| Business Data Model Data Model |
| Description | A 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 |
| Generalization | |
Pharmacy Claim Line Item_Claim Line_Gen |
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| Dependencies | |
NONE |
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| Reverse Dependencies | |
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| Attribute Details |
Claim Post Discount Amt
| Description | The cost of the service after applying discounts and excluding service cost. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Claim Pre Discount Amt
| Description | The cost of the service before applying any discounts and excluding service cost. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Compound Drug Ind
| Description | Indicates whether this drug is a compound or not. 1 Compound 0 Not a compound |
| Data Type | Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Compound Ingredient Modifier Code
| Description | A code that identifies special circumstances related to the dispensing/payment of the compound drug product. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Common Code [VARCHAR(80)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Dispensing Fee Paid Amt
| Description | The monetary value of the dispensing fee included in the payment for a pharmacy claim line. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Dispensing Fee Submitted Amt
| Description | The monetary value of a dispensing fee submitted by the pharmacy. This amount is included in the 'Pharmacy Gross Amount Submitted'. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Dosage Form Code
| Description | Indicates the dosage form of the complete compound mixture. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Incentive Amt
| Description | The contractually agreed upon incentive for specific services rendered. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Ingredient Cost Basis
| Description | Indicates the method of calculation used for the cost of ingredients in the relevant medication. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Ingredient Cost Paid Amt
| Description | The amount of the cost of the medication ingredients that has been paid. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Ingredient Cost Submitted Amt
| Description | The 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 Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Ingredient Ind
| Description | Indicates whether this drug is used as an ingredient in another drug. 1 Ingredient 0 Not an ingredient |
| Data Type | Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Level Of Effort Code
| Description | A 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 Type | Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Pharmacy Claim Line Item Status Reason
| Description | Indicates 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 Type | Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Pharmacy Co-Payment Basis
| Description | Indicates how co-payment amounts were calculated. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Pharmacy Dispensing Fee Basis
| Description | Indicates how dispensing fee amounts were calculated. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Pharmacy Fund Amt
| Description | The 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 Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Pharmacy Gross Amount Submitted
| Description | The total monetary value claimed, including applicable ingredient cost, dispensing fees, incentive amounts, professional service fees and sales tax. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Pharmacy Level Of Service
| Description | Indicates the level of service the provider rendered on a pharmacy claim line item. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Pharmacy Reimbursement Basis
| Description | Indicates how the reimbursement amount was calculated for a pharmacy claim line item. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Pharmacy Service Reason Code
| Description | A 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 Type | Standards - Data Domains.ddm/Data Domains/Common Code [VARCHAR(80)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Pharmacy Service Result Code
| Description | Indicates 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 Type | Standards - Data Domains.ddm/Data Domains/Common Code [VARCHAR(80)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Professional Pharmacy Service PPS Code
| Description | Professional 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 Type | Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Professional Service Fee Paid
| Description | The monetary amount included in the payment for a pharmacy claim line, representing the contractually agreed upon fee for professional services rendered. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Professional Service Fee Submitted
| Description | The monetary amount submitted by the provider for professional services rendered. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
| Generalization Details |
Pharmacy Claim Line Item_Claim Line_Gen
| Supertype | Claim Line |
| Subtype | Pharmacy Claim Line Item |
| Transform As | TABLE |
| Business Data Model Data Model |