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 Information Reporting transactions

• New functionality was added to the Information Reporting Transactions to support the pharmacy when 340B status was identified after providing service and is required by trading partner agreement to alert the payer

Batch Standard Implementation Guide Version 15

• Increased length of Transaction Reference Number

• Modified examples

• Added FAQs

• Use by multiple entity types was clarified

Subrogation Implementation Guide for Batch Standard Version 10

• Developed to address industry need

– Support compliance with requirements for recovery of federal, state and other plan overpayments

– Reduce manual processes currently required by pharmacies, PBMs and plans

– Provide a uniform approach to efficiently process post-payment subrogation claims and eliminate the numerous proprietary formats used in the industry today

– Achieve payment accuracy and support cost containment efforts

• Used in a batch mode

• Uses the Telecommunication Standard Implementation Guide

Subrogation Implementation Guide for Batch Standard Version 10 • Changes made to the Telecommunication Standard

– A new field, Subrogation Amount Requested, was added to the Pricing Segment.

– Medicaid Paid Amount was deleted from the standard

– A new field, Subrogation Requestors Reconciliation ID was added to the Response Claim Segment.

– Medicaid Subrogation Internal Control Number/Transaction Control Number (ICN/TCN) was deleted from the standard.

– Situations were modified in the Insurance, Patient, Claim, Pricing, Response Insurance and Response Claim Segments to support standardized subrogation.

– Table Designations were modified to remove Medicaid from the subrogation explanation.

NCVHS STANDARDS SUBCOMMITTEE March 26, 2018 Hearing

SNIP (Strategic National Implementation Process)

Annette Gabel – Chair

NCPDP Standards

• Telecommunication Version F2

• The Batch Standard

• The Batch Standard Subrogation Guide

Telecommunication Standard F2 Benefits

• Streamline Processes to maintain compliance

• Enhances reimbursement methodologies

• Enhances the availability of information allowing the pharmacy to better communicate to the patient

• Improves workflow automation

• Enhanced patient safety mechanisms

• Improved patient access to care

• Improved analytics

• Increase interoperability

Telecommunication Standard F2 Source of Benefits

• Modifications to Coordination of Benefits (COB) fields and segments better support the maturing COB environment and assist pharmacy providers and downstream payers in making claim billing decisions based on previous benefits and payment amounts.

• Enhancements to response segments that replace or supplement text messaging with codified information to better support workflow automation.

• Enhancement of the Eligibility Transaction (E1) and claim response transactions will provide better benefit identification and assist in coordination of benefits.

• Enhancements to the Request Claim segment that will provide additional information to improve patient safety. (for example: Opioid Prescriptions)

Telecommunication Standard F2 Source of Benefits (Cont.)

• Enhancements to the Prescriber Segment will improve prescriptive authority validation and reduce point of service conflicts and expedite patient access to care.

• Enhancements to the Sales Tax to provide clarity around the type of tax/fee submitted and paid as well as tax exemption status – New Pricing Segment fields in the request and response to improve the identification and flexibility of changes related to tax and regulatory fees.

• Expansion of the BIN/IIN routing identifier field will support the needs for IINs.

• Expansion of the Product/Service ID field will support alternate identifiers e.g. UDI

Telecommunication Standard F2 Source of Benefits (Cont.)

• Harmonized format of demographic attributes across the NCPDP standard supporting interoperability within NCPDP

• Harmonization of PA numbers to AN to match X12

• Intermediary segment created for REMS process

• Required identification of support centers/help desk to streamline communication protocols and claim resolution processes

• Removed Controlled Substance Transactions from the Telecommunication Standard to allow alignment with independent regulatory timelines.

Telecommunication Standard F2 Time Frame for Implementation

• Minimum of 3 Years

– Final Rule Publication Date 12/2019

– Used in Production Date 6/2022

– Compliance Date 6/2023

Benefits of the Batch Standard

• The updated Batch Standard enhances interoperability through documentation changes that were made to further clarify which entities are allowed to use the Batch Standard and under which situations.

• Reduces administrative cost by having one Batch Standard that aligns with the Telecommunication Standard Version F2 Implementation Guide.

Benefits of the Batch Standard Subrogation Implementation Guide

• Improves transparency through enhanced ability to accurately report subrogated pricing between trading partners

• Reduces administrative cost and increases interoperability by providing a single standard that can be used by a wider variety of payers.