Sending Prior Authorization Initiation Requests

A PAInitiationRequest should only be sent when it is reasonable to expect that the selected medication requires a prior authorization. A PAInitiationRequest should not be sent for every medication. Provider vendors should use the details from the formulary and (if implemented) Real-time Prescription Benefit solutions as the primary source of information regarding the need for a prior authorization.

Unlike other messages, Surescripts does not require provider vendors to determine ePA support by the PBM/payer. Provider vendors can initiate a PAInitiationRequest, no matter who the patient’s PBM/payer is, whenever the provider has reason to believe that the medication requires a PA. All PAInitiationRequests should be addressed to EPAINI.

Provider vendors shall send information (Payer ID, IIN (previously BIN), PCN, etc.) from the Eligibility Response in all PAInitiationRequests. See ACR PA.206 in the Application Certification RequirementsApplication Certification Requirements section for more information.

At a minimum, the PayerID (the Surescripts PBM Participant ID) is needed for Surescripts to be able to determine if the PBM/payer is enabled for ePA. If the provider vendor does not send a PayerID, Surescripts will return an error. In order to maximize the potential for a positive ePA response, the provider vendor needs to send all available fields referenced in the table below.