Program_Memos / 2001 / AB-01-04

Why This Topic Matters

It explains a significant claims-processing transition affecting Medicare drug billing and related system updates, with implications for electronic and paper claims workflows, contractor readiness, and provider communication.

Article Sections

1. Change Request 1441

   Introduces the memorandum as advance notice and a request for comments regarding an upcoming claims-processing change. It frames the document as informational and preparatory rather than instructional.

2. Basis for Change

   Summarizes the HIPAA administrative simplification context and the policy basis for the change. It also discusses the broader standardization goals related to health care transactions.

3. Description of NDC

   Explains the National Drug Code system, its background, and where related reference information may be obtained. It describes the general structure of the identifier and its relationship to drug product identification.

4. Medicare Claims Processing

   Outlines the anticipated impact on Medicare drug claims processing across electronic and paper workflows. It addresses contractor readiness, system considerations, and the transition timeline at a high level.

5. Paper Claims Submitted to Carriers and DMERCs

   Discusses paper claim handling for carrier and DMERC workflows and the need for form accommodation and scanner recognition. It covers general form-processing considerations for paper submissions.

6. Paper Claims Submitted to Fiscal Intermediaries (FIs)

   Addresses paper claim limitations for fiscal intermediary workflows and notes pending operational considerations. It focuses on form compatibility and billing system concerns.

7. Claims for Influenza and Pneumococcal Vaccines

   Describes how the transition affects vaccine-related roster claim forms and related updates for billing formats. It highlights the need for changes aligned to the implementation of the new standard.

8. Electronic Claims Submitted to Carriers and Durable Medical Equipment Regional Carriers (DMERCs)

   Summarizes the electronic claim formats used by different submitters and the general requirement to support the new drug identifier in those transactions. It distinguishes retail pharmacy and other entity workflows.

9. Electronic Claims Submitted to FIs

   Describes the electronic claim format expectations for fiscal intermediary transactions. It focuses on transaction layout and data field placement at a general level.

10. Other HIPAA-Related Requirements for Electronic Claims

    Provides background on standards organizations and the broader electronic transaction framework. It explains how these standards relate to health care claim data elements and code sets.

11. ASC X12N Claims Standards

    Discusses the national electronic claims standards adopted for certain professional and institutional transactions. It also references where implementation guides may be obtained.

12. NCPDP Claim Standard

    Summarizes the retail pharmacy electronic claim standard and where its implementation specifications may be obtained. It places the standard within the broader HIPAA transaction environment.

13. Common Working File (CWF)

    Notes that the common working file must be adapted for edits and data collection related to the change. It addresses system support at a high level.

14. Testing

    Identifies internal testing as a readiness activity to ensure changes function as intended. It points readers to related guidance for testing responsibilities.

15. Reporting

    States that reporting requirements for drug claims will align with the new drug identifier standard once implemented. It concerns claim reporting compliance at a general level.

16. Outreach

    Describes provider education and notification activities needed for a smooth transition. It includes timing considerations for informing providers about the upcoming change.

17. Questions and Comments Received

    Presents issues raised in response to the memorandum and summarizes the status of selected responses. It reflects stakeholder concerns about implementation, operations, and readiness.