In the comprehensive landscape of healthcare and pharmacy services, navigating the administrative processes can be a daunting task for both providers and patients. Amid these multifaceted procedures, the Universal Claim Form (UCF) stands out as a crucial tool designed to streamline the submission of pharmacy claims, especially for medications dispensed. From capturing essential patient information including their name, date of birth, and insurance coverage details, to the specifics about the prescribed medication—such as prescription number, date of service, quantity dispensed, and total cost—the UCF facilitates a cohesive platform for claims processing. Furthermore, it accommodates detailed information relevant to worker's compensation cases, making it versatile for varied claim scenarios. Also noteworthy is the form's structured layout that guides the provider through the certification of patient eligibility, prescription receipt, and the direct assignment of payments to the pharmacy, ensuring that privacy and accuracy are maintained. By consolidating these critical elements, the Universal Claim Form not only simplifies the claim submission process but also plays a pivotal role in ensuring the efficient delivery of pharmacy benefits and reimbursement, thus underscoring its significance in the healthcare industry’s operational framework.
| Question | Answer |
|---|---|
| Form Name | Universal Claim Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | universal claim form pdf, ncpdp universal claim, universal claim form download, universal claim form prescriptions |
1A4
(PERF)
CARDHOLDER
I.D.
CARDHOLDER
NAME L/F/MI
PATIENT
NAME L/F/MI
PATIENT
DATE OF BIRTH
MM
PHARMACY
NAME
ADDRESS
CITY
STATE & ZIP CODE
GROUP
I.D.
PLAN
NAME
OTHER |
PERSON |
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COVERAGE |
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CODE |
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PATIENT (3) |
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GENDER CODE |
RELATIONSHIP CODE |
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SERVICE |
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QUAL (5) |
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PROVIDER I.D. |
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PHONE NO. ( |
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FAX NO. |
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FOR OFFICE
USE ONLY
Copyright By NCPDP |
1842 - 1108 - 9227M |
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1A4 |
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UNIVERSAL |
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1977, 1979, 1983, 1987,1990, |
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WORKERS COMP. INFORMATION |
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EMPLOYER |
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I have hereby read the Certification Statement on the reverse side. I hereby certify to and accept the |
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NAME |
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terms thereof. I also certify that I have received 1 or 2 (please circle number) prescription(s) listed |
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below. |
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SPACES |
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PATIENT / |
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AUTHORIZED REPRESENTATIVE |
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CARRIER |
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EMPLOYER |
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ATTENTION RECIPIENT |
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PLEASE READ |
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APPROPRIATEINCOMPLETELY |
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I.D. |
(6) |
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PHONE NO. |
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CERTIFICATION |
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STATEMENT ON |
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DATE OF |
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CLAIM |
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INJURY |
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INGREDIENT |
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COST |
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SUBMITTED |
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DISPENSING |
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FEE |
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PRESCRIPTION / SERV. REF. # |
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DATE WRITTEN |
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DATE OF SERVICE |
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FILL# |
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QTY DISPENSED |
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SUPPLY |
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INCENTIVE |
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AMOUNT |
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PRODUCT / SERVICE I.D. |
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QUAL. |
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DAW |
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PRIOR AUTH # |
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PA TYPE |
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PRESCRIBER I.D. |
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QUAL. |
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SUBMITTED |
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(10) |
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CODE |
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SUBMITTED |
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(11) |
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(12) |
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SALES |
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|||
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|
|
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|
|
|
|
TAX |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|||
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
SUBMITTED |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
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|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
GROSS |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
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|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
AMOUNT DUE |
||
|
|
|
|
|
DUR/PPS CODES |
BASIS |
|
|
|
|
|
|
PROVIDER I.D. |
|
|
|
QUAL. |
|
|
|
|
DIAGNOSIS CODE |
|
|
QUAL. |
|
|
|
|
|
|
|
|
|
|
|
SUBMITTED |
|||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
(13) |
|
|
|
|
COST |
|
|
|
|
|
|
|
|
|
|
(15) |
|
|
|
|
|
|
|
|
(16) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(14) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PATIENT |
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
AND |
A |
|
|
B |
|
C |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PAID |
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
|
|
|
|
|||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
AMOUNT |
||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
OTHER PAYER |
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
AMOUNT |
||
|
|
|
NEATLY |
OTHER PAYER DATE |
|
OTHER PAYER I.D. |
|
QUAL. |
|
|
|
OTHER PAYER REJECT CODES |
|
|
USUAL & CUST. |
|
|
|
|
|
|
|
|
|
|
|
PAID |
|||||||||||||||||||||||||||||||||||||||||||||
|
|
|
(17) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
MM |
DD |
CCYY |
|
|
|
|
|
|
|
CHARGE |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
INGREDIENT |
||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
NET |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
AMOUNT |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
DUE |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
INFORMATION |
2 |
|
|
|
PRODUCT / SERVICE I.D. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PRESCRIBER I.D. |
2 |
|
|
COST |
|||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
SUBMITTED |
||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
DISPENSING |
|||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
FEE |
||
|
|
|
|
|
PRESCRIPTION / SERV. REF. # |
|
QUAL. |
|
|
|
|
DATE WRITTEN |
|
|
|
DATE OF SERVICE |
|
FILL# |
|
QTY DISPENSED |
(9) |
|
|
|
DAYS |
|
|
|
SUBMITTED |
|||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
(8) |
|
|
MM |
DD |
CCYY |
|
|
MM |
DD |
CCYY |
|
|
|
|
|
SUPPLY |
|
|
|
|
|
|
|
|||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
INCENTIVE |
|||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
AMOUNT |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
SUBMITTED |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
OTHER |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
AMOUNT |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
QUAL. |
|
DAW |
|
|
|
PRIOR AUTH # |
|
PA TYPE |
|
|
|
|
|
|
|
|
|
|
|
|
|
QUAL. |
|
|
|
|
SUBMITTED |
|||||||||||||||||||
|
|
|
ALL |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(10) |
|
|
CODE |
|
|
|
SUBMITTED |
|
|
(11) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(12) |
|
|
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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SALES |
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TAX |
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SUBMITTED |
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9227 |
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GROSS |
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AMOUNT DUE |
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DUR/PPS CODES |
BASIS |
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PROVIDER I.D. |
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QUAL. |
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DIAGNOSIS CODE |
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QUAL. |
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SUBMITTED |
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(13) |
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COST |
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(15) |
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(16) |
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(14) |
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PATIENT |
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|||
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A |
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B |
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C |
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PAID |
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AMOUNT |
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ORTYPE |
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OTHER PAYER |
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AMOUNT |
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OTHER PAYER DATE |
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OTHER PAYER I.D. |
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QUAL. |
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OTHER PAYER REJECT CODES |
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USUAL & CUST. |
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PAID |
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(17) |
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MM |
DD |
CCYY |
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CHARGE |
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NET |
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AMOUNT |
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DUE |
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CLAIM 2000 |
FORM (UCF) |
(PERF)
SCREENS: BOX 10%, TEXT 11%.
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 |
|
|
3=Other coverage |
4=Other coverage |
5=Managed care plan denial |
|
|
6=Other coverage |
7=Other coverage |
8=Claim is billing for a copay |
|
2. |
PERSON CODE: Code assigned to a specific person within a family. |
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|
|
3. |
PATIENT GENDER CODE |
|
|
|
|
0=Not Specified |
1=Male |
2=Female |
|
|
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|||
4. |
PATIENT RELATIONSHIP CODE |
|
|
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||
|
0=Not Specified |
1=Cardholder |
2=Spouse |
|
|
3=Child |
4=Other |
|
|
5. |
SERVICE PROVIDER ID QUALIFIER |
|
|
|
|
Blank=Not Specified |
01=National Provider Identifier (NPI) |
02=Blue Cross |
|
|
03=Blue Shield |
04=Medicare |
05=Medicaid |
|
|
06=UPIN |
07=NCPDP Provider ID |
08=State License |
|
|
09=Champus |
10=Health Industry Number (HIN) |
11=Federal Tax ID |
|
|
12=Drug Enforcement Administration (DEA) |
13=State Issued |
14=Plan Specific |
|
|
99=Other |
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|
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
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
Blank=Not Specified |
00=Not Specified |
02=Health Related Item (HRI) |
03=National Drug Code (NDC) |
05=Department of Defense (DOD) |
06=Drug Use Review/Professional Pharm. Service (DUR/PPS) |
08=Common Procedure Terminology (CPT5) |
09=HCFA Common Procedural Coding System (HCPCS) |
11=National Pharmaceutical Product Interface Code (NAPPI) |
12=International Article Numbering System (EAN) |
99=Other |
|
11. PRIOR AUTHORIZATION TYPE CODE
0=Not Specified |
1=Prior authorization |
3=EPSDT (Early Periodic Screening Diagnosis Treatment) |
4=Exemption from copay |
6=Family Planning Indicator |
7=Aid to Families with Dependent Children (AFDC) |
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 8=Payer Defined Exemption
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 ServiceB=Professional Service CodeC=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 |
01=International Classification of Diseases (ICD9) |
02=International Classification of Diseases (ICD10) |
03=National Criteria Care Institute (NDCC) |
04=Systemized Nomenclature of Human and Veterinary Medicine (SNOMED) |
05=Common Dental Term (CDT) |
07=American Psychiatric Association Diagnostic Statistical Manual of Mental Disorders (DSM IV) |
|
99=Other |
|
|
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. |
|
||
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Name |
|
NDC |
Quantity |
Cost |
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REGULAR BACKER, SCREEN 10%