Telecommunications Standard JULY 2012

Transcription

1 Telecommunications Standard

2 Telecommunications Standard Copyright 2012 National Council for Prescription Drug Programs, Inc. This work is owned by National Council for Prescription Drug Programs, Inc., 9240 E. Raintree Drive, Scottsdale, AZ 85260, (480) , and protected by the copyright laws of the United States. 17 U.S.C. 101, et. seq. Permission is given to Council members to copy and use the work or any part thereof in connection with the business purposes of the Council members. The work may not be changed or altered. The work may not be sold, used or exploited for commercial purposes. This permission may be revoked by National Council for Prescription Drug Programs, Inc., at any time. The National Council for Prescription Drugs Programs, Inc. is not responsible for any errors or damage as a result of the use of the work. NCPDP recognizes the confidentiality of certain information exchanged electronically through the use of its standards. Users should be familiar with the federal, state, and local laws, regulations and codes requiring confidentiality of this information and should utilize the standards accordingly. NOTICE: In addition, this NCPDP Standard contains certain data fields and elements that may be completed by users with the proprietary information of third parties. The use and distribution of third parties' proprietary information without such third parties' consent, or the execution of a license or other agreement with such third party, could subject the user to numerous legal claims. All users are encouraged to contact such third parties to determine whether such information is proprietary and if necessary, to consult with legal counsel to make arrangements for the use and distribution of such proprietary information.

3 TELECOMMUNICATIONS STANDARD Version n.n Table of Contents 3. BUSINESS ENVIRONMENT Objectives Participants Between Providers and Adjudicators... 2 iii

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5 TELECOMMUNICATIONS STANDARD Version n.n 3 BUSINESS ENVIRONMENT 3.1 Objectives The NCPDP Telecommunication Standard Implementation Guide (Version D and above) is intended to meet two needs within the pharmacy drug claim industry: 1. to provide practical guidelines for software developers throughout the industry as they implement the Version D and above Standard, and 2. to ensure a consistent implementation of the Version D and above Standard. This version of the standard facilitates a specific type of business communication among diverse parties within the third party environment. To do this successfully, it must accomplish the following goals: Support the needs of a wide base of potential users, Maximize use of existing relevant standards wherever possible, Be flexible enough to change as needs and technology change, Be unambiguous, and Be easy to implement by carriers and vendors. 3.2 Participants The NCPDP Telecommunication Standard Implementation Guide (Version D and above) supports prescription claim transactions, services, and reportings between the following industry participants: Between Providers and Adjudicators, and Between Adjudicators (aka Payer-to-Payer) Between these entities and Switches/Intermediaries as determined by business need The NCPDP Telecommunication Standard Implementation Guide facilitates the exchange of information supporting REMS (Risk Evaluation & Mitigation Strategies) operations, PDMP (Prescription Drug Monitoring Program) reporting, and general communications between the following participants: Between Providers and REMS Administrators Between Providers and PDMP program administrators Between these entities and Switches and/or Intermediaries as determined by business need 1

6 Version n.n TELECOMMUNICATIONS STANDARD Between Providers and Adjudicators The communication between Providers and Adjudicators is two-way and the record layout for the transmitted claim and the response to the claim are defined by the Version D and above standard. The diagram below illustrates the typical business environments in which the NCPDP Telecommunication Standard Implementation Guide (Version D and above) is employed between providers and adjudicators. Figure Provider/Adjudicator Participants A Provider may be a retail pharmacy, mail order pharmacy, doctor s office, clinic, hospital, long-term care facility, or any other entity, which dispenses prescription drugs and submits those prescrip tions to a payer for reimbursement. A provider may be an entity that collects and reports information about prescribing, dispensing, and consumption of dangerous or abusable drugs or products such as a grocery store or convenience store. The Adjudicator (hereinafter referred to as the Processor ) is often a third-party administrator of prescription drug programs on behalf of insurers. The Adjudicator also may be an insurer, a governmental program or any other entity, which receives prescription drug claims, makes a decision regarding the level of reimbursement to the provider, and transmits a response to the provider. An adjudicator may be an entity that receives reporting information, record keeping, auditing, or authorizations of services, such as an entity performing drug utilization review reporting or reporting related to abusable products. 2

7 TELECOMMUNICATIONS STANDARD Version n.n Providers may choose to transmit certain prescription drug claims to an Intermediary. Intermediaries receive claims from switches or providers, perform editing/messaging and then either pass the claims to the appropriate switch or adjudicator or return (reject) claims to the providers. The reply from the adjudicator also may pass to an intermediary for editing and messaging on its return to the provider. Providers may choose to transmit claims to an intermediary for a number of reasons, including the following: Consolidated provider reporting Inventory tracking Consolidated claim editing and messaging The Switch also receives transactions from providers and intermediaries as claims pass from providers to adjudicators. Switching companies accept transactions, optionally perform format conversions, and optionally perform pre-edits or post-edits., The switch passes the transaction to the appropriate processor. The reply from the processor also may pass through the switch on its return to the provider. (In some instances the switch returns an approved response if the transaction is for a cash prescription.) Providers utilize the services of a switch for a number of reasons, including the following: Capture of data Pre and/or post editing A processor may not support Dial-Up communications All transactions can be transmitted to one central point, the Switch Increased reliability of communications 3

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