PDE DATA DICTIONARY (January 2010) NAME TYPE LENGTH ------------------------------------- ------ 723 Part D Event ID CHAR 15 Identifies a unique Part D event for a beneficiary. SHORT NAME: PDE_ID LONG NAME: PDE_ID SOURCE: CCW NAME TYPE LENGTH ------------------------------------- ------ Encrypted 723 Beneficiary CHAR 15 ID A unique CCW beneficiary identifier field that is specific to the Chronic Condition Warehouse. This field is encrypted prior to delivery to researchers. The BENE_ID field is used to cross- reference data for each beneficiary across all claim and assessment data files. SHORT NAME: BENE_ID LONG NAME: BENE_ID SOURCE: CCW NAME TYPE LENGTH ----------------------------------- ------ RX CLAIM CONTROL NUMBER CHAR 40 This field is an optional field, free-form field. It is intended for use by plans to identify unique events or for other plan purposes. SHORT NAME: CLMCNTRL LONG NAME: RX_CLM_CNTL_ID SOURCE: CCW NAME TYPE LENGTH ---------------------------------------- ------ PATIENT DATE OF BIRTH (DOB). NUM 8 Date of birth of the patient as indicated on the event record. CCYYMMDD SHORT NAME: DOB_DT LONG NAME: DOB_DT SOURCE: CCW NAME TYPE LENGTH ----------------------------------- ------ PATIENT GENDER NUM 1 Gender of the patient as indicated on the event record. SHORT NAME: GNDR_CD LONG NAME: GNDR_CD CODES: 1 = Male 2 = Female SOURCE: CCW NAME TYPE LENGTH ----------------------------------- ------ RX SERVICE DATE (DOS) NUM 8 This field contains the date on which the prescription was filled. CCYYMMDD SHORT NAME: SRVC_DT LONG NAME: SRVC_DT SOURCE: CCW NAME TYPE LENGTH ----------------------------------- ------ PAID DATE NUM 8 This field contains the date the plan originally paid the pharmacy for the prescription drug. If the plan subsequently adjusts payment, the plan will report the original paid date in the adjustment PDE. This field is a mandatory field for fallback plans and optional for all other plan types. CCYYMMDD SHORT NAME: PD_DT LONG NAME: PD_DT SOURCE: CCW NAME TYPE LENGTH ---------------------------------------- ------ SERVICE PROVIDER ID QUALIFIER CHAR 2 This field indicates the type of provider identifier used in 'Service Provider Identifier'. SHORT NAME: PRVDQLFR LONG NAME: SRVC_PRVDR_ID_QLFYR_CD CODES: 01 = National Provider Identifier(NPI) 06 = UPIN 07 = NCPDP Number 08 = State License 11 = Federal Tax Number (TIN or EIN) 99 = Other Note: Values of 06, 08, 11, or 99 ARE only acceptable with NON-STANDARD FORMAT CODES of B, X or P. SOURCE: CCW NAME TYPE LENGTH -------------------------------------------------- SERVICE PROVIDER ID CHAR 15 This field identifies the pharmacy where the prescription was filled. CMS will transition to the use of the National Provider Identifier (NPI) when it is implemented. In the interim, this field typically contains the NCPDP number which all NCPDP billers are assigned. Some Part D service providers who submit in Non-Standard Format (e.g., home infusion, physicians when providing vaccines, etc.) will not have NCPDP numbers. For these providers, the Unique Provider Identification Number (UPIN), State License Number, Federal Tax Identification Number, Employer Identification Number, or the default value of 'PAPERCLAIM' will be the identifier. For Standard Data Format, valid values are: 01 = NPI 07 = NCPDP Provider Identifier For non-Standard data format, any value in Service Provider Identifier Qualifier is valid. When Plans report Service Provider Identifier Qualifier '99', this field will contain 'PAPERCLAIM'. SHORT NAME: PRVDR_ID LONG NAME: SRVC_PRVDR_ID SOURCE: CCW NAME TYPE LENGTH ----------------------------------------------- PRESCRIBER ID QUALIFIER CHAR 2 This field indicates the type of identifier that is used in the 'Prescriber Identifier' field. The type of PRESCRIBER ID. SHORT NAME: PRSCQLFR LONG NAME: PRSCRBR_ID_QLFYR_CD CODES: 01 = National Provider Identifier (NPI-when implemented) 06 = UPIN 08 = State License Number 12 = Drug Enforcement Administration (DEA) number SOURCE: CCW NAME TYPE LENGTH --------------------------------------------- PRESCRIBER ID CHAR 15 This field contains the prescriber's unique identification number. CMS will transition to the use of the NPI when it is implemented. In the interim, CMS requires use of a DEA number whenever it uniquely identifies the prescriber and is allowed by State law. In other cases, the prescriber's State license number or UPIN is used. SHORT NAME: PRSCRBID LONG NAME: PRSCRBR_ID SOURCE: CCW NAME TYPE LENGTH ----------------------------------- ------ RX SERVICE REFERENCE NUMBER NUM 9 This field contains the prescription reference number assigned by the pharmacy at the time the prescription is filled. Field length is 9 to accommodate proposed future NCPDP standard. SOURCE: CCW NAME TYPE LENGTH ----------------------------------- ------ PRODUCT SERVICE ID CHAR 19 This field identifies the dispensed drug using a National Drug Code (NDC). The NDC is reported in NDC11 format. In instances where a pharmacy formulates a compound containing multiple NDC drugs, the NDC of the most expensive drug is used. NDC code in the following format: MMMMMDDDDPP followed by 8 spaces. CMS rejects the following codes: 99999999999, 99999999992, 99999999993, 99999999994, 99999999995 and 99999999996. SHORT NAME: PRDSRVID LONG NAME: PROD_SRVC_ID SOURCE: CCW NAME TYPE LENGTH ------------------------------------- ------ Encrypted Plan Contract ID CHAR 5 Encrypted, unique number CMS assigns to each contract that a Part D plan has with CMS. This is the final contract to which the beneficiary was assigned at the time of payment reconciliation. The first character of the contract ID is a letter representing the type of plan. SHORT NAME: PLNCNTRC LONG NAME: PLAN_CNTRCT_REC_ID SOURCE: CCW CODES: H = Managed Care Organizations other than Regional PPO R = Regional PPO S = PDP E = Employer-Sponsored (starting January 2007) NAME TYPE LENGTH ------------------------------------- ------ Encrypted Plan Benefit Package ID CHAR 3 Encrypted, unique number CMS assigns to identify a specific plan benefit package within a contract. This is the final plan to which the beneficiary was assigned at the time of payment reconciliation. SHORT NAME: PLNPBPRC LONG NAME: PLAN_PBP_REC_NUM SOURCE: CCW NAME TYPE LENGTH ------------------------------------------------ COMPOUND CODE NUM 1 This field indicates whether or not the dispensed drug was compounded or mixed. SHORT NAME: COMPND_CD LONG NAME: COMPND_CD CODES: 0 = Not specified 1 = Not a compound 2 = Compound SOURCE: CCW NAME TYPE LENGTH -------------------------------------------------------------------------- DISPENSE AS WRITTEN (DAW) PRODUCT SELECTION CODE CHAR 1 This field indicates the prescriber's instruction regarding substitution of generic equivalents or order to dispense the specific product written. SHORT NAME: DAWPS_CD LONG NAME: DAW_PROD_SLCTN_CD CODES: 0 = No Product Selection Indicated 1 = Substitution Not Allowed by Prescriber 2 = Substitution Allowed - Patient Requested Product Dispensed 3 = Substitution Allowed - Pharmacist Selected Product Dispensed 4 = Substitution Allowed - Generic Drug Not in Stock 5 = Substitution Allowed - Brand Drug Dispensed as Generic 6 = Override 7 = Substitution Not Allowed - Brand Drug Mandated by Law 8 = Substitution Allowed Generic Drug Not Available in Marketplace 9 = Other SOURCE: CCW NAME TYPE LENGTH ----------------------------------------------- QUANTITY DISPENSED NUM 8 This field indicates the number of units, grams, milliliters, or other dispensed in the current drug event. If a compounded item, then the QUANTITY DISPENSED is the total of all ingredients. SHORT NAME: QTYDSPNS LONG NAME: QTY_DSPNSD_NUM SOURCE: CCW NAME TYPE LENGTH --------------------------------------------- DAYS SUPPLY CHAR 3 This field indicates the number of days' supply of medication dispensed by the pharmacy and will consist of the amount the pharmacy enters for the prescription. Possible values are 0 – 999. SHORT NAME: DAYSSPLY LONG NAME: DAYS_SUPLY_NUM SOURCE: CCW NAME TYPE LENGTH ---------------------------------------------- FILL NUMBER NUM 2 This field indicates the number fill of the current dispensed supply. Possible values are 0 - 99 with 0 used if FILL NUMBER is unavailable. SHORT NAME: FILL_NUM LONG NAME: FILL_NUM SOURCE: CCW NAME TYPE LENGTH --------------------------------------------- DISPENSING STATUS CODE CHAR 1 This field indicates how the pharmacy dispensed the complete quantity of the prescription. When the pharmacy partially fills a prescription, this field indicates a partial fill. When the full quantity is dispensed at one time, this field is blank. SHORT NAME: DSPNSTCD LONG NAME: DSPNSNG_STUS_CD CODES: Blank = Not specified or full quantity P = Partial fill C = Completion of partial fill SOURCE: CCW NAME TYPE LENGTH ------------------------------------------------ DRUG COVERAGE STATUS CODE CHAR 1 This field indicates whether or not the drug is covered under the Medicare Part D benefit and/or a specific PBP. SHORT NAME: DRCVSTCD LONG NAME: DRUG_CVRG_STUS_CD CODES: C = Covered E = Supplemental drugs (reported by Enhanced Alternative plans only) O = Over-the-counter drugs SOURCE: CCW NAME TYPE LENGTH ------------------------------------------------ ADJUSTMENT DELETION CODE CHAR 1 This field distinguishes original from adjusted or deleted PDE records so CMS can adjust claims and make accurate payment for revised PDE records. SHORT NAME: ADJDELCD LONG NAME: ADJSTMT_DLTN_CD CODES: Blank = Original PDE A = Adjustment R = Resubmitted SOURCE: CCW NAME TYPE LENGTH ----------------------------------------------- NON-STANDARD FORMAT CODE CHAR 1 This data element is used by CMS to identify PDE records that are compiled from non-standard sources. NCPDP is the standard format in which plans receive data from pharmacies. SHORT NAME: NSTFMTCD LONG NAME: NSTD_FRMT_CD CODES: X = X12 837 B = Beneficiary submitted claim P = Paper claim from provider Blank = NCPDP electronic format SOURCE: CCW NAME TYPE LENGTH ----------------------------------------------- RX PRICING EXCEPTION CODE CHAR 1 This field indicates that the PDE reports an out-of-network or Medicare as Secondary Payer (MSP) service that is subject to unique pricing rules. SHORT NAME: PRCGEXCD LONG NAME: PRCNG_EXCPTN_CD CODES: M = Medicare as secondary payer O = Out of network pharmacy Blank = In-network pharmacy and Medicare Primary SOURCE: CCW NAME TYPE LENGTH ----------------------------------------------- CATASTROPHIC COVERAGE CODE CHAR 1 This field indicates that a beneficiary has reached the out-of-pocket threshold or attachment point. At this point, catastrophic coverage provisions begin, namely reinsurance and reduced beneficiary cost sharing. SHORT NAME: CATCOVCD LONG NAME: CTSTRPHC_CVRG_CD CODES: A = Attachment point met on this event C = Above attachment point Blank = Attachment point not met SOURCE: CCW NAME TYPE LENGTH --------------------------------------------------------------------------- GROSS DRUG COST BELOW OUT-OF-POCKET THRESHOLD (GDCB) NUM 8 This field represents the gross drug cost paid to the pharmacy below the out-of-pocket threshold for a given PDE for a covered drug. For claims received prior to a beneficiary reaching the attachment point, this field will contain a positive dollar amount. For claims above the attachment point, this field will contain a zero dollar value. For a claim on which the attachment point is reached, there is likely to be a positive dollar amount in this field and there will be a positive dollar amount in GDCA. When CATASTROPHIC COVERAGE CODE = blank, this field equals INGREDIENT COST PAID + DISPENSING FEE PAID + TOTAL AMOUNT ATTRIBUTED TO SALES TAX. When CATASTROPHIC COVERAGE CODE = A this field equals the portion of INGREDIENT COST PAID + DISPENSING FEE PAID + TOTAL AMOUNT ATTRIBUTED TO SALES TAX falling at or below the OOP threshold. The remaining portion is reported in GDCA. SHORT NAME: GDCBOOPT LONG NAME: GDC_BLW_OOPT_AMT SOURCE: CCW NAME TYPE LENGTH --------------------------------------------------------------------------- GROSS DRUG COST ABOVE OUT-OF-POCKET THRESHOLD (GDCA) NUM 8 This field represents the gross drug cost paid to the pharmacy above the out-of-pocket threshold for a given PDE for a covered drug. For claims received prior to a beneficiary reaching the attachment point, this field will contain a zero dollar amount. For claims above the attachment point, this field will contain a positive dollar value. For a claim on which the attachment point is reached, there is likely to be a positive dollar amount in this field and there will be a positive dollar amount in GDCB. When CATASTROPHIC COVERAGE CODE = C, this field equals INGREDIENT COST PAID + DISPENSING FEE PAID + TOTAL AMOUNT ATTRIBUTED TO SALES TAX above the OOP threshold. When CATASTROPHIC COVERAGE CODE = A this field equals the portion of INGREDIENT COST PAID + DISPENSING FEE PAID + TOTAL AMOUNT ATTRIBUTED TO SALES TAX falling above the OOP threshold. The remaining portion is reported in GDCB. SHORT NAME: GDCAOOPT LONG NAME: GDC_ABV_OOPT_AMT SOURCE: CCW NAME TYPE LENGTH ---------------------------------------------- PATIENT PAY AMOUNT NUM 8 This field lists the dollar amount the beneficiary paid that is not reimbursed by a third party (e.g., copayments, coinsurance, deductible or other patient pay amounts). This amount contributes to a beneficiary's TrOOP only when it is payment for a covered drug. Payments made by the beneficiary or family and friends shall also be reported in this field. Other third party payments made on behalf of a beneficiary that contribute to TrOOP shall be reported in Other TrOOP Amount or Low-Income Cost-Sharing Amount and payments that do not contribute shall be reported in Patient Liability Reduction due to Other Payer Amount. Amount beneficiary paid that is not reimbursed by a third party. SHORT NAME: PTPAYAMT LONG NAME: PTNT_PAY_AMT SOURCE: CCW NAME TYPE LENGTH ---------------------------------------------- OTHER TROOP AMOUNT NUM 8 This field records all qualified third party payments that contribute to a beneficiary's TrOOP, except LICS SUBSIDY AMOUNT and PATIENT PAY AMOUNT. Examples include payments made on behalf of a beneficiary by a qualified State Pharmacy Assistance Program, charities, or other TrOOP-eligible parties. SHORT NAME: OTHTROOP LONG NAME: OTHR_TROOP_AMT SOURCE: CCW NAME TYPE LENGTH ------------------------------------------------------------------- LOW INCOME COST SHARING SUBSIDY AMOUNT (LICS) NUM 8 This field contains plan-reported LICS amounts per drug event so that CMS systems can reconcile prospective LICS payments made to plans with actual LICS amounts incurred by the plan at Point of Sale. Amount the plan reduced patient liability due to a beneficiary's LICS status. SHORT NAME: LICS_AMT LONG NAME: LICS_AMT SOURCE: CCW NAME TYPE LENGTH --------------------------------------------------------------------------------------- PATIENT LIABILITY REDUCTION DUE TO OTHER PAYER AMOUNT (PLRO) NUM 8 This field takes into account coordination of benefits that results in reduced patient liability, excluding any TrOOP-eligible payers. Amounts by which patient liability is reduced due to payment by other payers that are not TrOOP-eligible and do not participate in Part D. Examples of non-TrOOP-eligible payers: group health plans, worker's compensation, and governmental programs (e.g. VA, TRICARE). SHORT NAME: PLRO_AMT LONG NAME: PLRO_AMT SOURCE: CCW NAME TYPE LENGTH ------------------------------------------------------- COVERED D PLAN PAID AMOUNT (CPP) NUM 8 This field contains the net amount the plan paid for standard benefits (covered Part D drugs), where Drug Coverage Code = 'C'. If Drug Coverage Code = 'E' or 'O', the CPP field is zero. SHORT NAME: CPP_AMT LONG NAME: CVRD_D_PLAN_PD_AMT SOURCE: CCW NAME TYPE LENGTH ----------------------------------------------------------------- NON COVERED PLAN PAID AMOUNT (NPP) NUM 8 This field contains the net amount paid by the plan for benefits beyond the standard benefit. Net amount the plan has paid for all over-the-counter drugs, enhanced alternative drugs, and enhanced alternative cost- sharing amounts. SHORT NAME: NPP_AMT LONG NAME: NCVRD_PLAN_PD_AMT SOURCE: CCW NAME TYPE LENGTH ----------------------------------- ------ Gross Drug Cost NUM 8 This variable is derived from the sum of these variables: Ingredient Cost Paid Dispensing Fee Paid Total Amount Attributed to Sales Tax SHORT NAME: TOTALCST LONG NAME: TOT_RX_CST_AMT SOURCE: CCW NAME TYPE LENGTH ------------------------------------- ------ Benefit Phase CHAR 2 Indicates the benefit phase in which the claim was expected to occur based on a date of service ordering of the beneficiary's claims, the beneficiary's accumulated gross drug and out-of-pocket costs, and the plan's deductible, initial coverage limit (ICL) and out-of-pocket threshold (OOPT) amount. Phases may include Deductible, Pre-ICL, ICL (Coverage Gap) or Catastrophic. Events that occur between two different phases are called straddle PDEs. SHORT NAME: BNFTPHAS LONG NAME: BENEFIT_PHASE CODES: Blank = Not a covered drug XX = PDE Plan Identifiers do not link to the Plan Benefit file NA = National Pace or Employer Sponsored Plan DD = Deductible phase DP = Deductible to Pre-ICL Straddle PDE DI = Deductible to ICL (coverage gap) Straddle PDE DC = Deductible to Catastrophic Straddle PDE PP = Pre-ICL phase PI = Pre-ICL to ICL Straddle PDE PC = Pre-ICL to Catastrophic Straddle PDE II - ICL (coverage gap) Phase IC = ICL (coverage gap) to Catastrophic Straddle PDE CC = Catastrophic phase SOURCE: CCW NAME TYPE LENGTH ------------------------------------- ------ Prior Authorization Indicator CHAR 2 This variable indicates whether the formulary specifies the drug product is subject to prior authorization. SHORT NAME: PRAUTHYN LONG NAME: PRIOR_AUTHORIZATION_YN CODES: NA = NDC does not link to formulary XX = Unable to link to plan 1 = The drug is subject to prior authorization 0 = Either a) the drug is not subject to prior authorization or b) the plan is not required to submit a formulary so there are no restrictions on the drug SOURCE: CCW NAME TYPE LENGTH ------------------------------------- ------ Tier ID CHAR 2 This field represents the minimum cost sharing tier in which the product was placed in the sponsor's formulary. This identifier is also a key that links a Part D plan's cost sharing tier record to a prescription drug event record via contract ID, plan ID, and tier ID. SHORT NAME: TIER_ID LONG NAME: TIER_ID CODES: NA = The drug on the PDE does not link to the plan's formulary XX = Unable to link to plan 1-max = The tier on the plan's formulary associated with the drug on the PDE or if the plan is not required to submit a formulary then TIER_ID is assigned a value of '1' SOURCE: CCW NAME TYPE LENGTH ------------------------------------- ------ Quantity Limit Indicator CHAR 2 This variable indicates whether the formulary specifies the drug product has a quantity limit. SHORT NAME: QTYLMTYN LONG NAME: QUANTITY_LIMIT_YN CODES: NA = NDC does not link to formulary XX = Unable to link to plan 1 = The drug has quantity limits 0 = Either a) the drug does not have quantity limits or b) the plan is not required to submit a formulary so there are no restrictions on the drug SOURCE: CCW NAME TYPE LENGTH ------------------------------------- ------ Maximum Step Number CHAR 2 This variable indicates whether the formulary specifies the drug product is subject to a step therapy protocol. This field will be populated with the maximum step value (i.e., in instances where a product may be part of two different step therapy protocols) for the product. SHORT NAME: STEP LONG NAME: STEP CODES: Blank = Either a) the drug is not part of a Step Therapy Group or b) the drug is on Step 1 of a Step Therapy Group (i.e., not restricted) or c) the plan on the PDE is not required to submit a formulary, so there are no restrictions on the drug NA = The drug on the PDE does not link to the plan's formulary XX = Unable to link to plan 2-max = The maximum step on the plan's formulary associated with the drug on the PDE SOURCE: CCW