Pharmacy Online Rate Review Request

Mississippi: Request to Add State AAC Rate for Reimbursement

Pharmacy Provider Information:

Pharmacy providers should use this form after receiving a claims rejection code stating "NO RATE ON FILE." NOTE: All fields marked with an asterisk (*) must be completed for proper submission of this form. Please do not include any personal health information (PHI) with submitted form or invoice. For a downloadable Acrobat PDF version of this document, see the Help Desk section on the main Mississippi pharmacy page.

Inquiry Type:(Required)

Pharmacy Name:(Required)

NPI:(Required)

Address(Required)

City State / Province / Region

Phone:(Required)

Email:(Required)

Drug Information:

Please enter information for one (1) drug per submission form

Drug Name:(Required)

National Drug Code (NDC):(Required)

Provider Cost Information:

Cost Per Package:(Required)

Package Size:(Required)

Date of Purchase:(Required)

Claim Information:

Dispense Date:(Required)

Quantity Dispensed:(Required)

Dispensing Fee:(Required)

Is this a new NDC?(Required)

Comments:

Please fax or email the completed form to: Pharmacy Unit: Fax: 317-571-8481, Email: mspharmacy@mslc.com. Be sure to include copies of your purchase records that confirms your acquisition costs in addition to alternate NDC information. Once complete information is received, we will evaluate your inquiry and respond within 24 hours. For questions or to check the status of an inquiry, please contact us by e-mail at MSPharmacy@mslc.com or by phone at 800-591-1183.

Person Submitting This Request(Required)

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Pharmacy Online Rate Review Request

Mississippi: Request to Add State AAC Rate for Reimbursement

Pharmacy Provider Information:

Drug Information:

Provider Cost Information:

Claim Information:

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