QUEST Integration – Instructions for Completing Universal Drug Claim Form (Paper Claims)

Cardholder ID Number

Enter the patient’s QUEST Integration member number. Copy this number as it appears on the patient’s card, excluding the three characters prefix (e.g. “XLQ”), but including any leading zeros to form a ten-digit number. Remind patients to show their membership card each time they visit. Use this information to validate your records and for continued membership verification. Leaving this field blank or entering an erroneous number will delay claims processing or may result in denied claims. For newborn claims for services within 30 days from the date of birth, use the mother’s number. See QUEST Integration – Newborn Claims.

Submit Claim to:

Enter “HMSA-QST”.

Cardholder Name

Enter the patient’s last name, first name and middle initial as it appears on the membership card. Please do not use nicknames, abbreviations or titles.

Other Third Party Coverage

Check the appropriate “YES” or “NO” block.

Patient Last Name, First Name and Initial

This should be the same information as the cardholder name.

Date of Birth/Sex

Indicate the patient’s birth date by month, day and year. Please use the four-digit year of birth. The date must match the date in the QUEST Integration eligibility file for the patient or the claim will be delayed while patient information is verified. Place an “X” in the applicable gender box.

Name

Enter the name of the participating pharmacy submitting the claim.

Street Number/City, State and Zip Code

Provide the pharmacy address.

Pharmacy Number

Enter the NABP# of the pharmacy.

Date Rx(s) Filled

Provide the date that the prescription was filled.

Authorized Pharmacy Representative

The provider or authorized agent must sign. Signature stamps must be initialed by the provider or authorized agent. The authorized agent’s signature must be on file with HMSA.

Rx Number

Enter the prescription number for each drug item.

New/Refill

Place an “X” in the appropriate block to designate whether the prescription is New or a Refill.

Metric Quantity

When determining the metric quantity, refer to the product package label. If “ml” or “cc” is indicated, the metric quantity is the number of ml’s or cc’s whether the product is dry form or liquid, or a single-use disposable syringe such as tubex, bristoject or isoject.

If “ml”, “cc” or “gm” is not indicated on the label, the metric quantity is “1” for each unit. For example, the metric quantity for a product sold in cases of 24 bottles of 100 tablets would be the number of tablets dispensed.

This also applies to products that come with a separate vial or ampule of diluent, when no final volume is stated on the label, to “partial fill” products, and preps in an ointment, cream or powder form.

Products sold in bubble packs, e.g., Prempro and Premphase which are packaged two pills per bubble, should be billed by the tablet count, not by the bubble count.

If the product is a “partial fill, non-unit dose type”, such as Dextrose 5 percent 250 ml in a 500 ml bottle, the metric quantity is the fill volume containing the actual drug, e.g., 250 ml.

If the product is sold as a unit, the metric quantity is “1” for each unit; for example, the quantity for a box of 100 test tapes is “1” and not the number of tests. This includes multiple drug products packaged and dispensed in “unbreakable” containers, e.g., Thiosulfil Duo-Pak, which are treated as single units with quantity “1” for each unit.

The quantity is not to exceed 100 doses or a 30-day supply, whichever is greater.

Day Supply

Indicate the number of days that the metric quantity will last the patient.

National Drug Code

Identify the dispensed item with the NDC number. Right justify each part of the number in its respective field. Use the following NDC numbers for compounded drugs, and list each ingredient, metric quantity and cost on the back of the form after removing any carbons:

99999999999 – Legend, non-scheduled

99999999992 – Schedule II

99999999993 – Schedule III

99999999994 – Schedule IV

99999999995 – Schedule V

99999999996 – Miscellaneous compounds

If there is no NDC number for a drug, enter the name of the manufacturer in the labeler field, and the drug name, form and strength in the product/pkg fields.

Prescriber Ident.

Enter the name of the prescribing physician in last name, first name order. Do not include titles or degrees. Do not use the physician’s license number.

DAW (Dispense as Written)

Valid codes and their meanings are:

0 = no DAW specified

1 = physician DAW (brand medically necessary)

2 = patient DAW (patient requests brand)

3 = pharmacy DAW (pharmacy requests brand)

4 = no generic available (using standard purchasing practices)

5 = brand substituted as generic

Ingr Cost

Indicate the cost of the ingredient(s).

Disp Fee

Enter the professional fee for dispensing the drug.

Tax

Pharmaceuticals are tax-exempt. Tax may be charged for supplies.

Total Price

Indicate the total charge for the dispensed item.

Ded. Amount

Any collected QUEST Integration patient copayment may be entered if desired for recordkeeping.

Bal.

Enter the net balance billed for QUEST Integration reimbursement.