NCPDP, HIPPA, SCRIPT and V5.1 Overview

Phillip D. ScottNCPDP Senior Vice President

July 10, 2001

Agenda

• Who is NCPDP?

• Where have we been?

• Where are we?

• Where are we going?

• How can I get involved?

Who is NCPDP?

Who is NCPDP?

The National Council for Prescription Drug Programs (NCPDP) is an ANSI-

accredited standards development organization representing all facets of

pharmacy. We are a membership driven organization that was named in federal

legislation (HIPAA).

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.

Vision Statement

To be the model forum which empowers our members to enhance the quality of

health care through the creation of information solutions.

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

Voting Categories

Producer/Provider

314

Payer/Processor

509

Vendor/General Interest 477

Total Members = 1301

Where Have We Been?

NCPDP History

Pharmacies started installing computer systems in the late 1970’s First systems were installed on the IBM Series 1

Pharmacies started submitting computer generated paper claims to insurance companies

Every insurance company had their own unique form

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.

NCPDP History

1987 PCS introduced electronic claims Black Box that uses telephone line to call

PCS direct Proprietary format

Other PBMs (Pharmacy Benefit Managers) followedInstead of multiple form types, pharmacies now had multiple black boxes on their counters

NCPDP History

1988 NCPDP developed Version 1.0 of the Telecommunication Standard1988 Pharmacy software vendors and chains started coding for electronic claims No more double entry No need for black boxes Use of switching companies like

ENVOY/WebMD and NDC Health

Where Are We?

Standards Related to Electronic Prescribing

NCPDP has two standards that directly relate to electronic prescribing:

Telecommunication Standard

SCRIPT Standard

What is Telecom? Telecom is a data transmission standard

intended to facilitate the communication of prescription information between pharmacies and payers. It is used billions of times each year.

Telecom Standard Version History

Version 1.0 released in 1988

Version 3.2 in 1992

Version 3.3 in 1996 Compound Ingredients

Version 4.0 in 1997

Version 5.0 in 1999

What is SCRIPT?

SCRIPT is a data transmission standard intended to facilitate the communication of prescription information between prescribers and pharmacists.

SCRIPT Standard Version History

Version 1.0 was approved in April 1997

Version 3.1 was ANSI Accredited in 2000

Version 4.1 is in balloting status now

SCRIPT Can Be Used For

New Prescriptions from the prescriber to the pharmacyChange Requests to New Prescriptions by the pharmacy to the prescriberRefill Requests by the pharmacy to the prescriber

SCRIPT Can Be Used ForFill 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 requestHousekeeping transactions (password change, receive prescriptions, et cetera)

Every Business Request Transaction Includes:

Electronic envelopeSection to define the PrescriberSection to define the PharmacySection to define the Patient

Electronic Envelope Includes:

Sender ID

Receiver ID

Syntax information (version/release, delimiters)

Type of Message

Password

Trace Numbers

Date/Time

Prescriber Information May Include:

Identifier (State License, DEA, etc)

Prescriber name

Business name

Business address information

Phone number (telephone, beeper, fax)

Specialty Code (AMA Self-Designated Practice Specialty/Areas of Practice Code)

Authorizing Prescriber Agent Name

Pharmacy Information May Include:

Identifier (NCPDP Provider ID)

Pharmacy name

Pharmacist name

Pharmacy address information

Phone number (telephone, beeper, fax)

Patient Information May Include:

Patient Name

Date of Birth

Gender

Patient Address

Patient Phone Number

Relationship to Cardholder

Pharmacy/Prescriber’s internal Patient ID

Every Response Transaction Includes:

Electronic envelope

Response Status Acknowledgement of the receipt of the transaction

or “Paired” response transaction to the request which

may Approve the request Approve the request with changes Deny the request

Acknowledgement of an error in the transaction

Version 5

HIPPA Legislated Standard

Enhancements requested & approved for Version 5

Version 5 is a complete rewrite to the NCPDP Telecommunication Standard. It includes: New data elements Removed obsolete data elements

deleted Additions/modifications to the data

dictionary

Enhancements requested & approved for Version 5

The $ fields size have been increased Old size maximum was $9,999.99 New size is $999,999.99

Field Qualifiers were added NDC or UPC DEA, State License #, UPIN or Third Party ID

Enhanced Coordination of Benefits Secondary/Tertiary can see primary reject

codes Secondary/Tertiary can see all primary

payments (both Rx and Service Claims)

Enhancements requested & approved for Version 5

Expanded DUR (Drug Utilization Review) capability Ability for Provider to respond to multiple

alerts (Reason for Service Codes) in one transaction

Ability for Providers to send PPS codes and supporting info on claim

Professional Service Claim Claim can be submitted for service without

having to have an Rx Service Claim can refer to an Rx Easier for pharmacy to reconcile

Enhancements requested & approved for Version 5

Partial Fill capability Pharmacy can report the dispensing

of an initial partial fill (25 out of 30) Pharmacy can report the dispensing

of the remaining quantity without Additional dispensing fee Additional refill number DUR warnings

Duplicate therapy Too soon to refill

What’s new in Version 5?Segments restructures for efficiency Data elements grouped into logical

segments Variable format

Additional business functions Prior authorization enhanced Controlled substance reporting added Information reporting added

Where are We Going?

What We Know About HIPAA

• NCPDP Telecommunication Standard v5.1

• NCPDP Batch Standard v1.1

• ASC X12N 834

• ASC X12N 835

• Privacy Rules

What is Still to Come with HIPAA?

NPRM for Transactions and Code Sets (revisions/clarifications)NPRM for NDC versus HCPCS ClarificationsUnique Identifiers for Providers, Payers, Employers, and IndividualsSecurity RulesPrivacy Rule ModificationsEnforcement Rules

How NCPDP Helps Industry Plan for HIPAA?

NCPDP is a Designated Standards Maintenance Organization (DSMO) Pharmacy Strategic National Implementation Process (SNIP)August SummitWork Groups Continue to Monitor and Respond to HIPAA Rules Task Groups working to answer DHHS questions

Future Initiatives NCPDP has In Store

The Council’s newest project, HCIdea,

will establish a unique identifier

for prescribers.

How Can I Get Involved?

Attend NCPDP Meetings

August 2001 in Baltimore, MD4th Summit

5th Educational Forum6th – 8th Work Groups

November 2001 in Orlando, FL13th Educational Forum14th – 16th Work Groups

March 2002 in Phoenix, AZ23rd – 24th Work Groups24th – 27th Conference

How Can I Follow the Council’s Activities?

Become a memberAttend the quarterly Work Group MeetingsNCPDP NowWebsite (www.ncpdp.org)Council ConnectionAsk a Staff Member