<p> Claims Use Only: # of Claims: </p><p>Rx Claim- Claims Exception Form</p><p>** This form overrides only the fields that are marked or written in by the requestor.**</p><p>Date Submitted: SUBMITTED BY: Customer Care Account Mgmt Submitted by: Client Claims </p><p>Ext: SUBMIT PAYMENT TO: Member Pharmacy/Provider</p><p>Plan Participant ID# Carrier</p><p>Plan Participant Name Account</p><p>Address, City, State Group#</p><p>Patient DOB Rx Claim #</p><p>NATURE OF REQUEST – you may need to check more than one box. Step 1: Payment method (Must check which CLC code should be used to process the claim) CLC 92 (Out of network) CLC 94 (In network) CLC 95 (COB) CLC 96 (Foreign) CLC 01- (Home Health specific for MED D) CLC 03- (Nursing Home (specific for MED D) Client Specific CLC ______Step 2: Check all that apply Step 3: Adjustments-Provide the root cause for the adjustment PA Entered, OK to Process -indicate what copay should be on and who authorized the adjustment(s). Failure to provide this the claim once adjudicated ______. information will result in your request being delayed or rejected OK to process “Claim too old”Use PCN# Group back to the requestor. ______May Change PA if necessary ______OK to use Default NABP ______OK to use Default NDC# ______Okay to process claims past clients stop pay date. Must ______provide copy of Finance approval documentation. Make an adjustment to claim in the amount of $______. Provide a OK to override non participating pharmacy claim transaction number for the each paid claim that requires an Foreign claim-okay to pay adjustment. ______. Alternate Insurance paid in error- Use client procedures Pay Claims/ DO NOT REJECT- unless duplicate paid claim (rejects to identify possible duplicate include 79, 88,83. Please Note: The TAT for Adjustments is 30 days. For any adjustment verify in member’s history that claim has not been paid.) request over 50 those are considered a project and the TAT will be OTHER determined based upon current volume and staffing at the time the request is received. </p><p>CEF 11/12/2012 Claims Use Only: # of Claims: Account Manager instructions:</p><p>Today’s Date: Today’s Date: </p><p>CEF 11/12/2012 </p>