NewRx
To realize the full value of an ePA process, it is strongly recommended that prescriptions requiring a prior authorization are placed on hold and are released to the pharmacy only after a final determination is received from the PBM/payer. When the prior authorization is missing, some PBM/payers will deny the claim, which will require manual follow-up by the pharmacy.
- If the prescription must be sent prior to the ePA process being completed, the provider vendor should indicate it is in process using PriorAuthorizationStatus with the value of "R" (requested). This will let the pharmacy know that they should not initiate the prior authorization process.
- If the prior authorization has been completed and the PBM/payer indicates prior authorization is not required, the provider vendor should indicate that prior authorization is not required by returning a PriorAuthorizationStatus value of "N" (Not Required) in the NewRx.
PA Has Been Approved
To aid in claims processing at the pharmacy and eliminate duplicate prior auth workflows, the electronic prescription (NewRx) should contain the prior authorization approval number (if provided) and approved status. In the ePA response message, the approval number is found in the AuthorizationNumber element. In the NewRx, prior authorization information is found in MedicationPrescribed/PriorAuthorizationNumber and MedicationPrescribed/PriorAuthorizationStatus.
PA Has Been Denied
In situations where the prior authorization has been denied by the PBM/payer, the NewRx should indicate that the prior authorization was denied in MedicationPrescribed/PriorAuthorizationStatus.
PA Has Been Partially Denied
When providers receive a PartiallyDenied PAResponse, the request is closed. There are two options that may be utilized when a PartiallyDenied response is received. The provider may modify the existing NewRx and start a new PA reflecting the revised NewRx. The other option would be to modify the NewRx already on hold to reflect the details approved by the PBM/payer and release the prescription to the pharmacy. If releasing the NewRx with modified details, the status should reflect "A" (Accepted) and, if provided by the PBM/payer, include the AuthorizationNumber. This is not applicable for specialty pharmacies. In this type of instance, the specialty pharmacy should notify the prescriber of the response by the PBM/payer and let the prescriber know what they can change if they want to send a new prescription.
PAReferenceID and NewRx MessageID
Provider vendors may find it easier to track and associate ePA messages with NewRx messages by sharing a common identifier. Provider vendors can utilize a shared value for NewRx MessageID and PAReferenceID of PAInitiationRequest messages in order to provide efficiencies for troubleshooting and other tasks that may require knowledge of which NewRx had association with which ePA. Please see Message LinkageMessage Linkage for more detail.