Access To Standards

NCPDP Standards Information

NCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU).

Membership in NCPDP is required for access to standards.

As needs are identified, we update and enhance standards or create new ones. The current list of standards includes the following:

Audit Standard

Defines the record layout for batch audit transactions between Auditors and Providers to support electronic audit transactions that facilitate requests, responses and final outcomes transmissions for both “Desk Top” claim audits and for in-store audit notices. This standard addresses the types of communication between Auditors and Providers and allows that communication to occur in an electronic environment rather than paper-based.

Batch Standard Subrogation

Provides a uniform approach to efficiently process post-payment subrogation claims and eliminate the numerous custom formats used in the industry today.

Batch Transaction

Uses the functionality, syntax, formatting, data set, and rules of the Telecommunication Standard to "wrap" in a detail record for an implementer to "code once". A batch header and trailer are included to support a batch method of delivery.

Benefit Integration

Is intended to meet an industry need to facilitate the integration and exchange of accumulators between Benefit Partners to administer integrated benefits. It supports the communication of accumulator data in a standard format via transactions that are used to facilitate the delivery and receipt of this information. These transactions provide administrative efficiencies and allow for an industry standard to be used to share accumulator data (such as deductible and out of pocket) between Benefit Partners to administer integrated benefits for a member.

Billing Unit

Provides a consistent and well-defined billing unit for use in pharmacy transactions. This results in time savings and accuracy in billing and reimbursement.

Data Dictionary

Contains names and definitions and other information on all of the data elements used in all NCPDP Standards

External Code List

Contains values and other information on all of the data elements used in all NCPDP Standards.

Financial Info Reporting

Provides a standardized format for the exchange of accumulated financial information between Medicare Part D plans.

Formulary and Benefit

Provides a standard means for pharmacy benefit payers (including health plans and Pharmacy Benefit Managers) to communicate formulary and benefit information to prescribers via technology vendor systems.

Functional Profiles for EHR

Facilitates the capture and sharing of point of care prescription and medication related clinical data by Electronic Health Record (EHR) systems in a standard manner across the Healthcare Industry. The EHR-S Standalone Electronic Prescribing Functional Profile and the Pharmacy/Pharmacist Provider Functional Profile and the Standalone Electronic Prescription EHR-S Functional Profile were developed jointly by NCPDP and HL7. The profiles detail functions of systems and will be used to support the development of interoperable EHR systems and the certification of those systems by the Certification Commission for Health Information Technology (CCHIT).

Manufacturer Rebates

Supports the electronic submission of rebate information from Pharmacy Management Organizations (PMOs) to Pharmaceutical Industry Contracting Organizations (PICOs).

Medicaid Subrogation

Provides guidelines for the process whereby a Medicaid agency can communicate to a processor for reimbursement.

Medical Rebates Data Submission

Provides a standardized format for health plans’ rebate submissions to multiple manufacturers throughout the industry

Operating Rules for Connectivity

Provides consistent implementation of necessary business rules and guidelines for the electronic exchange of information used in pharmacy and electronic prescribing industry exchanges for NCPDP standards and the ASC X12 standards transactions that are not defined by a standard or its implementation specifications as adopted.

Pharmacy Combination ID Card

Provides guidelines for organizations or entities producing member identification (ID) cards for use in the pharmaceutical drug claim industry.

Post Adjudication

Supplies detailed drug or utilization claim information after the claim has been adjudicated.

Prescription Drug Monitoring

Provides guidelines for implementing the Prescription Drug Monitoring Programs (PDMP) Reporting Standard format to ensure a consistent implementation of the standard.

Prescription File Transfer

Transfers prescription files electronically between pharmacies.

Prior Authorization Transfer

Transfers existing prior authorization data between payer/processors when transitioning clients, performing system database or platform changes.

ProductIdentifiers

Provides education and general guidance for consistent formatting and utilization of product identifiers used within the NCPDP standards.

Real Time Prescription Benefits

Facilitates the pharmacy benefit payers/processors to communicate to providers information such as patient eligibility, product coverage, and benefit financials for a chosen product and pharmacy, and identifies coverage restrictions, and alternatives when they exist. The Standard supports two formats, EDI and XML, within a single implementation guide and common data content.

Retiree Drug Subsidy

Assists in the automation of summarized drug cost and related data transfer from one processor/pharmacy benefit manager to another processor/pharmacy benefit manager. It allows for the continuation of CMS Retiree Drug Subsidy (RDS) cost data reporting by the receiving entity for a given application ID plan year.

SCRIPT

Developed for transmitting prescription information electronically between prescribers, pharmacies, payers, and other entities for new prescriptions, changes of prescriptions, prescription refill requests, prescription fill status notifications, cancellation notifications, relaying of medication history, transactions for long-term care, electronic prior authorization and other transactions.

Sig Format

Standardizes the portion of an electronic prescription containing the directions for use using existing, accepted electronic transmission standards. This document is intended to facilitate communication between prescribers and pharmacists, to improve the efficiency of the prescribing and dispensing activities and to help reduce the opportunity for errors.

Specialized

Developed for transmitting information electronically between prescribers, providers, payers, pharmacies and other entities for medication therapy management, census events, central fill functions and other transactions.

Specialty Pharmacy Data Reporting

Provides a standardized format for the data submitted by specialty pharmacy to drug manufacturers/others to support programs and agreements between the parties.

State Medicaid Provider File

Provides practical guidelines for state Medicaid agencies or entities producing Medicaid Provider files for use in the pharmacy industry and to promote a consistent, streamlined implementation of the NCPDP adopted State Medicaid Provider File standard throughout the industry.

Telecommunication

Developed to provide a standard format for the electronic submission of third party drug claims and other transactions between pharmacy providers, insurance carriers, third-party administrators and other responsible parties. The Telecommunication Standard includes transactions for eligibility verification, claim and service billing, predetermination of benefits, prior authorization and information reporting.

Uniform Healthcare Payer Data

Used by Client Groups, Pharmacy Benefit managers (PBMs), Fiscal Agents, Vendors, Administrative Oversight Organizations and state entities to share pharmacy claim data that is used to support statistical reporting, evaluation of healthcare and state or regional reporting requirements. This standard should only be used for data submission to a state agency or to a state-sponsored healthcare payer data collection initiative.

Universal Claim Forms

For Telecommunication 5.1, D.0 and Workers’ Compensation/Property and Casualty manual claims processing.

XML Standard Implementation

Provides the basis for XML-based transactions used in NCPDP and supports the general transactions that may be used in implementation guides.