Tuesday, September 14, 2010

Know all about NCPDP

Who is NCPDP?

  • An ANSI-accredited standards development organization (SDO).
  • Develops and maintains standards for the pharmacy services sector of the health care industry.
  • NCPDP maintains the HIPAA-named national standard for the transmission of pharmacy claims (Telecom Version 5.1)


NCPDP 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.



Standardization of Paper Claims

  • NCPDP was formed in 1977 to standardize the drug insurance claim.
  • NCPDP’s developed the paper Universal Claim Form (UCF) which was adopted in 1978. 
  • Over three billion claim forms have been distributed to date.


The Evolution of Pharmacy Claims Processing - 80s
  • Eligibility checked on-line prior to Rx.
  • Claims submitted on tape or diskettes in NCPDP Batch Claims Standard Version 1.0 in 1984.
  • Claims processed after prescription was filled. Claims pended and processor “worked” or denied.
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Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download