Standards For Electronic Pharmacy Transactions

1. Standards For Electronic Pharmacy Transactions Patsy McElroy NCPDP July 9, 2002

2. Who Is NCPDP? The National Council for Prescription Drug Programs (NCPDP) is an ANSI-accredited standards development organization representing the pharmacy industry. We are a membership driven organization that was named in HIPAA regulations.

3. 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.

4. 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

5. NCPDP • Cross representation with other organizations • Participation in/from • WEDi, X12N, HL7 • NACDS, APhA, NCPA, ASAP, and other pharmacy organizations

6. NCPDP • NCPDP, the organization, does not develop standards • NCPDP, the Members, develop standards • NCPDP, the organization, is the administrative arm of the Members

7. NCPDP Membership • Over 1300 Members • Consensus building among three (3) categories

8. 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

9. Voting Categories Producer/Provider 335 Payer/Processor 514 Vendor/General Interest 486 Total Members = 1335

10. 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, real-time claims processing

11. 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 Work Groups

12. NCPDP Standards

13. 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

14. Telecommunication Standard • Version 5.1 named in HIPAA • Balloting version 8.0 • Developing post adjudicated history standard (for auditing, retrospective DUR, fee evaluations)

15. 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

16. 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

17. 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

18. 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

19. Payment Reconciliation Standard • Defines the format for electronic transmission of pharmacy payments • Cross-mapped to ASC X12N 835 and vice versa

20. 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

21. 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

22. Professional Pharmacy Services Implementation Guide • Used to assist with the billing of Services and Drug Use Review in the Telecommunication Standard

23. 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)

24. SCRIPT Standard • Developing standard for transfer of prescriptions between pharmacies • Public Key Encryption (PKI)-enabling SCRIPT Standard

25. 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

26. 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

27. 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

28. Thank you Patsy McElroy pmcelroy@ncpdp.org (480) 477-1000 ext. 124