PrognoCIS Help: Electronic Prior Authorization

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Introduction to Electronic Prior Authorization (ePA): Electronic Prior Authorization (ePA) integrates directly with EHR and Pharmacy software, enabling prescribers, specialty pharmacists, and technicians to quickly and easily obtain prior authorizations so patients can start their medications sooner and prescribers can have a hassle-free ePrescription process. PrognoCIS EMR now supports Electronic Prior Authorization (ePA) via Surescripts.

Prerequisites to enable the ePA service for a medic:

The ePriorAuthorization checkbox available under the Surescripts Services section on the Register eRx Provider popup, invoked by clicking the eRx button on the Medic Master (Navigation for the Medic Master (Provider): Go to Settings → Configuration → Users → Providers) should be checked.
The Product ePA with the appropriate roles — View, Prepare, and Submit — should be selected for the medic in the Medication Adherence and ePA Master popup, which is available by clicking the Med Mgmt button on the Medic Master.
The access rights definition Electronic Prior Authorization available on the Role Master in PrognoCIS (Go to Settings → Configuration → Admin → Role) should be provided to the medic's Role. At present, only Read access is provided for the Electronic Prior Authorization access right.

ePA Workflow: The Prior Authorization workflow for a drug is applicable only to patients who have a valid Eligibility applied. Further, the ePA workflow is generally applicable when the selected drug for the patient requires Prior Authorization. However, the ePA can also be sent for drugs not requiring Prior Authorization if the providers find it necessary. Whether the selected drug requires Prior Authorization or not can be checked by clicking the RTPB Info or Formulary Info button on the Prescription screen. On clicking the RTPB Info or Formulary Info button, the Real-Time Formulary and Prescription Benefit Information popup is invoked. The column Is PA Required on the RTPB tab of this popup gives a clear indication of whether Prior Authorization is required for the selected drug on the Prescription screen. For all drugs that have Y (Yes) in the Is PA Required field, the ePA workflow is applicable.
The following are the ways to initiate the Electronic Prior Authorization workflow from the Prescription screen of PrognoCIS:

By clicking the ePA button on the Prescription screen.
By clicking the ePA button on the Electronic Prior Authorization Warning popup.

Note: When a drug is selected on the Prescription screen, the drug details are filled, updated, and saved. Then, on clicking the eRx button, the system checks whether Prior Authorization is required for the selected drug. If Prior Authorization is required, the Electronic Prior Authorization Warning popup is shown on the screen. This popup contains a list of drugs in the prescription that require Prior Authorization, the status of any previously requested ePA, etc. It also contains further instructions on the usage of the ePA and eRx buttons. This popup has three buttons — ePA, eRx, and Close:

If the user clicks the eRx button on this popup, the ePrescription is sent.
If the user clicks the ePA button on this popup, the Electronic Prior Authorization popup is invoked.
If the user clicks the Close button, the Electronic Prior Authorization Warning popup is closed without any action.

Electronic Prior Authorization Popup: The Electronic Prior Authorization popup has two sections — Drug List and Surescripts Accelerator:

Drug List: The Drug List on the Electronic Prior Authorization popup displays the drugs on the Prescription screen for which Prior Authorization is required.

Field Descriptions:

Select: Select the checkbox associated with the drug.

Drug Description: Displays the details of the drug on the Prescription screen for which Prior Authorization is required. These details include the drug name, strength, and frequency as entered on the Prescription screen. Provision has been made to add drugs directly from the Electronic Prior Authorization popup. On clicking the Add Drugs

button, the Dispensable ePA Drug Names search popup is invoked. This search lists the ePA drug names that are applicable to the patient.

Request Dt: Populates the date as soon as the Prior Authorization is requested.

ICD Codes: Displays the ICD codes associated with the selected drug. ICD codes from the Assessment screen can directly be associated with drugs in this popup using the ICD Codes Multi-Select

button. Only ICD-10 codes are displayed in the ICD Codes column on the Electronic Prior Authorization popup; ICD-9 codes are not displayed.

To Rx: If ICD codes are assigned to a drug from this popup and the To Rx checkbox is checked for that drug, these selected ICD codes are associated with the drug and are reflected on the Prescription screen.

Priority: This checkbox is used to indicate whether the selected ePA request is urgent. The user can check this checkbox and then click the ePA Request button to notify Surescripts that the ePA request is urgent.

PBM: Displays the Pharmacy Benefit Manager as available from the selected Eligibility.

Plan: Displays the Plan as available from the selected Eligibility.

Response: Displays the response to the ePA request, as received from Surescripts. These responses may be:

O: Open: Indicates that Surescripts has yet to approve the ePA request.
A: Approved: Indicates that Surescripts has approved the ePA request.
D: Denied: Indicates that Surescripts has denied the ePA request.
P: Partially Denied: When the ePA request is in the Partially Denied status, the user can modify the prescription according to the remarks provided by Surescripts in the Note field. After performing these modifications, the user can send a NewRx by clicking the eRx button so that the Prior Authorization with the suggested modifications from the PBM is approved by the pharmacy.
C: Closed: Indicates that the ePA request is closed.
I: In Process: Indicates that the ePA request is in process.

Reason: Displays the reason for approval or rejection as received from Surescripts.

Note: Displays the notes or comments received from Surescripts. For example: Please fax supporting documents.

PA No.: Displays the Prior Authorization Number as received from Surescripts.

Action Buttons:

ePA Request button: Select the drug in the Electronic Prior Authorization popup and click the ePA Request button to send the ePA request to Surescripts. Once the ePA request is sent from PrognoCIS for a drug and a response is received from Surescripts, the fields Plan, Response, Reason, Note, and PA No. are populated upon the execution of a process.

Refresh button: Click the Refresh button to reload the data on the Electronic Prior Authorization popup.

Surescripts Accelerator: The Surescripts Accelerator has two tabs — Worklist and Task History.

Worklist

The Worklist tab displays actionable steps, such as a questionnaire that must be answered before the drug is authorized for dispensing.
If the user accessing the Electronic Prior Authorization popup has the View role selected in the Roles for only Accelerator column in the Medication Adherence and ePA Master popup on the Medic Master, the questionnaire can only be viewed.
If the user accessing the Electronic Prior Authorization popup has the Prepare role selected in the Roles for only Accelerator column in the Medication Adherence and ePA Master popup on the Medic Master, then the user can only answer the questionnaire and cannot submit it; therefore, only the Start button is made available on the Worklist tab towards the end.
If the user accessing the Electronic Prior Authorization popup has the Submit role selected in the Roles for only Accelerator column in the Medication Adherence and ePA Master popup on the Medic Master, then the Start button is made available on the Worklist tab. The user can then answer the questions in the questionnaire. Upon completing the questionnaire, the Submit button is made available, allowing the user to submit it for further action by Surescripts.

The following are the different types of responses received from Surescripts when an ePA request is sent:

If the Surescripts response is Prior Auth Approved, then on the Worklist tab, the Acknowledge Approved PA button is available.

The user must click the Acknowledge button to acknowledge the response to the Prior Authorization Request.

Task History

The Task History tab on the Electronic Prior Authorization popup shows the details of all the steps taken to authorize a drug. If the prior authorization of the drug is incomplete and the user wants to cancel the ePA request, a Cancel button is provided on the Task History tab for that request; clicking this button sends an ePA cancellation request to Surescripts.