Prescription Drug Programs Inc. / Goold Health Systems / /
Facility
pharmacy No / /
IndustryTerm
pharmacy claim processing / /
Organization
RW RW ROUTE OF ADMINISTRATION / European Union / 6ØØ-28 UNIT OF MEASURE RW If Ø8 / 12=Drug Enforcement Administration / National Council for Prescription Drug Programs / NCPDP Field Name PRESCRIBER ID QUALIFIER Claim Billing/Claim Rebill Value 12=Drug Enforcement Administration / Medicare / /
Person
Claim Billing / DEA DEA PRESCRIBER ID / / /
Position
physician / Prescription/Service Reference Number Qualifier / GENERAL INFORMATION Payer Name / PayerPatient Responsibility Qualifier / AMOUNT CLAIMED SUBMITTED QUALIFIER / qualifier / pharmacist / PayerPatient Responsibility Amount Qualifier / RESPONSIBILITY AMOUNT QUALIFIER / /
MAINE MEDEL NCPDP VERSION D.Ø PAYER SHEET REQUEST CLAIM BILLING/CLAIM REBILL ** Start of Request Claim Billing/Claim Rebill (B1/B3) Payer Sheet ** GENERAL INFORMATION Payer Name: Maine Medicaid