Resource Center

Add-ons

Electronic Prior Authorization

Electronic Prior Authorization helps you streamline your workflow by making the most efficient medication-related prior authorization process your default. With the ability to identify automatically and quickly process prior authorizations at the point of care, you will improve your practice’s efficiency, avoid post-visit disruptions, and deliver even more satisfying experiences for patients.

How it works

With Electronic Prior Authorization, you will strip away inefficiency, reduce disruption, and give patients a faster path to successful treatment.
EPA Workflow

Electronic Prior Authorization lets you improve and simplify your current workflow — what might look like a disruption today is ultimately an upgrade to a smoother, better process. We embed all functionality directly into your clinical EHR workflow and have prioritized features that help you avoid unnecessary work. Submit the prior authorization electronically and typically get an approval within 60 seconds.

It’s powered by Surescripts, which means it connects to more PBMs and payers than other options. Today, it is already linked to 89% of covered lives in the United States1 — a number that is growing every year.

Advantages

  • Adds a complete, guided prior authorization process into your everyday EHR workflow
  • Replaces faxes and phone calls with a completely automated process
  • Communicates in real-time directly with the nation’s largest PBMs
  • Covers all medication classes and specialty medications
  • Streamlines the prior authorization process at the practice level or for centralized teams
  • Combines with Real-Time Prescription Benefit to transform patients’ experiences

Example Usecase

EPA Usecase

How EPA and RTPB Work Together

By combining a fully electronic prior authorization validation and approval process with patient-specific coverage details and medication alternatives, our solutions will improve your practice’s efficiency, accelerate patient time to therapy, encourage prescription adherence, and improve patient satisfaction.

Together, Real-Time Prescription Benefit and Electronic Prior Authorization eliminate barriers to better prescribing, leading to an accelerated, optimized prescription process.
EPA and RTPB

Work Flow in ChARM EHR

Initiate electronic PA on writing prescription

Step #1: Open an encounter or Quick Rx view.

Step #2: Start writing a prescription using the 'Add Rx' option. Prescriptions can be also added in to the chart note through other options like templates, past Rx, etc..

Step #3: Search your drug and prescribe one
EPA Add RX

Step #4: With EPA enabled, selecting a prescription will show the formulary eligibility details of the prescription based on the patient's insurance plan details. If PA is required for the prescription in a plan, 'Prior Authorization Required' information will be shown in the Coverage details section.
EPA Choose PBM

Step #5: Choosing an insurance plan takes you to the prescription view. If the eligibility response of the prescription says Prior Authorization is required, the "Initiate Electronic Prior Authorization" check-box is checked by default.
EPA Enter Dosage

Say the "Initiate Electronic Prior Authorization" is not checked automatically as the eligibility response does not have a prior-auth required indicator. Still, the Prescriber can check the "Initiate Electronic Prior Authorization", if the Prescriber anticipates the prescription requires prior-auth.

Step #6: Days-supply, quantity, dispensing unit and pharmacy details need to be filled. RTPB pricing and alternative details will be fetched and displayed on the right side of the view, if available.

If any of the alternatives do not require PA, the user can choose the alternative instead of the current prescription to avoid PA. The prescriber can also uncheck "Initiate Electronic Prior Authorization" to avoid initiating prior-authorization automatically if the prescriber knows that this drug does not require prior-auth based on the patient's condition.

Step #7: Users can continue with the current medication or alternative medication that requires prior authorization. With the "Initiate Electronic Prior Authorization" is in checked state, adding the prescription to the system will automatically initiate electronic prior authorization request to Surescirpts-PBM services.
EPA Initiated

Step #8: Once EPA is initiated for a prescription, further EPA activities (like completing PA form, acknowledging, and appealing) for this prescription can be performed from 'Rx Holding Queue' until the prescription gets transmitted.
EPA RX Holding Queue

If the prescriber wants to transmit a prescription before completing the EPA process, it can be transmitted from either encounter view or Rx Holding Queue. Once a prescription is transmitted, the prescription is removed from Rx Holding Queue and its follow EPA activities should be performed from EPA WorkList View.

Initiate electronic PA for a Transmitted Prescription

EPA can be initiated for transmitted prescriptions from the Patient's Medication section by the prescriber/agent.
Initiate EPA

EPA activities for transmitted prescriptions can be handled in EPA WorkList View.
EPA Open Worklist View

EPA Activities on Prescription:

EPA status and follow up activities can be viewed and performed for the prescriptions from either 'Rx Holding Queue' or 'EPA Worklist' views. Rx Holding Queue view lists the prescriptions which are not yet transmitted and awaiting EPA completion. EPA Worklist view holds the list of transmitted prescriptions involved in the EPA process.

Initiating EPA process sends an EPA request to Surescripts. Surescripts forwards the request to the PA processor(PBM/Payer). The request is reviewed and the response is returned with any of the below statuses to the ChARM EHR account. Actions needed from the user based on received response is also mentioned in the table.

EPA Initial Response Action Required
Completed - PA not needed for medication/patient/health plan combination. No action is required from the prescriber end.
Completed - PA not allowed, medication not covered. This status represents PA cannot be proceed electronically. So either,

A manual PA process should be followed

-- Or --

Filling PA from via web-based PA forms provider
Open & Question Set Returned - PA allowed, please complete the attached question set. PBM returns Question-Set which needs to be filled by the prescriber/clinical end.

The status of the EPA process can be checked by clicking the refresh icon in the 'Last Updated Status' column.
EPA Refresh Queue

ChARM EHR uses Surescripts EPA Accelerator service for EPA activities. From both Rx Holding Queue and EPA Worklist view, clicking 'Process PA' action item launches Surescripts Accelerator UI to know the status and the actions to be performed by the user.
Process PA

Users will be redirected to Surescripts Accelerator UI(User Interface). This view shows the state of the workflow process, including the status of the process and context-specific details.
EPA Criteria

In the task-history list view, some tasks may be associated with action that is required on the part of the PBM/payer and will not require interaction on the part of the user within the prescriber system.
EPA Task History

Task-Names that may require action on part of the prescriber (or their proxy) include: 'Complete PA Form' and 'Acknowledge' tasks (e.g. 'AcknowledgeClosedPA'). Surescript Accelerator launches a question-set if the task is 'Complete Prior Auth Criteria/Form'.

Handling of EPAs returned with Question Set

Opening the 'Complete Prior Auth Criteria' task opens up the question sets the answering process view.
EPA Worklist
Fill PA Form

PA form questions need to be filled with appropriate answers for quicker approval of PA. PA form can be submitted at the end of answering the question-sets. These answers will be sent to PBM and await for PBM response.
Submit PA Form

After submission, the task is assigned to PBM for processing the complete PA form. The PBM(or health plan) will review the answer set and approve or deny the electronic PA based on the responses to the question set.

Approved EPA Worklist:

If the PA is approved by PBM, the status of the PA is updated to 'Approved' in the Work List view.
EPA Approved Worklist View

If the signed prescription is not yet transmitted and available in 'Rx Holding Queue', the prescription can electronically be transmitted to pharmacy.

Denied EPA Worklist:

If the PA is denied by PBM, the status of the PA is updated to 'Denied' in the worklist view.
EPA Denied Worklist View

For denied electronic PA, there may be an option to submit an electronic appeal, if the PBM or health plan supports the message type for this medication/health plan combination.
Appeal PA

Handling of EPAs with status 'Completed - PA not needed':

In this scenario, Surescripts Accelerator UI displays the worklist with the 'PA Not Needed' task. No further EPA related action is required from the prescriber/clinical end.

If the signed prescription is not yet transmitted and available in 'Rx Holding Queue', the prescription can be electronically transmitted to pharmacy.

Handling of EPAs with status 'Completed - PA not allowed':

Scenario #1:

Matching the information within the PA-Initiation-Request to a single PA form is generally not possible. The matching process typically results in multiple matches or no match. This is largely due to information such as BIN/PCN, Group IDs, and Plan IDs being used by multiple plans across several different PBMs.

In instances where Surescripts is not able to return a PA Form, the following will be received in a Closed – Other message.

Sorry but Surescripts cannot process this PA request electronically. Please refer to the back of the patient benefit card for information on how to process this prior authorization manually.

What to do next?

Users can send the medication to the pharmacy. If a PA is needed, the pharmacy will notify the clinic and a manual process should be used to ensure that the patients’ needs are addressed.

Scenario #2:

When Surescripts is not able to find an electronic path to complete a prior authorization, it will default to a PDF workflow to identify and return a PA form for the user to use to complete the PA.

What to do next?

The user should be directed to act on the PDF URL by clicking the hyperlink. A portal will open and present the user with a pre-populated PA form for them to complete. PDF URLs are only active for 72 hours.

Once the user fills out the PA form provided by the web-based PA forms provider, the form is faxed to the PBM/payer and there will be no further electronic communication to the EHR by either the web-based PA forms provider or Surescripts. The PBM/payer will fax the provider vendor back the approval or denial.

Rx Holding Queue and EPA Status Scheduler

Rx Holding Queue view lists the prescriptions which are not yet transmitted and awaiting EPA completion. ChARM EHR runs an EPA Status Scheduler at regular intervals to check the status of EPAs in progress. If the EPA status is approved or 'PA Not Needed', our EPA Status Scheduler checks the status of the related prescriptions to automatically transmit them to pharmacies electronically. Prescriptions already signed by the prescribers are automatically get transmitted to pharmacies without any user intervention and get cleared from Rx Holding Queue. If the prescriptions are not yet signed by the prescriber, those prescriptions are listed in the Rx Holding Queue to be signed by the prescriber for transmission.

On transmitting NewRx electronically, prior-auth status and details are sent part of the prescription script to the pharmacy, if the PA is processed electronically. Else if the PA is processed manually, the user can fill in the PA details manually in the prescription view before transmitting to the pharmacy to make the PA details part of the prescription script.

Re-initiate EPA

EPA can be re-initiated for the prescriptions not having any outstanding EPAs in progress, from the Patient's Medication section by the prescriber/agent.
Reinitiate EPA Option

Re-initiate EPA opens up the prescription view with EPA History details for reference.
Reinitiate EPA

The benefit plan can be changed and the EPA can be re-initiated. Re-initiated EPA follow-up activities can be followed up from Rx Holding Queue if the prescription is not yet transmitted. If the prescription is already transmitted, EPA activities can be performed from EPA Work List.

Configuring Authorized Representative for EPA Activities

When the prescriber initiates an EPA request for a prescription, EPA follow-up activities can be performed by the prescriber or by authorized representatives. Based on follow-up activities, authorization can be provided at multiple levels and the authorized representative can be configured based on their activity in EPA workflow.

  • PA Submitter: Have Create, Read, Edit and Submit permissions
  • PA Reviewer: Have Read-only permissions
  • PA Preparer: Have Create, Read and Edit permissions

EPA User Role View

PA Submitter role has all the privileges that are required in the EPA process. If you configure a person as PA Submitter for a prescriber, the other two roles are not required. In a practice, the same person can act as a PA representative for many prescribers. Few Use-cases are given below for your understanding,

  • 'Person A' can be configured as PA Submitter for 'Prescriber P1' and 'Prescriber P2'.
  • 'Person A' can act as PA Submitter for 'Prescriber P3' and PA Reviewer for 'Prescriber P4'

An authorized representative can perform the EPA related activities on-behalf of the associated prescribers from EPA Work List or Rx Holding Queue views.

EPA Work List & Rx Holding Queue view list all the EPAs for the prescriptions written by the associated prescribers. Users can apply filters to refine the EPAs on which they have to work.
EPA Status Filter

User's actionable tasks on in-progress EPAs

'Invoke WorkList' button in the Rx Holding Queue/EPA Work List view helps the user by listing the EPAs requiring action from the user/prescriber end.

Users can view his/her EPA actionable tasks in the Surescripts Accelerator Worklist view.
Surescript Worklist View

The user may select a task and trigger the Accelerator to go to the appropriate view for that task. Tasks related to ePA are assigned to the recipient of the ePA Message, e.g. the prescriber who has initiated the EPA request. Users can take action on the tasks. EPA process may get completed on performing a task or a new task may get created which requires additional action from the PBM side to complete the EPA process.