Pharmacy Claims Billing Request
This is the only acceptable paper form. Paper claim submission is permissible for the following cases:
- Newborns when a Medicaid cardholder ID number has yet to be issued.
- Special circumstances as defined by HHSC (e.g., natural disasters).
All other types of paper forms, and any form submitted for an unapproved reason, are not accepted and will be returned with no action taken. The “Submission Explanation” field is required and identifies why the form is being submitted. Pharmacy providers must sign and date the form prior to submitting to HHSC by mail. The form is kept for five years after the end of the federal fiscal year in which the pharmacy provider submits the form.
Refer to the mailing address in the VDP Correspondence section to submit the form.
Instructions
Pharmacy providers must complete the fields on the form using the NCPDP standard values when applicable. Refer to the Claims Billing (B1) Transaction for specific transaction, segment, and field requirements.
| 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 00 through 11. |
| Refill Number | Enter “00” to identify the original prescription. Enter value between “01” and “11” to identify a 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. |