Get Wellpoint D0 Payer Sheet Form

Filling out the Wellpoint D0 Payer Sheet Form online can streamline your claims processing with Express Scripts. This guide provides clear and supportive instructions for navigating each section of the form effectively.

Follow the steps to complete the Wellpoint D0 Payer Sheet Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the appropriate editor.
2. Begin by entering the Payer Name, which is 'Express Scripts, Inc.'
3. Input the Date of Service as specified for the transaction.
4. Fill out the Claim Billing section, starting with mandatory fields like BIN Number, Version Release Number, Transaction Code, and Processor Control Number.
5. Proceed to the Insurance Segment, ensuring to accurately enter Cardholder ID, First and Last Name, and Plan ID.
6. Complete the Patient Segment with required details such as Patient ID, Date of Birth, and Patient Gender Code.
7. In the Claim Segment, ensure to provide all mandatory fields including Prescription/Service Reference Number and Product/Service ID.
8. Continue filling the Pricing Segment followed by the Prescriber Segment, ensuring that all mandatory parts are filled in.
9. Review any situational segments necessary for coordination of benefits or DUR/PPS information.
10. Finally, after all required fields are completed, save your changes and options available include downloading, printing, or sharing the form.

Complete your Wellpoint D0 Payer Sheet Form online today for faster claims processing.