Transcript National Council for Prescription Drug Programs (NCPDP)

Standards For Electronic
Pharmacy Transactions
Patsy McElroy
NCPDP
July 9, 2002
Who Is NCPDP?
The National Council for Prescription
Drug Programs (NCPDP) is an ANSIaccredited standards development
organization representing the pharmacy
industry. We are a membership driven
organization that was named in HIPAA
regulations.
Mission Statement
To create and promote data interchange
standards for the pharmacy services
sector of the health care industry, and to
provide information and resources that
educate the industry and support the
diverse needs of our members.
NCPDP
 ANSI accredited Standards Development
Organization
 Member of the Designated Standards
Maintenance Organization (DSMO)
 Coordination and cooperation for the
maintenance of the HIPAA-named
transaction standards
NCPDP
 Cross representation with other
organizations
 Participation in/from
 WEDi, X12N, HL7
 NACDS, APhA, NCPA, ASAP, and
other pharmacy organizations
NCPDP
 NCPDP, the organization, does not
develop standards
 NCPDP, the Members, develop
standards
 NCPDP, the organization, is the
administrative arm of the Members
NCPDP Membership
 Over 1300 Members
 Consensus building among three
(3) categories
Membership Representation
 Producer/Provider (pink badges)
 Retail Pharmacy, Mail Service Pharmacy, Consulting
Pharmacists, and Manufacturers
 Payer/Processor (green badges)
 BCBS Organizations, HMOs, PBMs, and Government
Payers
 Vendors and General Interest (yellow
badges)
 Drug Wholesalers, Consultants, Clinical Programs,
and Software & Hardware Vendors, Physician
Services Organizations
Voting Categories
Producer/Provider
Payer/Processor
335
514
Vendor/General
Interest
486
Total Members = 1335
NCPDP History
 NCPDP was formed in 1977 to standardize
insurance forms
 NCPDP’s first standardization effort was the
paper universal claim form (UCF) which was
adopted in 1978. Over three billion claim
forms have been distributed
 1988 NCPDP developed Version 1.0 of the
Telecommunication Standard for online, realtime claims processing
NCPDP Work Groups
Telecommunication
Product Identification
Standard Identifiers
Provider Application and
Registration Standard
 Payment Reconciliation
 Manufacturer Rebates
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 Government Programs
 Professional Pharmacy
Services
 Prescriber/Pharmacist
Interface
 Data Security and
Patient Confidentiality
 Maintenance and Control
NCPDP Standards
Telecommunication Standard
 Defines the record layout for on-line, real-time
submission of:
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Pharmacy Claims
Pharmacy Services
Pharmacy Supplies
Reversals
Workers Compensation Claims
Prior Authorization Requests
Controlled Substance Reporting
Information Reporting
Eligibility
Coordination of Benefits
Telecommunication Standard
 Version 5.1 named in HIPAA
 Balloting version 8.0
 Developing post adjudicated history
standard (for auditing, retrospective
DUR, fee evaluations)
Billing Unit Standard
 Defines the standard measure for billing
units of drugs products and provides
guidance on exceptional items
 Enhance definitions of product qualifiers
in the Telecommunication Standard and
identify/define needed additional
qualifiers
Pharmacy ID Card
Implementation Guide
 Defines the format and fields for a
standard Pharmacy ID Card
 Reduce consumer time caused by the lack of
necessary information
 Minimum necessary information on front and back of
card
 Legislated usage or discussion stage in most states. To
date fifteen (15) states have passed legislation, thirtytwo (32) states have introduced legislation on the
uniform Pharmacy ID Card
NCPDP Provider Number
 Pharmacy identification number used
for claims payment purposes
 Implemented on April 1, 1977
 Contains over 60,000 Pharmacies
 Alternate Site Enumeration for licensed
dispensing sites
 BPA Audit Results-98% accuracy
Provider Application and
Registration Standard
 Used for the transfer of electronic
applications and registration information
for providers with Medicaid, Medicare,
third party administrators, prescription
benefit managers and other payer
entities
 In development stage
 Partnering with ACS X12N for use of the
274
Payment Reconciliation Standard
 Defines the format for electronic
transmission of pharmacy payments
 Cross-mapped to ASC X12N 835 and vice
versa
Manufacturer Rebates Standard
 Provides a consistent platform for
sending invoice and paid claims data
electronically between the payer and
labelers
 May be used for commercial, state
Medicaid and state sponsored programs
and their trading partner, the
pharmaceutical manufacturers
 Promoting use of the standard within the
Medicaid community
Batch Standard
 Defines the record layout for batched
pharmacy transactions
 Batch 1.0 named in HIPAA. Was corrected to
Batch 1.1 in correction Notice of Proposed
Rule Making (NPRM)
 Uses Telecommunication Version 5.1 as the
Detail Data Record in the Batch
 Same syntax for transactions, just in a batch file
layout
 Medicaid Subrogation Implementation Guide
Professional
Pharmacy Services Implementation
Guide
 Used to assist with the billing of
Services and Drug Use Review in the
Telecommunication Standard
SCRIPT Standard
 Standard for the communication of
prescription information between
prescribers and pharmacists
 New Prescriptions from the prescriber to the pharmacy
 Change Requests to New Prescriptions by the pharmacy
to the prescriber
 Refill Requests by the pharmacy to the prescriber
 Fill Status from the pharmacy to the prescriber (patient
picked up, patient picked up partial fill, patient never
picked up)
 The ability for a prescriber to cancel a previously
submitted request
 Housekeeping transactions (password change, receive
prescriptions, et cetera)
SCRIPT Standard
 Developing standard for transfer of
prescriptions between pharmacies
 Public Key Encryption (PKI)enabling SCRIPT Standard
HCIdea
 An NCPDP company
 Provide the health care industry with a
quality standard unique provider
identifier
 Establish a unique identifier for
prescribers
 Replace the current use of the DEA
number for claims processing and
adjudication
 Information available from
[email protected]
Attend NCPDP Meetings
August 2002
Washington, D.C.
27th Educational Forum
“HIPAA Privacy and Confidentiality”
28th – 30th Work Groups
November 2002
San Diego, CA
5th Educational Summit
“Understanding Manufacturer Rebates”
6th – 8th Work Groups
Get Involved - Stay Informed
 Become a member
 Attend the quarterly Work Group
Meetings
 NCPDP Now
 Website (www.ncpdp.org)
 Council Connection
 Ask a Staff Member
Thank you
Patsy McElroy
[email protected]
(480) 477-1000 ext. 124