Optumrx pharmacy manual claim form

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Pharmacy providers may request a price review by submitting a fully completed Claim. Reimbursement Review/Appeal Form to OptumRx within seven (7) business daysComplete and return this form when you have purchased a covered prescribed prescription drug at retail cost and are seeking reimbursement. Submit this form. Additional information and instructions on back, please read carefully. Send completed form with pharmacy receipt(s) to: OptumRx Claims Department, The Administrator Provider Manual (PM), also known as “Provider Manual”, includes the Claim form used by Network Pharmacy Provider for manual billing. Either complete Section A OR attach pharmacy receipts. Print the front and back pages and send completed form to: Optum Rx Claims Department, PO Box 650334, Coverage provided by Kaiser Foundation Health Plan of Washington. Complete this form, attach prescription labels and mail to: Optum Rx Manual Claims. and Kaiser Foundation Health Plan of Washington Options, Inc. Complete this form, attach prescription labels and mail to: Optum Rx Manual Claims. Online Claim Form: UHG, Medicare, PDP, MAPD, Commercial, PPO, Union and Others PDF · Claim Form United Health Group PDF · Claim Form Medicare Part D PDF · Claim Send completed form with pharmacy receipt(s) to: OptumRx Claims Department, P.O. Box 650334, Dallas, TX 75265-0334. Note: Cash and credit card receipts are not