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HIPAA Simplified
Pharmacy
The National Council for Prescription Drug Program (NCPDP) maintains standards for retail pharmacy.
The NCPDP Telecommunication Standard Implementation and the equivalent NCPDP Batch Standard Implementation define standards and business rules for retail pharmacy and supplier transactions, including:
- Retail Pharmacy Claims
- Retail Pharmacy Supplies and Professional Services
- Retail Pharmacy Eligibility
- Retail Pharmacy Prior Authorization
The NCPDP Medicaid Pharmacy Subrogation standard defines the specifications for the transmission of a claim from a Medicaid agency to a payer for the purpose of seeking reimbursement from the responsible health plan for a pharmacy claim the State has paid on behalf of a Medicaid recipient.
The SCRIPT standard defines the specifications for electronic prescribing (ePrescribing)
Standards
Current Mandated Transactions
The standards currently mandated for pharmacy transactions are:
- NCPDP Telecommunication Standard Implementation version D.0 and equivalent NCPDP Batch Standard Implementation Guide version 1.2
- NCPDP Medicaid Pharmacy Subrogation transaction standard version 3.0
Change Healthcare supports the NCPDP Telecommunication Implementation Guide version D.0. We do not support batch pharmacy transactions.
Please note that, based on responses received from the industry during the review period, the Transactions and Code Sets Modifications rule does not dictate the use of either NCPDP or ASC X12 standards to bill for supplies or for professional services; rather, this decision has been left to the trading partners based on their agreements.
Script Standards
On November 16, 2012, the Centers for Medicare & Medicaid Services (CMS) issued the Medicare Program: Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to-Face Encounters, Elimination of the Requirement for Termination of Non-Random Prepayment Complex Medical Review and Other Revisions to Part B for CY 2013; Final Rule which adopted NCPDP SCRIPT version 10.6 as the official Medicare Part D e-prescribing standard as of November 1, 2013, retiring SCRIPT version 8.1 as an allowable e-prescribing standard.
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