TX HHS Form 1319. Pharmacy Claims Billing Request

The TX HHS Form 1319, Pharmacy Claims Billing Request, is a crucial document for pharmacies to submit claims for reimbursement. This form helps pharmacies get paid for the prescription medications they dispense to patients. It's typically used by pharmacies participating in the Texas Vendor Drug Program.

This form requires pharmacies to provide detailed information about each claim submission, including the patient's name and date of birth, pharmacy details such as NPI and vendor ID, and product information like NDC code and quantity dispensed. The form also includes spaces for additional clarification and submission status codes.

Key features of this form include required fields for date submitted, national provider information, and cardholder ID, as well as sections for prior authorization and other payer information. By using this form, pharmacies can ensure accurate and timely reimbursement for their services. Note that the information contained in this facsimile transmission is confidential and intended only for the exclusive use of the addressee.

• This form is used by pharmacies participating in the Texas Vendor Drug Program to submit claims for prescription medications.
• The form requires detailed information about each claim submission, including patient and pharmacy details, product information, and prior authorization data.