Change ‘7’ from AFDC (Aid to Families with Dependent Children) to TANF (Temporary
Assistance for Needy Families)
Prior Authorization Type Code 461-EU Value Change ‘7’ from AFDC (Aid to Families with Dependent Children) to TANF (Temporary
Assistance for Needy Families)
H. JUNE 2002

Field Action
Delay Reason Code 357-NV X
I. DECEMBER 2002
1. Manufacturer Rebate Standard Version 03 Release 02

Field Action
Product Code Qualifier 601-19 Values Added:
5 -First DataBank Medication Name Identifier (FDB Med Name ID)
6 -First DataBank Routed Medication Identifier (FDB Routed Med ID)
7 -First Databank Routed Dosage Form Medication Identifier (FDB Routed Dosage Form Med
ID)
8 -First DataBank Medication Identifier (FDB MedID)
Therapeutic Class Code Qualifier 601-26 Values Added:

5 -First DataBank Medication Name Identifier (FDB Med Name ID)
6 -First DataBank Routed Medication Identifier (FDB Routed Med ID)
7 -First Databank Routed Dosage Form Medication Identifier (FDB Routed Dosage Form Med
ID)
8 -First DataBank Medication Identifier (FDB MedID)
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DATA DICTIONARY
J. FEBRUARY 2003

Field Action
K. AUGUST 2003

Field Action
Employer ID 333-CZ Comments Added:
The Internal Revenue Service, Department of the Treasury, assigns the Employer ID. The format
of this field is nine-digits with a hyphen, as in 00-0000000. The hyphen must be transmitted as
part of the Employer ID Number. Information on the Employer ID may be found at
http://www.irs.ustreas.gov/.
Appendix K- Product/Service Qualifier Column added for comments.
NOTE: Product/Service Qualifier Codes were moved to the ECL Value name change on 04 from Universal Product Number (UPN) to Health Industry Business
Communication Council (HIBCC).
Value name change on 12 from International Article Numbering System (EAN) to Global Trade
Identification Number (GTIN).
L. OCTOBER 2003

Field Action
Patient Location 307-C7 Values Added:
12 - End Stage Renal Disease Treatment Facility
Amount Attributed to Processor Fee 571-NZ X

Field Action
Reject Code 511-FB Values Added:
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DATA DICTIONARY
Field Action
(Values Added to Appendix F - VERSION 5 REJECT CODES FOR SF-Other Payer Amount Paid Count Does Not Match Number Of Repetitions
TELECOMMUNICATION STANDARD Subsection N) NOTE: Reject SG-Submission Clarification Code Count Does Not Match Number of Repetitions
Codes for Telecommunication were moved to the ECL SH-Other Payer-Patient Responsibility Amount Count Does Not Match Number of Repetitions
M. NOVEMBER 2003
1. Manufacturer Rebate Standard Version 03 Release 02 – New publication date of November 2003
Release of the November 2003 Data Dictionary is approved for use only by the Manufacturer Rebate Standard Version 03.02 for the External Code List (ECL) process.

Following are changes made to the Data Dictionary in preparation for the incorporation of the ECL process:
INTRODUCTION – Changed to add verbiage to explain the ECL process as it impacts the Data Dictionary and DERF submission.
BODY - “See ECL" was indicated in the Values Column of all Data Elements included in the External Code List and values removed. References in the Comments/Examples Column to see Appendices within the Rebate
Implementation Guide for values were removed.
APPENDICES - F – VERSION 5 REJECT CODES FOR THE TELECOMMUNICATION STANDARD, K – PRODUCT/SERVICE QUALIFIER, and L - UNITED STATES AND CANADIAN PROVINCE POSTAL SERVICE ABBREVIATIONS were removed
and remaining appendices reordered accordingly.
N. MAY 2004

Field Action
Procedure Modifier Code Count 458-SE Field Size Changed from 9(1) to 9(2)
O. AUGUST 2004
1. Telecommunication Standard Version A.0

Field Action
Diagnosis Code 424-DO Comments: Changed wording and deleted Examples
Version/Release Number 102-A2 Added value: A0=Version A.0
Remaining Benefit Amount 514-FE Comments: Corrected Note to 0000000{
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DATA DICTIONARY
P. OCTOBER 2004

Field Action
Other Coverage Code 308-C8 Values: Corrected values to show as 1-digit rather than 2-digits (removed leading zero).
Transaction Type 880-KD Values: Corrected values to show as 1-digit rather than 2-digits (removed leading zero).
2. Telecommunication Standard Version A.1

Field Action
Version/Release Number 102-A2 Added value: A1=Version A.1
Q. JANUARY 2005
1. SCRIPT Standard Versions 7.0 and 7.1

Updates to Appendix J – SCRIPT DATA ELEMENTS of this document noted.
R. MAY 2005
1. Telecommunication Standard Version B.0

Field Action
Patient Residence 384-4X X
Patient Location 307-C7 Field Name Changed to Place of Service, Definition Changed, Values: Existing deleted and new
added to ECL
Version/Release Number 102-A2 Added value: B0=Version B.0
Appendix A - ALPHABETIC CROSS REFERENCE X Added Patient Residence; Deleted Patient Location and Added Place of Service
Appendix B - NUMERIC CROSS REFERENCE X Added Patient Residence; Deleted Patient Location and Added Place of Service
S. JULY 2005
1. Telecommunication Standard Version C.0

Appendix or Field Name Field Action
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DATA DICTIONARY
Prescriber First Name 364-2J X
Prescriber Street Address 365-2K X
Prescriber City Address 366-2M X
Prescriber State/ Province Address 367-2N X
Prescriber Zip/Postal Zone 368-2P X
Facility Name 385-3Q X
Facility Street Address 386-3U X
Facility State/Province Address 387-3V X
Facility City Address 388-5J X
Facility Zip/Postal Zone 389-6D X
Narrative Message 390-BM X
Additional Documentation Type ID 369-2Q X
Length of Need 370-2R X
Length of Need Qualifier 371-2S X
Prescriber/Supplier Date Signed 372-2T X
Request Status 373-2U X
Request Period Begin Date 374-2V X
Request Period Recert/Revised Date 375-2W X
Supporting Documentation 376-2X X
Question Number/Letter Count 377-2Z X
Question Number/Letter 378-4B X
Question Percent Response 379-4D X
Question Date Response 380-4G X
Question Dollar Amount Response 381-4H X
Question Numeric Response 382-4J X
Question Alphanumeric Response 383-4K X
Segment Identification 111-AM Added Values: 14=Additional Documentation, 15=Facility, 16=Narrative
Version/Release Number 102-A2 Added Value: C0=Version C.0
Appendix A - ALPHABETIC CROSS REFERENCE X Added New Fields Shown Above
Appendix B - NUMERIC CROSS REFERENCE X Added New Fields Shown Above
2. SCRIPT Standard Versions 8.0

T. OCTOBER 2005

Field Action
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DATA DICTIONARY
Field Action
Other Payer BIN Number 990-MG X
Other Payer Processor Control Number 991-MH X
Other Payer Group ID 992-MJ X
Transaction Reference Number 880-K5 Definition Changed; Added Telecommunication to Standard Format; Added Segments to
Comments/Examples
Other Payer Cardholder ID 356-NU Added to Comments/Examples; “REQUEST INSURANCE SEGMENT. “
2. Formulary & Benefit Standard Version 1.0

Field Action
Front Matter of DD Added to Standard Formats –“F” = Formulary & Benefit Format and new Field Format Type “R”
= Numeric 0-9 with decimal point with explanation.
Absolute Row Number 900-BN X
Additional Message Information 526-FQ Added “F” to Standard Formats and Field Format and Field Length of x(100) for “F”
Alternatives ID 901-BP X
Change Identifier 600-64 Added “F” to Standard Formats
Class ID 902-BQ X
Class ID-Step Drug 903-BR X
Class Name 904-BS X
Classification ID 905-BT X
Copay ID 906-BU X
Copay List ID 907-BV X
Copay List Type 908-BW X
Copay Tier 909-BX X
Coverage ID 910-BY X
Coverage List ID 911-BZ X
Coverage List Type 912-B3 X
Data In Error 913-B4 X
Days Supply Per Copay 988-MB X
Diagnosis Code 424-DO Added “F” to Standard Formats
Diagnosis Code Qualifier 492-WE Added “F” to Standard Formats
Drug Qualifier-Step Drug 914-B5 X
Drug Reference Number 915-B6 X
Drug Reference Qualifier 916-B7 X
Drug Reference Number-Alternative 917-B8 X
Drug Reference Qualifier-Alternative 918-B9 X
Drug Reference Number-Source 919-CS X
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DATA DICTIONARY
Field Action
Drug Reference Qualifier-Source 920-CT X
Drug Reference Number-Step Drug 921-CU X
Drug Reference Qualifier-Step Drug 922-CV X
Extract Date 923-DD X
File Type 702-MC Added “F” to Standard Formats and added field ID of “MC”
First Copay Term 924-DH X
Flat Copay Amount 925-ES X
Formulary ID 926-FF X
Formulary Name 989-MF X
Formulary Status 927-FP X
Gender Code 721-MD Definition Changed, Added “F” to Standard Formats and deleted “M”, and added field ID of
“MD”
List Action 928-FR X
List Effective Date 929-FZ X
Load Status 930-F2 X
Maximum Age Qualifier 931-F8 X
Maximum Age 932-GA X
Maximum Amount 933-GB X
Maximum Amount Qualifier 934-GC X
Maximum Amount Time Period 935-GF X
Maximum Amount Time Period Start Date 936-GG X
Maximum Amount Time Period End Date 937-GH X
Maximum Amount Time Period Units 938-GJ X
Maximum Copay 939-GK X
Maximum Copay Tier 940-GM X
Message - Long 941-GN X
Message -Short 942-GP X
Minimum Age Qualifier 943-GQ X
Minimum Age 944-GR X
Minimum Copay 945-GS X
Non-Listed Prescription Brand Formulary Status 946-GT X
Non-listed Prescription Generic Formulary Status 947-GU X
Non-listed Brand Over The Counter Formulary Status 948-GV X
Non-listed Generic Over The Counter Formulary Status 949-GW X
Non-listed Supplies Formulary Status 950-GX X
Number of Drugs To Try 951-GY X
Out of Pocket Range Start 952-GZ X
Out of Pocket Range End 953-HP X
Percent Copay Rate 954-HQ X
Pharmacy Type 955–HR X
Preference Level 956-HS X
Product Name-Health Plan 957-HT X
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July 2016
DATA DICTIONARY
Field Action
Product/Service ID 407-D7 Added “F” to Standard Formats
Product/Service ID Qualifier 436-E1 Added “F” to Standard Formats and Added new value of “28” to the ECL
Product/Service ID-Alternative 958-HU X
Product/Service ID Qualifier-Alternative 959-HV X
Product/Service ID-Step Drug 960-HW X
Product/Service ID Qualifier-Step Drug 961-HX X
Product/Service ID-Source 962-HY X
Product/Service ID Qualifier-Source 963-HZ X
Product Type 964-JA X
Receiver ID 880-K7 Added “F” to Standard Formats and Added Field Format and Field Length of x(30) for “F”
Record Count 751-M9 Added “F” to Standard Formats, Added definition for “F”, and Added field ID of “M9”
Record Type 601-04 Added “F” to Standard Formats, Added Field Format and Field Length of x(3) for “F”, and Added
values for “F” to the ECL
Reject Code 511-FB Added “F” to Standard Formats, Added Field Format and Field Length of x(4) for “F”, and Added
values for “F” as a new appendix to the ECL
Relative Cost 966-JC X
Relative Cost Limit 967-JD X
Resource Link Type 968-JF X
RxNorm Code 969-JG X
RxNorm Qualifier 970-JH X
Section Column In Error 971-JJ X
Sender ID 880-K1 Added “F” to Standard Formats and Added Field Format and Field Length of x(30) for “F”
Source Name 972-JK X
Sender Participant Password 973-JM X
Step Order 974-JN X
Subclass ID 975-JP X
Subclass ID-Step Drug 976-JQ X
Subclass Name 977-JR X
Total Records 978-JS X
Total Errors 979-JT X
Total Rows In Error 980-JU X
Transmission Action 981-JV X
Transmission Control Number 601-56 Added “F” to Standard Formats and Added Field Format and Field Length of x(10) for “F”
Transmission Date 601-10 Added “F” to Standard Formats
Transmission Date-Originating 982-JW X
Transmission Number-Originating 983-JX X
Transmission Time 984-JY X
Transmission Time-Originating 985-JZ X
Transmission File Type 986-KJ X
URL 987-MA X
Version/Release Number 102-A2 Added “F” to Standard Formats and Added Formulary & Benefit to value of 10
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July 2016
DATA DICTIONARY
Field Action
3. SCRIPT Standard Versions 8.1 and 9.0

U. JUNE 2006

Field Action
Amount of Coinsurance 572-4U X
Basis of Calculation – Coinsurance 573-4V X
Compound Ingredient Modifier Code 363-2H X
Compound Ingredient Modifier Code Count 362-2G X
Medicaid Indicator 360-2B X
Medigap ID 359-2A X
Patient Sales Tax 575-EQ X
Plan Sales Tax 574-2Y X
Provider Accept Assignment Indicator 361-2D X
Amount of Copay/Coinsurance 518-FI Name of Field Changed to Amount of Copay; Definition Changed
Basis of Calculation 347-HJ Definition Changed
Other Payer-Patient Responsibility Amount Qualifier 351-NP Added Value: 7 Changed Value: 5 Definition from Amount of copay/coinsurance (518-FI) as
reported by previous payer to Amount of copay (518-FI) as reported by previous payer.
Appendix A - ALPHABETIC CROSS REFERENCE X Added New Fields Shown Above and Name Change for 518-FI
Appendix B - NUMERIC CROSS REFERENCE X Added New Fields Shown Above and Name Change for 518-FI
V. SEPTEMBER 2006
1. Post Adjudication Standard Version 1.0

Field Action
Adjudication Date 578 X
Adjudication Time 203 X
Adjustment Reason Code 204 X
Adjustment Type 205 X
Administrative Fee Amount 206 X
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July 2016
DATA DICTIONARY
Field Action
Administrative Fee Effect Indicator 207 X
Age 208 X
Average Cost Per Quantity Unit Price 209 X
Average Generic Unit Price 210 X
Average Wholesale Unit Price 211 X
Benefit Type 212 X
Billing Cycle End Date 213 X
Cardholder Date of Birth 214 X
Carrier Number 215 X
Check Date 216 X
Claim Date Received In The Mail 217 X
Claim Media Type 218 X
Claim Sequence Number 219 X
Client Assigned Location Code 220 X
Client Formulary Flag 221 X
Client Pass Through 222 X
Client Pricing Basis Of Cost 223 X
Client Specific Data 224 X
COB Carrier Submit Amount 225 X
COB Primary Claim Type 226 X
COB Primary Payer Allowed Amount 227 X
COB Primary Payer Amount Paid 228 X
COB Primary Payer Coinsurance 229 X
COB Primary Payer Copay 230 X
COB Primary Payer Deductible 231 X
COB Primary Payer ID 232 X
COB Secondary Payer Allowed Amount 233 X
COB Secondary Payer Amount Paid 234 X
COB Secondary Payer Coinsurance 235 X
COB Secondary Payer Copay 236 X
COB Secondary Payer Deductible 237 X
COB Secondary Payer ID 238 X
Communication Type Indicator 239 X
Contract Number 240 X
Copay Modifier ID 241 X
Cost Difference Amount 242 X
Dosage Form Code 243 X
Drug Category Code 244 X
Eligibility COB Indicator 245 X
Eligibility Group ID 246 X
Eligibility/Patient Relationship Code 247 X
Eligible Coverage Code 248 X
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July 2016
DATA DICTIONARY
Field Action
Excess Copay Amount 249 X
FDA Drug Efficacy Code 250 X
Federal Upper Limit Indicator 251 X
Federal DEA Schedule 252 X
Federal Upper Limit Unit Price 253 X
Fill Number Calculated 254 X
Formulary Code Type 255 X
Formulary File ID 256 X
Formulary Status 257 X
GCN Number 258 X
GCN Sequence Number 259 X
Generic Indicator 260 X
Generic Name 261 X
Generic Product Identifier 262 X
Health Care Reimbursement Account Amount Applied 263 X
Health Care Reimbursement Account Amount Applied Remaining 264 X
Hold Harmless Amount 265 X
In Network Indicator 266 X
Insurance Code 267 X
Internal Mail Order (Prescription/Service) Reference Number 268 X
Invoiced Amount 269 X
Line Of Business Code 270 X
MAC Price 271 X
MAC Reduced Indicator 272 X
Maintenance Drug Indicator 273 X
Medicare Plan Code 274 X
Medicare Recovery Dispensing Indicator 275 X
Medicare Recovery Indicator 276 X
Member Submit Amount 277 X
Member Submitted Claim Payment Release Date 278 X
Member Submitted Claim Program Code 279 X
Name Suffix 280 X
Net Amount Due 281 X
Non-POS Claim Override Code 282 X
Original Claim Received Date 283 X
Out Of Pocket Apply Amount 284 X
Patient Medicare Formulary Rebate Amount 285 X
Patient Spend Down Amount 286 X
Payment/Reference ID 287 X
Payroll Class 288 X
Pharmacy Class Code 289 X
Pharmacy Dispenser Type 290 X
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July 2016
DATA DICTIONARY
Field Action
Plan Benefit Code 291 X
Plan Cutback Reason Code 292 X
Preferred Alternative File ID 293 X
Prescribed Days Supply 294 X
Prescriber Certification Status 295 X
Prescriber Taxonomy Code 296 X
Prescription Over The Counter Indicator 297 X
Procedure Code 298 X
Processor Defined Prior Authorization Reason Code 299 X
Processor Payment Clarification Code 395 X
Processor Specific Data 396 X
Product/Service Name 397 X
Record Indicator 398 X
Record Status Code 399 X
Reject Override Code 878 X
Sending Entity Identifier 879 X
Service Provider Chain Code 886 X
Service Provider County Code 887 X
Submission Number 888 X
Therapeutic Chapter 889 X
Therapeutic Class Code – AHFS 890 X
Therapeutic Class Code – Generic 891 X
Therapeutic Class Code – Specific 892 X
Therapeutic Class Code – Standard 893 X
Total Amount Paid By All Sources 894 X
Total Net Amount Due 895 X
Transaction ID 896 X
Transaction ID Cross Reference 897 X
User Benefit ID 898 X
User Coverage ID 899 X
Address Line 1 726 Field Size change: Currently 30 Change to: 55 for Post Adjudication
Comment Change from: First line of street address of member. May be only line of address. To:
First line of street address. May be only line of address.
Address Line 2 727 Field Size change: Currently 30 Change to: 55 for Post Adjudication
Comment Change from: Second line of street address of member. Used only if first line will not
accommodate a complete address. To: Second line of street address. Used only if first line will
not accommodate a complete address.
Batch Number 806-5C Change Comment From "Format=CCYYDDD CC=Century YY=Year DDD=Julian date Examples:
2002252=September 9, 2002". Change to: "For B, P, C, and D: Format=CCYYDDD CC=Century
YY=Year DDD=Julian date Examples: 2002252=September 9, 2002. For A, a number generated
by the sender to uniquely identify this batch from others, especially when multiple batches
may be sent in one day."
Benefit ID 757 Definition Change From "Benefit assigned by processor identifying specific plan design assigned
to group or member." Change to: “Assigned by processor to identify a set of parameters,
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July 2016
DATA DICTIONARY
Field Action
benefits, or coverage criteria used to adjudicate a claim."
City 728 Definition Change From "City in which member resides." Change to "Free-form text for city
name." Field Size change: Currently 20 Change to: 30 for Post Adjudication
Database Indicator 532-FW Definition Change From: “Code identifying the source of drug information used for DUR
processing. Change to: “Code identifying the source of drug information used for DUR
processing or to define the database used for identifying the product.” Values Added: 6=
Redbook , 7= Multum
Drug Type 425-DP Valued Added: 5 = Multi-source Brand
First Name 717 Definition Change From "Member's first name." Change to: "First name". Field Size Change:
Currently 15 Change to: 25 for Post Adjudication
Gender Code 721-MD Definition Change From "Code identifying the gender of the individual member." Change to:
"Code identifying the gender of the individual." Field Format Change to Numeric for Post
Adjudication
Last Name 716 Definition Change From- "Last name of the member (required)." Change to "Last name". Field
Size change: Currently 25 Change to: 35 for Post Adjudication
Middle Initial 718 Definition Change From: “The middle initial of the member.” Change to “Individual middle
initial.”
Patient ID Qualifier 331-CX Values Added: 04 = Non-SSN-based patient identifier assigned by health plan , 05 = SSN-based
patient identifier assigned by health plan
Pharmacy Name 833-5P Field Size change: Currently 20 Change to: 35 for Post Adjudication
Product Strength 601-24 Definition Change: “The strength of the product identified in the ‘Product Code’ (601-18) field."
Change to "The strength of the product."
Record Type 601-04 Values Added: PA = Post Adjudication History Header Record, DE = Post Adjudication History
Detail Record, CD=Post Adjudication History Compound Detail Record, PT = Post Adjudication
History Trailer Record, PW = Post Adjudication Utilization Header Record, PU = Post
Adjudication Utilization Detail Record, PX = Post Adjudication Utilization Compound Detail
Record, PY = Post Adjudication Utilization Trailer Record
Reporting Period End Date 601-05 Definition Change "The last day of the period being reported in the plan flat file." Change to
"The last day of the period being reported in the file." or "For Manufacturer Rebates: The last
day of the period being reported in the plan flat file. For Post Adjudication History: The last day
of the period being reported in the file."
Reporting Period Start Date 601-06 Definition Change "The first day of the period being reported in the plan flat file." Change to
"The first day of the period being reported in the file." or "For Manufacturer Rebate: The first
day of the period being reported in the plan flat file. For Post Adjudication History: The first day
of the period being reported in the file.".
State 729 Definition Change "Abbreviation of state in which member resides." Change to "Abbreviation
of state."
Total Record Count 601-09 Format change. For Post Adjudication:: 9(10)
Comment Change for Post Adjudication add: Include header and trailer in count.
Transmission Action 981-JV Values Added: O = Original Submission (New), C = Correction/Adjustment to a previous batch,
D = Deletion of a previous batch, P = Replacement of a previous batch (delete followed by add)
Version/Release Number 102-A2 Value Added: Post Adjudication 10 Version 1.0
Accumulated Deductible Amount 512-FC Add “A” for Post Adjudication to the Standards Format Column
Amount Applied To Periodic Deductible 517-FH Add “A” for Post Adjudication to the Standards Format Column
Amount Attributed to Processor Fee 571-NZ Add “A” for Post Adjudication to the Standards Format Column
Amount Attributed To Product Selection 519-FJ Add “A” for Post Adjudication to the Standards Format Column
Amount Attributed To Sales Tax 523-FN Add “A” for Post Adjudication to the Standards Format Column
Amount Exceeding Periodic Benefit Maximum 520-FK Add “A” for Post Adjudication to the Standards Format Column
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July 2016
DATA DICTIONARY
Field Action
Amount of Coinsurance 572-4U Add “A” for Post Adjudication to the Standards Format Column
Amount Of Copay 518-FI Add “A” for Post Adjudication to the Standards Format Column
Associated Prescription/Service Date 457-EP Add “A” for Post Adjudication to the Standards Format Column
Associated Prescription/Service Reference Number 456-EN Add “A” for Post Adjudication to the Standards Format Column
Authorization Number 503-F3 Add “A” for Post Adjudication to the Standards Format Column
Basis of Calculation -Coinsurance 573-4V Add “A” for Post Adjudication to the Standards Format Column
Basis Of Calculation-Copay 347-HJ Add “A” for Post Adjudication to the Standards Format Column
Basis Of Calculation-Dispensing Fee 346-HH Add “A” for Post Adjudication to the Standards Format Column
Basis Of Calculation-Flat Sales Tax 348-HK Add “A” for Post Adjudication to the Standards Format Column
Basis Of Calculation-Percentage Sales Tax 349-HM Add “A” for Post Adjudication to the Standards Format Column
Basis Of Reimbursement Determination 522-FM Add “A” for Post Adjudication to the Standards Format Column
Cardholder ID 302-C2 Add “A” for Post Adjudication to the Standards Format Column
Claim/Reference ID 435-DZ Add “A” for Post Adjudication to the Standards Format Column
Compound Code 406-D6 Add “A” for Post Adjudication to the Standards Format Column
Compound Ingredient Basis Of Cost Determination 490-UE Add “A” for Post Adjudication to the Standards Format Column
Compound Ingredient Component Count 447-EC Add “A” for Post Adjudication to the Standards Format Column
Compound Ingredient Drug Cost 449-EE Add “A” for Post Adjudication to the Standards Format Column
Compound Ingredient Quantity 448-ED Add “A” for Post Adjudication to the Standards Format Column
Compound Product ID 489-RE Add “A” for Post Adjudication to the Standards Format Column
Compound Product ID Qualifier 488-TE Add “A” for Post Adjudication to the Standards Format Column
Compound Route Of Administration 452-EH Add “A” for Post Adjudication to the Standards Format Column
Creation Date 880-K2 Add “A” for Post Adjudication to the Standards Format Column
Creation Time 880-K3 Add “A” for Post Adjudication to the Standards Format Column
Date Of Birth 304-C4 Add “A” for Post Adjudication to the Standards Format Column
Date Of Injury 434-DY Add “A” for Post Adjudication to the Standards Format Column
Date Of Service 401-D1 Add “A” for Post Adjudication to the Standards Format Column
Date Prescription Written 414-DE Add “A” for Post Adjudication to the Standards Format Column
Days Supply 405-D5 Add “A” for Post Adjudication to the Standards Format Column
Days Supply Intended To Be Dispensed 345-HG Add “A” for Post Adjudication to the Standards Format Column
Diagnosis Code 424-DO Add “A” for Post Adjudication to the Standards Format Column
Diagnosis Code Qualifier 492-WE Add “A” for Post Adjudication to the Standards Format Column
Dispense As Written (DAW)/Product Selection Code 408-D8 Add “A” for Post Adjudication to the Standards Format Column
Dispensing Fee Paid 507-F7 Add “A” for Post Adjudication to the Standards Format Column
Dispensing Status 343-HD Add “A” for Post Adjudication to the Standards Format Column
DUR Co-Agent ID 476-H6 Add “A” for Post Adjudication to the Standards Format Column
DUR Co-Agent ID Qualifier 475-J9 Add “A” for Post Adjudication to the Standards Format Column
DUR/PPS Level Of Effort Code 474-8E Add “A” for Post Adjudication to the Standards Format Column
Eligibility Clarification Code 309-C9 Add “A” for Post Adjudication to the Standards Format Column
Facility ID 336-8C Add “A” for Post Adjudication to the Standards Format Column
File Type 702-MC Add “A” for Post Adjudication to the Standards Format Column
Fill Number 403-D3 Add “A” for Post Adjudication to the Standards Format Column
Flat Sales Tax Amount Paid 558-AW Add “A” for Post Adjudication to the Standards Format Column
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DATA DICTIONARY
Field Action
Gross Amount Due 430-DU Add “A” for Post Adjudication to the Standards Format Column
Group ID 301-C1 Add “A” for Post Adjudication to the Standards Format Column
Incentive Amount Paid 521-FL Add “A” for Post Adjudication to the Standards Format Column
Ingredient Cost Paid 506-F6 Add “A” for Post Adjudication to the Standards Format Column
Ingredient Cost Submitted 409-D9 Add “A” for Post Adjudication to the Standards Format Column
Level Of Service 418-DI Add “A” for Post Adjudication to the Standards Format Column
Network Reimbursement ID 545-2F Add “A” for Post Adjudication to the Standards Format Column
Number Of Refills Authorized 415-DF Add “A” for Post Adjudication to the Standards Format Column
Other Amount Paid 565-J4 Add “A” for Post Adjudication to the Standards Format Column
Other Amount Paid Qualifier 564-J3 Add “A” for Post Adjudication to the Standards Format Column
Other Coverage Code 308-C8 Add “A” for Post Adjudication to the Standards Format Column
Other Payer Amount Recognized 566-J5 Add “A” for Post Adjudication to the Standards Format Column
Other Payer-Patient Responsibility Amount 352-NQ Add “A” for Post Adjudication to the Standards Format Column
Other Payer-Patient Responsibility Amount Qualifier 351-NP
Add “A” for Post Adjudication to the Standards Format Column; Value Added:8=7= Amount
Attributed to Product Selection (519-FJ) for Non-preferred Formulary as reported by previous
payer. Value Changed: From 2 = Amount Attributed to Product Selection (519-FJ) as reported by
previous payer. To 2= Amount Attributed to Product Selection (519-FJ) for Brand as reported by
previous payer.
Patient Gender Code 305-C5 Add “A” for Post Adjudication to the Standards Format Column
Patient ID 332-CY Add “A” for Post Adjudication to the Standards Format Column
Patient Pay Amount 505-F5 Add “A” for Post Adjudication to the Standards Format Column
Patient Relationship Code 306-C6 Add “A” for Post Adjudication to the Standards Format Column
Percentage Sales Tax Amount Paid 559-AX Add “A” for Post Adjudication to the Standards Format Column
Percentage Sales Tax Basis Paid 561-AZ Add “A” for Post Adjudication to the Standards Format Column
Percentage Sales Tax Rate Paid 560-AY Add “A” for Post Adjudication to the Standards Format Column
Person Code 303-C3 Add “A” for Post Adjudication to the Standards Format Column
Plan Type 601-01 Add “A” for Post Adjudication to the Standards Format Column
Prescriber ID Qualifier 466-EZ Add “A” for Post Adjudication to the Standards Format Column
Prescriber ID 411-DB Add “A” for Post Adjudication to the Standards Format Column
Prescriber Location Code 467-1E Add “A” for Post Adjudication to the Standards Format Column
Prescription Origin Code 419-DJ Add “A” for Post Adjudication to the Standards Format Column
Prescription/Service Reference Number 402-D2 Add “A” for Post Adjudication to the Standards Format Column
Prescription/Service Reference Number Qualifier 455-EM Add “A” for Post Adjudication to the Standards Format Column
Primary Care Provider ID 421-DL Add “A” for Post Adjudication to the Standards Format Column
Primary Care Provider ID Qualifier 468-2E Add “A” for Post Adjudication to the Standards Format Column
Primary Care Provider Location Code 469-H5 Add “A” for Post Adjudication to the Standards Format Column
Prior Authorization Number - Assigned 498-PY Add “A” for Post Adjudication to the Standards Format Column
Prior Authorization Number Submitted 462-EV Add “A” for Post Adjudication to the Standards Format Column
Prior Authorization Type Code 461-EU Add “A” for Post Adjudication to the Standards Format Column
Procedure Modifier Code 459-ER Add “A” for Post Adjudication to the Standards Format Column
Product/Service ID 407-D7 Add “A” for Post Adjudication to the Standards Format Column
Product/Service ID Qualifier 436-E1 Add “A” for Post Adjudication to the Standards Format Column
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July 2016
DATA DICTIONARY
Field Action
Professional Service Code 440-E5 Add “A” for Post Adjudication to the Standards Format Column
Professional Service Fee Paid 562-J1 Add “A” for Post Adjudication to the Standards Format Column
Quantity Dispensed 442-E7 Add “A” for Post Adjudication to the Standards Format Column
Quantity Intended To Be Dispensed 344-HF Add “A” for Post Adjudication to the Standards Format Column
Quantity Prescribed 460-ET Add “A” for Post Adjudication to the Standards Format Column
Reason For Service Code 439-E4 Add “A” for Post Adjudication to the Standards Format Column
Receiver ID 880-K7 Add “A” for Post Adjudication to the Standards Format Column
Reject Code 511-FB Add “A” for Post Adjudication to the Standards Format Column
Remaining Benefit Amount 514-FE Add “A” for Post Adjudication to the Standards Format Column
Remaining Deductible Amount 513-FD Add “A” for Post Adjudication to the Standards Format Column
Result Of Service Code 441-E6 Add “A” for Post Adjudication to the Standards Format Column
Service Provider ID 201-B1 Add “A” for Post Adjudication to the Standards Format Column
Service Provider ID Qualifier 202-B2 Add “A” for Post Adjudication to the Standards Format Column
Submission Clarification Code 420-DK Add “A” for Post Adjudication to the Standards Format Column
Tax Exempt Indicator 557-AV Add “A” for Post Adjudication to the Standards Format Column
Telephone Number 732 Add “A” for Post Adjudication to the Standards Format Column
Unit Dose Indicator 429-DT Add “A” for Post Adjudication to the Standards Format Column
Unit Of Measure 600-28 Add “A” for Post Adjudication to the Standards Format Column
Usual And Customary Charge 426-DQ Add “A” for Post Adjudication to the Standards Format Column
Zip/PostalCode 730 Add “A” for Post Adjudication to the Standards Format Column
Appendix A - ALPHABETIC CROSS REFERENCE X Added New Fields and Indicated A for Existing Fields Shown Above
Appendix B - NUMERIC CROSS REFERENCE X Added New Fields and Indicated A for Existing Fields Shown Above

Field Action
Patient Assignment Indicator (Direct Member Reimbursement 391-MT X
Indicator)
Benefit Stage Count 392-MU X
Benefit Stage Qualifier 393-MV X
Benefit Stage Amount 394-MW X
Amount Attributed To Product Selection Qualifier 576-MQ X
Other Payer-Patient Responsibility Amount Qualifier 351-NP Added Value: 8= Amount Attributed to Product Selection (519-FJ) for Non-preferred Formulary
as reported by previous payer. Modified Value: From 2=Amount Attributed to Product
Selection (519-FJ) as reported by previous payer. To 2= Amount Attributed to Product Selection
(519-FJ) for Brand as reported by previous payer.
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DATA DICTIONARY
W. OCTOBER 2006
1. SCRIPT Standard Version 10.0

X. JANUARY 2007

Field Action
Internal Control Number 993-A7 X
Route of Administration 995-E2 X
Compound Type 996-G1 X
CMS Part D Defined Qualified Facility 997-G2 X
Estimated Generic Savings 577-G3 X
Other Payer Coverage Type 338-5C Added Values-See ECL
Unit Dose Indicator 429-DT Name Change to Special Packaging Indicator and Definition Change Added Values-
See ECL
Submission Clarification Code 420-DK Added Values-See ECL
URL 987-MA Added “T” for Telecommunication to the Standards Format Column
Reject Code 511-FB Added, Removed, and Modified Values-See ECL
Compound Route of Administration 452-EH Deleted “T” for Telecommunication to the Standards Format Column in order to use new data
element Route of Administration (995-E2)
Y. APRIL 2007

Field Action
Invoiced Amount 1 150-VF X
Invoiced Amount 2 151-VG X
Invoiced Amount 3 152-VH X
Invoiced Amount 4 153-VJ X
Invoiced Amount 5 154-VK X
Invoiced Per Unit Amount 1 155-VL X
Invoiced Per Unit Amount 2 156-VM X
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July 2016
DATA DICTIONARY
Field Action
Invoiced Per Unit Amount 3 157-VN X
Invoiced Per Unit Amount 4 158-VP X
Invoiced Per Unit Amount 5 159-VQ X
Invoice Price 1 160-VR X
Invoice Price 2 161-VS X
Invoice Price 3 162-VT X
Invoice Price 4 163-VU X
Invoice Price 5 164-VV X
Invoice Rate 1 165-VW X
Invoice Rate 2 166-VX X
Invoice Rate 3 167-VY X
Invoice Rate 4 168-VZ X
Invoice Rate 5 169-WA X
Invoice Type 1 170-WB X
Invoice Type 2 171-WC X
Invoice Type 3 172-WD X
Invoice Type 4 173-WF X
Invoice Type 5 174-WG X
Paid Amount 1 175-WH X
Paid Amount 2 176-WJ X
Paid Amount 3 177-WK X
Paid Amount 4 178-WL X
Paid Amount 5 179-WM X
Paid Base Price 1 180-WN X
Paid Base Price 2 181-WP X
Paid Base Price 3 182-WQ X
Paid Base Price 4 183-WR X
Paid Base Price 5 184-WS X
Paid Per Unit Amount 1 185-WT X
Paid Per Unit Amount 2 186-WU X
Paid Per Unit Amount 3 187-WV X
Paid Per Unit Amount 4 188-WW X
Paid Per Unit Amount 5 189-WX X
Paid Quantity 1 190-WY X
Paid Quantity 2 191-WZ X
Paid Quantity 3 192-XA X
Paid Quantity 4 193-XB X
Paid Quantity 5 194-XC X
Paid Rate 1 195-XD X
Paid Rate 2 196-XF X
Paid Rate 3 197-XG X
Paid Rate 4 198-XH X
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July 2016
DATA DICTIONARY
Field Action
Paid Rate 5 199-XJ X
Segment 1 638-XK X
Segment 2 639-XL X
Segment 3 640-XM X
Segment 4 641-XN X
Segment 5 642-XP X
Segment 6 643-XQ X
Segment Qualifier 1 644-XR X
Segment Qualifier 2 645-XS X
Segment Qualifier 3 646-XT X
Segment Qualifier 4 647-XU X
Segment Qualifier 5 648-XV X
Segment Qualifier 6 649-XW X
Pharmacy Service Type 147-U7 X
Adjudication Date 578 Added Rebates To Standards Format Column
Adjudication Time 203 Added Rebates To Standards Format Column
Adjusted Quantity 601-71 Definition Changed
Adjusted Variance Difference 601-72 Definition Changed
Baseline 601-77 Deleted Field
Baseline Description 601-78 Deleted Field
Baseline Qualifier 601-79 Deleted Field
Base Price 601-74 Deleted Field
Base Price Description 601-75 Deleted Field
Base Price Type 601-76 Deleted Field
Benefit Stage Qualifier 393-MV Added Rebates To Standards Format Column
Compound Code 406-D6 Added Rebates To Standards Format Column
Data Level 601-31 Values: Deleted CI=Contracting organization pharmacy ID level, CZ=Contracting organization
pharmacy zip code level, PI=Plan pharmacy ID level, PZ=Plan pharmacy zip code level; Added
RS=Reconciliation detail-State Medicaid, US=Utilization detail –State Medicaid
Dispensing Status 343-HD Added Rebates To Standards Format Column
Disputed Quantity 601-85 Definition Changed
Entity Zip/Postal Code 784 Added Rebates To Standards Format Column
FF Accepted Metric Decimal Quantity 601-86 Name Changed:
From: FF Accepted Metric Decimal Quantity
To: Accepted Quantity
FF Action Code 601-36 Name Changed:
From: FF Action Code
To: Submit Code
Values Changed:
To:
00=Original or initial submission of data.
02=Correction or Adjustment to previous submission rebate period.
03= Delete entire previous submission rebate period.
05=Replace entire previously submitted rebate period.
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July 2016
DATA DICTIONARY
Field Action
FF Contracting Organization (PMO) ID Qualifier 600-71 Name Changed:
From: FF Contracting Organization (PMO) ID Qualifier
To: Contracting Organization (PMO) ID Qualifier
Format Changed:
From: x(1)
To: x(2)
FF Data Provider ID Qualifier 601-37 Name Changed:
From: FF Data Provider ID Qualifier
To: Data Provider ID Qualifier
Format Changed:
From: x(1)
To: x(2)
FF Manufacturer (PICO) ID Qualifier 600-72 Name Changed:
From: FF Manufacturer (PICO) ID Qualifier
To: Manufacturer (PICO) ID Qualifier
Format Changed:
From: x(1)
To: x(2)
FF New/Refill Code 601-57 Deleted Field
FF Prescriber ID Qualifier 601-38 Deleted Field
FF Total Metric Decimal Quantity 601-39 Name Changed:
From: FF Total Metric Decimal Quantity
To: Total Quantity
FF Total Number Of Prescriptions 601-40 Name Changed:
From: FF Total Number Of Prescriptions
To: Total Number Of Prescriptions
Fill Number 403-D3 Added Rebates To Standards Format Column and move values to ECL
Grand Total Accepted Metric Decimal Quantity 601-87 Name Changed:
From: Grand Total Accepted Metric Decimal Quantity
To: Grand Total Accepted Quantity
Grand Total Metric Decimal Quantity 601-41 Name Changed:
From: Grand Total Metric Decimal Quantity
To: Grand Total Quantity
Definition Changed
Grand Total Paid Rebate Amount 601-88 Definition Change
Name Changed:
From: Grand Total Paid Rebate Amount
To: Grand Total Paid Amount
Grand Total Requested Rebate Amount 601-42 Name Changed:
From: Grand Total Requested Rebate Amount
To: Grand Total Requested Amount
Level Achieved 601-90 Deleted Field
Number of Rebate Type Records 601-91 Deleted Field
Other Coverage Code 308-C8 Added Rebates To Standards Format Column
Paid Rebate Amount 601-96 Definition Change
Performance 601-97 Deleted Field
Performance Description 601-98 Deleted Field
Performance Qualifier 601-99 Deleted Field
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July 2016
DATA DICTIONARY
Field Action
Pharmacy ID Code 601-45 Deleted Field
Pharmacy ID Qualifier 601-46 Deleted Field
Pharmacy Zip Code 835-5R Deleted Rebates To Standards Format Column
Plan Reimbursement Amount 601-47 Name Changed:
From: Plan Reimbursement Amount
To: Reimbursement Amount
Plan Reimbursement Qualifier 601-48 Name Changed:
From: Plan Reimbursement Qualifier
To: Reimbursement Qualifier
Definition Changed
Format Changed:
From: x(1)
To: x(2)
Values Changed (Added zero due to format change)

01=Includes dispensing fee
02=Excludes dispensing fee
Prescriber ID 411-DB Format Change For Rebates:
From: x(10)
To: x(15)
Prescriber ID Qualifier 466-EZ Added Rebates To Standards Format Column
Add Values for Rebate:

A=AMA or Medical Education (ME) number
B=AOA Doctor of Osteopathy (DO) number
C=Contracting Organization PMO number
D=DEA number
H=HIBCC HIN
M=Manufacturer (PICO) assigned number
P=National Provider Id
T=Telephone number
Z=Mutually agreed upon Id number
Prescription/Service Reference Number 402-D2 Added Rebates To Standards Format Column
Prescription/ 455-EM Added Rebates To Standards Format Column
Service Reference Number Qualifier Add Values for Rebate:
Rebates Standard Values:
1=Telecommunication v5.1-6.0 Rx- 7 bytes
2=Telecommunication v 7.0–C.4 Rx- 9 bytes
3=Telecommunication v D0 or higher Rx-12 bytes
Z=Trading Partner Defined
Product Code 601-18 Deleted Field

Product Code Qualifier 601-19 Deleted Field
Product Generic Name 601-23 Definition Change
Product/Service ID 407-D7 Added Rebates To Standards Format Column
Product/Service ID Qualifier 436-E1 Added Rebates To Standards Format Column
- 229 -
July 2016
DATA DICTIONARY
Field Action
Rebate Rate 602-04 Deleted Field
Rebate Type 602-05 Deleted Field
Rebate Type Description 602-06 Deleted Field
Rebate Variance Amount 602-07 Deleted Field
Rebate Version Release Number 601-03 Add Value:
04.01=Version 04.01
(Add to ECL)
Reconciliation Reason Code 602-10 Appendix Name Changed: (In ECL)
From: APPENDIX F – CMS RECONCILIATION REASON CODES FOR DETAIL (RD) RECORDS
To: APPENDIX F – CMS RECONCILIATION REASON CODES FOR DETAIL (RS) RECORDS
Record Type 601-04 Values: Deleted RT=Rebate Type Record
Added
US=Utilization Detail State Format
RS=Reconciliation Detail State Format
Service Provider ID 201-B1 Added Rebates To Standards Format Column
Service Provider ID Qualifier 202-B2 Added Rebates To Standards Format Column
Appendix A - ALPHABETIC CROSS REFERENCE X Added New Fields and Adjusted Standard Usage as Shown Above
Appendix B - NUMERIC CROSS REFERENCE X Added New Fields and Adjusted Standard Usage as Shown Above
Z. JULY 2007
1. Telecommunication Version D Release 0

Field Action
Billing Entity Type Indicator 117-TR X
Pay To Qualifier 118-TS X
Pay To ID 119-TT X
Pay To Name 120-TU X
Pay To Street Address 121-TV X
Pay To City Address 122-TW X
Pay to State/ Province Address 123-TX X
Pay To Zip/Postal Zone 124-TY X
Generic Equivalent Product ID Qualifier 125-TZ X
Generic Equivalent Product ID 126-UA X
Spending Account Amount Remaining 128-UC X
Health Plan-funded Assistance Amount 129-UD X
Additional Message Information Count 130-UF X
Additional Message Information Continuity 131-UG X
Additional Message Information Qualifier 132-UH X
Amount Attributed to Provider Network Selection 133-UJ X
Amount Attributed to Product Selection / Brand Drug 134-UK X
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July 2016
DATA DICTIONARY
Field Action
Amount Attributed to Product Selection / Non-Preferred Formulary 135-UM X
Selection
Amount Attributed to Product Selection / Brand Non-Preferred 136-UN X
Formulary Selection
Amount Attributed to Coverage Gap 137-UP X
CMS Low Income Cost Sharing (LICS) Level 138-UQ X
Medicare Part D Coverage Code 139-UR X
Next Medicare Part D Effective Date 140-US X
Next Medicare Part D Termination Date 141-UT X
Other Payer Person Code 142-UV X
Other Payer Patient Relationship Code 143-UW X
Other Payer Benefit Effective Date 144-UX X
Other Payer Benefit Termination Date 145-UY X
Other Payer Help Desk Phone Number 127-UB X
Pharmacy Service Type 147-U7 Added Telecommunication To Standards Format Column
Ingredient Cost Contracted/ Reimbursable Amount 148-U8 X
Dispensing Fee Contracted/ Reimbursable Amount 149-U9 X
Other Coverage Code 308-C8 Values: Modify definition: 8 = Claim is billing for patient financial responsibility only; 3=Other
Coverage Billed – claim not covered; 0= Not specified by patient Delete: 5=Managed care plan
denial; 6=Other coverage denied-not participating provider; 7=Other coverage exists-not in
effect on DOS
Preferred Product Copay Incentive 555-AT Field name to: Preferred Product Cost Share Incentive
Preferred Product Count 551-9F Comments Change to: ‘Preferred Product Cost Share Incentive’ (555-AT)
Prior Authorization Type Code 461-EU Values: Change 4=Exemption from Copay and/or Coinsurance; Add 9=Emergency
Preparedness=Code used to override claim edits during an emergency situation.
Other Amount Claimed Submitted Qualifier 479-H8 Values: Delete Blank=Not Specified
Other Amount Paid Qualifier 564-J3 Values: Change Blank=Not Specified (This value is not allowed for the Telecommunication
Standard)
Other Payer-Patient Responsibility Amount Qualifier 351-NP Values: Add 09=Amount attributed to Health Plan Assistance Amount (129-UD) as reported by
previous payer; 10 = Amount Attributed to Provider Network Selection (133-UJ) as reported by
previous payer. ; 11 = Amount Attributed to Product Selection - Brand Non-Preferred
Formulary Selection (136-UN) as reported by previous payer. ; 12=Amount Attributed to
Coverage Gap (137-UP) that was collected from the patient due to a coverage gap.; 13=
Amount Attributed to Processor Fee (571-NZ) as reported by previous payer. Change
02=Amount Attributed to Product Selection – Brand Drug (134-UK) as reported by previous
payer. 08= Amount Attributed to Product Selection - Non-Preferred Formulary Selection (135-
UM) as reported by previous payer.
Additional Message Information 526-FQ Format= Change from x(1)-x(200) to X(1)-x(40)
Amount Attributed To Product Selection 519-FJ Delete use of the Telecommunication Standard for this field.
Amount Attributed to Product Selection Qualifier 576-MQ Delete Field—Telecommunication is the only Standard that uses this field. Grey out in DD as
not used.
Approved Message Code 548-6F Values: Add
004 Filled During Transition Benefit
005 Filled During Transition Benefit/Prior Authorization Required
006 Filled During Transition Benefit/Non-Formulary
007 Filled During Transition Benefit/Other Rejection
- 231 -
July 2016
DATA DICTIONARY
Field Action
008 Emergency Fill Situation
009 Emergency Fill Situation/Prior Authorization Required
010 Emergency Fill Situation/Non-Formulary
011 Emergency Fill Situation/Other rejection
012 Level of Care Change
013 Level Of Care Change/ Prior Authorization Required
014 Level Of Care Change /Non-Formulary
015 Level Of Care Change /Other rejection
Transaction Response Status 112-AN Values: Add B=Benefit; Comments: Remove Comments: Used in the response status segment.
Transaction Code 103-A3 Values: Add D1=Predetermination of Benefits ; S1=Service Billing; S2=Service Reversal ;
S3=Service Rebill
Authorized Representative City Address 498-PH Comments: Remove Comments: Required by some plans to capture this information, if
applicable.
Authorized Representative First Name 498-PE Comments: Remove Comments: Required by some plans to capture this information, if
applicable.
Authorized Representative Last Name 498-PF Comments: Remove Comments: Required by some plans to capture this information, if
applicable.
Authorized Representative State/Province Address 498-PJ Comments: Remove Comments: Required by some plans to capture this information, if
applicable.
Authorized Representative Street Address 498-PG Comments: Remove Comments: Required by some plans to capture this information, if
applicable.
Authorized Representative Zip/Postal Zone 498-PK Comments: Remove Comments: Required by some plans to capture this information, if
applicable.
BIN Number 101-A1 Comments: Change BIN to IIN when referencing ANSI. Note that IIN is formerly BIN. Add note
about contacting NCPDP for Processor BIN Number.
Comments: Each processor will need to have a BIN IIN (formerly BIN) assigned by:
American National Standards Institute; 5 West 43rd Street; New York, NY 10036
(212) 642-4900
or a Processor Number assigned by:
National Council for Prescription Drug Programs; 9240 E Raintree Dr; Scottsdale, AZ; 85260-
7518;Phone: (480) 477-1000; Fax: (480) 767-1042; Contact: NCPDP Provider Services;
http://www.ncpdp.org
Date of Injury 434-DY Comments: Remove Comments: This field is used primarily for Worker's Compensation Claims.
Days Supply Intended to be Dispensed 345-HG Comments: Remove Comments: If sending this field, an assumption is made that ‘Quantity
Intended To Be Dispensed’ (344-HF) is also sent.
Dispensing Fee Paid 507-F7 Comments: Remove Comments: Included in the prescription response.
Dispensing Fee Submitted 412-DC Comments: Remove Comments: Included in the prescription request.
Dispensing Status 343-HD Comments: Remove Comments: A full quantity dispensed is indicated by either not sending or
not populating this field.
Values: Delete Blank=Not Specified
Flat Sales Tax Amount Paid 558-AW Comments: Remove Comments: Included in Prescription and Service Response.
Flat Sales Tax Amount Submitted 481-HA Comments: Remove Comments: Included in the Prescription Claim and Service Claim Request.
Add The submission of sales tax is governed by regulatory agencies (state, local, parish, etc). If
the sales tax reported is a flat rate, then it is a fixed amount for a certain dollar value (for
example for $xxx it is a certain amount). For example, for $100 the flat rate is $1.99. This flat
rate is then reported in Flat Sales Tax Amount Submitted (481-HA).
Group ID 301-C1 Comments: Remove Comments: Processor defined value to communicate the originator’s
grouping of the cardholder.
- 232 -
July 2016
DATA DICTIONARY
Field Action
Incentive Amount Paid 521-FL Comments: Remove Comments: Included in the prescription response.
Incentive Amount Submitted 438-E3 Comments: Remove Comments: Included in the Prescription Response.
Ingredient Cost Paid 506-F6 Comments: Remove Comments: Included in the Prescription Response.
Ingredient Cost Submitted 409-D9 Comments: Remove Comments: Included in the Prescription Request.
Intermediary Authorization Type ID 463-EW Comments: Change From: Comments: Usage Change—Check Implementation Guide when
value = 99 To: Comments: See Implementation Guide (Under Claim Segment in Specific
Segment Discussion) when value = 99 .
Originally Prescribed Product/Service Code 445-EA Comments: Remove Used to provide necessary data to calculate the exact difference in cost
between the prescribed product and the dispensed product.
Originally Prescribed Quantity 446-EB Comments: Remove To provide data necessary to calculate the exact difference in cost
between the prescribed product and the dispensed product. For use with therapeutic
interchange only.
Other Amount Claimed Submitted 480-H9 Comments: Remove Included in the Prescription Claim and Service Claim Request.
Amount is included in the ‘Gross Amount Due’ (430-DU).
Other Amount Paid 565-J4 Comments: Remove
Comments: Included in Prescription and Service Response.
Other Payer Amount Paid 431-DV Definition Change
Comments: Remove Comments: Included in the Prescription and Service Claim Request.
Other Payer Amount Recognized 566-J5 Definition Change
Comments: Remove Comments: Included in Prescription and Service Response.
Other Payer Cardholder ID 356-NU Comments: Remove Comments: Required on a rejected response when available. Change from
Response Status Segment. to Response Coordination of Benefits/Other Payers Segment.
Other Payer ID Count 355-NT Comments: Remove Comment: Required on a rejected response when the sender is providing
other payer information Change from Response Status Segment. to Response Coordination of
Benefits/Other Payers Segment.
Other Payer-Patient Responsibility Amount 352-NQ Comments: Remove Comment: This field is submitted by the pharmacist for the purpose of
billing the patient’s financial responsibility as reported by the previous payer.
Patient ID 332-CY Comments: Remove Comment: This field is used to uniquely identify the patient for purposes
other than billing.
Patient ID Qualifier 331-CX Values: Delete Blank=Not Specified Add 06=Medicaid ID
Patient Paid Amount Submitted 433-DX Comments: Remove Comments: Included in the Prescription and Service Claim Request. Add
Comments:. This field is not used in coordination of benefit transactions to pass patent liability
information to a downstream payer. See Other Payer-Patient Responsibility Amount (352-NQ)
Patient Pay Amount 505-F5 Comments: Remove Comments: Included in the Prescription Response.
Percentage Sales Tax Amount Paid 559-AX Comments: Remove Comments: Included in Prescription and Service Response.
Percentage Sales Tax Amount Submitted 482-GE Comments: Remove Comments: Included in prescription claim and service claim request. This
amount is included in the ‘Gross Amount Due’ (430-DU).
Add Comments:. The submission of sales tax is governed by regulatory agencies (state, local,
parish, etc).
Person Code 303-C3 Comments: Remove under Telecommunication Comments: Person Code is optionally used in
conjunction with the Cardholder ID, Field 302-C2, to uniquely identify family members within
the cardholder ID.
Prescriber Last Name 427-DR Comments: Remove Comments: This field is used sometimes when a prescriber number is
unknown or not available.
Prior Authorization Dollars Authorized 498-RB Examples: Remove Examples: Provided to the pharmacy by the processor to be used by the
pharmacy to bill the plan. If the prior authorization dollars authorized is $76.00 this field would
reflect: 760{.
Prior Authorization Quantity 498-RA Comments: Reword Comments: Provided to the pharmacy by the processor to allow convey the
- 233 -
July 2016
DATA DICTIONARY
Field Action
pharmacy to dispense the number of units authorized.
Prior Authorization Quantity Accumulated 498-PX Comments: Reword Comments: Provided to the pharmacy by the processor to be used by the
pharmacy for billing, and if applicable, reversal purposes. to determine quantity remaining for
billing.
Professional Service Fee Paid 562-J1 Comments: Remove Comments: Included in the Service Response.
Professional Service Fee Submitted 477-BE Comments: Remove Comments: Included in the Service Request. This amount is included in the
‘Gross Amount Due’ (430-DU).
Quantity Intended To Be Dispensed 344-HF Comments: Remove If sending this field, an assumption is made that ‘Days Supply Intended To
Be Dispensed’ (345-HG) is also sent.
Remaining Benefit Amount 514-FE Examples: Remove Examples: Patient has $100.00 benefits. The patient pays $40.00 for a
prescription. The remaining benefit amount would be $60.00, and this field would reflect: 600{.
Transaction Count 109-A9 Comments: Reword From: Field value defaults to ‘1’. A value >‘1’ applies to all transaction
codes except ‘E’ and ‘P’’ transactions. To: A transaction count of >’1’ is not allowed for
‘Eligibility’ and ‘Prior Authorization’ transactions.
Value: Delete Blank=Not Specified
Primary Care Provider Location Code 469-H5 Deleted use by the Telecommunication Standard
Prescriber Location Code 467-1E Deleted use by the Telecommunication Standard
Prescriber ID Qualifier 466-EZ Values: Add 15=HCID (HC IDea) = A 10-character, alphanumeric identifier assigned by NCPDP to
identify authorized prescribers of drugs. Change 99=Other = used to identify the HCIdea
number or other health plans and enumerating organizations not listed above.; Blank=Not
Specified (This value is not allowed for the Telecommunication Standard)
Primary Care Provider ID Qualifier 468-2E Values: Add 15=HCID (HC IDea) = A 10-character, alphanumeric identifier assigned by NCPDP to
identify authorized prescribers of drugs. Change 99=Other = used to identify the HCIdea
number or other health plans and enumerating organizations not listed above.; Blank=Not
Specified (This value is not allowed for the Telecommunication Standard)
Service Provider ID Qualifier 202-B2 Values: Add 15=HCID (HC IDea) = A 10-character, alphanumeric identifier assigned by NCPDP to
identify authorized prescribers of drugs. Change Blank=Not Specified (This value is not allowed
for the Telecommunication Standard); 99=Other = used to identify the HCIdea number or
other health plans and enumerating organizations not listed above.
Dispense As Written Product Selection Code 408-D8 Values: Change Name and Definition From: 9=Other-This value is reserved and currently not in
use. NCPDP does not recommend use of this value at the present time. Please contact NCPDP if
you intend to use this value and document how it will be utilized by your organization. To:
9=Substitution Allowed By Prescriber but Plan Requests Brand - Patient's Plan Requested Brand
Product To Be Dispensed - This value is used when the prescriber has indicated, in a manner
specified by prevailing law, that generic substitution is permitted, but the plan's formulary
requests the brand product. This situation can occur when the prescriber writes the
prescription using either the brand or generic name and the product is available from multiple
sources; Change Definition From: 0=No Product Selection Indicated-This is the field default
value that is appropriately used for prescriptions where product selection is not an issue.
Examples include prescriptions written for single source brand products and prescriptions
written using the generic name and a generic product is dispensed. To: 0=No Product Selection
Indicated - This is the field default value that is appropriately used for prescriptions for single
source brand, co-branded/co-licensed, or generic products. For a multi-source branded
product with available generic(s), DAW 0 is not appropriate, and may result in a reject. From:
1=Substitution Not Allowed by Prescriber-This value is used when the prescriber indicates, in a
manner specified by prevailing law, that the product is to be Dispensed As Written To: 1=
Substitution Not Allowed by Prescriber – This value is used when the prescriber indicates, in a
manner specified by prevailing law, that the product is to be Dispensed As Written. DAW 1 is
based on prescriber instruction and not product classification.
- 234 -
July 2016
DATA DICTIONARY
Field Action
Date of Service 401-D1 Definition Change
Submission Clarification Code 420-DK Values: Add 19= Split Billing - indicates the quantity dispensed is the remainder billed to a
subsequent payer when Medicare Part A expires. Used only in long-term care settings. Change
0=Not Specified, Default (This value is not allowed for the Telecommunication Standard)
Contract Number 240-U1 Comments: Add Response Insurance Additional Information Segment.; Field ID Add U1; Add
to Telecommunication for Standard Formats; Definition Change
Benefit ID 757-U6 Comments: Add Response Insurance Additional Information Segment. Note: For Part D, used
to identify the PBP (Plan Benefit Package) Number.; Field ID Add U6; Add to
Telecommunication for Standard Formats; Definition Change
Date of Birth 304-C4 Comments: Add Response Patient Segment.
Formulary ID 926-FF Comments: Add Response Insurance Additional Information Segment.; Add to
Telecommunication for Standard Formats
Other Payer Coverage Type 338-5C Comments: Add Response Coordination of Benefits/Other Payers Segment
Values: Remove 98=Coupon; 99=Composite
Other Payer Group ID 992-MJ Comments: Add Response Coordination of Benefits/Other Payers Segment; Remove Response
Status Segment
Other Payer ID 340-7C Comments: Add Response Coordination of Benefits/Other Payers Segment; Remove Response
Status Segment
Other Payer ID Qualifier 339-6C Comments: Add Response Coordination of Benefits/Other Payers Segment; Remove Response
Status Segment
Values: Remove Blank=Not Specified; 09=Coupon
Other Payer Processor Control Number 991-MH Comments: Add Response Coordination of Benefits/Other Payers Segment; Remove Response
Status Segment
Patient First Name 310-CA Comments: Add Response Patient Segment.
Patient Last Name 311-CB Comments: Add Response Patient Segment.
Other Payer Amount Paid Qualifier 342-HC Values: Remove Blank=Not Specified; 08=Sum of All Reimbursements; 98 = Coupon; 99=Other
Prescription/Service Reference Number 402-D2 Format= Change From 9(9) To 9(12)
Associated Prescription/Service Reference Number 456-EN Format= Change From 9(9) To 9(12)
Cardholder ID 302-C2 Definition Change
Comments: Add Response Insurance Segment.
Percentage Sales Tax Rate Submitted 483-HE Comments: Add Comments:. The submission of sales tax is governed by regulatory agencies
(state, local, parish, etc).
Percentage Sales Tax Basis Submitted 484-JE Comments: Add Comments:. The submission of sales tax is governed by regulatory agencies
(state, local, parish, etc).
Values: Delete 01=Gross Amount Due
Percentage Sales Tax Basis Paid 561-AZ Values: Delete 01=Gross Amount Due
Basis of Reimbursement Determination 522-FM Values: Add 14=Other Payer-Patient Responsibility Amount - Indicates reimbursement was
based on the Other Payer Patient Responsibility Amount (352-NQ); 15=Patient Pay Amount-
Indicates reimbursement was based on the Patient Pay Amount (505-F5).; 16=Coupon
Payment–Indicates reimbursement was based on the Coupon Value Amount (487-NE)
submitted or coupon amount determined by the processor.
Basis of Calculation -Coinsurance 573-4V Values: Change Blank= Not Specified (This value is not allowed for the Telecommunication
Standard); 00= Not Specified (This value is not allowed for the Telecommunication Standard)
Basis Of Calculation-Copay 347-HJ Values: Change Blank= Not Specified (This value is not allowed for the Telecommunication
Basis Of Calculation-Dispensing Fee 346-HH Values: Change Blank= Not Specified (This value is not allowed for the Telecommunication
- 235 -
July 2016
DATA DICTIONARY
Field Action
Basis Of Cost Determination 423-DN Values: Change Blank= Not Specified (This value is not allowed for the Telecommunication
Standard); 00= Not Specified Default
Clinical Significance Code 528-FS Values: Define 9=Undetermined—a value to describe a professional service with variable or
unknown severity.
Compound Code 406-D6 Values: Change Blank= Not Specified (This value is not allowed for the Telecommunication
Standard)
Compound Product ID Qualifier 488-RE Values: Change Blank= Not Specified (This value is not allowed for the Telecommunication
Standard)
(Reference Section II, Appendix B1 – Product/Service Qualifier of the ECL)
Coupon Type 485-KE Values: Delete Blank=Not Specified
Database Indicator 532-FW Values: Change Blank= Not Specified (This value is not allowed for the Telecommunication
Standard)
Diagnosis Code Qualifier 492-WE Values: Change Blank= Not Specified (This value is not allowed for the Telecommunication
Standard)
DUR Co-Agent ID Qualifier 475-J9 Values: Change Blank= Not Specified (This value is not allowed for the Telecommunication
Standard)
Help Desk Phone Number Qualifier 549-7F Values: Delete Blank=Not Specified
Number of Refills Authorized 415-DF Values: Change 0=No Refills Authorized
Originally Prescribed Product/Service ID Qualifier 453-EJ Values: Delete Blank=Not Specified; 00=Not Specified
Preferred Product ID Qualifier 552-AP Values: Delete Blank=Not Specified (Reference Section II,
Appendix B1 – Product/Service Qualifier of the ECL)
Prescription Origin Code 419-DJ Values: Change 0=Not Known
Prescription/Service Reference Number Qualifier 455-EM Values: Change Blank= Not Specified (This value is not allowed for the Telecommunication
Standard)
Product/Service ID Qualifier 436-E1 Values: Delete Blank=Not Specified (Reference Section II,
Appendix B1 – Product/Service Qualifier of the ECL)
Provider ID Qualifier 465-EY Values: Delete Blank=Not Specified
Other Payer-Patient Responsibility Amount Count 353-NR Format= Increased to 9(2)
Reject Code 511-FB See ECL for new reject codes.
Tax Exempt Indicator 557-AV Definition Change; Values: 2 deleted and 3 and 4 added—Values moved to ECL
Version/Release Number 102-A2 Added Value: D0=Version D.0
Appendix A - ALPHABETIC CROSS REFERENCE X Added New Fields and Adjusted Standard Usage as Shown Above
Appendix B - NUMERIC CROSS REFERENCE X Added New Fields and Adjusted Standard Usage as Shown Above
2. Medicaid Subrogation Implementation Guide Version 3 Release 0

Field Action
Medicaid Paid Amount 113-N3 X
Medicaid Subrogation Internal Control Number/Transaction Control 114-N4 X
Number (ICN/TCN)
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DATA DICTIONARY
Field Action
Medicaid ID Number 115-N5 X
Medicaid Agency Number 116-N6 X
Reject Code 511-FB See ECL for new reject codes.
Version/Release Number 102-A2 Added Value: 30=Version 3.0
Appendix A - ALPHABETIC CROSS REFERENCE X Added New Fields as Shown Above
Appendix B - NUMERIC CROSS REFERENCE X Added New Fields as Shown Above
3. SCRIPT Standard Implementation Guide Version 10 Release 1 and Version 10 Release 2

AA. JANUARY 2008
1. Financial Information Reporting Standard Implementation Guide Version 1 Release 0

Field Action
Accumulator Year 650-S1 X
Transaction Identifier 651-S2 X
Accumulated Patient True Out Of Pocket Amount 652-S3 X
Accumulated Gross Covered Drug Cost Amount 653-S4 X
DateTime 654-S5 X
Accumulator Month 655-S6 X
Accumulator Month Count 656-S7 X
BIN Number 101-A1 Added “N” for Financial Information Reporting To Standards Format Column
Transaction Code 103-A3 Added “N” for Financial Information Reporting To Standards Format Column See ECL for new
values.
Processor Control Number 104-A4 Added “N” for Financial Information Reporting To Standards Format Column
Transaction Count 109-A9 Added “N” for Financial Information Reporting To Standards Format Column
Software Vendor/Certification ID 110-AK Added “N” for Financial Information Reporting To Standards Format Column
Segment Identification 111-AM Added “N” for Financial Information Reporting To Standards Format Column See ECL for new
values.
Cardholder ID 302-C2 Added “N” for Financial Information Reporting To Standards Format Column
Group ID 301-C1 Added “N” for Financial Information Reporting To Standards Format Column
Person Code 303-C3 Added “N” for Financial Information Reporting To Standards Format Column
Header Response Status 501-F1 Added “N” for Financial Information Reporting To Standards Format Column
Message 504-F4 Added “N” for Financial Information Reporting To Standards Format Column
Transaction Response Status 112-AN Added “N” for Financial Information Reporting To Standards Format Column See ECL for
applicable values.
Authorization Number 503-F3 Added “N” for Financial Information Reporting To Standards Format Column
Reject Count 510-FA Added “N” for Financial Information Reporting To Standards Format Column
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July 2016
DATA DICTIONARY
Field Action
Additional Message Information 526-FQ Added “N” for Financial Information Reporting To Standards Format Column Uses field length
of 100
Reject Code 511-FB Added “N” for Financial Information Reporting To Standards Format Column See ECL for new
reject codes.
Version/Release Number 102-A2 Added “N” for Financial Information Reporting To Standards Format Column See ECL for new
values.
Appendix A - ALPHABETIC CROSS REFERENCE X Added Fields as Shown Above
Appendix B - NUMERIC CROSS REFERENCE X Added Fields as Shown Above
2. Post Adjudication Standard Implementation Guide Version 2 Release 0

Field Action
Pharmacy Dispenser Type Qualifier 146 X
Pharmacy Class Code Qualifier 150 X
Amount Attributed to Coverage Gap 137-UP Added “A” for Post Adjudication To Standards Format Column
Amount Attributed To Product Selection 519-FJ X Deleted field-not used in Post Adjudication Version 2.0
Amount Attributed to Product Selection / Brand Drug 134-UK Added “A” for Post Adjudication To Standards Format Column
Amount Attributed to Product Selection / Brand Non-Preferred 136-UN Added “A” for Post Adjudication To Standards Format Column
Formulary Selection
Amount Attributed to Product Selection / Non-Preferred Formulary 135-UM Added “A” for Post Adjudication To Standards Format Column
Selection
Amount Attributed to Provider Network Selection 133-UJ Added “A” for Post Adjudication To Standards Format Column
Benefit Stage Qualifier 393-MV Added “A” for Post Adjudication To Standards Format Column See ECL for new value.
Benefit Stage Amount 394-MW Added “A” for Post Adjudication To Standards Format Column
CMS Part D Defined Qualified Facility 997-G2 Added “A” for Post Adjudication To Standards Format Column
Compound Route of Administration 452-EH X Deleted field-not used in Post Adjudication Version 2.0
Compound Type 996-G1 Added “A” for Post Adjudication To Standards Format Column See ECL for new value.
GCN Number 258 X Deleted field-not used in Post Adjudication Version 2.0
GCN Sequence Number 259 X Deleted field-not used in Post Adjudication Version 2.0
Generic Product Identifier 262 X Deleted field-not used in Post Adjudication Version 2.0
Health Plan-funded Assistance Amount 129-UD Added “A” for Post Adjudication To Standards Format Column
Patient Residence 384-4X Added “A” for Post Adjudication To Standards Format Column
Pharmacy Class Code 289 Deleted comments “See values in NCPDP Pharmacy Database Files Standard Implementation
Guide”
Pharmacy Dispenser Type 290 Deleted comments “See values in NCPDP Pharmacy Database Files Standard Implementation
Guide”
Place of Service 307-C7 Added “A” for Post Adjudication To Standards Format Column See ECL for new value.
Prescriber Location Code 467-1E X Deleted field-not used in Post Adjudication Version 2.0
Primary Care Provider Location Code 469-H5 X Deleted field-not used in Post Adjudication Version 2.0
Product Code Qualifier 601-19 X This field had been deleted from the April 2007 DD (used in the Rebates Standard). Added back
into the DD for use in Post Adjudication Version 2.0 See ECL for values
Product Code 601-18 X This field had been deleted from the April 2007 DD (used in the Rebates Standard). Added back
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July 2016
DATA DICTIONARY
Field Action
into the DD for use in Post Adjudication Version 2.0
Record Status Code 399 Deleted value of blank in ECL
Record Type 601-04 Values modification and addition. See ECL
Route of Administration 995-E2 Added “A” for Post Adjudication To Standards Format Column
Service Provider Chain Code 886 Format changed from numeric to alphanumeric
Spending Account Amount Remaining 128-UC Added “A” for Post Adjudication To Standards Format Column
Therapeutic Class Code - AHFS 890 X Deleted field-not used in Post Adjudication Version 2.0
Therapeutic Class Code - Generic 891 X Deleted field-not used in Post Adjudication Version 2.0
Therapeutic Class Code - Specific 892 X Deleted field-not used in Post Adjudication Version 2.0
Therapeutic Class Code - Standard 893 X Deleted field-not used in Post Adjudication Version 2.0
Therapeutic Class Code 601-25 Added “A” for Post Adjudication To Standards Format Column
Therapeutic Class Code Qualifier 601-26 Added “A” for Post Adjudication To Standards Format Column
Version/Release Number 102-A2 See ECL for new values.
3. Prescription Transfer Standard Implementation Guide Version 1 Release 0

Action
Appendix or Field Name Field Number
Addition Deletion Modification
Address Count 603-MY X
Address Qualifier 604-NA X
Bed 671-W1 X
Client Name 605-NB X
Discontinue Date Qualifier 606-NC X
Discontinue Date 607-ND X
Easy Open Cap Indicator 608-NF X
Effective Date 609-NG X
Expiration Date 610-NH X
Facility Unit 672-W2 X
File Structure Type 611-NJ X
Hours Of Administration 673-W3 X
Inactive Prescription Indicator 612-NK X
Label Directions 613-NM X
Most Recent Date Filled 614-NW X
Number Of Fills To Date 615-NY X
Number Of Fills Remaining 616-PU X
Original Dispensed Date 617-RQ X
Prescribed Product Description 619-RW X
Package Acquisition Cost 633-SN X
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July 2016
DATA DICTIONARY
Action
Patient ID Qualifier Count 618-RR X
Pharmacist Initials 636-TD X
Prescriber ID Count 620-RX X
Prescriber Specialty 621-RY X
Prescriber Specialty Count 622-RZ X
Quantity Dispensed To Date 623-SA X
Record Delimiter 624-SB X
Remaining Quantity 625-SC X
Room 674-W4 X
Sender Name 626-SD X
Sending Pharmacy ID 627-SF X
Technician Initials 637-TF X
Telephone Number Count 628-SG X
Telephone Number Qualifier 629-SH X
Total Number Of Sending And Receiving Pharmacy 630-SJ X
Records
Transfer Flag 631-SK X
Transfer Type 632-SM X
Unique Record Identifier 634-SP X
Unique Record Identifier Qualifier 635-SQ X
Address Line 1 726-SR Added “V” for Prescription Transfer To Standards Format Column Add Field ID Add Comments:
For Prescription Transfer, qualified by ADDRESS QUALIFIER (604-NA)
Address Line 2 727-SS Added “V” for Prescription Transfer To Standards Format Column Add Field ID
Additional Message Information 526-FQ Added “V” for Prescription Transfer To Standards Format Column Field format increased to 200
for Prescription Transfer
Alternate ID Number 724-ST Added “V” for Prescription Transfer To Standards Format Column Add Field ID
Batch Number 806-5C Added “V” for Prescription Transfer To Standards Format Column
Cardholder First Name 312-CC Added “V” for Prescription Transfer To Standards Format Column Field format increased to 35
Cardholder ID 302-C2 Added “V” for Prescription Transfer To Standards Format Column
Cardholder Last Name 313-CD Added “V” for Prescription Transfer To Standards Format Column Field format increased to 35
City 728-SU Added “V” for Prescription Transfer To Standards Format Column Add Field ID
Compound Code 406-D6 Added “V” for Prescription Transfer To Standards Format Column
Creation Date 880-K2 Added “V” for Prescription Transfer To Standards Format Column
Creation Time 880-K3 Added “V” for Prescription Transfer To Standards Format Column
Date Of Birth 304-C4 Added “V” for Prescription Transfer To Standards Format Column
Date Of Service 401-D1 Added “V” for Prescription Transfer To Standards Format Column
Date Prescription Written 414-DE Added “V” for Prescription Transfer To Standards Format Column
Days Supply 405-D5 Added “V” for Prescription Transfer To Standards Format Column
Destination Name 818-5F Added “V” for Prescription Transfer To Standards Format Column Field format increased to 35
Dispense As Written (DAW)/Product Selection Code 408-D8 Added “V” for Prescription Transfer To Standards Format Column
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July 2016
DATA DICTIONARY
Action
Drug Description 516-FG Added “V” for Prescription Transfer To Standards Format Column Definition Change AND Field
format increased to 60 for Prescription Transfer
Facility ID 336-8C Added “V” for Prescription Transfer To Standards Format Column Field format increased to 35
Facility Name 385-3Q Added “V” for Prescription Transfer To Standards Format Column
Family ID Number 785-SV Added “V” for Prescription Transfer To Standards Format Column Add Field ID
File Type 702-MC Added “V” for Prescription Transfer To Standards Format Column
Fill Number 403-D3 Added “V” for Prescription Transfer To Standards Format Column
First Name 717-SX Added “V” for Prescription Transfer To Standards Format Column Add Field ID
Group ID 301-C1 Added “V” for Prescription Transfer To Standards Format Column
Last Name 716-SY Added “V” for Prescription Transfer To Standards Format Column Add Field ID
Middle Initial 718-SZ Added “V” for Prescription Transfer To Standards Format Column Add Field ID
Number Of Refills Authorized 415-DF Added “V” for Prescription Transfer To Standards Format Column
Originally Prescribed Product/Service Code 445-EA Added “V” for Prescription Transfer To Standards Format Column
Originally Prescribed Product/Service ID Qualifier 453-EJ Added “V” for Prescription Transfer To Standards Format Column
Other Payer ID 340-7C Added “V” for Prescription Transfer To Standards Format Column
Other Payer ID Count 355-NT Added “V” for Prescription Transfer To Standards Format Column
Other Payer ID Qualifier 339-6C Added “V” for Prescription Transfer To Standards Format Column See ECL for values added
Other Payer Processor Control Number 991-MH Added “V” for Prescription Transfer To Standards Format Column
Patient E-Mail Address 350-HN Added “V” for Prescription Transfer To Standards Format Column
Patient First Name 310-CA Added “V” for Prescription Transfer To Standards Format Column Field format increased to 35
Patient Gender Code 305-C5 Added “V” for Prescription Transfer To Standards Format Column
Patient ID Qualifier 331-CX Added “V” for Prescription Transfer To Standards Format Column See ECL for values added
Patient ID 332-CY Added “V” for Prescription Transfer To Standards Format Column
Patient Last Name 311-CB Added “V” for Prescription Transfer To Standards Format Column Field format increased to 35
Patient Liability Amount 601-44 Added “V” for Prescription Transfer To Standards Format Column Field format changed for
Prescription Transfer
Patient Relationship Code 306-C6 Added “V” for Prescription Transfer To Standards Format Column See ECL for values added
Patient Residence 384-4X Added “V” for Prescription Transfer To Standards Format Column
Payer ID 569-J8 Added “V” for Prescription Transfer To Standards Format Column
Payer ID Qualifier 568-J7 Added “V” for Prescription Transfer To Standards Format Column
Person Code 303-C3 Added “V” for Prescription Transfer To Standards Format Column
Pharmacy Name 833-5P Added “V” for Prescription Transfer To Standards Format Column
Pregnancy Indicator 335-2C Added “V” for Prescription Transfer To Standards Format Column
Prescriber ID 411-DB Added “V” for Prescription Transfer To Standards Format Column
Prescriber ID Qualifier 466-EZ Added “V” for Prescription Transfer To Standards Format Column
Prescription/ Service Reference Number 402-D2 Added “V” for Prescription Transfer To Standards Format Column Modification to Comment
Prior Authorization Number Submitted 462-EV Added “V” for Prescription Transfer To Standards Format Column
Processor Control Number 104-A4 Added “V” for Prescription Transfer To Standards Format Column
Processor Name 839-5V Added “V” for Prescription Transfer To Standards Format Column
Product Description 601-20 Added “V” for Prescription Transfer To Standards Format Column
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July 2016
DATA DICTIONARY
Action
Product Dosage Form 601-21 Added “V” for Prescription Transfer To Standards Format Column Field format increased to 30
Product/Service ID 407-D7 Added “V” for Prescription Transfer To Standards Format Column
Product/Service ID Qualifier 436-E1 Added “V” for Prescription Transfer To Standards Format Column See ECL for values added
Product Strength 601-24 Added “V” for Prescription Transfer To Standards Format Column Add Field ID
Quantity Dispensed 442-E7 Added “V” for Prescription Transfer To Standards Format Column Add Field ID
Quantity Prescribed 460-ET Added “V” for Prescription Transfer To Standards Format Column Add Field ID
Receiver ID 880-K7 Added “V” for Prescription Transfer To Standards Format Column
Record Count 751-M9 Added “V” for Prescription Transfer To Standards Format Column Definition Changed for
Prescription Transfer
Record Type 601-04 Added “V” for Prescription Transfer To Standards Format Column See ECL for values added
Reject Code 511-FB Added “V” for Prescription Transfer To Standards Format Column See ECL for new reject codes.
Sending Entity Identifier 879-N2 Added “V” for Prescription Transfer To Standards Format Column Add Field ID
Service Provider ID 201-B1 Added “V” for Prescription Transfer To Standards Format Column Add Field ID
Service Provider ID Qualifier 202-B2 Added “V” for Prescription Transfer To Standards Format Column See ECL for values added
Smoker/Non-Smoker Code 334-1C Added “V” for Prescription Transfer To Standards Format Column See ECL for values added
State 729-TA Added “V” for Prescription Transfer To Standards Format Column Add Field ID
Telephone Number 732-TB Added “V” for Prescription Transfer To Standards Format Column Add Field ID
Text Indicator 880-K4 Added “V” for Prescription Transfer To Standards Format Column Add Comment
Total Record Count 601-09 Added “V” for Prescription Transfer To Standards Format Column
Version/Release Number 102-A2 See ECL for new values.
Zip/Postal Code 730-TC Added “V” for Prescription Transfer To Standards Format Column Add Field ID
4. SCRIPT Standard Implementation Guide Version10 Release 3

BB. JUNE 2008
1. Formulary and Benefit Standard Implementation Guide Version 2 Release 0

Field Action
Prior Authorization Form ID 657-T5 X
Prior Authorization Form Title 658-T6 X
Prior Authorization Question Code 659-T7 X
Prior Authorization Question Code Qualifier 660-T8 X
Prior Authorization Question Sequence 661-T9 X
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July 2016
DATA DICTIONARY
Field Action
Prior Authorization Question Number 662-V1 X
Prior Authorization Applicability 663-V2 X
Prior Authorization Required Question 664-V3 X
Prior Authorization Response Type 665-V4 X
Prior Authorization Question Text 666-V5 X
Prior Authorization Basis Question Sequence Number 667-V6 X
Prior Authorization Comparison Type 668-V7 X
Prior Authorization Basis Value 669-V8 X
Prior Authorization Answer Value 670-V9 X
See ECL Publication of June 2008 for Added Field Values
2. SCRIPT Standard Implementation Guides Version10 Release 4 and Version 10 Release 5

CC. OCTOBER 2008
1. Telecommunication Standard Implementation Guide Version D Release 1

Field Action
Associated Prescription/Service Provider ID Qualifier 579-XX X
Associated Prescription/Service Provider ID 580-XY X
Associated Prescription/Service Reference Number Qualifier 581-XZ X
Associated Prescription/Service Fill Number 582-X0 X
Service Provider Name 583-YK X
Service Provider Street Address 584-YM X
Service Provider City Address 585-YN X
Service Provider State/Province Code Address 586-YP X
Service Provider Zip/Postal Code 587-YQ X
Seller Initials 590-YT X
Seller ID 679-Y9 X
Seller ID Qualifier 680-ZB X
Sales Transaction ID 681-ZF X
Purchaser ID Qualifier 591-YU X
Purchaser ID 592-YV X
Purchaser ID Associated State/Province Code 593-YW X
Purchaser Date of Birth 594-YX X
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July 2016
DATA DICTIONARY
Field Action
Purchaser Gender Code 595-YY X
Purchaser First Name 596-YZ X
Purchaser Last Name 597-Y0 X
Purchaser Street Address 598-Y1 X
Purchaser City Address 599-Y2 X
Purchaser Address State/Province Code 675-Y3 X
Purchaser Zip/Postal Code 676-Y4 X
Purchaser Country Code 677-Y5 X
Time of Service 678-Y6 X
Associated Prescription/Service Reference Number 456-EN Added new comment
See ECL Publication of October 2008 for Added Field Values
2. SCRIPT Standard Implementation Guides Version10 Release 6

Field Action
Reason for Service Code 439-E4 Change definition
Result of Service Code 441-E6 Change definition
Clinical Significance Code 528-FS Add: “S” to Standard Formats Column in Data Dictionary
3. Universal Claim Form and Workers’ Compensation/Property & Casualty Form

Field Action
Brand/Generic Indicator 686 X
Compound Ingredient Product Name 689 X
Date of Billing 589 X
Document Control Number 682 X
Generic Available 687 X
Jurisdictional Field (1-5) 688 X
Jurisdictional State 683 X
Pay To Phone Number 685 X
Workers Compensation/Property And Casualty Indicator 588 X
Basis of Cost Determination 423-DN Add: “Z” and “W” to Standard Formats Column in Data Dictionary
BIN Number 101-A1 Add: “Z” to Standard Formats Column in Data Dictionary
Cardholder First Name 312-CC Add: “Z” to Standard Formats Column in Data Dictionary
Cardholder ID 302-C2 Add: “Z” to Standard Formats Column in Data Dictionary
Cardholder Last Name 313-CD Add: “Z” to Standard Formats Column in Data Dictionary
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July 2016
DATA DICTIONARY
Field Action
Carrier Address 807-1D Add: “W” to Standard Formats Column in Data Dictionary
Carrier Location City 809-1F Add: “W” to Standard Formats Column in Data Dictionary
Carrier Location State 810-1G Add: “W” to Standard Formats Column in Data Dictionary
Carrier Name 811-1H Add: “W” to Standard Formats Column in Data Dictionary
Carrier Zip Code 813-1J Add: “W” to Standard Formats Column in Data Dictionary
Claim/Reference ID 435-DZ Add: “W” to Standard Formats Column in Data Dictionary
Compound Dispensing Unit Form Indicator 451-EG Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Compound Dosage Form Description Code 450-EF Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Compound Ingredient Basis of Cost Determination 490-UE Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Compound Ingredient Component Count 447-EC Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Compound Ingredient Drug Cost 449-EE Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Compound Ingredient Quantity 448-ED Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Compound Product ID 489-TE Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Compound Product ID Qualifier 488-RE Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Date of Birth 304-C4 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Add to the Comments Column of the Data Dictionary:
When used on the UCF and Workers Compensation/Property & Casualty Forms, the format is:
MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
Date of Injury 434-DY Add: “W” to Standard Formats Column in Data Dictionary
When used on the Workers Compensation/Property & Casualty Form, the format is:
MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
Date of Service 401-D1 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
Date Prescription Written 414-DE Add: “Z” and “W” to Standard Formats Column in Data Dictionary
MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
Days Supply 405-D5 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
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July 2016
DATA DICTIONARY
Field Action
Delay Reason Code 357-NV Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Diagnosis Code 424-DO Add: “Z” to Standard Formats Column in Data Dictionary
Diagnosis Code Qualifier 492-WE Add: “Z” to Standard Formats Column in Data Dictionary
Dispense as Written (DAW)/Product Selection Code 408-D8 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Dispensing Fee Submitted 412-DC Add: “Z” and “W” to Standard Formats Column in Data Dictionary
DUR/PPS Level of Effort 474-8E Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Employer City Address 317-CH Add: “W” to Standard Formats Column in Data Dictionary
Employer Contact Name 321-CL Add: “W” to Standard Formats Column in Data Dictionary
Employer Name 315-CF Add: “W” to Standard Formats Column in Data Dictionary
Employer Phone Number 320-CK Add: “W” to Standard Formats Column in Data Dictionary
Employer State/Province Address 318-CI Add: “W” to Standard Formats Column in Data Dictionary
Employer Street Address 316-CG Add: “W” to Standard Formats Column in Data Dictionary
Employer Zip/Postal Code 319-CJ Add: “W” to Standard Formats Column in Data Dictionary
Fill Number 403-D3 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Flat Sales Tax Amount Submitted 481-HA Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Gross Amount Due 430-DU Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Group ID 301-C1 Add: “Z” to Standard Formats Column in Data Dictionary
Ingredient Cost Submitted 409-D9 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Other Amount Claimed Submitted 480-H9 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Net Amount Due 281 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Other Coverage Code 308-C8 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Other Payer Amount Paid 431-DV Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Other Payer Date 443-E8 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
MMDDCCYY
MM=Month
DD=Day
CC=Century
YY=Year
Other Payer ID 340-7C Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Other Payer ID Qualifier 339-6C Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Other Payer Patient Responsibility Amount 352-NQ Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Other Payer Reject Code 472-6E Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Patient City Address 323-CN Add: “W” to Standard Formats Column in Data Dictionary
Patient First Name 310-CA Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Patient Gender Code 305-C5 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Patient ID 332-CY Add: “W” to Standard Formats Column in Data Dictionary
Patient ID Qualifier 331-CX Add: “W” to Standard Formats Column in Data Dictionary
Patient Last Name 311-CB Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Patient Paid Amount Submitted 433-DX Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Patient Phone Number 326-CQ Add: “W” to Standard Formats Column in Data Dictionary
Patient Relationship Code 306-C6 Add: “Z” to Standard Formats Column in Data Dictionary
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July 2016
DATA DICTIONARY
Field Action
Patient State/Province Address 324.CO Add: “W” to Standard Formats Column in Data Dictionary
Patient Street Address 322-CM Add: “W” to Standard Formats Column in Data Dictionary
Patient Zip/Postal Zone 325-CP Add: “W” to Standard Formats Column in Data Dictionary
Pay To City Address 122-TW Add: “W” to Standard Formats Column in Data Dictionary
Pay To ID 119-TT Add: “W” to Standard Formats Column in Data Dictionary
Pay To Name 120-TU Add: “W” to Standard Formats Column in Data Dictionary
Pay To Qualifier 118-TS Add: “W” to Standard Formats Column in Data Dictionary
Pay To Street Address 121-TV Add: “W” to Standard Formats Column in Data Dictionary
Pay To State/Province Address 123-TX Add: “W” to Standard Formats Column in Data Dictionary
Pay To Zip/Postal Zone 124-TY Add: “W” to Standard Formats Column in Data Dictionary
Percentage Sales Tax Amount Submitted 482-GE Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Person Code 303-C3 Add: “Z” to Standard Formats Column in Data Dictionary
Pharmacy Address 829-5L Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Pharmacy Location City 831-5N Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Pharmacy Location State 832-6F Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Pharmacy Name 833-5P Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Pharmacy Telephone Number 834-5Q Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Pharmacy ZIP Code 835-5R Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Place of Service 307-C7 Add: “Z” to Standard Formats Column in Data Dictionary
Plan Name 600-96 Add: “Z” to Standard Formats Column in Data Dictionary
Prescriber City Address 366-2M Add: “W” to Standard Formats Column in Data Dictionary
Prescriber First Name 364-2J Add: “W” to Standard Formats Column in Data Dictionary
Prescriber ID 411-DB Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Prescriber ID Qualifier 466-EZ Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Prescriber Last Name 427-DR Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Prescriber Phone Number 498-PM Add: “W” to Standard Formats Column in Data Dictionary
Prescriber State/Province Address 367-2N Add: “W” to Standard Formats Column in Data Dictionary
Prescriber Street Address 365-2K Add: “W” to Standard Formats Column in Data Dictionary
Prescriber Zip/Postal Zone 368-2P Add: “W” to Standard Formats Column in Data Dictionary
Prescription/Service Reference Number 402-D2 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Prescription/Service Reference Number Qualifier 455-EM Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Prior Authorization Number Submitted 462-EV Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Prior Authorization Type Code 461-EU Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Procedure Modifier Code 459-ER Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Processor Control Number 104-A4 Add: “Z” to Standard Formats Column in Data Dictionary
Product Description 601-20 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Product/Service ID 407-D7 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Product/Service ID Qualifier 436-E1 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Product Strength 601-24 Add: “W” to Standard Formats Column in Data Dictionary
Professional Service Code 440-E5 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Provider ID 444-E9 Add: “Z” to Standard Formats Column in Data Dictionary
Provider ID Qualifier 465-EY Add: “Z” to Standard Formats Column in Data Dictionary
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July 2016
DATA DICTIONARY
Field Action
Quantity Dispensed 442-E7 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Reason for Service Code 439-E4 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Result of Service Code 441-E6 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Route of Administration 995-E2 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Service Provider ID 201-B1 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Service Provider ID Qualifier 202-B2 Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Submission Clarification Code 420-DK Add: “Z” and “W” to Standard Formats Column in Data Dictionary
Unit of Measure 600-28 Add: “W” to Standard Formats Column in Data Dictionary
Usual and Customary Charge 426-DQ Add: “Z” and “W” to Standard Formats Column in Data Dictionary
DD. APRIL 2009

Field Action
Invoiced Date 690-ZG X Add: “A” to Standard Formats Column in Data Dictionary
Out Of Pocket Remaining Amount 691-ZH X Add: “A” to Standard Formats Column in Data Dictionary
Number Of Generic Manufacturers 692-ZJ X Add: “A” to Standard Formats Column in Data Dictionary
Total Gross Amount Due 693 X Add: “A” to Standard Formats Column in Data Dictionary
Total Patient Pay Amount 694 X Add: “A” to Standard Formats Column in Data Dictionary
2. SCRIPT Standard Implementation Guide Version 10 Release 7

EE. JUNE 2009

Field Action
Patient ID Associated State/Province Address A22-YR X
Purchaser Relationship Code A23-YS X
Prescriber ID Associated State/Province Address A24-ZK X
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DATA DICTIONARY
Field Action
Prescriber Alternate ID Qualifier A25-ZM X
Prescriber Alternate ID A26-ZP X
Prescriber Alternate ID Associated State/ Province Address A27-ZQ X
2. Prior Authorization Standard Implementation Guide Version 1 Release 0

Field Action
Benefit Amount A00 X Add: “X” to Standard Formats Column in Data Dictionary
Benefit Amount Time Period A01 X Add: “X” to Standard Formats Column in Data Dictionary
Benefit Amount Type A02 X Add: “X” to Standard Formats Column in Data Dictionary
Benefit Amount Used To-Date A03 X Add: “X” to Standard Formats Column in Data Dictionary
Claim Cost Ceiling Override Amount A04 X Add: “X” to Standard Formats Column in Data Dictionary
Claim Origination A05 X Add: “X” to Standard Formats Column in Data Dictionary
Compound Indicator A06 X Add: “X” to Standard Formats Column in Data Dictionary
Copay/Coinsurance Override Amount A07 X Add: “X” to Standard Formats Column in Data Dictionary
Copay/Coinsurance Override Type A08 X Add: “X” to Standard Formats Column in Data Dictionary
Copay Conjunction Sequence A09 X Add: “X” to Standard Formats Column in Data Dictionary
Days Supply Used to Date A10 X Add: “X” to Standard Formats Column in Data Dictionary
Dispense As Written (DAW) Difference A11 X Add: “X” to Standard Formats Column in Data Dictionary
Dosage Per Day A12 X Add: “X” to Standard Formats Column in Data Dictionary
Fills/Refills Used To-Date A13 X Add: “X” to Standard Formats Column in Data Dictionary
Prescriber Override Type A14 X Add: “X” to Standard Formats Column in Data Dictionary
Prior Authorization Create Date A15 X Add: “X” to Standard Formats Column in Data Dictionary
Prior Authorization Number of Fills Authorized A16 X Add: “X” to Standard Formats Column in Data Dictionary
Prior Authorization Reason Code A17 X Add: “X” to Standard Formats Column in Data Dictionary
Prior Authorization Update Date A18 X Add: “X” to Standard Formats Column in Data Dictionary
Receiver Name A19 X Add: “X” to Standard Formats Column in Data Dictionary
Service Provider Override Type A20 X Add: “X” to Standard Formats Column in Data Dictionary
Subgroup ID A21 X Add: “X” to Standard Formats Column in Data Dictionary
Additional Message Information 526-FQ Add: “X” to Standard Formats Column in Data Dictionary
Alternate ID Number 724-ST Add: “X” to Standard Formats Column in Data Dictionary
Batch Number 806-5C Add: “X” to Standard Formats Column in Data Dictionary
Cardholder ID 302-C2 Add: “X” to Standard Formats Column in Data Dictionary
Client Name 605-NB Add: “X” to Standard Formats Column in Data Dictionary
Creation Date 880-K2 Add: “X” to Standard Formats Column in Data Dictionary
Creation Time 880-K3 Add: “X” to Standard Formats Column in Data Dictionary
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DATA DICTIONARY
Field Action
Date Of Birth 304-C4 Add: “X” to Standard Formats Column in Data Dictionary
Days Supply 405-D5 Add: “X” to Standard Formats Column in Data Dictionary
Drug Type 425-DP Add to existing Value 0: = Not Specified (When used in the Prior Authorization Transfer
Standard 0=Specific but not limited; all legend and OTC's)
Add: “X” to Standard Formats Column in Data Dictionary and to External Code List
File Type 702-MC Add: “X” to Standard Formats Column in Data Dictionary and to External Code List
First Name 717-SX Add: “X” to Standard Formats Column in Data Dictionary
Group ID 301-C1 Add: “X” to Standard Formats Column in Data Dictionary
Last Name 716-SY Add: “X” to Standard Formats Column in Data Dictionary
Middle Initial 718-SZ Add: “X” to Standard Formats Column in Data Dictionary
Patient Gender Code 305-C5 Add: “X” to Standard Formats Column in Data Dictionary and to External Code List
Patient ID 332-CY Add: “X” to Standard Formats Column in Data Dictionary
Patient ID Qualifier 331-CX Add Values: 07 = Medicare HIC# - The identification of person assigned by Medicare.
08 = Employer Assigned ID - The identification of a person assigned by the employer.
09 = Payer/PBM Assigned ID - The identification of a person assigned by the payer or pharmacy
benefit manager.
Patient First Name 310-CA Add: “X” to Standard Formats Column in Data Dictionary
Patient Last Name 311-CB Add: “X” to Standard Formats Column in Data Dictionary
Patient Relationship Code 306-C6 Add: “X” to Standard Formats Column in Data Dictionary and to External Code List
Person Code 303-C3 Add: “X” to Standard Formats Column in Data Dictionary
Prescriber ID 411-DB Add: “X” to Standard Formats Column in Data Dictionary
Prescriber ID Qualifier 466-EZ Add: “X” to Standard Formats Column in Data Dictionary and to External Code List
Prescription/Service Reference Number 402-D2 Add: “X” to Standard Formats Column in Data Dictionary
Prescription/Service Reference Number Qualifier 455-EM Add: “X” to Standard Formats Column in Data Dictionary and to External Code List
Previous Date Of Fill 530-FU Add: “X” to Standard Formats Column in Data Dictionary
Prior Authorization Effective Date 498-PS Add: “X” to Standard Formats Column in Data Dictionary
Prior Authorization Expiration Date 498-PT Add: “X” to Standard Formats Column in Data Dictionary
Prior Authorization Number – Assigned 498-PY Add: “X” to Standard Formats Column in Data Dictionary
Prior Authorization Number Of Refills Authorized 498-PW Add: “X” to Standard Formats Column in Data Dictionary
Prior Authorization Number Submitted 462-EV Add: “X” to Standard Formats Column in Data Dictionary
Prior Authorization Quantity 498-RA Add: “X” to Standard Formats Column in Data Dictionary
Prior Authorization Quantity Accumulated 498-PX Add: “X” to Standard Formats Column in Data Dictionary
Product Code 601-18 Add: “X” to Standard Formats Column in Data Dictionary
Product Code Qualifier 601-19 Add Value: V = All products used = Represents all valid products regardless of type
Product/Service ID 407-D7 Add: “X” to Standard Formats Column in Data Dictionary
Product/Service ID Qualifier 436-E1 Add: “X” to Standard Formats Column in Data Dictionary and to External Code List
Record Type 601-04 Add Values: PE = Prior Authorization Transfer Header, PJ = Prior Authorization Transfer Detail,
PK - Prior Authorization Transfer Trailer
Sender Name 626-SD Add: “X” to Standard Formats Column in Data Dictionary
Service Provider ID 201-B1 Add: “X” to Standard Formats Column in Data Dictionary
Service Provider ID Qualifier 202-B2 Add: “X” to Standard Formats Column in Data Dictionary and to External Code List
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DATA DICTIONARY
Field Action
Telephone Number 732-TB Add: “X” to Standard Formats Column in Data Dictionary
Total Record Count 601-09 Add: “X” to Standard Formats Column in Data Dictionary
Version/Release Number 102-A2 Add: “X” to Standard Formats Column in Data Dictionary and to External Code List
3. SCRIPT Standard Implementation Guide Version 10 Release 8 and Version 10 Release 9

No Data Dictionary changes were made for Version 10.8. For Version 10.9, see updates to Appendix J – SCRIPT DATA ELEMENTS of this document noted.
4. Post Adjudication Standard Implementation Guide Version 2 Release 1 and Version

Field Action
Remaining Deductible Amount 513-FD Comments Column: Add Note: For the fixed format Post Adjudication Standard if this field is
not applicable, the field should contain 9999999I
Remaining Benefit Amount 514-FE Comments Column: Add Note: For the fixed format Post Adjudication Standard if this field is
Health Care Reimbursement Account Amount Remaining 264 Comments Column: Add Note: For the fixed format Post Adjudication Standard if this field is
Spending Account Amount Remaining 128-UC Comments Column: Add Note: For the fixed format Post Adjudication Standard if this field is
Out of Pocket Remaining Amount 691-ZH Comments Column: Add Note: For the fixed format Post Adjudication Standard if this field is
5. Universal Claim Form

Field Action
Prescription Origin Code 419-DJ Add: “Z” and “W” to Standard Formats Column in Data Dictionary
FF. OCTOBER 2009

Field Action
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July 2016
DATA DICTIONARY
2. Data Dictionary
Field Action
Appendices A-Alphabetic Cross Reference, C-Old Field Name Cross X
Reference in Version 5.0, D-New Field Name Cross Reference in
Version 5.0, and E-Deleted Data Elements Not Supported in Version
5.0
Appendix B-Numeric Cross Reference Renamed to Appendix A-Numeric Cross Reference
Appendix F-Version 1.0 Reject Codes for Payment Tape Renamed to Appendix B-Version 1.0 Reject Codes for Payment Tape
Appendix G-Version 2.0 Reject Codes for Payment Tape Renamed to Appendix C-Version 2.0 Reject Codes for Payment Tape
Appendix H-Version 3.0 and 4.0 Reject Codes for Payment Tape Renamed to Appendix D-Version 3.0 and 4.0 Reject Codes for Payment Tape
Appendix I-Telecommunication Phases With Flow Charts Renamed to Appendix E-Telecommunication Phases With Flow Charts
Appendix J-SCRIPT Data Elements Renamed to Appendix F-SCRIPT Data Elements
Appendix K-Publication Modifications Renamed to Appendix G-Publication Modifications
GG. JANUARY 2010

Field Action
CMS Part D Contract ID A33-ZX X
Medicare Part D Plan Benefit Package (PBP) A34-ZY X
Appendix A-Numeric Cross Reference Added Fields as Shown Above
See ECL Publication of January 2010 for Added Field Values

Field Action
Prescriber Specialty 621-RY Field Size: From 3 to 10
See ECL Publication of January 2010 for Added Field Values
HH. MARCH 2010

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July 2016
DATA DICTIONARY
Field Action
Adjudicated Payment Type A28-ZR X
Reported Payment Type A29-ZS X
Released Date A30-ZT X
Released Time A31-ZU X
Compound Preparation Time A32-ZW X
Compound Dosage Form Description Code 450-EF Format= Increased from 2 to 15
Compound Ingredient Modifier Code 363-2H Values :Referenced ECL for CMS link
Procedure Modifier Code 459-ER Values :Referenced ECL for CMS link
Total Amount Paid 509-F9 Comments: Added Prescription Response Formula and Service Response Formula
Appendix A - NUMERIC CROSS REFERENCE Added Fields as Shown Above
See ECL Publication of March 2010 for Added Field Values

See updates to Appendix F – SCRIPT DATA ELEMENTS of this document noted.
II. JUNE 2010

Field Action
CMS Part D Contract ID A33-ZX Add: “A” to Standard Formats Column in Data Dictionary
COB Primary Payer Allowed Amount 227 X Deleted for this version and greater
COB Secondary Payer Allowed Amount 233 X Deleted for this version and greater
Copay Waiver Amount A39 X
Medicare Part D Plan Benefit Package (PBP) A34-ZY Add: “A” to Standard Formats Column in Data Dictionary
Member Submitted Claim Reject Code A38 X
Patient Medicare Formulary Rebate Amount 285 Deleted “Medicare” from field name
Procedure Code 298 X Deleted for this version and greater
Procedure Modifier Code 459-ER Deleted “A” for use by this version and greater
Specialty Claim Indicator A37 X
Appendix A - NUMERIC CROSS REFERENCE Added/Deleted Fields as Shown Above

See updates to Appendix F – SCRIPT DATA ELEMENTS of this document noted.
- 253 -
July 2016
DATA DICTIONARY
JJ. SEPTEMBER 2010

Field Action
Patient Country Code A43-1K X
Appendix A - NUMERIC CROSS REFERENCE Added Field as Shown Above
See ECL Publication of September 2010 for Added Field Values

Field Action
Original Dispensed Quantity A44-ZL X
3. Data Dictionary
Field Action
Section I Introduction Add: “K=Connectivity Standard” to Standard Formats Key table
Format A42 X
PayloadType A40 X
TransactionStandard A41 X
See ECL Publication of September 2010 for Added Field Values
KK. DECEMBER 2010

Field Action
Veterinary Use Indicator A45-1R X
See ECL Publication of December 2010 for Added Field Values
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July 2016
DATA DICTIONARY
Field Action
Dosage Form ID Code 601-34 X
Interest Amount 601-89 X
Total Remittance 602-14 X
Appendix A - NUMERIC CROSS REFERENCE Low Lighted Fields Deleted Above
3. Formulary and Benefit Standard Version 3 Release 0

Field Action
Text Message Type A46-1S X
Class ID 902-BQ X
Subclass ID 975-JP X
Class Name 904-BS X
Subclass Name 977-JR X
Classification ID 905-BT X
Appendix A - NUMERIC CROSS REFERENCE Added Field as Shown Above and Low Lighted Fields Deleted Above
4. Specialized Implementation Guide Version 2010121

The following XML elements were incorporated into the main body of the Data Dictionary.
Field Action
AcknowledgementID X
AdditionalTraceNumber X
AddressLine1 X
AddressLine2 X
AddressTypeQualifier X
AllergyDrugProductCodedQualifier X
AnticipatedReturnDate X
AttachmentData X New Field
AttachmentSource X New Field
Bed X
BodyType X
BusinessName X
CardholderID X
CensusEffectiveDate X
City X
ClinicName X
- 255 -
July 2016
DATA DICTIONARY
Field Action
CommunicationTypeNumber X
CommunicationTypeQualifier X
Created X
DatatypesVersion X New Field
DateOfBirth X
DateValidated X
DaysSupply X
DeliveredID X
Description X New Field
DescriptionCode X
DispensingRequestCode X
DrugProductCoded X
DrugProductCodedQualifier X
ECLVersion X New Field
EffectiveDate X New Field
Ethnicity X New Field
ExpirationDate X New Field
FacilityIdentification X
FacilityName X
FacilityUnit X
FirstName X
FrequencyOfEncountersApprovedCode X New Field
FrequencyOfEncountersApprovedCodeQualifier X New Field
FrequencyOfEncountersApprovedText X New Field
From X
Gender X
GroupID X
GroupName X
LanguageNameCode X
LastFillDate X
LastName X
MailboxID X
MessageID X
MessageRequestCode X
MiddleInitial X
MIMEType X New Field
MTMPayerCaseIdentifier X New Field
NewPassword X
NoKnownAllergies X
Nonce X
Note X
- 256 -
July 2016
DATA DICTIONARY
Field Action
OldPassword X
Password X
PatientIdentification X
PatientRelationshipCode X
PayerIdentification X
PayerName X
PayerResponsibilityCode X
PersonCode X
PharmacyIdentification X
PharmacySpecialty X
PlaceLocationQualifier X
Prefix X
PregnancyIndicator X
PrescriberIdentification X
PrescriberOrderNumber X
Prescriber Specialty X
PrescriptionDeliveryMethod X
ProblemNameCode X
ProblemNameCodeQualifier X
ProblemNameCodeText X
ProductCode X
ProductQualifierCode x
ProviderIdentification X
ProviderSpecialty X
Race X New Field
ReactionCoded X
ReasonCode X
RelatesToMessageID X
RequestReferenceNumber X
ResidenceCode X
ReturnReceipt X
Room X
RxReferenceNumber X
SecondaryIdentification X
SenderSoftwareDeveloper X
SenderSoftwareProduct X
SenderSoftwareVersionRelease X
SentTime X
SeverityCoded X
Smoker X
- 257 -
July 2016
DATA DICTIONARY
Field Action
SNOMEDAdverseEventCode X
SNOMEDAdverseEventText X
SourceOfInformation X
State X
StatusCode X
StructuresVersion X New Field
Suffix X
SupervisorIdentification X
SupervisorSpecialty X
TargetedTypeOfServiceCode X New Field
TargetedTypeOfServiceCodeQualifier X New Field
TargetedTypeOfServiceFreeText X New Field
TargetedTypeOfServiceText X New Field
TertiaryIdentification X
TertiaryIdentifier X
Text X
TestMessage X
TimeZoneDifferenceQuantity X
TimeZoneIdentifier X
To X
TotalNumberOfEncountersApproved X New Field
TransactionDomain X New Field
TransactionErrorCode X
TransactionVersion X New Field
TransportVersion X New Field
TypeOfServiceCode X New Field
TypeOfServiceCodeQualifier X New Field
TypeOfServiceFreeText X New Field
TypeOfServiceText X New Field
Username X
VerifyStatusCode X
WrittenDate X
ZipCode X
5. SCRIPT Standard Implementation Guide Version 2010121

The following XML elements were incorporated into the main body of the Data Dictionary.
Appendix or Field Name Field Action
- 258 -
July 2016
DATA DICTIONARY
AcknowledgementID
AcknowledgementReason X
AdditionalRefillsAuthorized X
AdditionalTraceNumber X
AddressLine1 X
AddressLine2 X
AddressTypeQualifier X
AdministrationTimingCode X
AdministrationTimingCodeQualifier X
AdministrationTimingText X
Bed X
BodyMetricQualifier X
BodyMetricValue X
BodyType X
BusinessName X
CalculatedDoseNumeric X
CalculatedDoseUnitOfMeasureCode X
CalculatedDoseUnitOfMeasureCodeQualifier X
CalculatedDoseUnitOfMeasureText X
CardholderID X
ChangeOfPrescriptionStatusCode X
ChangeReasonText X New Field
City X
ClinicalInformationQualifier X
ClinicalSignificanceCode X
Clinical Significance Code 528-FS Removed use by SCRIPT, listed as separate field
ClinicName X
CoAgentCode X
CoAgentQualifier X
CompoundCode X
ComopundIngredientItemDescription X
Consent X
Created X
DatatypesVersion X New Field
DateOfBirth X
DateValidated X
DaysSupply X
DEAScheduleCode X
- 259 -
July 2016
DATA DICTIONARY
Field Action
DeliveredOnDate x
DeliveredID X
Description X
DescriptionCode X
Directions X
DoNotFill X
DoseCompositeIndicator X
DoseDeliveryMethodCode X
DoseDeliveryMethodCodeQualifier X
DoseDeliveryMethodModifierCode X
DoseDeliveryMethodModifierCodeQualifier X
DoseDeliveryMethodModifierText X
DoseDeliveryMethodText X
DoseFormCode X
DoseFormCodeQualifier X
DoseFormText X
DoseQuantity X
DoseRangeModifier X
DosingBasisNumericValue X
DosingBasisRangeModifier X
DosingBasisUnitofMeasureCode X
DosingBasisUnitofMeasureCodeQualifier X
DosingBasisUnitofMeasureText X
DrugAdminReasonCode X
DrugAdminReasonText X
DrugDBCode X
DrugDBCodeQualifier X
DrugCoverageStatusCode X
DrugDescription X
DurationNumericValue X
DurationText x
DurationTextCode X
DurationTextCodeQualifier X
ECLVersion X New Field
EffectiveDate X
EndDate X
ExpirationDate X
FacilityIdentification X
FacilityName X
- 260 -
July 2016
DATA DICTIONARY
Field Action
FacilityUnit X
FillNumber X
FinalCompoundPharmaceuticalDosageForm X
FinalRouteOfAdministrationCode X
FinalRouteOfAdministrationCodeText X
FirstName X
FMTVersion X
FollowUpRequest X
FrequencyNumericValue X
FrequencyUnitsCode X
FrequencyUnitsCodeQualifier X
FrequencyUnitsText X
From X
Gender X
GroupID X
GroupName X
IndicationPrecursorCode X
IndicationPrecursorCodeQualifier X
IndicationPrecursorText X
IndicationText X
IndicationTextCode X
IndicationTextCodeQualifier X
IndicationValueText X
IndicationValueUnit X
IndicationValueUnitOfMeasureCode X
IndicationValueUnitOfMeasureCodeQualifier X
IndicationValueUnitOfMeasureText X
IndicationVariableModifier X
IntervalNumericValue X
IntervalUnitsCode X
IntervalUnitsCodeQualifier X
IntervalUnitsText X
LanguageNameCode X
LastFillDate X
LastName X
MailboxID X
MaximumDoseRestrictionCodeQualifier X
MaximumDoseRestrictionNumericValue X
MaximumDoseRestrictionUnitsCode X
- 261 -
July 2016
DATA DICTIONARY
Field Action
MaximumDoseRestrictionUnitsText X
MaximumDoseRestrictionVariableDurationModifier X
MaximumDoseRestrictionVariableUnitsCode X
MaximumDoseRestrictionVariableUnitsCodeQualifier X
MaximumDoseRestrictionVariableUnitsText X
MaximumDoseRestrictionVariableNumericValue X
MeasurementDataQualifier X
MeasurementDimension X
MeasurementUnitCode X
MeasurementValue X
MessageID X
MessageRequestCode X
MiddleInitial X
MultipleAdministrationTimingModifier X
MultipleRouteOfAdminstrationModifier X
MultipleSigModifier X
MultipleSiteOfAdministrationTimingModifier X
MultipleVehicleModifier X
NeededNoLaterThanDate X
NeededNoLaterThanReason X
NewPassword X
Nonce X
Note X
NumberOfRefills X
ObservationDate X
OldPassword X
OrderCaptureMethod X
Password X
PatientIdentification X
PatientRelationshipCode X
PayerIdentification X
PayerName X
PayerResponsibilityCode X
PBMMemberID X
PeriodEnd X
PersonCode X
PharmacyIdentification X
PharmacyRequestedRefills X
PharmacySpecialty X
- 262 -
July 2016
DATA DICTIONARY
Field Action
Prefix X
PrescriberIdentification X
PrescriberOrderNumber X
Prescriber Specialty X
PrescriptionDeliveryMethod X
PrimaryDiagnosisCodeQualifierCode X
PrimaryDiagnosisValue X
PriorAuthorizationCodeValue X
PriorAuthorizationCodeValueQualifier X
PriorAuthorizationStatus X
ProductCode X
ProductQualifierCode X
ProfessionalServiceCode X
ProhibitRefillRequest X New Field
ProviderIdentification X
ProviderSpecialty X
QuantityCodeListQualifier. X
QuantityValue X
QuantityUnitOfMeasureCode X
RateOfAdministration X
RateUnitOfMeasureCode X
RateUnitOfMeasureCodeQualifier X
RateUnitOfMeasureText X
ReasonCode X
ReasonForSubstitutionCodeUsed X New Field
RefillsRemaining X
RelatesToMessageID X
RequestReferenceNumber X
ResumeDateTime X
ReturnReceipt X
Room X
RouteOfAdministrationCode X
RouteOfAdministrationCodeQualifier X
RouteOfAdministrationText X
RxReferenceNumber X
SecondaryDiagnosisCodeQualifierCode X
SecondaryDiagnosisValue X
SecondaryIdentification X
- 263 -
July 2016
DATA DICTIONARY
Field Action
SenderSoftwareDeveloper X
SenderSoftwareProduct X
SenderSoftwareVersionRelease X
SentTime X
ServiceReasonCode X
ServiceResultCode X
ServiceTypeCoded X
SigFreeText X
SigFreeTextStringIndicator X
SigSequencePositionNumber X
SiteOfAdministrationCode X
SiteOfAdministrationCodeQualifier X
SiteOfAdministrationText X
SNOMEDVersion X
SoldDate X
SourceDescription X
SourceQualifier X
StartDate X
State X
StatusCode X
StopIndicator X
StrengthForm X
StrengthUnitOfMeasure X
StrengthValue X
StructuresVersion X New Field
SubstitutionCode X
Suffix X
SupervisorIdentification X
SupervisorSpecialty X
SuspendDateTime X
TertiaryIdentification X
TertiaryIdentifier X
TestMessage X
TimePeriodBasisCode X
TimePeriodBasisCodeQualifier X
TimePeriodBasisText X
To X
TransactionDomain X New Field
TransactionErrorCode X
- 264 -
July 2016
DATA DICTIONARY
Field Action
TransactionVersion X New Field
TransportVersion X New Field
Username X
VariableFrequencyModifier X
VariableIntervalModifier X
VehicleName X
VehicleNameCode X
VehicleNameCodeQualifier X
VehicleQuantity X
VehicleUnitOfMeasureCode X
VehicleUnitOfMeasureCodeQualifier X
VehicleUnitOfMeasureText X
VerifyStatusCode X
WrittenDate X
ZipCode X
Appendix A - NUMERIC CROSS REFERENCE Deleted SCRIPT use of Field as Shown Above
6. Data Dictionary
Field Action
Appendix B – VERSION 1.0 REJECT CODES FOR PAYMENT TAPE X
Appendix C – VERSION 2.0 REJECT CODES FOR PAYMENT TAPE X
Appendix D – VERSION 3.0 and 4.0 REJECT CODES FOR PAYMENT X
TAPE
Appendix F – SCRIPT DATA ELEMENTS X
Appendix G-PUBLICATION MODIFICATIONS Renamed to Appendix D-PUBLICATION MODIFICATIONS
Appendix D-TELECOMMUNICATION PHASES WITH FLOW CHARTS Renamed to Appendix C- TELECOMMUNICATION PHASES WITH FLOW CHARTS
Appendix B - DATA DICTIONARY FIELDS USED FOR SCRIPT TO THE X
MODEL-DRIVEN SCHEMAS
I. INTRODUCTION Added verbiage for XML field naming convention and formats. Added ‘Q=Specialized
Implementation Guide to the STANDARD FORMATS KEY Table.
LL. APRIL 2011

Field Action
- 265 -
July 2016
DATA DICTIONARY
Field Action
Medicare Drug Coverage Code A73 X
See ECL Publication of April 2011 for Added Field Values
2. Data Dictionary
Field Action
Introduction Corrected example for “N’ = Unsigned Numeric under Field Format Values
Benefit Amount A00 Corrected Format Example to remove sign
Benefit Amount Used To-Date A03 Corrected Format Example to remove sign
Claim Cost Ceiling Override Amount A04 Corrected Format Example to remove sign
Copay/Coinsurance Override Amount A07 Corrected Format Example to remove sign
MM. JULY 2011
1. Medical Rebate Data Submission Standard Implementation Guide Version 01 Release 00

Field Action
Allowed Amount A74 X
Billed Amount A75 X
J Code A76 X
J Code Modifier 1 A77 X
Medical Rebate Version Release Number A81 X
Plan Reimbursed Amount A82 X
Quarterly Member Indicator A83 X
Adjudication Date 578 Medical Rebate Data Submission Standard added to the Standard Format column
Claim Number 601-68 Medical Rebate Data Submission Standard added to the Standard Format column
Contracting Organization (PMO) Contract Number 600-65 Medical Rebate Data Submission Standard added to the Standard Format column
Contracting Organization (PMO) ID Code 600-66 Medical Rebate Data Submission Standard added to the Standard Format column
Contracting Organization (PMO) ID Qualifier 600-71 Medical Rebate Data Submission Standard added to the Standard Format column
Contracting Organization (PMO) Name 600-43 Medical Rebate Data Submission Standard added to the Standard Format column
Data Level 601-31 Medical Rebate Data Submission Standard added to the Standard Format column
Data Provider ID Code 601-32 Medical Rebate Data Submission Standard added to the Standard Format column
Data Provider ID Qualifier 601-37 Medical Rebate Data Submission Standard added to the Standard Format column
- 266 -
July 2016
DATA DICTIONARY
Field Action
Data Provider Name 601-33 Medical Rebate Data Submission Standard added to the Standard Format column
Date Of Service 401-D1 Medical Rebate Data Submission Standard added to the Standard Format column
Diagnosis Code 424-DO Medical Rebate Data Submission Standard added to the Standard Format column
Diagnosis Code Qualifier 492-WE Medical Rebate Data Submission Standard added to the Standard Format column
Encrypted Patient ID Code 601-35 Medical Rebate Data Submission Standard added to the Standard Format column
Entity Zip/Postal Code 784 Medical Rebate Data Submission Standard added to the Standard Format column
Fill Number 403-D3 Medical Rebate Data Submission Standard added to the Standard Format column
Formulary Code 600-74 Medical Rebate Data Submission Standard added to the Standard Format column
Grand Total Quantity 601-41 Medical Rebate Data Submission Standard added to the Standard Format column
Grand Total Requested Amount 601-42 Medical Rebate Data Submission Standard added to the Standard Format column
Line Number 601-43 Medical Rebate Data Submission Standard added to the Standard Format column
Manufacturer (PICO) Contract Number 600-47 Medical Rebate Data Submission Standard added to the Standard Format column
Manufacturer (PICO) ID Code 600-48 Medical Rebate Data Submission Standard added to the Standard Format column
Manufacturer (PICO) ID Qualifier 600-72 Medical Rebate Data Submission Standard added to the Standard Format column
Manufacturer (PICO) Name 600-50 Medical Rebate Data Submission Standard added to the Standard Format column
Patient Liability Amount 601-44 Medical Rebate Data Submission Standard added to the Standard Format column
Place of Service 307-C7 Medical Rebate Data Submission Standard added to the Standard Format column
Plan ID Code 600-94 Medical Rebate Data Submission Standard added to the Standard Format column
Plan ID Qualifier 600-95 Medical Rebate Data Submission Standard added to the Standard Format column
Plan Name 600-96 Medical Rebate Data Submission Standard added to the Standard Format column
Prescriber ID 411-DB Medical Rebate Data Submission Standard added to the Standard Format column
Prescriber ID Qualifier 466-EZ Medical Rebate Data Submission Standard added to the Standard Format column
Prescription/ Service Reference Number 402-D2 Medical Rebate Data Submission Standard added to the Standard Format column
Prescription/Service Reference Number Qualifier 455-EM Medical Rebate Data Submission Standard added to the Standard Format column
Prescription Type 601-49 Medical Rebate Data Submission Standard added to the Standard Format column
Product Description 601-20 Medical Rebate Data Submission Standard added to the Standard Format column
Product/Service ID 407-D7 Medical Rebate Data Submission Standard added to the Standard Format column
Product/Service ID Qualifier 436-E1 Medical Rebate Data Submission Standard added to the Standard Format column
Rebate Period End Date 600-39 Medical Rebate Data Submission Standard added to the Standard Format column
Rebate Period Start Date 600-38 Medical Rebate Data Submission Standard added to the Standard Format column
Record Purpose Indicator 601-53 Medical Rebate Data Submission Standard added to the Standard Format column
Record Type 601-04 Medical Rebate Data Submission Standard added to the Standard Format column
Reimbursement Date 601-54 Medical Rebate Data Submission Standard added to the Standard Format column
Requested Rebate Amount 601-55 Medical Rebate Data Submission Standard added to the Standard Format column
Segment 1 638-XK Medical Rebate Data Submission Standard added to the Standard Format column
Segment 2 639-XL Medical Rebate Data Submission Standard added to the Standard Format column
Segment 3 640-XM Medical Rebate Data Submission Standard added to the Standard Format column
Segment 4 641-XN Medical Rebate Data Submission Standard added to the Standard Format column
Segment 5 642-XP Medical Rebate Data Submission Standard added to the Standard Format column
Segment 6 643-XQ Medical Rebate Data Submission Standard added to the Standard Format column
Segment Qualifier 1 644-XR Medical Rebate Data Submission Standard added to the Standard Format column
Segment Qualifier 2 644-XS Medical Rebate Data Submission Standard added to the Standard Format column
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DATA DICTIONARY
Field Action
Segment Qualifier 3 644-XT Medical Rebate Data Submission Standard added to the Standard Format column
Segment Qualifier 4 644-XU Medical Rebate Data Submission Standard added to the Standard Format column
Segment Qualifier 5 644-XV Medical Rebate Data Submission Standard added to the Standard Format column
Segment Qualifier 6 644-XW Medical Rebate Data Submission Standard added to the Standard Format column
Service Provider ID 201-B1 Medical Rebate Data Submission Standard added to the Standard Format column
Service Provider ID Qualifier 202-B2 Medical Rebate Data Submission Standard added to the Standard Format column
Service Provider State/Province Code Address 586-YP Medical Rebate Data Submission Standard added to the Standard Format column
Submit Code 601-36 Medical Rebate Data Submission Standard added to the Standard Format column
Therapeutic Class Code 601-25 Medical Rebate Data Submission Standard added to the Standard Format column
Therapeutic Class Code Qualifier 601-26 Medical Rebate Data Submission Standard added to the Standard Format column
Therapeutic Class Description 601-27 Medical Rebate Data Submission Standard added to the Standard Format column
Total Quantity 601-39 Medical Rebate Data Submission Standard added to the Standard Format column
Total Record Count 601-09 Medical Rebate Data Submission Standard added to the Standard Format column
Transmission Date 601-10 Medical Rebate Data Submission Standard added to the Standard Format column
Unit Of Measure 600-28 Medical Rebate Data Submission Standard added to the Standard Format column
See ECL Publication of July 2011 for Added Field Values
2. Manufacturer Rebate Utilization, Plan, Formulary, Market Basket, and Reconciliation Flat File Standard Implementation Guide
Version 05 Release 01
Field Action
Formulary Start Date A84 X
Formulary Termination Date A85 X
Plan Eligibility Start Date A86 X
Plan Eligibility Termination Date A87 X
Adjudicator ID Code 600-57 X
Adjudicator ID Qualifier 600-58 X
Adjudicator Name 600-59 X
Calculation Multiplier 600-62 X
Dependents 600-68 X
Enrollees 600-70 X
Hierarchical Level Terminology 600-79 X
Mail Order ID Code 600-80 X
Mail Order ID Qualifier 600-81 X
Mail Order Name 601-11 X
Membership Calculation Multiplier 600-82 X
Membership Dependents 600-84 X
Membership Enrollees 600-85 X
Number of Market Product Records 601-60 X
- 268 -
July 2016
DATA DICTIONARY
Field Action
Originator ID Code 601-66 X
Originator Name 601-67 X
Plan Affiliation Parent Plan ID 600-91 X
Plan Affiliation Parent Plan ID Qualifier 600-92 X
Plan Degree Managed 600-93 X
Plan Total Adjudicators Records 600-97 X
Plan Total Formulary Benefit Design Records 600-98 X
Plan Total Mail Order Records 601-09 X
Plan Type Service 602-02 X
Total # of Market Basket Records 601-69 X
Appendix A - NUMERIC CROSS REFERENCE Added and Removed Fields as Shown Above
3. Specialized Standard Implementation Guide Version 2011071

Field Action
AdditionalMessageIndicator X
ClinicalInfoFormatsRequested X
ClinicalInfoTypesRequested X
DateOfService X
MessageToFollowMessageIdentifier X
MTMActionCode X
MTMActionCodeQualifier X
MTMActionFreeText X
MTMActionText X
NoKnown X
ReasonForMTMServiceCode X
ReasonForMTMServiceCodeQualifier X
ReasonForMTMServiceFreeText X
ReasonForMTMServiceText X
ResultOfActionCode X
ResultOfActionCodeQualifier X
ResultOfActionFreeText X
ResultOfActionText X
TemplateID X
Version X
Consent Specialized Standard added to the Standard Format column
- 269 -
July 2016
DATA DICTIONARY
Field Action
SplitScript X
DaysSupply Format change
5. Audit Transaction Standard Implementation Guide Version 1 Release 0

Field Action
Audit Request Type A47 X
Audit Control Identification A48 X
Audit Sponsor A49 X
Requested Response Date A50 X
Estimated Arrival Time Description A51 X
Entity Email A52 X
Entity Fax Number A53 X
Audit Range Qualifier A54 X
Audit Range Start A55 X
Audit Range End A56 X
Audit Element Type 1 A57 X
Audit Element Response 1 A62 X
Billing Sequence A67 X
Discrepancy Code 1 A68 X
Discrepancy Message A71 X
Discrepancy Amount A72 X
Record Type 601-04 Audit Transaction Standard added to the Standard Format column
Transmission Date 601-10 Audit Transaction Standard added to the Standard Format column
Service Provider Chain Code 886 Audit Transaction Standard added to the Standard Format column
Service Provider ID 201-B1 Audit Transaction Standard added to the Standard Format column
Service Provider ID Qualifier 202-B2 Audit Transaction Standard added to the Standard Format column
- 270 -
July 2016
DATA DICTIONARY
Field Action
Record Count 751-M9 Audit Transaction Standard added to the Standard Format column and added separate field
definition for Audit Transaction
BIN Number 101-A1 Audit Transaction Standard added to the Standard Format column
Processor Control Number 104-A4 Audit Transaction Standard added to the Standard Format column
Group ID 301-C1 Audit Transaction Standard added to the Standard Format column
Prescription/ Service Reference Number 402-D2 Audit Transaction Standard added to the Standard Format column
Prescription/Service Reference Number Qualifier 455-EM Audit Transaction Standard added to the Standard Format column
Fill Number 403-D3 Audit Transaction Standard added to the Standard Format column
Authorization Number 503-F3 Audit Transaction Standard added to the Standard Format column
Date Of Service 401-D1 Audit Transaction Standard added to the Standard Format column
Total Amount Paid 509-F9 Audit Transaction Standard added to the Standard Format column
Receiver ID 880-K7 Audit Transaction Standard added to the Standard Format column
Claim Sequence Number 219 Audit Transaction Standard added to the Standard Format column
Message 504-F4 Audit Transaction Standard added to the Standard Format column
Entity Address Line 1 776 Audit Transaction Standard added to the Standard Format column and removed Workers
Compensation form definition.
Entity Address Line 2 777 Audit Transaction Standard added to the Standard Format column and removed Workers
Entity City 778 Audit Transaction Standard added to the Standard Format column and removed Workers
Entity Contact Name 779 Audit Transaction Standard added to the Standard Format column and removed Workers
Entity Name 780 Audit Transaction Standard added to the Standard Format column and removed Workers
Entity State 782 Audit Transaction Standard added to the Standard Format column
Entity Telephone Number 783 Audit Transaction Standard added to the Standard Format column
Entity Zip/Postal Code 784 Audit Transaction Standard added to the Standard Format column
Sending Entity Identifier 879-N2 Audit Transaction Standard added to the Standard Format column
Transmission File Type 986-KJ Audit Transaction Standard added to the Standard Format column
Submission Number 888 Audit Transaction Standard added to the Standard Format column
Version/Release Number 102-A2 Audit Transaction Standard added to the Standard Format column
Transmission Type 880-K6 Audit Transaction Standard added to the Standard Format column
6. Connectivity Operating Rule Version 1.0

Field Action
PayloadType A40 X Connectivity Standard changed to Operating Rules. This field is not used in Operating Rules.
TransactionStandard A41 Deleted field ID of A41; Changed field definition and comments
Format A42 Deleted field ID of A42; Changed field definition and deleted comments
PayloadEnvelopeVersion X
- 271 -
July 2016
DATA DICTIONARY
Field Action
Payload X
PayloadEnvelopeReferenceID X
Appendix A - NUMERIC CROSS REFERENCE Removed Field and Field ID as Shown Above

Field Action
8. Data Dictionary
Field Action
Introduction – Standard Formats Key Values: Added E and J; Changed K to Operating Rules
Amount Attributed To Product Selection 519-FJ Added field that was previously deleted. 0
Compound Route of Administration 452-EH Added field that was previously deleted. 0
NN. OCTOBER 2011
1. Uniform Healthcare Payer Data Standard Implementation Guide Version 1 Release 0

Field Action
Claim Processed Code A88 X
Encrypted Social Security Number A89 X
Insurance Type/Product Code A90 X
Line Counter A91 X
Middle Name A92 X
Service Provider Country Code A93 X
Type Of File A94 X
Adjudication Date 578 Uniform Healthcare Payer Data Standard added to the Standard Format column
Amount Applied To Periodic Deductible 517-FH Uniform Healthcare Payer Data Standard added to the Standard Format column
Amount Attributed to Coverage Gap 137-UP Uniform Healthcare Payer Data Standard added to the Standard Format column
Amount Attributed to Processor Fee 571-NZ Uniform Healthcare Payer Data Standard added to the Standard Format column
Amount Attributed To Product Selection 519-FJ Uniform Healthcare Payer Data Standard added to the Standard Format column
Amount Attributed to Product Selection / Brand Drug 134-UK Uniform Healthcare Payer Data Standard added to the Standard Format column
Amount Attributed to Product Selection / Brand Non-Preferred 136-UN Uniform Healthcare Payer Data Standard added to the Standard Format column
Formulary Selection
- 272 -
July 2016
DATA DICTIONARY
Field Action
Amount Attributed to Product Selection / Non-Preferred Formulary 135-UM Uniform Healthcare Payer Data Standard added to the Standard Format column
Selection
Amount Attributed to Provider Network Selection 133-UJ Uniform Healthcare Payer Data Standard added to the Standard Format column
Amount Attributed To Sales Tax 523-FN Uniform Healthcare Payer Data Standard added to the Standard Format column
Amount Exceeding Periodic Benefit Maximum 520-FK Uniform Healthcare Payer Data Standard added to the Standard Format column
Amount of Coinsurance 572-4U Uniform Healthcare Payer Data Standard added to the Standard Format column
Amount Of Copay 518-FI Uniform Healthcare Payer Data Standard added to the Standard Format column
Cardholder ID 302-C2 Uniform Healthcare Payer Data Standard added to the Standard Format column
Check Date 216 Uniform Healthcare Payer Data Standard added to the Standard Format column
City 728-SU Uniform Healthcare Payer Data Standard added to the Standard Format column
Compound Code 406-D6 Uniform Healthcare Payer Data Standard added to the Standard Format column
Creation Date 880-K2 Uniform Healthcare Payer Data Standard added to the Standard Format column
Date Of Birth 304-C4 Uniform Healthcare Payer Data Standard added to the Standard Format column
Date Of Service 401-D1 Uniform Healthcare Payer Data Standard added to the Standard Format column
Days Supply 405-D5 Uniform Healthcare Payer Data Standard added to the Standard Format column
Dispense As Written (DAW)/ Product Selection Code 408-D8 Uniform Healthcare Payer Data Standard added to the Standard Format column
Dispensing Fee Paid 507-F7 Uniform Healthcare Payer Data Standard added to the Standard Format column
Drug Type 425-DP Uniform Healthcare Payer Data Standard added to the Standard Format column
Eligibility Group ID 246 Uniform Healthcare Payer Data Standard added to the Standard Format column
Eligibility/Patient Relationship Code 247 Uniform Healthcare Payer Data Standard added to the Standard Format column
Fill Number Calculated 254 Uniform Healthcare Payer Data Standard added to the Standard Format column
First Name 717-SX Uniform Healthcare Payer Data Standard added to the Standard Format column
Flat Sales Tax Amount Paid 558-AW Uniform Healthcare Payer Data Standard added to the Standard Format column
Gross Amount Due 430-DU Uniform Healthcare Payer Data Standard added to the Standard Format column
Health Plan-funded Assistance Amount 129-UD Uniform Healthcare Payer Data Standard added to the Standard Format column
Ingredient Cost Paid 506-F6 Uniform Healthcare Payer Data Standard added to the Standard Format column
Incentive Amount Paid 521-FL Uniform Healthcare Payer Data Standard added to the Standard Format column
Internal Control Number 993-A7 Uniform Healthcare Payer Data Standard added to the Standard Format column
Last Name 716-SY Uniform Healthcare Payer Data Standard added to the Standard Format column
Message 504-F4 Uniform Healthcare Payer Data Standard added to the Standard Format column
Middle Initial 718-SZ Uniform Healthcare Payer Data Standard added to the Standard Format column
Net Amount Due 281 Uniform Healthcare Payer Data Standard added to the Standard Format column
Other Amount Paid 565-J4 Uniform Healthcare Payer Data Standard added to the Standard Format column
Other Amount Paid Qualifier 564-J3 Uniform Healthcare Payer Data Standard added to the Standard Format column
Patient Gender Code 305-C5 Uniform Healthcare Payer Data Standard added to the Standard Format column
Patient ID 332-CY Uniform Healthcare Payer Data Standard added to the Standard Format column
Patient Pay Amount 505-F5 Uniform Healthcare Payer Data Standard added to the Standard Format column
Payer ID 569-J8 Uniform Healthcare Payer Data Standard added to the Standard Format column
Percentage Sales Tax Amount Paid 559-AX Uniform Healthcare Payer Data Standard added to the Standard Format column
Person Code 303-C3 Uniform Healthcare Payer Data Standard added to the Standard Format column
Pharmacy Name 833-5P Uniform Healthcare Payer Data Standard added to the Standard Format column
Prescriber ID 411-DB Uniform Healthcare Payer Data Standard added to the Standard Format column
- 273 -
July 2016
DATA DICTIONARY
Field Action
Prescriber ID Qualifier 466-EZ Uniform Healthcare Payer Data Standard added to the Standard Format column
Product/Service ID 407-D7 Uniform Healthcare Payer Data Standard added to the Standard Format column
Product/Service ID Qualifier 436-E1 Uniform Healthcare Payer Data Standard added to the Standard Format column
Product/Service Name 397 Uniform Healthcare Payer Data Standard added to the Standard Format column
Professional Service Fee Paid 562-J1 Uniform Healthcare Payer Data Standard added to the Standard Format column
Quantity Dispensed 442-E7 Uniform Healthcare Payer Data Standard added to the Standard Format column
Record Status Code 399 Uniform Healthcare Payer Data Standard added to the Standard Format column
Record Type 601-04 Uniform Healthcare Payer Data Standard added to the Standard Format column
Reporting Period End Date 601-05 Uniform Healthcare Payer Data Standard added to the Standard Format column
Reporting Period Start Date 601-06 Uniform Healthcare Payer Data Standard added to the Standard Format column
Sending Entity Identifier 879-N2 Uniform Healthcare Payer Data Standard added to the Standard Format column
Service Provider ID 201-B1 Uniform Healthcare Payer Data Standard added to the Standard Format column
Service Provider ID Qualifier 202-B2 Uniform Healthcare Payer Data Standard added to the Standard Format column
State 729-TA Uniform Healthcare Payer Data Standard added to the Standard Format column
Total Records 978-JS Uniform Healthcare Payer Data Standard added to the Standard Format column
Version/Release Number 102-A2 Uniform Healthcare Payer Data Standard added to the Standard Format column
Zip/Postal Code 730-TC Uniform Healthcare Payer Data Standard added to the Standard Format column
2. Retiree Drug Subsidy Standard Implementation Guide Version 1 Release 0

Field Action
Application ID A95 X
Contact Person A96 X
Gross Retiree Cost A97 X
Limit Reduction A98 X
Qualified Covered Retiree HICN A99 X
Qualified Covered Retiree SSN B01 X
Threshold Reduction B02 X
Unique Benefit Option Identifier B03 X
Creation Date 880-K2 Retiree Drug Subsidy Standard added to the Standard Format column
Creation Time 880-K3 Retiree Drug Subsidy Standard added to the Standard Format column
Date Of Birth 304-C4 Retiree Drug Subsidy Standard added to the Standard Format column
First Name 717-SX Retiree Drug Subsidy Standard added to the Standard Format column
Last Name 716-SY Retiree Drug Subsidy Standard added to the Standard Format column
Middle Initial 718-SZ Retiree Drug Subsidy Standard added to the Standard Format column
Record Type 601-04 Retiree Drug Subsidy Standard added to the Standard Format column
Sender ID 880-K1 Retiree Drug Subsidy Standard added to the Standard Format column
Sending Entity Identifier 879-N2 Retiree Drug Subsidy Standard added to the Standard Format column
- 274 -
July 2016
DATA DICTIONARY
Field Action
Telephone Number 732-TB Retiree Drug Subsidy Standard added to the Standard Format column
Total Record Count 601-09 Retiree Drug Subsidy Standard added to the Standard Format column
Version/Release Number 102-A2 Retiree Drug Subsidy Standard added to the Standard Format column

Field Action
Average Cost Per Quantity Unit Price 209
Average Generic Unit Price 210
Average Wholesale Unit Price 211
Federal Upper Limit Unit Price 253
MAC Price 271
Version/Release Number 102-A2 Version updated in ECL

Field Action

Field Action
6. Data Dictionary
Field Action
Introduction – Standard Formats Key Values: Added L and Y
OO. JANUARY 2012

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July 2016
DATA DICTIONARY
Field Action
Next Available Fill Date B04-BT X

Field Action
MultipleSiteOfAdministrationTimingModifier Name of Field corrected to MultipleSiteOfAdministrationModifier
PP. APRIL 2012

Field Action
Field Formats All “xsd:string” were replaced with “an”

Field Action
PharmacistIdentification X
TypeOfServiceGroupSetting X
Field Formats All “xsd:string” were replaced with “an”
QQ. JULY 2012
1. Data Dictionary
Field Action
CompoundIngredientProductCode X
CompoundIngredientProductCodeQualifier X All “xsd:string” were replaced with “an”
Version/Release Number 102-A2 Version updated in ECL for Post Adjudication Version 3.1
- 276 -
July 2016
DATA DICTIONARY
RR. OCTOBER 2012
1. Data Dictionary
Field Action
Introduction Corrected BooleanCode values from True/False to Yes/No
AdditionalMessageIndicator Removed ‘See ECL’
ProhibitRefillRequest Format: from BooleanCode to xsd:boolean; removed ‘See ECL’
External Code List (ECL) See ECL publication of October 2012 for addition of values and reject codes.
SS. JANUARY 2013

Field Action
AdministrationIndicator X
AdministrationTimingClarifyingFreeText X
AdministrationTimingEventCode X
AdministrationTimingEventQualifier X
AdministrationTimingEventText X
AdministrationTimingModifierCode X
AdministrationTimingModifierQualifier X
AdministrationTimingModifierText X
AdministrationTimingNumericValue X
BeeperNumber X
BeeperExtension X
BeeperSupportsSMS X
ClarifyingFreeText X
DoseAmountText X
DoseAmountTextCode X
DoseAmountTextQualifier X
DoseClarifyingFreeText X
DoseCalculationClarifyingFreeText X
DurationClarifyingFreeText X
ElectronicMail X
FaxNumber X
FaxExtension X
FaxSupportsSMS X
HomeTelephoneNumber X
Home TelephoneExtension X
HomeTelephoneSupportsSMS X
- 277 -
July 2016
DATA DICTIONARY
Field Action
IndicationClarifyingFreeText X
IndicationValueCode X
IndicationValueQualifier X
InstructionIndicator X
MaximumDoseRestrictionClarifyingFreeText X
MaximumDoseRestrictionFormCode X
MaximumDoseRestrictionFormQualifier X
MaximumDoseRestrictionFormText X
OtherTelephoneExtension X
OtherTelephoneNumber X
OtherTelephoneSupportsSMS X
PrimaryTelephoneExtension X
PrimaryTelephoneNumber X
PrimaryTelephoneSupportsSMS X
RouteOfAdministrationClarifyingFreeText X
SiteOfAdministrationClarifyingFreeText X
StopIndicatorText X
StopIndicatorTextCode X
StopIndicatorTextQualifier X
TimingClarifyingFreeText X
TriggerText X
TriggerTextCode X
TriggerTextQualifier X
VehicleClarifyingFreeText X
VehiclePrepositionCode X
VehiclePrepositionQualifier X
VehiclePrepositionText X
WorkTelephoneExtension X
WorkTelephoneNumber X
WorkTelephoneSupportsSMS X
AddressLine1 Format Change
AdministrationTimingCode Name change to:AdministrationTimingUnitsCode; Format Change
AdministrationTimingCodeQualifier Name change to: AdministrationTimingUnitsQualifier:
AdministrationTimingText Name change to: AdministrationTimingUnitsText: Format Change
BodyMetricValue Format added to Comments Column
CalculatedDoseUnitOfMeasureCode Definition Change; Format Change
CalculatedDoseUnitOfMeasureCodeQualifier Name change to: CalculatedDoseUnitOfMeasureQualifier
CalculatedDoseUnitOfMeasureText Definition Change; Format Change
ClinicName Format Change
- 278 -
July 2016
DATA DICTIONARY
Field Action
DoseDeliveryMethodCode Format Change
DoseDeliveryMethodCodeQualifier Name Change to DoseDeliveryMethodQualifier
DoseDeliveryMethodText Format Change
DoseDeliveryMethodModifierCode Format Change
DoseDeliveryMethodModifierCodeQualifier Name change to: DoseDeliveryMethodModifierQualifier
DoseDeliveryMethodModifierText Definition Change; Format Change
DoseFormCode Definition Change; Format Change
DoseFormCodeQualifier Name change to: DoseFormQualifier
DoseFormText Definition Change; Format Change
DoseRangeModifier Format Change
DosingBasisNumericValue Name change to:DosingBasisNumeric
DosingBasisUnitOfMeasureCode Definition Change; Format Change
DosingBasisUnitOfMeasureCodeQualifier Name Change to: DosingBasisUnitOfMeasureQualifier
DosingBasisUnitOfMeasureText Definition Change; Format Change
DosingBasisRangeModifier Format Change
DurationNumericValue Format Change
DurationTextCode Format Change
DurationTextCodeQualifier Name Change to: DurationTextQualifier
DurationText Format Change
FacilityName Format Change
FMTVersion Definition Change; Format Change
FrequencyNumericValue Format Change
FrequencyUnitsCode Definition Change; Format Change
FrequencyUnitsCodeQualifier Name change to: FrequencyUnitsQualifier
FrequencyUnitsText Format Change
GroupName Format Change
IndicationPrecursorCode Definition Change; Format Change
IndicationPrecursorCodeQualifier Name change to: IndicationPrecursorQualifier
IndicationPrecursorText Format Change
IndicationTextCode Name change to:IndicationCode; Format Change
IndicationTextCodeQualifier Name change to:IndicationQualifier
IndicationText Definition Change; Format Change
IndicationValueText Definition Change; Format Change
IndicationValueUnitOfMeasureCode Definition Change; Format Change
IndicationValueUnitOfMeasureCodeQualifier Name change to:IndicationValueUnitOfMeasureQualifier
IndicationValueUnitOfMeasureText Definition Change; Format Change
IndicationVariableModifier Format Change
IntervalUnitsCode Format Change
IntervalUnitsCodeQualifier Name change to: IntervalUnitsQualifier
IntervalUnitsText Format Change
MaximumDoseRestrictionUnitsCode Definition Change; Format Change
- 279 -
July 2016
DATA DICTIONARY
Field Action
MaximumDoseRestrictionCodeQualifier Name change to: MaximumDoseRestrictionUnitsQualifier
MaximumDoseRestrictionUnitsText Definition Change; Format Change
MaximumDoseRestrictionVariableNumericValue Name change to: MaximumDoseRestrictionDurationValue; Definition Change
MaximumDoseRestrictionVariableUnitsCode Name change to: MaximumDoseRestrictionDurationUnitsCode; Definition Change; Format
Change
MaximumDoseRestrictionVariableUnitsCodeQualifier Name change to: MaximumDoseRestrictionDurationUnitsQualifier
MaximumDoseRestrictionVariableUnitsText Name change to: MaximumDoseRestrictionDurationUnitsText; Definition Change; Format
Change
MultipleSigModifier Name Change to: MultipleInstructionModifier; Definition Change, Format Change
MultipleAdministrationTimingModifier Name Change to: VariableAdministrationTimingModifier; Definition Change; Format Change
MultipleVehicleModifier Definition Change; Format Change
PayerName Format Change
RateUnitOfMeasureCode Format Change
RateUnitOfMeasureCodeQualifier Name change to:RateUnitOfMeasureQualifier
RateUnitOfMeasureText Definition Change; Format Change
RouteOfAdministrationCode Definition Change; Format Change
RouteOfAdministrationCodeQualifier Name Change to: RouteOfAdministrationQualifier
RouteOfAdministrationText Definition Change; Format Change
SigFreeText Name change to: SigText; Definition Change; Format Change
SiteOfAdministrationCode Definition Change; Format Change
SiteOfAdministrationCodeQualifier Name change to: SiteOfAdministrationQualifier
SiteOfAdministrationText Format Change
SNOMEDVersion Format Change
TimePeriodBasisCode Definition Change; Format Change
TimePeriodBasisCodeQualifier Name change to:TimePeriodBasisQualifier
TimePeriodBasisText Definition Change; Format Change
VariableFrequencyModifier Format Change
VariableIntervalModifier Format Change
VehicleName Name change to: Vehicle; Definition Change; Format Change
VehicleNameCode Name change to: VehicleCode; Definaiton Change; Format Change
VehicleNameCodeQualifier Name change to: VehicleQualifier
VehicleUnitOfMeasureCode Definition Change; Format Change
VehicleUnitOfMeasureCodeQualifier Name change to: VehicleUnitOfMeasureQualifier
VehicleUnitOfMeasureText Definition Change; Format Change
Directions X Sunset of Data Element
DoseCompositeIndicator X Sunset of Data Element
FinalRouteOfAdministrationCode X Sunset of Data Element
FinalRouteOfAdministrationCodeText X Sunset of Data Element
MaximumDoseRestrictionVariableDurationModifier X Sunset of Data Element
MultipleRouteOfAdminstrationModifier X Sunset of Data Element
MultipleSiteOfAdministrationModifier X Sunset of Data Element
- 280 -
July 2016
DATA DICTIONARY
Field Action
SigFreeTextStringIndicator X Sunset of Data Element
SigSequencePositionNumber X Sunset of Data Element
StopIndicator X Sunset of Data Element
External Code List (ECL) See ECL publication of January 2013 for updates of values

Field Action
CoAgentCodeDescription X
CompoundQuantityCodeListQualifier X
CompoundQuantityValue X
PrimaryDiagnosisCodeDescription X
QuantityValue Comments: Added format
SecondaryDiagnosisCodeDescription X

Field Action
Address Line 1 726-SR Format Change
Address Line 2 727-SS Format Change
First Name 717-SX Format Change
Pharmacy Name 833-5P Format Change
Telephone Number Extension B10-8A X

Field Action
Compound Ingredient Quantity 448-ED Format Change

- 281 -
July 2016
DATA DICTIONARY
Field Action
Entity Contact First Name B05 X
Entity Contact Last Name B06 X
Entity Telephone Number Extension B07 X
Entity Address Line 1 776 Format Change
Entity Address Line 2 777 Format Change
Entity Contact Name 779 Sunset of Data Element
Entity Name 780 Format Change

Field Action
Source Name 972-JK
Field Action
Contracting Organization (PMO) Name 600-43 Format Change
Data Provider Name 601-33 Format Change
Formulary Manager Company Name 601-15 Format Change
Manufacturer (PICO) Name 600-50 Format Change
Plan Name 600-96 Format Change
Rebate Version Release Number 601-03 Version updated in ECL
8. Medicaid Subrogation Implementation Guide Version 4 Release 0

Field Action
Patient Street Address Line 1 B08-7A X
Patient Street Address Line 2 B09-7B X
Patient Street Address 322-CM Sunset Data Element for this Standard
Patient First Name 310-CA Added for use by this Standard; Comment added regarding field size
- 282 -
July 2016
DATA DICTIONARY
Field Action
Patient Last Name 311-CB Added for use by this Standard; Comment added regarding field size
9. Medical Rebates Data Submission Standard Implementation Guide Version 02 Release 00

Field Action
Contracting Organization (PMO) Name 600-43 Format Change
Data Provider Name 601-33 Format Change
Manufacturer (PICO) Name 600-50 Format Change
Plan Name 600-96 Format Change
Medical Rebates Version Release Number A81 Version updated in ECL
10. Prescription File Transfer Standard Implementation Guide Version 3 Release 0

Field Action
Client Name 605-NB Format Change
Destination Name 818-5F Format Change
Facility Name 385-3Q Format Change
Last Name 716-SY Format Change
Processor Name 839-5V Format Change
Sender Name 626-SD Format Change
11. Prior Authorization Transfer Standard Implementation Guide Version 2 Release 0

Field Action
Client Name 605-NB Format Change
Last Name 716-SY Format Change
Patient First Name 310-CA Added for use by this Standard
- 283 -
July 2016
DATA DICTIONARY
Field Action
Patient Last Name 311-CB Added for use by this Standard
Receiver Name A19 Format Change
Sender Name 626-SD Format Change
12. Retiree Drug Subsidy Standard Implementation Guide Version 2 Release 0

Field Action
Contact Person A96 X
Contact Person First Name B11 X
Contact Person Last Name B12 X

Field Action
BeeperNumber X
BeeperExtension X
BeeperSupportsSMS X
ClinicName Format Change
ElectronicMail X
FacilityName Format Change
FaxNumber X
FaxExtension X
FaxSupportsSMS X
GroupName Format Change
HomeTelephoneNumber X
Home TelephoneExtension X
HomeTelephoneSupportsSMS X
OtherTelephoneExtension X
- 284 -
July 2016
DATA DICTIONARY
Field Action
OtherTelephoneNumber X
OtherTelephoneSupportsSMS X
PayerName Format Change
PrimaryTelephoneExtension X
PrimaryTelephoneNumber X
PrimaryTelephoneSupportsSMS X
WorkTelephoneExtension X
WorkTelephoneNumber X
WorkTelephoneSupportsSMS X
14. Telecommunication Standard Implementation Guide Version E Release 0

Field Action
Authorized Representative Street Address Line 1 B13-7D X
Authorized Representative Street Address Line 2 B14-8B X
Employer Street Address Line 1 B15-8D X
Employer Street Address Line 2 B16-7G X
Employer Contact First Name B17-7H X
Employer Contact Last Name B18-7J X
Employer Telephone Number Extension B19-7K X
Facility Street Address Line 1 B20-7M X
Facility Street Address Line 2 B21-7N X
Help Desk Telephone Number Extension B22-7P X
Other Payer Help Desk Telephone Number Extension B23-7Q X
Patient Street Address Line 1 B08-7A X
Patient Street Address Line 2 B09-7B X
Pay To Street Address Line 1 B24-7R X
Pay To Street Address Line 2 B25-7S X
Prescriber Telephone Number Extension B26-7T X
Prescriber Street Address Line 1 B27-7U X
Prescriber Street Address Line 2 B28-7V X
Purchaser Street Address Line 1 B29-7W X
Purchaser Street Address Line 2 B30-7X X
Service Provider Street Address Line 1 B31-7Y X
Service Provider Street Address Line 2 B32-7Z X
Authorized Representative First Name 498-PE X
Authorized Representative Last Name 498-PF X
Authorized Representative Street Address 498-PG X
Cardholder First Name 312-CC Comment added regarding field size
- 285 -
July 2016
DATA DICTIONARY
Field Action
Cardholder Last Name 313-CD Comment added regarding field size
Employer Street Address 316-CG Sunset of Data Element for this Standard
Employer Phone Number 320-CK Name change to: Employer Telephone Number
Employer Contact Name 321-CL Sunset of Data Element for this Standard
Facility Name 385-3Q Format Change
Facility Street Address 386-3U X
Help Desk Phone Number 550-8F Name change to: Help Desk Telephone Number
Help Desk Phone Number Qualifer 549-7F Name change to: Help Desk Telephone Number Qualifer
Other Payer Help Desk Phone Number 127-UB Name change to: Other Payer Help Desk Telephone Number
Patient Street Address 322-CM Sunset Data Element for this Standard
Patient First Name 310-CA Comment added regarding field size
Patient Last Name 311-CB Comment added regarding field size
Patient Phone Number 326-CQ Name change to: Patient Telephone Number
Pay To Name 120-TU Format Change
Pay To Street Address 121-TV Sunset Data Element for this Standard
Prescriber First Name 364-2J Format Change
Prescriber Last Name 427-DR Format Change
Prescriber Street Address 365-2K Sunset Data Element for this Standard
Prescriber Phone Number 498-PM Name change to: Prescriber Telephone Number
Primary Care Provider Last Name 470-4E Format Change
Purchaser First Name 596-YZ Format Change
Purchaser Last Name 597-Y0 Format Change
Purchaser Street Address 598-Y1 X
Service Provider Name 583-YK Format Change
Service Provider Street Address 584-YM X

Field Action
Compound Ingredient Quantity 448-ED Format Change
Field Action
- 286 -
July 2016
DATA DICTIONARY
Field Action
TT. APRIL 2013
1. Data Dictionary
Field Action
Introduction Modified Rules for Demographic Fields
External Code List (ECL) See ECL publication of April 2013 for updates of values

Field Action
Professional Service Fee Contracted/Reimbursement Amount B33-6G x
Authorized Representative State/Province Address 498-PJ Definition: modified
Authorized Representative Zip/Postal Zone 498-PK Name, Definition, Comments: modified; Examples: added
Employer State/Province Address 318-CI Definition: modified; Comments: deleted
Employer Zip/ Postal Zone 319-CJ Name, Definition, Comments: modified; Examples: added
Facility State/Province Address 387-3V Definition: modified
Patient ID Associated State/Province Address A22-YR Definition: modified
Patient State/Province Address 324-CO Definition: modified; Comments: deleted
Patient Zip/ Postal Zone 325-CP Name, Definiton, Comments: modified; Examples: added
Pay to State/Province Address 123-TX Definition: modified
Pay To Zip/Postal Zone 124-TY Name, Definiton, Comments: modified; Examples: added
Prescriber Alternate ID Associated State/Province Address A27-ZQ Definition: modified
Prescriber ID Associated State/Province Address A24-ZK Definition: modified
Prescriber State/Province Address 367-2N Definition: modified
Purchaser Address State/Province Code 675-Y3 Name, Definition: modified
Purchaser ID Associated State/Province Code 593-YW Name, Definition: modified
Purchaser Zip/Postal Code 676-Y4 Definition, Comments: modified
Service Provider Country Code A93 x Added 2-digit ID to field number
Service Provider State/Province Code Address 586-YP Name, Definition: modified
Service Provider Zip/Postal Code 587-YQ Definition, Comments: modified
DUR/PPS Level Of Effort 474-8E Comments: Moved to ECL
Authorized Representative Country Code B34-1U x
Employer Country Code B35-1V x
- 287 -
July 2016
DATA DICTIONARY
Field Action
Facility Country Code B37-1X x
Patient ID Associated Country Code B38-1Y x
Pay to Country Code B39-1Z x
Prescriber Alternate ID Associated Country Code B40-3A x
Prescriber ID Associated Country Code B41-3B x
Prescriber Country Code B42-3C x
Purchaser ID Associated Country Code B43-3D x
3. Workers’ Compensation/Property & Casualty Universal Claim Form

Field Action
Carrier Location State 810-1G Name: modified
Carrier Zip Code 813-1J Name,Definition: modified; Comments, Examples: added
Employer State/Province Address 318-CI Definition: modified; Comments: deleted
Employer Zip/ Postal Zone 319-CJ Name, Definition, Comments: modified; Examples: added
Patient State/Province Address 324-CO Definition: modified; Comments: deleted
Patient Zip/ Postal Zone 325-CP Name, Definiton, Comments: modified; Examples: added
Pay to State/Province Address 123-TX Definition: modified
Pay To Zip/Postal Zone 124-TY Name, Definition, Comments: modified; Examples: added
Pharmacy Location State 832-6F Name, Definition: modified
Pharmacy Zip Code 835-5R Name, Definition, Comments: modified; Examples: added
Prescriber State/Province Address 367-2N Definition: modified

Field Action
Entity State 782 Name, Definition: modified
Entity Zip/Postal Code 784 Definition: modified; Comments, Examples: added
Entity Country Code B36-1W x
5. Medical Rebates Data Submission Standard Implementation Guide Version 02 Release 01

- 288 -
July 2016
DATA DICTIONARY
Field Action
Entity Zip/Postal Code 784 Definition: modified; Comments, Examples: added
Service Provider State/Province Code Address 586-YP Name, Definition: modified

Field Action
Patient Country Code A43-1K x
State 729-TA Name, Definition: modified
Zip/Postal Code 730-TC Definition: modified; Comments: added
7. Universal Claim Form

Field Action
Pharmacy Location State 832-6F Name, Definition: modified
DUR/PPS Level Of Effort 474-8 Comments: Moved to ECL
Pharmacy Zip Code 835-5R Name, Definition, Comments: modified; Examples: added

Field Action
- 289 -
July 2016
DATA DICTIONARY
Field Action
State Name, Definition, Format: modified
PostalCode x

Field Action
State Name, Definition, Format: modified
PostalCode x
11. Prescription File Transfer Standard Implementation Guide Version 3 Release 1

Field Action
UU. JULY 2013
1. Specilaized Implementation Guide Version 2013071

Field Action
AuthorizationNumber x
CacluatedPrescriptionSellingPrice x
CFOrderID x
ChildResistantPackage x
Coating x
Color x
Counsel x
CounselNotes x
- 290 -
July 2016
DATA DICTIONARY
Field Action
DiscountAmount x
DrugShape x
Flavor x
Imprint1 x
Imprint2 x
IngredientCost x
LabelCode x
LabelGraphicCode x
LabelPriority x
LabelText x
LotExpiration x
LotNumber x
MailOrder x
ManufacturerName x
Markings x
MonographText x
PatientPayAmount x
PrescriptionSellPrice x
Priority x
RxBarcode x
RxRefillMessage x
ShippingAmount x
ShippingMethod x
ShipToteIdentification x
SubstitutedBrandDrug x
SubstitutionMessage x
TechnicianInitials x
TotalAmountBrandPenalty x
TotalNumberPackages x
TotalNumberVials x
ToteBarcode x
UnitOfUse x
PayerIdentification Field Size increased to 80
External Code List (ECL) See ECL publication of July 2013 for updates of values

Field Action
AdditionalFreeText x
AdditionalFreeTextIndicator x
- 291 -
July 2016
DATA DICTIONARY
Field Action
Answer x
AnswerValue x
AppealCaseID x
AttachmentControlNumber x
CancelReasonCode x
ChoiceID x
ChoiceText x
ClosedReasonCode x
CodedReferenceCode x
CodedReferenceDescription x
CodedReferenceQualifier x
CodedSystemVersion x
ComparisonOperator x
ComparisonValue x
DeadlineForReply x
DefaultNextQuestionID x
DeniedForCancelReasonCode x
IsDateTimeRequired x
IsEAppealSupported x
IsFreeText x
IsNumeric x
IsPatientNotified x
LowerBoundComparisonOperator x
LowerBoundComparisonValue x
NextQuestionID x
NumberOfCycles x
OtherReason x
PACaseID x
PANote x
PAReferenceID x
PAStructuresVersion x
PharmacyType x
PrescriberProvidedAnswer x
PrescriberProvidedNumericAnswer x
QuestionID x
QuestionLevel x
QuestionSetComment x
QuestionSetDescription x
QuestionSetID x
QuestionSetTitle x
QuestionText x
SeeTransactionLevelAttachmentControlNumber x
- 292 -
July 2016
DATA DICTIONARY
Field Action
SelectMultiple x
SequenceNumber x
UpperBoundComparisonOperator x
UpperBoundComparisonValue x
CouponNumber x
PriorAuthorizationCodeValue Field Name changed to PriorAuthorization
PriorAuthorizationCodeValueQualifier x
PayerIdentification Field Size increased to 80
Field Action
Prescription Origin Code 419-DJ Added for use by this Standard
4. Data Dictionary
Field Action
Appendix C x
Appendix D Publication Modifications Renamed to Appendix C
VV. OCTOBER 2013
1. Specilaized Implementation Guide Version 2013101

Field Action
AddressTypeQualifier Value added.
External Code List (ECL) See ECL publication of October 2013 for updates of values

Field Action
- 293 -
July 2016
DATA DICTIONARY
Field Action
x
DigitalSignatureIndicator x
DigitalSignatureVersion x
DigestValue x
LOINCVersion x
ObservationNotes x
SignatureValue x
UCUMVersion x
UnitOfMeasure x
VitalSign x
X509Data x
MeasurementDataQualifier x
MeasurementDimension x
MeasurementUnitCode x
MeasurementValue Deleted Comments

Field Action
Class ID--Step Drug 903-BR x
Prior Authorization Answer Value 670-V9 x
Prior Authorization Applicability 663-V2 x
Prior Authorization Basis Question Sequence Number 667-V6 x
Prior Authorization Basis Value 669-V8 x
Prior Authorization Comparison Type 668-V7 x
Prior Authorization Form ID 657-T5 x
Prior Authorization Form Title 658-T6 x
Prior Authorization Question Code 659-T7 x
Prior Authorization Question Code Qualifier 660-T8 x
Prior Authorization Question Number 662-V1 x
Prior Authorization Question Sequence 661-T9 x
Prior Authorization Question Text 666-V5 x
Prior Authorization Required Question 664-V3 x
Prior Authorization Response Type 665-V4 x
Relative Cost 966-JC x
Relative Cost Limit 967-JD x
Subclass ID-Step Drug 976-JQ x
Appendix A Deleted fields shown above
- 294 -
July 2016
DATA DICTIONARY
Field Action

Field Action
Intermediary ID Count B44-8G x
Intermediary ID Type Code B45-8H x
Intermediary ID Type Entity B46-8J x
Intermediary ID Qualifier B47-8K x
Intermediary ID B48-8M x
Intermediary ID State/Province Address B49-8N x
Intermediary ID Relationship Code B50-8P x
Intermediary Message B51-8Q x
Response Intermediary Authorization Count B52-8R x
Response Intermediary Authorization Type ID B53-8S x
Response Intermediary Authorization ID B54-8T x
Intermediary ID Country Code B55-8U x
Intermediary Authorization ID 464-EX x
Intermediary Authorization Type ID 463-EW x
Appendix A Deleted and added fields as shown above
WW. JANUARY 2014

Field Action
External Code List (ECL) See ECL publication of January 2014 for updates
2. Data Dictionary
Field Action
Transmission Time 984-JY Corrected format from 6 to 8
- 295 -
July 2016
DATA DICTIONARY
Field Action
Branded Generic Co-Pay Confidential 600-60 x For use in the Rebate Standard
Branded Product Co-Pay Amount 600-61 x For use in the Rebate Standard
Cost Index Point High Value 601-12 x For use in the Rebate Standard
Cost Index Point Low Value 601-13 x For use in the Rebate Standard
Dollar Sign Rating 601-14 x For use in the Rebate Standard
Formulary Manager Company Name 601-15 x For use in the Rebate Standard
Formulary Manager Person Name 601-16 x For use in the Rebate Standard
Formulary Non-Formulary Co-Pay Confidential 600-76 x For use in the Rebate Standard
Formulary Product Co-Pay Amount 600-77 x For use in the Rebate Standard
Formulary Product Co-Pay Confidential 601-17 x For use in the Rebate Standard
Generic Product Co-Pay Amount 600-78 x For use in the Rebate Standard
Non-Formulary Product Co-Pay Amount 600-90 x For use in the Rebate Standard
Product Dosage Form 601-21 x For use in the Rebate Standard
Product Formulary Status Code 601-22 x For use in the Rebate Standard
Product Generic Name 601-23 x For use in the Rebate Standard
Product Strength 601-24 x For use in the Rebate Standard
Therapeutic Use Code 601-28 x For use in the Rebate Standard
Therapeutic Use Description 601-29 x For use in the Rebate Standard
Appendix A Deleted fields as shown above
XX. APRIL 2014
1. Uniform Standard Implementation Guide Version 22

Action
Field Number Appendix or Field Name
879-N2 Sending Entity Identifier Revised size from 8 to 10
102-A2 Version/Release Number Version updated in ECL. See ECL publication of April 2014 for updates
2. Post Adjudication Standard Implementation Guide Version 43

Action
215 Carrier Number Revised size from 9 to 10
102-A2 Version/Release Number Version updated in ECL. See ECL publication of April 2014 for updates
- 296 -
July 2016
DATA DICTIONARY
Action
601-03 Rebate Version Release Number Version updated in ECL. See ECL publication of April 2014 for update of values.
4. Telecommunication Standard Implementation Guide Version E5

Action
B56-3E Last Known BIN Number X
B57-3F Last Known Processor Control Number X
B58-3G Last Known Group ID X
B59-3H Last Known Cardholder ID X
B60-3J Year of Last Paid Claim X
B61-3K Month of Last Paid Claim X
314-CE Home Plan X Sunset of field
102-A2 Version/Release Number Version updated in ECL
External Code List (ECL) See ECL publication of April 2014 for updates

Action
CancelReasonCode X Sunset of field
ClosedReasonCode X Sunset of field
DeniedForCancelReasonCode X Sunset of field
6. Audit Transaction Standard Implementation Guide Version 30

Action
548-6F Approved Message Code Added for use by Version 30 of the Audit Transaction Standard
252 Federal DEA Schedule Added for use by Version 30 of the Audit Transaction Standard
436-E1 Product/Service ID Qualifier Added for use by Version 30 of the Audit Transaction Standard
407-D7 Product/Service ID Added for use by Version 30 of the Audit Transaction Standard
466-EZ Prescriber ID Qualifier Added for use by Version 30 of the Audit Transaction Standard
411-DB Prescriber ID Added for use by Version 30 of the Audit Transaction Standard
420-DK Submission Clarification Code Added for use by Version 30 of the Audit Transaction Standard
- 297 -
July 2016
DATA DICTIONARY
Action
501-F1 Header Response Status Added for use by Version 30 of the Audit Transaction Standard
112-AN Transaction Response Status Added for use by Version 30 of the Audit Transaction Standard
511-FB Reject Code Added for use by Version 30 of the Audit Transaction Standard
Appendix A Added for use by Version 30 of the Audit Transaction Standard
7. Medical Rebate Data Submission Standard Implementation Guide Version 02 Release 02

Action
A81 Medical Rebates Version Release Number Version updated in ECL. See ECL publication of April 2014 for update of values.

Action
YY. JULY 2014
1. Data Dictionary
Action
Front Matter Added Format Limitations/Requirements
498-PK Authorized Representative Zip/Postal Code Definition clarified
813-1J Carrier Zip/Postal Code Definition clarified
319-CJ Employer Zip/Postal Code Definition clarified
784 Entity Zip/Postal Code Definition clarified
325-CP Patient Zip/Postal Code Definition clarified
124-TY Pay To Zip/Postal Code Definition clarified
835-5R Pharmacy Zip/Postal Code Definition clarified
676-Y4 Purchaser Zip/Postal Code Definition clarified
587-YQ Service Provider Zip/Postal Code Definition clarified

Field Number Appendix or Field Name Action
- 298 -
July 2016
DATA DICTIONARY
OfficeOfPharmacyAffairsID X
PrescriptionPreviouslyFilled X
TransferRequest X
RxFillIndicator X
RxFillConfirmIndicator X
TransferType X
External Code List (ECL) See ECL publication of July 2014 for updates

Action
Species X
DeliveryRequest X
DeliveryLocation X

Field Action
FillNumber Added for use in Specialized Standard and added Comments
DrugProductCoded x Incorrectly listed as separate element. See AllergyDrugProductCodedQualifier
DrugProductCodedQualifier x Incorrectly listed as separate element. See AllergyDrugProductCodedQualifier
5. Prescription Transfer Standard Implementation Guide Version 33

Field Action
ZZ. OCTOBER 2014
1. Formulary and Benefit Standard Implementation Guide Version 42

Field Number Appendix or Field Name Action
- 299 -
July 2016
DATA DICTIONARY
B62-1M Alternatives Group ID X
B63-1N Alternatives List Type X
B64-1P Step Medications Group ID X
B65-3M Minimum Drugs Per Step Group X
B66-3N Maximum Drugs Per Step Group X
914-B5 Drug Qualifier-Step Drug X Sunset of field
External Code List (ECL) See ECL publication of October 2014 for updates

Action
TestingFrequency X
TestingFrequencyNotes X
SupplyIndicator X
DateOfLastOfficeVisit X
InsulinDependent X
HasAutomatedInsulinDevice X
RelatesToMessageID Definition modified

Action
394-MW Benefit Stage Amount Definition modified
394-MW External Code List (ECL) See ECL publication of October 2014 for updates

Action
394-MW Benefit Stage Amount Definition modified
394-MW External Code List (ECL) See ECL publication of October 2014 for updates
- 300 -
July 2016
DATA DICTIONARY
AAA. JANUARY 2015

Action
2. Benefit Integration Standard Implementation Guide Version 10

Action
711 Action Code Reinstate field for use by Version 10 of the Benefit Integration Standard. Field previously used
by the Member Enrollment Standard (M)
204 Adjustment Reason Code Added for use by Version 10 of the Benefit Integration Standard
571-NZ Amount Attributed to Processor Fee Added for use by Version 10 of the Benefit Integration Standard
134-UK Amount Attributed to Product Selection/Brand Drug Added for use by Version 10 of the Benefit Integration Standard
523-FN Amount Attributed To Sales Tax Added for use by Version 10 of the Benefit Integration Standard
518-FI Amount Of Copay Added for use by Version 10 of the Benefit Integration Standard
806-5C Batch Number Added for use by Version 10 of the Benefit Integration Standard
761 Benefit Effective Date Reinstate field for use by Version 10 of the Benefit Integration Standard. Field previously used
759 Benefit Termination Date Reinstate field for use by Version 10 of the Benefit Integration Standard. Field previously used
212 Benefit Type Added for use by Version 10 of the Benefit Integration Standard
686 Brand/Generic Indicator Added for use by Version 10 of the Benefit Integration Standard
302-C2 Cardholder ID Added for use by Version 10 of the Benefit Integration Standard
313-CD Cardholder Last Name Added for use by Version 10 of the Benefit Integration Standard
215 Carrier Number Added for use by Version 10 of the Benefit Integration Standard
222 Client Pass Through Added for use by Version 10 of the Benefit Integration Standard
240-U1 Contract Number Added for use by Version 10 of the Benefit Integration Standard
880-K2 Creation Date Added for use by Version 10 of the Benefit Integration Standard
880-K3 Creation Time Added for use by Version 10 of the Benefit Integration Standard
304-C4 Date Of Birth Added for use by Version 10 of the Benefit Integration Standard
401-D1 Date Of Service Added for use by Version 10 of the Benefit Integration Standard
405-D5 Days Supply Added for use by Version 10 of the Benefit Integration Standard
408-D8 Dispense As Written (DAW)/Product Selection Code Added for use by Version 10 of the Benefit Integration Standard
785-SV Family ID Number Added for use by Version 10 of the Benefit Integration Standard
702-MC File Type Added for use by Version 10 of the Benefit Integration Standard
257 Formulary Status Added for use by Version 10 of the Benefit Integration Standard
430-DU Gross Amount Due Added for use by Version 10 of the Benefit Integration Standard
301-C1 Group ID Added for use by Version 10 of the Benefit Integration Standard
266 In Network Indicator Added for use by Version 10 of the Benefit Integration Standard
- 301 -
July 2016
DATA DICTIONARY
Action
267 Insurance Code Added for use by Version 10 of the Benefit Integration Standard
269 Invoiced Amount Added for use by Version 10 of the Benefit Integration Standard
504-F4 Message Added for use by Version 10 of the Benefit Integration Standard
718-SZ Middle Initial Added for use by Version 10 of the Benefit Integration Standard
310-CA Patient First Name Added for use by Version 10 of the Benefit Integration Standard
305-C5 Patient Gender Code Added for use by Version 10 of the Benefit Integration Standard
332-CY Patient ID Added for use by Version 10 of the Benefit Integration Standard
311-CB Patient Last Name Added for use by Version 10 of the Benefit Integration Standard
505-F5 Patient Pay Amount Added for use by Version 10 of the Benefit Integration Standard
306-C6 Patient Relationship Code Added for use by Version 10 of the Benefit Integration Standard
324-CO Patient State/Province Address Added for use by Version 10 of the Benefit Integration Standard
303-C3 Person Code Added for use by Version 10 of the Benefit Integration Standard
407-D7 Product/Service ID Added for use by Version 10 of the Benefit Integration Standard
436-E1 Product/Service ID Qualifier Added for use by Version 10 of the Benefit Integration Standard
397 Product/Service Name Added for use by Version 10 of the Benefit Integration Standard
442-E7 Quantity Dispensed Added for use by Version 10 of the Benefit Integration Standard
880-K7 Receiver ID Added for use by Version 10 of the Benefit Integration Standard
751-M9 Record Count Added for use by Version 10 of the Benefit Integration Standard
601-04 Record Type Added for use by Version 10 of the Benefit Integration Standard
511-FB Reject Code Added for use by Version 10 of the Benefit Integration Standard
880-K1 Sender ID Added for use by Version 10 of the Benefit Integration Standard
201-B1 Service Provider ID Added for use by Version 10 of the Benefit Integration Standard
202-B2 Service Provider ID Qualifier Added for use by Version 10 of the Benefit Integration Standard
888 Submission Number Added for use by Version 10 of the Benefit Integration Standard
601-25 Therapeutic Class Code Added for use by Version 10 of the Benefit Integration Standard
601-26 Therapeutic Class Code Qualifier Added for use by Version 10 of the Benefit Integration Standard
509-F9 Total Amount Paid Added for use by Version 10 of the Benefit Integration Standard
896 Transaction ID Added for use by Version 10 of the Benefit Integration Standard
897 Transaction ID Cross Reference Added for use by Version 10 of the Benefit Integration Standard
112-AN Transaction Response Status Added for use by Version 10 of the Benefit Integration Standard
601-10 Transmission Date Added for use by Version 10 of the Benefit Integration Standard
986-KJ Transmission File Type Added for use by Version 10 of the Benefit Integration Standard
984-JY Transmission Time Added for use by Version 10 of the Benefit Integration Standard
880-K6 Transmission Type Added for use by Version 10 of the Benefit Integration Standard
102-A2 Version/Release Number Added for use by Version 10 of the Benefit Integration Standard and Version added in ECL
B67 Accumulator Action Code X
B68 Accumulator Applied Amount X
B69 Accumulator Balance Benefit Type X
B70 Accumulator Balance Qualifier X
B71 Accumulator Balance Count X
B72 Accumulator Benefit Period Amount X
B73 Accumulator Change Source Code X
- 302 -
July 2016
DATA DICTIONARY
Action
B74 Accumulator Network Indicator X
B75 Accumulator Reference Time Stamp X
B76 Accumulator Remaining Balance X
B77 Accumulator Specific Category Type X
B78 Document Reference Identifier X
B79 Document Reference Identifier Qualifier X
B80 Optional Data Indicator X
B81 Penalty Amount X
B82 Processor Routing Identification X
B83 Record Length X
B84 Sender Reference Number X
B85 Transmission ID x
Appendix A added fields as shown above
BBB. APRIL 2015

Action
NoKnownAllergies Field Format: From BooleanCode To x(1)

Action
NoKnownAllergies Field Format: From BooleanCode To x(1)
CCC. JULY 2015

Action
BusinessName Field Format: Change size from 35 to 70
ClinicName X
- 303 -
July 2016
DATA DICTIONARY
Action
LabelCode Added for use by Version 2015071 of SCRIPT Standard
LabelGraphicCode Added for use by Version 2015071 of SCRIPT Standard
LabelPriority Added for use by Version 2015071 of SCRIPT Standard
LabelText Added for use by Version 2015071 of SCRIPT Standard
OtherReason X
QuantityValue Definition: modified
ReasonForMTMServiceCode Added for use by Version 2015071 of SCRIPT Standard
ReasonForMTMServiceCodeQualifier Added for use by Version 2015071 of SCRIPT Standard
ReasonForMTMServiceFreeText Added for use by Version 2015071 of SCRIPT Standard
ReasonForMTMServiceText Added for use by Version 2015071 of SCRIPT Standard
TargetedTypeOfServiceCode Added for use by Version 2015071 of SCRIPT Standard
TargetedTypeOfServiceCodeQualifier Added for use by Version 2015071 of SCRIPT Standard
TargetedTypeOfServiceFreeText Added for use by Version 2015071 of SCRIPT Standard
TargetedTypeOfServiceText Added for use by Version 2015071 of SCRIPT Standard
TypeOfServiceCode Added for use by Version 2015071 of SCRIPT Standard
TypeOfServiceCodeQualifier Added for use by Version 2015071 of SCRIPT Standard
TypeOfServiceFreeText Added for use by Version 2015071 of SCRIPT Standard
TypeOfServiceGroupSetting Added for use by Version 2015071 of SCRIPT Standard
TypeOfServiceText Added for use by Version 2015071 of SCRIPT Standard
AlternateContactRelationship X
AnticipatedDischargeDate X
CurrentTreatmentCycleNumber X
DateRecertified X
DiluentAmountValue X
DiluentAmountQuantityUnitOfMeasureCode X
DispensedPackageMethod X
GestationalAge X
HospiceIndicator X
InjuryRelated X
IVAccessTypeCode X
IVAccessTypeText X
NumberOfCyclesPlanned X
NumberOfLumens X
NumberOfPackagesDispensed X
NumberOfPackagesToBeDispensed X
PaymentType X
ProphylacticOrEpisodic X
ReportURL X
ScoreName X
ScoreSource X
ScoreValue X
SelfAdministrationAllowed X
- 304 -
July 2016
DATA DICTIONARY
Action
SpecificAdministrationGauge X
SubstanceLevelCode X
SubstanceLevelQualifier X
SubstanceLevelText X
SubstanceTypeCode X
SubstanceTypeQualifier X
SubstanceTypeText X
TreatmentIndicator X

Action
BusinessName Field Format: Change size from 35 to 70
ClinicName X
RouteOfAdministrationCode Added for use by Version 2015071 of Specialized Standard
RouteOfAdministrationQualifier Added for use by Version 2015071 of Specialized Standard
RouteOfAdministrationText Added for use by Version 2015071 of Specialized Standard
Smoker X
AlternateContactRelationship X
AvailabilityStartDate X
AvailabilityEndDate X
FinancialGuarantorRelationship X
GestationalAge X
HospiceIndicator X
NumberOfPackagesDispensed X
NumberOfPackagesToBeDispensed X
PayerType X
PriorPeriodCorrectionStartDate X
PiorPeriodCorrectionEndDate X
PriorPeriodCorrectionType X
ResponsibilityStartDate X
ResponsibilityEndDate X
SubstanceLevelCode X
SubstanceLevelQualifier X
SubstanceLevelText X
SubstanceTypeCode X
SubstanceTypeQualifier X
SubstanceTypeText X
- 305 -
July 2016
DATA DICTIONARY
Action

Action
B87-3P Quantity Limit Per Specific Time Period Count X
B88-3R Quantity Limit Per Specific Time Period X
B89-3S Quantity Limit Time Period X
B90-3T Days Supply Limit Per Specific Time Period Count X
B91-3W Days Supply Limit Per Specific Time Period X
B92-3X Days Supply Limit Time Period X
109-A9 Transaction Count Comments: modified
DDD. OCTOBER 2015

Action
B93-3Y List Expiration Date X
2. Health Care Identification Card – Pharmacy and/or Combination ID Card Implementation Guide Version 4.3
Action
B94 Cardholder Type Code X
EEE. JANUARY 2016

- 306 -
July 2016
DATA DICTIONARY
Action
B98-34 Reconciliation ID X
2. Batch Implementation Guide Version 13

Action
880-K5 Transaction Reference Number Field Length increased from 10 to 30
FFF. APRIL 2016

Action
DirectAddress X
ExpiringPACaseID X
IVAccessCatheterTipCode X
IVAccessCatheterTipDescription X
IVAccessCatheterTipText X
IVAccessDeviceTypeCode X
IVAccessDeviceTypeDescription X
IVAccessDeviceTypeText X
IVInfusionTypeCode X
IVInfusionTypeDescription X
IVInfusionTypeText X
MeasurementDurationClarifyingFreeText X
MeasurementDurationNumericValue X
MeasurementDurationText X
MeasurementDurationTextCode X
MeasurementDurationTextQualifier X
MeasurementDurationTriggerText X
MeasurementDurationTriggerTextCode X
MeasurementDurationTriggerTextQualifier X
MeasurementFrequencyNumericValue X
MeasurementFrequencyUnitsCode X
MeasurementFrequencyUnitsQualifier X
MeasurementFrequencyUnitsText X
- 307 -
July 2016
DATA DICTIONARY
Action
MeasurementIntervalNumericValue X
MeasurementIntervalUnitsCode X
MeasurementIntervalUnitsQualifier X
MeasurementIntervalUnitsText X
MeasurementTimingClarifyingFreeText X
MeasurementTimingEventCode X
MeasurementTimingEventQualifier X
MeasurementTimingEventText X
MeasurementTimingModifierCode X
MeasurmentTimingModifierQualifier X
MeasurementTimingModifierText X
MeasurementTimingNumericValue X
MeasurementTimingUnitsCode X
MeasurementTimingUnitsQualifier X
MeasurementTimingUnitsText X
PAPriorityIndicator X
PharmacyToTitrateDose X
PositionInOrderGroup X
PrescriberCheckedREMS X
PrescriberOrderGroupNumber X
REMSAuthorizationNumber X
REMSCaseID X
REMSNote X
REMSPatientRiskCategory X
REMSReferenceID X
RxReferenceOrderGroupNumber X
SpecificAdministrationBrand X
SpecificAdministrationLength X
SpecificAdministrationPump X
TitrationDoseMaximumValue X
TitrationDoseMeasurementNotes X
TitrationDoseMeasurementValue X
TitrationoDoseMeasurementValueUnitOfMeasureCode X
TitrationDoseMeasurementVitalSign X
TitrationDoseMinimumMeasurementValue X
TotalCountforOrderGroup X
VariableMeasurementFrequencyModifier X
VariableMeasurementIntervalModifier X
VariableMeasurementTimingModifier X
WoundDepth X
WoundLateralityCode X
WoundLateralityText X
- 308 -
July 2016
DATA DICTIONARY
Action
WoundLength X
WoundLocationCode X
WoundLocationText X
WoundWidth X
PAStructuresVersion X
DoseFormCode Name Change to DoseUnitOfMeasureCode; Definition Change, Comment Change
DoseFormQualifier Name Change to DoseUnitOfMeasureQualifier
DoseFormText Name Change to DoseUnitOfMeasureText; Definition Change
LotNumber Added for use by Version 2016041 of SCRIPT Standard
LotExpiration Added for use by Version 2016041 of SCRIPT Standard
ManufacturerName Added for use by Version 2016041 of SCRIPT Standard
SpecificAdministrationGauge Defnition Change

Action
DirectAddress X
PositionInOrderGroup X
PrescriberOrderGroupNumber X
RxReferenceOrderGroupNumber X
TotalCountforOrderGroup X
PAStructuresVersion X
GGG. JULY 2016

Action
DigestMethod X
FlavoringRequested X
PAProcessorIdentification X
UrgencyIndicatorCode X
- 309 -
July 2016
DATA DICTIONARY
2. Prescription Transfer Standard Implementation Guide Version 34
Action
462-EV Prior Authorization Number Submitted Name changed to Prior Authorization ID Submitted; Definition changed;Format from 9(11) to
x(35)

Action
x(35)
498-PY Prior Authorization Number-Assigned Name changed to Prior Authorization ID Assigned; Definition changed;Format from 9(11) to
x(35)
420-DK Submission Clarification Code Field Length from 2 to 3
4. Audit Transaction Standard Implementation Guide Version 31

Action
420-DK Submission Clarification Code Field Length from 2 to 3
5. Prior Authorization Transfer Standard Implementation Guide Version 21

Action
x(35)
498-PY Prior Authorization Number-Assigned Name changed to Prior Authorization ID Assigned; Definition changed;Format from 9(11) to
x(35)
- 310 -
July 2016

NCPDP Data Dictionary 201607

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NCPDP Data Dictionary 201607

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DATA DICTIONARY

National Council for Prescription Drug Programs

Phone: (480) 477-1000

STANDARD FORMATS KEY (THROUGHOUT DOCUMENT)

A = Post Adjudication Standard I = Benefit Integration Standard

FIELD and NAME of FIELD

FIELD FORMAT VALUES

“R” = Numeric 0-9 with decimal point

Example: A transmitted value of 12.34 represents a decimal value of 12.34.

The following field format values are supported in XML.

Rules for Demographic Fields

INTERNAL REPRESENTATION OF OVERPUNCH SIGNS

UNITS SIGNED POSITIVE SIGNED NEGATIVE

National Council for Prescription Drug Programs

II. DATA ELEMENTS

900-BN Absolute Row The absolute row or line number 9(10) F 10

512-FC Accumulated Amount in dollars met by the s9(6)v99 T,A 8 Format=s$$$$$$cc

653-S4 Accumulated Gross The accumulated cost incurred s9(6)v99 N 8 Format=s$$$$$$cc

652-S3 Accumulated The accumulated cost for s9(6)v99 N 8 Format=s$$$$$$cc

B67 Accumulator Action Describes the accumulator x(2) I 2 See ECL

B68 Accumulator Amount applied to the 9(8)v99 I 10 Format=$$$$$$$$cc

B69 Accumulator Code representing family or x(1) I 1 See ECL

B70 Accumulator Identifies the type of x(2) I 2 See ECL

B71 Accumulator The number of accumulator 9(2) I 2

656-S7 Accumulator Month Count of Accumulator Month 9(2) N 2

B74 Accumulator Indicates the type of x(1) I 1 See ECL

B76 Accumulator Amount remaining for the 9(8)v99 I 10 Format=$$$$$$$$cc

B77 Accumulator Identifies the accumulator x(2) I 2 See ECL

650-S1 Accumulator Year Identifies the accumulator year. 9(4) N 4 Format=CCYY

AcknowledgementI Responder control reference x(35) S, Q 35

AcknowledgementR Additional textual information x(100) S 100

711 Action Code Processing action requested. x(1) I 1 See ECL

AdditionalFreeText Free text x(2000) S 2000

AdditionalFreeTextI Indicates if the prescriber is x(2) S 2 See ECL

AdditionalMessageI Designates if a subsequent xsd:boolean Q

526-FQ Additional Message Free text message. x(1)-x(40) T 40

130-UF Additional Message Count of the Additional Message 9(2) T 2

AdditionalRefillsAut Number of additional refills 9(2) S 2

AdditionalTraceNum Trace number between trading x(3) S, Q 3

AddressLine1 First line of address information. x(40) S,Q 40

AddressLine2 Second line of address x(40) S,Q 40

604-NA Address Qualifier Qualifier of the address. 9(2) V 2 See ECL

204 Adjustment Reason Reason for adjustment x(3) A 3 For A:

205 Adjustment Type Type of adjustment. x(1) A 1 See ECL

AdministrationIndic Indicates the action to be taken an S See ECL

AdministrationTimin Used to add clarity to the x(255) S 255

AdministrationTimin The code representing the an S Qualified by AdministrationTimingEventQualifier.

AdministrationTimin Qualifier to identify the code an S See ECL

AdministrationTimin The textual representation of an S

AdministrationTimin The code representing the an S Qualified by

AdministrationTimin Qualifier to identify the code an S See ECL

AdministrationTimin The textual representation of the an S

AdministrationTimin The numeric value for the 9(18) S 18

AdministrationTimin The code representing the an S Qualified by AdministrationTimingUnitsQualifier.

AdministrationTimin Qualifier to identify the code an S See ECL

AdministrationTimin The textual representation of an S

206 Administrative Fee Administrative fee charge per s9(2)v99 A 4 Format=s$$cc

208 Age Calculated from Date of Birth 9(3) A 3 Format=YYY

AlternateContactRel Alternate contact relationship to 9(2) S,Q 2 See ECL

330-CW Alternate ID Person identifier to be used for x(20) T 20

B62-1M Alternatives Group ID assigned by payer to match x(40) F 40

901-BP Alternatives ID ID for the alternative list. x(10) F 10

See important information in the Uniform

Answer Value for the answer. x(2000) S 2000