Authorizations

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Prior authorizations are added as part of the Medicare Part D Predetermination of Benefits process. A prior authorization covers a specific quantity/days supply of the medication. If a prior authorization is required the D1 (POB) transaction will communicate this in the rejection message. An agency can contact the payers directly to obtain a prior authorization number for the specific claim submission.

Typically, a prior authorization number is a one-time override for a specific dispensing (Rx# and Fill#). It is possible that the payer would use the same prior authorization number for future refills, however, it is more likely that a new prior authorization would need to be obtained for every fill cycle. The prior authorization number should cover a certain quantity of medication and a days supply.

The prior authorization information is captured within RxConnect and then sent to myAvatar to file automatically within the Managed Care Authorization form. This information is then included within a D1 and B1 transaction.

The following areas are required for authorizations:

Prior Authorization section (RxConnect)

RxConnect > RxSummary

Once the PoB is submitted and myAvatar assigns the guarantor, prior authorization data may be entered.

If a prior authorization is required, the D1 (POB) transaction will communicate this in the rejection message.
Prior authorizations cover a specific quantity/days supply of the medication.
The pharmacist can contact the payers directly to obtain a prior authorization number for the specific claim submission.
Launch the Prior Authorization from within the Pre-Determination of Benefits screen in RxConnect.

Select one of three choices:

Submit No Prior Authorization
Use Prior Authorization History (select from list)
Use Prior Authorization Entry (entered on the Prior Authorization section)

The following represents some of information that can be captured on the Prior Authorization screen:

Auth Assignment Period
Guarantor ID/Name
Charge Code
Date Range for Prior Auth Number
Days Supply for Prior Auth Number
Prior Authorization Type
Prior Authorization Number

Managed Care Authorizations (Avatar PM)

All prior authorizations entered into RxConnect will be sent to myAvatar . The message received will automatically create a record within the Managed Care Authorizations form in myAvatar PM. The NCPDP-related prompts will be populated. Any edits necessary prior to billing will need to be made within the Managed Care Authorization form.

myAvatar PM > Client Management > Account Management

This form manages service authorization records for a client. When a prior authorization has been obtained and entered in RxConnect, that information will populate the following NCPDP-related fields:

Guarantor Number
Guarantor Name
Authorization Number
Authorization Start Date
Authorization End Date
Service Code(s)
Type of Authorization
U/R Staff Person
Rx# for Pharmacy Charges - Added for NCPDP billing
Auth Assignment Period for Pharmacy Charges - Added for NCPDP billing
NCPDP Prior Authorization Type - Added for NCPDP billing

The liability distribution process is updated to assign only Pharmacy authorizations to a service if the authorization and the service have matching Rx numbers.