Pharmacy Groups Standardize Rx Claim Messages

JULY 01, 2006

Thanks to an agreement by 3 of the largest pharmacy groups, third-party prescription claims by pharmacists will get easier. The National Community Pharmacists Association, the National Association of Chain Drug Stores, and America's Health Insurance Plans have reached an understanding on standardized electronic messaging. The messages will assist pharmacists and better serve beneficiaries when they have prescriptions filled at the pharmacy.

"I want to be clear that Medicare now views these consistent messages as best practices for the drug benefit, and we expect the entire industry to adopt and implement these practices as soon as possible," remarked Mark McClellan, MD, PhD, administrator for the Centers for Medicare & Medicaid Services (CMS). "CMS will be looking at these and other best practices as measurements of plan performance?we expect these messages to become requirements with the adoption of these standards by NCPDP [National Council for Prescription Drug Programs], and we will be monitoring whether we need to take further steps to make sure that happens."

Specifically, the pharmacy groups developed standarized electronic messages to help pharmacists quickly determine the right course of action for filling patients'prescriptions, with a focus on 4 critical areas: (1) when a particular drug is not covered; (2) when prior authorization is required; (3) when plan quantity or other coverage limitations have been exceeded; and (4) when the pharmacy is not contracted with the Part D plan's network.