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Forms & Documents
Payer sheets provide data requirements needed to electronically process NCPDP pharmacy claims for each line of business within Capital Rx. Each line of business will have a designated payer sheet for reference when setting up Capital Rx BIN/PCN numbers into the pharmacy system.
Last updated: December 2024
Reversal Payer sheets provide data requirements needed to electronically process NCPDP pharmacy claim reversals for each line of business within Capital Rx. Each line of business will have a designated reversal payer sheet for reference when a pharmacy chooses to reverse claims submitted to Capital Rx from their pharmacy system.
Last updated: October 2021
Please call us at (888) 832-2779 and our support team will work with you to validate the member's eligibility.
To submit a prior authorization (if required), please complete the prior authorization request form and fax it (along with any additional documentation required) to (833) 434-0563.
Prior authorization request forms can also be sent via mail to the below address:
Capital Rx
Attn: Prior Authorization
9450 SW Gemini Dr., #87234
Beaverton, OR 97008
The specific state specific additional requirements below for Arkansas, Mississippi, New Mexico, and Tennessee.
Pricing appeals must be submitted within 30 days from the date the claim was filled or within the time period required by applicable state law. Pricing appeals that are submitted outside of this timeframe may NOT be reviewed.
Note that pricing appeal submissions with missing information will be invalid and excluded from review. As permitted with applicable law, pricing appeal reviews of any individual claim from a pharmacy are final and will NOT be reviewed again.
Please note that the Capital Rx pricing appeal review process does not provide clinical advice nor direction for product substitutions. Please refer to your state substitution laws.
Questions related to the pricing appeals may be submitted to pricing.appeals@cap-rx.com or 833-502-1220.
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Our number one priority is ensuring the health and safety of our members through access to over 65,000+ retail pharmacies.
FAQ
Frequently asked questions
What BIN number is used to adjudicate claims?
Our BINs 610852 and 610770 adjudicate on Capital Rx's platform. For additional information on these BINs, please consult the payer sheet for Capital Rx.
What do I do if a claim rejects?
Please call us at (888) 832-2779 and our support team will work with you to resolve the rejection as quickly as possible.
What do I do if I cannot confirm a member's eligibility?
Please call us at (888) 832-2779 and our support team will work with you to validate the member’s eligibility. If for any reason the issue cannot be resolved in real-time, please suggest that the patient pay for the prescription upfront and, once the eligibility error has been corrected, submit a paper claim to us.
What should I do if a member thinks that his/her out-of-pocket obligation is incorrect?
Please call us at (888) 832-2779 to verify the patient pay amount.
How long does a prior authorization review take?
Most prior authorization reviews are completed within two business days provided that a complete prior authorization request form and all required documentation are correctly submitted. Our clinical team will notify you in advance of any declinations and assist in expediting your patient to a preferred alternative therapy.
How can I join the Capital Rx pharmacy network?
To join our network, please contact us at provider.relations@cap-rx.com.
Who do I contact for payment/remittance questions?
Please send your questions to ap@cap-rx.com.
