Mtm Billing Form Washington State Pharmacy Association
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1
2Prescriber Consultation
REASON: Drug Therapy Problem Detected
ACTION: Prescriber Consultation
MTM Billing Form
3
RESULT: Resolution of Drug Therapy Problem
Pharmacists Name ___________________________________________________ Pharmacy Phone (____)____________________________
Pharmacist ID (WA + last 5 # of license) ________________________________Pharmacists Outcomes Password ______________________
Pharmacy Name/Location ___________________________________________________ Pharmacy NABP______________________________
1. Describe the clinical situation that support(s) the selection of REASON.
Note: If choosing Other
170 or Other 370,
provide description of
2. Describe specific recommendation to the prescriber and the prescriber’s response.
the clinical situation,
pharmacist intervention,
and final outcome.
3. Rationale to support the ECA level selected.
4. List NDC, name, dose and qty for the drugs associated with Drug Therapy Problem (original drug, newly initiated drug or both interacting drugs).
Other Notes:
REMEMBER: If you have indicated patient will need a new/changed medication, a Patient Education and Monitoring Claim Encounter may result from this service.
Centralized Billing Option Provided by the:
How to Submit Claim: WRITE LEGIBLY and Fax to WSPA at (425)277-3897
Washington State Pharmacy Association
Billing submitted to Outcomes within 5 business days. WSPA will charge a processing fee of $2.00 per claim.
Questions? Call WSPA (425) 228-7171
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