NCPDP Implementation Overview

Implementation of the NCPDP
Standards for HIPAA II
11/2014
Slide 2-4 – see important implementation information on Quantity
Prescribed
1
Telecom D.0 Imp Guide Enhancement
for Rule Making
Implementation Guide Enhancement (2012)
 An issue was brought to NCPDP’s attention by CMS regarding an OIG
audit and Prescription Drug Event (PDE) reporting on Schedule II
Controlled Substance claims. Based on numerous discussions, a
recommendation was approved in November 2012 to support the use
of the Quantity Prescribed (46Ø-ET) in Telecom claims. This has
resulted in the republication of the Telecom Imp Guides from version D.
Ø forward. See Members Section, Standards Download
http://www.ncpdp.org/Members/Standards-Lookup for the November
2012 publication of the Telecommunication Imp Guide version D. Ø.
 NCPDP has requested the Department of Health and Human Services
proceed with rulemaking process to name this version. Please check
http://www.ncpdp.org/Resources/HIPAA under Implementation Guide
Corrections banner for background and updates as known.
 NCPDP has notified to the best of our information all who were
members (purchased guides) during this time and made the enhanced
Telecommunication Standard Implementation Guide available.
2
Telecom D.0 Imp Guide Enhancement
for Rule Making






March 2013 OESS notified NCPDP to proceed; see letter at
http://www.ncpdp.org/Resources/HIPAA under Implementation Guide
Corrections banner. OESS thought they would publish a notice in the
Federal Register.
Early summer 2013 The Office of General Counsel advised OESS that
it would not be a federal register notice. OESS created an Interim Final
Rule (IFC) per ACA section 1104 on Administration Simplification.
Later summer 2013 OGC advised OESS that ACA could not be used
and the Telecom change would have to go through full rulemaking
(Notice of Proposed Rule Making (NPRM) and Final Rule) process.
Late 2014 CMS said the NPRM would be issued in early 2015.
This delay of rulemaking has delayed the industry requested
January 2014 implementation date.
All entities are to put on hold the 01/2014 implementation of
Quantity Prescribed changes until regulatory process has been
invoked.
3
The HIPAA II Implementation of
the NCPDP Standards
4
Pharmacy Standards Named
 Version upgrade:
 Telecommunication Standard Implementation
Guide Version D.Ø (from Version 5.1)
 Batch Standard Implementation Guide
Version 1.2 (from Version 1.1)
 New standard:
 Medicaid Subrogation Standard
Implementation Guide Version 3.Ø
 Note: pharmacy industry utilizes the ASC X12 835
(remittance advice), 834 (enrollment) and the
270/271 (eligibility) is used in electronic prescribing
5
NCPDP Publication Change
 Since the advent of HIPAA, NCPDP has modified the
publication of documents to allow industry flexibility in
addressing new business needs in a regulated
environment. In the past NCPDP created three types
of documents. They were:
 Standard
 Implementation Guide
 Data Dictionary
 In old publications of documents, the above three
documents were needed for implementation.
6
NCPDP Publication Change
 In the current environment, NCPDP publishes the following
three types of documents:
 Standard Implementation Guide
 Data Dictionary
 External Code List
 The documents are used together, to provide a complete picture
of the implementation of the standard. See the Matrix for the
association
http://www.ncpdp.org/NCPDP/media/pdf/StandardsMatrix.pdf
 See the “read me” document on the member CD or under
“Standards Download”
http://www.ncpdp.org/Members/Standards-Lookup (choose
Telecommunication Standard)
7
NCPDP Standard
Implementation Guide
 The Standard Implementation Guide contains the
business and technical definition of the transactions
 the actual transaction layouts, the syntax and formatting
rules, the transaction rules, usage,
 further information about the implementation of the standard
by the use of descriptive paragraphs, business situations,
examples, and frequently asked questions.
 This one document combines what was in the
Standard and in the Implementation Guide in
previous versions.
8
NCPDP Data Dictionary
 The Data Dictionary contains the actual field
descriptions
 sizes, formats, comments, and usage instructions
 Which Data Dictionary do I use?
 See
the
Matrix
http://www.ncpdp.org/NCPDP/media/pdf/StandardsMatrix.pdf
(or
on the member CD)
 Use of the correct publication of the data dictionary
for a version of a standard is critical as each
publication directs the proper use of a data element
and data element values where applicable.
9
NCPDP External Code List
 The External Code List is a list of value codes with
descriptions for data elements.
 The actual data elements still appear in the main Data
Dictionary.
 The External Code List process allows values to be
added to a data element without going through a
ballot.
 The timeline to incorporate a value into a business need is
shortened.
 Versions are upgraded quarterly if needed and are
available for business use.
10
NCPDP External Code List
 Use of the correct publication of the External Code
List for a version of a standard is critical as each
publication directs the proper use of a data element
and data element values where applicable.
 Which External Code List do I use?
 See
the
Matrix
http://www.ncpdp.org/NCPDP/media/pdf/StandardsMatrix.pd
f (or on the member CD)
 Important for understanding the rules for usage - See
Understanding the External Code List Process at
http://www.ncpdp.org/Members/Standards-Lookup (left side)
11
Process Overview for External
Code List document
•
•
Provides the process to request additions, modifications, and deletions
to the data element values existing in the External Code List (ECL).
This document contains an ECL Publication and Implementation Chart
to provide key dates in which full ECL Publications and ECL
Emergency Values should be implemented across all industry
participants supporting the NCPDP Telecommunication Standard.
Emergency Values Addendum
• See the NCPDP Emergency Telecommunication External Code
List Value Addendum document
(http://www.ncpdp.org/Members/Standards-Lookup under External
Code Lists. The addendum is listed under a quarterly ECL) for the list
of values approved for emergency implementation and the ECL
Publication and Implementation Chart.
• Only applicable to Telecommunication Standard
• Specific to regulatory requirements/mandates
12
External Code List Publication
Recommendation
•
March 2Ø1Ø ECL publication should be the highest version in use
when implementing the NCPDP Telecommunication Standard Version
D.Ø to meet the January Ø1, 2Ø12 compliance date.
–
•
•
•
This is an industry recommendation. It does not have force of regulation.
Adoption of an annual ECL implementation schedule to incorporate up
to four (4) ECL publications each year.
Annual implementations are effective each October, starting with 2Ø12.
ECL Publication and Implementation Chart provides key dates in which
full ECL Publications and ECL Emergency Values should be
implemented.
13
NCPDP Version D Editorial

Frequently Asked Questions, Important Editorial Changes
 This document provides a consolidated reference point for
questions that have been posed based on the review and
implementation of the NCPDP Telecommunication Standard
Implementation Guide and Data Dictionary for Version D.
 This document also addresses editorial changes made to these
documents. Since the HIPAA-named Standards documents are
"frozen" from changes, this document provides helpful FAQs,
typographical changes and corrections, and further guidelines for
implementation.
 This document is very important to implementers of the
Telecommunication and Batch Standards, and Medicaid
Subrogation Implementation Guide, as appropriate . Please
continue to review this link as the document is updated as needed.
 This document is cited as a reference in the implementation guides,
and guidance given in this document is to be implemented as
standard.
 Is
available
on
the
HIPAA
Public
page
http://www.ncpdp.org/Resources/HIPAA under Telecommunication
Version D.0 banner, on the Standards Download page
http://www.ncpdp.org/Members/Standards-Lookup
and on the
members CD.
14
Reference for What Changed
 Each document contains an appendix of the running
list of changes
 Implementation guide
 Data Dictionary
 External Code List
 Version D Editorial
 Telecommunication Implementation Guide contains
 Matrices with legends for assisting with changes
 Appendix of changes from each version
 The Appendix containing Version D.0 changes also includes
a section on “editorial” corrections which will be updated as
needed.
15
Telecommunication Standard
Implementation Guide Version D.Ø
Supports the following processes (and others)
1.
2.
3.
4.
Eligibility Verification
Claim
Service
Information Reporting
a.
5.
6.
Not named in HIPAA, but is used in Medicare Part D True Out of Pocket
(TrOOP) reporting and in Drug Utilization Review reporting
Prior Authorization
Predetermination of Benefits
a.
New transaction, not named in HIPAA but can be used to identify if the patient
is eligible for prescription coverage, if the submitted product is covered, the
patient financial responsibility at that point in time, and identify clinically
relevant information that may influence the submission of a corresponding
prescription claim request.
b.
Does not result in payment or application to the patient’s benefit.
Transactions already named in HIPAA 1996.
16
What changed in Telecom?
 Field and Segment Defined Situations
 Fields and segments displayed as optional within the
Implementation Guide were reviewed and determined,
according to the transaction type and its associated
response, to be “Not Used”, “Required if”, “Required”, or
“Optional”. Fields and segments cannot be used in a manner
other than as stated in the situations. This action was taken
to address the situational versus optional data requirements
discussed in the HIPAA Privacy Regulations.
 Request and Response Matrices
 The industry expanded the segment usage matrices to help
clarify which segments and fields are sent for each
transaction type. The segments and the fields within each
transaction type have been very specifically defined.
17
What changed in Telecom?
 Medicare Part D enhancements –
 A new entity of Facilitator and the process of Informational
Transactions enhanced.
 Eligibility Transaction enhanced for the Facilitator to provide
patient eligibility information for Medicare Part D and other
insurance coverage,
 Long Term Care Pharmacy claim processing enhancements
to appropriately identify and process Medicare Part D claims.
 Medicare Part B enhancements –
 Three segments were added to allow for the processing of
Medicare certificates of medical necessity.
 New data elements were added to allow for the items
needed to process Medicare Part B transactions and assist
in the crossover of claims from Medicare to Medicaid.
18
What changed in Telecom?
 The only method for billing of compounds is by
the use of the Compound Segment. The two
alternatives supported in previous versions for
compounded claim processing were removed.
 Clarification for pricing guidelines. New fields
were added and existing fields redefined to further
clarify/correct the financial balancing of transactions.
 Coordination of Benefits (COB)  Extensive clarification was made to the Implementation
Guide for Coordination of Benefits processing. COB is more
complicated with more complex rules than in the past.
Specificity was given to the COB process by including new
data elements such as patient responsibility and benefit
stage fields as well as refining the use of the Other
Coverage Code field.
19
What changed in Telecom?
 Prior Authorization Additional guidance was given
for the Prior Authorization transactions with the
addition of a new section to the implementation
guide.
 Prescription/Service Reference Number (4Ø2-D2)
was increased to 12 digits.
 Payer to Payer processing addresses the business
needs of crossover and subrogation transactions and
Information Reporting.
 Service Billings now have their own Transaction
Code (S1, S2, S3).
20
Sections of Note in Telecom
 Each transaction set (Eligibility Verification, Claim
Billings, Service Billings, etc) have their own section
of explanation. Section contains
 Business and technical rules
 Segment diagrams for transmission
 Segment and field request tables with mandatory/situational
rules for usage
 Segment and field response tables with
mandatory/situational rules for usage
 Response Processing Guidelines
 Appropriate use of each response
 Pricing Guidelines
21
Sections of Note in Telecom





Specific Segment Discussion
Transmission Examples
Frequently Asked Questions
Appendix of Changes
Important reference appendices
22
Batch Standard Implementation Guide
Version 1.2
 Version change (from 1.1 to 1.2)
 Editorial changes made
 A batch “wrapper” for the Telecommunication
Standard Implementation Guide
 The same parsing routines can be used for the batch
detail records as the real-time transactions
 For documents needed for implementation
 See the “read me” document (Batch Standard
Implementation Guide information sections) on the member
CD or http://www.ncpdp.org/Members/Standards-Lookup
23
Medicaid Subrogation Standard
Implementation Guide Version 3.Ø
 New implementation guide named
 Medicaid Subrogation is a process whereby Medicaid
is the payer of last resort.
 The state has reimbursed the pharmacy provider for covered
claims and now is pursuing reimbursement from other
payers for these claims.
 Some states may choose to “Pay” all claims in full, through a
federal waiver, at the point of receipt and “Chase”
reimbursements from responsible third parties after the fact.
24
Medicaid Subrogation Standard
Implementation Guide Version 3.Ø
 The Medicaid Subrogation transactions use the
Telecommunication Standard Implementation Guide
transactions.
 May be real-time
 May be wrapped in the Batch Standard
Implementation Guide
 The same parsing routines are used.
 For documents needed for implementation
 See the “read me” document (Medicaid Subrogation
Standard Implementation Guide information sections) on the
member CD or http://www.ncpdp.org/Members/StandardsLookup
25
Other Reference Guides
 For specific subject matter, other NCPDP documents
may provide valuable information. These documents
include:
 Billing Unit Standard Implementation Guide
 Pharmacy ID Card Implementation Guide
 Standards Matrix
 Information about these documents is available at
http://www.ncpdp.org/Standards/Standards-Info and
http://www.ncpdp.org/NCPDP/media/pdf/StandardsMatrix.pdf
26
Obtaining NCPDP Documents
NCPDP receives its funding from membership.
With a yearly membership, you receive all the implementation
guides and associated documents for all the versions published.
You receive any updates to these documents via the Members
“Standards Download” section of the website.
You receive industry activities information.
You may attend the quarterly work group meetings at no charge as
a member.
You may attend educational programs and Annual Conference at
member rates.
We welcome your participation. See
http://www.ncpdp.org/Membership
27
So what do I need to implement
Telecommunication D.Ø?
Members only section, Standards Download
 http://www.ncpdp.org/Members/Standards-Lookup
(Choose Telecommunication in Search box)
 Telecommunication Implementation Guide
Version D.Ø
 Data Dictionary dated 07/2007
 Version D Editorial document (most current)
and…
28
So what do I need to implement
Telecommunication D.Ø?
 External Code List of 07/2007 through most current
(recommendation to use most current)
 See Process Overview for External Code List document
(slide 8 and 9)
 ECL Publication and Implementation Chart to provide key dates in
which full ECL Publications and ECL Emergency Values should be
implemented across all industry participants supporting the NCPDP
Telecommunication Standard.

Emergency Telecommunication External Code List
Value Addendum document (slide 8 and 9)
 The addendum is listed under a quarterly ECL) for the list of values
approved for emergency implementation and the ECL Publication and
Implementation Chart.
29
So what do I need to implement Batch
1.2?
Members only section, Standards Download
http://www.ncpdp.org/Members/Standards-Lookup
(Choose Batch, then Telecommunication in Search box)
 Batch Implementation Guide Version 1.2
 Telecommunication Implementation Guide
Version D.Ø
 Data Dictionary dated 07/2007
 External Code List of 07/2007 through most current
(recommendation to use guidance found under
Telecom slides 8-9 if implementing Telecom
transactions)
 Version D Editorial document (most current)
30
So what do I need to implement
Medicaid Subrogation 3.Ø?
Members only section, Standards Download
http://www.ncpdp.org/Members/Standards-Lookup
 If real-time processing




Medicaid Subrogation Implementation Guide Version 3.Ø
Telecommunication Implementation Guide Version D.Ø
Data Dictionary dated 07/2007
External Code List of 07/2007 through most current (Recommendation to
use most current. Recommendation if using based on Telecom claim data,
to use the Telecom recommendations on slide 8 and 9)
 Version D Editorial document (most current)
 If batch processing





Batch Implementation Guide Version 1.2
Medicaid Subrogation Implementation Guide Version 3.Ø
Telecommunication Implementation Guide Version D.Ø
Data Dictionary dated 07/2007
External Code List of 07/2007 through most current (Recommendation to
use most current. Recommendation if using based on Telecom claim data,
to use the Telecom recommendations on slide 8 and 9)
 Version D Editorial document (most current)
31
Implementing ASC X12 Transactions
Of note:
 Obtain ASC X12 Transactions
 http://www.x12.org/ or www.wpc-edi.com
 If using these transactions, obtain errata
 Errata for ASC X12 278 Health Care Services
Review – Request to Review and Response
 Errata for ASC X12 837 Health Care Claim:
Institutional Claims
 Errata for ASC X12 837 Health Care Claim: Dental
Claims
32
FYI
33
Problem Solvers

Task Groups are open to any interested party who are willing to
participate and work

Collaborative, focused, problem solving activities

Work done via conference calls, email

http://www.ncpdp.org/Standards/Standards-Info - lower left
side
34
For Example
These task groups handle responses to questions, scenarios are added to
the Version D Editorial document usually quarterly
 http://www.ncpdp.org/Resources/HIPAA - under
Telecommunication Version D.0 banner
 Telecommunication FAQ Task Group
 Handles questions from the industry about the Telecom Standard
 Coordination of Benefits (COB) Task Group handles
questions submitted
 Popular subject, can be difficult
 Medicare Part D FAQ Task Group
 Reviews questions related to consistent application of Medicare
Part D policy where claims or other applicable transactions,
Prescription Drug Events (PDE) are involved.
35
For Example
 Information Reporting Problems Task Group
 Addresses processing problems with the Information Reporting
transactions – specifically 4Rx Data (BIN, PCN, Group, Cardholder
ID) used in processing for Medicare and supplemental payers).
 Collaboration with ASC X12 for transactions that impact
pharmacy industry
 WG45 External Standards task groups for X12 270/271, 837, 835
transactions
 Long Term Care needs
 See WG14 Long Term Care and Post Acute Care task groups for
short cycle dispensing, billing issues, return credit, automated
dispensing and other functions being worked on.
36
Educational Activities
 NCPDP educational sessions
 http://www.ncpdp.org/Education/Webinar - and Archived
webinars
 ASC X12 educational sessions
 ASC X12 developing individual educational program by
transaction TR3
 Conducting audiocast and face-to-face educational sessions
 www. http://www.x12.org/webinars/
 Workgroup for Electronic Interchange (WEDI)
educational sessions
 Obtain input from industry on NPRMs (Transactions and
ICD10)
 http://www.wedi.org/
37
Guidance
NCPDP Strategic National Implementation Process (SNIP)


HIPAA Implementation White Paper for NCPDP Standards
Implementation Guide for Payer Sheets
 Consistent approach to sharing processing requirements

http://www.ncpdp.org/Resources/Standards-Transition.aspx
Payer (Plan Sheet) Templates - http://www.ncpdp.org/Resources/HIPAA under Telecommunication Version D.0 banner

ICD-10 – http://www.ncpdp.org/Resources/HIPAA - under ICD-10
banner
WEDI



Timeline project lead by NCHICA and WEDI
835 implementation guidance
Other papers as may be published
38
Thank you
www.ncpdp.org
39

Download Report