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

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Adoption Level	Federally required	Cost	Test Tool Availability
Implementation Specification	NCPDP Telecommunication Standard Implementation Guide, Version D, Release 0 (Version D.0), August 2010	Final	Production		No	$	Yes
Implementation Specification	ASC X12N/005010X222 Health Care Claim: Professional (837), May 2006 as an ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 and ASC X12N/005010X222A1 Type 1 Errata to Health Care Claim: Professional (837), June 2010 as Type 1 Errata to an ASC X12 Standards for Electronic Data Interchange Technical Report Type 3	Final	Production		Yes	$	Yes
Implementation Specification	NCPDP Uniform Healthcare Payer Date Standard Implementation Guide V24	Final	Production		No	$	No
Implementation Specification	NCPDP Telecommunication Standard, Implementation Guide, Version F2, March 2018 and Equivalent Batch Standard Implementation Guide, Version 15	Final	Production		No	$	Yes
Implementation Specification	NCPDP Batch Standard Medicaid Subrogation Implementation Guide, Version 3, Release 0 (Version 3.0), July 2007	Final	Production		Yes	$
Implementation Specification	NCPDP Uniform Healthcare Payer Data Standard Implementation Guide V28	Final	Production		No	$	No
Emerging Implementation Specification	NCPDP Batch Standard Medicaid Subrogation Implementation Guide, Version 10	Final	Pilot	Feedback Requested	No	$	No

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 by covered health care organizations - all health plans, covered health care providers and clearinghouses. 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 NCPDP 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), covered entities are required to use the telecommunication standard for eligibility verification as well as claim and service billing, predetermination of benefits, and prior authorization for retail pharmacy transactions. 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 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. For issues related to enforcement of the HIPAA standards and operating rules, ASETT is the HHS compliance tool to enable testing and complaint filing for all X12 and NCPDP transactions. The NCPDP Telecommunication Standard Implementation Guide Version F2 and subrogation Version 10 have been requested for adoption under HIPAA by NCVHS. The May 2018 recommendation letter to HHS may be viewed on the NCVHS website. For a description of the functionality of each X12 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.

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 by covered health care organizations - all health plans, covered health care providers and clearinghouses. 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 NCPDP 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), covered entities are required to use the telecommunication standard for eligibility verification as well as claim and service billing, predetermination of benefits, and prior authorization for retail pharmacy transactions. 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 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.
For issues related to enforcement of the HIPAA standards and operating rules, ASETT is the HHS compliance tool to enable testing and complaint filing for all X12 and NCPDP transactions.
The NCPDP Telecommunication Standard Implementation Guide Version F2 and subrogation Version 10 have been requested for adoption under HIPAA by NCVHS. The May 2018 recommendation letter to HHS may be viewed on the NCVHS website.
For a description of the functionality of each X12 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.

Comment

Submitted by [email protected] on 2021-09-29

NCPDP Comments

Update: 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.
Update: NCPDP Batch Standard Medicaid Subrogation Implementation Guide, Version 10 to the following:

Type: Implementation Specification
Standard / Implementation Specification: NCPDP Batch Standard Subrogation Implementation Guide Version 10
Implementation Maturity: Production
Adoption Level: 1

NCPDP Batch Standard Medicaid Subrogation Implementation Guide, Version 10 has been requested to be adopted under HIPAA

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

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NCPDP Comments