The Basics

This straightforward standard simply requires that your organization's electronic claims processing mechanism complies with the standards of the National Council for Prescription Drug Program.  The standard transactions are the codes set standards under federal privacy law for organizations operating in the retail pharmacy world.

Management Tips

While your organization no doubt complies with the standards, it will be particularly important that you clearly document, through policies and procedures for claims processing, that this is an internal requirement of your organization.  In addition, you will need to make sure that your pharmacy provider manual and your pharmacy agreements are consistent with your policies and procedures on claims processing.

URAC Accreditation Tips

This is a mandatory standard.

For the desktop review, you will need to submit your policies and procedures, pharmacy provider manual, and agreement template.

The reviewer will interview your information technology leadership and regulatory compliance officer about your claims processing standards.  In addition, the reviewer will want to see documentation that you monitor compliance with these standards.