Actually, the 835 does more than just replace the
paper EOB and checks from a payer. The pharmacy segment of the Healthcare
Industry has been using NCPDP standards for over a decade to provide data sets
(mostly magnetic tapes) to providers for reconciliation. Manual checks
accompany are sent under separate cover for the actual payment.
While it is true that NCPDP Version 5.1 is an
online billing and response transaction, the response is only an indicated to be
paid amount. It is not the payment. Most providers actually want to
have a reconciliation (ie, 835) data set that actually balances to the payment
amount. Many pharmacy providers also match the payment / reconciliation
data set with the responses from payers. A large number of pharmacies and
chain drug stores use a third party to perform the reconciliation process, with
the payment / reconciliation data set being sent directly to the "clearing
house". The pharmacy also sends a data set containing billing and online
response information and these data files are not only matched, but also
examined to determine if the results comply with existing
contracts.
NCPDP's Work Group 5, Payment / Reconciliation, has
expended a large amount of effort to map NCPDP Payment/Reconciliation Version
3.0 to the 835. The results of that mapping is available at www.ncpdp.org. Additionally, there is a task
group that is currently mapping the elements of NCPDP Version 5.1 billing
and responses to the 835. That mapping is expected to be completed by the
early part of August 2000 and will be posted on the NCPDP web site.
Any one with further information is encouraged to
visit the NCPDP web site. I certainly will be available to direct any
questions that you may have to the appropriate person, if I don't know the
answer, or the question is outside of my area of responsibility. There are
several other NCPDP coChairs that lurk around the transactions listserv, so
maybe they will speak up, too.
Ken Steen
----- Original Message -----
Sent: Wednesday, July 03, 2002 2:25
PM
Subject: RE: 835 Payment & Remittance
& Retail Pharmacy Claims
Hi
Kathy:
The 835 replaces the
check and remittance advice mailed by Health Plans and Pharmacy Benefit
Managers to pharmacies. It can be used to initiate financial transactions
(check issuance and EFT in a variety of forms) and send remittance data
electronically. The 835 can be used to send money and data together through
the banking system or separated, with money going through the banks and data
going separately. The IG does a good job of describing these options although
the focus is not on pharmacy payments. Today�s business practices include all
paper payment and remittance advices and combinations of EFT, check and
electronic remittance data delivery. One state we know sends a tape out to a
pharmacy chain every two weeks and one check for every 63 line items since
their system was set up to print one check per page. The 835 for electronic
remittance information and electronic funds transfer will be a significant
improvement over that practice.
Good
luck.
Jim
Jim
Moynihan
McLure-Moynihan.
Inc.
28720 Canwood Street
Suite 208
Agoura
Hills, CA 91301
818-706-3882
-----Original
Message-----
From: Kathy
Neugebauer [mailto:[EMAIL PROTECTED]]
Sent: Tuesday, July 02,
2002 9:36
AM
To: '[EMAIL PROTECTED]'
Subject: 835 Payment & Remittance
& Retail Pharmacy Claims
From the proposed modifications to
the Transaction Standards published on May 31, 2002 in the Federal
Register:
Therefore, we propose
to modify the standard for the health care payment and remittance advice
transaction for retail pharmacy transactions by adopting the ASC X12N 835 in
place of the NCPDP standard. With the implementation of this proposal, the ASC
X12N 835 would be the only standard for health care payment and remittance
advice transactions. All covered entities, including retail pharmacies (Sec.
162.1602), would be required to use ASC X12N 835 when conducting a health care
payment and remittance advice transaction.
Does anyone have any insight on
what type of transactions these would pertain to? Some examples? Most
pharmacies deal strictly with real-time online adjudication. From what I could
tell from various docs on this, this standard deals with moving of funds to a
provider's account - as the paying of Medicare Part A Institutional
Claims.
From reviewing the specs and the
WG5 Payment Reconciliation FAQ, this would not affect online claims
adjudication. However some practical examples would be
helpful.
Kathleen A. Neugebauer,
R.Ph.
Product Manager,
High Volume Group
TechRx(tm)
Inc.
The
Backbone of Pharmacy Commerce
Voice:
301-590-7740
Fax:
301-590-7764
Email:
[EMAIL PROTECTED]
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therefore represent the views of the individual participants, and do not
necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP.
If you wish to receive an official opinion, post your question to the WEDI
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=====================================================
The WEDI SNIP listserv to which you are subscribed is not moderated. The discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/.
Posting of advertisements or other commercial use of this listserv is specifically prohibited.
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