Third Party

Patient

Prescriber

Drug

info

Created By/On:Devel# 11/26/2015 | 5:23:47 AM

Maintained By/On: Jayden Smith 02/12/2018 | 5:06:479 AM

Basic Information

Payer Name

Group Name

Last Used Date

00/00/0000

Effective Date

Discontinue Date

Bin

Processor Cntl

Vndr/Cert ID

Plan ID

Switch

Adj Version

# Claims/Xmit

Plan Type

Formulary

Place of Service

Residence

Provider ID

Prescriber License

Medicare

Workers Comp

Medicaid

Stage of

Online Adj

Allow Adjudication to Non-Primary

Plan

Plan Name

Address Line 1

Address Line 2

City

State

ZIP

Attention.

Contact Name

Phone

Ext.

Tolerances

Brand

Amount

%

Basis

Alert

Generic

Amount

%

Basis

Alert

Non-Primary Billing

Type

Recalculate

SeniorCare

Send Other Payer Info

Usual & Customary

Use AAC for 340B U&C

U&C Based on Retail Cash Pricing

Set U&C Equal to Price

Include sales tax in price

Pharmacy Service Type

Price Schedules

Brand

Generic

OTC

Compound

Dispending Fees

Brand Fee Amt

%

Generic Fee Amt

%

OTC Fee Amt

%

Compound Fee Amt

%

Search Criteria

Third Party

BIN

Plan Name	BIN	Payer	Group	PCN
CA CMC	610144	CA CMC		DOCER
CMS 1500 Claim Form	610785	CCMS 1500 Claim Form(2012)		ERCLCERT
Eligibility Commercial Plan	610785	Commercial Plan		COMMCF
Eligibility Medicare Plan	610785	Medicare Plan		COMMCF