[NAME] STANDARD - NCPDP



SPAP ADAP BIN PCN

Reference Guide

Version 5.0

The NCPDP SPAP ADAP BIN PCN Reference Guide provides instructional information for the process to update and share BINs and PCNs for SPAPs and ADAPs for transaction processing for Medicare Part D beneficiaries.

|April 2016 | |

| | |

|National Council for Prescription Drug Programs | [pic] |

|9240 East Raintree Drive | |

|Scottsdale, AZ 85260 | |

| | |

|Phone: (480) 477-1000 | |

|Fax: (480) 767-1042 | |

|E-mail: ncpdp@ | |

|http: | |

SPAP ADAP BIN PCN Reference Guide

Version 5.0

COPYRIGHT (©) National Council for Prescription Drug Programs, Inc.

2015

This work is owned by National Council for Prescription Drug Programs, Inc., 9240 E. Raintree Drive, Scottsdale, AZ 85260, (480) 477-1000, ncpdp@, and protected by the copyright laws of the United States. 17 U.S.C. §101, et. seq. Permission is given to Council members to copy and use the work or any part thereof in connection with the business purposes of the Council members. 

The work may not be changed or altered. The work may not be sold, used or exploited for commercial purposes. This permission may be revoked by National Council for Prescription Drug Programs, Inc., at any time. The National Council for Prescription Drugs Programs, Inc. is not responsible for any errors or damage as a result of the use of the work.

NCPDP recognizes the confidentiality of certain information exchanged electronically through the use of its standards. Users should be familiar with the federal, state, and local laws, regulations and codes requiring confidentiality of this information and should utilize the standards accordingly.

NOTICE: In addition, this NCPDP Standard contains certain data fields and elements that may be completed by users with the proprietary information of third parties. The use and distribution of third parties' proprietary information without such third parties' consent, or the execution of a license or other agreement with such third party, could subject the user to numerous legal claims. All users are encouraged to contact such third parties to determine whether such information is proprietary and if necessary, to consult with legal counsel to make arrangements for the use and distribution of such proprietary information.

Published by:

National Council for Prescription Drug Programs

Publication History:

Version 1.0 November 2011

Version 2.0 January 2012

Version 3.0 April 2012

Version 4.0 September 2014

Version 5.0 April 2016

Table of Contents

1. INTRODUCTION 4

1.1 The Purpose of the Process and the Spreadsheet 4

1.2 Terms 5

2. The Process To Update the Spreadsheet 6

3. Frequently Asked Questions 7

3.1 What if my SPAP and ADAP both use the same BIN-PCN? 7

3.2 Who fills out the spreadsheet? 7

3.3 How Does a Plan Obtain a BIN/PCN? 7

3.4 Financial Contact Information - Is Reconciliation Referring to Claim Reversals and/or Reimbursements? 7

4. Appendix A. Submission Information SPAP ADAP Master List Tab 8

4.1 Instructions 8

5. Appendix B: Request for review by another entity 12

6. Appendix C. History of REFERENCE guide Changes 13

6.1 Version 2.0 13

6.1 Version 3.0 13

6.2 Version 4.0 13

6.3 Version 5.0 13

INTRODUCTION

The NCPDP SPAP ADAP BIN PCN Reference Guide provides instructional information for the process to update and share BINs and PCNs for SPAPs and ADAPs for transaction processing for Medicare Part D beneficiaries. This sharing of routing identifiers (BINs and PCNs) is done to facilitate the correct processing of pharmacy benefit claims for patient care.

The sharing of BINs and PCNs is via a simple spreadsheet that contains minimal information to assist the industry.

1 The Purpose of the Process and the Spreadsheet

There are inherent delays in the data availability and thus it is possible that a State Pharmaceutical Assistance Program (SPAP) or AIDS Drug Assistance Program (ADAP) may be paying claims for a beneficiary but the data has not yet been submitted or uploaded to the CMS systems. To mitigate this situation, CMS and the Transaction Facilitator have developed a process to increase the likelihood that these SPAP and ADAP claims are appropriately applied to the member’s TrOOP and that the appropriate entity is refunded in the event of a copay/coinsurance adjustment. NCPDP, with CMS and the Transaction Facilitator have developed a process to assist in sharing RxBIN and RxPCN for SPAPs and ADAPs.

If you provide your BIN-PCN information

The Transaction facilitator will “follow-up” any claims with your BIN-PCN when a match cannot be found on the CMS Eligibility file. If a match is not found when the claim is paid and forwarded to the Transaction Facilitator, it will be flagged for a follow-up 4 times during the first month and then once a month for two months. Each time the paid claim is “followed up”; it is matched against the CMS eligibility data as of the “follow-up” date. The total “follow-up” period will be 90 days which should be enough time for the eligibility record to catch up. Each time the paid claim is “followed up”; it is matched against the CMS eligibility data as of the “follow-up” date. Once a match occurs, an Information Reporting (N) transaction will be forwarded to the Part D plan of record.

NCPDP proposes that plans should use the SPAP/ADAP BIN-PCN list to ensure that any N transaction received from a BIN-PCN on this list should be applied to other TrOOP. In the event that the OHI on file for the same BIN-PCN indicates that it is not qualified, SPAP/ADAP BIN-PCN list should take precedent. If the Other Healthcare Information (OHI) is not updated in a reasonable amount of time, the plan should work with the supplemental payer to correct the data as they are the only entity that can update the records.

 

Please note that in order for transactions to be appropriately applied, the supplemental payer must only pay claims if the BIN-PCN and Cardholder ID on the submitted claim match what is provided to CMS. If they do not match, N transactions will not be generated.

The exchange of SPAP and ADAP BIN-PCN information is only as good as the industry participation in keeping the information on the spreadsheet updated, and in consuming the information on the spreadsheet.

All information is reported by the ADAP or SPAP and subject to their updates. Use of this information is restricted to the sharing of BINs and PCNs for plans, payers, and processors involved in coordination of benefits of Medicare Part D beneficiaries. This document and the spreadsheet are not to be distributed further, nor displayed in other public venues.

If you have any questions regarding the availability or content of the NCPDP SPAP ADAP BIN PCN Reference Guide, see , or contact the Council office at (480) 477-1000 or via e-mail at ncpdp@.

2 Terms

|ADAP |AIDS Drug Assistance Program |

|MARx |Medicare Advantage and Prescription Drug System |

|RxBIN |Bank Identification Number (BIN) |

|RxPCN |Processor Control Number (PCN) |

|SPAP |State Pharmaceutical Assistance Program |

|TrOOP |True Out Of Pocket |

The Process To Update the Spreadsheet

1. NCPDP has set up a website page that contains the SPAP ADAP BIN PCN Spreadsheet and informational documents.

2. On a timely basis, SPAP and ADAP entities are expected to review the spreadsheet and provide any updates to NCPDP.

a. Updates are submitted only by the principle SPAP or ADAP representative, not other entities in the industry.

b. Updates include adding new rows for new SPAP or ADAP programs, changing of information in an existing row, or supplying termination information.

c. See “Appendix A. Submission Information” for important information.

3. After receipt of an email with updated information, NCPDP will enter the information submitted, the Date Information Last Updated and Verified By Name information and post the updated spreadsheet.

a. NCPDP will endeavor to update the spreadsheet timely. At the start of the process, the spreadsheet may be updated once or twice a week. Once the updates are in place, it is anticipated the spreadsheet will not change that often.

4. When NCPDP posts an updated spreadsheet on the website, the date label will change. This lets entities know that the spreadsheet has been updated.

For example

Updated: 20140802 SPAP ADAP BIN PCN Spreadsheet

5. Entities can then download the updated spreadsheet and use according to the terms noted above.

Frequently Asked Questions

1 What if my SPAP and ADAP both use the same BIN-PCN?

Response: You must create a row for each plan that uses a BIN-PCN. Use the “Plan Name” and “SPAP (S) ADAP (A)” columns to differentiate between the different plans/entities.

2 Who fills out the spreadsheet?

Response: The spreadsheet is self-reported by the SPAP or ADAP. Additions or updates are to be sent to NCPDP at CMS-SPAP-ADAPplaninfo@ with Subject: SPAP ADAP Update. This information must be reviewed yearly or whenever data is updated by the SPAP or ADAP. The BIN, PCN, Coverage and/or Termination Dates reported must be the same data reported to CMS.

3 How Does a Plan Obtain a BIN/PCN?

Response: The Bank Identification Number (BIN) is a six-digit number that is assigned for electronic routing of transactions. The Processor Control Number (PCN) is secondary identifier that may be used in routing of pharmacy transactions. The PCN is defined by the PBM/processor as this identifier is unique to their business needs. There is no registry of PCNs. The PCN, like the BIN appear on the pharmacy ID card, in accordance with the rules defined in the NCPDP Pharmacy ID and Combination Card Implementation Guide. Not all entities may use the PCN to differentiate plans. Some entities may use the Group ID; still others may not need this level of differentiation. See (BIN) for more information.

4 Financial Contact Information - Is Reconciliation Referring to Claim Reversals and/or Reimbursements?

Response: Financial contact information is the entity (SPAP/ADAP or pharmacy benefit manager) who can be contacted for reconciliation of claims processing, for refunds and recoupments.

Appendix A. Submission Information SPAP ADAP Master List Tab

To facilitate the updating of data for the spreadsheet, this information is provided. Additions or updates are to be sent to NCPDP at CMS-SPAP-ADAPplaninfo@ with Subject: SPAP ADAP Update.

1. Use the tab “Blank Row”.

2. If adding a row to the spreadsheet (a new entry of an SPAP or ADAP), all fields are required.

3. If updating column(s) to an existing entry in the spreadsheet (updating information on an existing SPAP or ADAP row), copy the row from the BIN PCN tab and update the new information in all columns affected.

1 Instructions

Columns designated as “Filler” – please ignore.

1. Filler – do not use.

2. Filler – do not use.

3. Filler – do not use.

4. SPAP (S) ADAP (A): S for SPAP or ADAP operating as an SPAP, A for ADAP.

If functioning as SPAP and ADAP, enter information on two different rows.

5. If SPAP is qualified by CMS, enter Q otherwise enter N. If ADAP, enter S.

6. State: Enter the valid, two character US state abbreviation or US territory abbreviation.

7. Short Name: Enter a short name. See other rows for examples.

8. Plan Name: Name of SPAP or ADAP program.

9. RXBIN for Real-Time Claims Processing:

a. BIN Number. Six position numeric RxBIN assigned as TrOOP RxBIN to SPAP or ADAP. Must contain all six digits. Enter in leading zeroes if valid characters in the 6-digit BIN. If no BIN is assigned, enter N/A. If no BIN is assigned, this SPAP/APAP does not process real-time claims electronically.

b. Designate the data as ORANGE = NO BIN PCN GREEN = BATCH ONLY

10. RXPCN for Real-Time Claims Processing:

a. Processor Control Number. RxPCN assigned as TrOOP RxPCN to SPAP or ADAP.

If no PCN is assigned (the plan doesn't use a PCN), enter N/A.

OR

N/A may be entered if this SPAP/APAP does not process real-time claims electronically, therefore coordination of benefits is no. Name of contact person at SPAP/ADAP who should be reached in the event of TrOOP problems/questions, or for updates to this spreadsheet.

b. Designate the data as ORANGE = NO BIN PCN GREEN = BATCH ONLY (This is the same shading as item 9.)

11. RXGRP for Real-Time Claims Processing:

a. Rx Group. RxGroup assigned as TrOOP RxGroup to SPAP or ADAP.

If no Group is assigned (the plan doesn't use a Group), enter N/A.

OR

N/A may be entered if this SPAP/APAP does not process real-time claims electronically, therefore coordination of benefits is no. Name of contact person at SPAP/ADAP who should be reached in the event of TrOOP problems/questions, or for updates to this spreadsheet.

b. Designate the data as ORANGE = NO BIN PCN GREEN = BATCH ONLY (This is the same shading as item 9.)

12. Provides Batch Claims only:

a. Enter Y or N. If Y, this entity allows claims to be submitted by a pharmacy that contain something other than the BIN-PCN that is on file with CMS and they submit a nightly batch Information Reporting (N) file to the Transaction Facilitator that replaces the BIN/PCN on the claim with what is on the CMS file.

b. Designate the data as ORANGE = NO BIN PCN GREEN = BATCH ONLY (This is the same shading as item 9.)

13. RXBIN for Batch Claims Processing:

a. BIN Number. Six position numeric RxBIN assigned as TrOOP RxBIN to SPAP or ADAP. Must contain all six digits. Enter in leading zeroes if valid characters in the 6-digit BIN.

If no BIN is assigned, enter N/A. If no BIN is assigned, this SPAP/APAP does not process batch claims electronically.

This entity allows claims to be submitted by a pharmacy that contain something other than the BIN-PCN that is on file with CMS and they submit a nightly batch Information Reporting (N) file to the Transaction Facilitator that replaces the BIN/PCN on the claim with what is on the CMS file.

b. Designate the data as ORANGE = NO BIN PCN GREEN = BATCH ONLY (This is the same shading as item 9.)

14. RXPCN for Batch Claims Processing:

a. Processor Control Number. RxPCN assigned as TrOOP RxPCN to SPAP or ADAP.

If no PCN is assigned (the plan doesn't use a PCN), enter N/A.

OR

N/A may be entered if this SPAP/APAP does not process batch claims electronically, therefore coordination of benefits is no.

b. Designate the data as ORANGE = NO BIN PCN GREEN = BATCH ONLY (This is the same shading as item 9.)

15. Submits eligibility to CMS on Data Sharing Agreement:

a. Enter Y or N.

b. Designate the data as ORANGE = NO BIN PCN GREEN = BATCH ONLY (This is the same shading as item 9.)

16. SPAP/ADAP Operational Contact Name: Enter contact name for questions about this information.

17. SPAP/ADAP Operational Contact Phone: Telephone number of contact person at SPAP/ADAP who should be reached in the event of TrOOP problems/questions, or for updates to this spreadsheet.

18. SPAP/ADAP Operational Contact Email: Email address of contact person at SPAP/ADAP who should be reached in the event of TrOOP problems/questions, or for updates to this spreadsheet.

19. SPAP/ADAP Financial Contact Name

a. Name of contact person at SPAP/ADAP who should be reached in the event of financial reconciliation problems/questions.

b. Designate the data as ORANGE = NO BIN PCN GREEN = BATCH ONLY (This is the same shading as item 9.)

20. SPAP/ADAP Financial Contact Phone: Telephone number of contact person at SPAP/ADAP who should be reached in the event of reconciliation problems/questions.

21. SPAP/ADAP Financial Contact Email: Email address of contact person at SPAP/ADAP who should be reached in the event of reconciliation problems/questions.

22. SPAP ADAP Financial Payee Name: Enter the valid payee name.

23. SPAP ADAP Attention: Enter the Attention to. This may be a person or a department.

24. SPAP ADAP Financial Address Line 1: First line of address of Financial Payee Name.

25. SPAP ADAP Financial Address Line 2: Second line of address, if applicable of Financial Payee Name.

26. SPAP ADAP Financial City: City of Financial Payee Name.

27. SPAP ADAP Financial State: The valid, two character US state abbreviation or US territory abbreviation of Financial Payee Name.

28. SPAP ADAP Financial Zip: The valid ZIP Code of the Financial Payee Name.

29. First Date of Coverage for this RXBIN/RXPCN: Date when the coverage begins for this RxBIN/RxPCN. This date may be a future date.

30. Last Date of Coverage for this RXBIN/RXPCN: Date when the coverage ends for this RxBIN/RxPCN. This date may be a future date.

31. Date Information Last Updated: Enter the current date of entry.

32. Verified By Name: Enter the name of the person who has authority to request these changes.

33. First Effective Date of Real-time/Batch Processing for RxBIN/RxPCN: Date when the coverage begins for this RxBIN/RxPCN. This date may be a future date.

34. Termination Date with CMS (if applicable): Termination date of SPAP/ADAP contract with CMS or effective date when plan dissolved or ceased operations.

35. Facilitator comment: For Transaction Facilitator use only.

36. BIN/PCN Source: For NCPDP use only.

Appendix B: Request for review by another entity

As the spreadsheet is used by the principle participants, one entity using the spreadsheet may find columns in the spreadsheet that need to be updated by the owner of the row (SPAP or ADAP). NCPDP will only update information submitted by the owner of the row (SPAP or ADAP). However, we ask other principle participants to send an email/call the listed contact person to request they update their information. The verbiage below is suggested for use, but can be tailored as desired.

Dear xxx;

The information contained in the NCPDP SPAP ADAP BIN PCN spreadsheet appears to be incorrect or out of date. As this information is used by the industry for correctly processing of pharmacy benefit claims for patients, we request that you contact NCPDP with the updated information. Please see for the spreadsheet and instructions.

Thank you

Appendix C. History of REFERENCE guide Changes

1 Version 2.0

RxBIN and RxPCN columns were renamed to RXBIN for real-time claims processing and RXPCN for real-time claims processing.

Provides Batch claims only column was added.

RXBIN for batch claims processing column was added.

RXBIN for batch claims processing column was added.

Submits eligibility to CMS on Data Sharing Agreement column was added.

2 Version 3.0

The tabs for Instructions Financial Contact and Financial Contact List have been added to the spreadsheet and this guide.

3 Version 4.0

The spreadsheets were reworked into one tab containing both operational and financial information. Additional fields were added:

• ** For Future Use Attestation Completed Y/N

• ** For Future Use Attestation Date

• For Future Use Program Contact Person Attested

• New Short Name

• *NEW RXGRP for Real-Time Claims Processing

• *NEW SPAP/ADAP Financial Contact Name

• *NEW SPAP/ADAP Financial Contact Phone

• *NEW SPAP/ADAP Financial Contact Email

• *NEW SPAP ADAP Financial Payee Name

• *NEW SPAP ADAP Attention

• *NEW SPAP ADAP Financial Address Line 1

• *NEW SPAP ADAP Financial Address Line 2

• *NEW SPAP ADAP Financial City

• *NEW SPAP ADAP Financial State

• *NEW SPAP ADAP Financial Zip

• BIN/PCN Source

4 Version 5.0

The first three columns were designated as Fillers. The “*NEW” was removed from all fields.

Added Number 5 to Section 4.1 to address a column in the spreadsheet which already existed but no instructions were provided.

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