What you need to know

The Centers for Medicare and Medicaid Services (CMS) issued a Final Rule (CMS-0056-F) on Dec. 13, 2024, that outlines modifications to the Health Insurance Portability and Accountability Act (HIPAA) National Council for Prescription Drug Programs (NCPDP) retail pharmacy standards and Medicaid pharmacy subrogation standards. The changes impact data files including eligibility files, claim files and other reporting.  

Prime Therapeutics (Prime) has initiated an enterprise program to complete the necessary changes ahead of the final compliance date of April 14, 2028. We plan to begin the transition to the new standards on June 11, 2027. 

There is no action required by clients at this time, but Prime will provide updates and engage clients for data exchanges, testing and any other collaboration needed to comply with the requirements as the project progresses. 

Ovierview
Prime remains committed to ensuring full compliance with CMS requirements, and we value collaboration with pharmacies and our clients as we work to comply.  

Prime’s effort will ensure all claims adjudication platforms and pharmacy dispensing systems used by Prime have been updated to the new requirements.  

High-level changes required in the final rule include:  

• New claim segments, fields, and values, as well as the removal of some fields 

• Expansion of all dollar fields to 11 or 14 digits 

• Expansion of all fields containing the product service ID (NDC) to 40 characters  

• Other field size changes 

• Changes to the count of specific claim segments 

• 400+ external code list changes  

• Field name changes 

• The Bank Identification Number (BIN) replaced with Issuer Identification Number (IIN) increased to 8 digits 

• New adjudicated program type field will require granular identification of plan type during adjudication 

Next steps

Through the end of 2025, Prime will evaluate the requirements of the final rule and establish a plan to execute the required changes. As we transition to execution in 2026, Prime will engage clients as needed.  

We remain committed to keeping all stakeholders informed throughout each phase of this initiative. We will continue to provide updates that include detailed information and revised timelines, enabling all parties to effectively allocate resources and prepare for testing and data exchanges. Our ongoing communication is aimed at ensuring a smooth transition to the new regulatory requirements, supporting our clients at every step of the process. 

Questions
Please reach out to your Prime account team representative.