Get Hi 204 Instructions 2007-2025

The HI 204 Instructions provide a structured approach to completing the prescription drug claim form for the Fee For Service program. This guide will walk you through each section of the form to ensure accurate and efficient submissions.

Follow the steps to accurately complete the HI 204 Instructions.

1. Click the ‘Get Form’ button to access the HI 204 Instructions form and open it in your browser.
2. In the identification number field, enter the recipient’s identification number as required.
3. Fill in the recipient’s name, including their first and last name, in the designated field.
4. Input the recipient’s date of birth in the format mm/dd/yyyy, ensuring accuracy for identification purposes.
5. Enter the pharmacy’s National Provider Identifier (NPI) number in the relevant field.
6. Provide the name of the pharmacy where the prescription was filled.
7. Complete the pharmacy’s address, including city and zip code.
8. Input the prescriber’s NPI number in the respective field.
9. For controlled substances (C II – V drugs), enter the prescriber’s Drug Enforcement Agency (DEA) number.
10. Fill in the prescriber’s name as it appears on their official documents.
11. Indicate the status of other drug or liability coverage; if none, check 'No'; if applicable, check 'Yes' and specify the coverage name.
12. Enter the date of the accident or injury if applicable.
13. Check the appropriate box to indicate whether the illness or injury was work-related, third party, an automobile accident, or another type.
14. Indicate if the recipient is an ICF-MR/ICF/SNF by checking the appropriate box.
15. In the RX number field, enter the prescription number provided by the pharmacy.
16. Enter the metric quantity prescribed, ensuring to include decimal amounts if necessary.
17. Select the appropriate billing unit for this prescription from the National Council for Prescription Drug Program’s (NCPDP) list: Gm for grams, ML for milliliters, or Each for other forms.
18. Specify the number of days supplied for the prescription in the designated area.
19. Record the NDC number in the correct format: ##### - #### - ##.
20. Enter the date of service in the format MM/DD/YYYY.
21. Specify whether this submission is for a new prescription or a refill by checking the appropriate option.
22. Detail the name of the drug prescribed and its strength in the respective fields.
23. Enter the ‘dispense as written’ (DAW) code, selecting from the available options (0, 1, 5, 7, or 9).
24. If applicable, include the prior authorization number provided by the prescriber.
25. Provide the reason for a refill too soon override, selecting from the given categories.
26. If the prescription is a compound, check the corresponding box.
27. Enter the submitted charge amount for the prescription.
28. Document the amount paid by any third-party liability (TPL) and ensure to attach a copy of the Explanation of Benefits (EOB).
29. Calculate and enter the total amount for the drug, which is the submitted charge minus any TPL amount if applicable.
30. Before submission, ensure that any applicable notes (such as Early Refill, Spend Down, TPL) are clearly labeled on the document.
31. Save the completed form. Choose to download, print, or share your form as needed before submitting.

Start filling out your HI 204 Instructions online today for a smooth submission process.