Pharmacy

Datasets

A pharmacy claim is one dispensing event from a retail, mail-order or specialty pharmacy, adjudicated in the NCPDP telecommunication format rather than on a paper form. CARIN Blue Button STU 2.1.0 profiles it twice: the financial profile with amounts for Patient Access, and its parent Basis profile without amounts for Provider Access and Payer-to-Payer. You deliver one pair of files.

Both files carry every column from Explanation of Benefit. This page lists what the pharmacy profile adds and where it tightens a shared rule. A pharmacy claim almost always has one line, the drug dispensed; the split into two files is kept so every claim type has the same shape.

claims_pharmacy

One row per pharmacy claim.

Prescription

The NCPDP fields the profile requires of every pharmacy claim. Each is a supportingInfo entry tagged with its C4BBSupportingInfoType category. Four of them are mandatory, which no other claim type asks of its supporting information.

• days_supply, daw_code, refill_number and refills_authorized are mandatory: CARIN requires all four on every pharmacy claim, so a row missing any of them is rejected. refill_number 0 is the original fill, not a missing value.
• compound_code decides what the line carries. 0 or 1: the line's service_code is the NDC dispensed. 2: the line's service_code is blank, and the ingredients travel in the line's compound columns.
• The NCPDP code sets are licensed, so their value sets are linked to the IG rather than expanded here. Send the codes as your adjudication system holds them.

Care team

Bound to C4BBClaimPharmacyTeamRole, which has two roles.

• billing_provider_npi from the shared columns is the pharmacy, an organization. The profile also allows a practitioner there for the rare individually enrolled dispenser.
• The prescriber is not the dispenser. Send the prescriber's NPI here even when the pharmacy is the billing provider; it is how a member sees who prescribed what.

Adjudication

• benefit_payment_status sits on the claim row, as on the institutional claims. Pharmacy has no claim-level adjustment reasons: a rejected claim carries its NCPDP reject code on the line.
• payment_date from the shared columns is must-support here. Send it whenever the claim was paid.
• No diagnosis columns. The pharmacy profile does not ask for diagnoses, and NCPDP claims rarely carry them.

Amounts

The shared amount columns on the claim row become the claim totals, which are mandatory: at least one must be filled. The pharmacy profile has no claim-level adjudication amounts; line amounts are mandatory, see below. drug_cost_amount is the ingredient cost and is the one category that exists for pharmacy claims first; send it separately from eligible_amount, which includes the dispensing fee.

Set by Payerbox

claims_pharmacy_lines

One row per dispensed product. In practice one per claim; a compound is still one line, with its ingredients listed on it.

• service_code is the NDC as your system holds it. Both the 11-digit form with hyphens (00093-1058-01) and without (00093105801) are in the value set; send one form consistently.
• A compound has no single NDC. Leave service_code blank, set compound_code 2 on the claim row, and list every ingredient with its quantity in the two compound columns; each becomes an item.detail under the line. A line with a blank service_code on a claim whose compound_code is not 2 is rejected.
• service_date_start overrides the shared "Recommended": the fill date is mandatory, and a single date. Leave service_date_end blank.
• reject_reason_code replaces the CARC and RARC adjustment reasons of the other claim types; the pharmacy profile allows one NCPDP reject code per line and no other reason. A rejected claim carries submitted_amount, 0.00 in benefit_amount, the rejected amount in noncovered_amount and the code here.
• At least one amount is mandatory on every line. drug_cost_amount belongs on the line as well as in the totals.

These resources are served by Patient Access with amounts, and by Provider Access and Payer-to-Payer without them.