Transcript Version 5.1 Overview - Object Management Group

NCPDP, HIPPA, SCRIPT and
V5.1 Overview
Phillip D. Scott
NCPDP Senior Vice President
July 10, 2001
Agenda
Who is NCPDP?
Where have we been?
Where are we?
Where are we going?
How can I get involved?
Who is NCPDP?
Who is NCPDP?
The National Council for Prescription
Drug Programs (NCPDP) is an ANSIaccredited standards development
organization representing all facets of
pharmacy. We are a membership driven
organization that was named in federal
legislation (HIPAA).
Mission Statement
To create and promote data interchange
standards for the pharmacy services
sector of the health care industry, and to
provide information and resources that
educate the industry and support the
diverse needs of our members.
Vision Statement
To be the model forum which empowers
our members to enhance the quality of
health care through the creation of
information solutions.
Membership Representation
• Producer/Provider (pink badges)
– Retail Pharmacy, Mail Service Pharmacy,
Pharmacists, and Manufacturers
Consulting
• Payer/Processor (green badges)
– BCBS Organizations, HMOs, PBMs, and
Government Payers
• Vendors and General Interest (yellow badges)
– Drug Wholesalers, Consultants, Clinical Programs,
and Software & Hardware Vendors
Voting Categories
Producer/Provider
Payer/Processor
314
509
Vendor/General
Interest
477
Total Members = 1301
Where Have We Been?
NCPDP History
Pharmacies started installing computer
systems in the late 1970’s

First systems were installed on the IBM Series 1
Pharmacies started submitting computer
generated paper claims to insurance
companies
Every insurance company had their own
unique form
NCPDP History
NCPDP was formed in 1977 to
standardize insurance forms.
NCPDP’s first standardization effort was
the paper universal claim form (UCF)
which was adopted in 1978. Over three
billion claim forms have been
distributed.
NCPDP History
1987 PCS introduced electronic claims


Black Box that uses telephone line to call
PCS direct
Proprietary format
Other PBMs (Pharmacy Benefit
Managers) followed
Instead of multiple form types,
pharmacies now had multiple black
boxes on their counters
NCPDP History
1988 NCPDP developed Version 1.0 of
the Telecommunication Standard
1988 Pharmacy software vendors and
chains started coding for electronic
claims



No more double entry
No need for black boxes
Use of switching companies like
ENVOY/WebMD and NDC Health
Where Are We?
Standards Related to Electronic Prescribing
NCPDP has two standards that directly
relate to electronic prescribing:
Telecommunication Standard
SCRIPT Standard
What is Telecom?
Telecom is a data transmission standard
intended to facilitate the communication
of prescription information between
pharmacies and payers. It is used
billions of times each year.
Telecom Standard Version History
Version 1.0 released in 1988
Version 3.2 in 1992
Version 3.3 in 1996

Compound Ingredients
Version 4.0 in 1997
Version 5.0 in 1999
What is SCRIPT?
SCRIPT is a data transmission standard
intended to facilitate the communication
of prescription information between
prescribers and pharmacists.
SCRIPT Standard Version History
Version 1.0 was approved in April
1997
Version 3.1 was ANSI Accredited in
2000
Version 4.1 is in balloting status
now
SCRIPT Can Be Used For
New Prescriptions from the prescriber
to the pharmacy
Change Requests to New Prescriptions
by the pharmacy to the prescriber
Refill Requests by the pharmacy to the
prescriber
SCRIPT Can Be Used For
Fill Status from the pharmacy to the
prescriber (patient picked up, patient
picked up partial fill, patient never picked
up)
The ability for a prescriber to cancel a
previously submitted request
Housekeeping transactions (password
change, receive prescriptions, et cetera)
Every Business Request Transaction Includes:
Electronic envelope
Section to define the Prescriber
Section to define the Pharmacy
Section to define the Patient
Electronic Envelope Includes:
Sender ID
Receiver ID
Syntax information
(version/release, delimiters)
Type of Message
Password
Trace Numbers
Date/Time
Prescriber Information May Include:
Identifier (State License, DEA, etc)
Prescriber name
Business name
Business address information
Phone number (telephone, beeper, fax)
Specialty Code (AMA Self-Designated
Practice Specialty/Areas of Practice Code)
Authorizing Prescriber Agent Name
Pharmacy Information May Include:
Identifier (NCPDP Provider ID)
Pharmacy name
Pharmacist name
Pharmacy address information
Phone number (telephone, beeper,
fax)
Patient Information May Include:
Patient Name
Date of Birth
Gender
Patient Address
Patient Phone Number
Relationship to Cardholder
Pharmacy/Prescriber’s internal
Patient ID
Every Response Transaction Includes:
Electronic envelope
Response Status



Acknowledgement of the receipt of the transaction
or
“Paired” response transaction to the request which
may
 Approve the request
 Approve the request with changes
 Deny the request
Acknowledgement of an error in the transaction
Version 5
HIPPA Legislated Standard
Enhancements requested & approved for Version 5
Version 5 is a complete rewrite to the
NCPDP Telecommunication Standard. It
includes:



New data elements
Removed obsolete data elements deleted
Additions/modifications to the data
dictionary
Enhancements requested & approved for Version 5
The $ fields size have been increased
Old size maximum was $9,999.99
 New size is $999,999.99
Field Qualifiers were added



NDC or UPC
DEA, State License #, UPIN or Third Party ID
Enhanced Coordination of Benefits


Secondary/Tertiary can see primary reject codes
Secondary/Tertiary can see all primary payments
(both Rx and Service Claims)
Enhancements requested & approved for Version 5
Expanded DUR (Drug Utilization Review)
capability


Ability for Provider to respond to multiple alerts
(Reason for Service Codes) in one transaction
Ability for Providers to send PPS codes and
supporting info on claim
Professional Service Claim



Claim can be submitted for service without having
to have an Rx
Service Claim can refer to an Rx
Easier for pharmacy to reconcile
Enhancements requested & approved for Version 5
Partial Fill capability


Pharmacy can report the dispensing of an
initial partial fill (25 out of 30)
Pharmacy can report the dispensing of the
remaining quantity without
 Additional dispensing fee
 Additional refill number
 DUR warnings


Duplicate therapy
Too soon to refill
What’s new in Version 5?
Segments restructures for efficiency


Data elements grouped into logical
segments
Variable format
Additional business functions



Prior authorization enhanced
Controlled substance reporting added
Information reporting added
Where are We Going?
What We Know About HIPAA
NCPDP Telecommunication
Standard v5.1
NCPDP Batch Standard v1.1
ASC X12N 834
ASC X12N 835
Privacy Rules
What is Still to Come with HIPAA?
NPRM for Transactions and Code Sets
(revisions/clarifications)
NPRM for NDC versus HCPCS
Clarifications
Unique Identifiers for Providers, Payers,
Employers, and Individuals
Security Rules
Privacy Rule Modifications
Enforcement Rules
How NCPDP Helps Industry Plan for HIPAA?
NCPDP is a Designated Standards
Maintenance Organization (DSMO)
Pharmacy Strategic National Implementation
Process (SNIP)
August Summit
Work Groups Continue to Monitor and
Respond to HIPAA Rules
Task Groups working to answer DHHS
questions
Future Initiatives NCPDP has In Store
The Council’s newest project, HCIdea,
will establish a unique identifier
for prescribers.
How Can I Get Involved?
Attend NCPDP Meetings
August 2001 in Baltimore, MD
4th Summit
5th Educational Forum
6th – 8th Work Groups
November 2001 in Orlando, FL
13th Educational Forum
14th – 16th Work Groups
March 2002 in Phoenix, AZ
23rd – 24th Work Groups
24th – 27th Conference
How Can I Follow the Council’s Activities?
Become a member
Attend the quarterly Work Group
Meetings
NCPDP Now
Website (www.ncpdp.org)
Council Connection
Ask a Staff Member