Message Business Flow Response Summary

the following table shows details on how a customer should respond to certain business scenarios using the appropriate message type, reason code, and response text when applicable this table does not represent all codes note error codes are constrained by the schema reason code "by" (meaning other) should only be used when there is not a more explicit reason code available event id event response message type response status (responsestatus element) reason code (response status reasoncode) standard response text (responsestatus panote) comments pa initiation initiation main flow pbm/payer returns a pa question set in response to a syntactically valid painitiationrequest message from the provider system 1 1 provider system submits a valid painitiationrequest message to a pbm/payer pbm/payer returns a question set to be completed by the prescriber painitiationresponse open n/a n/a alternative flows in response to a syntactically valid pa initiation message from the provider system 1 2 prior authorization is not needed for this patient and medication painitiationresponse closed cc prior authorization not required for patient/medication 1 3 the patient in the request not recognized by the pbm/payer painitiationresponse closed cd cannot find matching patient 1 4 the patient in the request is not covered by the pbm/payer painitiationresponse closed ce patient not eligible (does not have coverage with the pbm/payer) 1 5 requested pa is a duplicate of one that has already been approved pbm/payer responds with information about the previously submitted request painitiationresponse closed cf prior authorization duplicate/approved 1 6 requested pa is a duplicate of another in process request painitiationresponse closed cg prior authorization duplicate/in process 1 7 prescriber for pa request is not allowed to submit painitiationresponse closed cm prescriber not allowed to submit pa request 1 8 the receiving pbm/payer is not the pa processor for this patient painitiationresponse closed co the receiver is not the pa processor for this patient the responder should include text providing information about how to contact the third party processor, if known when the pbm/payer returns this reason code, surescripts will try to determine the third party processor for the pa and generate a 2nd painitiationrequest if one is found 1 9 prescriber for pa request is not allowed to submit painitiationresponse closed cm prescriber not allowed to submit pa request 1 10 the receiving pbm/payer does not process pa for this patient and medication combination painitiationresponse closed cp the receiver is not the pa processor for this patient and medication combination the responder should include text providing information about how to contact the third party processor, if known when the pbm/payer returns this reason code, surescripts will generate a 2nd painitiationrequest to try and determine the third party processor for the pa 1 11 requested pa is a duplicate of another denied request painitiationresponse closed cy prior authorization duplicate/denied 1 12 prior authorization is not available for this drug/product under patient’s plan painitiationresponse closed fm product not covered by this plan prior authorization not available (used when the drug will not be covered even if the provider does a pa) 1 13 prior authorization is not required for the prescription amount painitiationresponse closed fn prescription within prescribing limits prior authorization not required for patient/medication (used when there are coverage rules in place, but the prescriber is not going outside of them) 1 14 patient’s plan will pay for the drug up to certain coverage limits for quantity and/or days supply painitiationresponse closed fo coverage limits may exist for quantity and/or days supply plan will pay up to coverage limit prior authorization not required for patient/medication (used when the plan will only pay up to a certain amount, but not above) if the pbm/health plan is going to send this, include details about the coverage limit in the panote 1 15 coverage limits have been exceeded and exceptions cannot be made if prescribing within limits, pa is not required painitiationresponse closed fp coverage limits have been exceeded, exception not available prior authorization not required for patient/medication when within coverage limit 1 16 there is an active pa on file for this patient/medication combination painitiationresponse closed fq active pa on file 1 17 the product code submitted in the pa is not valid painitiationresponse closed fr submitted product code is not valid please resolve and resubmit 1 18 the receiving pbm/payer does not support epa in this case painitiationresponse closed bx electronic prior authorization not currently supported by pbm/payer for this health plan/disease state/medication submit via other methods bx should only be used when the pbm/payer is the prior authorization processor, but epa is not available for that health plan or drug 1 19 other business exception for example version of icd diagnosis code sent is not supported or duplicate message, denied painitiationresponse closed by other not covered by other values the responder should include text describing the exception surescripts will send a closed response with a reason code by and a note ‘sorry but surescripts cannot process this pa request electronically please refer to the original instructions from the pbm for information on how to process this prior authorization manually parequest parequest main flow pbm/payer approves the pa (solicited epa workflow) in response to a syntactically valid parequest message from the provider system 2 1 provider system submits a valid parequest message to a pbm/payer pbm/payer returns its approval paresponse approved n/a n/a alternative flows in response to a syntactically valid parequest message from the provider system 2 2 denied response paresponse denied n/a 2 3 the pbm/payer requires additional information from the provider it responds with a message containing a question set with additional questions paresponse (including another question set) open n/a 2 4a answer in parequest is incomplete or invalid pbm/payer asks again paresponse (including another question set) open n/a the responder should indicate the question at issue 2 4b a notification that the request is in process, including the expected resolution date if known paresponse inprocess n/a 2 4c a notice indicating that the prior authorization has been approved by the payer, but with some limits these limits may include pharmacy type, quantity, days supply, number of cycles, or refills paresponse partiallydenied n/a 2 4d answer in parequest is incomplete or invalid pbm/payer closes the case paresponse closed cn response content is inconsistent with the question the responder should indicate the question at issue provider needs to open a new case 2 5a message attachment is valid, but the pbm/payer doesn't support the attachment type pbm/payer requests that the provider system provide the information in a different form, using another question set paresponse open n/a the pbm/payer should suggest a different way for the provider to provide the information 2 5b message attachment is valid, but the pbm/payer doesn't support the attachment type pbm/payer processes the request ignoring the attachment, if it is not needed paresponse pbm/payer processes normally pbm/payer processes normally 2 6a parequest was received after the deadlineforreply stated in the associated painitiationresponse message the pbm/payer closes the pa case paresponse closed by other not covered by other values message received after deadline to reply \[plus any additional text from the pbm/payer] 2 6b parequest was received after the deadlineforreply stated in the associated painitiationresponse message the pbm/payer ignores the date and processes anyway paresponse pbm/payer processes normally pbm/payer processes normally 2 7 after submitting a parequest message, but before the pbm/payer has responded with a paresponse, the provider requests by means other than the pa cancel request message that their case be closed the pbm/payer returns a paresponse message indicating the case was closed by the provider paresponse closed cj closed by provider 2 8 after the provider submits a parequest message, but before the pbm/payer has responded with a paresponse, the patient contacts the pbm/payer by phone or other means and requests that the case be closed the pbm/payer returns a paresponse message indicating the case was closed by the member paresponse closed ck closed by member 2 9 requested pa is a duplicate of one that has already been approved pbm/payer responds with information about the previously submitted request paresponse closed cf prior authorization duplicate/approved 2 10 requested pa is a duplicate of another in process request paresponse closed cg prior authorization duplicate/in process 2 11 pbm/payer is not able to accept the request from the prescriber identified in the parequest message paresponse closed cm prescriber not allowed to submit parequest 2 12 other business exception paresponse closed by other not covered by other values the responder should include text describing the exception 2 13 the pbm/health plan/processor closes the case for an undefined reason paresponse closed ch – closed by pbm/health plan/processor the responder should include text describing the closed reason 2 14 the pbm/health plan closes the case due to communication with the member paresponse closed ck – closed by member the responder should include text describing the closed reason 2 15 the pbm/health plan/processor does not accept the attachment type sent by the submitter paresponse open cl – attachment type (mime type) type not supported the responder should avoid sending this reason code if possible and should instead return an open response indicating that the originally provided attachment is not supported by the receiver responders may not return an error if an unsupported attachment type is received all attachment types supported by the ncpdp epa standard must be received without error, per acr pa 212 2 16 requested pa is a duplicate of another denied request paresponse closed cy prior authorization duplicate/denied 2 17 provider responded after deadline to reply pa must be reinitiated paresponse closed fl provider responded after deadline to reply pa must be reinitiated 2 18 prior authorization is not available for this drug/product under patient’s plan paresponse closed fm product not covered by this plan prior authorization not available (used when the drug will not be covered even if the provider does a pa) 2 19 prior authorization is not required for the prescription amount paresponse closed fn prescription within prescribing limits prior authorization not required for patient/medication (used when there are coverage rules in place, but the prescriber is not going outside of them) 2 20 patient’s plan will pay for the drug up to certain coverage limits for quantity and/or days supply paresponse closed fo coverage limits may exist for quantity and/or days supply plan will pay up to coverage limit prior authorization not required for patient/medication (used when the plan will only pay up to a certain amount, but not above) if the pbm/health plan is going to send this, include details about the coverage limit in the panote 2 21 coverage limits have been exceeded and exceptions cannot be made if prescribing within limits, pa is not required paresponse closed fp coverage limits have been exceeded exception not available prior authorization not required for patient/medication when within coverage limit 2 22 there is an active pa on file for this patient/medication combination paresponse closed fq active pa on file 2 23 the product code submitted in the pa is not valid paresponse closed fr submitted product code is not valid please resolve and resubmit pa appeal pa appeal main flow pbm/payer approves the appeal in response to a syntactically valid paappealrequest message from the provider system 3 1 provider system submits a valid paappealrequest message to a pbm/payer pbm/payer returns its approval pa appeal response approved n/a n/a alternative flows in response to a syntactically valid pa appeal message from the provider system 3 2 denied response pbm/payer returns its denial pa appeal response denied n/a 3 3 pbm/payer requests additional information pbm/payer returns a request for additional information (by including a question set in its response) pa appeal response open n/a 3 4a answer in pa appeal request is incomplete or invalid pbm/payer asks again pa appeal response (including another question set) open n/a the responder should indicate the question at issue 3 4b answer in pa appeal request is incomplete or invalid pbm/payer closes the case pa appeal response closed cn response content is inconsistent with the question the responder should indicate the question at issue 3 5 the provider submits a pa appeal request for a case where electronic appeal is not available the pbm/payer notifies the provider system that electronic appeal is not available for this case pa appeal response closed by other not covered by other values electronic appeals are not supported for this case \[plus any additional text from the pbm/payer] 3 6a pa appeal request was received after the deadlineforreply stated in an earlier paappealresponse message the pbm/payer closes the pa appeal case pa appeal response closed by other not covered by other values message received after deadline to reply \[plus any additional text from the pbm/payer] 3 6b pa appeal request was received after the deadlineforreply stated in an earlier paappealresponse message the pbm/payer ignores the date and continues to process pa appeal response pbm/payer processes normally pbm/payer processes normally 3 7 after the provider submits a parequest message, the patient contacts the pbm/payer by phone or other means and requests that the case be closed the pbm/payer returns a pa appeal response message indicating the case was closed by the member pa appeal response closed ck closed by member 3 8 requested pa is a duplicate of one that has already been approved pbm/payer responds with information about the previously submitted request pa appeal response closed cf prior authorization duplicate/approved 3 9 requested pa is a duplicate of another in process request pa appeal response closed cg prior authorization duplicate/in process 3 10 pbm/payer is not able to accept the request from the prescriber identified in the parequest message pa appeal response closed cm prescriber not allowed to submit parequest 3 11 other business exception pa appeal response closed by other the responder should include text describing the exception 3 12 the pbm/payer/health plan/processor closes the case for an undefined reason pa appeal response closed ch closed by pbm/health plan/processor the responder should include text describing the closed reason 3 13 the pbm/payer/health plan/processor does not accept the attachment type sent by the submitter pa appeal response open cl attachment type (mime) type not supported the responder should not send this reason code all attachment types supported by the ncpdp epa standard must be received without error, per acr pa 212 pa cancel pa cancel main flow pbm/payer successfully cancels the pa case in response to a syntactically valid pacancelrequest message from the provider system 4 1 provider system submits a valid pacancelrequest message to a pbm/payer pbm/payer returns its approval of the pa cancel request pa cancel response approved n/a n/a alternative flows in response to a syntactically valid pacancelrequest message from the provider system 4 2 pa case id was not found by the pbm/payer pa cancel response denied bz can’t find pacaseid 4 3 the pbm/payer is unable to locate a case matching the submitted case id and patient information pa cancel response denied ca unable to locate based on insufficient information/identifiers do not match 4 4 the provider submits a pa cancel request for a case that has already been determined pa cancel response denied cb request already processed/final determination has been made 4 5 other business exception pa cancel response denied by other not covered by other values the responder should include text describing the exception