Standards For Electronic Pharmacy Transactions Patsy McElroy NCPDP July 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, HL7 NACDS, 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 Total Members = 1335 Producer/Provider Payer/Processor 514 Vendor/General Interest 486 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 Government Programs Telecommunication Professional Pharmacy Services Prescriber/Pharmacist Interface Data Security and Patient Confidentiality Maintenance and Control Telecommunication Product Identification Standard Identifiers Provider Application and Registration Standard Payment Reconciliation Manufacturer Rebates

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 rbranson@ncpdp.org

Attend NCPDP Meetings August 2002 November 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

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

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