Pharmacy staff should complete the fields on the form using the NCPDP standard values when applicable. Refer to the VDP website "Pharmacy Payer Sheets" page to review the values on the Claim Billing Transaction (B1) payer sheet.

Field Usage

Submission Explanation

Enter the type of claim submittal or adjustment and reason must be stated in the explanation line before the claim will be processed by HHSC.

Date Submitted

Enter the date the form is being submitted to HHSC.

Pharmacy Name

Enter the name of pharmacy.

NPI

Enter the 10-digit National Provider Identifier number.

Vendor ID

Enter the 6-digit vendor ID number.

Pharmacy Phone

Enter the pharmacy phone number (plus area code).

Pharmacy Fax

Enter the pharmacy fax number (plus area code).

Cardholder ID 

Enter person’s program-specific identification number.

• If the claim is for a newborn and no Cardholder ID number is available, this field should be left blank. Do not enter the mother’s ID number.

Date of Birth

Enter person’s date of birth.

Gender

Enter using standard NCPDP values.

Date of Service

Enter the date the prescription was filled.

Date RX Written

Enter the date prescription was written.

Product ID

Enter 11-digit National Drug Code.

Quantity Dispensed

Enter the quantity dispensed expressed in metric decimal units.

Units

Enter using standard NCPDP values.

Days Supply

Enter estimated duration of the prescription supply in days.  Refer to Maximum Days Supply By Program.

Quantity Prescribed

Enter quantity prescribed expressed in metric decimal units.

RX Number

Enter prescription/service reference number.

Prescription (Rx) Origin Code

Enter using standard NCPDP values.

Refill Authorization

Enter ØØ through 11.

Refill Number Enter “ØØ” to identify original prescription. 

 

Enter value between “01” and “11” to identify refill.

Dispense as Written

Enter “1” to override the MAC when a physician wants a brand name dispensed and hand writes the phrase "Brand Necessary," "Brand Medically Necessary," "Brand Name Necessary," or "Brand Name Medically Necessary" across the face of the prescription.

Prescriber ID Enter 10-digit Prescriber NPI.

Prior Authorization Type

Enter if prior authorization number submitted is transmitted.  Follow VDP-accepted values.

Prior Authorization Number

Enter if prior authorization type code is transmitted.  Follow VDP-accepted values.

Other Coverage Code

Required if Coordination of Benefits (COB) segment is submitted.  Enter using standard NCPDP values.

Usual and Customary Charge

Enter usual and customary cost (amount claimed for reimbursement).

Gross Amount Due

Enter gross amount due.

Patient Paid Amount Submitted

Not used.

Basis of Cost Determination

Enter using standard NCPDP values.

Submission Clarification Code Count

Enter using standard NCPDP values.

Submission Clarification Code

Enter using standard NCPDP values.  Repeating field.

Coverage Type

Enter using standard NCPDP values.

Other Payer ID Qualifier

Enter using standard NCPDP values.

Other Payer ID

Enter ID assigned to other payer.

Other Payer Date

Enter payment or rejection date of the claim submitted to other payer.

Other Payer Amount Paid Qualifier

Enter code qualifying the Other Payer Amount Paid.  Repeating field.

Other Payer Amount Paid

Amount of any payment known by the pharmacy from other sources.  Repeating field.

Other Payer Reject Code

Enter using standard NCPDP values.

Amount Paid

HHSC use only.

Paid Date HHSC use only.