Field

Data Type

Description

Contracted Entity ID*

Alphanumeric, may contain dashes – starts with 2 or 3 letters

HRSA assigned identifier of the 340B covered entity that designated the dispense as 340B. If the 340B ID contains a suffix, this must be included.

Date of Service*

Date

The date on which the prescription was filled by the dispensing pharmacy.

Date Prescribed*

Date

The date on which the prescription was written by the prescribing healthcare provider.

NDC*

Numeric (11 Digits)

The 11-digit National Drug Code (NDC) identifying the manufacturer, drug product, and package size of the medication dispensed.

Quantity*

Numeric

Number of units dispensed to the patient. Appropriate Units of Measure for each product will be provided within the NDC list.

Rx Number*

Numeric

The native (unmodified) prescription number for the prescription as generated by the pharmacy.

Service Provider ID*

Numeric (10 Digits), no leading zeros.

The unique identifier of the pharmacy that dispensed the prescription.

Prescriber ID

Numeric (10 Digits)

The unique public ID for the prescribing physician. Accepted IDs include the NPI and DEA ID.

Wholesaler Invoice Number

Numeric

The invoice number assigned by the wholesaler for the replenishment order made by the 340B covered entity. For claims with multiple invoice numbers, submit each invoice number as a separate claim line.

Payer BIN

Alpha numeric, may contain leading zeros

The bank identification number of the primary payer on the prescription.

Payer PCN

Alphanumeric

Processor Control Number. Identifier used to determine which processor will handle a prescription drug claim.

Ship to Date

Standard Date Formats

Date when the drug was shipped to the Ship To location.

Ship to Location

Numeric

NPI, DEA, or NCPDP of the pharmacy where the drug was physically shipped.

340B Account Number

Alpha numeric

Account number assigned by the wholesaler and used for the purchase.

Product Serialization Number

Numeric

Unique ID assigned to the package shipped from the manufacturer to the wholesaler.

Fill Number

Numeric (0-99)

Indicates the number of times the prescription has been filled as of the current fill. For example, a value of "0" indicates that the prescription has not been filled previously and the current fill is the first one. The first refill would have a value of "1".

Encounter Billing Service Provider ID*

Alphanumeric

A unique, public ID for the healthcare entity that billed for the patient's healthcare encounter.

Encounter Date of Service*

Date

Date on which the patient was seen by a healthcare provider and received a healthcare service.

Encounter Rendering Physician ID*

Alphanumeric

A unique, public ID for the physician that provided the healthcare service to the patient.

Encounter HCPCS Code*

Alphanumeric

The five digit HCPCS code corresponding to the health service performed on the encounter claim.

Encounter HCPCS Code Modifier(s)

Alphanumeric

Modifier to the HCPCS code. Up to four modifier codes may be entered for the same claim line.

Primary Encounter Diagnosis Code*

Alphanumeric

ICD-10 diagnosis code assigned as the primary diagnosis for the healthcare encounter. Note ONLY ICD-10 codes are accepted in this field.

Supplemental Encounter Diagnosis Code(s)

Alphanumeric

ICD-10 diagnosis code assigned as the supplemental diagnosis for the healthcare encounter. Note ONLY ICD-10 codes are accepted in this field.

Encounter Place of Service Code*

Numeric

Two-digit code indicating the facility type where the healthcare encounter occurred.