Health Care Claims or Equivalent Encounter Information for Retail Pharmacy Claims

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Type Standard / Implementation Specification Standards Process Maturity Implementation Maturity Adoption Level Federally required Cost Test Tool Availability
Implementation Specification
Rating 5
Limitations, Dependencies, and Preconditions for Consideration Applicable Value Set(s) and Starter Set(s)
  • 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.
  • Before implementation of a new version of a standard, end to end testing should be conducted with vendor systems and between trading partners to ensure changes have been accommodated.
  • 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.
  • 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.


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.