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Florida D.0. Payer Specification NCPDP Version D Claim Billing/Claim Re-bill Template Request Claim Billing/Claim Re-bill Payer Sheet Template **Start of Request Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template**
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Document Date: 2011-11-08 16:11:24

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File Size: 887,49 KB

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City

PATIENT / /

Company

Magellan Medicaid Administration Inc. / First DataBank / /

Facility

Nursing Facility / Hospice 12=Psychiatric Residential Treatment Facility 13=Comprehensive Inpatient Rehabilitation Facility 14=Homeless Shelter / Pharmacy Imp Guide / Partial Hospitalization 9=Intermediate Care Facility/Mentally Retarded 1Ø=Residential Substance Abuse Treatment Facility / Pharmacy Repackaging / Custodial Care Facility / Skilled Nursing Facility / PART B ONLY 6=Group Home 7=Inpatient Psychiatric Facility 8=Psychiatric Facility / /

MedicalTreatment

dialysis / /

Organization

6ØØ-28 UNIT OF MEASURE / European Union / regulatory / Medicare / 4Ø1-D1 DATE OF SERVICE / /

/

Position

PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER / Payer Sheet Template** General Information Payer Name / 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER / PRODUCT/SERVICE ID QUALIFIER / /

Product

Term Care Replacement Medication / /

ProgrammingLanguage

R / /

Technology

dialysis / /

URL

http /

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