Vyvanse Coupon PDF Details

If you are prescribed Vyvanse for ADHD, there is a coupon form that can help you save on your prescription. This helpful form provides discounts on the medication so that it is more affordable. By taking advantage of this coupon, you could potentially save hundreds of dollars on your prescription each year. Be sure to check with your insurance company to see if they will cover the cost of the medication before using the coupon. If you have any questions about how to use the Vyvanse Coupon Form, be sure to speak with your doctor or pharmacist. They can help guide you through the process and answer any questions you may have.

Below is the data regarding the file you were seeking to fill in. It will show you the time it should take to complete vyvanse coupon, what parts you will have to fill in and a few other specific facts.

QuestionAnswer
Form NameVyvanse Coupon
Form Length23 pages
Fillable?Yes
Fillable fields24
Avg. time to fill out10 min 33 sec
Other namestherapy first card, therapy first discount card, online coupon, emdeon therapy first plus

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

1

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

 

 

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

2

 

 

 

Patient Segment

 

 

 

 

Claim Billing/Claim Re-bill

 

 

 

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

3

 

 

 

Claim Segment

 

 

 

 

Claim Billing/Claim Re-bill

 

 

 

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

4

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

5

 

 

 

Pricing Segment

 

 

 

 

Claim Billing/Claim Re-bill

 

 

 

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

 

 

 

 

 

 

 

 

 

This Segment is always sent

 

X

 

 

 

 

 

This Segment is situational

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prescriber Segment

 

 

 

 

 

 

Claim Billing/Claim Re-bill

 

 

 

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

6

 

 

 

Prescriber Segment

 

 

 

 

Claim Billing/Claim Re-bill

 

 

 

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

7

 

 

 

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

 

 

R

 

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.

RW

 

Imp Guide: Required if Other Payer Reject

 

 

 

 

 

 

 

 

 

 

 

 

Code (472-6E) is used.

 

 

 

 

 

 

 

 

 

 

 

 

Payer Requirement: Same as Imp Guide

 

472-6E

OTHER PAYER REJECT CODE

 

 

 

 

 

RW

 

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.

RW

 

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

 

 

 

 

 

RW

 

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

 

 

 

 

 

RW

 

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

 

 

 

X

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.

R

 

Imp Guide: Required if DUR/PPS

 

 

 

 

 

 

 

 

 

 

 

 

Segment 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

8

 

 

 

DUR/PPS Segment

 

 

 

 

 

Claim Billing/Claim Re-bill

 

 

 

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

 

 

 

 

X

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

 

 

 

 

 

M

 

 

 

 

DESCRIPTION CODE

 

 

 

 

 

 

 

 

 

451-EG

 

COMPOUND DISPENSING UNIT

 

 

 

 

 

M

 

 

 

 

FORM INDICATOR

 

 

 

 

 

 

 

 

“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

9

 

 

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

©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

10

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