Get Form 3700 - Texas Medicaid/chip Vendor Drug Program

Filling out the Form 3700, also known as the Pharmacy Claims Billing Request, is crucial for submitting paper claims to the Texas Medicaid/CHIP Vendor Drug Program. This guide will provide a clear process to assist you in completing the form accurately and efficiently.

Follow the steps to accurately complete the Form 3700 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling out the form by entering the cardholder ID. This is the unique identifier for the client. If the claim is for a newborn and no ID number is available, leave this field blank.
3. Next, input the date of birth of the client. Ensure this information is accurate as it can affect claim processing.
4. Specify the patient location and gender. The gender options are '1' for male and '2' for female.
5. Indicate if the patient is pregnant by entering '1' for not pregnant or '2' for pregnant in the pregnancy indicator field.
6. Enter the date of service, which refers to the date the prescription was filled and also specify the date the prescription was written.
7. Input the product ID, which is an 11-digit National Drug Code.
8. Fill in the quantity dispensed in appropriate metric units, and specify the days supply. Note that days supply cannot exceed specific limits based on the program.
9. Document the quantity prescribed and the RX number, ensuring the RX number is right-justified and zero-filled as needed.
10. If there are any refills, include the refill authorization number and the number of refills.
11. Provide the prescriber ID, which is the 10-digit National Provider Identifier, along with the prescriber's name.
12. Complete details regarding prior authorization, including the type and number if applicable.
13. Record the usual and customary charge, the gross amount due, and any patient paid amount submitted.
14. Lastly, ensure that the form is signed and dated by the vendor or authorized representative before submission.
15. After filling out the form, you can save changes, download, print, or share the completed form as needed.

Complete your documents online today to ensure timely processing of your claims.