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