by Jared Staheli
July 8th, 2015
The National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard Version D.0 and Batch Standard 1.2 is the HIPAA standard for electronic retail pharmacy drug claims and coordination of benefits (COB). See the NCPDP web site at http://www.ncpdp.org for additional information.
DME MACs that process retail pharmacy drug transactions require their retail pharmacy claimants to use this standard. Retail pharmacies must use the ASC X12 837 professional claim format to submit claims other than retail pharmacy claims to the DME MACs.
DME MACs and VMS shall accommodate quarterly and monthly NDC crosswalk updates as needed. DME MACs shall provide such crosswalks to CEDI.
DME MACs and CEDI shall reject NDC codes that have been deactivated/end dated.
A - Requirements for Implementing the NCPDP Standard
Retail pharmacies are identified by a value of A5 in the specialty code as received by the National Supplier Clearinghouse. Only suppliers with an A5 specialty code may use the NCPDP standard. DME MACs, EDI submitters, and other DME MAC trading partners are required to transmit the NDCs in the NCPDP standards for identification of prescription drugs dispensed through a retail pharmacy. NDCs replace the drug HCPCS codes for retail pharmacy drug transactions billed via the NCPDP standards.
B - Certificate of Medical Necessity (CMN)
The CMN for Parenteral Nutrition (Form CMS-852) is required. The DME Information Form for Immunosuppressive Drugs (Form DMERC-08.02) is not required when billing for immunosuppressive drugs with dates of service on or after April 1, 2006. As with other electronic formats, CMN data must be submitted within the valid transaction.
For claims submitted on the paper Form CMS-1500, retail pharmacies will continue to supply hard copy CMNs when required.
C - NCPDP Companion Document
The NCPDP Companion Guide is available at: http://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/downloads/NCPDPD0 CG.pdf
CEDI provides supplemental instructions as needed to retail pharmacy drug claim submitters (either provider, billing agent, or clearinghouse) that will submit retail pharmacy drug claims to Medicare electronically