PBM/Payer Requirements

PA.215: If the PBM/health plan receives a PAInitiationRequest or PARequest that contains a PAPriorityIndicator of "X" (expedited), the PBM/health plan shall process the request and respond in an expedited manner. If the PAInitiationRequest or PARequest needs to be manually reviewed for priority, then the PBM/health plans shall make the priority indicator available for display.

PA.216: If the provider vendor populates the Provider composite, the PBM system shall make the Provider composite contents available to be viewed by the user.

PA.217: The PBM/payer system shall make available for display the QuestionSetComment from the PARequest and the PAAppealRequest if the prior authorization request would otherwise be denied or approved with modifications.

PA.218: The PBM/payer system shall only send one PAResponse with a status of 'InProcess' and include the ExpectedResponseDate and/or PANote. This PAResponse is to be followed by a subsequent PAResponse with the final determination or request for additional information.