DOXIL Revised 1500 Sample Claim Form ® x 1. Note ] Payers’ policies regarding use of the 10-digit NDC format (59676-960-01) or the 11-digit format (59676-0960-01) may vary. Consult your payers or DOXILine at 1-800-609-1083 to obtain specific coding guidance. 000-00-1234 Doe, John B. 07 01 30 Doe, John B. X x 3914 Spruce Street Anytown 3914 Spruce Street Anytown AS 203 555-1234 01010 203 555-1234 01010 AS 2. Note ] Some payers may ask providers to specify name, dosage strength, NDC, and method of administration. Payer requirements vary. Note: Some payers require alternate product codes. Contact DOXILine at 1-800-609-1083 to confirm payer-specific coding requirements. Signature on file 3. Note ] Indicate diagnosis using the appropriate ICD-9-CM code. 10 01 2013 4. Note ] Indicate appropriate CPT and HCPCS codes and modifiers if required. Be sure to enter the correct CPT codes by payer. The HCPCS code for DOXIL is Q2050. From January 1, 2013 to June 30, 2013, use J9002. From July 1December 31, 2012, use Q2048. Consult your local payers for coding policy. Please contact DOXILine at 1-800-609-1083 to confirm payer requirements. 3 454 10 03 2013 8a 1 2 7. Item 24F ] Use of the Q2050 code to indicate a 10 mg unit of DOXIL may refer to either the 20 mg or 50 mg dosage depending on the NDC. Consult your payers or DOXILine at 1-800-609-1083 to obtain specific coding guidance. 9 XXX.XX 5 4 6 8b N45967696001 ME10 10 03 13 10 03 13 11 Q2050 A XXX XX XX 10 03 13 11 96413 A XXX XX XX 7 13 6. Item 24E ] Indicate $ charges. Note: When DOXIL is delivered to providers by specialty pharmacies or brought to the office by the patient, enter “$00.00” or “$00.01,” with respect to Q2050, depending upon payer claims processing system requirements. Signature on file 431 10 03 5. Note ] Refer to the diagnosis for this service (see Item 21). 0B 0B Z1234567890 123-456-7890 Z1234567890 123-456-7890 8a-d. Items 17b, 24J, 32a, 33a ] For proper use of the NPI, please refer to the CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing, Chapter 26; available at www.cms.hhs.gov/manuals. How Supplied DOXIL 20 mg vial - NDC 59676-960-01 50 mg vial - NDC 59676-960-02 94-1234567 John Jones, MD X 123456 X 10/3/13 XXXX.XX XX.XX 800 888-8888 John Jones, MD 123 Park Avenue AnyTown, CA 99999 8d 0BZ1234567890 1234567890 Please click here to read the full Prescribing Information, including Boxed WARNINGS, for DOXIL®. The information provided on this form is not a guarantee of reimbursement or coverage. The health care professional or prescribing physician is responsible for determining and recording the patient's accurate diagnosis and for providing health-related information. www.janssenaccessone.com/pages/doxil/index.jsp Janssen Products, LP 10/13 006009-131107