UCF Instructions - Long Form

Please follow these instructions when submitting a Universal Claim Form (UCF) long form [PDF] for claims processing. Please discontinue use of the short form.

The UCF may be typed, hand-printed, or computer-generated.

The address that you send your claim to depends on the service date. For claims with service dates on or after Jan. 1, 2013, send to HMSA's pharmacy benefit manager at the appropriate address below:

For claims with service dates on or before December 31, 2012, send to Express Scripts:

Express Scripts
PO Box 14718
Lexington, KY  40512

If you have questions about completing the UCF long form for submission to Express Scripts, please call 1-800-922-1557 toll-free.

Please complete all required information indicated in these instructions. Required information is denoted in these instructions by an asterisk (*). If necessary, fill in all conditional blocks of the UCF. These areas are required only if certain conditions (e.g. prescription for a controlled substance) are met and are indicated on the instructions by two asterisks (**).

Omission of data may cause claim processing delays, as the claim will be returned to the pharmacist or dispensing physician.

Claims must be submitted within one year from the date the prescription is filled.

NOTE: If the claims are submitted to another address, payment(s) will be directed to the member.

Item Explanation

The following instructions are applicable to the UCF. Items denoted by an asterisk (*) are required information on all UCFs sent to Medco. Claims will be rejected if this information is missing.

Items denoted by two asterisks (**) are conditional, meaning that the applicable information is required only if certain criteria are met (e.g., prescription for a controlled substance). UCFs will be returned if this information is omitted.

*ID - the subscriber ID number from the member's HMSA Membership Card

*Group ID - the group identification number

*Name - the member's name from his or her HMSA Membership Card

Plan Name - name of plan from the member's HMSA Membership Card

*Patient Name - patient's first and last names

*Other Coverage Code:

0 = Not Specified

1 = No other coverage identified

2 = Other coverage exists - payment collected

3 = Other coverage exists - this claim not covered

4 = Other coverage exists - payment not collected

5 = Managed care plan denial

6 = Other coverage denied - not a participating provider

7 = Other coverage exists - not in effect at time of service

8 = Claim is billing for a copayment

*Patient Date of Birth - birthday of patient. Format: MMDDYY

*Patient Gender Code:

0 = Not Specified

1 = Male

2 = Female

*Patient Relationship Code

0 = Not Specified

1 = Cardholder

2 = Spouse

3 = Child

4 = Other

*Pharmacy Name and Address - complete name and address of pharmacy/provider

Service Provider ID/QUAL - The NPI number of the provider submitting the claim.

Service Provider ID Qualifier:

Blank = Not Specified

01 = National Provider Identifier (NPI)

Phone No. - dispensing pharmacy's/provider's telephone number

*Prescription/Serv. Ref. # - the prescription number consisting of a prefix (if one is used) and a maximum of seven digits

Date Written - date the prescription was written

*Date of Service - month, day and year the prescription(s) was filled. Format: MMDDYY

**Fill # - place a "0" in the box if this is a new prescription or a number greater than "0" in the box if this is a refill, note the fill numbers should represent the refill number of the prescription, so the first refill would have a fill number ‘1’, second refill would be fill number ‘2’, etc.

**Qty Dispensed - the number of tablets, capsules, etc. dispensed. When liquids are dispensed use ml or cc. For original packages, such as ointments, drops, etc., use metric units dispensed such as grams or cc (i.e., Aristocort Cr ½ oz. should show 15, referring to the number of grams). Include the metric form being used (i.e., ml or cc) on the UCF.

*Days Supply - the number of days the medication will last the patient, when taken according to directions

*Product/Service ID - The National Drug Code (NDC) for the drug being dispensed.

Compound drugs can be transmitted Point-of-Sale (POS). In the event a paper claim is submitted, please refer to the following instructions.

Filing paper claims for Compound Drugs

The following changes will apply when filing paper claims:

• In the NDC area on the front of the UCF, write either "brand compound Rx" or "generic compound Rx," along with the NDC number based on the filling instructions above.
• [If you are using the older version of the UCF, the total charge of the compound should be indicated in the "TOTAL PRICE" field.] If you are using the newer version of the UCF, the total charge of the compound should be indicated in the "GROSS AMOUNT DUE SUBMITTED" field.
• On the back of the form under the :COMPOUND PRESCRIPTION" section, correct information must be entered in the following fields for the claim to be processed:
  • Drug name
  • Corresponding NDCs used for compound
  • Cost
• All of the drugs in the compound must be listed with the required corresponding information. If any of the required information is missing or illegible, the claim will be returned to you.

If drug is submitted via hard copy, complete the section titled COMPOUND PRESCRIPTIONS on the back of the UCF (refer to example 3).

Each drug should be listed individually as shown below.

A compounded prescription should be considered brand if it contains one or more brand ingredients and generic if it contains no brand ingredients.

Payable items without NDC numbers should be described in this field.

**DAW (Dispensed as Written):

Valid Codes:

0 = No DAW

1 = Physician DAW

2 = Patient DAW

3 = Pharmacy DAW

4 = No generic available

5 = Brand Dispensed, Priced as Generic

If no code is entered, "0" will be the default DAW code.

Prior Auth # Submitted - a prior authorization number, if applicable

PA Type - refer to the back of the UCF for Prior Authorization Type Codes

*Prescriber ID

Pharmacies - this is the physician's DEA number (required). If the number is not available, then AP-5555555 may be used. Use of this number will be audited and should only be used if the physician's DEA number cannot be obtained.

When a controlled substance is dispensed, the DEA number is required without exception.

Dispensing Physicians - please enter your DEA number (required).

DUR/PPS Codes - refer to the back of the UCF for DUR/PPS Codes.

Basis Cost - refer to the back of the UCF for Basis of Cost Determination codes.

Provider ID - HMSA identification number of the pharmacy/provider

**Other Payer Date - date any other carrier paid on this claim

**Other Payer ID - the carrier name of other payer on this claim

**Other Payer Reject Codes - reason(s) other payer did not pay on this claim

Usual & Cust. Charge - your public charge

Ingredient Cost Submitted - the cost of ingredients. Format: $$$.¢¢

Dispensing Fee Submitted - the professional fee charged for dispensing the drug. Format: $$$.¢¢

Incentive Amount Submitted - not applicable

Other Amount Submitted - not applicable

Sales Tax Submitted - the pertinent state tax, as applicable

*Gross Amount Due Submitted - total cost of drug. Format: $$$.¢¢

*Patient Paid Amount - amount paid by patient. Format: $$$.¢¢

**Other Payer Amount Paid - amount other carrier paid on this claim. Format: $$$.¢¢

**Net Amount Due - the total amount billed to HMSA. Format: $$$.¢

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