Change Request Detail
No.
1063
Date
10/6/2007
Submitter
Type of Request
Retail Pharmacy Claim
Status
DSMO Process Completed
Business Reason
The NCPDP membership is requesting a new standard be named in HIPAA for use in the pharmacy industry the Post Adjudication Standard Implementation Guide, version 2.. The Post Adjudication Standard Implementation Guide version 2. supports the reporting of post-adjudicated pharmacy claim data that may be submitted in the NCPDP Telecommunication Standard Implementation Guide version D.. Since the industry has requested the movement to D., post claims reporting needs to be in sync by moving to version 2.. This implementation guide provides standard methods that entities can use to share this data.

Client Groups, Pharmacy Benefit Managers (PBMs), Payers, Fiscal Agents, Vendors, and Administrative Oversight Organizations will use this format to share post adjudicated pharmacy claim data.  The data is used to support
1.    Auditing of services
2.    Retrospective DUR review
3.    Statistical reporting
4.    Evaluate Health Care
5.    Evaluate Contractor performance
6.    Develop and evaluate Capitation rates
7.    Pay reinsurance (stop loss) to contractors
8.    Develop fee for service payment rates. 

In the current environment, Post Adjudication Standard Implementation Guide version 1. is in use. Proprietary files are also used. With the movement to D., post claims reporting needs to move to version 2..

More information on this business function is found in the NCPDP Post Adjudication Standard Implementation Guide.
Suggestion
Request the DSMO approve this change request and thus begin the process for a new standard to be named in HIPAA.
DSMO Category
I
Recommendation
Approve. The DSMO is supportive of the work done by NCPDP to develop the Post Adjudication Standard version 2..  We are aware that this new standard supports the reporting of post adjudication pharmacy claim data that may be submitted in the NCPDP Telecommunication Standard version D..  In addition, this new standard will bring efficiency and decrease administrative burden in the current process.
Appeal Recommendation