Tuesday, September 14, 2010

NCPDP AND Telecommunication Standard v1.0

NCPDP Standardizes Electronic Claims for Pharmacy

  • In 1989, NCPDP developed the “real time” Telecommunication Standard  v1.0
  • By HIPAA Final Rule in 2000, 98% of all “third party” prescription drug claims processed using v3.x. HIPAA required v5.1.


Transactions Supported in v5.1

  • Claim Billing
  • Claim Reversal
  • Claim Rebill
  • PA Request & Billing
  • PA Reversal
  • PA Inquiry
  • PA Request Only
  • Eligibility Verification
  • Information Reporting
  • Reporting Reversal
  • Reporting Rebill
  • CS Reporting
  • CS Reporting Reversal
  • CS Reporting Rebill


General Structure of v5.1 Transaction

  • Transmission
  • Header Segment
  • Patient Segment
  • Insurance Segment
  • Transaction (up to 4)
  • Claim Segment
  • Pharmacy Provider Segment
  • Prescriber Segment
  • Coordination of Benefits Segment


  • Transaction, continued
  • Worker’s Compensation Segment
  • DUR/PPS Segment
  • Pricing Segment
  • Coupon Segment
  • Prior Authorization Segment
  • Clinical Segment

  • Response
  • Response Header Segment
  • Response Message Segment
  • Response Insurance Segment
  • Transaction Response
  • Response Status Segment
  • Response Claim Segment
  • Response Pricing Segment
  • Response DUR/PPS Segment
  • Response Prior Authorization Segment



Relevant Documents

  • NCPDP Telecommunication Standard Format 5.1
  • Implementation Guide 5.1
  • Data Element Dictionary
  • Data Dictionary Quick Reference Manual
  • Billing Unit Standard Version 1.4
Labels:

0 comments:

Post a Comment

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