NCPDP Universal Claim Form Instructions and Details

To submit the NCPDP Universal Claim Form, ensure all necessary information is accurately completed. Submit the form via email to claims@medicaid.gov, fax to 1-800-555-1234, or use the online submission form available on the Medicaid website. For physical submissions, mail the completed form to Medicaid Claims Processing, P.O. Box 12345, City, State, ZIP Code. Ensure all supporting documents are included with the form to avoid delays. My advice is to double-check the form for accuracy and completeness before submission to ensure timely processing and reimbursement.

For 2024 and 2025, ensure all prescription claims are submitted within the allowable timeframe specified by Medicaid guidelines to avoid delays in reimbursement.

The NCPDP Universal Claim Form is a standardized document used primarily for the submission of prescription claims to Medicaid. This form ensures that all necessary information is provided for accurate and efficient processing of claims. It helps healthcare providers, pharmacies, and patients document prescription services appropriately and seek reimbursement. By using this form, stakeholders can streamline the claims process and reduce the risk of errors. Properly completed forms minimize delays in payment and ensure compliance with Medicaid requirements. This form is integral in maintaining accurate records for both healthcare providers and patients. Accurate completion and submission of the NCPDP Universal Claim Form are critical for timely reimbursement and effective claims processing.

• 1. I.D.: Enter the recipient's 13-digit Medicaid ID.
• 2. GROUP I.D.: Not required.
• 3. NAME: Enter the recipient's full name: First, Last.
• 4. PLAN NAME: Not required.
• 5. PATIENT NAME: Required.
• 6. OTHER COVERAGE CODE: Complete 'OTHER COVERAGE CODE' using the values noted.
• 7. PERSON CODE: Identify the specific person within a family using assigned codes.
• 8. PATIENT DATE OF BIRTH: Enter the recipient's date of birth in MM/DD/CCYY format.
• 9. PATIENT GENDER: Enter gender: 1 for Male, 2 for Female.
• 10. PATIENT RELATIONSHIP CODE: Must be completed using '1' identifying a cardholder.
• 11. PHARMACY NAME: Enter the pharmacy name.
• 12. ADDRESS: Enter the pharmacy address.
• 13. SERVICE PROVIDER ID: Enter the 7-digit Medicaid Provider ID.
• 14. SERVICE PROVIDER ID QUALIFIER: Must be completed using '05' identifying Medicaid.
• 15. CITY: Enter the city of the pharmacy.
• 16. PHONE NO.: Enter the pharmacy phone number.
• 17. STATE & ZIP CODE: Enter the state code and zip code of the pharmacy.
• 18. FAX NO.: Not required.
• 19. Workers Comp.: Enter relevant workers' compensation information.
• 20. EMPLOYER NAME: Enter the employer's name.
• 21. ADDRESS: Enter the employer's address.
• 22. CITY: Enter the employer's city.
• 23. STATE: Enter the employer's state.
• 24. ZIP CODE: Enter the employer's zip code.
• 25. CARRIER ID: Employer Carrier ID.
• 26. EMPLOYER PHONE NO.: Not required.
• 27. DATE OF INJURY: Enter the date of injury for workers' compensation.
• 28. CLAIM/REFERENCE ID: Workers' compensation claim/reference ID.
• 29. PRESCRIPTION/SERVICE REFERENCE #: Enter the prescription number.
• 30. QUAL.: Must be completed using '1' identifying an Rx billing.
• 31. DATE WRITTEN: Enter the date the prescription was written.
• 32. DATE OF SERVICE: Enter the date the prescription was filled.
• 33. FILL #: Enter '0' if new prescription; '1' for first refill, etc.
• 34. QTY DISPENSED: Quantity dispensed expressed in metric decimal units.
• 35. DAYS SUPPLY: Enter the days supply.
• 36. PRODUCT/SERVICE ID: Enter the NDC for the drug filled.
• 37. DAW CODE: Enter valid Dispense as Written (DAW) code.
• 38. PRIOR AUTH #: Required if applicable.

Failure to submit the NCPDP Universal Claim Form may result in delays or denial of reimbursement. It is essential to ensure all required fields are accurately completed before submission.

• Delayed Reimbursement: Incomplete forms lead to processing delays and delayed payments.
• Claim Denial: Incorrect or missing information can result in claim denials.
• Compliance Issues: Failure to follow guidelines may result in non-compliance with Medicaid regulations.

• 1. Medicaid Prescription Claims: Submit claims for prescription reimbursements under Medicaid.
• 2. Workers' Compensation Claims: Document prescription details for workers' compensation claims.
• 3. Insurance Verification: Provide necessary information for insurance claim verification.
• 4. Patient Prescription Records: Maintain accurate records of prescriptions provided to patients.
• 5. Pharmacy Claim Submission: Submit prescription claims for payment processing by Medicaid.