Providers can submit prescription drug prior authorization (PA) requests electronically for Blue Cross and Blue Shield of Minnesota members who have Prime Therapeutics as their pharmacy benefit manager (PBM) and for specialty drugs covered under the medical benefit.
What is electronic prior authorization (ePA)?
ePA is the process a prescriber (e.g., doctor) follows to transmit a pre-certification or pre-authorization coverage request to a payer (e.g., health plan, pharmacy benefit manager) to check benefit coverage for a specific drug and patient. Pre-authorization is based on medical necessity review and is not a guarantee of payment. Payment requires that the patient's benefit contract is in force on the day services are provided by the prescriber and is subject to all provisions and limitations in the subscriber's contract including any applicable contract exclusions, health plan allowed amounts, prior treatment, medical necessity policies, and clinical diagnosis/findings.
Historically, providers have used facsimile (fax), mail, and telephone to send PA drug requests and clinical information to payers. However in recent years, providers have started submitting online PA drug requests using payer-specific web portals or Electronic Medical Record (EMR) systems that can transmit a secure electronic file that follows the National Council of Prescription Drug Programs (NCPDP) standard file format.
Why use ePA?
Submitting prescription drug PA requests electronically via payer-web portals and EMR systems offers many time-saving features to prescribers and payers.
ePA tools can help identify for prescribers what clinical information is needed for a payer to complete a medical necessity review.
In Minnesota, state law requires prescribers exchange drug PA requests electronically to support the industry movement toward electronic PA processing and away from paper and fax-based workflows.
How can prescribers transmit ePA requests?
Prescribers can submit ePA drug requests for Blue Cross members who have pharmacy benefits through Blue Cross by either submitting a request through CoverMyMeds's free web portal or by sending an electronic NCPDP file to Prime through an integrated Electronic Medical Record (EMR) system during the e-prescribing process.
For specialty drugs covered under a Blue Cross member's medical benefits, prescribers can submit ePA requests online thru Availity or transmit NCPDP file requests to Blue Cross from their EMR system via CenterX. To learn more about how to transmit NCPDP files, prescribers can talk with their EMR vendor and/or contact CenterX at 855-CenterX (236-8379) or info@centerx.com.
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It’s helpful if you have your provider number or NPI and, if applicable, the member’s ID number, account number and claim number handy when you call.