The U.S. Department of Health and Human Services has issued a final rule with changes to the Health Insurance Portability and Accountability Act (HIPAA) National Council for Prescription Drug Programs (NCPDP) Retail Pharmacy Requirements and the Medicaid Pharmacy Subrogation Requirement.
The HHS proposed adjustments to these HIPAA requirements in November 2022 to enable better data exchange, enhance benefits coordination, and offer extended financial fields to remove the requirement to manually input free text, divide claims, or make and submit a paper Universal Claim Form.
The major adjustments implemented in the Final Rule are shown in the table below.
| Old Guide | New Guide |
|---|---|
| NCPDP Batch Standard Implementation Guide, Version 1, Release 2 (Version 1.2) | NCPDP Batch Standard Implementation Guide, Version 15 |
| NCPDP Telecommunication Standard Implementation Guide, Version D, Release 0 (Version D.0) | NCPDP Telecommunication Standard Implementation Guide, Version F6 |
| NCPDP Batch Standard Medicaid Subrogation Implementation Guide, Version 3, Release 0 (Version 3.0) | NCPDP Batch Standard Subrogation Implementation Guide, Version 10 |
The transition period starts on August 11, 2027. It is still allowed to use the old and new versions. The permanent move to the new versions will begin on February 11, 2028.
The proposed rule wanted to expand the extent of the subrogation transaction to cover not just State Medicaid agencies, but all health plans, which include Medicare Part D, commercial health plans, and State assistance programs.
After reading the suggestions on the proposed adjustments, HHS decided to follow Version 10 only for state Medicaid agencies. Although non-Medicaid organizations do not need to adopt version 10 in the Final Rule, they are allowed to adopt the new standard.
On December 13, 2024, the Final Rule, which includes the Adoption of Pharmacy Subrogation Standard and the Administrative Simplification: Modifications of Health Insurance Portability and Accountability Act of 1996 (HIPAA) National Council for Prescription Drug Programs (NCPDP) Retail Pharmacy Standards, was publicized in the Federal Register.
Image credits: DisobeyArt, AdobeStock
