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  • NCVHS NCPDP Standards Update Background

    Margaret Weiker | NCPDP Director of Standards Development

  • About Us

    • NCPDP is a not-for-profit, American National Standards Institute (ANSI)-accredited, Standards Development Organization (SDO) with over 1,400 members representing virtually every sector of the pharmacy services industry.

    • NCPDP is a member-driven organization. Our diverse membership provides leadership and healthcare business solutions through education and standards, created using the consensus-building process.

    • Real-time Prescriber and Pharmacy Data Products

    • Best Practices for Patient Safety – Safe Use of Acetaminophen, mL Dosing

  • Background - Timeline

    • January 2009

    – Telecommunication Standard Implementation Guide Version D.0

    – Batch Standard Implementation Guide Version 1.2

    – Batch Standard Medicaid Subrogation Implementation Guide Version 3.0

    • Transactions: – Health care claim or equivalent encounter information;

    – Eligibility for a health plan;

    – Referral certification and authorization;

    – Coordination of benefits; and

    – Medicaid pharmacy subrogation

  • Background - Timeline

    • October 2010

    – HHS published Maintenance Notification to correct errors in the Telecommunication Standard

    • November 2014

    – NCPDP WG1 participants began discussing moving to a new version of the standards

    • February 2015

    – NCPDP WG1 participants voted to bring forward the balloted version out of August 2016 as the next HIPAA version

  • Background - Timeline

    • August 2016

    – NCPDP WG1 participants voted to delay the next version to be adopted under HIPAA by six months (February 2017)

    • August 2017

    – DSMO Requests were entered

    • January 2018

    – DSMO Letter to NCVHS

  • DSMO Request 1201 The NCPDP membership is requesting a new version of the Telecommunication and Batch Standard be named in HIPAA. The Telecommunication Standard Implementation Guide is version F2. The Batch Standard Implementation Guide is version 15, which supports the Telecommunication Standard version F2 in a batch mode. The Telecommunication Standard Implementation Guide supports the following processes: 1. Eligibility Verification 2. Claim 3. Service 4. Information Reporting 5. Prior Authorization 6. Predetermination of Benefits NCPDP is requesting the DSMO approve this change request and thus begin the process for a new version to be named in HIPAA.

  • DSMO Request 1202

    The NCPDP membership is requesting the Subrogation Implementation Guide for Batch Standard version 10 be named in HIPAA to replace the Medicaid Subrogation Standard Implementation Guide, version 3.0 for Medicaid use only. The Medicaid Subrogation Implementation Guide was established to address the Federal and State requirements for Medicaid Agencies to seek reimbursement from the correct responsible health plan. However, the Medicaid Subrogation Implementation Guide did not address similar requirements for other payers, such as Medicare Part D, State Assistance Programs or Private Health Plans.

  • DSMO Request 1202 • A standardized Subrogation Implementation Guide is needed to:

    1. Support compliance with requirements for recovery of federal, state and other plan overpayments 2. Reduce manual processes currently required by pharmacies, PBMs and plans 3. Provide a uniform approach to efficiently process post-payment subrogation claims and eliminate the numerous proprietary formats used in the industry today 4. Achieve payment accuracy and support cost containment efforts The Medicaid Subrogation Implementation Guide was used as the base to create the Subrogation Implementation Guide. NCPDP is requesting the DSMO approve this change request and thus begin the process for the standard to be named in HIPAA for use by Medicaid Agencies.

  • Telecommunication Standard Version F2

    • 111 Data Element Request Forms (DERFs) requesting changes to the standard

    – 218 data elements have been added

    – 46 data elements have been sunset

    • 156 DERFs requesting changes to the NCPDP External Code List (ECL)

    – 152 existing data elements had values added, redefined or renamed

    – 211 reject codes were added

    – 125 reject codes were sunset

  • Telecommunication Standard Version F2 Notable Changes • Support for the 8 byte IIN was added and the BIN number was

    removed

    • The Compound Product ID, DUR Co-Agent ID, Generic Equivalent Product ID, Originally Prescribed Product/Service Code, Preferred Product ID, and Product/Service ID field lengths were increased to 40 characters

    • Total Prescribed Quantity Remaining was added for controlled substance use. This field allows the processor to identify the accumulated prescribed quantity remaining

    • The situation for Quantity Prescribed was updated

    • Prescriber DEA Number was added to support the submission of the Prescriber’s DEA Number for controlled substance claims.

  • Telecommunication Standard Version F2 Notable Changes • Do Not Dispense Before Date was added to support providers

    writing multiple, one month prescriptions for C-IIs as well as state requirements on the number of days a patient has to fill a controlled substance from the date written.

    • Modified Benefit Stage Fields to allow usage by other payers and supplemental payers

    • Added a new eligibility segment to support CMS’ enhancements to eligibility data

    • A new grouping of fields was added to the Response Status segment to allow comprehensive communication of Help Desk Contact information

    • Multiple transactions within a transmission has been removed

  • Telecommunication Standard Version F2 Notable Changes • Added 14 fields to support plan benefit parameters

    • Other Payer Benefit Classification was added to the Response Other Payers Segment

    • Combination of Other Payer Relationship Types, Other Payer Benefit Classification, Other Payer Adjudicated Program Type and Other Payer Coverage Type provides the appropriate information to the pharmacy provider to manage the other payer information

    • Coordination of Benefits/Other Payments Count was reduced to a maximum count of 3

    • Mandated return of Reconciliation ID

  • Telecommunication Standard Version F2 Notable Changes • Harmonized 28 demographic fields with other NCPDP standards

    • Added functionality for REMS and PDMP

    • A Pricing Guidelines Section was added

    • A new COB Processing Guideline section was added

    • Added 4 fields to support the association of a partial fill claim billing or service billing to the original billing

    • The Controlled Substance Reporting, Reversal, and Rebill transactions (C1, C2, and C3) were removed

    • Sales tax fields and definitions were modified to support all tax type amounts

  • Telecommunication Standard Version F2 Notable Changes • Three new fields were added to support compounds – Compound

    Level of Complexity, Preparation Environment Type, and Preparation Environment Event Code

    • Added Benefit Type Opportunity Count and Benefit Type Opportunity to provide additional information on the patient’s benefit

    • Payer ID Qualifier and Payer ID fields were restructured to allow multiple identifiers to be returned on a single transaction response

    • Added Submission Type Code Count and Submission Type Code to identify the type of submission as needed for appropriate transaction processing

  • Telecommunication Standard Version F2 Notable Changes • Added Multiple Prescription/Service Order Group ID and Multiple

    Prescription/Service Order Group Reason Code to indicate the reason why multiple prescriptions for the same patient are being grouped together

    • A new datatype of ECS (Email Character Set) was added to the standard. The Patient E-Mail Address character designation was modified to this new datatype

    • The Response Other Related Benefit Detail Segment was modified by adding 16 fields to support commercial insurance benefits and to build in flexibility to support future benefit details.

    • Duplicate logic has been enhanced for downstream payers

  • Telecommunication Standard Version F2 Notable Changes • Added eight new fields to the Response Claim Segment to support

    the identification of the reason for formulary alternatives and the identification of required treatment

    • The Provider First Name and Provider Last Name were added. These new fields are used for Workers’ Compensation to report the provider responsible for the dispensing as required by state regulation

    • The Original Manufacturer Product ID and Original Manufacturer Product ID Qualifier were added

    • Added a situation to Compound Type to support Workers’ Compensation/Property and Casualty statute/regulation

  • Telecommunication Standard Version F2 Notable Changes • Created new transaction payer identification fields and a new

    segment to support Informa

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