Smarter Decisions, Superior Outcomes

4 Essential Keys to a Solid ePA Knowledge-base

Posted by Kathleen Sabo on February 2, 2016 at 8:30 AM

ePA will continue to gain momentum.

Electronic Prior Authorization (ePA) is not going anywhere—and, we're not talking about the folks who test drinking water and lobby for reduction of air pollutants. There has been a lot of talk about ePA over the past year. In fact, Google records nearly 3.9 million results for the term and nearly every week there is a legislative update, industry news story, or forum on the topic. Don't expect that to change this year.

With benefit managers struggling under the weight of requirements from Federal rules like HIPAA, HITECH, and Meaningful Use, as well as State regulations, ePA has become an essential strategy for the evolution of pharmacy benefit programming and maintaining regulatory standards. However, the value of ePA reaches much further than compliance. ePA substantially increases efficiency in the continuum of care for everyone, including providers, dispensers, patients, health plans, and payors. Faxing forms is cumbersome and depends on old, outdated technology. With ePA, a determination can be received in just minutes, often times when the patient is still in the doctor's office. And, this value is what providers have been waiting for.

While major attention has been paid to ePA in meetings, conferences, and industry shows over the past year, it is imperative to keep in mind that ePA is about much more than just simplifying the coverage determination process. ePA will continue to remain a hot topic in health care technology this year. But, let's remember that ePA is part of a much larger puzzle: full interoperability of all health care data. When you focus on the larger intent, you'll be able to make smart decisions about your ePA project. 

Health plans who recognize this value are moving toward an integrated approach to ePA implementation that is mindful to ePA standards. The following list outlines 4 Essential Keys to a Solid ePA Knowledge Base. Without a solid understand of these key areas, you may risk implementation of an ePA project that provides long-term success for your organization.

Here's what you need to know about ePA...  


4 Essential Keys to a Solid ePA Knowledge-base

1. Meaningful Use has been trumped by the Interoperability Roadmap (at least for now).

Signed into law in 2009 as part of the American Recovery and Reinvestment, the HITECH Act promotes the adoption of Meaningful Use of health information technology while addressing the privacy and security concerns that are associated with the electronic transmission of health information. ePA falls into the category of technologies that create Meaningful Use, and it is important for health plans to understand the intricacies of these two legislative efforts.

Meaningful Use Stage 1 was about capturing patient data electronically via Electronic Health Records systems (EHRs). Incentives for Stage 1 are not being paid any longer. This phase has ended even though very few systems across the country have implemented because of complexity and cost. CMS doesn't care which EHR, they just wanted providers to use one. The standards will allow them to share health care data, and share it securely.

Meaningful Use Stage 2 emphasizes care coordination and electronic exchange of patient information. This is right where ePA comes into play. By submitting coverage determination requests electronically, responding with criteria questions, and returning determinations electronically between parties, such as providers, plans, payers, intermediaries, and coverage determination service providers, Stage 2 goals will be met and plans will be setting the course for superior health outcomes for their patients. 

CMS put major effort into developing and rolling out Meaningful Use and HITECH. But, it was clear that additional steps now outlined in Meaningful Use or HITECH would be necessary to meet the end goal. Enter Office of the National Coordinator for Health Information Technology (ONC). The ONC swooped in last year with further detail regarding how to achieve successful health care data sharing through their Interoperability Roadmap. Its pretty clear that the roadmap has trumped all previous plans and is reigning supreme. It certainly gives clarity to some of the vague and long-winded portions of the previous rules. Now, what ONC (and CMS) wants to know now is are you interoperable. Grants for state-run health programs are now being awarded to to interoperability projects rather than Meaningful Use adoption.

Further, we’re not surprised to see that Meaningful Use Stage 3 has been delayed because Stage 3 was designed to focus on improving health outcomes. Why does this matter? Interoperability, including successful ePA implementation, needs to be accomplished during Stage 2 in order to implement Stage 3 and effectively move to an HIE-enabled, outcomes-based reimbursement model‒the ultimate goal of CMS. Objectives are still being defined (or re-defined) so stay tuned!

4 Essential Keys to a Solid ePA Knowledge-base

2. Transaction standards are vital to creating a viable, successful ePA program.

Since the early 90s, the coverage determination process, often called the prior authorization (PA) request process, has been the bane of provider’s existence. Constant publishing of gripes and grimaces regarding the difficulties and dissenting approaches to this process based on plan, vendor, and service provider. So, the ONC, CMS, and NCPDP began to design a vision for the coverage determination process to be embedded in the e-Prescribing process. It just makes sense: prescribing takes place within the EHR, my PA request is linked to my script, the provider can data is populated in my ePA transaction directly from my EHR, the drug compendium helps the provider to choose valid dosages and forms, and I get a faster decision turnaround when making a PA request. The result is an NCPDP SCRIPT Standard for ePA transactions and it is vital to the ability for true interoperability establishment.

The ONC Interoperability Roadmap specifies ePA in the NCPDP SCRIPT Standard. And, States are including the Standard as a specific requirement of their ePA legislation. Why? They know that using a standard is going to ultimately make Interoperability work. NCPDP published NCPDP SCRIPT Standard 2013101, an approved SCRIPT Standard for ePA transactions and electronic prescribing. Use of the SCRIPT Standard is a requirement for Meaningful Use. Also, per NCPDP President Lee Ann Stember, the Standard “enables the health care industry to exchange prior authorization requirements for medications as part of the doctor-patient encounter” and enhances the electronic prescribing workflow to assist in more complete information exchange between stakeholders. In short, the Standard makes ePA processes consistent across the industry regardless of a provider’s EHR system.

There are a lot of vendors in the market space “doing ePA” without using the NCPDP SCRIPT Standard. While they may be implementing short-term successful projects, the long-term viability of these projects may cause risk to the organizations these Intermediaries serve. Without using the Standard, the project cannot meet the Interoperability Roadmap. And, let’s remember that ePA is just a piece of the big picture.

4 Essential Keys to a Solid ePA Knowledge-base

3. Each State has it's own ePA rules.

The ePA process has a large assortment of stakeholders—prescribers, payers, pharmacists, patients, intermediaries, and the federal government. But there is one actor often left from the list that has considerable impact on ePA rules and regulations: your State.

State legislatures are rapidly mandating ePA. Some States have required a standardized request form, some states have legislative rules for ePA in progress, and some states have already passed legislation. And, all current legislation requires the NCPDP SCRIPT Standard. Become familiar with your State's mandates. Many of them require health plans to meet specific ePA "go live" deadlines. And, we’re certain you prefer not to be fined for non-compliance.

4 Essential Keys to a Solid ePA Knowledge-base

4. Making informed decisions about implementation approach will determine your success.

With a deeper understanding of the federal and state laws guiding ePA, you might be ready to procure a system and implement the process. But ePA is only possible through thoughtful, consistent coordination of stakeholders.

Every state has an HIE and all major PBMs are already participating e-prescribers because its CMS required for Medicaid and Medicare. Why does this matter for ePA implementation? (Stay with us here…) 

  • Chances are that you're already e-prrescribing since it is required by CMS, so if you are you have an ASC X12 270/271 transaction already in place.


  • You're contracted with an Intermediary.


  • Most e-prescribing Intermediaries already have ePA capabilities that can utilize the e-prescribing integration.

It's our recommendation that your first conversation is with your e-prescribing Intermediary in order to facilitate the most effective and efficient Interoperability program for your plan. Don't fall into the trap of believing that you need a new Intermediary to support ePA requirements. Take care to use an e-prescribing Intermediary so that you are set to meet full Interoperability requirement compliance. If you chart another course, you may be coming back to shore sooner than you hoped.

Each stakeholder plays a crucial role for short and long term success.

It's time to get moving if you haven't already.

Now that you have the key knowledge base under your belt, you need to get moving. ePA implementation is not quick and dirty. It takes careful organizational assessment, strategic planning, and smart execution.  The Interoperability Roadmap is long and there is much to accomplish. 

We’re not an Intermediary, but we have working relationships with many of them. As an independent, objective clinical services organization, our experts are here to provide guidance and consulting on implementing ePA programs, including Intermediary and HIE considerations. Download our ePA Pre-Implementation Assessment to make sure you have all your ducks in a row.




Topics: Interoperability, NCPDP Standards, ePA, Meaningful Use, Coverage Determination Process, Prior Authorization, Interoperability Roadmap

Independent & Objective

Clinical expertise without the noise

Getting the facts matters. Following our corporate mission, we're committed to using this blog to enhance your knowledge of evolutionary events and discussions in the pharmacy services and technology arena. 

Here's what we're focused on right now:

  • Lowering ingredient cost
  • Enhancing the coverage determination process
  • Creating robust prior authorization criteria
  • Producing actionable drug trend analyses
  • Enhancing prescription drug monitoring 
  • Implementing interoperability efforts

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