PBM/Payer Development and Integration

medication and patient matching the painitiationrequest might not include the pbm member id in all cases pbm/payers must develop secondary patient matching criteria to successfully find the patient unmatchable patients may go into to a manual queue for the pbm/payer, or the painitiationrequest may be responded to with an automated “patient not found” response work queue there are several instances where prior authorizations might need to be manually worked medication cannot be matched provider vendor sends an attachment denials and other cases where you are contractually or regulatory obliged to send to a manual queue exceptions and medicaid process pbm/payers should avoid generic prior authorization forms whenever possible however, a generic form may be acceptable in some situations, such as for medicaid formulary exceptions or quantity and gender limit exceptions workflow and internal process pbm/payers should consider sending coded references (e g loinc codes) along with questions in a question set this will allow the provider vendor to extract information from the patient's record instead of manually answering each question handling prior authorization priority with script version 2023011 ncpdp supports a priority flag field called papriorityindicator please see the painitiationrequest elements docid\ janghwpo1abnysw9lvjc6 for details service date as there is no discrete servicedate field in the painitiationrequest, pbm/payers should treat the painitiationrequest message senttime field as the de facto service date of the message