I am interested in laearning all about Pharmacy claims processing in
the USA.
How do pharmacies process an insurance claim.
The pharmacy does not dial into each seperate insurer (oxford /
Medicaid / Medicare / Blue Cross etc....) rather he dials into a
clearing house. Such as NDC.

I am looking for the following information:

1. What does NDC do (do they get authorizations -  do they transfer
payments)
2. What type of equipment do parmacisits use.
3. What type of reporting does NDC etc... Provide
4. What is the market saturation (ie. NDC vs others)

Any other use full inforamtion would be appreciated

I am looking for infomration from a Pharmacisits/software
developer/consultant point of view

Thanks

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Clarification of Question by pay_com-ga on 05 May 2003 11:20 PDT

I would like as much detailed information on the data flow between
pharmacist and insurer as possible.

Also important is what type of reports / reporting tools are available
(are there any online tools etc...)

Hello -

Important note: this answer is not finished until you're satisfied
with it.  If you choose to rate this answer, please do so after asking
for any necessary information/clarification.  Thanks for your
understanding.

As you stated, NDCHealth is a general clearing house for a good number
of insurance companies.  A pharmacy looking to process claims would
simply open an account with this company, and then connect their
computer systems to the clearing house via an EDI network connection
of some sort, utilizing one of the compatible software products. 
TechRX is a leading provider of products that interface with the NDC
system.  DataSat, Zadall, Condor are their software products that
interface with NDCHealth.

See this link for information on these products: 
http://www.techrx.com/PDFs/Fall02.pdf

The National Council For Prescription Drug Programs is THE
organization that handles the origination of formats, transfering, and
related standards.  They can be reached at www.ncpdp.org.  NSF and
ANSI are the two prominent standards.

Envoy Corporation is also a leading provider of claims processing. 
See their product suite at:

http://www.webmdenvoy.com/pages/pharmacies/pharm.html
[left hand side]

Contact: 

Holly Finley
615-231-4840
888-869-0369

For information on specifics, setup requirements, etc.

Here's a link to some other companies that do processing:

INC System
http://www.incsystem.com/linkedpgs/stratall.html

Pharmacy Benefit Direct
http://www.pharmacybenefitdirect.com/claims.htm

Additional Link:
www.edihealthcare.com/html/clearinghouse.htm

Search strategy:
pharmacy claims processing

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Request for Answer Clarification by pay_com-ga on 06 May 2003 07:00 PDT

Thank you.
There is some good information here.

Many Insurance cards have magnetic swips - Are these used in general
and how - is the swipe data sent out (like credit card processing)
etc..

Just to clarify - Do NDC and Envoy provide connectivity to all
insureurs or do I have to use an envoy account to access envoy
connected and ND for NDC connected etc..

Lastly - Does NDC or Envoy etc.. Have a Online reporting tool? (I see
that EDI health care does)

Thank you

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Clarification of Answer by jbf777-ga on 06 May 2003 12:38 PDT

>Many Insurance cards have magnetic swips - Are these used in general
>and how - is the swipe data sent out (like credit card processing)
>etc..

This is all a function of the software that the Pharmacy chooses to
use, not so much the clearinghouse.   As of right now, TechRX doesn't
support this, but they plan on doing that in the future.  It is
possible there is X software/terminal combos out there that may work
with Y clearinghouse, although the rep I spoke with has not heard of
any other company doing that.  Credit card processing general works as
either a swipe, or a manual-entering of the same information [account
number, expiration, etc.]  I would imagine the insurance card would
work the same way... right now it's just the manual-entering side.

>Just to clarify - Do NDC and Envoy provide connectivity to all
>insureurs or do I have to use an envoy account to access envoy
>connected and ND for NDC connected etc..

Envoy provides access to probably 95% of them.  I'm waiting to hear
back from NDC Health on that, but you may want to email
generalinfo@ndchealth.com for their number.

>Lastly - Does NDC or Envoy etc.. Have a Online reporting tool? (I see
>that EDI health care does)

This is also a function of the Pharmacy's software, according to
Envoy.  If, by "online," you mean "web" or "Internet," TechRX doesn't
utilize the Internet for reporting.  But they have reporting tools
through their database system.  I would encourage you to call TechRX
at 800.860.2372 and talk to a rep about this more in depth.

Please let me know if you need any additional clarification.

Thanks,

jbf777-ga
GA Researcher

Very Clear and concise

Thank you very much for the rating + tip!