As a business owner, you may be wondering what Form Mo 886 4405 is and how it affects your company. This form is used to report certain types of transactions, and it's important that you understand its purpose and how to complete it. In this blog post, we'll provide an overview of Form Mo 886 4405 and explain why it's important for businesses to file this form. We'll also offer tips on how tocomplete the form correctly. So if you're looking for information about Form Mo 886 4405, you've come to the right place!
| Question | Answer |
|---|---|
| Form Name | Form Mo 886 4405 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | NDC, DISPENSING, ADMIN, PROVIDER |
MISSOURI DEPARTMENT OF SOCIAL SERVICES |
RETURN TO: PHARMACY ADMIN |
MO HEALTHNET DIVISION |
MO HEALTHNET DIVISION |
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PO BOX 6500 |
REQUEST FOR BACKDATE
JEFFERSON CITY, MO
***THIS IS NOT A PHARMACY CLAIM FORM. ***
THERE MUST BE A DENIED CLAIM SUBMITTED TO MO HEALTHNET FOR THE REVIEW PROCESS TO BEGIN. ALL REQUIRED INFORMATION MUST BE SUPPLIED OR THE REQUEST CANNOT BE PROCESSED.
PHONE:
PLEASE CHECK ONE
Initial Request Duplicate Request
CURRENT DATE
PROVIDER NAME
MO HEALTHNET PROVIDER IDENTIFIER OR NPI
CONTACT NAME
TELEPHONE NUMBER
FAX NUMBER
CONTACT MAILING ADDRESS (INCLUDING CITY, STATE, AND ZIP)
PARTICIPENT NAME |
DCN |
DATE OF BIRTH |
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DATE OF SERVICE |
DRUG NAME/STRENGTH |
NDC |
PRESCRIPTION |
SUBMITTED CHARGE |
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NUMBER |
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DIAGNOSIS
PHYSICIAN DEA NO. OR MO HEALTHNET PROVIDER NO. OR NPI
NAME OF PRESCRIBING PHYSICIAN |
DATE DRUG WAS FIRST USED |
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LIST ALL OTHER RELATED MEDICATIONS PREVIOUSLY TRIED INCLUDING LENGTH AND DATES OF EACH
DETAILED EXPLANATION FOR WHY THE OVERRIDE WAS NOT OBTAINED PRIOR TO DISPENSING THE THERAPY
RECIPIENT NAME |
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DCN |
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DATE OF BIRTH |
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DATE OF SERVICE |
DRUG NAME/STRENGTH |
NDC |
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PRESCRIPTION NUMBER |
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SUBMITTED CHARGE |
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DIAGNOSIS |
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DATE DRUG WAS FIRST USED |
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NAME OF PRESCRIBING PHYSICIAN |
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PRESCRIPTION DEA NO. OR MO |
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HEALTHNET PROVIDER NO. |
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LIST ALL OTHER RELATED MEDICATIONS PREVIOUSLY TRIED INCLUDING LENGTH AND DATES OF EACH
DETAILED EXPLANATION FOR WHY THE OVERRIDE WAS NOT OBTAINED PRIOR TO DISPENSING THE THERAPY
MO