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Standards For Electronic Pharmacy Transactions Lynne Gilbertson NCPDP August 1-2, 2002

Who Is NCPDP?

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NCPDP NCPDP, the organization, does not develop standards NCPDP, the Members, develop standards NCPDP, the organization, is the administrative arm of the Members Over 1300 members representing Retail Pharmacy, Mail Service Pharmacy, Consulting Pharmacists, and Manufacturers BCBS Organizations, HMOs,  Pharmacy Benefit Managers (PBMs), and Government Payers Drug Wholesalers, Consultants, Clinical Programs, and  Software & Hardware Vendors, Physician Services Organizations

NCPDP History NCPDP was formed in 1977 to standardize prescription insurance forms 1978 the paper Universal Claim Form (UCF) was adopted Over three billion claim forms have been distributed 1988 NCPDP developed Version 1.0 of the Telecommunication Standard for online, real-time claims processing

NCPDP Work Groups Telecommunication Product Identification Standard Identifiers Provider Application and Registration Standard Payment Reconciliation Manufacturer Rebates 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: Pharmacy Claims Pharmacy Services Pharmacy Supplies Reversals Workers Compensation Claims Prior Authorization Requests Controlled Substance Reporting Information Reporting Eligibility Coordination of Benefits

Telecommunication Standard Over 3 billion claims annually use NCPDP Telecommunication Standard Version 5.1 named in HIPAA Balloting version 8.0

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, thirty-two (32) states have introduced legislation on the uniform Pharmacy ID Card

Payment Reconciliation Standard Defines the format for electronic transmission of pharmacy payments Cross-mapped NCPDP Standard 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 Used for commercial, state Medicaid and state sponsored programs and their trading partner, the pharmaceutical manufacturers

Batch Standard Defines the record layout for batched pharmacy transactions Batch 1.0 named in HIPAA. 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 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)

Standards In Development Post-Adjudicated History Standard for auditing, retrospective DUR, fee evaluations Prescription Transfer Standard Transfer between pharmacies

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

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

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 rbranson@ncpdp.org

Attend NCPDP Meetings Educational Forum - “HIPAA Privacy and Confidentiality” August 27, 2002 Washington, D.C. 28th – 30th  Work Groups Educational Forum – “Discount Cards and Coupons – Rx for Health Care?” September 12, 2002 San Francisco, CA Educational Forum – “Discount Cards and Coupons – Rx for Health Care?” October 1, 2002 Chicago, IL Educational Summit – “Understanding Manufacturer Rebates” November 5, 2002 San Diego, CA 6th – 8th Work Groups

Healthcare Opportunities More industry involvement in Standards Organizations Education Of industry initiatives Of standards usage Meet the needs of industry Open forum discussions Bring together different topic subject matter experts

Healthcare Opportunities Sharing of nomenclature initiatives Too many at cross purposes? Initiatives are unknown?

Healthcare Considerations Consider the industry Consider the business practices and workflow Enhance what is currently available, not force new technologies Use the momentum of existing standards in use If “this” was easy, everyone would be doing it

HIPAA Considerations HIPAA is not a “one size fits all” (Although it may attempt) Many open issues still “Conformance” may be a thought for the future, but many are implementing now CMS, SDOs, code set developers, and the industry must work more closely for the future – before the regs are written

"Thank you" Thank you Lynne Gilbertson lgilbertson@ncpdp.org (480) 477-1000 ext. 120