Allows Prescriber to Electronically Request Prior Authorization for Medications

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Type Standard Implementation/Specification Standards Process Maturity Implementation Maturity Adoption Level Federally required Cost Test Tool Availability
Implementation Specification
Final
Production
Rating 2
No
$
No
Limitations, Dependencies, and Preconditions for Consideration Applicable Security Patterns for Consideration
  • The following transactions need to be implemented for interoperability purposes:
    • PAInitiationRequest and PAInitiationResponse
    • PARequest and PAResponse
    • PAAppealRequest and PAAppealResponse
    • PACancelRequest and PACancelResponse
  • Both the prescriber and the payer/processor/pharmacy benefits manager (PBM) must have their systems configured for the transaction in order to facilitate successful exchange.
  • See NCPDP projects in the Interoperability Proving Ground.
  • Secure Communication – create a secure channel for client-to- serve and server-to-server communication.
  • Secure Message Router – securely route and enforce policy on inbound and outbound messages without interruption of delivery.
  • Authentication Enforcer – centralized authentication processes.
  • Authorization Enforcer – specifies access control policies.
  • Credential Tokenizer – encapsulate credentials as a security token for reuse (e.g., – SAML, Kerberos).
  • Assertion Builder – define processing logic for identity, authorization and attribute statements.
  • User Role – identifies the role asserted by the individual initiating the transaction.
  • Purpose of Use - Identifies the purpose for the transaction.

Comments

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    • The adoption level should be modified to a 2.
    • Under Limitations, Dependencies, and Preconditions for Consideration add the following:
      • The following transactions need to be implemented for interoperability purposes:
        • PAInitiationRequest and PAInitiationResponse
        • PARequest and PAResponse
        • PAAppealRequest and PAAppealResponse
        • PACancelRequest and PACancelResponse
      • Both the prescriber and the payer/processor/pharmacy benefits manager (PBM) must have their systems configured for the transaction in order to facilitate successful exchange.
    • Under Applicable Security Patterns for Consideration add the following:
      • Secure Communication – create a secure channel for client-to- serve and server-to-server communication.
      • Secure Message Router – securely route and enforce policy on inbound and outbound messages without interruption of delivery.
      • Authentication Enforcer – centralized authentication processes.
      • Authorization Enforcer – specifies access control policies.
      • Credential Tokenizer – encapsulate credentials as a security token for reuse (e.g., – SAML, Kerberos).
      • Assertion Builder – define processing logic for identity, authorization and attribute statements.
      • User Role – identifies the role asserted by the individual initiating the transaction.
      • Purpose of Use - Identifies the purpose for the transaction.