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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.

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Question	Answer
Form Name	Ncpdp Billing Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	117
Avg. time to fill out	23 min 54 sec
Other names	universal claim form pharmacy, universal claim form, ncpdp claim format, ncpdp universal claim form

12

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
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 universal 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 universal 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 ncpdp claim format

Within the section EMPLOYER, CLAIM, COST, INGREDIENT, SUBMITTED, DISPENSING FEE, QU, AL DATE, WRITTEN CC, YY, MM, DD DATE, OF, SERVICE, CC, YY FILL, Q, TY, DISPENSED QU, AL DATE, WRITTEN CC, YY, MM, DD and DATE, OF, SERVICE, CC, YY write down the information that the application requires you to do.

ncpdp claim format EMPLOYER, CLAIM, COST, INGREDIENTSUBMITTEDDISPENSING, FEE, QUAL, DATEWRITTEN, CCYYMMDD, DATEOFSERVICECCYY, FILL, QTYDISPENSED, QUAL, DATEWRITTEN, CCYYMMDD, and DATEOFSERVICECCYY blanks to insert

The application will ask you to present certain significant info to effortlessly submit the segment DUR, PP, S, CODES BASIS, COST PROVIDE, RID OTHER, PAYER, DATE, MM, DD, CC, YY OTHER, PAYER, ID QU, AL QU, AL DIAGNOSIS, CODE OTHER, PAYER, REJECT, CODES QU, AL USUAL, CU, ST CHARGE, SUBMITTED, GROSS, and AMOUNT, DUE, SUBMITTED, PATIENT

part 3 to finishing ncpdp claim format

It is essential to define the rights and obligations of all parties in field Name, ND, C Quantity, and Cost.

ncpdp claim format Name, NDC, Quantity, and Cost blanks to fill

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.

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