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

   1. 1. claimant name;
   2. 2. claimant address;
   3. 3. unique claimant identifier;
   4. 4. date prescription was filled;
   5. 5. national drug code;
   6. 6. drug name;
   7. 7. drug quantity;
   8. 8. total charge;
   9. 9. number of days prescribed;
   10. 10. prescribing providers name;
   11. 11. prescribing providers NPI;
   12. 12. pharmacists I.D.;
   13. 13. dispensing facility address;
   14. 14. dispensing facility phone number;
   15. 15. medication charge; and
   16. 16. dispensing fee charge.

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

   1. 1. claimant name;
   2. 2. claimant address;
   3. 3. unique claimant identifier;
   4. 4. date prescription was filled;
   5. 5. national drug code;
   6. 6. drug name;
   7. 7. amount charged per prescription;
   8. 8. total amount charged;
   9. 9. individual drug reimbursement;
   10. 10. total bill reimbursement;
   11. 11. individual tax reimbursement;
   12. 12. total tax reimbursement;
   13. 13. total amount reimbursed;
   14. 14. payor name;
   15. 15. payor address; and
   16. 16. payor phone number.

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

   1. 1. Group Number―leave blank.
   2. 2. Cardholder's I.D. Number―enter claimants Social Security number.
   3. 3. Cardholder's Name―enter claimant's full name.
   4. 4. Pharmacy Name―enter name of pharmacy.
   5. 5. Street No.―enter physical address of pharmacy.
   6. 6. City, State, Zip―enter pharmacy city, state and zip.
   7. 7. Pharmacy No.―leave blank.
   8. 8. Phone Number―enter telephone number of pharmacy.
   9. 9. Other Party Coverage―leave blank.
   10. 10. Claimant's Last Name, First Name and Middle Initial―enter claimant's name.
   11. 11. Date of Birth―enter month, day, year.
   12. 12. Sex―check the appropriate box.
   13. 13. Relationship to the Cardholder―should be same as claimant.
   14. 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. 15. Authorized Pharmacy Representative―enter pharmacist's name.
   16. 16. Date Rx Written―enter date prescription originally written.
   17. 17. Date Rx Filled―enter date of purchase.
   18. 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. 19. New/Refill―check the appropriate box.
   20. 20. Metric Quantity―report the quantity of the drug dispensed.
   21. 21. Days Supply―indicate days supply for which the prescription is dispensed.

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

       1. a. Labeler Code―first five digits;
       2. b. Product Code―middle four digits;
       3. c. Package Code―last two digits.
   23. 23. Prescriber I.D.―leave blank.
   24. 24. - 29. Complete same as Items 18-23 if second prescription is filed.
   25. 30. INGR Cost―indicate the Red Book AWP.
   26. 31. DISP Fee―leave blank.
   27. 32. Tax―do not complete.
   28. 33. Total Price―enter your normal retail charge (total price).
   29. 34. DED Amt―leave blank.
   30. 35. Balance―leave blank.

Authority Note

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

Historical Note

HISTORICAL NOTE: 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).