Alternate RxChange Workflows for Prior Authorization

workflow overview surescripts provides multiple workflows to enable pharmacies to automate the retrospective prior authorization process the preferred workflow is when both the pharmacy and the prescribing system have implemented the ncpdp rxchange message alternatively, when the prescriber is not rxchange enabled, surescripts uses the structured data from the rxchangerequest message to allow the prescriber to complete the prior authorization process electronically using surescripts prior authorization portal the alternate workflow provides benefits to the pharmacy rxchange for prior authorization workflow when communicating with prescribers who have not yet implemented rxchange including improved pa turnaround time using electronic prior authorization (epa) provides pa determination to pharmacies using rxchangeresponse to close the loop alternate workflows surescripts supports two alternate rxchange for priorauthorization workflows in one workflow, surescripts performs the enablement check, and in the other, the pharmacy performs the check the following are the steps for each workflow surescripts determines route – rxchangerequest to generic spi (recommended) surescripts determines whether to route the rxchangerequest electronically or by fax in this workflow the pharmacy sends the rxchangerequest to a generic spi and surescripts determines what the delivery route should be if the prescriber is enabled, the message is delivered electronically, and if not the message is converted to fax note surescripts uses a generic faxing template a pharmacy specific branding template is available upon request in some instances the fax template provides instructions for using surescripts prior authorization portal, and it also outlines other options available to prescribers for responding to the pa notifications pharmacy processes the prescription and identifies the need for prior authorization pharmacy sends surescripts an rxchangerequest to spi “0000000000000” (a generic spi) note surescripts requires the pharmacy to send the provider’s fax number pharmacies should review fax number accuracy on a regular basis and have a secondary process in place if the fax process fails if the rxchangerequest is related to a newrx, include the benefitscoordination from the newrx pharmacy should always send the iinnumber (formerly bin) the pharmacy should always send the processoridentificationnumber (pcn), if known surescripts attempts to match the provider demographics in the rxchangerequest to a provider with an rxchange service level in the surescripts directory a if surescripts finds a match i surescripts sends the rxchangerequest to the provider’s rxchange enabled spi ii prescribing vendor receives the rxchangerequest and initiates the prior authorization with the pbm (pharmacy benefit manager)/payer identified in the benefitscoordination composite note if the spi is not epa enabled, surescripts can append the note field with a transaction (trx) code on behalf of the sending pharmacy this trx code can be used by the prescriber to complete the prior authorization within surescripts prior authorization portal the trx code with the portal url will be appended to the note field only if there are available characters per the schema surescripts will not edit or remove any existing pharmacy notes the trx code will only be added to the note field from pharmacies that have opted into this service iii prescribing vendor completes the epa process with the pbm/payer iv prescribing vendor sends an rxchangeresponse to the pharmacy via surescripts and notes whether the prior authorization was approved or denied b if surescripts does not find a match i surescripts faxes a prior authorization notification including directions for completing the pa to the prescriber using the pharmacy provided fax number the fax includes a surescripts generated unique trx code which can be used to retrieve and initiate the pa on surescripts prior authorization portal so it can be completed electronically note once surescripts generates the unique trx code, the prescriber has seven days to sign into surescripts prior authorization portal to complete the pa the trx code expires after that time ii if the prescriber chooses surescripts prior authorization portal, the prescriber uses the unique trx code that is found on the fax to initiate the pa iii once the epa process is complete, surescripts sends an rxchangeresponse to the pharmacy with an approval/denial response and the authorization number, if applicable iv the rxchangeresponse is addressed from 8398058138001, not the generic spi the pharmacy initially addressed the rxchangerequest to note in cases where the prescriber does not complete the pa using surescripts electronic prior authorization or prior authorization portal, surescripts cannot send an rxchangeresponse as the ncpdp standard does not have an appropriate reason when the outcome of the pa is unknown pharmacies should utilize a secondary process for notifying the prescriber if they do not receive an rxchangeresponse after 48 hours pharmacy checks directory to determine route – surescripts faxes the pharmacy checks the surescripts directory to determine the prescriber’s rxchange enablement if the prescriber has the rxchange service level, the pharmacy follows the normal flow and sends the message electronically if not, surescripts converts the message to fax note surescripts uses a generic fax template a pharmacy specific branding template is available upon request in some instances the fax template provides instructions for using surescripts prior authorization portal, and it also outlines other options available to prescribers for responding to the pa notifications pharmacy processes the prescription and identifies the need for prior authorization pharmacy attempts to match the provider demographics to a provider with an rxchange service level in the surescripts directory a if the pharmacy finds a match i the pharmacy sends the rxchangerequest to the prescriber’s rxchange enabled spi and follows the normal rxchange workflow note if the spi is not epa enabled, surescripts can append the note field with a transaction (trx) code on behalf of the sending pharmacy this trx code can be used by the prescriber to complete the prior authorization within surescripts prior authorization portal the trx code with the portal url will be appended to the note field only if there are available characters per the schema surescripts will not edit or remove any existing pharmacy notes the trx code will only be added to the note field from pharmacies that have opted into this service b if the pharmacy does not find a match or if the provider is not in the surescripts directory i the pharmacy sends surescripts an rxchangerequest to spi “0000000000000” (a generic spi) note surescripts requires the pharmacy to send the provider’s fax number in the rxchangerequest ii if the rxchangerequest is related to a newrx, include the benefitscoordination from the newrx pharmacy should always send the iinnumber (formerly bin) the pharmacy should always send the processoridentificationnumber (pcn), if known iii surescripts attempts to match the prescriber demographics to a prescriber with an rxchange service level in the surescripts directory c if surescripts finds a match i follow step 4a in the surescripts determines route – rxchangerequest to generic spi (recommended) docid\ l3s6vkubx5ercsnnjmpgf section d if surescripts does not find a match i follow step 4b in the surescripts determines route – rxchangerequest to generic spi (recommended) docid\ l3s6vkubx5ercsnnjmpgf section key elements of the rxchangerequest pharmacies sending the rxchangerequest to the generic surescripts spi “0000000000000" are required to send valid rxchange transactions the requirements in this section define elements required to be included in the transaction for this workflow this may include data that is now optional in the schema, or explains what data is required for the actual field refer to the schema for additional requirements fields listed in the table below are required if applicable fields are not sent, it may prevent the rxchange from being processed properly refer to the ncpdp script schema listed in document references for a complete list of fields element name comments header to the identification of the intended receiver of the message to must be populated with spi “0000000000000” (a generic spi) patient humanpatient address \<font color="#000000"> \</font> addressline1 contains the patient’s demographic information city contains the patient’s demographic information state contains the patient’s demographic information zipcode contains the patient’s demographic information prescriber fax number contains the prescriber’s fax number in at least one element benefits coordination note the pharmacy should include the information for the pbm/payer who rejected the claim payeridentification contains the pbm/payer’s surescripts participant id iinnumber contains the health plan’s card issuer id or issuer identification number processoridentificationnumber contains the health plan’s pcn, if known groupid contains the health plan’s group number, if available key elements of the rxchangeresponse this section outlines some of the key elements on the rxchangeresponse for the prior authorization workflow these elements are sent to the pharmacy to provide visibility into the outcome of the prior authorization refer to the ncpdp script schema listed in document references for a complete list of elements element name comments medication prescribed priorauthorization prescribing vendor systems should send the prior authorization number, if provided by the pbm/payer priorauthorizationstatus the status of the prescription’s prior authorization as known by the sender