Field

Data Type

Description

340B ID*

Alphanumeric

HRSA assigned identifier of the 340B covered entity that designated the administration as 340B.

Claim Number*

Alphanumeric

The unique claim number identifying the claim.

Claim Line Number*

Numeric

Identifies an individual line number on a claim. Line numbers distinguish services that are submitted on the same claim. Wastage Claims or undispensed units submitted should include a separate claim line number from the dispensed units.

Date of Service*

Date

Date on which the medication was administered to the patient.

HCPCS Code

Alphanumeric

The five digit HCPCS code corresponding to the medication administered. For drugs billed using a non-specific or miscellaneous HCPCS code (e.g., A9270, J3490), please leave this field blank.

HCPCS Code Modifier

Alphanumeric

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

Health Plan Name*

Alphanumeric

Name of the patient's primary health insurance plan. If the patient is uninsured or a cash payer, mark "CASH" in this field. If no health plan information is recorded, mark "NONE" in this field.

Health Plan ID*

Alphanumeric

The identifier code of the patient's primary health insurance plan. If the patient is uninsured or a cash payer, mark "CASH" in this field. If no health plan information is recorded, mark "NONE" in this field.

NDC-11*

Numeric (11 Digits)

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

Rendering Physician ID

Numeric (10 Digits)

The NPI of the healthcare provider who rendered or supervised the care reported on the claim.

Quantity*

Numeric

The quantity of medication administered to the patient. If a specific (non-miscellaneous) HCPCS code with CMS-defined billing units is reported, quantity must reflect the CMS-defined billable units for that HCPCS code. If no HCPCS code is reported, quantity must reflect standardized billing units as defined by NCPDP for the NDC-11.

Unit of Measure

Alphanumeric

Either HCPCS code or UOM is required. If no specific (non-miscellaneous) HCPCS code is reported, UOM must be reported, and it must be consistent with standardized billing units as defined by NCPDP for the NDC-11.

Service Provider ID*

Numeric (10 Digits)

The NPI of the healthcare entity where the patient received the medication administration. For example, this could be the NPI of a hospital outpatient surgery center or the NPI of an outpatient infusion center.

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.

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.