1. NCPDP, HIPPA, SCRIPT and V5.1 Overview Phillip D. Scott NCPDP Senior Vice President July 10, 2001

2. Agenda Who is NCPDP? Where have we been? Where are we? Where are we going? How can I get involved?

3. Who is NCPDP?

4. The National Council for Prescription Drug Programs (NCPDP) is an ANSI- accredited standards development organization representing all facets of pharmacy. We are a membership driven organization that was named in federal legislation (HIPAA).

5. Mission Statement To create and promote data interchange standards for the pharmacy services sector of the health care industry, and to provide information and resources that educate the industry and support the diverse needs of our members.

6. Vision Statement To be the model forum which empowers our members to enhance the quality of health care through the creation of information solutions.

7. Membership Representation Producer/Provider (pink badges) –Retail Pharmacy, Mail Service Pharmacy, Consulting Pharmacists, and Manufacturers Payer/Processor (green badges) –BCBS Organizations, HMOs, PBMs, and Government Payers Vendors and General Interest (yellow badges) –Drug Wholesalers, Consultants, Clinical Programs, and Software & Hardware Vendors

8. Voting Categories Producer/Provider 314 Payer/Processor 509 Vendor/General Interest477 Total Members = 1301

9. Where Have We Been?

10. NCPDP History Pharmacies started installing computer systems in the late 1970’s First systems were installed on the IBM Series 1 Pharmacies started submitting computer generated paper claims to insurance companies Every insurance company had their own unique form

11. NCPDP History NCPDP was formed in 1977 to standardize insurance forms. NCPDP’s first standardization effort was the paper universal claim form (UCF) which was adopted in 1978. Over three billion claim forms have been distributed.

12. NCPDP History 1987 PCS introduced electronic claims Black Box that uses telephone line to call PCS direct Proprietary format Other PBMs (Pharmacy Benefit Managers) followed Instead of multiple form types, pharmacies now had multiple black boxes on their counters

13. NCPDP History 1988 NCPDP developed Version 1.0 of the Telecommunication Standard 1988 Pharmacy software vendors and chains started coding for electronic claims No more double entry No need for black boxes Use of switching companies like ENVOY/WebMD and NDC Health

14. Where Are We?

15. Standards Related to Electronic Prescribing NCPDP has two standards that directly relate to electronic prescribing: Telecommunication Standard SCRIPT Standard

16. What is Telecom? Telecom is a data transmission standard intended to facilitate the communication of prescription information between pharmacies and payers. It is used billions of times each year.

17. Telecom Standard Version History Version 1.0 released in 1988 Version 3.2 in 1992 Version 3.3 in 1996 Compound Ingredients Version 4.0 in 1997 Version 5.0 in 1999

18. What is SCRIPT? SCRIPT is a data transmission standard intended to facilitate the communication of prescription information between prescribers and pharmacists.

19. SCRIPT Standard Version History Version 1.0 was approved in April 1997 Version 3.1 was ANSI Accredited in 2000 Version 4.1 is in balloting status now

20. SCRIPT Can Be Used For New Prescriptions from the prescriber to the pharmacy Change Requests to New Prescriptions by the pharmacy to the prescriber Refill Requests by the pharmacy to the prescriber

21. SCRIPT Can Be Used For Fill Status from the pharmacy to the prescriber (patient picked up, patient picked up partial fill, patient never picked up) The ability for a prescriber to cancel a previously submitted request Housekeeping transactions (password change, receive prescriptions, et cetera)

22. Every Business Request Transaction Includes: Electronic envelope Section to define the Prescriber Section to define the Pharmacy Section to define the Patient

23. Electronic Envelope Includes: Sender ID Receiver ID Syntax information (version/release, delimiters) Type of Message Password Trace Numbers Date/Time

24. Prescriber Information May Include: Identifier (State License, DEA, etc) Prescriber name Business name Business address information Phone number (telephone, beeper, fax) Specialty Code (AMA Self-Designated Practice Specialty/Areas of Practice Code) Authorizing Prescriber Agent Name

25. Pharmacy Information May Include: Identifier (NCPDP Provider ID) Pharmacy name Pharmacist name Pharmacy address information Phone number (telephone, beeper, fax)

26. Patient Information May Include: Patient Name Date of Birth Gender Patient Address Patient Phone Number Relationship to Cardholder Pharmacy/Prescriber’s internal Patient ID

27. Every Response Transaction Includes: Electronic envelope Response Status Acknowledgement of the receipt of the transaction or “Paired” response transaction to the request which may  Approve the request  Approve the request with changes  Deny the request Acknowledgement of an error in the transaction

28. Version 5 HIPPA Legislated Standard

29. Enhancements requested & approved for Version 5 Version 5 is a complete rewrite to the NCPDP Telecommunication Standard. It includes: New data elements Removed obsolete data elements deleted Additions/modifications to the data dictionary

30. Enhancements requested & approved for Version 5 The $ fields size have been increased Old size maximum was $9,999.99 New size is $999,999.99 Field Qualifiers were added NDC or UPC DEA, State License #, UPIN or Third Party ID Enhanced Coordination of Benefits Secondary/Tertiary can see primary reject codes Secondary/Tertiary can see all primary payments (both Rx and Service Claims)

31. Enhancements requested & approved for Version 5 Expanded DUR (Drug Utilization Review) capability Ability for Provider to respond to multiple alerts (Reason for Service Codes) in one transaction Ability for Providers to send PPS codes and supporting info on claim Professional Service Claim Claim can be submitted for service without having to have an Rx Service Claim can refer to an Rx Easier for pharmacy to reconcile

32. Enhancements requested & approved for Version 5 Partial Fill capability Pharmacy can report the dispensing of an initial partial fill (25 out of 30) Pharmacy can report the dispensing of the remaining quantity without  Additional dispensing fee  Additional refill number  DUR warnings Duplicate therapy Too soon to refill

33. What’s new in Version 5? Segments restructures for efficiency Data elements grouped into logical segments Variable format Additional business functions Prior authorization enhanced Controlled substance reporting added Information reporting added

34. Where are We Going?

35. What We Know About HIPAA NCPDP Telecommunication Standard v5.1 NCPDP Batch Standard v1.1 ASC X12N 834 ASC X12N 835 Privacy Rules

36. What is Still to Come with HIPAA? NPRM for Transactions and Code Sets (revisions/clarifications) NPRM for NDC versus HCPCS Clarifications Unique Identifiers for Providers, Payers, Employers, and Individuals Security Rules Privacy Rule Modifications Enforcement Rules

37. How NCPDP Helps Industry Plan for HIPAA? NCPDP is a Designated Standards Maintenance Organization (DSMO) Pharmacy Strategic National Implementation Process (SNIP) August Summit Work Groups Continue to Monitor and Respond to HIPAA Rules Task Groups working to answer DHHS questions

38. Future Initiatives NCPDP has In Store The Council’s newest project, HCIdea, will establish a unique identifier for prescribers.

39. How Can I Get Involved?

40. Attend NCPDP Meetings August 2001 in Baltimore, MD 4 th Summit 5 th Educational Forum 6 th – 8 th Work Groups November 2001 in Orlando, FL 13 th Educational Forum 14 th – 16 th Work Groups March 2002 in Phoenix, AZ 23 rd – 24 th Work Groups 24 th – 27 th Conference

41. How Can I Follow the Council’s Activities? Become a member Attend the quarterly Work Group Meetings NCPDP Now Website (www.ncpdp.org) Council Connection Ask a Staff Member