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Elizabeth M. Whitehorn, Director

Payor Sheet

Specific programming instructions for submittal of NCPDP D.0 format transactions are contained in each payor sheet. Pharmacies are encouraged to pay particular attention to the Coordination of Benefits/Other Payments Segment Questions section of the payor sheet.

 

Illinois Medicaid NCPDP Version D.0 Payor Sheet (PDF)   (Updated 12/1/2017)

 

Illinois Medicaid NCPDP Version E1 Payor Sheet (PDF)

Pharmacies may also submit claims electronically via the Internet through the Illinois Rx Provider Portal using Direct Data Entry (DDE). Users may submit claims, and receive a real-time response to claims submission. Registration to the ILLINOIS Rx Provider Portal is available free of charge to pharmacies registered with IMPACT. 

Note: The DDE system may be used to submit a claim or request a prior approval, but does not have the capability to reverse a claim.

For additional questions or assistance regarding the Payor Sheet, or submission of claims via DDE, please contact a Bureau of Professional and Ancillary Services Pharmacy Billing Consultant at 877-782-5565.