DWC SV4 Pharmacy Services Public Use Data File (PUDF) Data Dictionary
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:
- Records that failed to pass EDI reporting edits and were rejected;
- Records replaced, updated or deleted through subsequent submissions and bill sequencing; and
- 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.
| 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.
| 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
