Medicaid Subrogation NCPDP Standards

1. Medicaid Subrogation NCPDP Standards Annette Gabel Medco Health Solutions Inc.

2. Medicaid Subrogation Standard Implementation Guide Version 3.Ø Medicaid Subrogation is a process whereby Medicaid is the payer of last resort. The state has reimbursed the pharmacy provider for covered claims and now is pursuing reimbursement from other payers for these claims. Some states may choose to “Pay” all claims in full, through a federal waiver, at the point of receipt and “Chase” reimbursements from responsible third parties after the fact. The Medicaid Subrogation transactions use the Telecommunication Standard Implementation Guide transactions wrapped in the Batch Standard Implementation Guide (The same parsing routines can be used for the batch detail records.)

3. Medicaid Subrogation Standard Implementation Guide Version 3.Ø New implementation guide requested to be HIPAA named standard One standard eliminates coding and maintaining multiple proprietary standards Claim responses are sent using the NCPDP Medicaid Subrogation batch response. Claim payment is made using the X12 835 4010 standard (5010 standard once mandated) Medicaid Subrogation standard added four new fields specific to Medicaid billing Medicaid Agency Medicaid ID number Medicaid Paid Amount Medicaid Subrogation Internal Control number (ICN/TCN) Med Agency number - Number assigned by processor to identify the individual Medicaid Agency or representative. Medicaid ID # - A unique member identification number assigned by the Medicaid Agency. Medicaid Paid Amount – Amount paid by the Medicaid Agency Medicaid Subrogation Internal Control Number (ICN/TCN) - Claim number assigned by the Medicaid Agency Med Agency number - Number assigned by processor to identify the individual Medicaid Agency or representative. Medicaid ID # - A unique member identification number assigned by the Medicaid Agency. Medicaid Paid Amount – Amount paid by the Medicaid Agency Medicaid Subrogation Internal Control Number (ICN/TCN) - Claim number assigned by the Medicaid Agency

4. NCPDP White Paper Timeline for Adoption of NCPDP Standards/ Dates Proposed in NPRM NCPDP Medicaid Subrogation Timeline August 2008 release of NPRM business planning begins August 2009 development begins February 2011 transition to Medicaid Subrogation version 3.0 begins September 2011 Regulatory compliance date NPRM Proposed Dates No later than 24 months after the effective date of the final rule. Small health plans would have an additional 12 months for compliance. Willing trading partners would be able to agree to use the Medicaid Subrogation standard voluntarily at any time before the compliance date. For example, covered entities that implement Version D.0 may choose to implement the Medicaid Subrogation standard at the same time because such an action can be accommodated in the work flow. The NCPDP recommendation for compliance date is earlier than the CMS required compliance date since the final rule is not posted and the earliest it could be posted would be the beginning of November. The NCPDP recommendation for compliance date is earlier than the CMS required compliance date since the final rule is not posted and the earliest it could be posted would be the beginning of November.

5. NCPDP SNIP (Strategic National Implementation Plan) Creating a response to the NPRM Creating a payer sheet Will provide guidance for implementation and testing

6. Actions Participate or designate a representative to participate in NCPDP efforts http://www.ncpdp.org/news_hipaa_snip.asp Read the NPRM Comment On impact Cost Benefit Savings Proposed implementation date