This page contains the following sections. Click a link to access the information in that section.

• Draft NCPDP 5.1 Prior Authorization Network Specifications
• NCPDP 5.1 Certification Process for CALPOS Pharmacy Claims
• Final NCPDP Network and CMC Specifications for Pharmacy Claims
• Medi-Cal POS NCPDP Pharmacy Transaction Specifications, Third Party Vendors
• Links to Other Technical Publications

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Draft NCPDP 5.1 Prior Authorization Network Specifications

Draft NCPDP 5.1 Prior Authorization Network Specifications (304 KB) are now available. These specifications are for NCPDP 5.1 prior authorization transactions. In this draft specifications document, a shaded field indicates an optional field. If an entire segment is optional, this is noted in the text preceding the segment's specifications rather than by shading the entire segment.

NCPDP Prior Authorization transactions have been implemented into production as of March 2005. The above draft NCPDP 5.1 Prior Authorization Network Specifications have been integrated into the existing Medi-Cal POS NCPDP Pharmacy Transaction Specifications, Third Party Vendors (Dial-Up and Leased-Line) (Updated March 4, 2009) document. Refer to the Medi-Cal POS Network Telecommunications Interface Standards, Third Party Vendors (Draft) document for more information about NCPDP transaction formatting.

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NCPDP 5.1 Certification Process for CALPOS Pharmacy Claims

Software developers must have their NCPDP 5.1 software certified before it can be used to submit claims. All developers should have their submitter ID and four-character software version number ready before they call the TSC. To certify software, in-state providers should call the TSC at 1-800-541-5555 (out-of-state providers should call [916] 636-1200) and select the POS/Internet prompt option to reach the POS/Internet Help Desk.

The four-character software version number in combination with your submitter ID will become the PC/POS Version Number used in all NCPDP 5.1 transactions submitted to the POS network.

Prior to testing each new software release/upgrade, you must notify the POS/Internet Help Desk of your new four-character software version number.

Obtaining a Valid Submitter ID
If you do not have a current submitter ID, call the TSC at 1-800-541-5555 and select the prompt option for Computer Media Claims (CMC) to obtain a submitter ID. Out-of-state providers and developers should call (916) 636-1200.

If you are currently submitting claims through CMC or POS NCPDP 3.2, you will not be assigned another submitter ID. Use your current submitter ID.

Testing NCPDP 5.1 Software
Providers are required to submit transactions using pre-defined test cases to test their NCPDP 5.1 software. These pre-defined test cases can be found in Section 5 of the document Medi-Cal POS NCPDP Pharmacy Transaction Specifications, Third Party Vendors (Dial-Up and Leased-Line) (Updated March 4, 2009). For each test case transaction, a test response will be sent back to the provider. The test verification depends on the use of the correct test case pharmacy provider number for the pharmacy tests. If the transaction key and the pharmacy provider number are not found on the test verification file, this error message will be returned: "ERROR UNABLE TO DETERMINE TEST CASE."

The POS/Internet Help Desk will receive a comparison report of all the software test transactions from the previous day. If all of the fields in each test case pass the edits, the POS/Internet Help Desk will update its database, allowing your NCPDP 5.1 software to be used within the POS Network. All of the reports and results will be mailed back to the test submitter after being reviewed by the POS/Internet Help Desk.

If the comparison report data does not adequately describe the test transaction problem, contact the POS/Internet Help Desk for assistance.

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Final NCPDP Network and CMC Specifications for Pharmacy Claims

Medi-Cal has upgraded to both the National Council for Prescription Drug Programs (NCPDP) Version 5.1 (for online, real-time submission of pharmacy drug claims) and NCPDP 1.1 (for batch pharmacy drug claims). The final network specifications for these transaction types can be accessed in the Medi-Cal POS Network Telecommunications Interface Standards, Third Party Vendors (Draft) (63 KB - updated February 20, 2008).

Highlights:

• Metric decimal quantities are mandated on all pharmacy claims with dates of service on or after October 1, 2002. Pay special attention to the requirements for the Quantity Dispensed field in the network specifications for Versions 5.1 and 1.1.
• Version 5.1 and 1.1 only allow for a metric decimal quantity.

Medi-Cal discontinued its proprietary Computer Media Claims (CMC) pharmacy transmission format on October 1, 2002 and replaced it with the NCPDP Batch Standard Version 1.1.

Recertification is required for both the NCPDP Batch Standard Version 1.1 and the NCPDP Version 5.1 for online, real-time submission of pharmacy claims. Recertification procedures, for CALPOS claims submission, including those who must recertify, are listed above. For CMC submission recertification, submitters must send a test file to gain approval for NCPDP Batch Standard Version 1.1 format pharmacy claims.

Refer to the Pharmacy Frequently Asked Questions page for answers to common questions, including billing compound claims in the NCPDP Version 5.1 format. For CALPOS and CMC questions, call the TSC at 1-800-541-5555 and select the appropriate prompt option. POS and CMC submitters outside of California should call (916) 636-1200.

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Medi-Cal POS NCPDP Pharmacy Transaction Specifications, Third Party Vendors

The document Medi-Cal POS NCPDP Pharmacy Transaction Specifications, Third Party Vendors (Dial-Up and Leased-Line) (Updated March 4, 2009) is intended to allow third party developers to code pharmacy transactions submitted via dial-up or leased-line connections. The document includes all specifications required to submit pharmacy transactions. Note that compound drug transactions will only be accepted via lease-line connections; they will not be accepted via dial-up connections.

The supplemental documents below offer additional information to assist with submitting pharmacy NCPDP 5.1 transactions.

Supplemental Documents

• Medi-Cal POS Network Telecommunications Interface Standards, Third Party Vendors (Draft) (63 KB - updated February 20, 2008)
• Check Digit Algorithms (updated May 15, 2007)
• Medi-Cal Identification Cards Magnetic Stripe Formats (41 KB)
• Medi-Cal Electronic Attachment and Image Specifications – Third-Party Vendors (39 KB)

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Links to Other Technical Publications

• Medi-Cal Computer Media Claims (CMC) Billing and Technical Manual – Proprietary formats, Medi-Cal CHDP CMC, ANSI ASC X12N v.4010A1 and NCPDP Batch Version 1.1. (updated September 5, 2007)
• ASC X12N Version 4010A1 Companion Guides – 270/271, 276/277, 835 and 837 transactions
• CMC Developers, Vendors and Billing Services Directory (Updated November 19, 2010)
• Supplemental Claims Payment Information (SCPI) User Guide (Updated December 14, 2011)
• Paid Claims and Encounters Data 35-File Data Element Dictionary (New December 6, 2010)