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 / /