Our health plan contracts with a third party Pharmacy Benefits Management (PBM) company to handle our drug benefits. We currently exchange data with them and with Medicaid for encounter reporting using the NCPDP Claim Billing Tape format v2.
Our understanding of the HIPAA regulations and the Implementation Guide for the NCPDP transaction is that this transaction applies only to the exchange between the retail pharmacy and the payer (i.e., the PBM in our case). Our conclusion is that HIPAA does not apply to our business transaction as a business associate with our PBM, and therefore we should continue to exchange the Claim Billing Format v2. (We are waiting for a reply from Medicaid to determine what they will require for our reporting to them.)
Has any organization with a similar business configuration reached a conclusion on this issue?
I would appreciate any input on this issue.
Thank you,
Ellen Tatge
IS Project Manager
Presbyterian Healthcare Services
505/923-6882
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