Is Your Pharmacy Benefit Manager (PBM) Compliant with New Standards?

PBMs Should Collect and Submit Electronic Messages to Pharmacies.

Providers that use a Pharmacy Benefit Manager (PBM) should be aware of requirements that went into effect on July 1, 2015. A hospice Data Element Request Form (DERF) was approved and required for pharmacy online claim adjudication effective July 1, 2015.

The hospice DERF came out of NCPDP, the not-for-profit pharmacy standards development organization, work groups to facilitate appropriate medication billing by pharmacies for hospice based on recent CMS regulations. The DERF requires that hospice PBMs have the ability to collect and submit various messages to pharmacies electronically, which include:

  • Non-Related Medications Being Covered by Hospice be Flagged as a “Compassionate Fill”
  • Related Medications Not Being Covered by Hospice be Flagged as “Beneficiary Responsibility”
  • Non-Related Medications Not Being Covered by Hospice be Flagged as “Unrelated and Other Payer Eligible”

NCPDP standards (including the hospice DERF) are mandated under HIPAA and are subjective to compliance oversight. HospiScript, one of the largest PBMs in operation, recently announced support of the new standard. If you are utilizing a vendor other than HospiScript and have not received notification of their compliance, HEALTHCAREfirst recommends verifying your Hospice PBM vendors’ system is compliant.

Additional information can be found on the NCPDP website.