Health Care Claims or Equivalent Encounter Information for Retail Pharmacy Claims

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Federally required	Cost	Test Tool Availability
Implementation Specification	NCPDP® Telecommunication Standard Implementation Guide, Version D, Release 0 (Version D.0), August 2010	Final	Production	Yes	$	Yes
Implementation Specification	NCPDP Telecommunication Standard, Implementation Guide, Version F2, March 2018 and Equivalent Batch Standard Implementation Guide, Version 15	Final	Production	No	$	No
Implementation Specification	NCPDP Batch Standard Medicaid Subrogation Implementation Guide, Version 3, Release 0 (Version 3.0), July 2007	Final	Production	Yes	$
Implementation Specification	NCPDP Batch Standard Medicaid Subrogation Implementation Guide, Version 10	Final	Production	No	$
Implementation Specification	HL7® FHIR® DaVinci Provider Data Exchange (PDex: Formulary) Implementation Guide	Balloted Draft	Production	No	Free	Yes

Limitations, Dependencies, and Preconditions for Consideration	Applicable Security Patterns for Consideration
NCPDP submitted request in February 2018 to have updated standards adopted under HIPAA: NCPDP Telecommunication Standard Implementation Guide Version F2 and Subrogation standard Version 10. Pending rulemaking 10/2021. The pharmacy telecommunication standard provides a standard format for the electronic submission of third party drug claims and other transactions between pharmacy providers, health plans (payers, insurance companies), third-party administrators, and others with financial responsibility. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), all covered entities – health plans, clearinghouses and covered health care providers are required to use the telecommunication standard for claim and service billing, as well as eligibility verification, predetermination of benefits, and prior authorization. The standard can perform a variety of other functions as well. The Medicare Part D program may require use of different NCPDP standards per statute. Costs for access to the NCPDP standards are based on membership. NCPDP's Standards Matrix is available as a reference providing a high-level overview of the latest version/release and/or the most commonly used of NCPDP standards and implementation guides, as well as NCPDP’s Data Dictionary and External Code List. Information about the CMS May 2020 Interoperability and Patient Access final rule and the HL7 FHIR APIs included in that rule may be found on the CMS Interoperability website. This rule includes use of the HL7 FHIR DaVinci Provider Data Exchange (PDex: Formulary) Implementation Guide.	All covered entities and their business associates are required to comply with the HIPAA Privacy and Security Rules. Health and Human Services has partnered with the Office of the National Coordinator and the National Institutes of Standards and Technology to publish comprehensive guidance for Security specific to electronic protected health information. A self-assessment tool kit is available to support integrating privacy and security into practices.

Limitations, Dependencies, and Preconditions for Consideration

Applicable Security Patterns for Consideration

NCPDP submitted request in February 2018 to have updated standards adopted under HIPAA: NCPDP Telecommunication Standard Implementation Guide Version F2 and Subrogation standard Version 10. Pending rulemaking 10/2021.
The pharmacy telecommunication standard provides a standard format for the electronic submission of third party drug claims and other transactions between pharmacy providers, health plans (payers, insurance companies), third-party administrators, and others with financial responsibility.
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), all covered entities – health plans, clearinghouses and covered health care providers are required to use the telecommunication standard for claim and service billing, as well as eligibility verification, predetermination of benefits, and prior authorization. The standard can perform a variety of other functions as well.
The Medicare Part D program may require use of different NCPDP standards per statute.
Costs for access to the NCPDP standards are based on membership. NCPDP's Standards Matrix is available as a reference providing a high-level overview of the latest version/release and/or the most commonly used of NCPDP standards and implementation guides, as well as NCPDP’s Data Dictionary and External Code List.
Information about the CMS May 2020 Interoperability and Patient Access final rule and the HL7 FHIR APIs included in that rule may be found on the CMS Interoperability website. This rule includes use of the HL7 FHIR DaVinci Provider Data Exchange (PDex: Formulary) Implementation Guide.

All covered entities and their business associates are required to comply with the HIPAA Privacy and Security Rules. Health and Human Services has partnered with the Office of the National Coordinator and the National Institutes of Standards and Technology to publish comprehensive guidance for Security specific to electronic protected health information. A self-assessment tool kit is available to support integrating privacy and security into practices.

Comment

Submitted by pwilson@ncpdp.org on 2022-09-30

NCPDP Comments

NCPDP recommends updating: NCPDP Batch Standard Medicaid Subrogation Implementation Guide, Version 10 to the following:
1. NCPDP Subrogation Implementation Guide for Batch Standard Version 10

NCPDP recommends updating: NCPDP Telecommunication Standard, Implementation Guide, Version F2, March 2018 and Equivalent Batch Standard Implementation Guide, Version 15 to the following:
1. NCPDP Telecommunication Standard Implementation Guide, Version F6, April 2022 and equivalent Batch Standard Implementation Guide Version 15

NCPDP recommends removing the following:
1. Standard / Implementation Specification: HL7® FHIR® DaVinci Provider Data Exchange (PDex: Formulary) Implementation Guide and
2. Limitations, Dependencies, and Preconditions for Consideration: Information about the CMS May 2020 Interoperability and Patient Access final rule and the HL7 FHIR APIs included in that rule may be found on the CMS Interoperability website. This rule includes use of the HL7® FHIR® DaVinci Provider Data Exchange (PDex: Formulary) Implementation Guide.
  1. Rationale: You cannot submit a claim using the HL7® FHIR® DaVinci Provider Data Exchange (PDex: Formulary) Implementation Guide. This guide possibly belongs under the section “Allows Pharmacy Benefit Payers to Communicate Formulary and Benefit Information to Prescriber Systems”; however, the purpose of the guide is to allow a consumer to verify formulary and benefit information.

Submitted by pwilson@ncpdp.org on 2021-09-29

NCPDP Comments

Modify NCPDP Telecommunication Standard, Implementation Guide, Version F2, March 2018 and equivalent Batch Standard Implementation Guide, Version 15 to reflect Version F6.
NCPDP Telecommunication Standard, Implementation Guide, Version F6, April 2020 is published, adoption level of N/A and not Federally Required yet.
NCPDP has requested this version be named under HIPAA.

Submitted by pwilson@ncpdp.org on 2018-10-01

NCPDP Comment

Add the following:

Type-Implementation Specification

Standard Implementation/Specification- NCPDP Telecommunication Standard, Implementation Guide, Version F2, March 2018 and Equivalent Batch Standard Implementation Guide, Version 15

Standards Process Maturity – Final

Implementation Maturity- Pilot

Adoption Level – 1

Federally Required – No

Cost – $

Test Tool Availability – No.

Limitations, Dependencies, and Preconditions for Consideration
The Telecommunication Standard Implementation Guide Version F2 has been requested to be adopted under HIPAA. NCPDP is in the investigative stage of providing a test tool.

Submitted by pwilson@ncpdp.org on 2017-11-20

NCPDP - Comment

- The Standard Listed – NCPDP Version D.0 is incorrect. The Standard and Implementation Guide are not separated. There is no separate standard and the Standard section material should be deleted.
- Standard Implementation/Specification: incorrectly lists the wrong version of the Telecommunication Standard Implementation Guide. It should be Telecommunication Standard Implementation Guide, Version D, Release 0 (Version D.0), August 2010.

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Health Care Claims or Equivalent Encounter Information for Retail Pharmacy Claims

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