Message Descriptions

prior authorizations have two possible message flows solicited and unsolicited in the solicited model, the provider vendor notifies the pbm/payer that they wish to start the prior authorization process to determine if an authorization is needed for the patient and desired medication in the unsolicited model, the provider vendor presumes that an authorization is needed and submits the information they anticipate the pbm/payer needs provider vendors and pbm/payers are required to support all message types outlined below painitiationrequest in the solicited model, this message is used by the provider vendor to initiate the prior authorization process by notifying the pbm/payer of the patient and the medication for which prior authorization is being requested, along with the provider vendor’s information and other related details provider vendors are encouraged to include any available relevant information when populating the painitiationrequest to receive the timeliest decision possible the more detail provided up front, the less the pbm/payer must come back and ask for later painitiationresponse in the solicited model, the pbm/payer returns a painitiationresponse after receiving the painitiationrequest this message could contain either a set of questions established by the pbm/payer for the prior authorization or a request for information sent in lieu of the question set if no pa is required, the pbm/payer sends a closed painitiationresponse without a question set a painitiationresponse should be returned for each painitiationrequest note for prior authorization renewal requests (unsolicited painitiationresponse), the pbm/payer does not receive a painitiationrequest before sending the painitiationresponse the pbm/payer sends the painitiationresponse to electronic prior authorization initiate (epaini) and surescripts performs a provider lookup to identify the receiving surescripts provider identification (spi) the painitiationresponse from the payer should identify all information required to complete the pa determination this allows a determination to be made in one exchange of the parequest and response messages the painitiationresponse is for the medication (name, strength, and dosage form) indicated in the painitiationrequest when responding, the pbm/payer should not alter the values indicated in the painitiationrequest (e g , replying with a generic product equivalent to brand product) with the availability of the prior authorization renewal request (also known as the unsolicited painitiationresponse), this allows pbm/payers to send a question set for an expiring pa case if the ehr is not certified to receive this, surescripts will attempt to deliver the question set to a pa gateway worklist if this option is also not available, surescripts will send a pdf notification of the renewal via clinical direct message or fax parequest the provider vendor presents questions for the provider to answer and/or extracts information from the patient’s electronic medical record, then sends the information to the pbm/payer in the parequest message paresponse the pbm/payer determines whether an authorization can be granted and provides the determination to the provider vendor in the paresponse message this message may indicate that the pbm/payer needs additional information to make a decision if needed the payer will also indicate whether it supports electronic appeals for this case provider vendors implementing an epa solution should ensure that they have determined how they will support all possible response statuses (approved, denied, partially denied, in process, open, or closed) paappealrequest the paappealrequest message enables the provider vendor to obtain the information required to submit an appeal the paappealrequest message also enables the provider vendor to submit the appeal information for a prior authorization determination note paappealrequest should only be sent when the iseappealsupported flag is set to “1” in the paresponse paappealresponse the paappealresponse message provides information from the pbm/payer to the provider vendor on what is needed for an appeal the paappealresponse message is also used by the pbm/payer to indicate the outcome of an appeal in some cases, the paappealresponse message may indicate that the pbm/payer needs additional information in order to make a decision pacancelrequest the provider vendor sends the pacancelrequest to a pbm/payer to indicate that they are no longer pursuing their most recent request this can be sent any time after the painitiationresponse with the pacaseid is received by the provider vendor the provider vendor should ensure that, if changes are permitted to a prescription with an associated pa, the prescription and pa remain in sync if a prescription changes, the original pa should be cancelled a determination should be made as to whether a new pa is needed based on the new prescription details note pacancelrequest messages should only be sent for pa cases that are still considered open and valid at the pbm/payer if a closed painitiationresponse, paresponse, or paappealresponse determination has been returned to the provider vendor, a pacancelrequest should not be sent to the pbm/payer pacancelresponse the pbm/payer sends the pacancelresponse to a provider vendor to indicate whether the parequest was canceled this is only sent if a pacancelrequest is sent by the provider vendor to the pbm/payer panotification the panotification message is used to notify the provider vendor or pharmacy vendor of the status of the prior authorization panotification is a one way, information only message that can be sent from the pharmacy to the provider or from the provider to the pharmacy this message is required for customers using ncpdp script messages panotification messages close the communication gap at the pharmacy of the status of the prior authorization and reduce duplicate prior authorization workflows note notification of the prior authorization status also occurs via the newrx or rxchange transaction