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Standards For Electronic Pharmacy Transactions
Patsy McElroyNCPDPJuly 9, 2002
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.
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.
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
NCPDP Cross representation with other
organizations Participation in/from
WEDi, X12N, HL7NACDS, APhA, NCPA, ASAP, and other pharmacy organizations
NCPDP
NCPDP, the organization, does not develop standards
NCPDP, the Members, develop standards
NCPDP, the organization, is the administrative arm of the Members
NCPDP Membership
Over 1300 Members Consensus building among
three (3) categories
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
Voting Categories
Producer/Provider
335
Payer/Processor
514
Vendor/General Interest486
Total Members = 1335
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
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
Version 5.1 named in HIPAA Balloting version 8.0 Developing post adjudicated
history standard (for auditing, retrospective DUR, fee evaluations)
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
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
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
Payment Reconciliation Standard
Defines the format for electronic transmission of pharmacy payments Cross-mapped 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 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
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
Professional Pharmacy Services
Implementation Guide
Used to assist with the billing of Services and Drug Use Review in the Telecommunication Standard
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)
SCRIPT Standard
Developing standard for transfer of prescriptions between pharmacies
Public Key Encryption (PKI)-enabling SCRIPT Standard
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 [email protected]
Attend NCPDP Meetings
August 2002Washington, D.C.
27th Educational Forum“HIPAA Privacy and Confidentiality”
28th – 30th Work Groups
November 2002San Diego, CA
5th Educational Summit“Understanding Manufacturer Rebates”
6th – 8th Work Groups
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
