Texas Medicaid/CHIP Vendor Drug Program Pharmacy Claims Billing Request About The Pharmacy Claims Billing Request (Form 3700) is the only acceptable method to submit paper claims to the Medicaid/CHIP Vendor Drug Program. Paper submission is only allowed for certain state-approved situations (e.g. natural disasters) as defined in the Texas Pharmacy Provider Procedure Manual. All other types of paper forms, and Billing Request Forms submitted for unapproved reasons, are not accepted and will be returned with no action taken. The reason for the claim submittal or adjustment must be stated on the face of the form before the claim will be processed. Form 3700 is kept for five years after the end of the federal fiscal year in which the provider sends the form. Instructions Please refer to payer specification documents at TxVendorDrug.com/downloads/ for specific field instructions. For clients enrolled in Fee-For-Service Medicaid, CSHCN, KHC, and TWHP only. Forms must be signed and dated prior to submission. Return the form: By mail: Texas Health and Human Services Commission Medicaid/CHIP Vendor Drug Program (2250) 4900 North Lamar Blvd. Austin, TX 78751 Rev. 10/2014 File: vdp_ecm_pcbrq Page 1 of 2 www.TxVendorDrug.com Texas Medicaid/CHIP Vendor Drug Program Pharmacy Claims Billing Request Field Cardholder ID Date of Birth Patient Location Gender Pregnancy Indicator Date of Service Date RX Written Product ID Quantity Dispensed Units Days Supply Quantity Prescribed RX Number Prescription (Rx) Origin Code Refill Authorization Refill Number Dispense as Written Prescriber ID Prescriber Name Prior Authorization Type Prior Authorization Number Usual and Customary Charge Gross Amount Due Patient Paid Amount Submitted Basis of Cost Determination Submission Clarification Code Explanation Amount Paid Other Coverage Code Coverage Type ID Qualifier Other Payer ID Other Payer Date Amount Paid Qualifier Amount Paid Reject Code Signature Rev. 10/2014 File: vdp_ecm_pcbrq Usage Client identification number. If claim is for a Newborn and no ID# is available, this field should be left blank. Do not enter the Mother’s ID number. Client’s date of birth. Optional Follow NCPDP Standard (refer to TxVendorDrug.com/downloads/). Follow NCPDP Standard. Date the prescription was filled. Date prescription was written. 11-digit National Drug Code Quantity dispensed expressed in metric decimal units. Follow NCPDP Standard. Estimated duration of the prescription supply in days. This field may not exceed 185 for Medicaid and CSHCN. Days supply for KHC is limited to 34. Quantity prescribed expressed in metric decimal units. Prescription/service reference number. Follow NCPDP Standard. Enter ØØ through 11. A value of ØØ is used to indicate an original prescription. Any other value of 1-1Ø indicates a refill prescription. Enter “1” to override the MAC when a physician wants a brand name dispensed and hand writes the phrase "Brand Necessary," "Brand Medically Necessary," "Brand Name Necessary," or "Brand Name Medically Necessary" across the face of the prescription. 10-digit Prescriber National Provider Identifier (NPI). Enter first two letters of Prescriber’s last name. Required if Prior Authorization Number Submitted is transmitted. Follow VDP Accepted Values (refer to TxVendorDrug.com/downloads/). Required if Prior Authorization Type Code is transmitted. Follow VDP Accepted Values. Usual and customary (amount claimed for reimbursement). Used to reflect Usual & Customary price less discount or special price. Pharmacy providers who are required to bill actual invoice cost plus fee also can use it. For future use. Follow NCPDP Standard. Follow NCPDP Standard. The type of claim submittal or adjustment and reason must be stated in the explanation line before the claim can be processed. HHSC use only Required if Coordination of Benefits (COB) segment is submitted. Follow NCPDP Standard. Follow NCPDP Standard. Follow NCPDP Standard. ID assigned to the payer. Payment or denial date of the claim submitted to the other payer. Code qualifying the Other Payer Amount Paid. Amount of any payment known by the pharmacy from other sources. The error encountered by the previous Other Payer in Reject Code. The provider or authorized representative signs in ink after completing the form. Page 2 of 2 www.TxVendorDrug.com TEXAS HEALTH & HUMAN SERVICES COMMISSION PHARMACY CLAIM BILLING REQUEST - FORM 3700 Pharmacy Name Pharmacy Address (Street/P.O. Box, City, State & ZIP) Service Provider ID (10-digit NPI) Vendor ID (6 digit) Date Submitted Date of Birth Loc. Gender Unit Days Supply Revised 10 / 2014 Cardholder ID Product ID (11 digits) Refill Auth. Refiill Nmbr. Gross Amount Due Quantity Dispensed DAW Prescriber ID (NPI) Patient Paid Amount Prescriber Name Basis of Cost Pregnancy Date of Service Quantity Prescribed PA Type PA Number Sub.Clar.Cd. HHSC USE ONLY Date RX Written RX Number Rx Origin U & C Amount Amount PD Explanation (Required) Coordination of Benefits 1. Other Payer Coverage Type ID Qualifier Other Coverage Code ID Date Other Payer Rejects Coverage Type Amount Paid Qualifier Amount Paid Amount Paid Qualifier Amount Paid Amount Paid Qualifier Amount Paid Amount Paid Qualifier Amount Paid ID Qualifier ID Date Reject Codes ID Qualifier ID Date Amount Paid Qualifier Amount Paid Amount Paid Qualifier Amount Paid Amount Paid Qualifier Amount Paid Amount Paid Qualifier Amount Paid 2. Other Payer Coverage Type Other Payer Rejects Coverage Type ID Qualifier ID Date Reject Codes ID Qualifier ID Date Amount Paid Qualifier Amount Paid Amount Paid Qualifier Amount Paid Amount Paid Qualifier Amount Paid Amount Paid Qualifier Amount Paid 3. Other Payer Coverage Type Other Payer Rejects Coverage Type MAIL TO ID Qualifier ID MEDCIAID/CHIP VENDOR DRUG PROGRAM (2250) HEALTH AND HUMAN SERVICES COMMISSION 4900 NORTH LAMAR BLVD. AUSTIN, TEXAS 78751 Date Reject Codes Signature (Vendor or Authorized Representative) PHONE TxVendorDrug.com/about/contact.shtml FAX
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