Access To Standards

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.

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

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.

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.

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

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

NCPDP/X12 jointly developed an implementation guidance document on the sharing of pharmacy inventory data among stakeholders using the X12 852 Product Activity Report Specification. The X12 852 transaction set is used to advise a trading partner of inventory, sales, and other product activity information which enables a trading partner to plan and ship, or propose inventory replenishment quantities, for distribution centers, warehouses or retail outlets.

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

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

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.

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).

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

Meets an industry need to supply detailed drug and utilization information as part of the Medicaid pharmacy benefit after the claim has been adjudicated.

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

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

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.

Provides guidance to the pharmacy sector of the healthcare industry on the use of the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) Standard for Trial Use Release 2.11 (C-CDA Template) and C-CDA on FHIR 1.1.0 - (FHIR R4) STU Release 1.1 Consultation Note Profile2 (FHIR Profile) in creating a Pharmacist Consultation Note. The Pharmacist Consultation Note is used for exchange of a pharmacist’s recommendations with the appropriate care providers, including long term and post acute care (LTPAC) facility staff and the physician(s) of record for the patient.

This document represents the collaborative efforts of NCPDP and HL7® for an electronic care plan with enhanced medication management content based on the templates in the HL7® Implementation Guide for C-CDA Release 2.1: Consolidated CDA for Clinical Notes and C-CDA on FHIR® R4. The Pharmacist Care Plan serves as a standardized, interoperable document for exchange of consensus-driven prioritized medication-related activities, plans and goals for an individual needing care. Pharmacists work in multiple environments (community, hospital, long term care, clinics, etc.) and increasingly participate in patient-centered care teams providing essential clinically oriented patient care services such as medication therapy management, clinical reconciliation (medication, allergies and problems), patient immunization management, disease state monitoring, and therapy adherence programs.

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

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

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

Transfers prescription files electronically between pharmacies.

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

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

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.

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.

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.

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.

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.

NCPDP/HL7® jointly developed this implementation guide to describe the exchange of data (patient demographic and coverage, prescription, and clinical) for dispensing specialty medications by pharmacies as well as facilitating enrollment of patients in programs offered by third parties such as, but not limited to, hub vendors and pharmaceutical manufacturers.

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

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.

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.

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.

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

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