Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 29 - Pharmacy Reimbursement Schedule, Billing Instruction and Maintenance Procedures
Section I-2915 - Billing Instructions
Universal Citation: LA Admin Code I-2915
Current through Register Vol. 50, No. 9, September 20, 2024
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.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.
Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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