Change Request Detail
No.
1189
Date
8/5/2013
Submitter
Type of Request
Referrals
Status
DSMO Process Completed
Business Reason
Health Care Services: Referral Certification and Authorization - specifically electronic prior authorization by prescribers for the pharmacy benefit.

NCPDP has worked for a long time on electronic transactions for the exchange of prior authorization functions between prescribers and processors for the pharmacy benefit. In 2011 industry work was begun again (open to any interested party) on prior authorization transactions when regulations were introduced in various states for PA. The regulations cite the use of the transactions as created by NCPDP. In July 2013, the electronic prior authorization transactions were published after the successful ballot. The NCPDP SCRIPT Standard version 2013071 contains the electronic prior authorization transactions for the pharmacy benefit environment. After much work by the industry, it is requested the ePA transactions be named for prior authorization functions in electronic prescribing for the pharmacy benefit. This does not impact the use of the ASC X12 transactions for authorization that are available for use under HIPAA. Precendence was set with the naming of both the Telecom and the X12 transactions for service billing functions. This would name the SCRIPT Prior Authorization transactions for the pharmacy benefit with the X12 transaction for pa for the medical benefit. History on the NCPDP work is avaialble if needed.
Suggestion
Naming of the NCPDP SCRIPT Standard Version 2013071 Prior Authorization transactions only, for the exchange of prior authorization information between prescribers and processors for the pharmacy benefit.

The NCPDP prior authorization transactions are intended to be used for products covered by a patientís pharmacy benefit (e.g. medications and supplies).
DSMO Category
I
Recommendation
Approved with modification to name the NCPDP SCRIPT Standard Version 2013101 Prior Authorization transactions only, for the exchange of prior authorization information between prescribers and processors for the pharmacy benefit.
Appeal Recommendation