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.

FieldUsage
Submission ExplanationEnter 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 SubmittedEnter the date the form is being submitted to HHSC.
Pharmacy NameEnter the name of pharmacy.
NPIEnter the 10-digit National Provider Identifier number.
Vendor IDEnter the 6-digit vendor ID number.
Pharmacy PhoneEnter the pharmacy phone number (plus area code).
Pharmacy FaxEnter 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 BirthEnter person’s date of birth.
GenderEnter using standard NCPDP values.
Date of ServiceEnter the date the prescription was filled.
Date RX WrittenEnter the date prescription was written.
Product IDEnter 11-digit National Drug Code.
Quantity DispensedEnter the quantity dispensed expressed in metric decimal units.
UnitsEnter using standard NCPDP values.
Days SupplyEnter estimated duration of the prescription supply in days. Refer to Maximum Days Supply By Program.
Quantity PrescribedEnter quantity prescribed expressed in metric decimal units.
RX NumberEnter prescription/service reference number.
Prescription (Rx) Origin CodeEnter using standard NCPDP values.
Refill AuthorizationEnter 00 through 11.
Refill Number

Enter “00” to identify the original prescription. Enter value between “01” and “11” to identify a refill.

 

Dispense as WrittenEnter “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 IDEnter 10-digit Prescriber NPI.
Prior Authorization TypeEnter if prior authorization number submitted is transmitted. Follow VDP-accepted values.
Prior Authorization NumberEnter if prior authorization type code is transmitted. Follow VDP-accepted values.
Other Coverage CodeRequired if Coordination of Benefits (COB) segment is submitted. Enter using standard NCPDP values.
Usual and Customary ChargeEnter usual and customary cost (amount claimed for reimbursement).
Gross Amount DueEnter gross amount due.
Patient Paid Amount SubmittedNot used.
Basis of Cost DeterminationEnter using standard NCPDP values.
Submission Clarification Code CountEnter using standard NCPDP values.
Submission Clarification CodeEnter using standard NCPDP values. Repeating field.
Coverage TypeEnter using standard NCPDP values.
Other Payer ID QualifierEnter using standard NCPDP values.
Other Payer IDEnter ID assigned to other payer.
Other Payer DateEnter payment or rejection date of the claim submitted to other payer.
Other Payer Amount Paid QualifierEnter code qualifying the Other Payer Amount Paid. Repeating field.
Other Payer Amount PaidAmount of any payment known by the pharmacy from other sources. Repeating field.
Other Payer Reject CodeEnter using standard NCPDP values.
Amount PaidHHSC use only.
Paid DateHHSC use only.