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NCPDP VERSION D Claim Billing/Claim Re-bill Template
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Document Date: 2014-03-19 11:50:32

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File Size: 380,92 KB

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City

OTHER PAYER / Patient / /

Company

Magellan Health Services Inc. / GE / /

Facility

Pharmacy Support / /

Organization

regulatory / 6ØØ-28 UNIT OF MEASURE / European Union / /

Person

PRESCRIBER LAST / /

/

Position

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

ProgrammingLanguage

R / /

Technology

016523 Processor / /

SocialTag