CMS Pub. 100-18, ch. 7, § 30.10

For MTM claims processing, covered entities should use the American Standards Committee

(ASC) X12 837P Version 4010/4010A1. CMS articulated in its January 28, 2005 Final Rule on

the Medicare Prescription Drug Benefit that CMS viewed MTM as a clinical service (70 FR

4194, 4231). Therefore, claims for MTM would be considered professional health care claims

rather than retail pharmacy drug claims. Pursuant to the Health Insurance Portability and

Accountability Act (HIPAA) of 1996, the ASC X12 837P was adopted as the transaction

standard for professional health care claims. Therefore, similar to physician clinical services, if

MTM providers bill Part D sponsors electronically for MTM services, such billing claims must

be transmitted using the ASC X12 837 P Version 4010/4010A1. Part D sponsors are not

precluded from using the NCPDP 5.1 system edits as a method to identify targeted beneficiaries,

or provide applicable information at the point of service to pharmacists or other MTM providers

responsible for providing the MTM services, but the health care claim must be transmitted using

the ASC X12 837P.

While CMS adheres to its foregoing interpretation of the regulations requiring that MTM retail

pharmacy services be reported using the X12 837P standard, CMS recognizes that a reasonable

argument could be advanced in response to the Department of Health and Human Services

(HHS) seeking to enforce this regulation, contending that the regulations could be read to instead

direct the use of the NCPDP, Version 5.1 standard for such services. CMS further realizes that

notice and comment rulemaking, which HHS anticipates initiating in the near future, will very

likely resolve the apparent ambiguity of these regulatory provisions. In light of the foregoing

planned rulemaking and the uncertain outcome of any enforcement action, CMS elects not to

take enforcement action against those covered entities that continue to use the NCPDP, Version

5.1 standard for this transaction.