Automated Drug Prior Authorization System
Industry Challenge
Prior authorization (PA) programs manage costs by requiring prescribers to obtain approval before prescribing a non-preferred medication. However, a common concern is that PA processing can be time-consuming for both providers and patients.
Solution
HID’s RxPert® PA application provides a fully automated solution for PA processing. RxPert, an Internet browser-based pharmacy PA system, provides automated PA processing with point of sale (POS) data capture and clinical edit screening. Its innovative design provides processing and speed advantages over other automated PA solutions.
RxPert checks claims received at the point of sale against its database of patient information, which includes pharmacy, medical and diagnosis data. If the required criteria for approval are met, RxPert immediately issues the PA approval to the POS claims processing vendor, which passes it on to the pharmacist. If the criteria are not met or if there are other reasons the PA cannot be approved, RxPert indicates that a manual PA is needed. The provider can submit a PA request for further clinical evaluation using an online form, via fax, or over the phone.
RxPert’s internal logic and technical design are the reasons it can adjudicate claims so quickly. HID constructed the RxPert database using methods that optimize PA processing. RxPert loads only data relevant to the PA process and organizes and indexes the data so that information specific to any particular PA request can be located very rapidly.
Features
- Automated claims screening. RxPert’s Clinical Editing engine screens claims against beneficiary information derived from the Medical and Pharmacy Claims database.
- Rapid claims assessment. RxPert completes its assessment of every claim less than a second (average processing time is 500 milliseconds).
- Secure access to data. All PA activities are posted electronically. Agency staff can access data securely using an Internet browser.
- Electronic PA request interchange. There is no intermediary between RxPert and the POS claims processing system; transactions are communicated directly between them.
Benefits
- Decreased cost through minimized physician paperwork. RxPert eliminates a significant amount of paperwork for physicians.
- Minimized need for manual PA processing. RxPert refers claims for clinical evaluation only if they cannot be approved through the Clinical Editing engine.
- Decreased telephone traffic. RxPert decreases call center telephone traffic for the Medicaid agency or healthcare program manager.
For more information on how RxPert can help your organization, contact us. For a product brochure, click here.