PBM/Payer Requests Additional Information Using PAResponse
2 min
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 parequest (from prescriber – initial submission) docid\ i 98qz1lfslaumcdxuing paresponse (from pbm/payer) docid\ oxhvahcnytcxxev t1xez parequest (from prescriber – additional information submission) docid 1cna4d913p8tcgcpvkorp