La. Admin. Code tit. 40 § I-2915

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-2915 - Billing Instructions

A. Pharmaceutical billing must occur on either the CMS 1500 or a company invoice. Billing document will include the following minimum information:

1. claimant name;

2. claimant address;

3. unique claimant identifier;

4. date prescription was filled;

5. n ational drug code;

6. drug name;

7. drug quantity;

8. total charge;

9. number of days prescribed;

10. prescribing providers name;

11. prescribing providers NPI;

12. pharmacists I.D.;

13. dispensing facility address;

14. dispensing facility phone number;

15. medication charge; and

16. dispensing fee charge.

B. Entities issuing reimbursement documentation will include the following information:

1. claimant name;

2. claimant address;

3. unique claimant identifier;

4. date prescription was filled;

5. national drug code;

6. drug name;

7. amount charged per prescription;

8. total amount charged;

9. individual drug reimbursement;

10. total bill reimbursement;

11. individual tax reimbursement;

12. total tax reimbursement;

13. total amount reimbursed;

14. payor name;

15. payor address; and

16. payor phone number.

C. Item by Item Instructions for Completion of the Drug Form

1. Group Number-leave blank.

2. Cardholder's I.D. Number-enter claimants Social Security number.

3. Cardholder's Name-enter claimant's full name.

4. Pharmacy Name-enter name of pharmacy.

5. Street No.-enter physical address of pharmacy.

6. City, State, Zip-enter pharmacy city, state and zip.

7. Pharmacy No.-leave blank.

8. Phone Number-enter telephone number of pharmacy.

9. Other Party Coverage-leave blank.

10. Claimant's Last Name, First Name and Middle Initial-enter claimant's name.

11. Date of Birth-enter month, day, year.

12. Sex-check the appropriate box.

13. Relationship to the Cardholder-should be same as claimant.

14. Patient/Authorized Representative-signature must be present. If signature is on file at the pharmacy, then indicate "signature on file" in the patient's signature box.

15. Authorized Pharmacy Representative-enter pharmacist's name.

16. Date Rx Written-enter date prescription originally written.

17. Date Rx Filled-enter date of purchase.

18. Rx Number-indicate the alpha and/or numeric prescription number assigned by the pharmacy as it appears on the prescription order. Omit spaces or punctuation.

19. New/Refill-check the appropriate box.

20. Metric Quantity-report the quantity of the drug dispensed.

21. Days Supply-indicate days supply for which the prescription is dispensed.

22. National Drug Code-enter the 11 digit national drug code which identifies the drug dispensed.

a. Labeler Code-first five digits;

b. Product Code-middle four digits;

c. Package Code-last two digits.

23. Prescriber I.D.-leave blank.

24. - 29. Complete same as Items 18-23 if second prescription is filed.

30. INGR Cost-indicate the Red Book AWP.

31. DISP Fee-leave blank.

32. Tax-do not complete.

33. Total Price-enter your normal retail charge (total price).

34. DED Amt-leave blank.

35. Balance-leave blank.

La. Admin. Code tit. 40, § I-2915

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994), amended by the Workforce Commission, Office of Workers' Compensation, LR 38:837 (March 2012).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.