Ncpdp Billing Form PDF Details

The Ncpdp billing form is a standardized billing form used by healthcare providers to submit claims to Medicare. The form was developed by the National Council for Prescription Drug Programs (ncpdp), and is used to bill for prescription drugs, as well as other services and items provided by healthcare providers. The ncpdp billing form can be used to bill Medicare Part B, Part D, and Medicare Advantage Plans. Learn more about the ncpdp billing form and how to use it in this article.

Below is the data relating to the form you were looking for to complete. It can show you the time it will need to finish ncpdp billing form, what fields you need to fill in, and so forth.

QuestionAnswer
Form NameNcpdp Billing Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespharmacy claim form, blank universal claim form, pharmacy universal claim form, ucf form

Form Preview Example

UCF Long Form (front)

 

 

 

GROUP

 

 

 

 

 

 

 

ID_____________________________________________

ID ___________________________________________________

 

 

 

 

 

 

 

 

 

PLAN

NAME _________________________________________________________________

NAME _______________________________________

PATIENT

 

 

 

OTHER

 

 

PERSON

 

 

 

 

 

 

 

COVERAGE

 

 

 

 

 

 

NAME _____________________________________________

CODE

 

 

________

CODE

(2)

________

(1)

PATIENT

 

 

 

PATIENT

 

 

PATIENT

 

 

 

 

 

(3)

(4)

DATE OF BIRTH ________

________

________

 

GENDER

CODE _________ RELATIONSHIP CODE ________

MM

DD

CCYY

 

 

 

 

 

 

 

 

 

 

 

PHARMACY

NAME _____________________________________________________________________________________________________

SERVICE

 

 

QUAL (5)

ADDRESS___________________________________________ PROVIDER ID ________________________________ _________

CITY _______________________________________________ PHONE NO. (

)

 

STATE & ZIP CODE ___________________________________ FAX NO.

(

)

 

FOR OFFICE

USE ONLY

WORKERS COMP. INFORMATION

EMPLOYER

NAME ____________________________________________

ADDRESS_________________________________________

I have hereby read the Certification Statement on the reverse side. I hereby certify to and accept the terms thereof. I also certify that I have received 1 or 2 (please circle number) prescription(s) listed below.

PATIENT /

AUTHORIZED REPRESENTATIVE

CITY _____________________________________________ STATE _____________ ZIP CODE _____________

CARRIER

 

 

 

 

EMPLOYER

ID

(6)

_________________________________________ PHONE NO._____________________________________

DATE OF

 

 

CLAIM

 

 

 

 

(7)

INJURY _______ _______ _______

REFERENCE ID _________________________________________________

 

 

MM

DD

CCYY

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

PRESCRIPTION / SERV. REF. #

 

QUAL.

 

 

DATE WRITTEN

DATE OF SERVICE

FILL #

 

QTY DISPENSED

 

 

 

 

 

DAYS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(9)

 

 

 

SUPPLY

 

(8)

MM

 

DD

CCYY

MM DD CCYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRODUCT / SERVICE ID

 

 

 

 

QUAL.

 

DAW

 

 

PRIOR AUTH #

PA TYPE

 

PRESCRIBER ID

 

QUAL.

 

 

 

 

 

 

 

 

 

(10)

 

 

CODE

 

 

SUBMITTED

 

(11)

 

 

 

 

 

(12)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DUR/PPS CODES

BASIS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUAL.

 

 

 

 

 

 

 

 

QUAL.

 

 

 

 

 

 

 

 

 

 

(13)

 

 

 

 

COST

 

 

 

 

 

PROVIDER ID

 

 

 

(15)

 

 

 

DIAGNOSIS CODE

 

 

(16)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(14)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER PAYER DATE

 

OTHER PAYER ID

 

 

 

 

QUAL.

 

 

 

OTHER PAYER REJECT CODES

 

USUAL & CUST.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM DD

 

 

 

CCYY

 

 

 

 

 

 

(17)

 

 

 

 

 

CHARGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

PRESCRIPTION / SERV. REF. #

 

QUAL.

 

 

DATE WRITTEN

DATE OF SERVICE

FILL #

 

QTY DISPENSED (9)

 

 

 

 

DAYS

 

 

 

(8)

 

MM

 

DD

CCYY

MM DD CCYY

 

 

 

 

SUPPLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRODUCT / SERVICE ID

 

 

 

 

QUAL.

 

DAW

 

 

PRIOR AUTH #

PA TYPE

PRESCRIBER ID

 

 

 

 

QUAL.

 

 

 

 

 

 

 

 

 

(10)

 

 

CODE

 

 

SUBMITTED

 

(11)

 

 

 

 

 

 

(12)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DUR/PPS CODES

BASIS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUAL.

 

 

 

 

 

 

 

 

 

QUAL.

 

 

 

 

 

 

COST

 

 

 

 

PROVIDER ID

 

 

 

DIAGNOSIS CODE

 

 

 

 

 

 

 

(13)

 

 

 

 

(14)

 

 

 

 

 

 

 

 

(15)

 

 

 

 

 

(16)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER PAYER DATE

 

OTHER PAYER ID

 

 

 

 

QUAL.

 

 

 

OTHER PAYER REJECT CODES

 

USUAL & CUST.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM DD

 

 

 

CCYY

 

 

 

 

 

 

(17)

 

 

 

 

 

CHARGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTENTION RECIPIENT

PLEASE READ

CERTIFICATION

STATEMENT ON

REVERSE SIDE

INGREDIENT

COST

SUBMITTED

DISPENSING

FEE

SUBMITTED

INCENTIVE

AMOUNT

SUBMITTED

OTHER

AMOUNT

SUBMITTED

SALES

TAX

SUBMITTED

GROSS

AMOUNT DUE

SUBMITTED

PATIENT

PAID

AMOUNT

OTHER PAYER

AMOUNT

PAID

NET

AMOUNT

DUE

INGREDIENT

COST

SUBMITTED

DISPENSING

FEE

SUBMITTED

INCENTIVE

AMOUNT

SUBMITTED

OTHER

AMOUNT

SUBMITTED

SALES

TAX

SUBMITTED

GROSS

AMOUNT DUE

SUBMITTED

PATIENT

PAID

AMOUNT

OTHER PAYER

AMOUNT

PAID

NET

AMOUNT

DUE

Blank=Not Specified
02-Health Related Item (HRI) 05=Department of Defense (DOD) 08=Common Procedure Terminology (CPT5)
11=National Pharmaceutical Product Interface Code (NAPPI) 99=Other
11. PRIOR AUTHORIZATION TYPE CODE 0=Not Specified
3=EPSDT (Early Periodic Screening Diagnosis Treatment) 6=Family Planning Indicator

UCF Long Form (back)

IMPORTANT I certify that the patient information entered on the front side of this form is correct, that the patient named is eligible for the benefits and that I have received the medication described. If this claim is for a workers compensation injury, the appropriate section on the front side has been completed. I hereby assign the provider pharmacy any payment due pursuant to this transaction and authorize payment directly to the provider pharmacy. I also authorize release of all information pertaining to this claim to the plan administrator, underwriter, sponsor, policyholder and the employer.

PLEASE SIGN CERTIFICATION ON FRONT SIDE FOR PRESCRIPTION(S) RECEIVED

INSTRUCTIONS

1.Fill in all applicable areas on the front of this form.

2.Enter COMPOUND RX in the Product Service ID area(s) and list each ingredient, name, NDC, quantity, and cost in the area below. Please use a separate claim form for each compound prescription.

3.Worker’s Comp. Information is conditional. It should be completed only for a Workers Comp. Claim.

4.Report diagnosis code and qualifier related to prescription (limit 1 per prescription).

5.Limit 1 set of DUR/PPS codes per claim.

DEFINITIONS / VALUES

1. OTHER COVERAGE CODE

0=Not Specified

1=No other coverage identified

2=Other coverage exists-payment collected

3=Other coverage exists-this claim not covered

4=Other coverage exists-payment not collected

5=Managed care plan denial

6=Other coverage denied-not a participating provider

7=Other coverage exists-not in effect at time of service

8=Claim is billing for a copay

2.PERSON CODE: Code assigned to a specific person within a family.

3.PATIENT GENDER CODE

0=Not Specified

1=Male

4. PATIENT RELATIONSHIP CODE

 

0=Not Specified

1=Cardholder

3=Child

4=Other

5. SERVICE PROVIDER ID QUALIFIER

 

Blank=Not Specified

01=National Provider Identifier (NPI)

03=Blue Shield

04=Medicare

06=UPIN

07=NCPDP Provider ID

09=Champus

10=Health Industry Number (HIN)

12=Drug Enforcement Administration (DEA)

13=State Issued

99=Other

 

6.CARRIER ID: Carrier code assigned in Worker’s Compensation Program.

7.CLAIM/REFERENCE ID: Identifies the claim number assigned by Worker’s Compensation Program.

8.PRESCRIPTION/SERVICE REFERENCE # QUALIFIER

Blank=Not Specified

1=Rx billing

9.QUANTITY DISPENSED: Quantity dispensed expressed in metric decimal units (shaded areas for decimal values).

10.PRODUCT/SERVICE ID QUALIFIER: Code qualifying the value in Product/Service ID (407-07)

00=Not Specified

03=National Drug Code (NDC)

06=Drug Use Review/Professional Pharm. Service (DUR/PPS) 09=HCFA Common Procedural Coding System (HCPCS) 12=International Article Numbering System (EAN)

1=Prior authorization 4=Exemption from copay

7=Aid to Families with Dependent Children (AFDC)

2=Female

2=Spouse

02=Blue Cross 05=Medicaid 08=State License 11=Federal Tax ID 14=Plan Specific

2=Service billing

01=Universal Product Code (UPC) 04=Universal Product Number (UPN) 07=Common Procedure Terminology (CPT4) 10=Pharmacy Practice Activity Classification (PPAC) 13=Drug Identification Number (DIN)

2=Medical Certification 5=Exemption from Rx limits

12.PRESCRIBER ID QUALIFIER: Use service provider ID values.

13.DUR/PROFESSIONAL SERVICE CODES: Reason for Service, Professional Service Code, and Result of Service. For values refer to current NCPDP data dictionary.

A=Reason for Service

B=Professional Service Code

C=Result of Service

14. BASIS OF COST DETERMINATION

 

 

Blank=Not Specified

00=Not Specified

01=AWP (Average Wholesale Price)

02=Local Wholesaler

03=Direct

04=EAC (Estimated Acquisition Cost)

05=Acquisition

06=MAC (Maximum Allowable Cost)

07=Usual & Customary

09=Other

 

 

15. PROVIDER ID QUALIFIER

 

 

Blank=Not Specified

01=Drug Enforcement Administration (DEA)

02=State License

03=Social Security Number (SSN)

04=Name

05=National Provider Identifier (NPI)

06=Health Industry Number (HIN)

07=State Issued

99=Other

16. DIAGNOSIS CODE QUALIFIER

Blank=Not Specified

00=Not Specified

02=International Classification of Diseases (ICD10)

03=National Criteria Care Institute (NDCC)

05=Common Dental Term (CDT)

06=Medi-Span Diagnosis Code

99=Other

 

01=International Classification of Diseases (ICD9)

04=Systemized Nomenclature of Human and Veterinary Medicine (SNOMED) 07=American Psychiatric Association Diagnostic Statistical Manual of Mental Disorders (DSM IV)

17. OTHER PAYER ID QUALIFIER

Blank=Not Specified

01=National Payer ID

02=Health Industry Number (HIN)

03=Bank Information Number (BIN)

04=National Association of Insurance Commissioners (NAIC)

09=Coupon

99=Other

 

 

COMPOUND PRESCRIPTIONS – LIMIT 1 COMPOUND PRESCRIPTION PER CLAIM FORM.

Name

NDC

Quantity

Cost

How to Edit Ncpdp Billing Form Online for Free

Filling out pharmacy claim form is not difficult. Our experts designed our software to really make it intuitive and allow you to fill in any form online. Listed here are steps you will want to take:

Step 1: On this website page, click the orange "Get form now" button.

Step 2: Once you access our pharmacy claim form editing page, you will see all the functions it is possible to take about your document in the top menu.

To get the template, provide the content the software will request you to for each of the appropriate segments:

part 1 to writing where to order universal claim forms

Within the section DATE OF INJURY REFERENCE ID MM, PRESCRIPTION SERV REF, QUAL, DATE WRITTEN, CCYY MM DD, DATE OF SERVICE CCYY, FILL, QTY DISPENSED, PRODUCT SERVICE ID, QUAL, DAW CODE, PRIOR AUTH SUBMITTED, PA TYPE, PRESCRIBER ID, and DURPPS CODES write down the information that the application requires you to do.

where to order universal claim forms DATE OF INJURY REFERENCE ID MM, PRESCRIPTION SERV REF, QUAL, DATE WRITTEN, CCYY MM DD, DATE OF SERVICE CCYY, FILL, QTY DISPENSED, PRODUCT SERVICE ID, QUAL, DAW CODE, PRIOR AUTH SUBMITTED, PA TYPE, PRESCRIBER ID, and DURPPS CODES blanks to insert

The application will ask you to present certain significant info to effortlessly submit the segment COMPOUND PRESCRIPTIONS LIMIT, Name, NDC, Quantity, and Cost.

part 3 to finishing where to order universal claim forms

Step 3: Press the button "Done". The PDF form is available to be transferred. You can download it to your computer or send it by email.

Step 4: Generate duplicates of the document. This should save you from potential future issues. We don't check or distribute the information you have, thus feel comfortable knowing it's going to be safe.

Watch Ncpdp Billing Form Video Instruction

Ncpdp Billing Form isn’t the one you’re looking for?

Related Documents

  • Ne Form 458

    "... Ne Form 458 ..."

  • Ncis 757

    "... 2006. National crop insurance services inc. crop hail insurance or 2006 ncis757 rev 10. 2006 multiple peril crops insurance Assignment of indemnity. Policy number. Insured name. Creditor name. Name of creditor. The creditor's mailing address. ..."

  • Ncnd Form

    "... The parties have agreed to an irrevocable, non-cancelable, non-circumvention and non-disclosure agreement. While the parties expect to enter into business transactions between themselves or with other parties, and while the parties acknowledge the intrinsic value ..."

  • Ncui 101 Form

    "... Nc Dept of Commerce Division of Employment Security Box 26504 Raleigh NC 27611 6504 Employer Quarterly Tax and Wage Report You can fill this report online at www.ncesc.com. Please enter the following information: quarter end ..."

Please rate Ncpdp Billing Form

1 Votes

Related Resources

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .