Vyvanse Coupon – Fill Out and Use This PDF

The Vyvanse Coupon form, provided by Emdeon under the patient choice programs such as Therapy First and Therapy First Plus, is a document that facilitates the claim billing or claim re-billing process for pharmacies. It outlines specific details such as payer name, plan names, BIN, PCN, processor details, effective dates, and transaction codes along with supported transactions for billing, reversal, and re-bill processes. If you're looking to understand how to navigate the complexities of processing your prescription claims, click the button below to learn more about filling out the Vyvanse Coupon form.

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Vyvanse Coupon PDF Details

Navigating the complexities of prescription drug claims can often be an overwhelming process for both patients and healthcare providers. The Vyvanse Coupon Form, issued by Emdeon under the Patient Choice, Therapy First, and Therapy First Plus plans, seeks to simplify this process. Dated 10/17/2011 and effective as of 11/17/2011, this document outlines the precise requirements and procedures for claim billing and re-billing according to the NCPDP (National Council for Prescription Drug Programs) Telecommunication Standard version D.0. It specifies essential information such as the BIN (Bank Identification Number), PCN (Processor Control Number), and offers detailed guidelines on various transactions including Billing, Reversal, and Re-Bill. Each segment and field within the transaction is labeled as mandatory, required, or qualified, indicating when certain information must be submitted. Additionally, it addresses other essential details like patient information, prescription details, and insurance coverage specifics. Understanding this payer sheet can significantly streamline the pharmacy claim process, ensuring that both patients access their medications promptly and pharmacies are reimbursed correctly.

Question	Answer
Form Name	Vyvanse Coupon
Form Length	23 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	5 min 45 sec
Other names	vyvanse coupon 2020, emdeon therapy first plus, therapy first coupon, vyvanse coupon

Form Preview Example

Emdeon

PATIENT CHOICE / THERAPY FIRST / THERAPY FIRST PLUS

NCPDP vD.0 Payer Sheet

Claim Billing / Claim Re-bill

GENERAL INFORMATION

Payer Name: Patient Choice / Therapy First / Therapy First	Date: 10/17/2011
Plus
Plan Name/Group Name: Patient Choice	BIN: 004682	PCN: CN
Plan Name/Group Name: Therapy First	BIN: 004682	PCN: CN
Plan Name/Group Name: Therapy First Plus	BIN: 004682	PCN: CN
Processor: Emdeon
Effective as of: 11/17/2011	NCPDP Telecommunication Standard Version/Release #: D.0

NCPDP Data Dictionary Version Date: 9/2010	NCPDP External Code List Version Date: 9/2010

Contact/Information Source: 800-422-5604

Pharmacy Help Desk Info: 800-422-5604

Other versions supported: 5.1 Telecommunication Standard Supported until 12/31/2011. Refer to the 5.1 payer sheet.

OTHER TRANSACTIONS SUPPORTED

Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

Transaction Code	Transaction Name
B1	Billing Transaction
B2	Reversal Transaction
B3	Re-Bill Transaction

FIELD LEGEND FOR COLUMNS

Payer Usage	Value	Explanation	Payer
Column			Situation
			Column
MANDATORY	M	The Field is mandatory for the Segment in	No
		the designated Transaction.

REQUIRED	R	The Field has been designated with the	No
		situation of "Required" for the Segment in the
		designated Transaction.
QUALIFIED	RW	“Required when”. The situations designated	Yes
REQUIREMENT		have qualifications for usage ("Required if x",
		"Not required if y").

Fields that are not used in the Claim Billing/Claim Re-bill transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template.

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

CLAIM BILLING/CLAIM RE-BILL TRANSACTION

The following lists the segments and fields in a Claim Billing or Claim Re-bill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø.

Transaction Header Segment Questions			Check	Claim Billing/Claim Re-bill
				If Situational, Payer Situation
This Segment is always sent			X

		Transaction Header Segment				Claim Billing/Claim Re-bill
Field #		NCPDP Field Name	Value		Payer	Payer Situation
					Usage
	1Ø1-A1	BIN NUMBER	004682		M
	1Ø2-A2	VERSION/RELEASE NUMBER	DØ		M
	1Ø3-A3	TRANSACTION CODE	B1 OR B3		M
	1Ø4-A4	PROCESSOR CONTROL NUMBER	CN		M
	1Ø9-A9	TRANSACTION COUNT	1		M
	2Ø2-B2	SERVICE PROVIDER ID QUALIFIER	01 – NPI		M
	2Ø1-B1	SERVICE PROVIDER ID	NPI		M
	4Ø1-D1	DATE OF SERVICE			M
	11Ø-AK	SOFTWARE	ALL SPACES		M
		VENDOR/CERTIFICATION ID

Insurance Segment Questions			Check	Claim Billing/Claim Re-bill
				If Situational, Payer Situation
This Segment is always sent			X

		Insurance Segment					Claim Billing/Claim Re-bill
		Segment Identification (111-AM) =
		“Ø4”
Field #		NCPDP Field Name	Value		Payer		Payer Situation
					Usage
	3Ø2-C2	CARDHOLDER ID			M
	3Ø1-C1	GROUP ID			R	Imp Guide: Required if necessary for
						state/federal/regulatory agency programs.
						Required if needed for pharmacy claim
						processing and payment.

Patient Segment Questions			Check	Claim Billing/Claim Re-bill
				If Situational, Payer Situation
This Segment is always sent			X
This Segment is situational

		Patient Segment					Claim Billing/Claim Re-bill
		Segment Identification (111-AM) =
		“Ø1”
Field		NCPDP Field Name	Value		Payer		Payer Situation
					Usage
	3Ø4-C4	DATE OF BIRTH			R
	3Ø5-C5	PATIENT GENDER CODE			R
	31Ø-CA	PATIENT FIRST NAME			R	Imp Guide: Required when the patient has
						a first name.
	311-CB	PATIENT LAST NAME			R
	322-CM	PATIENT STREET ADDRESS			RW	Imp Guide: Optional.
						Payer Requirement: Required when
						available.

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			Patient Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			Segment Identification (111-AM) =
			“Ø1”
Field		NCPDP Field Name		Value	Payer		Payer Situation
					Usage
	323-CN		PATIENT CITY ADDRESS		RW	Imp Guide: Optional.
						Payer Requirement : Required when
						available.
	324-CO		PATIENT STATE /		RW	Imp Guide: Optional.
			PROVINCE ADDRESS
						Payer Requirement : Required when
						available.
	325-CP		PATIENT ZIP / POSTAL ZONE		RW	Imp Guide: Optional.
						Payer Requirement: Required when
						available.
	326-CQ		PATIENT PHONE NUMBER		RW	Imp Guide: Optional.
						Payer Requirement: Required when
						available.
	35Ø-HN		PATIENT E-MAIL ADDRESS		RW	Imp Guide: May be submitted for the
						receiver to relay patient health care
						communications via the Internet when
						provided by the patient.
						Payer Requirement: Required when
						available.

Claim Segment Questions			Check	Claim Billing/Claim Re-bill
				If Situational, Payer Situation
This Segment is always sent			X
This payer supports partial fills
This payer does not support partial fills			X

		Claim Segment					Claim Billing/Claim Re-bill
		Segment Identification (111-AM) =
		“Ø7”
Field #		NCPDP Field Name	Value		Payer		Payer Situation
					Usage
	455-EM	PRESCRIPTION/SERVICE	1 = Rx Billing		M		Imp Guide: For Transaction Code of
		REFERENCE NUMBER QUALIFIER					“B1”, in the Claim Segment, the
							Prescription/Service Reference Number
							Qualifier (455-EM) is “1” (Rx Billing).
	4Ø2-D2	PRESCRIPTION/SERVICE	up to 12 positions		M
		REFERENCE NUMBER
	436-E1	PRODUCT/SERVICE ID QUALIFIER	03 - NDC		M		00 if Compound Code (406-D6) = 2
	4Ø7-D7	PRODUCT/SERVICE ID	11 digit NDC		M		0 if Compound Code (406-D6) = 2
	442-E7	QUANTITY DISPENSED	Format 9(7)V999		R

	4Ø3-D3	FILL NUMBER	New = 00 (zeros must be		R
			sent)
	4Ø5-D5	DAYS SUPPLY			R
	4Ø6-D6	COMPOUND CODE	1 = Not a Compound		R	Refer to Compound Segment when
			2 = Compound			Compound Code (406-D6) = 2
	4Ø8-D8	DISPENSE AS WRITTEN			R
		(DAW)/PRODUCT SELECTION CODE
	414-DE	DATE PRESCRIPTION WRITTEN			R
	415-DF	NUMBER OF REFILLS AUTHORIZED			R	Imp Guide: Required if necessary for plan
						benefit administration.
		“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			Claim Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			Segment Identification (111-AM) =
			“Ø7”
Field #			NCPDP Field Name	Value	Payer		Payer Situation
					Usage
	419-DJ	PRESCRIPTION ORIGIN CODE			R	Imp Guide: Required if necessary for plan
						benefit administration.
	354-NX	SUBMISSION CLARIFICATION CODE		Maximum count of 3.	RW	Imp Guide: Required if Submission
		COUNT				Clarification Code (42Ø-DK) is used.
						Payer Requirement: Same as Imp Guide
	42Ø-DK	SUBMISSION CLARIFICATION CODE			RW	Imp Guide: Required if clarification is
						needed and value submitted is greater
						than zero (Ø).
						If the Date of Service (4Ø1-D1) contains
						the subsequent payer coverage date, the
						Submission Clarification Code (42Ø-DK)
						is required with value of “19” (Split Billing
						– indicates the quantity dispensed is the
						remainder billed to a subsequent payer
						when Medicare Part A expires. Used only
						in long-term care settings) for individual
						unit of use medications.
						Payer Requirement: Same as Imp Guide
	3Ø8-C8	OTHER COVERAGE CODE		0 = Not specified by patient	RW	Imp Guide: Required if needed by
				1 = No other coverage		receiver, to communicate a summation of
				3 = Other coverage exist –		other coverage information that has been
				claim not covered*		collected from other payers.
				8 = Claim is billing for patient
				financial responsibility		Required for Coordination of Benefits.
				only*
						Payer Requirement: Same as Imp Guide.
						*requires COB segment to be sent.
	461-EU	PRIOR AUTHORIZATION TYPE CODE		1 = Prior Authorization, if	RW	Imp Guide: Required if this field could
				applicable		result in different coverage, pricing, or
						patient financial responsibility.
						Payer Requirement: Same as Imp Guide
	462-EV	PRIOR AUTHORIZATION NUMBER		If applicable to Rx	RW	Imp Guide: Required if this field could
		SUBMITTED				result in different coverage, pricing, or
						patient financial responsibility.
						Payer Requirement: Same As Imp Guide
	995-E2	ROUTE OF ADMINISTRATION			RW	Imp Guide: Required if specified in trading
						partner agreement.
						Payer Requirement: When compound
						code (406-D6) = 2

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

Pricing Segment Questions			Check	Claim Billing/Claim Re-bill
				If Situational, Payer Situation
This Segment is always sent			X

		Pricing Segment				Claim Billing/Claim Re-bill

		Segment Identification (111-AM) =
		“11”
Field #		NCPDP Field Name	Value		Payer	Payer Situation
					Usage
	4Ø9-D9	INGREDIENT COST SUBMITTED			R
	412-DC	DISPENSING FEE SUBMITTED			R	Imp Guide: Required if its value has an
						effect on the Gross Amount Due (43Ø-
						DU) calculation.
	433-DX	PATIENT PAID AMOUNT SUBMITTED			R	Imp Guide: Required if this field could
						result in different coverage, pricing, or
						patient financial responsibility.
	438-E3	INCENTIVE AMOUNT SUBMITTED			RW	Imp Guide: Required if its value has an
						effect on the Gross Amount Due (43Ø-
						DU) calculation.
						Payer Requirement: Same as Imp Guide
	478-H7	OTHER AMOUNT CLAIMED	Maximum count of 3.		RW	Imp Guide: Required if Other Amount
		SUBMITTED COUNT				Claimed Submitted Qualifier (479-H8) is
						used.
						Payer Requirement: Same as Imp Guide
	479-H8	OTHER AMOUNT CLAIMED			RW	Imp Guide: Required if Other Amount
		SUBMITTED QUALIFIER				Claimed Submitted (48Ø-H9) is used.
						Payer Requirement: Same as Imp Guide
	48Ø-H9	OTHER AMOUNT CLAIMED			RW	Imp Guide: Required if its value has an
		SUBMITTED				effect on the Gross Amount Due (43Ø-
						DU) calculation.
						Payer Requirement: Same as Imp Guide
	481-HA	FLAT SALES TAX AMOUNT			RW	Imp Guide: Required if its value has an
		SUBMITTED				effect on the Gross Amount Due (43Ø-
						DU) calculation.
						Payer Requirement: Same as Imp Guide.
						If Sales Tax applies to State.
	482-GE	PERCENTAGE SALES TAX AMOUNT			RW	Imp Guide: Required if its value has an
		SUBMITTED				effect on the Gross Amount Due (43Ø-
						DU) calculation.
						Payer Requirement: Same as Imp Guide.
						If Sales Tax applies to State.
	483-HE	PERCENTAGE SALES TAX RATE			RW	Imp Guide: Required if Percentage Sales
		SUBMITTED				Tax Amount Submitted (482-GE) and
						Percentage Sales Tax Basis Submitted
						(484-JE) are used.
						Required if this field could result in
						different pricing.
						Required if needed to calculate
						Percentage Sales Tax Amount Paid (559-
						AX).
						Payer Requirement: Same as Imp Guide.
						If Sales Tax applies to State.

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			Pricing Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			Segment Identification (111-AM) =
			“11”
Field #		NCPDP Field Name		Value	Payer		Payer Situation
					Usage
	484-JE	PERCENTAGE SALES TAX BASIS			RW	Imp Guide: Required if Percentage Sales
		SUBMITTED				Tax Amount Submitted (482-GE) and
						Percentage Sales Tax Rate Submitted
						(483-HE) are used.
						Required if this field could result in
						different pricing.
						Required if needed to calculate
						Percentage Sales Tax Amount Paid (559-
						AX).
						Payer Requirement: Same as Imp Guide.
						If Sales Tax applies to State.
	426-DQ	USUAL AND CUSTOMARY CHARGE			R	Imp Guide: Required if needed per trading
						partner agreement.
	43Ø-DU	GROSS AMOUNT DUE			R
	423-DN	BASIS OF COST DETERMINATION			R	Imp Guide: Required if needed for
						receiver claim/encounter adjudication.

Prescriber Segment Questions				Check	Claim Billing/Claim Re-bill
					If Situational, Payer Situation
					If Situational, Payer Situation
This Segment is always sent				X
This Segment is situational

			Prescriber Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			Segment Identification (111-AM) =
			“Ø3”
Field #		NCPDP Field Name		Value		Payer	Payer Situation
						Usage
	466-EZ	PRESCRIBER ID QUALIFIER		01 – NPI		R	Imp Guide: Required if Prescriber ID (411-
				12 - DEA			DB) is used.
	411-DB	PRESCRIBER ID		NPI or DEA		R	Imp Guide: Required if this field could
							result in different coverage or patient
							financial responsibility.
							Required if necessary for
							state/federal/regulatory agency programs.
	427-DR	PRESCRIBER LAST NAME				RW	Imp Guide: Required when the Prescriber
							ID (411-DB) is not known.
							Required if needed for Prescriber ID (411-
							DB) validation/clarification.
							Payer Requirement: Required when
							submitting DEA
	364-2J	PRESCRIBER FIRST NAME				RW	Imp Guide: Required if needed to assist in
							identifying the prescriber.
							Required if necessary for
							state/federal/regulatory agency programs.
							Payer Requirement: Required when
							submitting DEA

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			Prescriber Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			Segment Identification (111-AM) =
			“Ø3”
Field #		NCPDP Field Name		Value	Payer		Payer Situation
					Usage
	365-2K	PRESCRIBER STREET ADDRESS			RW	Imp Guide: Required if needed to assist in
						identifying the prescriber.
						Required if necessary for
						state/federal/regulatory agency programs.
						Payer Requirement: Required when
						submitting DEA
	366-2M	PRESCRIBER CITY ADDRESS			RW	Imp Guide: Required if needed to assist in
						identifying the prescriber.
						Required if necessary for
						state/federal/regulatory agency programs.
						Payer Requirement: Required when
						submitting DEA
	367-2N	PRESCRIBER STATE/PROVINCE			RW	Imp Guide: Required if needed to assist in
		ADDRESS				identifying the prescriber.
						Required if necessary for
						state/federal/regulatory agency programs.
						Payer Requirement: Required when
						submitting DEA
	368-2P	PRESCRIBER ZIP/POSTAL ZONE			RW	Imp Guide: Required if needed to assist in
						identifying the prescriber.
						Required if necessary for
						state/federal/regulatory agency programs.
						Payer Requirement: Required when
						submitting DEA

Coordination of Benefits/Other Payments			Check	Claim Billing/Claim Re-bill
Segment Questions				If Situational, Payer Situation
This Segment is always sent
This Segment is situational			X	Required	only for secondary, tertiary, etc claims.			Other	Coverage
				Code (308-C8) = 3 or 8.

Scenario 2 - Other Payer-Patient Responsibility			X	Required	only for secondary, tertiary, etc claims.			Other	Coverage
Amount Repetitions and Benefit Stage Repetitions				Code (308-C8) = 3 or 8.
Only

		Coordination of Benefits/Other					Claim Billing/Claim Re-bill
		Payments Segment
		Segment Identification (111-AM) =					Scenario 2- Other Payer-Patient
		“Ø5”					Responsibility Amount Repetitions and
							Benefit Stage Repetitions Only
Field #		NCPDP Field Name	Value			Payer	Payer Situation
						Usage
	337-4C	COORDINATION OF	Maximum count of 9.			M
		BENEFITS/OTHER PAYMENTS
		COUNT
	338-5C	OTHER PAYER COVERAGE TYPE				M
	339-6C	OTHER PAYER ID QUALIFIER	03 - BIN			R	Imp Guide: Required if Other Payer ID
							(34Ø-7C) is used.
		“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

Coordination of Benefits/Other

Claim Billing/Claim Re-bill

Payments Segment

Segment Identification (111-AM) =

Scenario 2- Other Payer-Patient

“Ø5”

Responsibility Amount Repetitions and

Benefit Stage Repetitions Only

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

34Ø-7C

OTHER PAYER ID

BIN

Imp Guide: Required if identification of the

Other Payer is necessary for

claim/encounter adjudication.

471-5E

OTHER PAYER REJECT COUNT

Maximum count of 5.

Imp Guide: Required if Other Payer Reject

Code (472-6E) is used.

Payer Requirement: Same as Imp Guide

472-6E

OTHER PAYER REJECT CODE

Imp Guide: Required when the other

payer has denied the payment for the

billing, designated with Other Coverage

Code (3Ø8-C8) = 3 (Other Coverage

Billed – claim not covered).

Payer Requirement: Same as Imp Guide

353-NR

OTHER PAYER-PATIENT

Maximum count of 25.

Imp Guide: Required if Other Payer-

RESPONSIBILITY AMOUNT COUNT

Patient Responsibility Amount Qualifier

(351-NP) is used.

Payer Requirement: Same as Imp Guide

351-NP

OTHER PAYER-PATIENT

Imp Guide: Required if Other Payer-

RESPONSIBILITY AMOUNT

Patient Responsibility Amount (352-NQ) is

QUALIFIER

used.

Payer Requirement: Same as Imp Guide

352-NQ

OTHER PAYER-PATIENT

Imp Guide: Required if necessary for

RESPONSIBILITY AMOUNT

patient financial responsibility only billing.

Required if necessary for

state/federal/regulatory agency programs.

Not used for non-governmental agency

programs if Other Payer Amount Paid

(431-DV) is submitted.

Payer Requirement: Same as Imp Guide

DUR/PPS Segment Questions

Check

Claim Billing/Claim Re-bill

If Situational, Payer Situation

This Segment is always sent

This Segment is situational

for use to define professional service or override clinical edits

DUR/PPS Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“Ø8”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

473-7E

DUR/PPS CODE COUNTER

Maximum of 9 occurrences.

Imp Guide: Required if DUR/PPS

Segment is used.

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			DUR/PPS Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			Segment Identification (111-AM) =
			“Ø8”
Field #		NCPDP Field Name		Value	Payer		Payer Situation
					Usage
	439-E4	REASON FOR SERVICE CODE			R	Imp Guide: Required if this field could
						result in different coverage, pricing,
						patient financial responsibility, and/or drug
						utilization review outcome.
						Required if this field affects payment for or
						documentation of professional pharmacy
						service.
	44Ø-E5	PROFESSIONAL SERVICE CODE			R	Imp Guide: Required if this field could
						result in different coverage, pricing,
						patient financial responsibility, and/or drug
						utilization review outcome.
						Required if this field affects payment for or
						documentation of professional pharmacy
						service.
	441-E6	RESULT OF SERVICE CODE			R	Imp Guide: Required if this field could
						result in different coverage, pricing,
						patient financial responsibility, and/or drug
						utilization review outcome.
						Required if this field affects payment for or
						documentation of professional pharmacy
						service.
	474-8E	DUR/PPS LEVEL OF EFFORT			R	Imp Guide: Required if this field could
						result in different coverage, pricing,
						patient financial responsibility, and/or drug
						utilization review outcome.
						Required if this field affects payment for or
						documentation of professional pharmacy
						service.
	475-J9	DUR CO-AGENT ID QUALIFIER			R	Imp Guide: Required if DUR Co-Agent ID
						(476-H6) is used.
	476-H6	DUR CO-AGENT ID			R	Imp Guide: Required if this field could
						result in different coverage, pricing,
						patient financial responsibility, and/or drug
						utilization review outcome.
						Required if this field affects payment for or
						documentation of professional pharmacy
						service.

Compound Segment Questions

Check

Claim Billing/Claim Re-bill

If Situational, Payer Situation

This Segment is always sent

This Segment is situational

required when Compound Code (406-D6) = 2

Compound Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“1Ø”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

45Ø-EF

COMPOUND DOSAGE FORM

DESCRIPTION CODE

451-EG

COMPOUND DISPENSING UNIT

FORM INDICATOR

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

447-EC	COMPOUND INGREDIENT	Maximum 25 ingredients	M
	COMPONENT COUNT
488-RE	COMPOUND PRODUCT ID	03 - NDC	M
	QUALIFIER
489-TE	COMPOUND PRODUCT ID	11 digit NDC	M
448-ED	COMPOUND INGREDIENT QUANTITY		M
449-EE	COMPOUND INGREDIENT DRUG		R	Imp Guide: Required if needed for
	COST			receiver claim determination when
				multiple products are billed.
49Ø-UE	COMPOUND INGREDIENT BASIS OF		R	Imp Guide: Required if needed for
	COST DETERMINATION			receiver claim determination when
				multiple products are billed.

	End of Request Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

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Prepare the emdeon therapy first plus PDF by entering the data needed for each section.

Fill out the PERCENTAGE SALES TAX AMOUNT, PERCENTAGE SALES TAX RATE SUBMITTED, Payer Requirement Same as Imp, Payer Requirement Same as Imp, Required if this field could, Required if needed to calculate, Payer Requirement Same as Imp, and Materials Reproduced With the field with all the details required by the system.

Put together the significant particulars in the Pricing Segment Segment, Value, Field, PERCENTAGE SALES TAX BASIS, USUAL AND CUSTOMARY CHARGE, ØDU DN, GROSS AMOUNT DUE BASIS OF COST, Payer Situation, Imp Guide Required if Percentage, Required if this field could, Required if needed to calculate, Payer Requirement Same as Imp, Imp Guide Required if needed for, Payer Usage RW, and R R segment.

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The This Segment is always sent This, Prescriber Segment Segment, Field, PRESCRIBER ID QUALIFIER, PRESCRIBER ID, Value, NPI DEA NPI or DEA, PRESCRIBER LAST NAME, Claim BillingClaim Rebill, Payer Usage R, Payer Situation, Imp Guide Required if Prescriber, Required if necessary for, Required if needed for Prescriber, and Payer Requirement Required when box is the place to include the rights and obligations of all parties.

Look at the areas PRESCRIBER FIRST NAME, Payer Requirement Required when, Required if necessary for, Payer Requirement Required when, Materials Reproduced With the, and Patient Choice Therapy First and next fill them in.

vyvanse coupon 2020 PRESCRIBER FIRST NAME, Payer Requirement Required when, Required if necessary for, Payer Requirement Required when, Materials Reproduced With the, and Patient Choice Therapy First blanks to insert

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