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DWC SV4 Pharmacy Services Public Use Data File (PUDF) Data Dictionary

   Updated March 5, 2010

Claimant Confidentiality | Excluded Records | Data Dictionary | File Structure | Header File Layout | Detail File Layout | Citation | Disclaimer

Introduction

The Texas Department of Insurance, Division of Workers' Compensation (DWC), maintains a statewide database of medical services billing information. An extract of this database, the Public Use Data File (PUDF), is available to the public for a reasonable fee established by the commissioner under Texas Labor Code §413.007 and §413.007(c).

   Claimant Confidentiality

In providing the Public Use Data File (PUDF), the identities of injured employees and beneficiaries may not be disclosed as required under Texas Labor Code §402.082, §402.083, and §413.007. Information remains confidential when released as under Texas Labor Code §402.086 Transfer of Confidentiality. In order to comply with these confidentiality requirements, certain data elements contained in the source medical billing/payment data base were either encrypted or removed from the PUDF. Some variables are unpopulated because they are optional or conditional, and were not populated when the carrier reported the data to DWC.

   Excluded Records

The PUDF excludes the following records:

  1. Records that failed to pass EDI reporting edits and were rejected;
  2. Records replaced, updated or deleted through subsequent submissions and bill sequencing; and
  3. Records that were determined to be duplicates of other records by DWC.

   Data Dictionary

Definitions

The following information is provided in the data dictionary:

Column Definition
DN# IAIABC data element number
Edit Variable validation/edit rule:
M = Mandatory
C = Conditional
O = Optional
Name Name of the variable
Start Beginning position number of the variable
Length Length of the variable
Description Variable description including coding scheme and valid codes

   File Structure

The DWC SV4 Pharmacy Services PUDF contains billing information for pharmacy services. It consists of a header and detail file for each reporting period. Each file is in a fixed width format. The header file contains billing level information and the detail file contains itemized service level information. The "Bill ID" is a unique identification number contained in both the header and detail files. It is used as the primary key linking the bill level and service level information. The detail file contains one or more lines of service level information.

   Header File Layout

The header file contains information about the EDI submission, carriers, employers, employees, and bill level information.

Header Variables
DN# Edit Name Start Length Description
    Bill ID 1 41 Bill ID uniquely identifies a bill and links line items to the bill.
523 M Billing Provider Unique Bill Identification Number 42 38 A unique number assigned by the billing provider to a specific bill within a batch of bills.
500 M Unique Bill ID Number 80 30 Assigned by and unique to the Insurer. This number should never be reused except when sending bill submission type "01" for cancellations or "05" for replacing a bill. Acknowledgements will refer to this number when a bill is accepted or rejected.
    Bill Type 110 3 SV1 = Professional Service,
SV2 = Institutional (Hospital) Service
SV3 = Dental Service
SV4 = Drug (Pharmacy) Service
615 M Reporting Period Start Date 113 8 The start date during which the information sent was processed. Format: CCYYMMDD
615 M Reporting Period End Date 121 8 The end date during which the information sent was processed. Format: CCYYMMDD
6 M Insurer FEIN 129 9 Encrypted
The federal identification number of the carrier or self-insured assuming responsibility for workers' compensation claims.
616 M Insurer Postal Code 138 5 The zip code of the carrier or self-insured's specific business site.
187 M Claim Administrator FEIN 143 9 Encrypted
The federal identification number of the entity licensed or allowed to adjust a bill.
188 M Claim Administrator Name 152 35 The name of the entity licensed or allowed to adjust a bill.
14 M Claim Administrator Postal Code 187 5 The mailing zip code of the claim administrator's processing facility.
353 M Transaction Set Purpose Code 192 2 Identifies the purpose of the transaction set.
16 O Employer FEIN 194 10 Encrypted
The federal identification number of the employer where the employee was employed at the time of the injury.
21 M Employer Physical City 204 30 The city name of the facility where the injured worker was employed at the time of the injury.
22 C Employer Physical State Code 234 2 The two-character state code of the facility where the injured worker was employed at the time of the injury.
23 C Employer Physical Postal Code 236 5 The zip code of the facility where the injured worker was employed at the time of the injury.
164 M Employer Physical Country Code 241 3 A three-character code indicating the country where the injured worker was employed at the time of the injury.
48 M Employee Mailing City 244 30 The city name of the injured worker's mailing address.
49 C Employee Mailing State Code 274 2 The two-character state code of the injured worker's mailing address.
50 C Employee Mailing Postal Code 276 5 The zip code of the injured worker's mailing address.
155 M Employee Mailing Country Code 281 3 A three-character code indicating the country of the injured worker's mailing address.
52 M Employee Date of Birth 284 6 The year and month the injured worker was born. Format: CCYYMM
53 C Employee Gender Code 290 1 Indicates the sex of the injured worker:
M=Male
F=Female U=Unknown
54 C Employee Marital Status Code 291 1 Indicates the marital status of the injured worker:
I=Single
K=Unknown
M=Married
S=Separated
U=Widowed
15 M Claim Administrator Claim Number 292 30 Encrypted
A number assigned by the insurance carrier or TPA to identify a specific claim.
31 M Employee Date of Injury 322 6 The year and month the accident occurred. Format: CCYYMM
    Filler 328 2  
501 M Total Charge Per Bill 330 15 The cumulative dollar amount of all line items on the bill.
502 C Billing Type Code 345 2 Identifies the kind of billing:
DM = Durable Medical
MO = Mail Order Drug
RX = Pharmacy or Drug
555 C Place of Service Bill Code 347 2 Identifies the place of service at the bill level.
503 M Billing Format Code 349 2 Indicates whether the data is from a UB92 or CMS1500.
A = Institutional (UB 92)
B = Professional (CMS 1500)
Note: If the bill is not a UB92 or CMS 1500, uses 'B' as the default.
506 C Provider Signature On File Indicator 351 1 Indicates if the signature of the provider is on file.
Y=Yes
N=No
526 O Release of Information Code 352 1 Identifies whether the release of information related to a claim is authorized or not.
A = Appropriate release of information on file at health care service provider or at a URA.
I = Informed consent to release medical information for conditions or diagnosis regulated by Federal Statues.
M = The provider has a limited or restricted ability to release data related to a claim.
N = No, provider is not allowed to release data.
O = On file at payor or at plan sponsor.
Y = Yes, provider has signed statement permitting release of medical billing data related to the claim.
507 M Provider Agreement Code 353 1 Identifies the kind of provider agreement applicable to a bill:
H=Network
N=No Agreement
P=Participant Agreement
Y=PPO Agreement
504 C Filler 354 40 Identifies the kind of facility where treatment was rendered.
508 M Bill Submission Reason Code 394 2 Identifies the bill submission/re-submission type:
00 = Original
01 = Cancellation (removed during bill sequencing)
05 = Replacement
511 M Date Insurer Received Bill 396 8 The calendar date the insurer received the bill from the provider. Format: CCYYMMDD
509 C Service Bill From Date 404 8 The starting date in which services were performed. Format: CCYYMMDD
509 C Service Bill To Date 412 8 The ending date in which services were performed. Format: CCYYMMDD
510 M Date of Bill 420 8 The provider's bill date. Format: CCYYMMDD
512 M Date Insurer Paid Bill 428 8 The calendar date the insurer or financially responsible party paid the bill or received credit from the provider. Format: CCYYMMDD
515 O Contract Type Code 436 2 Identifies the kind of contractual agreement for provider reimbursement:
01 = Diagnosis Related Group
02 = Per Diem
03 = Variable per diem
04 = Flat fee per service
05 = Capitate
06 = Percent
09 = Other
516 M Total Amount Paid Per Bill 438 15 The dollar amount paid or credited for a submitted bill by payor after adjustments.
517 O Patient Account Number 453 30 A unique number assigned by the provider to identify the patient/claimant.
    Filler 513 120  
678 C Facility Name 633 35 The name of the facility where the medical services were rendered. Mandatory for SV1 bills.
679 O Facility FEIN 668 9 Encrypted
The federal identification number of the facility where the medical services were rendered.
684 C Facility Primary Address 677 50 The first line in the facility's address.
685 O Facility Secondary Address 727 32 The second line in the facility's address.
686 C Facility City 759 30 The city name of the facility's address.
687 C Facility State Code 789 2 The two-character state code of the facility's address.
688 C Facility Postal Code 791 5 The zip code of the facility's address.
689 C Facility Country Code 796 3 A three-character code indicating the country of the facility's mailing address.
680 O Facility State License Number 799 20 A unique number assigned to identify the facility.
681 O Facility Medicare Number 819 10 A unique number assigned to the facility by the Medicare program.
682 O Facility National Provider ID 829 20 The unique National Provider ID of the facility.
208 O Filler 849 30  
528 M Billing Provider Last Name or Group 879 35 The surname of the person or full name of an organization receiving payment. It is assumed to be the rendering provider for all services unless a specific rendering provider is identified at the bill or service line levels. If the billing provider is a non-person, a specific individual rendering bill provider may be required by a jurisdiction.
529 M Billing Provider First Name 914 25 The given name of the billing provider.
530 O Billing Provider Middle Name Initial 939 25 The middle name or initial of the billing provider.
531 O Billing Provider Last Name Suffix 964 10 The legally recognized last name suffix of the billing provider which is used on legal documents. Examples: Jr., Sr., II, III
629 M Billing Provider FEIN 974 9 Encrypted
The federal tax identification number of the billing provider.
534 O Billing Provider Gate Keeper Indicator 983 3 Indicates that the billing provider is the treating doctor. If present, must = 'GP' (Gateway Provider).
537 O Billing Provider Primary Specialty Code 986 10 Indicates the primary specialty of the billing provider.
538 M Billing Provider Primary Address 996 50 The first line in the billing provider's address.
539 O Billing Provider Secondary Address 1046 32 The second line of the billing provider's address.
540 M Billing Provider City 1078 30 The city name of the billing provider's address.
541 C Billing Provider State Code 1108 2 The two-character state code of the billing provider's address.
542 C Billing Provider Postal Code 1110 5 The zip code of the billing provider's address.
569 M Billing Provider Country Code 1115 3 A three-character code indicating the country of the billing provider's mailing address.
630 C Billing Provider State License Number 1118 20 The billing provider's license type, license number and jurisdiction code.
632 O Billing Provider Medicare Number 1138 10 The specific number issued to the billing provider by the Medicare program.
581 O Treatment Authorization Number 1148 1 A number assigned by the carrier to identify pre-authorized or pre-certified treatment plans.
Y = reported,
N = not reported.
634 O Billing Provider National Provider ID 1149 20 The unique National Provider ID of the billing provider.
638 C Rendering Bill Provider Last Name or Group 1169 35 The surname of the individual provider actually rendering care. If not present, the billing provider is assumed to be the rendering provider for all services on this bill. If the billing provider was not an individual, a jurisdiction may require a rendering bill provider to be specified.
639 C Rendering Bill Provider First Name 1204 25 The given name of the rendering bill provider.
640 O Rendering Bill Provider Middle Name Initial 1229 25 The middle name or initial of the rendering bill provider.
641 O Rending Bill Provider Last Name Suffix 1254 10 The legally recognized last name suffix of the rendering bill provider which is used on legal documents. Examples: Jr., Sr., II, III
642 O Rendering Bill Provider FEIN 1264 9 Encrypted
The federal tax identification number of the rendering bill provider.
534 O Rendering Bill Provider Gate Keeper Indicator 1273 3 Indicates that the rendering bill provider is the treating doctor. If present, must = 'GP' (Gateway Provider).
651 O Rendering Bill Provider Primary Specialty Code 1276 10 Indicates the primary medical specialty of the rendering bill provider.
652 O Rendering Bill Provider Primary Address 1286 50 The first line of the rendering bill provider's address.
653 O Rendering Bill Provider Secondary Address 1336 32 The second line of the rendering bill provider's address.
654 O Rendering Bill Provider City 1368 30 The city name of the rendering bill provider's address.
655 O Rendering Bill Provider State Code 1398 2 The two-character state code of the rendering bill provider's address.
656 O Rendering Bill Provider Postal Code 1400 5 The zip code in the rendering bill provider's address.
657 O Rendering Bill Provider Country Code 1405 3 A three-character code indicating the country of the rendering bill provider's mailing address.
643 C Rendering Bill Provider State License Number 1408 20 The rendering bill provider's license type, license number and jurisdiction code.
647 C Rendering Bill Provider National Provider ID 1428 20 The unique National Provider ID of the rendering bill provider.
690 C Referring Provider Last Name or Group 1448 35 The surname of the provider referring claimant for care. Only used when needed to document that a bill results from care provided based on a referral from another provider.
691 C Referring Provider First Name 1483 25 The given name of the referring provider.
692 O Referring Provider Middle Name Initial 1508 25 The middle name or initial of the referring provider.
693 O Referring Provider Last Name Suffix 1533 10 The legally recognized last name suffix of the referring provider which is used on legal documents. Examples: Jr., Sr., II, III
694 O Referring Provider FEIN 1543 9 Encrypted
The federal tax identification number of the referring provider.
534 O Referring Provider Gate Keeper Indicator 1552 3 Indicates that the referring provider is the treating doctor. If present, must = 'GP' (Gateway Provider).
695 C Referring Provider State License Number 1555 20 The referring provider's license type, license number and jurisdiction code.
701 O Referring Provider Specialty License Number 1575 30 The specific license number issued by a state to the referring provider that denotes specialty of the referring provider.
697 O Referring Provider Medicare Number 1605 10 The specific number issued to the referring provider by the Medicare Program.
699 C Referring Provider National Provider ID 1615 20 The unique National Provider ID of the referring provider.

   Detail File Layout

The detail file contains line item information, and line item adjustments.

Detail Variables
DN# Edit Name Start Length Details
    Bill ID 1 41 Bill ID uniquely identifies a bill and links line items to the bill.
    Line Number 42 6 The number of the line item on the bill.
721 M NDC Billed Code 48 15 The National Drug Code (or equivalent code value) identifying the drugs or pharmaceutical products billed.
561 C Prescription Line Number 63 6 A unique number assigned by the dispenser to identify the prescription at the line level.
562 C Dispensed as Written Code 69 1 A code denoting methodology used in dispensing the drugs or pharmaceuticals. Dispense as Written Code - ANSI DE 1329
0 = Not dispense as written
1 = Physician dispense as written
2 = Patient dispense as written
3 = Pharmacy dispense as written
4 = No generic available
5 = Brand dispensed as generic
6 = Override
7 = Substitution not allowed - brand name drug mandated by law
8 = Substitution not allowed - generic not available in marketplace
9 = Other
563 C Drug Name 70 80 Name of the dispensed drug or pharmaceutical.
564 C Basis Of Cost Determination Code 150 2 Method by which drug cost was calculated.
0 = Not Specified
1 = Average Wholesale Price (AWP)
2 = Local Wholesaler
3 = Direct
4 = Estimated Acquisition Cost
5 = Acquisition Cost
6 = Maximum Allowable Cost (MAC)
7 = Usual, Customary and Reasonable (UCR)
8 = Unit Dose
9 = Brand Medically Necessary
605 C Service Line From Date 152 8 The starting date that services were performed for the line item. Format: CCYYMMDD
605 C Service Line To Date 160 8 The ending date that services were performed for the line item. Format: CCYYMMDD
527 R Date of Prescription 168 8 The date the prescription was filled at the bill level. Format: CCYYMMDD
527 R Date of Prescription 168 8 The date the prescription was filled at the bill level. Format: CCYYMMDD
570 C Drugs/Supplies Quantity Dispensed 176 15 The number of units of drugs/supplies dispensed.
571 C Drugs/Supplies Number of Days 191 15 The number of units of drugs/supplies.
579 C Drugs/Supplies Dispensing Fee 206 15 Amount billed for dispensing drugs/supplies.
572 C Drugs/Supplies Billed Amount 221 15 The amount billed for drugs/supplies.
574 M Total Amount Paid Per Line 236 15 The total dollar amount paid or credited to the line item.
728 C NDC Paid Code 251 15 Identifies the drug or pharmaceutical that was paid.
580 C Days/Units Paid 266 10 The number of services paid for the line item in days or units.
    Number of Service Adjustments 276 1 The number of service adjustments for the line item.
731 M Service Adjustment Group Code 1 277 2 A code indicating the general category of the first adjustment made to the dollar amount paid or credited to the line item.
CO = Contractual Obligations
OA = Other Adjustments
PI = Payer initiated reductions
PR = Patient Responsibility
732 M Service Adjustment Reason Code 1 279 5 A code indicating the detailed reason of the first adjustment made to the dollar amount paid or credited to the line item.
733 M Service Adjustment Amount 1 284 15 The dollar amount of the first adjustment paid or credited to the line item.
734 M Service Adjustment Units 1 299 15 The number of units applicable to the first adjustment to the line item.
731 M Service Adjustment Group Code 2 314 2 A code indicating the general category of the second adjustment made to the dollar amount paid or credited to the line item.
732 M Service Adjustment Reason Code 2 316 5 A code indicating the detailed reason of the second adjustment made to the dollar amount paid or credited to the line item.
733 M Service Adjustment Amount 2 321 15 The dollar amount of the second adjustment paid or credited to the line item.
734 M Service Adjustment Units 2 336 15 The number of units applicable to the second adjustment to the line item.
731 M Service Adjustment Group Code 3 351 2 A code indicating the general category of the third adjustment made to the dollar amount paid or credited to the line item.
732 M Service Adjustment Reason Code 3 353 5 A code indicating the detailed reason of the third adjustment made to the dollar amount paid or credited to the line item.
733 M Service Adjustment Amount 3 358 15 The dollar amount of the third adjustment paid or credited to the line item.
734 M Service Adjustment Units 3 373 15 The number of units applicable to the third adjustment to the line item.
731 M Service Adjustment Group Code 4 388 2 A code indicating the general category of the fourth adjustment made to the dollar amount paid or credited to the line item.
732 M Service Adjustment Reason Code 4 390 5 A code indicating the detailed reason of the fourth adjustment made to the dollar amount paid or credited to the line item.
733 M Service Adjustment Amount 4 395 15 The dollar amount of the fourth adjustment paid or credited to the line item.
734 M Service Adjustment Units 4 410 15 The number of units applicable to the fourth adjustment to the line item.
731 M Service Adjustment Group Code 5 425 2 A code indicating the general category of the fifth adjustment made to the dollar amount paid or credited to the line item.
732 M Service Adjustment Reason Code 5 427 5 A code indicating the detailed reason of the fifth adjustment made to the dollar amount paid or credited to the line item.
733 M Service Adjustment Amount 5 432 15 The dollar amount of the fifth adjustment paid or credited to the line item.
734 M Service Adjustment Units 5 447 15 The number of units applicable to the fifth adjustment to the line item.

   Citation

Any reporting or analysis based on the data shall cite the source as the following: DWC SV4 Pharmacy Services Public Use Data File (PUDF). Texas Department of Insurance, Division of Workers' Compensation, Austin, TX.

   Disclaimer

Please note that DWC is providing the PUDF as a public service, and users of this data are responsible for checking the accuracy, completeness, currency and/or suitability of all information themselves. DWC assumes no responsibility for any errors or for the use of the information provided. Additionally, DWC makes no representations, guarantees, or warranties as to the accuracy, completeness, currency, or suitability of this information. DWC expressly disclaims all implied warranties of merchantability and of fitness for a particular purpose. You expressly agree that your use of this data is at your own risk. Under no circumstances shall DWC be liable for any direct, indirect, incidental, special, punitive, or consequential damages that result in any way from your use of this site or from reliance on or use of information provided on this site or that result from deletion of files, delays in operation or transmission of data, or any failure of performance of the site. For purposes of this disclaimer, the term "DWC" includes the Texas Department of Insurance (TDI), the State of Texas, and their employees. For additional information, consult TDI's Web Site Disclaimer, which also applies to the DWC SV4 Pharmacy Services Public Use Data Files (PUDF).


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Last updated: 12/01/2011



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