Electronic claim for Medication Therapy Management Program services

QUESTION: When a Provider submits an electronic claim for Medication Therapy Management Program services, to a health plan, including a Part D drug plan, should they use the NCPDP 5.1 standard or must they use the X12N 837P standard, under HIPAA?

ANSWER: Please note that this FAQ has been revised to include a HIPAA enforcement addendum as of October 22, 2007.

To bill MTM services, covered entities should use the American Standards Committee (ASC) X12N 837P Version 4010/4010A1. We articulated in our January 28, 2005 Final Rule on the Medicare Prescription Drug Benefit that we viewed Medication Therapy Management (MTM) as a clinical service (70 FR 4194, 4231). Therefore, claims for MTM would be considered professional health care claims rather than retail pharmacy drug claims. Pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the ASC X12N 837P was adopted as the transaction standard for professional health care claims. Therefore, similar to physician clinical services, if MTM providers bill Part D sponsors electronically for MTM services, such billing claims must be transmitted using the ASC X12N 837 P Version 4010/4010A1. Part D Sponsors are not precluded from using the NCPDP 5.1 system edits as a method to identify targeted beneficiaries, or provide applicable information at the point of service to pharmacists or other MTM providers responsible for providing the MTM services, but the health care claim must be transmitted using the ASC X12N 837P.

Enforcement Addendum-10/22/07
While CMS adheres to its foregoing interpretation of the regulations requiring that MTM retail pharmacy services be reported using the X12N 837P standard, we recognize that x industry practice included NCPDP, Version 5.1 standard for billing of such services. CMS will not to take enforcement action against covered entities that use NCPDP, Version 5.1 pharmacy claim for MTM, supplies or services.

The final rule adopting new versions of the X12 and NCPDP standards allows for the use of either x12 or NCPDP for billing pharmacy supplies and services, and MTM.

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