New HIPAA standards coming for electronic claims and transmissions

August 15, 2011

As healthcare moves swiftly toward a more comprehensive electronic platform, pharmacies will be required to upgrade their claim submission standard from NCPDP 5.1 to NCPDP D.0, an updated version of the HIPAA standard for pharmacy claims transactions.

Key Points

Pharmacies also will be required to upgrade to HIPAA X12 Version 5010, a new set of standards that regulate the electronic transmission of eligibility, claim status, referrals, claims, and remittances.

In each case, pharmacies, along with all other so-called HIPAA "covered entities" such as health plans and healthcare clearinghouses, as well as physicians, hospitals, and other healthcare providers, are required to comply with D.0 and 5010 as of January 1, 2012.

Specific transactions relating to pharmacy services that were named in the final regulations include retail pharmacy claims, retail pharmacy supplies and professional services, Medicaid subrogation, retail pharmacy eligibility, retail pharmacy claims coordination of benefits, and retail pharmacy prior authorization. The standards also support other transactions that not listed in the final rule.