Prior Authorization Use Cases

the prior authorization gateway supports two use cases pharmacy direct submit prior authorizations – pharmacy initiates and submits the prior authorization on behalf of the provider pharmacy prior authorization notification – pharmacy creates a notification that contains the necessary patient and prescription information to generate a trx code that is delivered to the provider to complete the prior authorization note trx codes are delivered to a provider to retrieve and quickly submit an electronic prior authorization from the prior authorization gateway add new pa each prior authorization use case begins by selecting add new pa from the top navigation to enter the related prescriber, patient, and prescription information prescriber search creating a new prior authorization begins with selecting the prescriber the prescriber search requires an npi users can access the nppes npi registry https //npiregistry cms hhs gov/ to search by prescriber name to find the npi users will enter the npi and click search for prescriber the prescriber location and fax number are then selected note the fax number of the location selected will be used to deliver the prior authorization with the associated trx code when creating a pa notification if a location with an appropriate fax number is not listed, a new location can be added by clicking on add new prescriber location patient search full demographic patient information is required to identify benefit coverage enter the required data fields and click search for patient coverage information for the patient will be returned select the plan / pbm where the prior authorization will be processed and click confirm the coverage note if a patient has dual coverage, a list of each individual plan information will be displayed for selection users can manually enter benefit information when coverage is not found for the patient prescription information the medication, quantity, days supply, and sig are required prescription information users can enter the medication name in the medication search to select the quantity unit of measure will default based on the selected medication the quantity and days supply of the prescription can then be entered the sig is also required and can be updated click confirm prescription after the prescription information is entered pharmacy information users are associated to at least one pharmacy the pharmacies associated to the user will be available to select and assign to the prior authorization if only one pharmacy is associated to a user, it will be selected by default and the pharmacy selection will be bypassed the pharmacy associated to the prior authorization is displayed on the left navigation card users can click confirm pharmacy or select review and send… to continue to the final process of selecting the use case to use to initiate the prior authorization prior authorization review and use case selection users will be required to select the use case for how the prior authorization will be initiated and processed direct submit – the pharmacy initiates, completes the required question set on behalf of the provider, and submits the prior authorization for a determination send pa notification – the pharmacy creates a notification that contains the necessary patient and prescription information to generate a trx code that is delivered to the provider’s office to complete the prior authorization direct submit summary prior authorization notification summary note trx codes are faxed to a provider location and can be used to submit the electronic prior authorization provider users need to create an account in the prior authorization gateway before they can use the trx code to complete the prior authorization