Get Medicare Part-d Prescription Drug Claims Form - Coventry

The First Health® Rx Bin number is 002286. You may request a copy of the First Health® Rx payor specifications at FirstHealthRx@firsthealth.com. The Pharmacy Program Administrator claims processing system is available for on-line processing 24 hours a day.

What are the 837P and Form CMS-1500? The 837P (Professional) is the standard format used by health care professionals and suppliers to transmit health care claims electronically. The Form CMS-1500 is the standard paper claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper claim is allowed.

Form CMS-1696 can be downloaded at .cms.gov or obtained by calling the Customer Service number on your member ID card. The claim may be submitted via mail or fax to the address or phone number on the Medicare Part D Prescription Drug Claim Form.

The CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of ...

The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities. This would include things like surgery, radiology, laboratory, or other facility services. The HCFA-1500 form (CMS-1500) is used to submit charges covered under Medicare Part B.

Fill out the claim form, called the Patient Request for Medical Payment form (CMS-1490S) [PDF, 52KB).

You have to inform your pharmacist that you are covered by the Public Prescription Drug Insurance Plan. You must also present your valid Health Insurance Card and, if applicable, your valid claim slip. If you have not informed your pharmacist, you will have to pay the total cost of your medications.

Photocopies of the CMS-1500 claim form are NOT acceptable. Medicare will accept any Page 3 type (i.e., single sheet, snap-out, continuous feed, etc.) of the CMS-1500 claim form for processing. To purchase forms from the U.S. Government Printing Office, call (202) 512-1800.