Form 1319 "Pharmacy Claims Billing Request" - Texas

What Is Form 1319?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 1319 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 1319 "Pharmacy Claims Billing Request" - Texas

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Form 1319
October 2020-E
Texas Vendor Drug Program
Pharmacy Claims Billing Request
Submission Explanation (Required)
Date Claim Submitted
Name of Pharmacy
National Provider Information (NPI)
Vendor ID
Area Code and Phone No. of Pharmacy
Area Code and Fax No. of Pharmacy
Cardholder ID
Date of Birth (MMDDYY)
Gender
Date of Service
Date Rx Written
Product ID (NDC)
Prescription (RX) Quantity Dispensed No. of Units No. of Days Supply Provided
Quantity Prescribed RX No.
RX Origin
Refill
Refill No.
Dispense as
Prescriber ID (NPI)
Prior Authorization
PA No.
Other Coverage Code
Authorization
Written (DAW)
(PA) Type
UAC Amount
Gross Amount
Formulary
Basis of Cost
Submission Clarification
SCC #1
SCC #2
SCC #3
Due
Status
Code (SCC) Count
DUR Overrides
Reason for Service Code
Professional Services Code
Result of Service Code
Other Payer (Paid)
Coverage Type
ID Qualifier
ID
Date
Amount Paid Qualifier #1 Amount Paid #1
Amount Paid Qualifier #2 Amount Paid #2
Amount Paid Qualifier #3 Amount Paid #3
Other Payer (Deny)
Coverage Type
ID Qualifier
ID
Date
Reject Code(s)
HHS Use Only
Amount Paid
Paid Date
Confidential Health Information Enclosed. The information contained in this facsimile transmission is confidential. It may also be
subject to the attorney-client privilege, work product or proprietary information. This information is intended for the exclusive use
of the addressee named above. If you are not the intended recipient, you are hereby notified that any use, disclosure,
dissemination, distribution (other than to the addressee named above), copying or the taking of any action because of this
information is strictly prohibited. If you have received this information in error, please notify the sender immediately to arrange for
return or destruction of these documents.
Form 1319
October 2020-E
Texas Vendor Drug Program
Pharmacy Claims Billing Request
Submission Explanation (Required)
Date Claim Submitted
Name of Pharmacy
National Provider Information (NPI)
Vendor ID
Area Code and Phone No. of Pharmacy
Area Code and Fax No. of Pharmacy
Cardholder ID
Date of Birth (MMDDYY)
Gender
Date of Service
Date Rx Written
Product ID (NDC)
Prescription (RX) Quantity Dispensed No. of Units No. of Days Supply Provided
Quantity Prescribed RX No.
RX Origin
Refill
Refill No.
Dispense as
Prescriber ID (NPI)
Prior Authorization
PA No.
Other Coverage Code
Authorization
Written (DAW)
(PA) Type
UAC Amount
Gross Amount
Formulary
Basis of Cost
Submission Clarification
SCC #1
SCC #2
SCC #3
Due
Status
Code (SCC) Count
DUR Overrides
Reason for Service Code
Professional Services Code
Result of Service Code
Other Payer (Paid)
Coverage Type
ID Qualifier
ID
Date
Amount Paid Qualifier #1 Amount Paid #1
Amount Paid Qualifier #2 Amount Paid #2
Amount Paid Qualifier #3 Amount Paid #3
Other Payer (Deny)
Coverage Type
ID Qualifier
ID
Date
Reject Code(s)
HHS Use Only
Amount Paid
Paid Date
Confidential Health Information Enclosed. The information contained in this facsimile transmission is confidential. It may also be
subject to the attorney-client privilege, work product or proprietary information. This information is intended for the exclusive use
of the addressee named above. If you are not the intended recipient, you are hereby notified that any use, disclosure,
dissemination, distribution (other than to the addressee named above), copying or the taking of any action because of this
information is strictly prohibited. If you have received this information in error, please notify the sender immediately to arrange for
return or destruction of these documents.