Health Care Claims or Equivalent Encounter Information for Retail Pharmacy Supplies and Professional Services

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Type Standard Implementation/Specification Standards Process Maturity Implementation Maturity Adoption Level Federally required Cost Test Tool Availability
Standard
Final
Production
Rating 5
Yes
$
Yes
Implementation Specification
Final
Production
Rating 5
Yes
$
Yes
Implementation Specification
Final
Production
Rating 5
Yes
$
Yes
Limitations, Dependencies, and Preconditions for Consideration Applicable Security Patterns for Consideration
  • The Administrative Simplification provisions of HIPAA apply to the adoption of electronic transaction standards and operating rules for use in the health care industry. HIPAA has some different requirements for information exchange than EHRs, but there is hope for convergence in the future. Information about the HIPAA regulations regarding standards and operating rules can be found at https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/HIPAA-ACA/index.html. Readers can find information about requirements for covered entities and their business associates and enforcement from this link.
  • 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 eligibility verification as well as claim and service billing, 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 to access the NCPDP standards is 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.
  • Additional information is available on testing, and the full cost on any of the X12 transactions. ASETT is the HHS compliance tool to enable testing and complaint filing for all X12 and NCPDP transactions.
  • For a description of the functionality of each transaction, visit the X12 website. Click on a transaction set name to toggle the display of the purpose and scope of that transaction set. 
  • 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.

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  • 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.
  • Standard Implementation/Specification: The Telecommunication Standard, Implementation Guide Version 5, Release 1, September 1999 should be deleted.

 

  • Add a bullet for Medicaid Pharmacy Subrogation

Type-Implementation Specification

Standard Implementation/Specification- NCPDP Batch Standard Medicaid Subrogation Implementation Guide, Version 3, Release 0 (Version 3.0), July 2007

Standards Process Maturity – Final

Implementation Maturity- Production

Adoption Level – 5

Federally Required – Yes

Cost – $

Test Tool Availability –

  • Add a bullet for Uniform Healthcare Payer Data Standard

Type-Implementation Specification

Standard Implementation/Specification- NCPDP Uniform Healthcare Payer Date Standard Implementation Guide V24

Standards Process Maturity – Final

Implementation Maturity- Production

Adoption Level – 1

Federally Required – No

Cost – $

Test Tool Availability –