Transcript NCPDP’s New Member Orientation Training Session

Operating Rules Status
NCVHS Subcommittee on Standards
December 3, 2010
Updated on enhancements to Operating Rules for Eligibility and Claim
Status
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What is NCPDP?

An ANSI-accredited standards development organization.

Provides a forum and marketplace for a diverse membership focused
on health care and pharmacy business solutions.

A member driven organization that has been named in various
government legislation and rulings, such as HIPAA and the Medicare
Part D Regulation.

One of several Standards Development Organizations (SDOs) involved
in Healthcare Information Technology and Standardization.
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Focus on pharmacy services, and has the highest member
representation from the pharmacy services sector of healthcare.
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HIPAA Eligibility and Claim Status

NCPDP:

Telecommunication Standard Implementation Guide
Version D.0

Batch Standard Implementation Guide Version 1.2

ASC X12:

ASC X12 270/271 Technical Report Type 3

ASC X12 276/277 Technical Report Type 3

Note: pharmacy industry utilizes the ASC X12 835 (remittance
advice), 834 (enrollment) and the 270/271 (eligibility) is used
as part of electronic prescribing.

Note: pharmacy industry does not use the claim status
transaction.
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Operating Rules Definition
(1) DEFINITION OF OPERATING RULES.—Section 1171 of the Social
Security Act (42 U.S.C. 1320d) is amended by adding at the end
the following:
‘‘(9) OPERATING RULES.—The term ‘operating rules’ means the
necessary business rules and guidelines for the electronic
exchange of information that are not defined by a standard or
its implementation specifications as adopted for purposes of
this part.’’
Points from the regulation:

Recognized that business rules and guidelines may already be
present in the implementation specifications.

Operating rules may cover exchange not already defined in the
implementation specifications.

SDOs govern the data content of the transmissions and the business
rules and reference documents required to support the data content.

Operating Rules cannot add, modify or remove requirements defined
in the implementation specifications.
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Operating Rules Recommendations
 Publication of documents
 Operating rules are impacted by implementation specifications.
 Operating rules may also be updated between implementation
specifications to satisfy appropriate business requirements that
would not have an impact on the implementation specifications.
 Operating Rule entities must collaborate where possible.
 NCPDP, CORE and other named entities will continue to
collaborate.
 Operating Rule entities must use the existing process to bring
regulatory requests forward – the industry understands this
process.
 Submission of new versions of operating rules to DSMO.
 DSMO recommends new versions of operating rules to NCVHS.
 NCVHS recommends new versions of operating rules to the
Secretary of HHS.
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Concerns that must be addressed
The charge to operating rules entities was to address eligibility and
claim status transactions.

Additional topics have not been vetted fully by the entire
industry and therefore must not be imposed on the entire
industry.
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Connectivity
Response time
System availability
“Companion guides”
Difference identified


Acknowledgements
Additional topics to be addressed by HHS
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Safe harbor
Certification
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Connectivity
There is a serious concern if regulations are issued constraining
existing connections, for example, Internet as the only choice
versus private network connections.
If the regulation would include connectivity, it must

Allow existing connections (safe harbor). The regulation must
not require a “rip and replace” of infrastructure already in
place.

Clarify that Internet is not the only connectivity allowed.
The regulation must clarify

Trading partners negotiate connectivity. Entities must be
given the option of supporting both public or private
connectivity.
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NCPDP Connectivity

NCPDP created the NCPDP Connectivity Standard
Implementation Guide for the CAQH CORE Connectivity
Rule Version 1.0


In collaboration with CORE
Addressed real-time connectivity only when supporting CORE
rule
Actions:

NCPDP is creating a connectivity operating guide for NCPDP and
X12 transactions used by the pharmacy and electronic prescribing
industry.

Incorporate existing documents of X12 guidance for
pharmacy industry.
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Incorporate NCPDP defined Payload data elements for use.

Will collaborate with CORE where possible.

NCPDP membership will consider approval in 2011.
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Response Time and System Availability
Topics have not been vetted by the entire industry and therefore
must not be imposed on the entire industry.
If the regulation would include response time and system
availability, it must

Clarify that the CORE rules do not address pharmacy and
electronic prescribing requirements.
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“Companion” Guides
The term “Companion Guide” and its related issues are not shared
in pharmacy and electronic prescribing industries.
If the regulation would include the “companion guide” topic, it must
clarify

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The CORE or HHS rules do not address pharmacy and electronic
prescribing environments.
NCPDP publishes a Payer Template Implementation Guide
 This document has been used by the pharmacy industry since Telecom 5.1.
 Provides rules on the creation of payer-specific information without
changing the intended use of the Telecom guide.
 Plans and payers use this template and guide to create their “payer sheets”.
 Payer sheets are referenced in Medicare Part D claim processing
requirements.
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Acknowledgments
DSMO recommendation:
Approve. DSMO approves this request for ASC X12 transactions.
However, the DSMO recommends further public comment be
accepted about the 835 and 820 acknowledgments as there are
business cases where acknowledgements may not be the most
appropriate. We recommend that the acknowledgement files for the
835 and 820 transactions be based upon trading partner
agreements.
If a regulation were to name acknowledgements, it must

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Support the DSMO recommendation.
Name acknowledgements as a HIPAA-named exchange.


Industry input on 835 and 820 acknowledgments.
Operating rules for the 999 acknowledgement would need to be
developed if they aren’t already contained in the guide and/or
developed by X12.
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Certification
It is unclear if certification will be stipulated in the regulation.
If the regulation would include certification, it must

Allow existing connections (safe harbor). The regulation must
not require a “rip and replace” of infrastructure already in
place.

Clarify which entities are required to certify and what entities
are to certify.

Provide specific requirements as to the certification process.

Allow entities the option of supporting both public or private
connectivity.
The CORE certification requirements were not intended for the pharmacy and
electronic prescribing industries as these were outside of scope.
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Pharmacy Eligibility
‘‘(i) ELIGIBILITY FOR A HEALTH PLAN AND HEALTH CLAIM
STATUS.—The set of operating rules for eligibility for a health
plan and health claim status transactions shall be adopted not
later than July 1, 2011, in a manner ensuring that such operating
rules are effective not later than January 1, 2013, and may allow
for the use of a machine readable identification card.”
How it works:
 The NCPDP Telecommunication Standard Implementation
Guide includes guidelines recommended by the industry.
 The rules and guidance in the Implementation Guide adequately
support the needs of eligibility verification use in commercial,
Medicare, and Medicaid processing.
 The pharmacy industry utilizes the real-time claim which
provides the complete verification of eligibility/benefit checking
as well as claims processing.
 The network infrastructure is mature.
See ID Card section at end of presentation.
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Pharmacy Eligibility Recommendations
Recommendation:
The NCPDP Telecommunication Standard Implementation Guide
Version D.0 Eligibility Verification rules be named as operating
rules for pharmacy industry.
NCPDP membership will consider approval of connectivity
operating rules in 2011.
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Eligibility and Electronic Prescribing
Eligibility impact – electronic prescribing environment

ASC X12 270/271 are used to obtain and provide patient Eligibility,
Formulary and Benefit information.
Recommendation:
Operating rules named for the X12 270/271 must not be
adopted for electronic prescribing functions without additional
NCPDP guidance.

Note: NCPDP has mapped the pharmacy-industry routing identifiers
(BIN/PCN/Group) to the 4010A1 270/271 and the 5010 270/271 for use
in eligibility verification. This provides vendors the information to
support a prescriber office using the standard pharmacy ID card to
perform an eligibility check on a patient’s pharmacy benefits using the
270/271.
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ID Card
 NCPDP publishes a Health Care Identification Card
Pharmacy and/or Combination ID Card Implementation
Guide
 WEDI has Health Identification Card Implementation Guide.
 Both are based on standard ANSI INCITS 284 Identification
Card - Health Care Identification Cards. Collaborative work.
 NCPDP publishes a Pharmacy ID Card to X12 270/271 Health
Care Eligibility Benefit Inquiry and Response – Excel
document
 Pharmacy routing identifiers (BIN/PCN/Group) and patient
information from the pharmacy ID Card to the 4010A1 270/271 (and
the 5010) 270/271 for use in electronic prescribing in obtaining
Formulary and Benefit identifiers.
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ID Card Concerns
CORE 258: Phase II Normalizing Patient Last Name Rule if
incorporated into regulation, should not include the ID Card. Its
intent is the X12 270/271 transaction, but need to be clear.
 It has not been vetted with industry whether this works with the
NCPDP ID Card Implementation Guide.
 It has not been vetted with industry whether this works with the
electronic prescribing use of the 270/271.
If the regulation would include ID Card topic, it must clarify

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The CORE 258 rule is only for the X12 270/271 for eligibility verification
(it’s intent).
The CORE 258 rule is out of scope for the ID Card and the electronic
prescribing environments.
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ID Card Actions
Actions:
 INCITS updated version will be published soon.
 NCPDP and WEDI will update their guides to provide assistance
on how to use the card for transactions.
 NCPDP has collaborated with CORE in the development of a
Phase III Health ID Card operating rule.
 NCPDP is in the process of adding guidance for use of data
elements found on the card in specific transactions.
 NCPDP will discuss whether to submit the NCPDP ID Card
Implementation Guide into the regulatory process.
 NCPDP membership will consider approval in 2011.
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835 and Pharmacy Industry
The existing NCPDP “835 documents” (approved by X12) show
how to take the NCPDP Telecommunication D.0 claim transaction
data and consistently report the remittance advice data on the 835.
Action:
NCPDP operating rules document will incorporate:
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The metadata fields at the envelope layer.
Allowance of any appropriate Acknowledgement as determined by the
pharmacy industry, but will not require.
Existing NCPDP 835 documents (for the NCPDP claim to X12 remit).
Internet must not be the only option for 835 transport.
NCPDP membership will consider approval in 2011.
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Thank You
Lynne Gilbertson
VP, Standards Development
NCPDP
[email protected]
Annette Gabel
NCPDP Board of Trustees
[email protected]
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