Mandate for updated versions of NCPDP's Telecommunication Standard and NCPDP Batch Standard, and modified the standard for Medicaid pharmacy subrogation transactions to NCPDP's Batch Standard Subrogation Implementation Guide. These standards provide more robust interoperability, workflow automation, enhanced patient safety, improved coordination of benefits, and expanded financial fields.
SCOTTSDALE, Ariz., Dec. 19, 2024 /PRNewswire-PRWeb/ -- NCPDP announced three of its standards have been named by the Office of the Secretary, Department of Health and Human Services (HHS) in the "Administrative Simplification: Modifications of Health Insurance Portability and Accountability Act of 1996 (HIPAA) National Council for Prescription Drug Programs (NCPDP) Retail Pharmacy Standards; and Modification of the Medicaid Pharmacy Subrogation Standard." This final rule adopts updated versions of the retail pharmacy standards for electronic transactions adopted under the Administrative Simplification subtitle of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). These updated versions are modifications to the currently adopted standards for the following retail pharmacy transactions: health care claims or equivalent encounter information; eligibility for a health plan; referral certification and authorization; and coordination of benefits. This final rule also adopts a modification to the standard for the Medicaid pharmacy subrogation transaction. The final rule cites the following NCPDP standards and implementation timelines:
- NCPDP Telecommunication Standard Version F6 is required as of February 11, 2028.
- NCPDP Batch Standard Version 15 is required as of February 11, 2028.
- NCPDP Batch Standard Subrogation Implementation Guide Version 10 is required by February 11, 2028.
The NCPDP Telecommunication Standard Version F6 facilitates real-time processing of billions of pharmacy claims, defining the record layout for prescription claim transactions and practical guidelines for software developers and others who must implement the standard. The standard not only provides a format for billing of pharmacy transactions and the exchange of data from provider-to-payer, it also encompasses transactions for eligibility verification, service billing, prior authorization, and information reporting.
The NCPDP Batch Standard Version 15 provides practical guidelines and ensures consistent implementation throughout the industry of a file submission standard to be used between pharmacies and processors, or pharmacies, switches, and processors when using the Telecommunication Standard framework. The batch file is to be submitted in a non-real-time mode.
The NCPDP Batch Standard Subrogation Implementation Guide Version 10 was established to address requirements for payers, such as Medicaid agencies, Medicare Part D, state assistance programs or private health plans to seek reimbursement from the correct responsible health plan. While this standard supports subrogation for multiple payer types, the final rule only mandates its use for Medicaid state agencies. Subrogation occurs when a payer has paid a claim that is subsequently determined to be the responsibility of another payer. This is commonly referred to as "pay and chase". The implementation guide provides guidelines for the process whereby payers and PBMs can communicate to other payers' reimbursement requests for covered services paid to pharmacy providers for which the other payers are responsible.
How to Prepare and Plan for Implementation:
NCPDP has developed resources to support industry education, adoption, planning and implementation of the standards. These are opportunities to learn from the experts: NCPDP and its member leaders who participated in the development of the standards. These educational programs can be found on NCPDP's website and are available to view at no charge for NCPDP members. Non-NCPDP members will pay a nominal fee to view each educational program.
- NCPDP Pharmacy Standards – HIPAA Updates
- Strategic National Implementation Process (SNIP) Update
- Header Segment Modifications
- Eligibility Verification (E1) – F6 Impacts
- Information Reporting for Medicare Part D
- Telecommunication vF6 Claim and Service Request Billing Transactions – Critical Impacts to the Healthcare Industry
- Telecommunication vF6 B1 Response Transaction – What's Behind the Changes to Over 180 Data Elements
- COB Functionality in Telecommunication Version F6
- The Future of Reversals
- Batch Standard V15 and Batch Standard Subrogation Implementation Guide V10
- NCPDP Resources and How to Use Them
In 2025, NCPDP will be providing an in-depth Coordination of Benefits webinar in addition to other webinars on related topics to the final rule. When available, these programs will be promoted via eblasts to NCPDP Members, on NCPDP's LinkedIn page as well as on its website – http://www.ncpdp.org.
About NCPDP
The National Council for Prescription Drug Programs (NCPDP) is a not-for-profit American National Standards Institute (ANSI) Accredited Standards Developer (ASD) consisting of more than 1,400 members representing entities including, but not limited to, claims processors, data management and analysis vendors, federal and state government agencies, insurers, intermediaries, pharmaceutical manufacturers, pharmacies, pharmacy benefit managers, professional services organizations, software and system vendors and other parties interested in electronic standardization within the pharmacy services sector of the healthcare industry. NCPDP provides a forum wherein our diverse membership can develop business solutions, including ANSI-accredited standards and guidance for promoting information exchanges related to medications, supplies, and services within the healthcare system.
NCPDP has been named in federal legislation, including HIPAA, MMA, and HITECH. NCPDP members have created standards such as the Telecommunication Standard and Batch Standard, the SCRIPT Standard for ePrescribing, the Manufacturers Rebate Standard, and more to improve communication within the pharmacy industry. Our data products include dataQ®, a robust database of information on more than 80,000 pharmacies, resQ™, an industry pharmacy credentialing resource, and HCIdea®, an innovative prescriber database that provides continually updated information on more than 3.7 million prescribers. NCPDP's RxReconn® is a legislative tracking program for real-time monitoring of pharmacy-related state and national legislative and regulatory activity. For more information about NCPDP Standards, Data Services, Products, Educational Programs and Work Group Meetings, go online at https://www.ncpdp.org or call 480.477.1000.
Media Contact
Sherri Teille, NCPDP, 4804771000, [email protected], https://ncpdp.org/
Whitney Ellington, NCPDP, 4804771000, [email protected], https://ncpdp.org/
SOURCE NCPDP
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