PBM/Payer Requests Additional Information Using PAResponse
In this example (unrelated to the previous example) a PBM/payer uses the PAResponse message to request additional information from the provider vendor. Specifically, this scenario illustrates a situation where the PBM/payer receives a valid attachment in the provider vendor’s PARequest message—but of a type it cannot process. In response, the PBM/payer asks the provider vendor to provide the information in a different form.
The example below illustrates the following exchange between the provider and the patient’s PBM/payer:
- The provider vendor sends a PARequest containing the completed question set and an attached patient clinical summary in CCD format. The PBM/payer returns a Status response.
- The PBM/payer determines that the supplied attachment was not of the requested type and sends the provider vendor a PAResponse requesting a supported attachment type. The provider vendor returns a Status response.
- The provider vendor sends a PARequest containing an attached patient clinical summary in PDF format. The PBM/payer returns a Status response and then completes the PA process by sending a PAResponse containing approval.
Note: This example only shows these three messages to illustrate the business scenario. There would also be PAInitiationRequest, PAInitiationResponse, Status, Verify, and/or Error messages.
The requested medication is Lovenox (Lovenox 40 MG Per 0.4 ML Prefilled Syringe; RxNorm SBD 854236; NDC 58016487201).
The prior authorization questions to be completed by the prescriber are:
- Is this patient home self-administering? (Y/N)
- Is the medication to be used to treat prophylaxis? (Y/N)
- [IF YES] When was or will the surgery be done? (Date without time portion)
- [Continue to question #6] Is the medication to be used for treatment of DVT? (Y/N)
- [IF YES] What is the patient’s current weight (in pounds)? (Numeric)
- Describe result of warfarin use (include INR and date drawn) or reason why patient can’t use warfarin. You may attach supporting information in a PDF document. (Free text)
This section contains the following examples: