Health Care Eligibility Benefit Inquiry and Response for Retail Pharmacy Coverage

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Type Standard Implementation/Specification Standards Process Maturity Implementation Maturity Adoption Level Federally required Cost Test Tool Availability
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.
  • This standard and the transaction were adopted under the Health Insurance Portability Act of 1996 (HIPAA) to increase efficiency in the health care system by reducing the use of paper and increasing the exchange of health care information electronically.  This information is often maintained in provider practice management and billing systems but duplicates information in electronic health records.
  • 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 are based on membership status. 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.

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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.