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1.0 Introduction

1.1 Overview

The HITSP Medication Formulary and Benefits Information Transaction Package addresses two tasks. The first task is to perform an eligibility check for a specific patients pharmacy benefits. The eligibility check can be performed by a prescriber using ASC X12 270/271 transaction standards together with the X12 Insurance Subcommittee (X12N) Implementation Guides reference numbers 004010X92 and its addenda 004010X92A1. The eligibility response will tell the prescriber if the patient is eligible for retail and mail order pharmacy benefit. The eligibility response will also contain a set of IDs which link a given benefit to the associated formulary and benefits information. An eligibility check can also be performed by a pharmacy using NCPDP Telecommunication Standard transactions. Both of these methods of verification are done in real time. The second task of the HITSP Medication Formulary and Benefits Information Transaction Package is to obtain the medication formulary and benefit information.

The Accredited Standards Committee (ASC) X12 Insurance Subcommittee X12N Implementation Guides are used for various transactions, but specific to this Transaction Package, they are used by a prescriber system to obtain an individuals pharmacy benefit eligibility, coverage and benefits. They also provide the key identifiers that are used to obtain detailed formulary and benefits information. The eligibility response can contain single or multiple pharmacy benefit coverage.

Each of the formulary and benefits lists has a unique identifier (ID) that ties that specific formulary and benefit list to the patient benefit information returned in the ASC X12N 271 response. These formulary IDs are contained in the detail level of each formulary list type. The ID types are Formulary ID, Alternative ID, Classification ID, Coverage ID, and Copay ID. Once the appropriate eligibility is known and appropriate pharmacy plan parameters have been identified, the detailed formulary and benefits information can be obtained. This is accomplished using the NCPDP Formulary and Benefit Standard Implementation Guide Version 1.0 specification. This is accomplished in a batch mode.

Note: In the event that the eligibility information is not available (via the ASC X12N 270/271), a cross-reference file (obtained in the transmission of the NCPDP Formulary and Benefit Standard Implementation Guide file) can be utilized to link the individual to the appropriate formulary and benefit information that is applicable for their pharmacy coverage .

The eligibility checking is not a required prerequisite to the loading of formulary information. The Formulary Publisher develops their formulary and benefit file layout according to the NCPDP Formulary and Benefit Data Load specification. The Formulary Publisher sends a formulary and benefit message and file that contain one or more of the formulary and benefit list types (e.g., formulary status, alternative, coverage, copay, and classifications). The Formulary and Benefit Data are electronically transmitted to the Formulary Retriever. A physical validation of the file is done and a Formulary Response File is sent back to the Publisher indicating the Formulary and Benefit Data load status. The Response File indicates any errors encountered in the load process. Once the file is successfully processed and loaded, this information is stored locally in a formulary database. This database is queried to match a patient benefit to the appropriate formulary information based on the results of an eligibility query and the formulary IDs that are returned.

The NCPDP Telecommunication Standard is used by the pharmacy industryfor various transactions, but specific to this Transaction Package it is used for the Eligibility Verification and Predetermination of Benefits transactions. The Eligibility Verification transaction is used by the Pharmacy to request that the Administrator, Processor or Reporting Entity verify the eligibility of a specific patient according to appropriate plan parameters. This transaction is used to request verification of a patients or cardholders status for a given benefit program. This is a real-time request/response transaction set. Eligibility Verification using the Telecommunication Standard for pharmacies is named in HIPAA and the Medicare Modernization Act of 2003 (MMA). The Pharmacy queries directly to the plan, through a switch/clearinghouse to the plan or the plans agent (the Pharmacy Benefit Manager (PBM)) or in the case of Medicare Part D, to a Facilitator that holds past/current/future information about Medicare Part D beneficiaries. The Facilitator returns the identification for other plans if the patient has multiple coverage or has changed coverage.

The Predetermination of Benefits inquiry transaction is used by the Pharmacy to request the following:

To determine if the patient is eligible for prescription coverage

To determine if the submitted product is covered

To identify the patients financial responsibility at that point in time

To potentially identify clinically relevant information

Conversely, the Predetermination of Benefits transaction response is used by the Processor to communicate the following:

To identify if the patient is eligible for prescription coverage

To identify if the submitted product is covered

To identify the patients financial responsibility at that point in time

To potentially identify clinically relevant information that may influence the submission of a corresponding prescription claim request

1.2 Copyright Permissions

COPYRIGHT NOTICE

2009 ANSI. This material may be copied without permission from ANSI only if and to the extent that the text is not altered in any fashion and ANSIs copyright is clearly noted.

1.3 Reference Documents

This section provides a list of key reference documents and background material. If you are already familiar with this information, proceed to Section 2.0.

A list of key reference documents and background material is provided in the table below. These documents can be retrieved from www.hitsp.org.

Table 1-1 Reference Documents

1.4 Conformance

This section describes the conformance criteria, which are objective statements of requirements that can be used to determine if a specific behavior, function, interface or code set has been implemented correctly.

1.4.1 Conformance Criteria

In order to claim conformance to this construct specification, an implementation must satisfy all the requirements and mandatory statements listed in this specification, the associated HITSP Interoperability Specification, its associated construct specifications, as well as conformance criteria from the selected base and composite standards. A conformant system must also implement all of the required interfaces within the scope, subset or implementation option that is selected from the associated Interoperability Specification.

Claims of conformance may only be made for the overall HITSP Interoperability Specification or Capability with which this construct is associated.

1.4.2 Conformance Scoping, Subsetting and Options

A HITSP Interoperability Specification must be implemented in its entirety for an implementation to claim conformance to the specification. HITSP may define the permissibility for interface scoping, subsetting or implementation options by which the specification may be implemented in a limited manner. Such scoping, subsetting and options may extend to associated constructs, such as this construct. This construct must implement all requirements within the selected scope, subset or options as defined in the associated Interoperability Specification to claim conformance.

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