Home Claims Form 10_2011 MedImpact Prescription Drug Claim Form

Form 10_2011 MedImpact Prescription Drug Claim Form

Form 10_2011 MedImpact Prescription Drug Claim Form

 

INSTRUCTIONS: ALABAMA PRESCRIPTION DRUG CLAIM FORM (Form 10_2011)

 

 

To process claims for prescription drugs for Alabama public employees enrolled in coverage administered by Medimpact, use the claim form discussed in this article. This document can be obtained from the website maintained by the Retirement Systems of Alabama.

 

Alabama Prescription Drug Claim Form 10_2011 Step 1: The first section concerns the primary member. Enter their cardholder identification number and name on the first line.

 

Alabama Prescription Drug Claim Form 10_2011 Step 2: Enter the name of the health plan or insurance and the member's day and evening phone numbers on the second line.

 

Alabama Prescription Drug Claim Form 10_2011 Step 3: Enter the member's street address, city, state and zip code on the third line.

 

Alabama Prescription Drug Claim Form 10_2011 Step 4: The next section concerns the patient. Enter the patient's first name, middle name, last name and date of birth on the first blank line. 

 

Alabama Prescription Drug Claim Form 10_2011 Step 5: Indicate the patient's relationship to the member with a check mark.

 

Alabama Prescription Drug Claim Form 10_2011 Step 6: If you are covered under any other insurance, check the box where indicated and enter the name of your primary insurance.

 

Alabama Prescription Drug Claim Form 10_2011 Step 7: If you receive worker's compensation, check the box where indicated and submit the form to your employer.

 

Alabama Prescription Drug Claim Form 10_2011 Step 8: The next section concerns prescriptions. You may document up to three prescriptions on one page. For each, enter the RX number, date filed, quantity, day supply, directions, total price with tax, medication name, strength and form, Vac admin fee, prescribing physician's name and DEA number and NDC. Check the boxes next to all applicable statements as directed.

 

Alabama Prescription Drug Claim Form 10_2011 Step 9: At the top of the second page, enter the pharmacy's name, telephone number, street address, NABP, city, state, zip code, and an official's signature and the date.

 

Alabama Prescription Drug Claim Form 10_2011 Step 10: The claimant should sign the form where indicated.

 

Alabama Prescription Drug Claim Form 10_2011 Step 11: If any compound prescriptions have been issued, the table at the bottom of the second page must be completed by the pharmacy. For each such compound prescription, enter the NDC number, drug ingredient, quantity and charge.

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