Direct Member Reimbursement Form Page 2
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2CLAIM SUBMISSION
When submitting a claim, the following information
must be included on all pharmacy receipts or printouts.
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Pharmacy printout
Pharmacy Name
Date Purchased
NDC#
or Rx label must
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include:
Pharmacy NCPDP
Drug Name
Drug Charge
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Prescription #
Quantity
Strength
DO NOT include charges for durable medical equipment which required a prescription to obtain. No benefits will be
provided under this contract for such items.
DO NOT submit cancelled checks, cash register slips, or personal itemization. These are not acceptable as substitutes
for original Rx labels.
DO NOT submit statements with ‘balance’ amounts only.
Pharmacy printouts require a pharmacist signature.
Claims older than six months are not eligible for reimbursement.
HOW TO COMPLETE THIS FORM
Complete all member and patient information in Part 1 on reverse side.
Cardholder/
Patient Information
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The cardholder ID number can be found on your ID card.
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The group is the name of your company or association through which you have coverage.
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Sign and date in the space provided.
Your signature certifies that the information is correct and complete.
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Complete a separate form for each family member.
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Obtain claim forms from your company association and mail directly to Argus Health Systems.
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Please make a copy of all documents and receipts before you send to Argus as no documents will be returned.
MAIL THIS FORM TO:
Arkansas BCBS
Dept. #276
Argus Health Systems
PO Box 419019
Kansas City, MO 64141
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