Rx Claim Dataset Specification

RX Claim Dataset Specification

RX Claim

RX Claim Raw

The “RX Claim Dataset Specification” is a representation of customer data ingestion. Information on RX (pharmacy) claims is received with customer files, including simple enrichment using drug lookups data. Its unique key is Claim_Number. It references Members by Member_ID and Owning Providers by Provider_ID. It is referenced from Episodes.

Key Aspects of the Dataset

Member Details: Captures essential information about the members who are receiving prescriptions, including identification data and relevant personal details. This ensures that claims are accurately associated with the correct individuals.
Prescription Details: Stores comprehensive data on the prescriptions themselves, such as medication names, dosages, and prescription dates, providing a detailed view of the prescribed treatment.
Provider Information: Includes information about the healthcare providers who issued the prescriptions, such as names and contact details. This is essential for verifying the legitimacy of prescriptions and facilitating communication if needed.
Claim Status: Records the current status of each prescription claim, from initial filing through processing to completion. This helps track the progress of claims and identify any issues that may require intervention.
Additional Data Points: Contains other relevant data such as claim amounts, approval statuses, and any denials or challenges to claims. This comprehensive data supports thorough analysis and effective management of prescription claims.

This dataset is invaluable for healthcare and insurance organizations, enabling them to efficiently process prescription claims, ensure compliance with healthcare regulations, and provide timely services to members.

Table Specification

RX_Claim Table

Column Name	Is Nullable	Data Type	Description
`Claim_Number`	YES	STRING	Unique identifier for the pharmacy claim.
`Member_ID`	YES	STRING	Identifier linking the claim to the specific member receiving the medication.
`Membership_ID`	YES	STRING	Identifier for the membership or insurance plan under which the claim is filed.
`Subscriber_ID`	YES	STRING	Identifier for the subscriber or policyholder of the insurance plan.
`Relationship_Code`	YES	STRING	Code indicating the member's relationship to the subscriber (e.g., self, spouse).
`Relationship_Description`	YES	STRING	Textual description of the member’s relationship to the subscriber.
`Claim_Status_Code`	YES	STRING	Code representing the current status of the claim.
`Claim_Status_Description`	YES	STRING	Description of the claim's current status.
`Client_ID`	YES	STRING	Identifier for the client or entity responsible for managing the claim.
`Subclient_ID`	YES	STRING	Identifier for a specific subgroup or division within the client entity.
`Prescription_ID`	YES	STRING	Unique identifier for the specific prescription within the claim.
`Ordering_Provider_ID`	YES	STRING	Identifier for the healthcare provider who prescribed the medication.
`Ordering_Provider_DEA_ID`	YES	STRING	Drug Enforcement Administration (DEA) number of the prescribing provider.
`Pharmacy_ID`	YES	STRING	Identifier for the pharmacy where the prescription was filled.
`Pharmacy_Chain_Code`	YES	STRING	Code representing the pharmacy chain or group.
`Prescribed_Date`	YES	DATE	Date when the medication was prescribed.
`Filled_Date`	YES	DATE	Date when the prescription was filled at the pharmacy.
`Reversed_Date`	YES	DATE	Date when the claim was reversed, if applicable.
`National_Drug_Code`	YES	STRING	Standard identifier for the medication prescribed and dispensed.
`Brand_Or_Generic_Code`	YES	STRING	Code indicating whether the medication is: `B` = Brand, `G` = Generic, `T` = Trademark.
`Strength`	YES	STRING	The concentration or potency of the medication dispensed.
`Allowed_Amount`	YES	FLOAT64	The total cost allowed by the insurance for the claim.
`Days_Supply_Count`	YES	INT64	The number of days the dispensed medication is expected to last.
`Quantity_Dispensed_Count`	YES	FLOAT64	The quantity of medication dispensed in the prescription.
`Refill_Count`	YES	INT64	The number of times the prescription has been refilled.
`Dispense_As_Written_Code`	YES	INT64	Code indicating whether the pharmacy must dispense the brand-name medication as written by the provider.
`Prescription_Origin`	YES	STRING	Source of the prescription: `Y` = Telephoned In, `N` = Not Telephoned In.
`Ordering_Provider_NPI`	YES	STRING	National Provider Identifier for the provider who ordered the medication.
`Pharmacy_NPI`	YES	STRING	National Provider Identifier for the dispensing pharmacy.
`National_Drug_Code_Description`	YES	STRING	Descriptive information about the medication as per the NDC.
`Brand_Type`	YES	STRING	Type of brand for the medication (e.g., original, off-patent).
`Brand_Name`	YES	STRING	The commercial name of the brand medication.
`Drug_Code_Description`	YES	STRING	Description of the medication code.
`Drug_Class_Code`	YES	STRING	Code categorizing the medication into a specific pharmacological class.

Relationship Codes

1 = Cardholder/Self
2 = Spouse
3 = Dependent
4 = Other
U = Unspecified

Claim Status Codes

P = Paid: Code indicating that the transaction has been processed using plan rules and was paid.
X = Reversed: The paid claim was reversed.

Dispense As Written Codes

0 = No product selection indicated (use this as default)
1 = Substitution not allowed by prescriber
2 = Substitution allowed - patient requesting product dispensed
3 = Substitution allowed - pharmacist selected product dispensed
4 = Substitution allowed - generic drug not in stock
5 = Substitution allowed - brand drug dispensed as a generic
6 = Override
7 = Substitution not allowed - brand drug mandated by law
8 = Substitution allowed - generic drug not available in marketplace
9 = Other