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 Total Members = 1335 Producer/Provider
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 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. 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

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

26. 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

27. Get Involved - Stay Informed
Become a member
Attend the quarterly Work Group Meetings
NCPDP Now
Website (
Council Connection
Ask a Staff Member

28. Thank you
Patsy McElroy
(480) ext. 124