Billing L&I for Pharmacy Services

For pharmacy providers billing through a third party pharmacy biller

In order to use a third party pharmacy biller, you must:

  • Have a signed Supplemental Agreement Third Party Pharmacy Provider form (F249-021-000). This agreement:
    • Allows the third party pharmacy biller to route bills on the pharmacy's behalf and
    • Shows you agree to follow L&I rules, regulations and policies.
  • Ensure that the third party pharmacy biller uses the POS system.
  • Review and resolve all on-line POS system edits during the dispensing episode.
    • Only a licensed pharmacist can resolve POS system edits.
    • Third party pharmacy billers cannot resolve POS edits.

The following table shows the required entries in the Transaction Header Segment of the NCPDP 5.1 specifications when billing through a third party pharmacy biller.

Transaction Header Segment - Required
Transaction Header Segment - Required
Field name Data element number Required Valid values/comments
Service provider ID qualifier 202-B2 Yes 13 [State Issued]
Other valid values are accepted but not for third party billing.
Service provider ID 202-B1 Yes Enter 7-digit L&I dispensing pharmacy provider ID associated with the third party pharmacy biller.
Other valid values are accepted but not for third party pharmacy billing.

Pharmacy providers who submit bills on their own behalf and also use a third party pharmacy biller need to be sure to use the correct service provider ID. Payments will be made to the account associated with the submitted service provider ID.

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