Texas Medicaid/CHIP Vendor Drug Program Pharmacy Claims Billing Request About

Texas Medicaid/CHIP Vendor Drug Program
Pharmacy Claims Billing Request
About
The Pharmacy Claims Billing Request (Form 3700) is the only acceptable method to submit paper claims to the
Medicaid/CHIP Vendor Drug Program. Paper submission is only allowed for certain state-approved situations (e.g.
natural disasters) as defined in the Texas Pharmacy Provider Procedure Manual.
All other types of paper forms, and Billing Request Forms submitted for unapproved reasons, are not accepted and will be
returned with no action taken. The reason for the claim submittal or adjustment must be stated on the face of the form
before the claim will be processed.
Form 3700 is kept for five years after the end of the federal fiscal year in which the provider sends the form.
Instructions
Please refer to payer specification documents at TxVendorDrug.com/downloads/ for specific field instructions.
For clients enrolled in Fee-For-Service Medicaid, CSHCN, KHC, and TWHP only. Forms must be signed and dated
prior to submission. Return the form:
By mail:
Texas Health and Human Services Commission
Medicaid/CHIP Vendor Drug Program (2250)
4900 North Lamar Blvd.
Austin, TX 78751
Rev. 10/2014
File: vdp_ecm_pcbrq
Page 1 of 2
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Texas Medicaid/CHIP Vendor Drug Program
Pharmacy Claims Billing Request
Field
Cardholder ID
Date of Birth
Patient Location
Gender
Pregnancy Indicator
Date of Service
Date RX Written
Product ID
Quantity Dispensed
Units
Days Supply
Quantity Prescribed
RX Number
Prescription (Rx) Origin Code
Refill Authorization
Refill Number
Dispense as Written
Prescriber ID
Prescriber Name
Prior Authorization Type
Prior Authorization Number
Usual and Customary Charge
Gross Amount Due
Patient Paid Amount Submitted
Basis of Cost Determination
Submission Clarification Code
Explanation
Amount Paid
Other Coverage Code
Coverage Type
ID Qualifier
Other Payer ID
Other Payer Date
Amount Paid Qualifier
Amount Paid
Reject Code
Signature
Rev. 10/2014
File: vdp_ecm_pcbrq
Usage
Client identification number. If claim is for a Newborn and no ID# is available, this field
should be left blank. Do not enter the Mother’s ID number.
Client’s date of birth.
Optional
Follow NCPDP Standard (refer to TxVendorDrug.com/downloads/).
Follow NCPDP Standard.
Date the prescription was filled.
Date prescription was written.
11-digit National Drug Code
Quantity dispensed expressed in metric decimal units.
Follow NCPDP Standard.
Estimated duration of the prescription supply in days. This field may not exceed 185 for
Medicaid and CSHCN. Days supply for KHC is limited to 34.
Quantity prescribed expressed in metric decimal units.
Prescription/service reference number.
Follow NCPDP Standard.
Enter ØØ through 11.
A value of ØØ is used to indicate an original prescription. Any other value of 1-1Ø
indicates a refill prescription.
Enter “1” to override the MAC when a physician wants a brand name dispensed and hand
writes the phrase "Brand Necessary," "Brand Medically Necessary," "Brand Name
Necessary," or "Brand Name Medically Necessary" across the face of the prescription.
10-digit Prescriber National Provider Identifier (NPI).
Enter first two letters of Prescriber’s last name.
Required if Prior Authorization Number Submitted is transmitted.
Follow VDP Accepted Values (refer to TxVendorDrug.com/downloads/).
Required if Prior Authorization Type Code is transmitted.
Follow VDP Accepted Values.
Usual and customary (amount claimed for reimbursement).
Used to reflect Usual & Customary price less discount or special price. Pharmacy
providers who are required to bill actual invoice cost plus fee also can use it.
For future use.
Follow NCPDP Standard.
Follow NCPDP Standard.
The type of claim submittal or adjustment and reason must be stated in the explanation line
before the claim can be processed.
HHSC use only
Required if Coordination of Benefits (COB) segment is submitted. Follow NCPDP
Standard.
Follow NCPDP Standard.
Follow NCPDP Standard.
ID assigned to the payer.
Payment or denial date of the claim submitted to the other payer.
Code qualifying the Other Payer Amount Paid.
Amount of any payment known by the pharmacy from other sources.
The error encountered by the previous Other Payer in Reject Code.
The provider or authorized representative signs in ink after completing the form.
Page 2 of 2
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TEXAS HEALTH & HUMAN SERVICES COMMISSION
PHARMACY CLAIM BILLING REQUEST - FORM 3700
Pharmacy Name
Pharmacy Address (Street/P.O. Box, City, State & ZIP)
Service Provider ID (10-digit NPI)
Vendor ID (6 digit)
Date Submitted
Date of Birth
Loc.
Gender
Unit
Days Supply
Revised 10 / 2014
Cardholder ID
Product ID (11 digits)
Refill Auth.
Refiill Nmbr.
Gross Amount Due
Quantity Dispensed
DAW
Prescriber ID (NPI)
Patient Paid Amount
Prescriber Name
Basis of Cost
Pregnancy
Date of Service
Quantity Prescribed
PA Type
PA Number
Sub.Clar.Cd. HHSC
USE
ONLY
Date RX Written
RX Number
Rx Origin
U & C Amount
Amount PD

Explanation (Required)
Coordination of Benefits
1. Other Payer
Coverage Type
ID Qualifier
Other Coverage Code
ID
Date
Other Payer Rejects
Coverage Type
Amount Paid Qualifier
Amount Paid
Amount Paid Qualifier
Amount Paid
Amount Paid Qualifier
Amount Paid
Amount Paid Qualifier
Amount Paid
ID Qualifier
ID
Date
Reject Codes
ID Qualifier
ID
Date
Amount Paid Qualifier
Amount Paid
Amount Paid Qualifier
Amount Paid
Amount Paid Qualifier
Amount Paid
Amount Paid Qualifier
Amount Paid
2. Other Payer
Coverage Type
Other Payer Rejects
Coverage Type
ID Qualifier
ID
Date
Reject Codes
ID Qualifier
ID
Date
Amount Paid Qualifier
Amount Paid
Amount Paid Qualifier
Amount Paid
Amount Paid Qualifier
Amount Paid
Amount Paid Qualifier
Amount Paid
3. Other Payer
Coverage Type
Other Payer Rejects
Coverage Type
MAIL TO
ID Qualifier
ID
MEDCIAID/CHIP VENDOR DRUG PROGRAM (2250)
HEALTH AND HUMAN SERVICES COMMISSION
4900 NORTH LAMAR BLVD.
AUSTIN, TEXAS 78751
Date
Reject Codes
Signature (Vendor or Authorized Representative)
PHONE
TxVendorDrug.com/about/contact.shtml
FAX