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 hassle free ePrescription process. PrognoCIS EMR now supports Electronic Prior Authorization (ePA) via Surescripts.

Prerequisites for to enable ePA service for a medic:

The ePriorAuthorization checkbox available under Surescripts Services section on the Register eRx Provider popup, invoked on clicking the eRx button on the Medic master (Navigation for Medic master(Provider): Go to Settings → Configuration → Users → Providers) should be checked.
The Product ePA with appropriate roles —View, Prepare, Submit; should be selected for the medic in the Medication Adherence and ePA master popup available on clicking the Med Mgmt button on 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 Electronic Prior Authorization access right.

ePA Workflow: Prior Authorization Workflow for a drug is applicable only for the patients having valid Eligibility applied. Further, ePA workflow is generally applicable when the selected drug for the patient requires Prior Authorization. However, 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 present on the Prescription screen. On clicking the 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 that for the selected drug on Prescription screen, Prior Authorization is required. For all the drugs which have Y(Yes) for is PA required field, the ePA is workflow is applicable.
Following are the ways to initiate Electronic Prior Authorization workflow from the Prescription screen of PrognoCIS:

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

Note: When a drug is selected in the Prescription screen, drug details are filled up and further it is updated and saved, then on clicking the eRx button, the system checks whether Prior Authorization is required for the selected drug or not. If Prior Authorization is required, then Electronic Prior Authorization Warning is shown in popup on the screen. This popup contains the list of drugs in the Prescription that require Prior Authorization, the status of previously requested ePA, etc. It also contains further instruction on usage of ePA and eRx buttons. This popup has 3 buttons—ePA, eRx, close:

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

Electronic Prior Authorization popup: Electronic Prior Authorization popup has 2 sections—Drug List and Surescripts Accelerator:

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

Field Description:

Select: Check the checkbox associated with the drug to select that drug.

Drug Description: Displays the drug details of the Drug in the Prescription for which Prior Authorization is required. The Details include the Drug Name, Strength and the Frequency as available on the Prescription screen. Provision has been made to add drugs directly from the Electronic Prior Authorization popup. On clicking the ADD DRUGS

button, Dispensable ePA Drug Names search popup is invoked. This search lists out the ePA Drug Names that are applicable for 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 ICD10 codes are displayed in the ICD codes column on the Electronic Prior Authorization popup. ICD9 codes are not displayed.

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

Priority: This checkbox is used to indicate whether the selected ePA request is urgent or not. User can check this checkbox and then click on 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 ePA request, as received from Surescripts. These responses may be:

O:Open: Indicates that Surescripts is 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, User can perform modifications to the prescription according to the remarks given by Surescripts in the Note field. After performing these modifications, User can send NewRx by clicking on the eRx button so that the Prior Authorization with suggested modification from PBM are taken as approved by Pharmacy.
C:Close: 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 as 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 on the ePA Request button to send ePA request to Surescripts. Once ePA request is sent from PrognoCIS for a drug and is responded from Surescripts, then on execution of a process, the fields Plan, Response, Reason, Note and PA No. are populated.

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

Surescripts Accelerator: Surescripts Accelerator has 2 tabs —Worklist and Task History.

Worklist

The tab Worklist displays actionable steps such as a questionnaire that needs to be replied to before the drug is authorized to be dispensed.
If the user accessing Electronic Prior Authorization popup has the View role selected in the Roles for only Accelerator column in Medication Adherence and ePA master popup on Medics Master, then the questionnaire can only be viewed.
If the user accessing Electronic Prior Authorization popup has the Prepare role selected in the Roles for only Accelerator column in Medication Adherence and ePA master popup on Medics Master, then the user can only answer the questionnaire and not Submit it, hence, only the Start button is made available on the Worklist tab towards the end.
If the user accessing Electronic Prior Authorization popup has the Submit role selected in the Roles for only Accelerator column in Medication Adherence and ePA master popup on Medics Master, then the Start button is made available on the Worklist tab. The user can go ahead and answer the questions in the questionnaire. On replying to the questionnaire, the Submit button is made available. The user can then submit the questionnaire for further action from Surescripts.

Following are the different types of responses received from Surescripts when ePA request is sent:

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

The user is required to click on the Acknowledge button to acknowledge the response to Prior Authorization Request.

Task History

The Task History tab on the Electronic Prior Authorization popup shows the details of all the steps taken for authorizing a drug. When the prior authorization of the drug is not complete and the user wants to cancel the ePA request, then on the Task History tab, for the request sent, a Cancel button is provided, clicking on which ePA cancel request is sent to Surescripts.