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NCPDP Standards Overview

NCPDP Standards Overview. Lynne Gilbertson Vice President, Standards Development NCPDP June 2, 2008. What is NCPDP?. The National Council for Prescription Drug Programs (NCPDP) is an ANSI-accredited standards development organization.

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NCPDP Standards Overview

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  1. NCPDP Standards Overview Lynne Gilbertson Vice President, Standards Development NCPDP June 2, 2008

  2. What is NCPDP? The National Council for Prescription Drug Programs (NCPDP) is an ANSI-accredited standards development organization. Provides a forum and marketplace for a diverse membership focused on health care and pharmacy business solutions. NCPDP is a member driven organization that has been named in various government legislation and rulings, such as HIPAA and the Medicare Prescription Drug Benefit. NCPDP is one of several Standards Development Organizations (SDOs) involved in Healthcare Information Technology and Standardization. NCPDP has a focus on pharmacy services, and has the highest representation from the pharmacy services sector of healthcare.

  3. Participants by Industry Role • Producer/Provider • Includes Pharmacies, Pharmacists, and Manufacturers. A client service oriented sector. • Payer/Processor • Includes HMO’s, Pharmacy Benefit Managers, Government Payers, Health Insurers. A financial oriented sector. • Vendors and General Interest • Drug Wholesalers, Consultants, Clinical Programs, Telecommunication and Software & Hardware Vendors. The link between the 2 sectors above.

  4. NCPDP Standards • Paper, Guidance, Batch and Real-Time Standards • Paper - NCPDP was formed in 1977 to standardize prescription insurance forms • 1978 the paper Universal Claim Form (UCF) was adopted • Billions of claim forms have been distributed

  5. Health Care Identification Card - Pharmacy and/or Combination ID Card Billing Unit Standard Professional Pharmacy Services Online Real-time Drug Utilization Review Compound Processing Prior Authorization Processing Version 5 Editorial Long-Term Care (LTC) Rebate Reporting Guide for Medicare Part D Rebate Reference Guide Medication Therapy Management White Paper National Provider ID (NPI) White Paper Emergency Preparedness Payer Templates Guidance Documents

  6. NCPDP Batch Standards Fixed length records – Header, Detail(s), Trailer • Medicaid Subrogation • Post Adjudicated History • Manufacturer Rebate • Batch Standard for Telecommunication usage • Formulary And Benefit • Prescription Transfer • In development • Prior Authorization Transfer

  7. NCPDP Real-Time Standards Variable format, request/response • Telecommunication Standard • 1988 NCPDP developed Version 1.Ø of the Telecommunication Standard for online, real-time claims processing • Transactions for eligibility, billings, prior authorization, information reporting, predetermination of benefits, etc • 2ØØ7 Telecommunication Version D.Ø • 2ØØ8 Version D.1 under ballot

  8. NCPDP Real-Time Standards Variable format, request/response • SCRIPT Standard • 1997 SCRIPT Version 1.Ø for electronic prescribing • Transactions for new prescriptions, refills, change, cancel, medication history, fill notification, census, etc • 2ØØ8 SCRIPT Version 1Ø.6 in Ballot • Structured and Codified Sig Format Implementation Guide Version 1 Release Ø • Provides a structured and codified format for the Sig component of an electronic prescription that may be incorporated into existing e-prescribing transaction standards, such as NCPDP SCRIPT and HL7.

  9. NCPDP Real-Time Standards Variable format, request/response • Financial Information Reporting • Version 1.Ø Medicare Part D business need - Provides a real-time method to pass financial information from one pharmacy benefit manager (PBM) to another PBM when a patient under one plan sponsor has changed from one benefit plan PBM to another benefit plan PBM, to allow accurate claims processing with gross covered drug cost and True Out of Pocket (TrOOP) balances.

  10. NCPDP Real-Time Standards Underway • In development • Long Term Care Return/Reuse

  11. Interchange Formats • Formats support the business exchange of information • Pull from a common data dictionary and external code list • Reference other code lists (X12 data elements, FMT, SNOMED) • NCPDP standards do not address transport or security

  12. XML • SCRIPT Standard has EDI and XML syntax • Requirements established by eprescribing task group: • EDI should map 1-1 to XML • Re-Use existing Schema Data Types When Possible • Enforce EDI validation rules via WC3 XML Schema. • Rules for handling qualifiers, repeating segments, repeating fields • Use the <xs:annotation> element to document schema

  13. Other Information • Use of Altova XMLSpy for XML • NCPDP Modeling Task Group • Working with Galen Mulrooney, VA for modeling steps • Leverage other industry work • Use of COTS where possible • Take reasonable steps

  14. Questions? Thank you Lynne Gilbertson lgilbertson@ncpdp.org 615-754-0445 direct 480-477-1000 NCPDP HQ

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