Entity Pharmacy Claim Line Item

DescriptionA claim line that is in respect of drug products and medication services provided by a dispensing facility such as a hospital pharmacy or retail pharmacy.

For example:
A charge for 30 days supply of beta blockers

Attributes
Claim Post Discount AmtClaim Post Discount Amt
Claim Pre Discount AmtClaim Pre Discount Amt
Compound Drug IndCompound Drug Ind
Compound Ingredient Modifier CodeCompound Ingredient Modifier Code
Dispensing Fee Paid AmtDispensing Fee Paid Amt
Dispensing Fee Submitted AmtDispensing Fee Submitted Amt
Dosage Form CodeDosage Form Code
Incentive AmtIncentive Amt
Ingredient Cost BasisIngredient Cost Basis
Ingredient Cost Paid AmtIngredient Cost Paid Amt
Ingredient Cost Submitted AmtIngredient Cost Submitted Amt
Ingredient IndIngredient Ind
Level Of Effort CodeLevel Of Effort Code
Pharmacy Claim Line Item Status ReasonPharmacy Claim Line Item Status Reason
Pharmacy Co-Payment BasisPharmacy Co-Payment Basis
Pharmacy Dispensing Fee BasisPharmacy Dispensing Fee Basis
Pharmacy Fund AmtPharmacy Fund Amt
Pharmacy Gross Amount SubmittedPharmacy Gross Amount Submitted
Pharmacy Level Of ServicePharmacy Level Of Service
Pharmacy Reimbursement BasisPharmacy Reimbursement Basis
Pharmacy Service Reason CodePharmacy Service Reason Code
Pharmacy Service Result CodePharmacy Service Result Code
Professional Pharmacy Service PPS CodeProfessional Pharmacy Service PPS Code
Professional Service Fee PaidProfessional Service Fee Paid
Professional Service Fee SubmittedProfessional Service Fee Submitted

Generalization
Pharmacy Claim Line Item_Claim Line_GenPharmacy Claim Line Item_Claim Line_Gen

Dependencies
 NONE

Reverse Dependencies
 

Attribute Details

 Claim Post Discount Amt
DescriptionThe cost of the service after applying discounts and excluding service cost.
Data TypeStandards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Claim Pre Discount Amt
DescriptionThe cost of the service before applying any discounts and excluding service cost.
Data TypeStandards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Compound Drug Ind
DescriptionIndicates whether this drug is a compound or not.

1 Compound
0 Not a compound
Data TypeStandards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Compound Ingredient Modifier Code
DescriptionA code that identifies special circumstances related to the dispensing/payment of the compound drug product.
Data TypeStandards - Data Domains.ddm/Data Domains/Common Code [VARCHAR(80)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Dispensing Fee Paid Amt
DescriptionThe monetary value of the dispensing fee included in the payment for a pharmacy claim line.
Data TypeStandards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Dispensing Fee Submitted Amt
DescriptionThe monetary value of a dispensing fee submitted by the pharmacy. This amount is included in the 'Pharmacy Gross Amount Submitted'.
Data TypeStandards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Dosage Form Code
DescriptionIndicates the dosage form of the complete compound mixture.
Data TypeStandards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Incentive Amt
DescriptionThe contractually agreed upon incentive for specific services rendered.
Data TypeStandards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Ingredient Cost Basis
DescriptionIndicates the method of calculation used for the cost of ingredients in the relevant medication.
Data TypeStandards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Ingredient Cost Paid Amt
DescriptionThe amount of the cost of the medication ingredients that has been paid.
Data TypeStandards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Ingredient Cost Submitted Amt
DescriptionThe monetary cost or estimated acquisition cost for the ingredients of the medication dispensed in the prescription. The method for determining ingredient cost amount may be the average wholesale price less a discount, as an estimate of the pharmacy's acquisition cost, or the maximum allowable cost per unit dispensed.
Data TypeStandards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Ingredient Ind
DescriptionIndicates whether this drug is used as an ingredient in another drug.

1 Ingredient
0 Not an ingredient
Data TypeStandards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Level Of Effort Code
DescriptionA code that classifies a pharmacy claim line item identified as a compound according to the amount of work involved. The code indicates the level of effort as determined by the complexity of decision making or resources used by a pharmacist to perform a professional service.
Data TypeStandards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Pharmacy Claim Line Item Status Reason
DescriptionIndicates why a change was made to the status of a pharmacy claim line item.

For example:
Drug not covered for patient age
Non-matched cardholder ID
Non-matched prescriber ID
Prior authorization required
Refill too soon
Data TypeStandards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Pharmacy Co-Payment Basis
DescriptionIndicates how co-payment amounts were calculated.
Data TypeStandards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Pharmacy Dispensing Fee Basis
DescriptionIndicates how dispensing fee amounts were calculated.
Data TypeStandards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Pharmacy Fund Amt
DescriptionThe monetary amount that the health plan has paid for the cost of dispensing the medication specifically from the pharmacy fund excluding any portion from the members health benefit funds.
Data TypeStandards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Pharmacy Gross Amount Submitted
DescriptionThe total monetary value claimed, including applicable ingredient cost, dispensing fees, incentive amounts, professional service fees and sales tax.
Data TypeStandards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Pharmacy Level Of Service
DescriptionIndicates the level of service the provider rendered on a pharmacy claim line item.
Data TypeStandards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Pharmacy Reimbursement Basis
DescriptionIndicates how the reimbursement amount was calculated for a pharmacy claim line item.
Data TypeStandards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Pharmacy Service Reason Code
DescriptionA code identifying the type of usage conflict detected or the reason for the pharmacist's professional service.

For example:
Additional drug needed
Additive toxicity
Adverse drug reaction
Chronic disease management
Drug allergy
Drug-drug interaction
Excessive quantity
Nonformulary drug
Prescriber consultation
Preventive healthcare
Suboptimal compliance
Data TypeStandards - Data Domains.ddm/Data Domains/Common Code [VARCHAR(80)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Pharmacy Service Result Code
DescriptionIndicates action taken by a pharmacist in response to a conflict or the result of a pharmacists professional service.

For example:
0=Not Specified,
1A=Filled As Is False Positive,
1B=Filled Prescription As Is,
1C=Filled With Different Dose,
1D=Filled With Different Directions,
1E=Filled With Different Drug,
1F=Filled With Different Quantity,
1G=Filled With Prescriber Approval
Data TypeStandards - Data Domains.ddm/Data Domains/Common Code [VARCHAR(80)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Professional Pharmacy Service PPS Code
DescriptionProfessional pharmacy services (PPS) codes defined by NCPDP are used to document requests for and delivery of professional services by pharmacists to their patients who are enrolled in pharmacy service benefit plans. PPS codes define the reason for service (conflict), the professional service rendered (intervention) and the result of service (outcome).

For example:
AS=Patient assessment
CC=Coordination of care,
DE=Dosing evaluation/determination,
FE=Formulary enforcement,
GP=Generic product selection,
M=Prescriber consulted
MA=Medication administration,
MR=Medication review,
No intervention
PA=Patient consulted
PE=Patient education/instruction,
PH=Patient medication history,
PM=Patient monitoring,
PT=Perform laboratory test,
RA=Pharmacist consulted other source
RT=Recommend laboratory test,
SC=Self-care consultation,
SW=Literature search/review,
TC=Payer/processor consulted,
TH=Therapeutic product interchange
Data TypeStandards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Professional Service Fee Paid
DescriptionThe monetary amount included in the payment for a pharmacy claim line, representing the contractually agreed upon fee for professional services rendered.
Data TypeStandards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse



 Professional Service Fee Submitted
DescriptionThe monetary amount submitted by the provider for professional services rendered.
Data TypeStandards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKeyfalse
Is Requiredfalse
Is Derivedfalse
Is Surrogate Keyfalse

Generalization Details

 Pharmacy Claim Line Item_Claim Line_Gen
SupertypeClaim Line
SubtypePharmacy Claim Line Item
Transform AsTABLE