Practice Fusion has partnered with Surescripts to provide a new, enhanced electronic prior authorization solution in your EHR. Read below to learn more about the new workflow that will be rolled out in the coming weeks.
Practice Fusion supports streamlined electronic prior authorizations (ePA) within your EHR, facilitating the exchange of information necessary to request coverage of a specific prescription drug under a patient’s pharmacy benefits.
Prior authorizations (PAs) may be triggered by sending an e-prescription (eRx) or by manually initiating a request to complete a prior authorization. Prior authorization forms can be completed and submitted by any member of the practice from the patient’s Timeline, the Prior authorization report, or the Tasks section of the EHR.
Generate a prior authorization by sending an eRx
1. Order medication. Choose a medication and fill in order details. Click Order as shown in Graphic 1 below.
Graphic 1: Order Medication
2. Prior authorization required. If the patient’s prescription benefits plan requires a prior authorization for the medication, a Prior Authorization required alert will display as shown in Graphic 2 below. Click Next to continue the medication order.
Graphic 2: Prior Authorization Required
3. Dispense as written checkbox. Notice the Dispense as written checkbox on the order details page (see Graphic 3 below). If Dispense as written is not selected, a new eligibility check will be performed to determine if the patient’s prescription benefits plan requires a prior authorization for the generic form of the prescribed medication instead of the brand medication. The prior authorization process will be initiated upon sending the eRx only if the generic form requires a prior authorization.
Ensure that Dispense as written is checked if the originally selected brand name medication is intended to be dispensed at the pharmacy. Once the details have been reviewed, click Next to continue the medication order.
Graphic 3: Dispense as Written Checkbox
4. Send eRx to initiate prior authorization. Once the medication order is submitted electronically, you will receive a notification that a task will be created when the prior authorization form is available (see Graphic 4 below). Click Go to Timeline to check an updated status.
Graphic 4: Notification of PA Task
5. Prior authorization status. The prior authorization status in the patient’s Timeline will appear as Awaiting PA form until a question set has been received from the payer (see Graphic 5 below). Once a form is received, the status will change to Incomplete. A task will be created to fill out the prior authorization form in the Tasks section of the EHR.
Graphic 5: Prior Authorization Status in Timeline
If the status is Closed, the payer did not return a question set because the patient already has a prior authorization on file or the payer does not support electronic prior authorization.
Complete and submit prior authorization form
1. Open prior authorization question set. Click on the Incomplete prior authorization from Tasks, Timeline, or Prior authorizations report to open the question set modal. The first page provides information about the prior authorization question set (see Graphic 6 below).
- Click Delete to delete the prior authorization question set and submit a cancellation request to the payer.
- Click Finish later to complete the prior authorization form at a later time.
- Click Next to proceed to the first question in the form.
Graphic 6: Sample Information Page on Prior Authorization Question Set
2. Answer and complete question set. Answer the questions as shown in Graphic 7 below. You must fill out any required question before moving to the next question in the form. If a free text response is required, the Next button will not appear until you have entered text in the field. Other features of the prior authorization question set modal include:
- Access to the patient’s chart while completing the prior authorization: The question set modal can be moved around the screen, and you can navigate to other areas of the EHR, such as the patient’s chart, to help answer questions (see Graphic 7 below).
- A variety of question types: Question sets can include multiple choice, multi-select, and free text question types.
- Auto-save: Progress can be tracked via the progress bar towards the top of the modal. Answers will be auto-saved as you complete the form. If you must close out the prior authorization form before it is completed, all previously entered answers will be saved, including any free text. Upon re-opening the form, click Next to proceed to where you previously left off.
- Ability to attach a document: If a question set requests a document to be attached, this can be done at the end of the question set (see Graphic 8 below). A document should be attached only if requested in the question set. Only one document with a maximum size of 20 MB may be attached. Supported document types include: TIFF, PNG, JPEG, PDF, CDA, and CCR.
Graphic 7: Question Set
Graphic 8: Attach Document to PA
3. Submit prior authorization. Review the summary of your answers. You will not be able to make changes after submission (see Graphic 9 below). Click Submit to send the form to the payer. The status in the Timeline and Prior authorizations report will now appear as Submitted.
Graphic 9: Submit Prior Authorization
4. Payer response. The payer will review the completed prior authorization form to determine whether the medication will be covered by the patient’s benefits. The payer may send the following responses back:
- Approved. Prior authorization has been approved, and the payer will cover the prescribed medication. No further action is needed.
- Denied. Prior authorization has been denied, and the payer will not cover the prescribed medication. If the payer supports electronic appeals, the option to appeal the denial will be available in the prior authorization details.
- More info needed. Payer requires additional information to make a determination and sent back a question set. A task will be created to complete and submit the question set.
Review, cancel, or appeal prior authorization
Pending and historical prior authorizations can be accessed from the Prior authorizations section of the patient Timeline or the Prior authorizations report. From these sections in the EHR, you can also review prior authorization notes, appeal a denied prior authorization, or request to cancel a prior authorization.
1. Review submitted forms and notes from the payer. The details page will display the most recent question set submitted to the payer for the prior authorization, as well as any notes sent from the payer about the prior authorization.
2. Cancel a prior authorization. A prior authorization can be cancelled any time after a question set has been submitted and if the payer’s response is pending. To request a cancellation, follow these steps:
- Navigate to the patient’s Timeline and click on the submitted prior authorization you want to cancel.
- Click Cancel PA as shown in Graphic 10 below.
- Confirm cancellation by clicking Cancel PA on the warning notification (see Graphic 11 below). You will receive a notification that your cancellation request was sent. Upon receiving cancellation approval, the prior authorization status will change to Cancelled.
Graphic 10: Cancel PA
Graphic 11: Cancel Notification
3. Appeal a denied prior authorization If the payer denies a prior authorization, you can request to appeal the decision if the payer supports electronic appeals. If electronic appeal is supported, the Appeal button will appear in the prior authorization details. To request an appeal, follow the steps below:
Navigate to the patient’s Timeline and click on the denied prior authorization you want to appeal.
Click Appeal as shown in Graphic 12 below.
Confirm appeal request by clicking Appeal on the warning notification (see Graphic 13 below). You will receive a notification that your appeal request was sent.
The payer will send a form with questions required to complete the appeal process. Upon receiving the appeal question set, the status will change to Info needed. A task will be created to fill out the form in the Tasks section of the EHR.
After submitting the appeal question set, the payer will respond with a determination of Approved or Denied. If the appeal is approved, the payer will cover the prescribed medication. If the appeal is denied, the payer will not cover the prescribed medication. No additional electronic appeals may be submitted for this prior authorization.
Graphic 12: Appeal Denied PA
Graphic 13: Confirm Appeal Request
Physicians’ Desk Reference forms
Surescripts partnered with Physicians’ Desk Reference (PDR) to provide prior authorization coverage for patients whose health plan does not support ePA. PDR provides a library of editable PDF prior authorization forms.
If a Closed response is returned because the payer does not support ePA, a link to the PDR library will be displayed in the Notes from patient insurance section of the prior authorization details page. Click this link to access the prior authorization PDF via the PDR website. All actions taken in the PDR website are outside of the EHR and any completed forms should be downloaded or printed for your records. After filling out the PDF form, click Submit to Plan (see Graphic 14 below) to submit the form via PDR to the patient’s payer.
Graphic 14: Submit to Plan
Manually generate a prior authorization
You have the option to manually initiate the prior authorization process by submitting a request to the patient’s payer for a prior authorization form. This can be performed from a patient’s chart or from the Prior authorizations report.
From a patient’s chart:
- Select Add prior authorization from the Actions dropdown menu as shown in Graphic 15 below.
- Choose medication. Select a new medication or medication from the patient’s eRx list (see Graphic 16 below). If the prior authorization is for a new medication, the Dispense, Unit, and Days Supply fields must be filled in. If the prior authorization is for a previously submitted eRx, these fields will auto-populate with details from the prescription.
- Request prior authorization. Fill out all required fields, then click Request PA as shown in Graphic 17 below. You will receive a notification that your prior authorization request has been sent. In the patient’s Timeline, the status will show as Awaiting PA form until a form has been received. Once a question set has been received, the status will change to Incomplete.
- Complete and submit question set. Once a PA form has been received, a task will be created for you to fill out the question set. Complete the question set and submit to the payer.
Graphic 15: Add prior authorization
Graphic 16: Fill out quantity fields
Graphic 17: Request PA
From Prior authorizations report:
- Navigate to Prior authorizations report by clicking Reports and then clicking Prior authorizations as shown in Graphic 18 below.
- Click Add Prior Authorization (see Graphic 19 below).
- Fill out required fields. Type in or select patient from dropdown menu (see Graphic 20 below). Then choose a medication and complete the remaining required fields.
- Request prior authorization. After filling out all required fields, click Request PA as shown in Graphic 21 below. You will receive a notification that your prior authorization request has been sent. In Prior authorizations report and Timeline, the status will show as Awaiting PA form. Once a question set has been received, the status will change to Incomplete.
- Complete and submit question set. Once a prior authorization form has been received, a task will be created for you to fill out the question set. Complete the question set and submit to the payer.
Graphic 18: Prior Authorizations in Report section
Graphic 19: Add Prior Authorization from Report Section
Graphic 20: Select Patient
Graphic 21: Request PA from Reports Section