Get Catarman Direct Member Reimbursement Form 2011-2025

Filling out the Catarman Direct Member Reimbursement Form online is a straightforward process. This guide will walk you through each section of the form to ensure you provide all necessary information for a successful reimbursement request.

Follow the steps to complete the reimbursement form accurately

1. Press the ‘Get Form’ button to retrieve the reimbursement form and open it in the editing interface.
2. Begin by providing the patient's full name in the field labeled 'Prescription filled for (Patient Name)'. Ensure this matches the name on the prescription.
3. Enter the date of birth of the patient in the 'Date of Birth (Patient DOB)' field. This information is vital for verifying the patient's identity.
4. Locate and input the Plan Participant Identification Number found on the prescription card into the 'Plan Participant Identification Number' field.
5. Fill out the 'Mailing Address' section with the patient's current address to receive the reimbursement check.
6. Document the plan name, which is usually the employer or group name, in the 'Plan Name' field.
7. Provide the prescription number (Rx #) in the appropriate section, using the specific number assigned to the prescription.
8. Input the pharmacy's NABP or NPI number as required in the form.
9. Fill out the 'Fill Date' with the exact date when the prescription was filled.
10. List the drug name along with its strength in the field labeled 'Drug Name (including strength)'.
11. Enter the National Drug Code (NDC) number in the respective field to help process the claim efficiently.
12. Provide the physician's DEA or NPI number as part of the claim requirements.
13. Fill in the quantity of the medication received and the days' supply for clarity on the prescription length.
14. Document the total amount paid for the medication in the 'Amount Paid' section.
15. If you do not have a detailed receipt, have the pharmacist sign and date the form in the 'Pharmacist Signature' section and enter the pharmacy’s phone number.
16. Select the appropriate reason for the reimbursement request by checking one of the options provided to ensure proper processing.
17. Review all entries for completeness and accuracy. Make any necessary edits before finalizing.
18. Save changes to the form once all fields are filled out correctly. You may then download, print, or share the completed form as needed.

Start filling out your reimbursement form online to ensure a smooth claims process.