What is a prior authorization?
Pharmacy Benefit Managers (PBM) periodically require additional medically necessary information to approve a medication for a patient. This approval process is called prior authorization (PA). Many practices are accustomed to completing these forms on paper or by phone.
What is an electronic prior authorization?
An electronic prior authorization (ePA) is an electronic version of the paperwork sent in a secure format to PBMs and pharmacies. CoverMyMeds offers electronic connections and workflows to submit prior authorizations to insurance companies and pharmacies without the use of paper. Their service covers payers with available electronic connections and also offers the ability to digitally fax PBMs that are still using paper to process prior authorizations.
What prior authorization capabilities are enabled with the CoverMyMeds integration with NextGen Office?
Our partnership with CoverMyMeds enables our providers to send prospective ePAs to pharmacies and insurance companies directly from the NextGen® Office application. In a prospective workflow, a provider or staff member initiates an ePA before sending the medication to the pharmacy. Providers can avoid having to send ePAs after the medication has reached the pharmacy, and decreases the amount of time a patient has to wait for a medication requiring prior authorization.
The integration with CoverMyMeds saves providers and their staff time while also providing a better patient experience.
Why is the CoverMyMeds integration important?
- A prior authorization takes 20 minutes and 3–5 business days through a manual process. An ePA can reduce this to a five-minute process and 1–2 business days.
- Reduces issues of patient abandonement, thus helping to reduce time to therapy for the patient and increase the likelihood that the patient will pick up the medications they need to live a healthier life.
- One in 20 electronic prescriptions require a preauthorization.
- Prior authorization is a common workflow in many of our clients' practices
- Helps with patient satisfaction, physician burnout, and staff satisfaction
Is there a cost for this integration?
No. This is available to all clients who choose to use the workflow.
How do I initiate the CoverMyMeds integration?
All users must accept the user agreement before they can use the feature. After acceptance, we start sending information to CoverMyMeds. If users do not accept the user agreement, we never send information to CoverMyMeds. The feature is for the entire practice so it cannot be turned on or off per provider aside from not accepting the user agreement. Even if a provider does not accept the user agreement, they will still be prompted to "Get Started" on all prescriptions.
Where can I access the CoverMyMeds integration?
Medication List, Medication History, and Prescribe
What happens if a provider does not send the prior authorization and the pharmacy initiates the prior authorization request?
If the provider does not initiate the prior authorization, the pharmacy will initiate the authorization and send it to the provider’s practice for completion. This process is called a retrospective workflow.
NextGen Office does not currently support the retrospective workflow. The practice instead receives a fax requesting that the authorization be completed on the CoverMyMeds webportal.
What are my options if I receive a retrospective PA?
- Option A: Go to the CoverMyMeds website to complete the authorization. The provider and staff will receive a fax to the practice requesting the authorization be completed on the CoverMyMeds webportal.
- Option B: Go to the patient's chart.
- From Medication List, select the medication.
- Select ePrescribe.
- Create the PA, but do not transmit the medication (cancel the prescription).
What is a key benefit of using CoverMyMeds in NextGen Office vs the CoverMyMeds website?
If you use the CoverMyMeds website, the user is required to fill out all of the information from the patient's chart.
Using CoverMyMeds in NextGen Office, the information is mainly prefilled and avoids as much double entry as possible. Additionally, users can refer to PA and historical PA without leaving the system.
What if I accidentally archive a PA?
- From Medication List, select the medication.
- Select ePrescribe.
- Create the PA, but do not transmit the medication (cancel the prescription).
Why would I use Archive instead of Delete?
- Archive keeps a record of the PA for reference. We suggest using Archive when an ePA is in Determined status so as to not clutter the worklist.
- Delete removes the PA from the worklist and updates CoverMyMeds that we are not going to take action. Delete is used to permanently delete the record from the UI. We are soft deleting and will retain for our records on the backend.
What if CoverMyMeds does not present a form?
If CoverMyMeds cannot identify which form to use, the user has the option to search for the appropriate form. Locate the appropriate form, select the form, and complete the PA.
What if the form selected by CoverMyMeds is the wrong form?
- Select Switch Form.
- Locate the appropriate form
- Complete the PA.
What else should I consider when filling out the PA?
- The ICD-10 code must always be entered on the form and will require the (.) in the ICD-10 code.
- Since the doctor is on the PA when creating an PA, it is good practice to have the doctor enter the ICD-10 code when creating the PA.
- CoverMyMeds does not send back the quantity and dose of the medication so a staff member must manually enter the quantity and dose.
- Since the doctor is on the medication when creating an PA, it is good practice to have the doctor enter the dose and quantity before adding the PA to the worklist or tasking the PA to a staff member.
What happens after I submit the PA?
- The fax workflow can take 3-4 days for a response.
- An ePA with a direct connection could respond instantaneously or in one business day.
- After the PA is received:
- The PA could be approved.
- The PA could be denied.
- Additional questions could be requested.
- Complete the questions and send to plan.
- The PA could be canceled (because the plan does not accept ePAs).
What does fax workflow and direct connection mean?
CoverMyMeds has direct connections to payers and sends ANSI messages to payers. These can have instantaneous responses or a one-day response time.
CoverMyMeds also does backend work and will fax PAs to payers if there is not a direct connection. With a faxed PA, the response from the payer takes 3-4 business days on average.
The user will see an additional page where they will complete information sent by fax.
What options does the provider have when a prescription says an PA is not required?
CoverMyMeds' determination of whether a PA is required is a prediction based on a history of responses for the medication and not a live call to the plan. If the provider knows that a PA is required, they can create a PA.
What options does the provider have when a prescription says PA is required?
CoverMyMeds' determination of whether a PA is required is a prediction based on a history of responses for the medication and not a live call to the plan. If the provider knows that a PA is not required, they can transmit the prescription without submitting a PA. Additionally, CoverMyMeds does not know if an ePA is already on file for the medication, in which case, the provider can ignore the PA is required prompt.
If a PA is required and this is ignored, the pharmacy will notice the requirement and send a request via fax to the practice.
What options does the provider have when a prescription says CoverMyMeds is not able to determine if a PA is required?
CoverMyMeds' determination of whether a PA is required is a prediction based on a history of responses for the medication and not a live call to the plan. The provider can decide whether to create the PA. There is no issue for the patient if the provider submits a PA and there is already one on file.
If a PA is required and this is ignored, the pharmacy will notice the requirement and send a request via fax to the practice.
What does the status Response Needed mean?
The plan has returned follow-up questions related to the PA for this medication that need to be answered and sent back to the plan. The user must complete the questions, save the PA, and send to the plan.
When I receive a response back from the payer, where do I see the details?
- From the Pharmacy Alerts: Prior Authorization page, select the Auth ID to open the PA.
- Review the status and the notes on the top left of the screen.
How do I add lab results to a PA?
The payer may require lab results or additional documentation. This occurs for PAs in the Response Needed status. If the PA requires you to add lab results, you must save the lab result from the patient's chart as a PDF and then upload the PDF under the
Document Upload section of preauthorization request form.
What if I need more medical information on the patient chart?
We currently do not allow two tabs. You must close the PA screen, find the information, and reopen the PA. Alternatively, you could use two browsers to access the system.
