- New Prescriptions
- Rx Processing Alerts
- Verification
- Dispensing
- Counseling
- Clinical Services
- Drug Info
 Dispensing Notes: none |
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Please correct information and resubmit claim.
| PHARMACY - Claim Rejection - ID# 696083 | ||
NCPDP Code |
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Description |
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| First Name |
Last Name |
Date of Birth |
| Gender |
Plan Name |
Member Name |
| Member ID |
Person Code |
Group ID |
| Rx BIN |
Rx PCN |
Rx GRP |
| Rx # |
Date Filled |
Date Written |
| Drug |
Strength |
Dosage Form |
| Rx Qty |
Refills |
Total Quantity |
| Directions |
Qty Dispensed |
Unit of Measure |
| Days Supply |
NDC |
Brand or Generic |
Origin Code |
DAW Code |
Refill Number |
| Ingredient Cost |
Professional Fee |
Total Cost |
Formulary Tier |
Compound Indicator |
Dispense Status |
| Prescriber Name |
Prescriber DEA# |
Prescriber NPI |
| Pharmacy Name |
Pharmacy License# |
Pharmacy NPI |
Insurance Card
Member Name: Stanley M. Bontrager
Member ID: 861531780
Person Code: 00 Bontrager, Stanley M.
Group ID: 1055129
RxBIN: 298485
RxPCN: CA1N82H
RxGROUP: MTX344
Member ID: 861531780
Person Code: 00 Bontrager, Stanley M.
Group ID: 1055129
RxBIN: 298485
RxPCN: CA1N82H
RxGROUP: MTX344
Patient Profile |
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Last Name |
Bontrager |
First Name |
Stanley M. |
Address |
421 E. 21st Street |
Phone |
(316) 555-4551 |
Date of Birth |
7/11/1992 |
Gender |
M |
Safety Caps? |
Yes |
Chronic Illness |
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Allergies |
Fish (omega-3 fatty acids) and shellfish hypersensitivity (rash, swelling) |
Prescriber Info |
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Name |
Carolyn Abman |
Practice |
Family Practice |
Group |
Family Practice Physician Group |
Address |
1315 W. 12th Street |
Telephone |
(316) 555-3277 |
DEA |
BA4132647 |
NPI |
1269594188 |
Pharmacy Info |
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Name |
SupeRx Pharmacy |
Address |
605 Main Steet |
Zip Code |
54321 |
Telephone |
(800) 555-1212 |
State License |
6-54792 |
NPI |
6247183295 |
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