Prescription Eligibility for PA Processors (PBM/Payers, Health Plans, and Third-Party Processors)
3 min
prescription eligibility responses (x12 eligibility response (271) messages) it is important that the iin, pcn, and group id from the eligibility response (271) are included in the epa message these ids can be used by surescripts to determine the appropriate entity that should receive a painititiationrequest providing these details helps to ensure that the appropriate entity receives all intended epa messaging the following scenarios would result in surescripts using iin, pcn, and/or group id benefitscoordination/payerid is invalid or corresponds to a payer that is not enabled for epa benefitscoordination/payerid corresponds to a payer that does not process prior authorizations for the requested patient and/or prescription benefit (as indicated by a “co” or “cp” painitiationresponse from the payer) health plans and third party pa processors should work directly with their pbm/payer to ensure that these values are being populated 100% of the time in eligibility response (271) to ensure that all epas will be directed to the appropriate pbm/payer and/or pa processor updating iin/pcn/group ids for directly connected health plans and third party pa processors there are health plans that have decided to use another processor for their prior authorizations in those instances, surescripts requires the plan specific information (iin/pcn/groupid) to be able to route transactions to the correct processor it is imperative that surescripts is notified in advance of any changes or additions to iin/pcn/group id combinations to allow for proper routing of the painitiationrequests notes if a health plan or third party pa processor processes pas for all plans under an individual iin or iin/pcn combination, that may be used in lieu of providing a list of all iin/pcn/group id combinations under the specified iin or iin/pcn please work with a surescripts account manager or open a service ticket for more information