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.