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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F13073 (07/12) STATE OF WISCONSIN DHS 106.03(1), Wis. Admin. Code COMPOUND DRUG CLAIM Instructions: Type or print clearly.

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How to fill out compound drug claim

How to fill out compound drug claim:

01

Obtain the necessary claim form from your insurance provider or pharmacy.

02

Fill in your personal information accurately, including your name, address, and contact details.

03

Provide your insurance information, including policy number and group number.

04

Clearly indicate the date of the prescription and the name of the prescribing healthcare provider.

05

List the compound drugs being claimed, including the medication names, strengths, and quantities.

06

If applicable, indicate any generic or brand name requirements specified by your insurance plan.

07

Include the National Drug Code (NDC) for each medication, which is usually found on the prescription label.

08

Specify the reason for the compound drug prescription, such as allergy or dosage requirements.

09

If the compound drug is being prescribed for a specific condition or diagnosis, include that information as well.

10

Provide any additional required documentation, such as prior authorization forms or medical necessity letters.

11

Review the completed claim form for accuracy and completeness before submitting it to your insurance provider.

Who needs compound drug claim:

01

Individuals who are prescribed compound medications by their healthcare provider.

02

Patients who require specialized medications tailored to their specific needs.

03

Individuals whose insurance plan covers compound drugs and requires claims for reimbursement or coverage purposes.

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What is compound drug claim?

Compound drug claim is a claim for medication that is made up of two or more active pharmaceutical ingredients.

Who is required to file compound drug claim?

Healthcare providers or pharmacies who dispense compound drugs are required to file compound drug claims.

How to fill out compound drug claim?

Compound drug claims can be filled out electronically or using paper forms provided by the payer.

What is the purpose of compound drug claim?

The purpose of compound drug claim is to request reimbursement for the cost of compounded medications.

What information must be reported on compound drug claim?

Compound drug claims must include information such as the NDC numbers of the ingredients, the quantity dispensed, and the prescriber's information.

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