Collection of Drug Event Data from Contracted Part D Providers For Payments (CMS-10174)

Prescription Drug Event Record Layout
HDR RECORD
FIELD
NO.
1

FIELD NAME
RECORD ID

NCPDP
FIELD

POSITION
1-3

PICTURE
X(3)

LENGTH
3

NCPDP,
CMS OR
PDFS
DEFINED
PDFS

DEFINITION / VALUES
"HDR"

2

SUBMITTER ID

4-9

X(6)

6

CMS

Unique ID assigned by CMS.

3

FILE ID

10 - 19

X(10)

10

PDFS

Unique ID provided by Submitter. Same ID
cannot be used within 12 months.

4

TRANS DATE

20 - 27

9(8)

8

PDFS

Date of file transmission to PDFS.

5

PROD TEST CERT IND

28 - 31

X(4)

4

PDFS

TEST, CERT or PROD

6

FILLER

32 - 512

X(481)

481

SPACES

BHD RECORD

POSITION
1-3

PICTURE
X(3)

LENGTH
3

NCPDP,
CMS OR
PDFS
DEFINED
PDFS

SEQUENCE NO

4 - 10

9(7)

7

PDFS

Must start with 0000001

3

CONTRACT NO

11 - 15

X(5)

5

CMS

Assigned by CMS

4

PBP ID

16 - 18

X(3)

3

CMS

Assigned by CMS

5

FILLER

19 - 512

X(494)

494

FIELD
NO.
1

FIELD NAME
RECORD ID

2

NCPDP
FIELD

DEFINITION / VALUES
"BHD"

SPACES

DET RECORD

PICTURE
X(3)

LENGTH
3

NCPDP, CMS
OR PDFS
DEFINED
PDFS

9(7)

7

PDFS

Must start with 0000001

11 - 50

X(40)

40

CMS

Optional Field

51 - 70

X(20)

20

CMS

Medicare Health Insurance Claim Number or Railroad Retirement Board
(RRB) number.

302-C2

71 - 90

X(20)

20

NCPDP

Plan identification of the enrollee. Assigned by plan.

PATIENT DATE OF BIRTH
(DOB)

304-C4

91 - 98

9(8)

8

NCPDP

CCYYMMDD
Optional Field

7

PATIENT GENDER CODE

305-C5

99 - 99

9(1)

1

NCPDP

1=M
2=F
Unspecified or unknown values are not accepted

8

DATE OF SERVICE (DOS)

401-D1

100 - 107

9(8)

8

NCPDP

CCYYMMDD

9

PAID DATE

108 - 115

9(8)

8

CMS

CCYYMMDD, The date the plan paid the pharmacy for the prescription
drug.
Mandatory for Fallback plans , Optional for all other plans

10

PRESCRIPTION SERVICE
REFERENCE NO

116 - 124

9(9)

9

NCPDP

11

FILLER

125 - 126

X(2)

2

The field length is 9 to accommodate proposed future NCPDP standard.
Under 5.1 right justify and fill with 2 leading zeros.
When plans compile PDEs from non-standard formats, the plans must
assign a unique reference number if necessary. A reference number must
be unique for any DOS and Service Provider ID combination.
SPACES

12

PRODUCT SERVICE ID

127 - 145

X(19)

19

NCPDP

DDPS accepts NDC only. Do not report HRI or UPC codes. Fill the first
11 positions, no spaces or hyphens, followed by 8 spaces. Format is
MMMMMDDDDPP.
If Compound Code (field 17) = 2 (Compound) and the NCPDP Compound
Segment is used in claims processing, the Product Service ID (field 12)
contains the NDC of the most expensive Part D covered drug from the
Compound Product ID (489-TE) occurrences.
If Compound Code (field 17) = 2 (Compound) and the Compound Segment
is not used in claims processing, the Product Service ID (field 12) contains
the NDC from the Product/Service ID (407-D7) from the NCPDP Claim
Segment.

FIELD
NO.
1

FIELD NAME
RECORD ID

2

SEQUENCE NO

3

CLAIM CONTROL NUMBER

4

HEALTH INSURANCE
CLAIM NUMBER (HICN)

5

CARDHOLDER ID

6

NCPDP
FIELD

POSITION
1-3
4 - 10

402-D2

407-D7 or
489- TE

DEFINITION / VALUES
"DET"

FIELD
NO.

FIELD NAME

NCPDP
FIELD

POSITION

PICTURE

LENGTH

NCPDP, CMS
OR PDFS
DEFINED

DEFINITION / VALUES
DDPS will reject the following billing codes for compounded legend
and/or scheduled drugs: 99999999999, 99999999992, 99999999993,
99999999994, 99999999995, and 99999999996.

13

SERVICE PROVIDER ID
QUALIFIER

202-B2

146 - 147

X(2)

2

NCPDP

Mandatory for Standard Format
The type of pharmacy provider identifier used in field 14.
01 = National Provider Identifier (NPI)
06 = UPIN
07 = NCPDP Number
08 = State License
11 – Federal Tax Number
99 – Other
For Non-Standard formats any of the above values are acceptable.
For Standard Data Format, valid values are
01 – NPI or
07 – NCPDP Provider ID

14

SERVICE PROVIDER ID

201-B1

148 - 162

X(15)

15

NCPDP

15

FILL NUMBER

403-D3

163 - 164

9(2)

2

NCPDP

When Plans report Service Provider ID Qualifier = ‘99’ - Other, populate
Service Provider ID with the default value “PAPERCLAIM” defined for
TrOOP Facilitation Contract.
When Plans report Federal Tax Number (TIN), use the following format:
ex: 999999999 (do not report embedded dashes)
Values = 0 - 99. If unavailable, use 0.

16

DISPENSING STATUS

343-HD

165 -165

X(1)

1

NCPDP

17

COMPOUND CODE

406-D6

166 - 166

9(1)

1

NCPDP

Blank = Not Specified
P = Partial Fill
C = Completion of Partial Fill
0=Not specified
1=Not a Compound
2=Compound

FIELD
NO.
18

FIELD NAME
DISPENSE AS WRITTEN
(DAW) PRODUCT
SELECTION CODE

NCPDP
FIELD
408-D8

POSITION
167 - 167

PICTURE
X(1)

LENGTH
1

NCPDP, CMS
OR PDFS
DEFINED
NCPDP

DEFINITION / VALUES
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

19

QUANTITY DISPENSED

442-E7

168 - 177

9(7)V999

10

NCPDP

Number of Units, Grams, Milliliters, other. If compounded item, total of all
ingredients will be supplied as Quantity Dispensed.

20

DAYS SUPPLY

405-D5

178 - 180

9(3)

3

NCPDP

0 – 999

21

PRESCRIBER ID QUALIFIER

466-EZ

181 - 182

X(2)

2

NCPDP

22

PRESCRIBER ID

411-DB

183 - 197

X(15)

15

NCPDP

The type of prescriber identifier used in field 22.
01 = National Provider Identifier (NPI when implemented)
06 = UPIN
08 = State License Number
12 = Drug Enforcement Administration (DEA) number
Mandatory for Standard Format.
Optional when non-standard data format = ‘B’, ‘C’, ‘P’, or ‘X’
Mandatory for Standard Format.
Mandatory for non-standard data format when Prescriber ID Qualifier is
present and valid.
Optional when non-standard data format = ‘B’, ‘C’, ‘P’, or ‘X’ when
Prescriber ID Qualifier is not present

FIELD
NO.
23

FIELD NAME
DRUG COVERAGE STATUS
CODE

NCPDP
FIELD

POSITION
198 - 198

PICTURE
X(1)

LENGTH
1

NCPDP, CMS
OR PDFS
DEFINED
CMS

DEFINITION / VALUES
Coverage status of the drug under part D and/or the PBP.
C = Covered
E = Supplemental drugs (reported by Enhanced Alternative plans only)
O = Over-the-counter drugs

24

ADJUSTMENT DELETION
CODE

199 - 199

X(1)

1

CMS

A = Adjustment
D = Deletion
Blank = Original PDE

25

NON- STANDARD FORMAT
CODE

200 - 200

X(1)

1

CMS

26

PRICING EXCEPTION CODE

201 - 201

X(1)

1

CMS

27

CATASTROPHIC
COVERAGE CODE

202 - 202

X(1)

1

CMS

Format of claims originating in a non-standard format.
B = Beneficiary submitted claim
C = COB claim
P = Paper claim from provider
X = X12 837
Blank = NCPDP electronic format
M = Medicare as Secondary Payer
O = Out-of-network pharmacy
Blank = In-network pharmacy and Medicare Primary
A = Attachment Point met on this event
C = Above Attachment Point
Blank = Attachment Point Not Met

28

INGREDIENT COST PAID

506-F6

203 - 210

S9(6)V99

8

NCPDP

Amount the pharmacy is paid for the drug itself. Dispensing fees or other
costs are not included in this amount.

29

DISPENSING FEE PAID

507-F7

211 - 218

S9(6)V99

8

NCPDP

Amount the pharmacy is paid for dispensing the medication. The fee may
be negotiated with pharmacies at the plan or PBM level. Additional fees
may be charged for compounding/mixing multiple drugs. Do not include
administrative fees.
Vaccine Admin. Fee reported in Field 40

30

TOTAL AMOUNT
ATTRIBUTED TO SALES
TAX

219 - 226

S9(6)V99

8

CMS

31

GROSS DRUG COST BELOW
OUT- OF-POCKET
THRESHOLD (GDCB)

227 - 234

S9(6)V99

8

CMS

Depending on jurisdiction, Sales Tax may be calculated in different ways
or reported in multiple NCPDP fields. Plans will report the total sales tax
for the PDE irregardless of how the tax is calculated or reported at pointof-sale.
When the Catastrophic Coverage Code = blank, this field equals the sum of
Ingredient Cost Paid + Dispensing Fee Paid + Total Amount Attributed to
Sales Tax+ Vaccine Admin Fee.
When the Catastrophic Coverage Code = A this field equals the portion of
Ingredient Cost Paid + Dispensing Fee Paid + Total Amount Attributed to
Sales Tax+ Vaccine Admin Fee falling at or below the OOP threshold.
The remaining portion is reported in GDCA.

FIELD
NO.
32

FIELD NAME
GROSS DRUG COST ABOVE
OUT-OF-POCKET
THRESHOLD (GDCA)

NCPDP
FIELD

505-F5

POSITION
235 - 242

PICTURE
S9(6)V99

LENGTH
8

NCPDP, CMS
OR PDFS
DEFINED
CMS

243 - 250

S9(6)V99

8

NCPDP

DEFINITION / VALUES
When the Catastrophic Coverage Code = ‘C’, this field equals the sum of
Ingredient Cost Paid + Dispensing Fee Paid + Total Amount Attributed to
Sales Tax + Vaccine Admin. Fee above the OOP threshold.
When the Catastrophic Coverage Code = ‘A’ this field equals the portion
of Ingredient Cost Paid + Dispensing Fee Paid + Total Amount Attributed
to Sales Tax + Vaccine Admin Fee falling above the OOP threshold. The
remaining portion is reported in GDCB.
Payments made by the beneficiary or by family or friends at point of sale.
These amounts count towards a beneficiary's TrOOP costs.

33

PATIENT PAY AMOUNT

34

OTHER TROOP AMOUNT

251 - 258

S9(6)V99

8

CMS

Other health insurance payments by TrOOP-eligible other payers. This
field records all third party payments that contribute to a beneficiary's
TrOOP, i.e. all TrOOP eligible payments except LICS and Patient Pay
Amount. Examples: payments made on behalf of a beneficiary by charities
or qualified SPAPs.

35

LOW INCOME COST
SHARING
SUBSIDYAMOUNT (LICS)

259 - 266

S9(6)V99

8

CMS

Amount the plan reduced patient liability due to a beneficiary's LICS
status. The MMA provides for Medicare payments to plans to subsidize
the cost-sharing liability of qualifying low-income beneficiaries at the point
of sale. This amount counts towards a beneficiary's TrOOP costs.

36

PATIENT LIABILITY
REDUCTION DUE TO
OTHER PAYER AMOUNT
(PLRO)

267 - 274

S9(6)V99

8

CMS

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, governmental
programs (e.g. VA, TRICARE), Workers' Compensation, Auto/NoFault/Liability Insurances.

37

COVERED D PLAN PAID
AMOUNT (CPP)

275 - 282

S9(6)V99

8

CMS

The net Medicare covered amount which the plan has paid for a Part D
covered drug under the Basic benefit. Amounts paid for supplemental
drugs, supplemental cost-sharing and over-the-Counter drugs are excluded
from this field.

FIELD
NO.
38

FIELD NAME
NON COVERED PLAN PAID
AMOUNT (NPP)

NCPDP
FIELD

POSITION
283 - 290

PICTURE
S9(6)V99

LENGTH
8

NCPDP, CMS
OR PDFS
DEFINED
CMS

39

ESTIMATED REBATE AT
POS

291 -298

S9(6)V99

8

CMS

40

VACCINE
ADMINISTRATION FEE

299-306

S9(6)V99

8

CMS

41

PRESCRIPTION ORIGIN
CODE

307-307

X(1)

1

NCPDP

42

FILLER

308-512

X(205)

205

CMS

419-DJ

DEFINITION / VALUES
The amount of plan payment for enhanced alternative benefits (cost sharing
fill-in and/or non-Part D drugs). This dollar amount is excluded from risk
corridor calculations and TrOOP accumulation.

The estimated amount of rebate that the plan sponsor has elected to apply
to the negotiated price as a reduction in the drug price made available to
the beneficiary at the point of sale. This estimate should reflect the rebate
amount that the plan sponsor reasonably expects to receive from a
pharmaceutical manufacturer or other entity.
The fee reported by a pharmacy, physician, or provider to cover the cost of
administering a vaccine, excluding the ingredient cost and dispensing fee
‘0’=Not Specified
‘1’=Written
‘2’=Telephone
‘3’=Electronic
‘4’=Facsimile

SPACES

Notes:
For any field that references NCPDP values, please refer to the appropriate NCPDP specification to ensure compliance.
All dollar fields are mandatory. If the field is not applicable, report a default value of zeroes. Since the field is a signed field, plans must utilize the appropriate overpunch signs as
specified in the NCPDP Telecommunications Standard, Version 5.1.

BTR RECORD

POSITION
1-3

PICTURE
X(3)

LENGTH
3

NCPDP,
CMS OR
PDFS
DEFINED
PDFS

SEQUENCE NO

4 - 10

9(7)

7

PDFS

Must start with 0000001

3

CONTRACT NO

11 - 15

X(5)

5

CMS

Must match BHD

4

PBP ID

16 - 18

X(3)

3

CMS

Must match BHD

5

DET RECORD TOTAL

19 - 25

9(7)

7

CMS

Total count of DET records

6

FILLER

26 -512

X(487)

487

CMS

SPACES

FIELD
NO.
1

FIELD NAME
RECORD ID

2

NCPDP
FIELD

DEFINITION / VALUES
"BTR"

TLR RECORD
FIELD
NO.
1

FIELD NAME
RECORD ID

NCPDP
FIELD

POSITION
1-3

PICTURE
X(3)

LENGTH
3

NCPDP,
CMS OR
PDFS
DEFINED
PDFS

DEFINITION / VALUES
"TLR"

2

SUBMITTER ID

4-9

X(6)

6

CMS

Must match HDR

3

FILE ID

10 - 19

X(10)

10

PDFS

Must match HDR

4

TLR BHD RECORD TOTAL

20 - 28

9(9)

9

CMS

Total count of BHD records

5

TLR DET RECORD TOTAL

29 - 37

9(9)

9

CMS

Total count of DET records

6

FILLER

38 -512

X(475)

475

CMS

SPACES

Note:
Maximum number of detail records per file is 3 million records. If one file contains multiple batches, maximum record count applies to the cumulative total across all batches.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0982. The time required to complete this information collection is estimated to average
two (2) hours per one million (1,000,000) transactions or 0.0074 seconds per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.