User Guide — Electronic Prior Authorization (ePA) for Prescriptions

 

You can grant delegate permissions to users who do not have the Clinicals: Order/Prescription Sign-off permission so that they can approve ePA requests on your behalf.

Important: If an ordering provider does not grant delegate permissions to another user, the provider must approve each ePA request personally. Unapproved ePA requests are not sent to the payer.

 

Tip: If you use task assignment overrides to assign tasks to selected users, review the overrides to make sure that tasks will be assigned to delegated users appropriately.

1. Display the Manage My Order Delegation page:

   1. On the Main Menu, click the Settings icon .
   2. Under MY CONFIGURATIONS, click Order Delegation.
2. From the Delegations tab, select Individual delegations as the Delegation method.
   
3. Click Add Individual Delegation.
   
4. Users — Select each user who can approve ePA requests on your behalf.
5. Order type groups — Select Prior Authorization.
6. Click Add Delegation.

 

To send ePA payer determinations to a person or role other than the ordering provider, you can create a task assignment override (TAO). You can set up a TAO to send all determinations to one person or role, or you can choose to send only some determinations, such as "Prior authorization approved" or "Prior authorization denied," to a person or role.

Note: To create and edit TAOs, you must have the Clinicals Admin: Task Assignment Overrides/Document Types permission, or you must have the Communicator and Communicator Admin permissions.

1. Display the Task Assignment Overrides page: On the Main Menu, click Settings > Clinicals. In the left menu, under Practice Links — Other, click Task Assignment Overrides.
2. Click add new.
   The Add Task Assignment Override view appears.
3. Select type — Click the Inbound documents option.
4. Class — Select Prescription.
5. Subclass — Click Selected and then select Prescription - Prior Authorization Request.
6. Status — Select REVIEW or NOTIFY as the status that triggers athenaOne to assign prescription prior authorization documents to a person or role in your practice.
7. Action (optional) — Click Selected and then select one or more of these options:
• Send to REVIEW: No determination made for prior authorization
• Send to REVIEW: Prior authorization denied
• Send to REVIEW: Prior authorization needs additional information
• Send to NOTIFY: Prior authorization approved
• Send to NOTIFY: Prior authorization not required
8. Assignee — Select the person or role to whom the task should be routed.
9. Department(s) — Select the departments to which this TAO applies.
   Note: If the department was recently created (within the hour, approximately), it may take more time for the department to appear for selection in the TAO admin page. If you are attempting to create a TAO for a newly created department and the department does not appear, attempt again after at least an hour and the department should be available for selection.
   
10. Provider(s) — Select the providers to whom this TAO applies.
11. Order Type — Enter the first few letters of the order type and then select the type from the matching list. (This field is optional.)
12. Ordering — Enter a digit to indicate the order for this TAO, relative to other TAOs for the selected document class. This number determines which TAO has priority if a conflict arises.
    Note: athenaOne applies the rules from lowest to highest order number. As a general rule, the more specific the TAO, the lower the ordering number should be within the document class.
13. Click Save.
    athenaOne routes all relevant ePA determinations to the person or role when the payer sends a determination.
    Tip: Make a note of the TAO ID in case you need to find it in the list at the bottom of the page.

 

You can generate electronic prior authorization requests in response to:

• Requests from pharmacies (via inbound faxed prior authorization requests)
• Existing prescription orders and prescription renewals

 

 

 

 

After you complete the prior authorization request form for the payer, an authorized user at your practice must approve the ePA request. For information about delegating this approval task to other users, see To delegate order prior authorization approval permissions.

1. In the Clinical Inbox, open the Prescription - Prior Authorization Request document.

2. Complete the prior authorization form. Fields that require input are outlined in red.
   Note: Enter all telephone and fax numbers in this format: XXX-XXX-XXXX.
3. Click view actions.
4. Select Approve.
5. Click Save.
   athenaOne sends the completed ePA form to the payer for evaluation and validates each value in the form with the payer.
   Note: If any values do not pass validation, athenaOne returns the form to the ordering provider with a note indicating which fields need to be corrected.

 

 

 

Payers sometimes send additional documentation related to the denial or approval of an ePA request. Electronic prior authorization documents in athenaOne include links to any additional documentation.

1. In the Clinical Inbox, select an approved or denied ePA document.
   Note: The payer's determination appears in the Description line for ePA requests. You can also see these payer determinations by searching for the document.
2. At the top of the document view, look for the Download original payer fax #[n] links.
3. Click one or more of the links.
   The payer documentation is downloaded and appears as a link in the History section of the document view.
4. Click a payer document to view it.

 

athenaOne creates an event in the medication flowsheet to represent the creation of each prescription prior authorization document. To view more information:

1. Hover over the corresponding dot in the medication flowsheet to display the medication name, the dosage, and the date that the prior authorization document was created.
   
   
2. Click the corresponding dot to display more information below the graph.
3. Click Details in the list below the graph to display the prior authorization document.

1. Generate an electronic prior authorization request.
2. Open the Prescription - Prior Authorization Request task.
3. If necessary, search for and select the correct ePA form.
4. Complete the ePA form.
5. Approve the ePA request.
6. athenaOne submits the ePA request to the payer.
7. The payer may send additional questions before making a final determination.
8. athenaOne displays the payer determination for the ePA request.

 

After an authorized user at your practice approves an ePA request, it remains in SUBMITTED status for up to 3 business days until the payer processes the ePA, makes a determination, and sends the response to athenaOne.

Note: If you set up task assignment overrides for payer determinations, athenaOne routes the ePA documents to the designated users or user roles (see "To route ePA payer determinations to a user or role").

 

Depending on the response returned by the payer, athenaOne processes ePA documents as follows.

 

 

 

 

 

 

 

You can monitor the status of all prescription prior authorizations in the Clinical Inbox. The Clinical Inbox includes the payer's determination in the Description line for ePA requests that have been approved or denied. You can also see these payer determinations by searching for the document.