Best Practices

the following best practices apply to all epa message types drugdescription customers should work with their drug database vendors to obtain the preferred drug description the description should align with industry best practice standards as well as surescripts requirements it should be noted that medications that are sent with the same drug name and form may appear slightly different among customers depending on the system’s drug compendia examples prevacid 30 mg oral delayed release capsule prevacid 30 mg dr capsule handling parequests when a health plan changes epa processing vendor in instances where the pbm/payer set the \<deadlineforreply> date occurring after their transition from processing the specific epa, the pbm/payer is still to normally process any epa message received through that date for example, if the pbm/payer sends a question set on 12/30/2019 with a \<deadlineforreply> date of 1/5/2020 and the transition date is 1/1/2020, the epa messages are still to be normally processed by that pbm/payer through 1/5/2020 prescriber order number if the prescriber order number (pon) is available, it is strongly recommended to be sent utilization for non pa coverage rules provider vendors are strongly encouraged to initiate an epa if the target medication has an indication that prior authorization may be required additionally, coverage factors can help to determine when an epa may be required example coverage limit example gender limit the gender limit indicates coverage for females only, but the doctor wants to prescribe for a male patient age limit the age limit indicates a cap at 30 years of age, but the doctor wants to prescribe for a 43 year old patient quantity limit the quantity limit coverage list indicates a coverage limit of 15 days for imitrex, a migraine treatment, but the doctor wants to prescribe a 30 day treatment step medication the step medication list indicates that before bextra (a cox 2 inhibitor) is covered, at least one medication from the cox 1 inhibitor category must be tried (e g ibuprofen), but the doctor wants to prescribe bextra without trying a cox 1 inhibitor first step therapy the step therapy coverage list identifies medications that must be tried before the patient can receive coverage for retin a, a brand of dermatologic preparation used to treat acne, but the patient has already failed treatment with generic topical tretinoin 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 real time prescription benefit solution as the primary source of information regarding the need for prior authorization if this is unavailable, the provider vendor should use formulary as back up alternative 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 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 identifier 271 painitiationrequest iin 2110c1/ref/02 ref/01 = “n6” qualifier benefitscoordination/payeridentification/iinnumber pcn 2110c1/ref/03 ref/01 = “n6” qualifier benefitscoordination/payeridentification/processoridentificationnumber interchange control number isa/13 benefitscoordination/payeridentification/mutuallydefined group number 2110c1/ref/02 ref/01 = “6p” qualifier benefitscoordination/groupid pbm member id 2100c/nm1/09 benefitscoordination/pbmmemberid cardholder id 2100c/ref/02 ref/01 = ”hj” qualifier benefitscoordination/cardholderid pbm participant id 2100a/nm1/09 benefitscoordination/payeridentification/payerid painitiationresponse reason codes for pbm/payers it is recommended to use all reason codes available and not a subset of reason codes see message business flow response summary # for more information the reason code "by – other" should only be used when the reason for the closed response is not covered under another reason code electronic appeals when a pbm/payer chooses to accept electronic appeals for a pa determination, they should make sure to provide as much detail as possible regarding the requirements that apply this could include any of the following within the appeal element a descriptive panote indicating specific information that may be needed from the prescriber in order to return an approved response contact information for the pbm/payer that may indicate where a prescriber can reach out for information on the pa or appeal process a discrete expirationdate that indicates the date after which an appeal will no longer be considered for the pa automatically initiating epa for rxchange messages rxchange messages can be sent from the pharmacy to request changes to a received prescription for rxchange messages with a code of “p” (prior authorization), it is recommended to automatically initiate an electronic prior authorization if eligibility information is less than 72 hours old, provider vendors should include all benefit information from the original eligibility response (271) that is listed in the sending prior authorization initiation requests # section if eligibility information is more than 72 hours old, provider should send a new eligibility request (270) for purposes of populating the benefitscoordination segment of the painitiationrequest re submitting and re initiating painitiationrequests it is recommended that provider vendors allow their users the ability to re submit or re initiate epas in the event of a pbm/payer processing error, or if the deadline for reply has passed if the deadline has passed, the open question set should be cancelled with a pacancelrequest and the original painitiationrequest should be resubmitted with a unique pareferenceid newrx to realize the full value of an epa process, it is strongly recommended that prescriptions requiring a prior authorization are placed on hold and are released to the pharmacy only after a final determination is received from the pbm/payer when the prior authorization is missing, some pbm/payers will deny the claim, which will require manual follow up by the pharmacy if the prescription must be sent prior to the epa process being completed, the provider vendor should indicate it is in process using priorauthorizationstatus with the value of "r" (requested) this will let the pharmacy know that they should not initiate the prior authorization process if the prior authorization has been completed and the pbm/payer indicates prior authorization is not required, the provider vendor should indicate that prior authorization is not required by returning a priorauthorizationstatus value of “n” (not required) in the newrx pa has been approved to aid in claims processing at the pharmacy and eliminate duplicate prior auth workflows, the electronic prescription (newrx) should contain the prior authorization approval number (if provided) and approved status in the epa response message, the approval number is found in the authorizationnumber element in the newrx, prior authorization information is found in medicationprescribed/priorauthorizationnumber and medicationprescribed/priorauthorizationstatus pa has been denied in situations where the prior authorization has been denied by the pbm/payer, the newrx should indicate that the prior authorization was denied in medicationprescribed/priorauthorizationstatus pa has been partially denied when providers receive a partiallydenied paresponse, the request is closed there are two options that may be utilized when a partiallydenied response is received the provider may modify the existing newrx and start a new pa reflecting the revised newrx the other option would be to modify the newrx already on hold to reflect the details approved by the pbm/payer and release the prescription to the pharmacy if releasing the newrx with modified details, the status should reflect “a” (accepted) and, if provided by the pbm/payer, include the authorizationnumber this is not applicable for specialty pharmacies in this type of instance, the specialty pharmacy should notify the prescriber of the response by the pbm/payer and let the prescriber know what they can change if they want to send a new prescription pareferenceid and newrx messageid provider vendors may find it easier to track and associate epa messages with newrx messages by sharing a common identifier provider vendors can utilize a shared value for newrx messageid and pareferenceid of painitiationrequest messages in order to provide efficiencies for troubleshooting and other tasks that may require knowledge of which newrx had association with which epa attachments surescripts accelerator supports the sending of pdf attachments it is recommended that provider vendors enable this functionality to allow additional documentation to be included with prior authorization requests only send an attachment if the question set specifically asks for it if you do not receive a request for an attachment, do not send one sending unnecessary attachments may result in manual review and delays message size (including attachments) is limited to a maximum of 20mb pbm/payers and provider vendors should allow users to view and send pdfs, at a minimum, to keep the prior authorization workflow electronic however, pbm/payers should populate the questionset/header/questionsetcontactcommunicationnumber/fax/number field in epa response messages so provider vendors know where to fax any requested attachments they are unable to send electronically if an attachment must be sent through fax, the fax should include the pacaseid from the painitiationresponse to aid in linking it to the electronic messages the provider vendor should also include in the questionsetcomment field of the parequest that they are faxing documentation ndc codes provider vendors should send the representative national drug code (ndc) of the medication, if available, in the painitiationrequest the ndc is not required by the ncpdp standard, but pbm/payers may do additional validation on this field or may return errors if not included sending the ndc can help ensure that the medication can be easily identified in the pbm/payer system a representative ndc is an 11 digit code that depicts a category of medication regardless of package size and manufacturer/labeler representative ndcs should be used in the pa process to maximize the opportunity that the selected value exists among the various medication files a representative ndc should not be a repackaged, obsolete, private label, or unit dose ndc unless it is the only available identifier note the drug database compendia should be current so the most applicable ndc available for the requested medication can be sent pbm/payers should not expect that provider vendors are always populating the ndc in the painitiationrequest and should consider additional medication matching logic in cases when the ndc is not populated surescripts may verify ndcs included in painitiationrequest messages in the case of an obsolete ndc being discovered upon verification, surescripts may replace the original ndc with a non obsolete representative ndc when surescripts replaces ndcs, surescripts will provide notice of the change to the prescriber via the panote in the corresponding painitiationresponse empty tags do not send empty elements within xml messaging sending empty tags may cause a message to be rejected or error out controlled substances provider vendors are able to use electronic prior authorization for controlled substances even if they are currently not enabled for epcs on the surescripts network there are no prohibitions in the ncpdp script standard regarding the use of epa for controlled substances however, if the newrx has been placed on hold, the release of such prescriptions should not be automated any epcs prescriptions must continue to adhere to dea audit requirements including the support of two factor authentication and ensuring that only providers with a dea license are permitted to issue such prescriptions