TELECOMMUNICATION VERSION D AND ABOVE QUESTIONS, ANSWERS AND EDITORIAL UPDATES

Transcription

1 TELECOMMUNICATION VERSION D AND ABOVE QUESTIONS, ANSWERS AND EDITORIAL UPDATES DOCUMENTATION 12/2014 See important update in section Quantity Prescribed (460-ET) National Council for Prescription Drug Programs 9240 East Raintree Drive Scottsdale, AZ Phone: (480) Fax: (480) ncpdp@ncpdp.org http:

2 Telecommunication Version D and Above Questions, Answers and Editorial Updates COPYRIGHT ( ) National Council for Prescription Drug Programs, Inc National Council for Prescription Drugs Programs, Inc. (NCPDP) publications are owned by NCPDP, 9240 East Raintree Drive Scottsdale, AZ 85260, 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 be shared within the member company but may not be distributed and/or copied for/by others outside of the member s company. The work may not be sold, used or exploited for commercial purposes. This permission may be revoked by NCPDP at any time. NCPDP is not responsible for any errors or damage as a result of the use of the work. All material is provided "as is", without warranty of any kind, expressed or implied, including but not limited to warranties of merchantability, fitness for a particular purpose, accuracy, completeness and non-infringement of third party rights. In no event shall NCPDP, its members or its contributors be liable for any claim, or any direct, special, indirect or consequential damages, or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use or performance of the material. 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. Published by: National Council for Prescription Drug Programs Publication History: Version 1.0, Version 2.0 June 2009 Version 18.0 August 2012 Version 36.0 December 2016 Version 3.0 July 2009 Version 19.0 December 2012 Version 37.0 May 2017 Version 4.0 September 2009 Version 20.0 February 2013 Version 38.0 August 2017 Version 5.0 November 2009 Version 21.0 April 2013 Version 39.0 December 2017 Version 6.0 January 2010 Version 22.0 May 2013 Version 7.0 February 2010 Version 23.0 August 2013 Version 8.0 May 2010 Version 24.0 November 2013 Version 9.0 August 2010 Version 25.0 February 2014 Version 11.0 February 2011 Version 26.0 May 2014 Version 12.0 June 2011 Version 27.0 August 2014 Version 13.0 August 2011 Version 28.0 December 2014 Version 14.0 October 2011 Version 29.0 February 2015 Version 15.0 November 2011 Version 30.0 May 2015 Version 16.0 February 2012 Version 31.0 August 2015 Version 17.0 May 2012 Version 32.0 January 2016 Version 15.0 November 2011 Version 33.0 March 2016 Version 16.0 February 2012 Version 34.0 May 2016 Version 17.0 May 2012 Version 35.0 August 2016 Page: 2

3 Table of Contents 1 PURPOSE OF THIS DOCUMENT REPUBLICATION OF TELECOMMUNICATION STANDARD IMPLEMENTATION GUIDE VERSION D.0 JULY Scheduled Prescription ID Number (454-EK) REPUBLICATION OF TELECOMMUNICATION STANDARD IMPLEMENTATION GUIDE VERSION D.0 AUGUST Benefit Stage Formula Denote Individual Amounts of Patient Financial Responsibility as Reported from a Previous Payer ENHANCEMENT OF TELECOMMUNICATION STANDARD IMPLEMENTATION GUIDE VERSION D.0 NOVEMBER Quantity Prescribed (460-ET) USE OF THIS DOCUMENT How Soon Support This Document? Medicaid Subrogation Editorial Document NCPDP IMPORTANT EXTERNAL CODE LIST (ECL) INFORMATION NCPDP RECOMMENDATIONS FOR 4RX USAGE IN MEDICARE PART D PROCESSING DOCUMENTS NCPDP EMERGENCY PREPAREDNESS RESOURCE EDITORIAL CORRECTIONS CITED IN TELECOM D REQUEST SEGMENT DISCUSSION CLAIM SEGMENT (07) Days Supply (405-D5) Dispense As Written (408-D8) Value 9 During Transition Other Coverage Code (308-C8) Submitting to Multiple Payers? Non-COB Claims Government COB? Other Coverage Code (308-C8) to Submit When One Other Payer Has Paid $0? OTHER COVERAGE CODE WHEN DRUG BENEFIT AMOUNT IS ZERO Prescription Origin Code (419-DJ) Important Note Transfers Use of Prescription Origin Code Product/Service ID/Qualifier in Compounds Route of Administration (995-E2) and SNOMED Codes Date of Service (401-D1) Unit of Measure (600-28) and Multi-Ingredient Compounds Level of Service Submission Clarification Code (SCC) COMPOUND SEGMENT (10) COORDINATION OF BENEFITS SEGMENT (05) INSURANCE SEGMENT (04) Medicaid Indicator (360-2B) Medicaid ID Number (115-N5) and Cardholder ID (302-C2) Medigap ID (359-2A) Use PATIENT SEGMENT (01) Place of Service (307-C7) and Patient Residence (384-4X) PRICING SEGMENT (11) B Processing Pricing Segment Contains Values as if the Claim was Primary Billing Transaction For Free Fills Page: 3

4 3.6.4 Provider Fees FACILITY SEGMENT (14) PRESCRIBER SEGMENT (03) RESPONSE SEGMENT DISCUSSION RESPONSE COORDINATION OF BENEFITS/OTHER PAYERS SEGMENT (28) RESPONSE PATIENT SEGMENT (29) RESPONSE PRICING SEGMENT (23) Amount Attributed to Processor Fee (571-NZ) Basis of Reimbursement Determination (522-FM) Adjust the Ingredient Cost Paid and Dispensing Fee Paid? Benefit Stage Health Plan-Funded Assistance Amount (129-UD) Total Amount Paid (509-F9) Negative? Response Processing Guidelines Negative Patient Pay Values Brand Medically Necessary RESPONSE STATUS SEGMENT (21) Additional Message Information Additional Message Information Continuity (131-UG) Use of Additional Message Information for Next Available Date of service Additional Message Information Qualifier (132-UH) appear more than once? Duplicate Transaction Reject Code (511-FB) 70 and MR TYPOGRAPHICAL ERRORS TELECOMMUNICATION STANDARD IMPLEMENTATION GUIDE FIELDS Additional Message Information Examples Date of Service (401-D1) Help Desk Phone Number Qualifier (549-7F) Internal Control Number (993-A7) Other Coverage Code (308-C8) Other Payer Coverage Type (338-5C) Quantity Prescribed (460-ET) Repeating Designation Route of Administration (995-E2) TELECOMMUNICATION STANDARD IMPLEMENTATION GUIDE SEGMENTS General Claim Segment Coupon Segment Prior Authorization Request And Billing Transaction Clinical Segment Patient Segment Purchaser Segment Response Claim Segment Medicaid Subrogation Claim Billing or Encounter Prior Authorization Request And Billing Response Response Coordination of Benefits/Other Payers Segment TELECOMMUNICATION STANDARD IMPLEMENTATION GUIDE EXAMPLES Billing Transaction Code B1 Coordination of Benefits Scenario Pharmacy Bills To Secondary Which Meets Designation As Government Payer, Patient Requests Brand Billing Transaction Code B1 Coordination of Benefits Scenarios Pharmacy Bills To Insurance Designated By Patient Page: 4

5 5.3.3 Billing - Transaction Code B1 - COB Scenario - Pharmacy Bills Reporting Amount Paid by Previous Payer Only Controlled Substance Reporting (General) Examples Examples using Medigap ID (359-2A) APPENDIX A. HISTORY OF DOCUMENT CHANGES CORRECTIONS EXTERNAL CODE LIST NOTABLES Reject Code (511-FB) List Prescription/Service Reference Number (455-EM) Value GENERAL QUESTIONS BIN AND IIN HOW SOON SUPPORT THIS DOCUMENT? PRINTABLE CHARACTERS REJECT CODE GUIDANCE Telecommunication Phases with Flow Chart When should Reject Code 84 be used? Prescriber ID Rejections Information Reporting Transactions Which NCPDP ECL Values (Reject Code, SCC, Approved message Code) should be used for Medicaid Ordering Referring Provider Requirements RPh Prescriptive Authority Validation SYNTAX ERROR NOT USED DATA ELEMENT VACCINE ADMINISTRATION ICD-9 VERSUS ICD-10 INFORMATION ICD-10 SUBMISSION NUMBER OF DIAGNOSIS CODE FIELDS MINIMUM AND MAXIMUM FIELD LENGTH UNIQUE DEVICE IDENTIFIER CONVERSION GUIDANCE FOR OPIOID LIMITS CLAIM REJECTIONS NCPDP BATCH STANDARD DELIMITER RESPONSE FORMAT SEGMENT DEFINITION Batch Standard Segment Usage Different than Telecommunication Standard? TRANSACTION PROCESSING Batch Processing Reject LONG-TERM AND POST-ACUTE CARE (LTPAC) PHARMACY CLAIMS SUBMISSION RECOMMENDATIONS FOR VERSION D INTRODUCTION (PURPOSE) BACKGROUND ISSUES AND RECOMMENDATIONS Provider Contracts How do we know we have a LTPAC transaction? Qualifying the patient Qualifying the pharmacy service Special Packaging Leave of Absence Medications Page: 5

6 9.3.5 Medication Lost, Dropped, or Patient Spits out Emergency Box / Kit Dispensing Operations LTPAC Admissions and Readmissions Coverage Ends for Medicare Part A Resident Before Medication Supply is Used On-Line Window for Submission of New and Rejected Claims Predetermination of Benefits Date of Service for LTPAC Billing Claim Cycle Fills Back Up Pharmacies IMPLEMENTATION OF CHANGES REQUESTED APPROPRIATE DISPENSING (SHORT CYCLE) FOR LTC Dispensing Methodologies for LTC in PPACA Submission Clarification Code Combinations and Rejections Plan Support of Submission Clarification Code Appropriate Dispensing and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFIID) and Institute of Mental Disease (IMD) COORDINATION OF BENEFITS INFORMATION CLARIFICATION OF NET AMOUNT DUE IN COORDINATION OF BENEFITS Payable Components of Other Payer-Patient Responsibility Amounts THREE OPTIONS FOR COORDINATION OF BENEFITS Only Three Options Allowed? Multiple COB Options Per BIN/PCN? Component Pieces Not Sum to Patient Pay Amount? OTHER PAYER AMOUNT PAID QUALIFIER (342-HC) VALUE FOR SALES TAX OTHER PAYER COVERAGE TYPE (338-5C) IS UNKNOWN OTHER AMOUNT PAID (565-J4) AND COB OTHER PAYER AMOUNT PAID QUALIFIER (342-HC) VALUES SUNSETTED Medicaid Allowed Amount and Prescription Response Formula OTHER PAYER AMOUNT PAID QUALIFIER (342-HC) VALUE 99? LIKE AMOUNTS SUBMITTED AS INCENTIVE FEE DRUG BENEFIT OTHER PAYER REJECT CODE (472-6E) OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT (352-NQ) TO EACH PAYER? GOVERNMENT COB OPPRA AND OTHER COVERAGE CODE VALUE PROCESSOR VS. PHARMACY RESPONSIBILITY FOR AGGREGATING OTHER PAYER AMOUNTS PATIENT PAID AMOUNT SUBMITTED (433-DX) Accounting for Monies Paid to the Patient? Receiving Patient Paid Amount Submitted (433-DX) when Previous Payer Paid the Claim? Receiving Patient Paid Amount Submitted (433-DX) when Previous Payer Rejected the Claim? COORDINATION OF BENEFITS SEGMENT (05) VS. PRICING SEGMENT (11) COORDINATION OF BENEFITS AND PRIOR AUTHORIZATION How should Medicare and Medicaid handle the processing of benzodiazepine and barbiturates? MEDICAID PAY ONLY APPLICABLE COMPONENTS? RESPONSE COORDINATION OF BENEFITS/OTHER PAYERS SEGMENT (28) Other Payer Coverage Type (338-5C) and Processing for Mid-Stream Payers Ingredient Cost Paid (506-F6) and Total Patient Responsibility Amount from Last Payer TRANSITION OF VERSIONS AND COB WORKERS COMPENSATION AND COB Page: 6

7 Provide Guidance for Handling Workers Compensation Payer as Primary, that is not Required to Send Telecom D REVERSALS AND COB DOLLAR FIELD NOT RECEIVED RECOMMENDATIONS FOR CLAIM REVERSAL PROCESSING FOR TELECOMMUNICATION VERSION D CURRENT INFO ON CLAIM REVERSAL PROCESSING FOR TELECOMMUNICATION VERSION D WHY IS GUIDANCE NEEDED? NCPDP MEDICAID SUBROGATION STANDARD TYPOGRAPHICAL ERRORS WORKERS COMPENSATION-SPECIFIC INFORMATION WORKERS COMPENSATION AND REPACKAGED NDCS IMPROVING THE VALUE OF THE CLAIM RESPONSE WITH ADDITIONAL MESSAGING BACKGROUND SPECIFIC DATA FIELD USE RECOMMENDATIONS Benefit- or Plan-Generated Rejections Reject Code 76 (Plan Limitations Exceeded) Reject Code 79 (fill Too Soon) Reject Code 52 (Non-Matched Cardholder ID) Reject Code 69 (DATE OF SERVIE After Coverage Terminated) Reject Code 68 (DATE OF SERVICE AFTER Coverage Expired) Reject Code 70 (Product/Service Not Covered Plan/Benefit Exclusion) Reject Code 06 (M/I Group ID) Reject Code 19 (M/I Days Supply) Reject Code 88 (DUR Reject Error) Reject Code 65 (Patient Is Not Covered) Reject Code 07 (M/I Cardholder ID) Reject Code 54 (Non-Matched Product/Service ID Number) Reject Code 75 (Prior Authorization Required) Reject Code 09 (M/I Date Of Birth) Reject Code 51 (Non-Matched Group ID) Reject Code 41 (Submit Bill To Other Processor Or Primary Payer) Other Notable Reject Codes Reject Code 83 (Duplicate Paid/Captured Claim) Reject Code 92 (System Unavailable/Host Unavailable) Reject Code 85 (Claim Not Processed) Reject Code 87 (Claim Not Processed) Reject Code 53 (Non-Matched Person Code) Reject Code 40 (Pharmacy Not Contracted with Plan) Reject Code 608 (Step Therapy) DUR/PPS-GENERATED REJECTIONS PARTICIPATING ORGANIZATIONS LONG TERM CARE TRANSITION, EMERGENCY SUPPLY AND CHANGE IN LEVEL OF CARE MESSAGING FOR REJECTED AND PAID CLAIMS Background When Prior Authorization Number (498-PY) Required Transition and Safety-Related Rejects Claims Paid Due To CMS Initial Eligibility Transition Period Approved Message Code 004 (DISPENSED During Transition Benefit) Claims Paid Due To CMS Emergency Supply Requirement Approved Message Code 008 (Emergency SUPPLY Situation) Claims Paid Due To CMS Change In Level Of Care Requirement Page: 7

8 Approved Message Code 012 (Level of Care Change) MULTI-INGREDIENT COMPOUND PROCESSING CORRECT TELECOM VERSION? LEAVE OFF INGREDIENTS THAT ARE IDENTIFIABLE BY THE PHARMACY AND THE PAYER? COMPOUND INGREDIENT QUANTITY (448-ED) SMALLER THAN 3 DIGITS OF PRECISION TO THE RIGHT OF THE DECIMAL COMPOUND INGREDIENT MODIFIER CODE (363-2H) BASIS OF REIMBURSEMENT (423-DN) AND MULTI-INGREDIENT COMPOUNDS UNIT OF MEASURE (600-28) AND MULTI-INGREDIENT COMPOUNDS RECOMMENDATIONS ON THE SUBMISSION OF IDENTIFIABLE INGREDIENTS THAT ARE NOT RECOGNIZED BY THE PAYER CORRELATE COMPLEXITY IN COMPOUNDING AND DUR/PPS LEVEL OF EFFORT (474-8E) COMPOUND INGREDIENT PRODUCT IDENTIFIER AND QUALIFIER USE USE OF THE COMPOUND SEGMENT FOR THE BILLING OF 2 COMMERCIALLY AVAILABLE PRODUCTS VACCINE SERVICES PHARMACY BENEFIT BILLING & PROCESSING OVERVIEW NEW/MODIFIED CODE VALUES Reject Codes New Basis Values PHARMACY BENEFIT BILLING PRIMARY VACCINE CLAIMS Question: When Billing a Vaccine Claim to a Pharmacy Benefit Using the NCPDP Telecommunication Standard, What are the Responsibilities of the Pharmacy? Question: How Do I Determine the Submitted Value in the Usual & Customary Charge for Vaccine Product and Administration Claim Billing? Question: Should the Usual & Customary Charge on the Billing Request Resubmission Remain Unchanged? Alternatively, Should the Administration Fee be Removed? Question: What Actions are Expected of the Pharmacy in the Scenario in Which a Billing Request for a Vaccine Product and Administration was Rejected by the Pharmacy Benefit Processor to Indicate that the Product is Reimbursable and the Administration Fee is Not Reimbursable? Question: Should the Submitted Date of Service Reflect the Date of the Billing Request or the Date in Which the Vaccine is Administered? Question: Can NCPDP Provide Inbound Billing Request Examples (Header, Claim, DUR/PPS, and Pricing Segments) for the following three vaccine claim billing examples? Question: When Submitting a Prescription Billing Request for a Vaccine, What Value Should a Pharmacy Submit in the Days Supply? Question: Which NDC Should be Submitted in a Vaccine Billing Request when a Vaccine has an Outer Package NDC and an Inner Package NDC? PHARMACY BENEFIT PROCESSING PRIMARY CLAIMS Question: When Processing a Vaccine Billing Request using the NCPDP Telecommunication Standard, What are the Responsibilities of the Pharmacy Benefit Processor? Reject Scenario Matrix Question: When Processing a Billing Request for a Vaccine, What Value is Received in the Days Supply? Question: When Processing a Claim for a Vaccine Product and Administration, What is Meant by the Terms Bundled Reimbursement or Separate Reimbursement? Question: Can NCPDP Provide Response Examples (Claim, DUR/PPS, and Pricing Segments) for the Following Scenarios? Question: When Processing a Bundled Payment Claim, Can the Incentive Amount Paid be $0.00 or a Negative Dollar Amount? Question: When Processing a Pharmacy Billing Request for a Vaccine when the Pharmacy Benefit Processor Knows the Patient s Medical Benefit Covers the Vaccine Product, what Information is Returned by in the Claim? Page: 8

9 Question: Does the Telecommunication Standard Support the Billing from a Single Provider the Vaccine Product and the Administration Via Separate Transaction Types? COORDINATION OF BENEFIT CLAIMS PROCESSING Question: What Value does the Pharmacy Assign to the Other Payer Amount Paid Qualifier (342-HC) to Report the Vaccine Administration Fee (Incentive Amount Paid) Paid by the Previous Payer? Question: Can NCPDP Provide Other Payer Amount Paid COB Claim examples (COB Method 1) for the Following Two Scenarios? Question: What Value Should the Pharmacy Benefit Processor Recognize in the Other Payer Amount Paid Qualifier (342-HC) when Processing a COB Billing Request for a Vaccine Product and Administration? APPENDIX A. MODIFICATIONS TO THIS DOCUMENT VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION VERSION APPENDIX B. WHERE DO I FIND Page: 9

10 18.1 ANSWERS MAY BE FOUND IN THE FOLLOWING DOCUMENTS ADDITIONAL INFORMATION MAY BE FOUND IN THE FOLLOWING DOCUMENTS PARTICULAR TOPICS MAY BE FOUND IN THE FOLLOWING DOCUMENTS What Transactions Are Supported For What Business Purposes? What Fields Changed? Which Fields Are Allowed In Which Segments? Where Do The Segments Belong? What Are The Valid Responses For Each Transmission? Recommended Use Of Dollar Fields And Calculated Amounts? Explain The Syntax Rules For Version D Documentation Dates What If I Have A New Question? CMS Place of Service Codes? APPENDIX C. MEDICARE PART D AND MULTI-INGREDIENT COMPOUND PROCESSING KEY TERMS USED IN GENERAL ASSUMPTIONS GENERAL ASSUMPTIONS PDE REPORTING COST SHARE CALCULATION FOR MULTI-INGREDIENT COMPOUND CLAIMS THAT STRADDLE THE COVERAGE GAP AND CATASTROPHIC PHASES EXAMPLE 1: MAPD PLAN COVERS THE PART D INGREDIENTS AND SOME OF THE NON-PART D INGREDIENTS OF THE COMPOUND Example 2: PDP Alternate Basic Plan covers only the Part D ingredients of the compound Example 3a: MAPD Plan covers the Part D ingredients and one non-part D ingredient (#3) in the compound Example 3b: MAPD Plan covers the Part D ingredients and one non-part D ingredient (#4) in the compound Example 3c: MAPD Plan covers the Part D ingredients and both excluded non-part D ingredients (#3 & #4) in the compound Example 4: MAPD Plan covers the enhanced ingredients and OTC ingredients of the compound (no Part D drugs included) Example 5: MAPD Plan covers the OTC ingredients of the compound (no Part D drugs included) APPENDIX D. MEDICARE PART D TOPICS HARDCODED VALUES NOTICE OF APPEAL RIGHTS REJECTED CLAIM Reject Code 569 and Submission Clarification Code NOTICE OF APPEAL RIGHTS PAID CLAIM NOTICE OF MEDICARE DRUG COVERAGE RIGHTS REJECTED CLAIM Reject Code 569 and Submission Clarification Code 8 (Compound Processing) NOTICE OF MEDICARE DRUG COVERAGE RIGHTS PAID CLAIM BENEFIT STAGE RULES AND EXAMPLES Benefit Stage Rules Cost Share Parameters Used in Examples 1 thru Example 1: $50 claim - Amount remaining to meet deductible is $ Example 2: $50 claim - Amount remaining to meet non-lis deductible is $260. Amount remaining to meet LIS 4 deductible is $ Example 3: $50 claim - Amount remaining to meet non-lis deductible is $10. LIS 4 deductible already met Example 4: $50 claim - Amount remaining to meet Initial Coverage limit is $ Example 5: $50 claim - Initial Coverage Limit of $2830 already met. Amount remaining to meet TrOOP is $ Example 6: $50 claim - Amount remaining to meet TrOOP is $ Page: 10

11 Cost Share Parameters Used in Examples 7 thru Example 7: $50 claim - Amount remaining to meet Initial Coverage limit is $ Example 8: $50 claim - Initial Coverage Limit of $2830 already met. Amount remaining to meet TrOOP is $ Example 9: $100 claim - Initial Coverage Limit of $2830 already met. Amount remaining to meet TrOOP is $ Cost Share Parameters Used in Example Example 10: $100 claim for brand drug. Amount remaining to meet Initial Coverage limit is $ Cost Share Parameters Used in Examples Example 11: $100 claim No coverage gap; amount remaining to meet TrOOP is $ Cost Share Parameters Used in Examples Example 12: $50 claim for generic drug No deductible for generics; amount remaining to meet brand non-lis Deductible is $100. LIS deductible already met Cost Share Parameters Used in Examples Example 13: $20 claim for generic drug; initial coverage limit already met; $500 remaining to meet TrOOP. Non-LIS generic copay applies because it is less than LIS copay Example 14: $100 Medicare Secondary Payer claim for brand drug; initial coverage limit already met; $500 remaining to meet TrOOP. Other Payer Amount Paid is $ BENEFIT STAGE QUALIFIER VALUES TO IDENTIFY CLAIMS COVERED UNDER THE NOT PART D PORTION OF THE MEDICARE D PLAN BENEFIT STAGE IMPLEMENTATION FOR 01/01/ BENEFIT STAGE IMPLEMENTATION FOR 07/01/ BENEFIT STAGE IMPLEMENTATION FOR 10/01/ IMPACT ON DOWNSTREAM PAYER FOR ALTERNATIVE/FORMULARY OTHER IMPACTS TO BENEFIT STAGE? PART D SPONSOR TRANSITION NOTICE OR DENIAL LETTER? BENEFIT STAGE REQUIRED FOR PART D? Can Non-Government Processor Require? Medicare Part D Claim Without Benefit Stage Fields? COVERAGE GAP AND AMOUNT ATTRIBUTED TO COVERAGE GAP (137-UP) NON-FORMULARY PENALTY AND COVERAGE GAP VACCINE ADMINISTRATION BIN AND PCN FROM RESPONSE TO REQUEST CMS DEFINITION OF PRIMARY INSURER S PAYMENT DUAL ELIGIBILITY PART D SPONSORS APPLYING MEDICARE SECONDARY PAYER (MSP) REQUIREMENTS PRESCRIBER IDENTIFICATION Foreign Prescriber Identifier Valid Prescriber ID? Processing with Prescriber ID Definition of a Valid Prescriber CMS 4157 Prescriber reject Matrix Inactive state license How can the payers and providers leverage the NCPDP standard to comply with Section 507 of the MACRA legislation? Prescriber ID and PDE Questions Veterinarian Identifiers State License Questions Other Prescriber ID Questions MEDICARE PART D/MEDICAID BENZODIAZEPINE AND BARBITURATE CLAIMS PROCESSING RISKS OTHER CARRIER PAYMENT MEETS OR EXCEEDS PAYABLE MILITARY TREATMENT FACILITIES GOVERNMENT BILLING THE GOVERNMENT PROVISIONAL FILL ELIGIBILITY VERIFICATION EXAMPLES Page: 11

12 Eligibility Medicare Part D to Facilitator Request Could not find this member Eligibility Medicare Part D to Facilitator Reject Response - Could Not Find This Member Eligibility Medicare Part D to Facilitator Request Found Member But No Coverage Eligibility Medicare Part D to Facilitator Reject Response Found Member But No Coverage Eligibility Medicare Part D to Facilitator Request- Member Has Current Medicare Part D Coverage and No Other Coverage Eligibility Medicare Part D to Facilitator Approved Response - Member has Current Medicare Part D Coverage and No Other Coverage Eligibility Medicare Part D to Facilitator Request Member Has Current Medicare Part D Coverage (Primary) and Current Other Coverage Eligibility Medicare Part D to Facilitator Approved Response Member Has Current Medicare Part D Coverage (Primary) and Current Other Coverage Eligibility Medicare Part D to Facilitator Request Member Has Current Medicare Part D Coverage and No Other Coverage (Date of Service is Based upon Allowed Future Date Range) Eligibility Medicare Part D to Facilitator Approved Response Member Has Current Medicare Part D Coverage and No Other Coverage APPENDIX E. ROUTE OF ADMINISTRATION QUESTIONS ROUTE OF ADMINISTRATION USED IN NCPDP TELECOMMUNICATION STANDARD APPENDIX F. POINT OF SERVICE PRESCRIBER VALIDATION GUIDANCE APPLICABLE TO CMS 4159 AND IFC INTRODUCTION BACKGROUND: TIMELINE (AS OF 03/01/2016) CMS DOCUMENTATION REFERENCES CMS CLARIFICATION OPEN AREAS OF CONCERN FAQS HIGH LEVEL HIERARCHICAL RULES: PRESCRIBER RELATED REJECT CODES PRESCRIBER RELATED SUBMISSION CLARIFICATION CODES PRESCRIBER RELATED APPROVED MESSAGE CODES 548-6F MEDICARE PART D PRESCRIBER VALIDATION REJECT MATRIX CMS 4159 AND IFC QUICK REFERENCE MATRIX MEDICARE PART D PRESCRIBER VALIDATION VISIO APPENDIX G. SUPPORT OF THIS DOCUMENT Page: 12

13 1 PURPOSE OF THIS DOCUMENT This document provides a consolidated reference point for questions that have been posed based on the review and implementation of the NCPDP Telecommunication Standard Implementation Guide Version D and above, the Data Dictionary, and the External Code List. This document also addresses editorial changes made to these documents. As members reviewed the documents, questions arose which were not specifically addressed in the guides or could be clarified further. These questions were addressed in the Work Group 1 Telecommunication meetings. Editorial changes include typographical errors, comments that do not match a field value, a reference pointer in error. Important Note: In July 2007 the NCPDP Telecommunication Standard Implementation Guide Version D.0 was published. Editorial changes were made until April 2009 and are noted in Appendix A. History of Document Changes, Version D.0, Editorial Corrections. Implementers should verify they are using the version of the implementation guide that has the editorial corrections noted below. Any further modifications will be noted in this document. Business needs brought forward and further changes to the implementation guide will result in future versions. Editorial or clarification changes to the implementation guide, as well as format changes will be made to future versions of the Telecommunication standard. Clarifications that affect implementation of Telecommunication Standard Implementation Guide Version D.0 will be cited in this document. NCPDP Telecommunication Standard Implementation Guide Version D.0 was named in Final Rule published January 16, 2009 for the Health Insurance Portability and Accountability Act (HIPAA). It should be noted that values may be added/changed/deleted in the External Code List on a quarterly basis. This allows the industry to adapt to business needs when values are needed. The topics are in categories which provide a high level reference. For example, a category may be a Segment in the format, with a subcategory of a field in that segment. The question and answer is then posed for that field found in that segment. Where appropriate, the question may be the actual heading in the index for ease of research. This document will continue to be updated as questions and answers or editorial changes are necessary. Note: within the guide, when dollar fields and amounts are discussed, all digits may be seen for readability. When actually using the field, rules should be followed for the overpunch character, as applicable. 1.1 REPUBLICATION OF TELECOMMUNICATION STANDARD IMPLEMENTATION GUIDE VERSION D.0 JULY SCHEDULED PRESCRIPTION ID NUMBER (454-EK) Scheduled Prescription ID Number (454-EK) has been changed from Not used to Required if necessary for state/federal/regulatory agency programs in Claims and Service Billings, Information Reporting, and their Rebills, Prior Authorization Request and Billing (Claim, Service), and Predetermination of Benefits transactions. The previous versions of Telecommunication Implementation Guide supported the use of the field. This was brought to NCPDP s attention by NYS Medicaid. NCPDP provided background to the Office of e-health Standards and Services with the request to correct the implementation guide named in HIPAA in The request was granted. See under Implementation Guide Corrections banner. Page: 13

14 454-EK SCHEDULED PRESCRIPTION ID NUMBER Q Claim Billing/Encounter: Required if necessary for state/federal/regulatory agency programs. Note that Telecom D.1 and above were also updated, with the inclusion of the Controlled Substance Reporting transaction specifications. 1.2 REPUBLICATION OF TELECOMMUNICATION STANDARD IMPLEMENTATION GUIDE VERSION D.0 AUGUST BENEFIT STAGE FORMULA New CMS requirements for Part D multi-ingredient compound claims (which represent a very small percentage of pharmacy claims) introduce a possible scenario where the standard Benefit Stage formula no longer balances. This scenario would occur if multi-ingredient compound prescription claims submitted by a pharmacy to a primary Medicare Part D payer contained some ingredients that cannot be covered by Part D due to regulation and the plan chooses to offer enhanced benefits to cover some/all of the remaining ingredients. This imbalance was found as part of the industry building examples for multi-ingredient compounds to comply with Medicare Part D regulations. The formula was modified to include Other Payer Amount Recognized (566-J5) and clarifying guidance was added in section Response Pricing Segment. The Telecommunication Standard Implementation Guide Version D.0 (and above) has been modified to clarify the Benefit Stage formula as follows (additions shown in highlight): Telecommunication Implementation guide clarification: Benefit Stage Amount (394-MW) The sum of all submitted Benefit Stage Amounts must equal the sum of Patient Pay Amount (505-F5), Other Payer Amount Recognized (566-J5) and Total Amount Paid (509-F9). (Calculation: Sum Benefit Stage Amount occurrences 1 through 4 = Patient Pay Amount (505-F5) + Other Payer Amount Recognized (566-J5) + Total Amount Paid (509-F9)). Note: If a plan chooses to pay for non-medicare Part D ingredients in a compound that also contains a payable Medicare Part D ingredient, the Benefit Stage Amount (394- MW) will reflect the correct amount attributed to Medicare Part D benefit stage, but it will not equal the sum of Patient Pay Amount (505-F5) and Other Payer Amount Recognized (566-J5) and Total Amount Paid (509-F9). Multi-ingredient compounds only: When plans chose to cover ingredients under an enhanced plan that are not Medicare Part D covered drugs, the Benefit Stage balancing formula does not apply, due to the sum of the Patient Pay Amount (505-F5), Total Amount Paid (509-F9) and Other Payer Amount Recognized (566-J5) being greater than the amounts covered under the Medicare D benefit. If using Other Payer-Patient Responsibility Amount (352-NQ) as the basis for your coordination of benefit payment, no change is required to Benefit Stage calculation DENOTE INDIVIDUAL AMOUNTS OF PATIENT FINANCIAL RESPONSIBILITY AS REPORTED FROM A PREVIOUS PAYER Section "Denote Individual Amounts of Patient Financial Responsibility as Reported from a Previous Payer" had an invalid reference to sales tax, and Amount Attributed to Product Selection/Brand Drug (134-UK), which should not apply to Service Billings. The Telecommunication Standard Implementation Guide Version D.0 (and above) has been modified to Page: 14

15 For example, in an original claim or service billing, the primary payer returns amounts in the Amount Attributed to Product Selection/Brand Drug (134-UK) and Amount Attributed to Sales Tax (523-FN) Amount of Copay (518-FI). The pharmacy submits the claim or service billing to the secondary payer. The amounts in these two fields are then reflected in two occurrences of the Other Payer-Patient Responsibility Amount, with the Qualifier reflecting one occurrence with a value of 02 (Amount Attributed to Product Selection/Brand Drug (134-UK) as reported by a previous payer) and a second occurrence with a value of 05 (Amount of Copay (518-FI) as reported by previous payer). NCPDP provided background to the Office of e-health Standards and Services with the request to correct the implementation guide named in HIPAA in The request was granted. See under Implementation Guide Corrections banner. 1.3 ENHANCEMENT OF TELECOMMUNICATION STANDARD IMPLEMENTATION GUIDE VERSION D.0 NOVEMBER QUANTITY PRESCRIBED (460-ET) 11/2014 Update: 09/2014: Timeframe of NPRM publication has been reported by OESS as: May /2014: Implementation timeframe information was sent to OESS. See under Implementation Guide Corrections banner. 08/2014 Update: Two items NCPDP has open with OESS are regulations for electronic Prior Authorization transactions (eprescribing) and Quantity Prescribed (Telecom version D.0). Per OESS, these are included in one NPRM because both are pharmacy NCPDP related, and per OESS, both proposals require a notice of proposed rulemaking (NPRM). The NPRM is at the stage: Response from OESS: internal comments on the proposed rule are being addressed. A timeframe for publication of the NPRM: Response from OESS: We hope to have the proposed rule published before early The NPRM does not have a suggested implementation timeframe. Response from OESS: Feel free to send your suggestions. Thanks! WG1 Telecommunication FAQ Task Group will start working on a suggested timeframe for adoption of the Quantity Prescribed field. We can t at this point say as of this date, but we can discuss recommending xxx days from the publication of the final rule, if we want a transition timeframe, etc. See the NCPDP Collaborative Calendar for WG1 Telecommunication FAQ Task Group calls in August/September timeframe. 03/2014 Update: NCPDP received a response from HHS to the 03/2013 letter that the request would have to go through the full rulemaking process (NPRM and Final Rule). We are awaiting a timeframe for the NPRM from OESS. 08/2013 Update: The original industry requested implementation timeframe for Quantity Prescribed was 01/2014. THIS IS NOW ON HOLD PENDING REGULATORY APPROVAL PROCESSES. The Telecommunication Standard Version D.0 of 08/2010 continues to be the ONLY HIPAA-approved version. See under the banner Implementation Guide Corrections for updated information when it is available. NCPDP will use the NCPDP NOW and other mechanisms to notify the industry. Background: In November 2012 NCPDP published an enhancement of the Telecommunication Standard Implementation Guide Version D.0. The enhanced guide contains a publication date of November In the guide in section Page: 15

16 Appendix A. History of Document Changes, Version D.0, November 2012 Enhancement, the following entry appears: Quantity Prescribed (460-ET) for claim billings was changed from not used to situational for Schedule II dispensing under the following situational circumstance Required for all Medicare Part D claims for drugs dispensed as Schedule II. May be used by trading partner agreement for claims for drugs dispensed as Schedule II only. (This modification was made to Claim Billing/Encounter, Claim Rebill, Prior Authorization Request And Billing (Claim)). 11/2012: NCPDP provided a request to the Office of e-health Standards and Services to publish regulatory notice about the implementation guide enhancement in preparation for a 01/2014 implementation. The industry was preparing for the 01/2014 use of Quantity Prescribed (460-ET) in the billing transactions. In 2012 and 2013, requests for HIPAA rule making notifications were sent to OESS and NCVHS. DSMO Change Request 1182 was filed and approved. In 03/2013, NCPDP received approval from OESS to proceed with industry outreach and the timeframe. However in 08/2013 important updated information was provided. Initially OESS thought they could publish a notice announcing the change in the Federal Register and responded that way in a letter to NCPDP. In early summer 2013, the HHS Office of General Counsel (OGC) advised OESS that this could not be a federal register notice. OESS created an Interim Final Rule (IFC) per ACA section 1104 on Administration Simplification. OGC advised OESS that ACA did not apply to this situation and the Telecommunication change would have to go through the full rulemaking (Notice of Proposed Rule Making (NPRM) and Final Rule) process. NCPDP is following up to determine if there is a timely alternative. This delay in rulemaking has delayed the industry requested January 2014 implementation date. All entities should put on hold the implementation of Quantity Prescribed changes pending the regulatory process outcome. We will update the industry with additional information as soon as it is available. Editorial Correction: Note, in the original November 2012 publication of the Telecommunication Standard Implementation Guide Version D.0, an editorial error was present in the section Transmission Structure, Request Segment Matrices By Field Within Segment where the Quantity Prescribed was not changed to Q on the Claim Billing column. This has been corrected. 1.4 USE OF THIS DOCUMENT This document should be used as a reference for the Telecommunication Standard Version D.0 and above, the Batch Standard Version 1.2 and the Medicaid Subrogation Implementation Guide Version 3.0 as applicable. In the Batch Standard format, and the Medicaid Subrogation Implementation Guide (when used in batch mode), the Detail Data Record consists of the NCPDP Data Record, which consists of the Telecommunication Standard record format. Therefore references in these documents apply to all three standards as applicable HOW SOON SUPPORT THIS DOCUMENT? Question: Once the Version D Editorial is published, how soon do implementers need to support? Response: When the Version D Editorial is published, it is effective for use immediately unless the specific section or response lists an effective date. See Appendix G. Support of This Document. Page: 16

17 1.4.2 MEDICAID SUBROGATION EDITORIAL DOCUMENT In July 2011, the NCPDP Medicaid Subrogation Standard Implementation Guide Version 3.0 Questions, Answers and Editorial Updates was published based on Work Group 9 (WG9) Government Programs recommendations. This document should be consulted for specific guidance. It is noted that general information about Telecommunication segments, data fields, etc. that is contained in this document should be consulted as well. 1.5 NCPDP IMPORTANT EXTERNAL CODE LIST (ECL) INFORMATION During the May 2010 Joint Technical Work Group meeting of the Maintenance and Control Work Group, the ECL Implementation Task Group was formed to develop an ECL implementation process as it applied to the Telecommunication Standard Version D.0 and above. The purpose of this task group was to facilitate consistent adoption of the approved ECL versions within a reasonable, workable timeframe, across all industry participants. Please review the NCPDP Process Overview for External Code List document at - lower left side. This document provides the process to request additions, modifications, and deletions to the data element values existing in the External Code List (ECL). It provides the rules governing the procedures and steps for this process and maintenance of the ECL as approved by the NCPDP Board of Trustees. In addition, this document outlines the Telecommunication ECL implementation time table used to facilitate consistency across the industry. This document contains an ECL Publication and Implementation Chart to provide key dates in which full ECL Publications and ECL Emergency Values should be implemented across all industry participants supporting the NCPDP Telecommunication Standard. See the NCPDP Emergency Telecommunication External Code List Value Addendum document ( under External Code Lists. The addendum is listed under a quarterly ECL) for the list of values approved for emergency implementation and the ECL Publication and Implementation Chart. 1.6 NCPDP RECOMMENDATIONS FOR 4RX USAGE IN MEDICARE PART D PROCESSING DOCUMENTS During the August 2011 Joint Technical Work Group meeting, WG1 Telecommunication approved the reference and linkage in this document to the NCPDP Recommendations for Effective 4Rx Usage in Medicare Part D Processing documents. A Centers for Medicare and Medicaid Services (CMS) directive entitled Clarification of Unique BIN (or BIN/PCN) Requirements as of January 1, 2012 [ (c)(4) as revised by CMS-4085-F] 1 released on November 12, 2010 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 above documents. The intent of these provisions is to ensure that: 1. Pharmacies can routinely identify situations in which they are billing a Medicare Part D claim and 2. Payers supplemental to Medicare Part D can properly coordinate benefits on Part D claims. 1 Document is included in this packet of information. Page: 17

18 It is important to note that this documentation only addresses the matching and the consistent use of the 4Rx data to accept or reject transactions in processing. It does not address how benefits are established. Transactions that are rejected for reasons other than the 4Rx matching are out of scope. The term 4Rx refers to RxBIN - Part D Rx Bank Identification Number (BIN) RxPCN - Part D Rx Processor Control Number (PCN) RxGroup - Part D Rx Group and RxID - Part D Rx ID for the beneficiary NCPDP explored with CMS the possibility of a transition period through the end of February 2012 to minimize year end member disruption. If an extension is granted this documentation will be updated to reflect the new final implementation date, however plans may implement at any point prior to this date. The NCPDP Recommendations for Effective 4Rx Usage in Medicare Part D Processing documents can be found at NCPDP EMERGENCY PREPAREDNESS RESOURCE The NCPDP Emergency Preparedness Information document provides guidance for the pharmacy industry for resources available during a declared emergency. The intended audience is healthcare industry providers who would need resource information for eligibility and claims processing affecting displaced individuals. It is available at under NCPDP Industry Guidance banner. Other guidance on patient demographic information during displacement is given. References to the Prior Authorization Number Submitted (462-EV) are available in the NCPDP External Code List. Page: 18

19 2 EDITORIAL CORRECTIONS CITED IN TELECOM D.0 Editorial changes were made directly into the NCPDP Telecommunication Standard Implementation Guide Version D.0 until April 2009 and are noted in Appendix A. History of Document Changes, Version D.0, Editorial Corrections of the guide. Any further modifications will be noted in this document. The following are corrections made which are cited in the NCPDP Telecommunication Standard Implementation Guide Version D.0. Field DUR Additional Text (570-NS) was inadvertently left off the Response DUR/PPS Segment in sections Response DUR/PPS Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Paid) Response DUR/PPS Segment (Claim Rebill) (Transmission Accepted/Transaction Paid) In the matrix section, Segment - field Facility ID (336-BC) was corrected to (336-8C). Preferred Product Description (551-9F) was corrected to (556-AU), Amount of Copay (518-F1) was corrected to (518-FI). Inadvertent editorial errors were corrected (fields designated as not used, but Mandatory/Situation column had an S or Q instead of N, or fields with S designation should have been Q.) Prescription/Service Reference Number Qualifier (455-EM) a mandatory field has a guidance note in some of the transactions, but not all. The guidance note has been added to all. Date Prescription Written (414-DE) in Information Reporting Rebill the situation was inadvertently not consistent with Information Reporting. In the Response Message Segment and Response Status Segment, when a transmission does not support more than one transaction, the reference to >1 has been removed in the Transaction Count (109-A9) and Additional Message Information (526-FQ) Eligibility Verification and Prior Authorization transactions. Response Prior Authorization Segment inadvertently was listed in the table heading as Mandatory even though all other references were for a situational segment. The table heading has been changed in Response Prior Authorization Segment (Claim Billing or Encounter) (Transmission Accepted/Transaction Rejected) Response Prior Authorization Segment (Service Billing) (Transmission Accepted/Transaction Rejected) Response Prior Authorization Segment (Claim Rebill) (Transmission Accepted/Transaction Rejected) Response Prior Authorization Segment (Service Rebill) (Transmission Accepted/Transaction Rejected) Inadvertent editorial errors were corrected in Preferred Product Description (556-AU) for Prior Authorization Inquiry (Claim) situation, and Response Status Segment note on Prior Authorization Inquiry Response (Deferred). In section Transmission Examples, section Billing Transaction Code B1 Coordination of Benefits Scenarios Pharmacy Bills to Insurance Designated By Patient, subsection Scenario 2 Response: Secondary Insurance Pays The Claim Submitted With Net Other Payer-Patient Responsibility Amount and Scenario 3 Response: Secondary Insurance Pays The Claim Submitted With The Pieces Of Other Payer-Patient Responsibility Amount the Ingredient Cost Paid and/or Dispensing Fee Paid was correctly listed in the Value column, but the Comments column was incorrect. In section Transmission Examples, section Compounded Rx Billing - Transaction Code B1 (01) Coordination of Benefits Scenario, subsection Secondary Insurance Pays The Claim Submitted With Amount Paid By Other Payer, the Basis of Reimbursement Determination incorrectly showed a value of 1. It was changed to 3 to match the comment. Page: 19