Universal Claim Forms

The NCPDP Universal Claim Forms (UCF) are purchased from CommuniForm.

When existing standard field lengths are not adequate to support business needs, trading partners should come to an agreement on how to utilize the Universal Claim Form for claim submission. This may include adding additional characters to a field. For example, drug costs in excess of $999,999.99 may require adding additional characters to the Ingredient Cost Submitted (UCF Field 81) and/or other currency fields. Trading partners should consider other downstream processes and data exchanges that may be impacted or may not support these larger dollar amounts.

The table below explains. On previous versions of forms (Version 5), compound information was placed on the back of the form. In designing the “Version D.0” and “Workers’ Compensation/Property and Casualty” forms, it was decided that due to additional data elements and the ability to Page: 2 enter individual ingredients of a compound, one prescription per form is supported.

The back of the NCPDP forms contain a list of common data element values. NCPDP has published the Manual Claim Forms Reference Guide for pharmacies or other providers who are filling out the “Version D” Universal Claim Form or the Workers’ Compensation/Property and Casualty Universal Claim Forms. This guide is also for use by health plans/processors who are accepting these claim forms. The guide is available via the customer-only web page of CommuniForm, for entities that purchase the form(s). The guide is also available to NCPDP members within the member portal of the NCPDP website. This guide is copyrighted and cannot be reproduced or distributed. For specific information about what a payer needs to see on the universal claim form, a general rule is to fill out all applicable information. However, the payer should be contacted, or their website referenced for specific information about their requirements within the form.

Where do I find more information about the values to use on the form that are not listed on the back of the UCF?

The Universal Claim Form or the Workers’ Compensation/Property and Casualty Universal Claim Form are to be sent to the insurer/payer/health plan for the patient/member. A completed form must not be sent to NCPDP. NCPDP creates the forms but does not pay or process the claims/bills.