Fillable Hdform NADAC - Request for Medicaid Reimbursement Review

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Hdform NADAC - Request for Medicaid Reimbursement Review

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The Hdform NADAC - Request for Medicaid Reimbursement Review form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Centers for Medicare & Medicaid Services

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Pharmacy Provider Information
:
- - *
: - -
/ /
/ /
):
NATIONAL AVERAGE DRUG ACQUISITION COST (NADAC) – REQUEST FOR MEDICAID REIMBURSEMENT REVIEW
Pharmacy providers should use form to submit NADAC pricing inquiries.
NOTE: A COPY OF YOUR CURRENT PURCHASE RECORDS THA T CONFIRMS YOUR ACQUISITION COSTS AND ALL
FIELDS MARKED WITH AN ASTERICK (*) MUST BE COMPLETED FOR PROPER SUBMISSION OF THIS FORM
*Pharmacy Name
*NPI:
*City:
*Phone:
*Pharmacy Type:
*State:
Email:
(i.e. Retail, LTC, Etc.)
Drug Information: Please enter infor
mation for one (1) drug per submission form
Drug Name and Strength:
*National Drug Code (NDC)
Provider Cost Information
Yes
No
*Cost Per Package:
Is this a recent change in reimbursement?
*Package Size:
Has there been a recent increase in acquisition cost?
*Date of Purchase:
Are there availability issues?
Are you able to purchase alternate NDCs?
Claim Information
PBM/ Payer Name:
Dispense Date:
Comments:
Quantity Dispensed:
Dispensing Fee:
Total reimbursement for claim (including DF
Medicaid co-pay due from recipient:
Ingredient Reimbursement (per unit):
Be sure to include copies of your purchase records that confirms your acquisition costs.
Once complete information is received, we will evaluate your inquiry. If there is a rate update it will be found on the next available NADAC file.
For questions or to check the status of an inquiry, please contact us by email at
info@mslcrps.com or by phone at 855-457-5264. To submit
form and or invoices via facsimile please fax to 844-860-0236.
Person Submitting this Request:
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Hdform NADAC - Request for Medicaid Reimbursement Review

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Completed 16 November 2019

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