CHAINS and BUSINESS

Pharmacies sought for testing new claim standard

If all goes well, it may turn out to be a nonevent like Y2K. That's what the industry is hoping. The "it" refers to the requirement for pharmacies to move to a new claims processing standard by Oct. 16, 2002. The new standard is the National Council for Prescription Drug Program's (NCPDP) version 5.1, required by the Health Insurance Portability & Accountability Act (HIPAA) of 1996.

To ensure that version 5.1 is an industry-acceptable format, PDX/NHIN, a technology firm in Fort Worth, is offering to test chains, software developers, and claims processors. Speaking at the National Association of Chain Drug Stores' pharmacy conference in Chicago last month, Benjamin Loy, senior v.p. of industry relations and privacy officer for the firm, said the testing will be free of charge to participants. NHIN will donate its staff and resources to support this effort, seeing that it is such a critical development for the industry.

Loy said NCPDP's version 5.1 is markedly different from version 3.2, the standard the industry is currently using. The changes involve not only new fields of information but also new logic, such as partial Rx fills. To compound matters, the 5.1 standard will have to be up and running next October—although small health plans have an additional year to comply—whereas version 3.2 was implemented over the past 10 years. So time is running short for this daunting task, which Loy said is far more complicated than testing for Y2K, an initiative his firm was also engaged in.

As part of the test, which will begin this October, each chain and software developer will be paired with a processor randomly assigned by NHIN. Two test sets will be provided to participants. One test set involves NCPDP's SNIP 1A data elements. (SNIP, or the Strategic National Implementation Process, is a work group created to implement the HIPAA standards.) The second test set includes the SNIP 1A data elements as well as new claim types, such as partial fills. Six months after the initial testing date (i.e., in April 2002), NHIN will provide only the second test set to participants.

NHIN will also test the syntax and format of chains' claims submissions. To this end, starting in October, the company will provide the PDX Adjudication Simulator to chains and software vendors for submission testing.

How will the test results be reported? NHIN is creating a Web site that will list which chains, pharmacy benefit managers, and software vendors are registered for testing and their testing status. To date, many companies have offered feedback to this initiative. Chains involved include Albertson's, Eckerd, Kmart, Kroger, Target, Wal-Mart, and Walgreen. In terms of PBMs, they cover AdvancePCS, Express Scripts, and Merck-Medco. Independent pharmacists' interests will also be represented, since the National Community Pharmacists Association was invited to participate along with NACDS.

Ideally, NHIN hopes to finish piloting the first test set by April 2002 so that work can be completed on the additional claim types in the remaining time. "But we will allow testing right up to Oct. 1, 2002," Loy told the audience. He suspects there will be a "huge rush" of companies signing up at the last minute, as with the Y2K testing.

Through the use of an industry-developed comprehensive testing process, NHIN hopes the implementation of NCPDP's version 5.1 will be as noneventful as Y2K. "If no one hears about it, we'll have a party," Loy joked.

Companies that wish to take part in the testing should contact Garry Murray, project manager at NHIN. He can be reached by phone at (817) 367-4259 and by e-mail at nhin5.1test@pdxinc.com.

Judy Chi

Judy Chi. Pharmacies sought for testing new claim standard.

Drug Topics

2001;18:53.