07=NCPDP) Insert Insert Service Insert Service Insert Pharmacy Name Provider ID Number of Provider ID 2008 (e.g., Pharmacy) Qualifier PDEs Jill’s (e.g., (e.g., (e.g., 590) 0101011111) (etc.) (Insert Name, e.g., Pharmacy) Pharmacy’s Jack’s (Insert Justification for Pharmacy) Jack’s SAMPLE: The RAC audit as being excluded. In our investigation misidentified Jack’s Pharmacy we have found that has never been excluded from the Medicare Program. The Jack’s Pharmacy exhibits that have been submitted as our supporting documentation related to Jack’s Pharmacy are listed below. (List non-PDE exhibits related to Pharmacy) Jack’s (Insert Name, e.g., Pharmacy) Pharmacy’s Jill’s (Insert Justification for Pharmacy) Jill’s SAMPLE: The RAC audit misidentified Pharmacy as being excluded. In our investigation Jill’s we have found that Pharmacy has never been excluded from the Medicare Program. The Jill’s exhibits that have been submitted as our supporting documentation related to Pharmacy are Jill’s listed below. (List non-PDE exhibits related to Pharmacy) Jill’s (etc.)
07=NCPDP) Insert Pharmacy Name (e.g., Jill’s Pharmacy) Insert Service Provider ID Qualifier (e.g., Insert Service Provider ID (e.g., 0101011111) 2008 Insert Number of PDEs (e.g., 590) (etc.) (Insert Pharmacy’s Name, e.g., Jack’s Pharmacy) (Insert Justification for Jack’s Pharmacy) SAMPLE: The RAC audit misidentified Jack’s Pharmacy as being excluded. In our investigation we have found that Jack’s Pharmacy has never been excluded from the Medicare Program. The exhibits that have been submitted as our supporting documentation related to Jack’s Pharmacy are listed below. (List non-PDE exhibits related to Jack’s Pharmacy) (Insert Pharmacy’s Name, e.g., Jill’s Pharmacy) (Insert Justification for Jill’s Pharmacy) SAMPLE: The RAC audit misidentified Jill’s Pharmacy as being excluded. In our investigation we have found that Jill’s Pharmacy has never been excluded from the Medicare Program. The exhibits that have been submitted as our supporting documentation related to Jill’s Pharmacy are listed below. (List non-PDE exhibits related to Jill’s Pharmacy) (etc.)