Detailed Electronic Prior Authorization Message Scenarios

the following diagrams depict various scenarios where verify, error, and status messages are sent in response to a prior authorization message note this applies to any of the epa messages for all of these scenarios surescripts detailed electronic prior authorization message flow scenarios note in the following scenarios, any messages sent from the provider vendor after the painititiationrequest should utilize the sender id of the received message to populate the receiver id of the response scenario 1 surescripts cannot recognize message 1a) a pa message is sent to surescripts 1b) surescripts cannot recognize the message and sends error text back to the provider vendor scenario 2 surescripts recognized message format but errors found 2a) a pa message is sent to surescripts 2b) surescripts recognizes the format as ncpdp but finds errors in the message surescripts returns an error message scenario 3 pbm/payer cannot recognize message 3a) a pa message is sent to surescripts 3b) surescripts forwards the message on to the pbm/payer 3c) the pbm/payer cannot recognize the message and sends error text to surescripts 3d) surescripts creates an error message and returns it to the provider vendor scenario 4 pbm/payer validates message and returns status (code 010) 4a) a pa message is sent to surescripts 4b) surescripts forwards the message on to the pbm/payer 4c) the pbm/payer validates the message and returns a status (code 010) message to surescripts status (code 010) is a synchronous message and means the message was accepted by ultimate receiver 4d) surescripts forwards the status (code 010) message back to the provider vendor scenario 5 pbm/payer validates message and returns error message 5a) a pa message is sent to surescripts 5b) surescripts forwards the message on to the pbm/payer 5c) the pbm/payer validates the message, finds errors in the message, and returns an error message to surescripts 5d) surescripts forwards the error message back to the provider vendor scenario 6 pbm/payer returns status (code 000) and message results in error 6a) a pa message is sent to surescripts 6b) surescripts forwards the message on to the pbm/payer 6c) the pbm/payer validates the message and returns a pending status (code 000) message to surescripts 6d) surescripts forwards the pending status (code 000) message back to the provider vendor 6e) the pbm/payer fails trying to process message and initiates a new error message (sometimes referred to as a free standing error) to surescripts 6f) surescripts forwards the error message to the provider vendor 6g) the provider vendor acknowledges the error by returning a verified status (code 010) message to surescripts 6h) surescripts forwards the verified status (code 010) message to the pbm/payer scenario 7 pbm/payer returns status (code 000) and message is accepted 7a) a pa message is sent to surescripts 7b) surescripts forwards the message on to the pbm/payer 7c) the pbm/payer validates the message and returns a status (code 000) message to surescripts in this case the message has not reached its ultimate destination 7d) surescripts forwards the status (code 000) message back to the provider vendor 7e) the pbm/payer delivers the pa message to the end point and returns a verify message 7f) surescripts forwards the verify message to the provider vendor 7g) the provider vendor acknowledges the verify message by returning status (code 010) to surescripts status (code 010) means it was accepted by the ultimate receiver 7h) surescripts forwards the status (code 010) message to the pbm/payer note where the status message is used, the status code can be either 000 – transmission successful or 010 – successfully accepted by ultimate receiver status (code 000) indicates that there could be an error or verify message forthcoming if an error or verify message is not received following status (code 000), then no assumptions should be made as to whether the message has been received successfully or not status (code 010) indicates that no further messages will follow