Introduction to National Council for Prescription Drug Programs (NCPDP)

Transcription

1 Introduction to National Council for Prescription Drug Programs (NCPDP)

2 The following information will help you Gain an overall understanding of NCPDP. Understand what is happening in the pharmacy industry related to healthcare information technology and standards, and what role NCPDP plays. Identify NCPDP work groups and understand their roles and goals. Learn about leadership opportunities with NCPDP and how you can help influence what happens in our industry.

3 Introduction Outline Section One Overview of NCPDP Industry Drivers NCPDP Mission and Vision NCPDP Organizational Structure Section Two NCPDP Work Group Overview Work Group Meeting Protocol and Participation Section Three NCPDP Standards Data Element Request Form (DERF) Process Section Four NCPDP Executive Leadership

4 SECTION ONE Overview of NCPDP

5 The National Council for Prescription Drug Programs (NCPDP) NCPDP is one of several Standards Development Organizations (SDOs) involved in healthcare information technology and standardization. NCPDP is the only SDO that has a focus on pharmacy services, and has the highest representation from the pharmacy services sector of healthcare. There are more industry drivers influencing the need for increased standardization in healthcare than any other time in history. Many of these are driven by government.

6 Industry Drivers Consumer Driven Health Plans Discount Drug Cards Drug Importation The Economy Electronic Prescribing Mandate FDA Barcode Rule FDA NDC Initiative HITECH Medicare Modernization Act Office of the National Coordinator Patient Protection and Affordable Care Act Presidential Executive Order on Health Information Technology Electronic Health Records Patient Health Records Privacy & Security (HIPAA) Request of New Versions, Standards in HIPAA Streamlining the HIPAA process

7 What is NCPDP? NCPDP is a not-for-profit, American National Standards Institute (ANSI)-accredited, Standards Development Organization (SDO) with over 1,600 members representing virtually every sector of the pharmacy services industry. NCPDP is a member-driven organization. Our diverse membership provides leadership and healthcare business solutions through education and standards, created using the consensus-building process. NCPDP s standards have been named in various government legislation, such as the Health Insurance Portability and Accountability Act (HIPAA), Medicare Modernization Act (MMA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act.

8 What is NCPDP? Standards NCPDP is an American National Standards Institute (ANSI) accredited standards development organization (SDO). Diverse Forum NCPDP provides a forum and marketplace for a diverse membership focused on healthcare and pharmacy business solutions. Memberdriven NCPDP is a member-driven organization that has been named in various government regulations and policies (including HIPAA and Medicare Modernization Act.

9 Who is NCPDP? Vision Lead the industry in healthcare standards and solutions for the common good. Purpose To standardize the exchange of healthcare information to improve outcomes.

10 Who is NCPDP? Core Values Collaboration Inclusiveness Integrity & Ethical Behavior Leadership Innovation

11 Industry Acronyms The healthcare industry is filled with a veritable alphabet soup of acronyms, many which you ll see or hear regularly in NCPDP meetings and documents. What follows is just a small sample: ANSI: American National Standards Institute accredits SDOs for open, balanced processes. Standards are approved via open notification and verification of processes. ASC X12: Accredited Standards Committee X12, an SDO. X12N is the subcommittee on the insurance industry. CMS: Center for Medicare and Medicaid Services DERF: Data Element Request Form (specific to NCPDP) DSMO: Designated Standards Maintenance Organizations (defined in HIPAA) HHS: Department of Health and Human Services continued

12 Industry Acronyms HIPAA: Health Insurance Portability and Accountability Act of 1996 HL7: Health Level 7, a healthcare industry SDO MMA: Medicare Modernization Act of 2003 NCPDP: National Council for Prescription Drug Programs NCVHS: National Committee on Vital and Health Statistics NPI: National Provider Identifier Mandated by HIPAA NPRM: Notice of Proposed Rule Making ONC: Office of the National Coordinator SDO: Standards Development Organization SNIP: Strategic National Implementation Process WEDI: Workgroup for Electronic Data Interchange To view NCPDP s Acronym Dictionary, please visit

13 NCPDP Structure: Membership By Industry Role Producer/Provider (pink badge) The client service-oriented sector which includes pharmacies, pharmacists, and manufacturers. Payer/Processor (green badge) The financial-oriented sector which includes Health Maintenance Organizations (HMOs), Pharmacy Benefit Managers (PBMs), Government Payers & Health Insurers. Vendor and General Interest (yellow badge) The link between the previous two sectors; which includes Drug Wholesalers, Consultants, Clinical Programs, Telecommunication and Software & Hardware Vendors.

14 NCPDP Membership Voting Categories Producer/Provider Payer/Processor 27% 31% 42% Vendor/General Interest

15 NCPDP Structure - Governance The NCPDP Board of Trustees Has supervision, control and general charge of the business of the Council. Establishes and modifies the Council s policies and executes the purposes of the Council. Has discretion in the disbursement of the Council s funds. Establishes dues for membership. Establishes strategic direction. Adopts rules and regulations for the conduct of the Council s business. Appoints Standardization Committee and acts on their requests. Has final authority on all industry standard development procedures, appeals, hardship applications and conduct of process documentation record retention.

16 BOT Members Payer/Processor William J. Barre, R.Ph. CitizensRx, LLC Laurie Littlecreek Express Scripts Mara N. Mitchel Magellan Rx Management Gregory Watanabe, R.Ph., MBA MedImpact Healthcare Systems, Inc.

17 BOT Members Producer/Provider Alan K. Gardner, MBA RxResults Scott M. Robertson, R.Ph., Pharm.D. Kaiser Permanente Linda L. Schock Coherus BioSciences Christian Tadrus, R.Ph., Pharm.D., FASCP, NSC Independent Pharmacist

18 BOT Members Vendor/General Interest Richard Klein Brook erx Network Perry Lewis CoverMyMeds, LLC Kay Morgan Elsevier Charles Reed AmerisourceBergen ǀ Elevate Provider Network Chair

19 NCPDP Structure: Committees and Groups Annual Conference This committee provides guidance on all aspects of planning NCPDP's Annual Technology and Business Conference; including selection of keynote speakers, track speakers, exhibits and other activities. Awards Maintains the criteria used for selecting and evaluating candidates for award recognition and applies the criteria to nominees to determine the final slate of candidates presented to the NCPDP membership, or Board of Trustees, for vote. Bylaws The Bylaws Committee provides direction for the "nuts and bolts" of the Council's business operations. It ensures that as an SDO, NCPDP keeps current with ANSI changes in order to maintain its accreditation status. Educational Advisory Group The Education Advisory Group designs, develops and implements high quality and affordable educational programs for members and potential members. Emerging Professionals Group The Emerging Professionals Group welcomes members in their first seven years of NCPDP membership or new to the healthcare industry. The Group provides an opportunity to connect with other members and support one another through networking, ongoing professional development and leadership opportunities. continued

20 NCPDP Structure: Committees and Groups Finance The Finance Committee oversees NCPDP's budgeting process. It reviews the annual budget and makes recommendations to the Board of Trustees and NCPDP Management. Membership and Leadership Development The Membership and Leadership Development Committee develops a strategic plan for increasing NCPDP membership and retaining current members. It also develops programs and opportunities for members to grow into leadership positions. Nominating This committee prepares and reviews the slate of candidates for both the Board of Trustees (ensuring equal balance within each category) and Standardization Committee. Standardization The Standardization Committee monitors the Council's development and continuous maintenance of all corporation standards, documents, and specifications, which are or are intended to become industry standards and American National Standards (ANS). Strategic Planning The Strategic Planning Committee guides the development of NCPDP, including overseeing the membership recruitment and retention efforts, identifying new target markets, products and services, and helping shape the direction of the Council.

21 The NCPDP Path to Leadership *Board appointed (usually a Board member)

22 Committee Participation Be Active! Volunteer to serve on a committee or subcommittee. NCPDP membership required for committee and subcommittee participation. Contact the NCPDP office (Membership Services) to indicate your interest in participation. Take an active role on the conference calls and initiatives within the committee of your choice.

23 SECTION TWO Work Group Overview

24 Work Groups and Task Groups Work Groups (WG) develop standards documents and specifications There are 10 WGs, plus Maintenance & Control (MC). WGs meet four times a year. There is no charge for members to attend. Voting is limited to members who are present. More information: Task Groups work on specific issues within a work group Conducted via conference calls; weekly, biweekly or monthly depending on the group. Must have a leader assigned by the work group members. Membership is not required to participate. See Standards Information Information for a list of task groups.

25 WG1 Telecommunication Scope: Work Group 1 Telecommunication (WG1) develops and maintains standards and guidelines to accommodate the collection, transmission, and processing of electronic pharmacy claim information, i.e., administering and certifying eligibility, prior authorization, and prescribing drug benefits for traditional, managed care, and government programs; billing; payment or denial of compensation with explanations, and concurrent drug use review.

26 WG2 Product Identification Scope: Work Group 2 Product Identification (WG2) deals with issues relating to the identification of drugs and health related products within NCPDP s stated mission. Identification consists of how the product is billed (billing units, quantity designations), product identification systems, and any type of descriptive data that serves to uniquely identify a product with the intent to establish standards for product identification such that there is no ambiguity in distinguishing one product from another.

27 WG7 Manufacturer and Associated Trading Partner Transaction Standards Scope: Work Group 7 Manufacturer and Associated Trading Partner Transaction Standards (WG7) develops, monitors, and maintains standards for the electronic exchange of data between manufacturers and data providers, and/or trading partners. Additionally, the work group will facilitate the implementation and education of the standards and processes.

28 WG9 Government Programs Scope: Work Group 9 Government Programs (WG9) in conjunction with WG1 Telecommunication, guides and advises Federal and State funded pharmacy programs and their agents on standards implementation, supports data processing initiatives, and provides design alternatives for standards, which support government requirements. WG10 Professional Pharmacy Services Scope: Work Group 10 Professional Pharmacy Services (WG10) assists in the development and maintenance of standards to support electronic documentation and transmission of data for professional pharmacy services.

29 WG11 eprescribing & Related Transactions Scope: Work Group 11 eprescribing & Related Transactions (WG11) develops standardized messages for prescribers, pharmacists, payers and/or other interested parties to exchange information. WG14 Long Term & Post Acute Care (LTPAC) Scope: Work Group 14 Long Term and Post Acute Care (LTPAC), in conjunction with the other work groups, guides and advises payers, processors, and providers of the long term care industry and institutional pharmacy programs and their agents on standards implementation and supports data processing initiatives.

30 WG16 Property and Casualty/ Workers Compensation Scope: Work Group 16 Property and Casualty/Workers' Compensation (WG16) will ascertain, monitor and analyze regulatory requirements to develop correlating fields to be supported in the Telecommunication Standard format; evaluate, and maintain a Property and Casualty/Workers Compensation standard paper claim form; proactively promote and educate pharmacy industry stakeholders and regulatory policy makers on the form and format standards found in Property and Casualty/Workers Compensation (including but not limited to uniform billing, state reporting policies and the overall delivery of pharmacy services/care).

31 WG18 Specialty Pharmacy Scope: Work Group 18 Specialty Pharmacy (WG18) Newly formed work group. The scope statement will be posted when approved by the Board of Trustees August

32 WG45 External Standards Assessment, Harmonization, and Implementation Guidance Scope: Work Group 45 External Standards Assessment, Harmonization and Implementation Guidance reviews, assesses and works to continually monitor the development of standards and/or operating rules by other Standards Development Organizations (SDOs) and/or other non-ncpdp entities that may impact the pharmacy industry. Communicates SDO developments and identifies actions needed by this or other NCPDP work groups. These include, but are not limited to, the ASC X12N Implementation Guides and the Health Level Seven International (HL7) Standards. Develops and maintains guidelines for the pharmacy industry to accommodate pharmacy implementation of the Health Insurance Portability and Accountability Act (HIPAA) and Affordable Care Act (ACA) mandated electronic data interchange (EDI) transactions and operating rules not developed by NCPDP as determined by the membership. Contributes to the development and maintenance of operating rules that impact the pharmacy industry. To this end, WG45 will collaborate with other SDOs, operating rules entities or other non- NCPDP entities to provide the pharmacy perspective and represent the industry needs in the development of standards and guidelines.

33 MC Maintenance and Control Scope: MC Maintenance and Control (MC) monitors and maintains the development of NCPDP standards, implementation guides and reference documents; promotes consistent business and technical administration; makes recommendations to the Standardization Co-Chairs on development procedures, due process compliance, as well as ethical and legal matters. MC provides a forum for updates of work group activities, resolution of inter-work group issues and discussion of legislative, regulatory, policy, and court decisions, which may affect the pharmacy industry.

34 Work Group Goals For individual NCPDP work group goals, please visit Listing and select the link of the individual group name(s). The work group page contains a link to the task groups, the NCPDP acronym dictionary, and displays the goals.

35 Work Group Meeting Protocol NCPDP has documented guidelines for work group meetings. Where guidelines do not exist, Robert s Rules of Order will be followed. Issues that impact published documentation require approval by the attendees, using the following process: Discussion of the issue Motions (making a motion & second) Discussion on the motions Potential amendment to the motions Voting on the motions with balance across attendees Different kinds of motions Speakers must be identified by the discussion leader. Microphones are provided for capturing minutes. Cell phone protocol maintained (penalty = song/dance/joke).

36 Parliamentary Procedure Parliamentary Procedure provides common rules and procedures for deliberation and debate in order to place the whole membership on the same footing and speaking the same language. For detailed information, please refer to Purpose: Expedite business. Maintain order. Ensure equality for all. Accomplish objectives of the work group. continued

37 Parliamentary Procedure Motion sequence: Member makes a motion. Another member seconds the motion. Co-Chair states the motion. Participants debate the motion. Co-Chair puts the question to a vote. Co-Chair announces results of vote. Other types of motions: Motion to amend (friendly amendment) - a proposal to modify another motion. Motion to end debate (call the question) - a proposal to stop discussion of the motion currently on the floor and proceed to a vote.

38 Work Group Participation Visit the work group pages on Review minutes and documents prior to attending work group meetings. Bring documents to work group meeting for reference. Read the NCPDP Now (electronic newsletter). Speak out! Take an active role in the meetings. Join a task group or work group. Membership is not required for task group participation. Vote! This is your opportunity to have a direct impact on the standards development process. Attend the February Networking Reception. Contact the NCPDP office (Membership Services) to indicate your interest in participating.

39 SECTION THREE NCPDP Standards

40 Existing NCPDP Standards & Guides Audit: supports an electronic audit transaction that facilitates requests, responses, and final outcomes transmissions for both Desk Top claim audits and for in-store audit notices. Batch: allows a batch to contain claims from multiple pharmacies at a centralized site to multiple processors via a switch. Benefit Integration: facilitates the integration and exchange of accumulator data between Benefit Partners to administer integrated benefits. 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. continued

41 Existing NCPDP Standards & Guides External Code List: contains values and other information on all of the data elements used in all NCPDP Standards. Financial Information 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 Electronic Health Record (EHR) Systems: developed jointly with HL7 to facilitate the capture and sharing of point of care prescription and medication related clinical data by EHR systems. continued

42 Existing NCPDP Standards & Guides Manufacturer Rebates: allows for integration of multiple file formats and provides a standard electronic format to adjudicate rebate claims. 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 indust Operating Rules for Connectivity: 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. continued

43 Existing NCPDP Standards & Guides Pharmacy and/or 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 Transfer: to electronically transfer prescriptions between pharmacies. Prior Authorization Transfer: transferring existing prior authorization data between payer/processors when transitioning clients, performing system database or platform changes. Product Identifiers: developed to provide education and general guidance for consistent formatting and utilization of product identifiers in healthcare. continued

44 Existing NCPDP Standards & Guides 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, providers, and other entities. The standard addresses the electronic transmission of new prescriptions, changes of prescriptions, prescription refill requests, prescription fill status notifications, cancellation notifications, relaying of medication history and transactions for long-term care. continued

45 Existing NCPDP Standards & Guides Specialized: developed for transmitting information electronically between prescribers, providers, payers, pharmacies and other entities. Structured and Codified Sig: For prescriptions that are transmitted via electronic means, this implementation guide establishes a convention to be used with standards that support electronic prescribing for the consistent expression of the directions for use to a patient for the corresponding prescription. 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 development of the standard was to accommodate the eligibility verification process at the point-of-sale and to provide a consistent format for electronic claims processing. continued

46 Existing NCPDP Standards & Guides Uniform Healthcare Payer Data: to share pharmacy claim data that is used to support statistical reporting, evaluation of healthcare, and State or regional reporting requirements. Universal Claim Forms: For Telecommunication 5.1, D.Ø, and Workers Compensation/Property and Casualty manual claims processing. XML: Integral piece of the NCPDP XML-based standards and provides the basis for XML-based transactions used in NCPDP like SCRIPT and Specialized.

47 Enrollment Manufacturer Rebating Pharmacy Claim The Prescribing Process Cardholder & dependent(s) Physician or Prescriber Patient Pharmacy Card Electronic Prescription POC Vendor Eligiblity Formulary Drug History Remittance Advice Processor/ PBM Switch or Service Intermediary Eligibility Payor/ Healthplan Pharmaceutical Manufacturer Drug Wholesaler

48 Standards in the Prescribing Process

49 Data Element Request Form (DERF) Process This is the process to request an addition or modification to NCPDP's current or new standards or other documents. The DERF is submitted to the Council office with accompanying information that may include proposed standard, implementation guide, data element dictionary, modification log if needed, and change log if needed. See form: The DERF is then submitted to Standardization co-chairs and Maintenance and Control co-chairs for determination as to what work groups will review. Submitter is notified as the DERF goes through the major steps. continued

50 Data Element Request Form (DERF) Process The DERF is available on website to members prior to next scheduled quarterly work group meeting via NCPDP's website. The DERF is reviewed by work groups during quarterly meeting. We strongly encourage submitters or their representatives to attend the meeting to discuss their requests. If submitter or representative is unable to attend the work group meeting, the submitter may ask a work group co-chair to represent the request. Once the DERF is approved at the work group level, a data maintenance ballot is prepared. The ballot process occurs twice yearly; in February and August, which is within thirty (30) days of approval at the prior work group session. If the DERF is approved, it is prepared into a standard that will go to the ballot in the next scheduled ballot timeframe. The ballot notification is distributed to the consensus voting group participants and the NCPDP membership at large, and is made available via a press release to non-ncpdp members wishing to provide comments on the ballot. Once the ballot process is complete the Board of Trustees certifies the results. continued

51 Data Element Request Form (DERF) Process This is a consensus building process and requires 60% consensus voting response, balance among the three categories of membership, and at least a 75% approval rate of the affirmative and negative votes with reasons to pass. All related comments received on a ballot are adjudicated at the next scheduled quarterly work group meeting. The results are published in the Council's publication along with a press release announcement. The approved DERF is then included in the Data Dictionary/External Code List within ninety (90) days of final approval. For more information and a calendar please visit

52 DERF Process: Adjudication of Ballots All valid ballots containing related comments must be reviewed and addressed. Each comment must be adjudicated via an official motion and minimum of 2/3 must categorize comments as: Not persuasive Persuasive and editorial Persuasive and substantive

53 SECTION FOUR NCPDP Leadership

54 NCPDP Leaders Lee Ann Stember President and CEO John W. Hill, MBAHCM Executive Vice President and GM

55 Executive Management Maggie Bruce Senior Vice President, Strategic Planning and Communications John Klimek, R.Ph. Senior Vice President, Standards and Information Technology Steve Mullenix, R.Ph. Senior Vice President, Public Policy and Industry Relations Phillip D. Scott Senior Vice President, Business Development

56 For questions about NCPDP, please contact the Council office: or visit: