HHS Publishes Final Rule Modifying HIPAA NCPDP Retail Pharmacy & Medicaid Pharmacy Subrogation Standards
The U.S. Department of Health and Human Services has published a final rule modifying the Health Insurance Portability and Accountability Act (HIPAA) National Council for Prescription Drug Programs (NCPDP) Retail Pharmacy Standards and the Medicaid Pharmacy Subrogation Standard.
Modifications to these HIPAA standards were proposed by the HHS in November 2022 to support more robust data exchange, improve coordination of benefits, and provide expanded financial fields to eliminate the need to manually enter free text, split claims, or prepare and submit a paper Universal Claim Form.
The key modifications adopted in the Final Rule are:
- NCPDP Telecommunication Standard Implementation Guide, Version D, Release 0 (Version D.0) replaced with NCPDP Telecommunication Standard Implementation Guide, Version F6
- NCPDP Batch Standard Implementation Guide, Version 1, Release 2 (Version 1.2) replaced with NCPDP Batch Standard Implementation Guide, Version 15
- NCPDP Batch Standard Medicaid Subrogation Implementation Guide, Version 3, Release 0 (Version 3.0) replaced with NCPDP Batch Standard Subrogation Implementation Guide, Version 10
According to the final rule, the transition period begins on August 11, 2027, from when the old and new versions may be used, with the permanent switch to the new version required by February 11, 2028. A technical error was made when setting that date, which should have been June 11, 2027. That error must be corrected with an updated version published in the Federal Register. On February 11, 2025, the HHS published an update in the Federal Register delaying the effective and compliance dates by 60 days.
Get The FREE
HIPAA Compliance Checklist
Immediate Delivery of Checklist Link To Your Email Address
Please Enter Correct Email Address
Your Privacy Respected
HIPAA Journal Privacy Policy
The proposed rule sought to broaden the scope of the subrogation transaction to apply to all health plans, including Medicare Part D, State assistance programs, and commercial health plans, rather than just State Medicaid agencies.
After reviewing feedback on the proposed change, HHS opted to adopt Version 10 solely for state Medicaid agencies. While Version 10 has not been adopted for non-Medicaid agencies in the Final Rule, non-Medicaid agencies are permitted to use the new standard.
The Final Rule – Administrative Simplification: Modifications of Health Insurance Portability and Accountability Act of 1996 (HIPAA) National Council for Prescription Drug Programs (NCPDP) Retail Pharmacy Standards; and Adoption of Pharmacy Subrogation Standard – was published in the Federal Register on December 13, 2024.
