Issue: Pharmacy Claim Versioning for 79413A & 95446

0041

79413A and 95446

Jan 3, 2020

 Dec 15, 2020 Sep 10, 2021

This issue has been resolved moving forward (from the update date) however it still exists within data pulled from past versions of the APCD. This issue will remain active until previously fulfilled data files are no longer being used.

Pharmacy claim versioning

Resolved

Because the pharmacy claim numbers (PC004) are suffixed with the characters P or X, the prescribed claim versioning rules for these SEs did not work correctly.  These issues are being addressed with an anticipated resolution by June 2020.  To use these data, the following workaround is recommended:  Remove the P or X from the last character of the value in PC004.  Group claims by PC004, PC005 and select the claim line with the latest paid date (PC017) and where PC110 = O that does not have a corresponding claim line based on claim number where PC110 = B.

For example:  

Member (PC107)    Claim Number (PC004)   Claim Line (PC005)  Claim Number w/o P/X           Claim Status (PC110)         Paid Date (PC017)          Fill Number (PC028)           Use?

116110808271        190592416169275959P           1                         190592416169275991                         O                            2019-02-28                              01                             Y
116110808271        190592416169275991P           1                         190592416169275991                         O                            2019-02-12                              01                             N

116110808271        190592416169275991X           1                         190592416169275991                         B                            2019-02-12                              01                             N

Versioning

Data Quality

Issue