National Council for Prescription Drug Program (NCPDP) Claim

70.2 - National Council for Prescription Drug Program (NCPDP) Claim Requirements (Rev. 2803, Issued: 10-28-13, Effective: 09-17-13, Implementation: 09-17-13) A. NCPDP Batch Transaction The NCPDP batch transaction format is intended to provide a file transmission standard for submission in a non-real-time mode of the telecommunications standard transaction for drug claims from retail pharmacies. CEDI will not accept retail pharmacy drug claims that are not submitted as batch transactions. NCPDP users are required to transmit National Drug Codes (NDCs) in the NCPDP standard for identification of prescription drugs dispensed through a retail pharmacy. NDCs replace the drug HCPCS codes for retail pharmacy drug transactions submitted to CEDI and delivered to the DME MACs via the NCPDP standard. The DME MAC shared system (VMS) will convert NDCs to HCPCS codes for internal claim processing. The CMS will provide the HCPCS codes for these drugs and an NDC to HCPCS crosswalk for use by VMS and the DME MACs. B. Generating a Batch NCPDP Response CEDI will return the NCPDP batch response for all NCPDP transmissions received. The NCPDP term “transaction” is equivalent to a Medicare service or line item and the NCPDP term “transmission” is equivalent to a Medicare claim. The NCPDP implementation guide allows for up to 4 transactions (line items) per transmission (claim). This means that each claim can have up to 4 line items. Therefore, if one transaction (line item) rejects, the entire transmission (claim) will be returned. All transactions (up to 4) in the transmission will be treated as one claim, and each transmission in a batch will be treated as a separate claim. For a transmission (claim) where one or more claim transactions (lines) have errors, the following will occur: 1. CEDI will reject all claim transactions (line items) in the transmission (claim) if any one claim (transmission) has detail errors. 2. The response status for all transactions will equal R (rejected). 3. CEDI will send up to 5 reject codes for claim transactions (line items) that have detail errors. 4. No transaction level reject code will be reflected for the line item with no error. Instead, the 504-F4 response message field at the header level is being used to denote acceptance or rejection of the entire claim. C. NCPDP Implementation Guide (IG) Edits CEDI shall allow segments to be submitted in any order including AM07, AM03 and AM11 as permitted by the NCPDP standard. CEDI must create the NCPDP flat file segments in numeric order for receipt by the DME MACs shared system maintainer. D. Misdirected Claims With the implementation of CEDI, there are no longer “mis-directed” claims. CEDI receives all DME ASC X12 and NCPDP claims, performs all front end editing and translation. Claims accepted by CEDI are assigned the Claim Control Number and delivered to the appropriate DME MAC based on the beneficiary state code submitted on the claim.