Electronic Prior Authorization Overview
About Electronic Prior Authorization
Electronic Prior Authorization (ePA) integrates directly with provider vendor and PBM/payer systems, enabling healthcare professionals to easily obtain prior authorizations at the point of care. The prior authorization messages are designed to support the exchange of information obtained from the electronic health record system. The messages allow for the use of coded references, increasing the opportunity for interoperability. It is important for both provider vendors and PBM/payers to implement ePA using the most automated system possible to ensure timely responses to each of the messages.
About This Guide
The Surescripts Electronic Prior Authorization Companion Guide was created to assist PBM/payers and provider vendors in developing and transferring ePA messages based on the NCPDP Script standard. Each message supports a particular step in the prior authorization process, which electronically supports the exchange of information necessary to facilitate the request for coverage of a specific medication under a patient’s pharmacy benefit.
The audience for this document includes any customer responsible for developing a system interface for these electronic prior authorization messages.
Notes:
- The terms PBM/payer or processor, who acts on behalf of the PBM/payer, are referred to as PBM/payer throughout this guide.
- The term provider vendor in this document refers to both provider vendors and specialty pharmacies completing electronic prior authorizations on behalf of providers.
- The term third-party processor is used to describe the following:
- A third-party that processes prior authorizations (PA) on behalf of the PBM/payer or health plan.
- A health plan that processes their own PAs rather than delegating PA processing to their PBM/payer.
Document References
Please reference the following documents when reading this guide:
Surescripts provided materials |
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Connectivity and Authentication Implementation Guide |
Surescripts Directory Implementation Guide |
Eligibility 2.2 (or later) Companion Guide |
Formulary 2.0 (or later) Companion Guide |
E-Prescribing 6.2 (or later) Companion Guide |
Real-Time Prescription Benefit for PBM/Payers Implementation Guide 1.3 (or later) Implementation Guide |
Error Guidance Supplement - Provides common errors and specific recommendations related to SCRIPT TransactionErrorCodes(s), DescriptionCode(s), and other errors experienced on the network. |
Electronic Prior Authorization Translation Matrix - Provides details on translation between different versions of the Surescripts implementation of the NCPDP SCRIPT standard. |
External materials to be obtained by the customer (available at www.NCPDP.org) |
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NCPDP SCRIPT Standard 2023011 files (please note that the schema files version may change and will not be considered final until published in the Generally Available guide):
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NCPDP SCRIPT Implementation Recommendations (latest version) |
NCPDP External Code List 202301 (NCPDP online tool) |