Medicaid Subrogation NCPDP Standards

1
Medicaid Subrogation NCPDP Standards

• Annette Gabel
• Medco Health Solutions Inc.

2
Medicaid Subrogation Standard Implementation
Guide Version 3.Ø

• Medicaid Subrogation is a process whereby
  Medicaid is the payer of last resort.
• The state has reimbursed the pharmacy provider
  for covered claims and now is pursuing
  reimbursement from other payers for these claims.
  
• Some states may choose to Pay all claims in
  full, through a federal waiver, at the point of
  receipt and Chase reimbursements from
  responsible third parties after the fact.
• The Medicaid Subrogation transactions use the
  Telecommunication Standard Implementation Guide
  transactions wrapped in the Batch Standard
  Implementation Guide (The same parsing routines
  can be used for the batch detail records.)

3
Medicaid Subrogation Standard Implementation
Guide Version 3.Ø

• New implementation guide requested to be HIPAA
  named standard
• One standard eliminates coding and maintaining
  multiple proprietary standards
• Claim responses are sent using the NCPDP Medicaid
  Subrogation batch response.
• Claim payment is made using the X12 835 4010
  standard (5010 standard once mandated)
• Medicaid Subrogation standard added four new
  fields specific to Medicaid billing
• Medicaid Agency
• Medicaid ID number
• Medicaid Paid Amount
• Medicaid Subrogation Internal Control number
  (ICN/TCN)

4
NCPDP White Paper Timeline for Adoption of NCPDP
Standards/ Dates Proposed in NPRM

• NCPDP Medicaid Subrogation Timeline
• August 2008 release of NPRM business planning
  begins
• August 2009 development begins
• February 2011 transition to Medicaid Subrogation
  version 3.0 begins
• September 2011 Regulatory compliance date
• NPRM Proposed Dates
• No later than 24 months after the effective date
  of the final rule.
• Small health plans would have an additional 12
  months for compliance.
• Willing trading partners would be able to agree
  to use the Medicaid Subrogation standard
  voluntarily at any time before the compliance
  date. For example, covered entities that
  implement Version D.0 may choose to implement the
  Medicaid Subrogation standard at the same time
  because such an action can be accommodated in the
  work flow.

5
NCPDP SNIP (Strategic National Implementation
Plan)

• Creating a response to the NPRM
• Creating a payer sheet
• Will provide guidance for implementation and
  testing

6
Actions

• Participate or designate a representative to
  participate in NCPDP efforts
• http//www.ncpdp.org/news_hipaa_snip.asp
• Read the NPRM
• Comment
• On impact
• Cost
• Benefit
• Savings
• Proposed implementation date