Change Request Detail
Type of Request
Retail Pharmacy Claim
DSMO Process Completed
Business Reason
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.

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.   The Medicaid Subrogation transactions use the Telecommunication Standard transactions.

More information on this business function is found in the NCPDP “Medicaid Subrogation Implementation Guide”.
Request the DSMO approve this change request and thus begin the process for a new standard to be named in HIPAA.
DSMO Category
Approve.  The DSMO is supportive of the work done by NCPDP to develop this standard.  We are aware that this new standard will bring efficiency and decrease administrative burden in the current Medicaid pharmacy subrogation process.
Appeal Recommendation