CAQH partnership focuses on synchronizing med, pharmacy e-transaction rules

The National Council for Prescription Drug Programs (NCPDP) and the Council for Affordable Quality Healthcare's Committee on Operating Rules for Information Exchange (CAQH CORE) have agreed to collaborate on activities related to harmonizing electronic data interchange standards and operating rules across the healthcare industry. The two organizations, which have been working together informally for several years, made this formal agreement to simplify administrative transactions for providers and patients and to meet the goals of the Patient Protection and Affordable Care Act (PPACA) in this area.

The Department of Health and Human Services (HHS) has asked the National Committee on Vital and Health Statistics (NCVHS), a government advisory body, to make recommendations that will enable HHS to implement the administrative simplification provisions of the ACA. In turn, NCVHS has tasked NCPDP with providing operating rules for pharmacy transactions and CORE--which represents health plans and other industry stakeholders--with devising operating rules for non-pharmacy transactions. The rules apply to areas such as eligibility, claims status, electronic funds transfer, and electronic remittance advice.

In an interview with FierceHealthIT, Gwendolyn Lohse, deputy director and CORE managing director at CAQH, notes that NCVHS expects CORE to deliver a set of operating rules for payment and remittance by Aug. 1 of this year. "Those rules will address how the medical and the pharmacy [payment systems] collaborate and reference one another," she says. After going through a government rulemaking and comment process, she adds, the operating rules must be ready for industrywide use by July 2012.

As they develop their own sets of rules, CORE and NCPDP will look ahead to see where they need to be harmonized, Lohse points out. Examples of areas that may require collaboration include:

  • Payment enrollment: Whether providers elect to receive payment by check, EFT, or some other method, the medical and pharmacy industries will discuss how to make this easier. "For instance, if providers enroll for payments that have both pharmacy and medical included, how can we coordinate that?" Lohse asks. This already occurs, she notes, in the oncology field.
  • Denial codes: With over 100 of these codes in use, NCPDP and CORE are discussing the possibility of harmonizing frequently used codes to make it easier for the end user to deal with them.
  • Billing over the Internet: Medical and pharmacy groups could agree on common digital certificates in line with the efforts of the Office of the National Coordinator for Health IT to improve online security.
  • Shared milestones: CORE and NCPDP should adopt rule changes in a coordinated way so that, Lohse says, "when we move to a fully electronic system, we're not setting up so many variations in how security works, or in how approaches to simplification work, that we actually cause more confusion [among end users and patients]."

To learn more:
- read the CORE-NCPDP press release 

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