HIPAA Transactions and Code Sets Current

What Do I Need Now for HIPAA?

Implementation of the NCPDP Standards
Implementation Guide Corrections
White Paper for HIPAA Implementation of NCPDP Standards
NCPDP Payer Sheet Template for Telecommunication Version D.0
Version D Editorial - May 2013
NCPDP Telecommunication Standard vD.0 Implementation Tracking
NCPDP Payer Sheet Template for Medicaid Subrogation Version 3.0
Recommendations for Effective 4Rx Usage in Medicare Part D Processing
4Rx Spreadsheet Available for Proactive Pharmacy Part D Profile Updates
NCPDP Telecommunication Standard vD.0 Transition Guidance
Medicaid Subrogation v3.0 Questions


References

2009 HIPAA Regulations
NCPDP Responds to NPRM on HIPAA Transactions
HHS HIPAA Information
WEDI Guidance for HIPAA (medical info)
ASC X12 Provides 5010 Overview
NCVHS Recommendations on HIPAA Implementation
NCVHS Testimony on Industry Preparedness and Survey Results
Post Adjudication Standard Survey Results
Support for Streamlining HIPAA Processes

Implementation of the NCPDP Standards

NCPDP IMPLEMENTATION OVERVIEW Updated 11/2012 - NCPDP has created this document to provide summary information of the transactions requested in the next round of HIPAA. This document also provides important information needed for analysis and planning, and resource links.High-level Dispensing Model of Telecommunication Transactions Standards Information

11/17/2011 CMS Announces 90-Day Period of Enforcement Discretion
NCPDP SNIP Discretion Recommendations

CMS Resource for HIPAA implementation

[Top]

Implementation Guide Corrections

11/2012 Telecommunication Standard D.Ø Enhancement for Publication
Based on approval during the November 2012 work group meetings of DERF 001097, a new publication of the Telecommunication Standard Version D.Ø (November 2012) has been posted to the Standards Download section of the website. The enhancement is for the use of Quantity Prescribed (46Ø-ET) in the billing transactions. A request for HIPAA rule making notification has been sent to OESS and NCVHS.DSMO Change Request 1182 was also filed. As of 03/2013, we have received approval from OESS. The timeline and steps include

• NCPDP published the updated Telecommunication Standard and Version D Editorial in November 2012, which are available for download.
• Federal notification or action by OESS is expected soon (per the letter).
• CMS to issue HPMS memo notifying the plan sponsors.
• The implementation date requested by the industry is 01/01/2014 (see DERF 001097).

08/2010 Telecommunication Standard D.Ø Correction
NCPDP has republished the Telecommunication Standard Implementation Guide Version D.Ø as of August 2010. It is very important that implementers download the August 2010 version of the implementation guide to pick up the corrected information. While the impact may be less to some entities, as soon as the corrections were approved, it was important to have the document republished. Modifications included Schedule ID Issue, clarification to the Benefit Stage Amount formula for multi-ingredient compounds and a correction to section "Denote Individual Amounts of Patient Financial Responsibility as Reported from a Previous Payer". Details on the modification can be found here.

In October 2010, the Office of eHealth Standards and Security (OESS) of the Department of Health and Human Services published the technical corrections notice on the NCPDP Telecommunication Standard Version D.0 and the ASC X12N 5010 errata. These technical corrections are the modifications made to the implementation specifications that the industry has requested; the final step in the regulatory process is the notice in the Federal Register. Note, NCPDP is aware of several inconsistencies in the notice and has contacted OESS about them. The D.0 imp guide is available for download at NCPDP to members. Previous members have been contacted to obtain a corrected version. The NCPDP Version D Editorial document provides correction information for implementers.

ASC X12N also has corrections to the 5010 Technical Report 3s

[Top]

White Paper for HIPAA Implementation of NCPDP Standards

In the January 16, 2009 Federal Register, the Department of Health and Human Services listed the Final Rule to Update HIPAA Code Sets and the Final Rule to Update HIPAA Transactions.  Entities should begin their business planning and timelines to support the next transactions and code sets. The NCPDP Strategic National Implementation Process (SNIP) has created an important white paper to assist the industry in preparing for the implementation of transactions. Click here for a copy.

[Top]

NCPDP Payer Sheet Template for Telecommunication Version D.0

In anticipation of the move to the Telecommunication Standard Implementation Guide Version D.0 as the next HIPAA-named version for pharmacy claims, the NCPDP SNIP Committee developed guidance to be used in filling out and creating payer sheets based on Version D.0 and above. Payer Sheets may be used in addition to provider manuals or included in provider manuals. Payers may take the request and response template sections within the guidance document, fill out the template per their usage, and send to their trading partners. The guidance also provides instructional sections to assist the payers in completing their payer sheets. Click here for Version 1.5.

[Top]

NCPDP Telecommunication Standard vD.0 Implementation Tracking

In preparation of the implementation of the HIPAA mandated Telecommunication Standard vD.0, NCPDP SNIP has created a Sub-Task Group to track the industry readiness. The vD.0 Sub-Task Group needs your assistance to properly track the testing and implementation of NCPDP Telecommunication Standard vD.0. The group has created two forms - one for Plan/Payer and one for Pharmacy/Vendors. Instructions for completing the forms are found in the detailed field definitions on the instruction tab. Completed form or additional questions should be sent to Teresa Strickland at tstrickland@ncpdp.org. Click here for a copy of the blank form. Click here for the Industry Provided Implementation documentation including Medicaid and "4Rx Data".

NCPDP Payer Sheet Template for Medicaid Subrogation Version 3.0

In anticipation of the move to the Medicaid Subrogation Implementation Guide Version 3.0 as the HIPAA-named version for subrogation, the NCPDP SNIP Committee developed guidance to be used in filling out and creating payer sheets based on Medication Subrogation Implementation Guide Version 3.Ø, Batch Standard Implementation Guide Version 1.2 and Telecommunication Standard Implementation Guide Version D.Ø and above. Payer Sheets may be used in addition to provider manuals or included in provider manuals. Payers may take the request and response template sections within the guidance document, fill out the template per their usage, and send to their trading partners. The guidance also provides instructional sections to assist the payers in completing their payer sheets. Click here for Version 1.0.

[Top]

NCVHS Recommendations on HIPAA Implementation

The National Committee on Vital and Health Statistics (NCVHS) conducted two days of hearings on December 9th and 10th, 2009 on implementation and readiness for the next round of HIPAA. NCVHS has published recommendations to the Secretary of Health and Human Service (HHS) on the implementation of updated versions of the HIPAA transaction standards and ICD-10 code sets.

[Top]

NCPDP Responds to NPRM on HIPAA Transactions

On August 22, 2008 the Notices of Proposed Rule Making (NPRM) for the new versions of the HIPAA transactions and code sets were published in the Final Register. The NCPDP SNIP Committee has completed its review of the Standards NPRM and submitted comments to HHS. Click Here to view the NCPDP Comments.

[Top]

2009 HIPAA Regulations

January 2009 The Final Rules for the Transactions and Code Sets have been published in the Final Register by the Department of Health and Human Services. Under the transaction standards final rule, covered entities must comply with ASC X12 Version 5010 (for some health care transactions) and NCPDP Telecommunication Standard Version D.0 (pharmacy transactions) on January 1, 2012. Covered entities must comply with the standard for the Medicaid pharmacy subrogation transaction (NCPDP Medicaid Subrogation Standard Version 3.0) on Jan. 1, 2012. However, for Version 3.0, small health plans have an additional year and must comply on Jan. 1, 2013. The ICD-10 code sets rule sets the compliance date at Oct. 1, 2013.

Final Rule Information for Pharmacy The following document is provided by NCPDP as a service, but readers should consult a copy of the rules and corrections and determine their business needs accordingly. This document will be updated, as new information is known. Last Updated: 12/2012. HIPAA Current Final Rule Information As It Relates to the Pharmacy Industry

August 2008 The Notices of Proposed Rule Making (NPRM) for the new versions of the HIPAA transactions and code sets have been published in the Final Register. The standards to be named:

• Telecommunication Version D.֠and Batch Standard 1.2 Implementation Guides
• ASC X12 835 Health Care Claim: Payment/Advice
• ASC X12 837 Health Care Claim: Institutional
• ASC X12 837 Health Care Claim: Professional
• ASC X12 837 Health Care Claim: Dental
• ASC X12 276/277 Health Care Claim: Status Request and Response
• ASC X12 278 Health Care Services Review Request to Review and Response
• ASC X12 834 Benefit Enrollment and Maintenance
• ASC X12 820 Payroll Deducted and Other Group Premium Payment for Insurance Products
• ASC X12 270/271 Health Care Eligibility Benefit Inquiry and Information Response
• Medicaid Subrogation Implementation Guide Version 3.ּ

• ICD-10 code sets

[Top]

HHS HIPAA Information

The Department of Health and Human Services has a website for HIPAA information. This site has program memorandums, outreach documents, frequently asked questions, and schedules for educational sessions.
Please see http://www.cms.hhs.gov/HIPAAGenInfo/.

[Top]

ASC X12 Provides 5010 Overview

ASC X12 has provided slides which give health care providers a comprehensive overview of what to consider in the ASC X12 005010 migration. The slides for this webinar are available at http://www.himss.org/content/files/HIPAA005010RoadToSuccessPresentationSlides.pdf Other X12 educational material may be available on this site or at www.x12.org

[Top]

NCVHS Testimony on Industry Preparedness and Survey Results

On December 9-10, 2009, NCVHS received testimony from many industry participants on the industry’s preparedness for the transition to the updated HIPAA Transactions and Code Sets. In preparation for NCPDP’s testimony, the NCPDP SNIP Committee created three surveys for readiness for the NCPDP Telecommunication Standard Version D.0, the Batch Standard Version 1.2, the Medicaid Subrogation Standard Version 3.0, the ASC X12N 835 transaction and the transition to the ICD-10 code sets. To view the results of these surveys click here. To view the testimony presented to NCVHS click here.

[Top]

Post Adjudication Standard Survey Results

The NCPDP SNIP Committee developed a survey on the NCPDP Post Adjudication Standard Version 2.0 that has been requested for the next round of HIPAA. The survey requested input from Client Groups, Pharmacy Benefit Managers (PBM’s), Payers, Fiscal Agents, and Insurance Programs that currently implement or plan to implement the NCPDP Post Adjudication Standard. The NCPDP survey to gather cost/benefit analysis on this standard closed on January 11, 2008. Survey results will be provided to the Department of Health and Human Services via testimony at the National Committee on Vital and Health Statistics meeting in late January 2008. Click here for a copy of the NCPDP Post Adjudication Standard Version 2.0 Survey results.

[Top]

Support for Streamlining HIPAA Processes

Since the passage of the HIPAA regulation, the three standards development organizations (SDOs) named in HIPAA - ASC X12, HL7, and NCPDP have worked with the Office of E-Health Standards and Services (OESS) to propose a process of naming new versions of standards under HIPAA that is more timely and efficient for the industry. The SDOs testified to the National Committee on Vital and Health Statistics (NCVHS) in December 2005 and October 2006 and presented this paper with discussion of the current problems in the process and a proposal for the future. NCVHS discussed with HHS who noted they are constrained by their interpretation of the Administrative Procedures Act. Modifications to this process would require regulatory changes.

White Paper for HIPAA Implementation of the ICD-10 Code Sets

In the January 16, 2009 Federal Register, the Department of Health and Human Services posted the Final Rule to Update the Medical Data Code Sets Standards to use the ICD-10 code sets. Entities should begin their business planning and create timelines to support the new code sets. The NCPDP Strategic National Implementation Process (SNIP) has created an important white paper to assist the industry in preparing for the implementation of the ICD-10 code sets. Click here for a copy.

[Top]

Recommendations for Effective 4Rx Usage in Medicare Part D Processing

These documents were created by the industry to address a Centers for Medicare and Medicaid Services (CMS) directive entitled “Clarification of Unique BIN (or BIN/PCN) Requirements as of January 1, 2012 [§423.120(c)(4) as revised by CMS-4085-F]” which was released on November 12, 2010 that provided clarification of Unique BIN (or BIN/PCN) requirements. This directive covered the required assignment and exclusive use of unique routing and beneficiary identifiers for the Medicare Part D program. Implementing this directive consistently in the industry is the subject of the documents. The intent of these provisions is to ensure that:

1. Pharmacies can routinely identify situations in which they are being reimbursed for a Medicare Part D claim and
2. Payers supplemental to Medicare Part D can identify when a claim is being billed for a covered Medicare Part D beneficiary and drug so they can properly coordinate benefits.

• Clear guidance on how plans should submit 4Rx information on the MARx file to CMS when a plan or processor does not use PCN or group or only matches on a portion of those fields.
• A standard method for plans to communicate to pharmacies correct Part D 4Rx when a claim is submitted with incorrect 4Rx.
• Clarification on when to use the new benefit stage qualifiers to clearly indicate to the pharmacy and downstream payers when a claim submitted under a Part D BIN/PCN is processed under something other than Part D as allowed by CMS.

NCPDP Telecommunication Standard vD.0 Transition Guidance

In preparation for the transition from the Telecommunication Standard v5.1 to vD.0, the NCPDP SNIP Committee has provided guidance for help in the implementation of the versioning changes.

[Top]

Medicaid Subrogation Questions, Answers and Editorial Updates

This document provides a consolidated reference point for questions that have been posed based on the review and implementation of the NCPDP Medicaid Subrogation Standard Implementation Guide Version 3.Ø, and the Data Dictionary and External Code List only as they apply to Medication Subrogation. This document also addresses an editorial change made to the implementation guide in October 2Ø1Ø. Please continue to review this link as the document is updated as needed.

[Top]