Testimony by Lynne Gilbertson for the July 30-31, 2007 NCVHS Subcommittee on Standards and Security Hearing

National Committee on Vital and Health Statistics

Subcommittee on Standards and Security

July 30-31, 2007

NCPDP Telecommunication Standard Implementation Guide Version D.Ø and
Batch Standard Implementation Guide Version 1.2

DSMO Change Request 1055: The NCPDP membership is requesting a new version of the Telecommunication and Batch Standard be named in HIPAA. The Telecommunication Standard Implementation Guide is version D.Ø. The Batch Standard Implementation Guide is version 1.2, which supports Telecommunication version D.Ø in a batch mode.

The Telecommunication Standard Implementation Guide supports the following processes

Eligibility Verification
Claim
Service
Information Reporting
Prior Authorization
Predetermination of Benefits

NCPDP’s SNIP Committee has submitted a Benefit Analysis Survey to WEDI. WEDI will report on the survey findings.

Changes from version 5.1 to version D.Ø are provided under separate cover. Changes include the addition of fields to support Medicare Part D functionality, enhancements to coordination of benefits processing, more guidance for balancing and pricing support as business needs have evolved, and the addition of mandatory/situational designations per the HIPAA Privacy regulation.

Web casts were held in January and February 2ØØ7. NCPDP Telecommunication Standard Implementation Guide Version D.Ø was published July 2007.

Overview of NCPDP Telecommunication Standard Implementation Guide Version D.Ø

Since the NCPDP Telecommunication Standard Implementation Guide Version 5.1 was named in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the industry has brought forward enhancements and modifications, based on business needs, with intent for the most recent version D.Ø to be the new version named in HIPAA.

In the continuation of member driven improvements, the Telecommunication Standard Implementation Guide has been modified through several iterations of versions since the HIPAA-named Version 5.1. It should be noted that Version C.1 is being used in the industry today to handle Information Reporting transactions for Medicare Part D processing.

Two very important changes made since version 5.1 and incorporated into the NCPDP Telecommunication Standard Implementation Guide Version D.Ø are:

Field and Segment Defined Situations
Fields and segments displayed as optional within the Implementation Guide were reviewed and determined, according to the transaction type and its associated response, to be “Not Used”, “Required if”, “Required”, or “Optional”. Fields and segments cannot be used in a manner other than as stated in the situations. This action was taken to address the situational versus optional data requirements cited in the HIPAA Privacy Regulations.

Request and Response Matrices
The industry expanded the segment usage matrices to help clarify which segments and fields are sent for each transaction type. The segments and the fields within each transaction type have been very specifically defined.

Additional Noteworthy Modifications:

Medicare Part D enhancements – To accommodate the processing and flow of claims required for the Medicare Modernization Act, a new entity of Facilitator was introduced and the process of Informational Transactions enhanced by the addition of new data elements and rejection codes. The business requirement for the Facilitator to provide patient eligibility information for Medicare Part D and also on other insurance coverage, required large changes to the Eligibility Transaction request and response. Changes include the addition of three segments along with new data elements and rejection codes and the shifting of data elements from one segment to a new segment. Additionally, Long Term Care Pharmacy claim processing required new data elements and new rejection and messaging codes in order to appropriately identify and process Medicare Part D claims.
Medicare Part B enhancements – Three segments were added to allow for the processing of Medicare certificates of medical necessity. New data elements were identified and added to allow for the items needed to process Medicare Part B transactions and assist in the crossover of claims from Medicare to Medicaid.
Extensive clarification was added to the Implementation Guide by the addition of sections for pricing guidelines. New fields were added and existing fields redefined to further clarify/correct the financial balancing of transactions.
In Version D.Ø, the only method for billing of compounds is by the use of the Compound Segment. The two alternatives supported in previous versions for compounded claim processing were removed.
Coordination of Benefits (COB) Extensive clarification was made to the Implementation Guide for Coordination of Benefits processing. COB is more complicated with more complex rules than in the past. Specificity was given to the COB process by including new data elements such as patient responsibility and benefit stage fields as well as refining the use of the Other Coverage Code field.
Prior Authorization Additional guidance was given for the Prior Authorization transactions with the addition of a new section to the implementation guide.
To continue the enablement of uniquely identifying the prescription number (a key data field in claims adjudication and report writing) the length of Prescription/Service Reference Number (4Ø2-D2) was increased to 12 digits.
Payer to Payer processing addresses the business needs of crossover and subrogation transactions and Information Reporting.
Service Billing now have their own Transaction Code (S1, S2, S3).

The Data Dictionary and External Code List were updated to house the data element modifications made to the Telecommunication Standard Implementation Guide from version 5.1 to D.Ø.

Detail is provided in the document “Modifications To Telecommunication Standard Implementation Guide From Version 5.2 to D.Ø”. A list of all changes is included in the appendix section “History of Document Changes” in the NCPDP Telecommunication Standard Implementation Guide Version D.Ø, as well as history sections pertinent to the NCPDP Telecommunication Standard Implementation Guide must also be reviewed in all reference documents that apply to this standard.

New fields added:

Patient E-Mail Address	Unit Dose Indicator	Basis of Cost Determination
DUR Additional Text
Other Payer-Patient Responsibility Amount Qualifier	Other Payer-Patient Responsibility Amount	Other Payer-Patient Responsibility Amount Count
Other Payer Cardholder ID	Other Payer ID Count	Submission Clarification Code Count
Delay Reason Code	Amount Attributed to Processor Fee	Patient Location was renamed to Place of Service (3Ø7-C7) with new values assigned. A new field Patient Residence (384-4X) was added
PRESCRIBER FIRST NAME	PRESCRIBER STREET ADDRESS	PRESCRIBER CITY ADDRESS
PRESCRIBER STATE/PROVINCE ADDRESS	PRESCRIBER ZIP/POSTAL ZONE	ADDITIONAL DOCUMENTATION TYPE ID
REQUEST PERIOD BEGIN DATE	REQUEST PERIOD RECERT/REVISED DATE	REQUEST STATUS
LENGTH OF NEED QUALIFIER	LENGTH OF NEED	PRESCRIBER/SUPPLIER DATE SIGNED
SUPPORTING DOCUMENTATION	QUESTION NUMBER/LETTER COUNT	QUESTION NUMBER/LETTER
QUESTION PERCENT RESPONSE	QUESTION DATE RESPONSE	QUESTION DOLLAR AMOUNT RESPONSE
QUESTION NUMERIC RESPONSE	QUESTION ALPHANUMERIC RESPONSE	FACILITY ID (MOVED FROM THE INSURANCE SEGMENT)
FACILITY NAME	FACILITY STREET ADDRESS	FACILITY CITY ADDRESS
FACILITY STATE/PROVINCE ADDRESS	FACILITY ZIP/POSTAL ZONE	NARRATIVE MESSAGE
OTHER PAYER BIN NUMBER	OTHER PAYER PROCESSOR CONTROL NUMBER	OTHER PAYER CARDHOLDER ID
OTHER PAYER GROUP ID	TRANSACTION REFERENCE NUMBER	OTHER PAYER PROCESSOR CONTROL NUMBER (Version D.Ø moved to new Response Coordination of Benefits Segment)
OTHER PAYER GROUP ID (Version D.Ø moved to new Response Coordination of Benefits Segment)	MEDIGAP ID	MEDICAID INDICATOR
PROVIDER ACCEPT ASSIGNMENT INDICATOR	COMPOUND INGREDIENT MODIFIER CODE COUNT	COMPOUND INGREDIENT MODIFIER CODE
PATIENT SALES TAX AMOUNT	PLAN SALES TAX AMOUNT	Amount Of Copay/Coinsurance (518-FI) was split up into two fields Amount Of Copay (518-FI) and Amount Of Coinsurance (572-4U)
Basis of Calculation-Coinsurance	PATIENT ASSIGNMENT INDICATOR (DIRECT MEMBER REIMBURSEMENT INDICATOR)	BENEFIT STAGE COUNT
BENEFIT STAGE QUALIFIER	BENEFIT STAGE AMOUNT	AMOUNT ATTRIBUTED TO PRODUCT SELECTION QUALIFIER (Field was removed in D.Ø)
CMS Part D Defined Qualified Facility	ROUTE OF ADMINISTRATION	COMPOUND ROUTE OF ADMINISTRATION – removed
COMPOUND TYPE	INTERNAL CONTROL NUMBER (Modification made in D.Ø)	ESTIMATED GENERIC SAVINGS
URL	SPENDING ACCOUNT AMOUNT REMAINING	Health Plan-funded Assistance Amount
Amount Attributed to provider Network selection	amount attributed to product selection/brand drug	amount attributed to product selection/non-preferred formulary selection
amount attributed to product selection/Brand non-preferred formulary selection	PRESCRIBER LOCATION CODE – deleted	PRIMARY CARE PROVIDER LOCATION CODE – deleted
Medicaid ID NUMBER	Medicaid agency number	Medicaid subrogation internal control number/transaction control number (Icn/TCN)
Pharmacy service type	Medicaid Paid amount	Billing entity type indicator
pay to qualifier	pay to id	pay to name
pay to street address	pay to city Address	Pay to state/Province Address
pay to zip/postal Zone	generic equivalent product id Qualifier	generic equivalent product id
MEDICARE PART D COVERAGE CODE	CMS Low Income Cost Sharing (LICS) Level	Contract Number
FORMULARY ID	Benefit ID	Next medicare part d effective date
next medicare part d termination date	ADDITIONAL MESSAGE INFORMATION QUALIFIER	ADDITIONAL MESSAGE INFORMATION CONTINUITY
Amount Attributed to coverage gap	INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT	DISPENSING FEE CONTRACTED/REIMBURSABLE AMOUNT

Values added/modified/clarification added/modified to existing fields:

Measurement Dimension	Measurement Unit	Clinical Significance Code
Database Indicator	Diagnosis Code Qualifier	Prior Authorization Type Code
Product Code Qualifier	Submission Clarification Code	Therapeutic Class Code Qualifier
Intermediary Authorization Type ID	Prior Authorization/Medical Certification Code and Number	Prior Authorization Type Code
Product/Service ID Qualifier	Employer ID	Patient Location
Product/Service ID Qualifier	Diagnosis Code Qualifier	Submission Clarification Code
Other Payer-Patient Responsibility Amount Qualifier	SPECIAL PACKAGING INDICATOR (was Unit Dose Indicator)	Submission Clarification Code
Patient Pay Amount (5Ø5-F5) definition was modified to include coinsurance	Prior Authorization Type Code	Preferred Product Copay Incentive (555-AT) field name was modified to Preferred Product Cost Share Incentive
Other Payer-Patient Responsibility Amount Qualifier	Patient ID Qualifier	definition of Other Payer Amount Paid
definition of Other Payer Amount Recognized	Other Coverage Code	Dispense As Written/Product Selection Code
Prescriber ID Qualifier	Primary Care Provider ID Qualifier	Service Provider ID Qualifier
Date of Service (4Ø1-D1) definition	Submission Clarification Code	Dispense As Written/Product Selection Code
Prior Authorization Type Code	Other Payer-Patient Responsibility Amount Qualifier	Basis of Reimbursement Determination
Percentage Sales Tax Basis Submitted (484-JE)	Percentage Sales Tax Basis Paid	Tax Exempt Indicator
Other Payer Coverage Type	Other Payer ID Qualifier	Other Payer Amount Paid Qualifier
Approved Message Code

Clarifications/more guidance (less impact):

Zero Dollar Amounts section clarification

Count & Counters section clarification

Support of multiple reversal transactions guidance

Transaction Response Status (112-AN) duplicate values for the Rebill, Information Reporting Rebill, and Controlled Substance Reporting Rebill transactions were not needed

Numeric Truncation” and “Alphanumeric Truncation” sections added

Clarification was made in section “Compound Segment”

Guidance added that Diagnosis code fields must adhere to the owner’s code set rules and formats

Guidance for reporting CPT codes in billing

Removed the verbiage that forced a composite when there were more than 4 payers

FAQs updated

Clean up/removal of comments in Data Dictionary

Clarifications/more guidance (impact depends on whether entities using the business case):

Section “Prior Authorization Transaction Discussion” has been added

“Business Function of Capture” section added

Section “Long Term Care Transition, Emergency Fill and Change in level of Care Messaging for Rejected and Paid Claims” was added

Added verbiage about payer-to-payer usage

Clarifications to Coupon processing

Section was added “Medicaid Subrogation”

Prescriber Segment in the Eligibility Transaction has changed from “Not Used” to “Optional”.

Certificate of Medical Necessity (CMN) needs.Segments added:

Additional Documentation Segment
Facility Segment
Narrative Segment

Predetermination Of Benefits transaction has been added

Clarifications/more guidance (more overall impact):

In each of the transaction sections “Eligibility Information”, “Reversal Information”, “Rebill Information”, etc, the diagrams have been reviewed according to Protocol Document decisions. Segments have been added or removed as applicable to the specific transaction.

Definitions for “Copay/Amount of Copay”, “Coinsurance/Amount of Coinsurance”, and “Patient Financial Responsibility” were added

Compound Processing – the two alternatives (Scenario A (Most expensive legend drug) and Scenario B (Billing codes)) are no longer supported

Additional logic has been added to duplicate processing

Enhancements for eligibility checking, specifically for Medicare Part D usage

Modifications have been brought forward to support claims processing functions under the Medicare Modernization Act (MMA).

Service Billings have their own Transaction Code

Additional Message Information (text message fields have been enhanced)

The document has been reviewed for verbiage of “may” “might”, “could”, and other less specific language. Where appropriate, the verbiage has been modified to “must”, “will”, etc.

The Telecommunication Specification and the Telecommunication Standard Implementation Guide were combined into one document

Support of External Code List document

Compound Implementation Guide and Prior Authorization Implementation Guide were incorporated into Telecommunication Standard Implementation Guide

Professional Pharmacy Services Implementation Guide was incorporated into Telecommunication Standard Implementation Guide

Updated ORDUR manual added as an appendix to Telecommunication Standard Implementation Guide

Guidance of the original “Two-Way Communication to Increase the Value of On-Line Messaging” document to this document as an appendix to Telecommunication Standard Implementation Guide

Corrections:

Response Claim Pricing Examples

Miscellaneous NDC Product/Service ID Qualifier examples

Diagram corrections

Added Reject Codes (511-FB) for Count fields that were mistakenly left out of Data Dictionary

Errant references to section “Segment Quick Reference” were modified to correctly state section “Structure Quick Reference”.

Field size expansion:

Associated Prescription/Service Reference Number	Prescription/Service Reference Number	Procedure Modifier Code Count – DSMO Change Request System (CRS) 763 that was approved to add more repetitions for Procedure Modifiers, the Procedure Modifier Code Count (458-SE) has increased in size and the number of repetitions
Other Payer-Patient Responsibility Amount Count

Overview of Batch Standard Implementation Guide Version 1.2

Editorial changes made:

Clarification was made that the Sender ID and Receiver ID values are reversed when sending the response batch file.
The Transaction Header and Transaction Trailer records were renamed to Transmission Header and Transmission Trailer to correctly reflect that they are at the transmission level.
Example errors were corrected.

This version was published in January 2ØØ6.

Medicaid Subrogation Standard Implementation Guide Version 3.Ø

DSMO Change Request 1057: The NCPDP membership is requesting a new standard be named in HIPAA for use in the pharmacy industry – the Medicaid Subrogation Standard Implementation Guide, version 3.Ø.

More information on this business function is found in the NCPDP “Medicaid Subrogation Implementation Guide”.

Overview of Medicaid Subrogation Standard Implementation Guide Version 3.Ø

Medicaid Subrogation is a process whereby Medicaid is the payer of last resort. The state has reimbursed the pharmacy provider for covered claims and now is pursuing reimbursement from other payers for these claims. Some states may choose to “Pay” all claims in full, through a federal waiver, at the point of receipt and “Chase” reimbursements from responsible third parties after the fact. There are some services for which states are required by federal regulation to do pay and chase – children’s preventive health services and maternity services. These are defined by diagnosis and procedure code. Subrogation is also used to recover costs for emergency services where the primary is auto or property casualty insurance.

The Medicaid Subrogation Standard Implementation Guide uses the same format as the Batch and Telecommunication Standard. There is guidance in the Telecommunication Standard Version D.Ø for the use of fields for Subrogation. There is also payer-to-payer guidance in Telecom D.Ø. Subrogation must be in sync with other claims processed.

Today, when the Medicaid Subrogation Standard is not used, a proprietary interpretation of the Batch Standard is used or proprietary formats are used.

NCPDP Medicaid Subrogation Standard Implementation Guide Version 3.Ø was published July 2007

Version 2.Ø changes include updating of field names and definitions and updating examples to reflect the NCPDP Telecommunication Standard Version 5.1, the support of the External Code List document for data values, and the document was moved to a new standard template structure. Synchronization with the Telecommunication Standard Version 5.1 (HIPAA-named) – fields needed for Subrogation were “kludged” into existing fields so that transactions could flow.

Version 3.Ø was updated to support the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Subrogation specific requirements for use of data elements 524-FO Plan ID, 33Ø-CW Alternate ID, 463-EW Intermediary Authorization Type ID and 464-EX Intermediary Authorization ID were discontinued.

The following fields were added for Subrogation usage:

Medicaid Paid Amount	Medicaid ID Number
Medicaid Subrogation Internal Control Number/Transaction Control Number (ICN/TCN)	Medicaid Agency number