CoverMyMeds ePA

This article describes the functionality of the CoverMyMeds ePA task list. This list is composed of Electronic Prior Authorizations for medications, routed through CoverMyMeds and eventually direct connections to the Payers/PBMs. This document will describe the steps for configuring, accessing, using, and ultimately completing an ePA.

Prerequisites & Configurations

Features

• CoverMyMeds (Legacy SSO)
• CoverMyMeds ePA Integration

Settings

• The settings below are REQUIRED for the Prospective ePA workflow, to begin an ePA with CoverMyMeds, it must first be determined that the prescribed medication requires prior authorization. This is done via the Real-Time Benefit Check (RxBC) functionality on the prescription pad. These settings enable the RxBC to be run when printing/sending/queuing a prescription:
  • Company Setting: Run Real-Time Prescription Benefit Check (RxBC) = True/Checked
  • User Setting: Run Real-Time Prescription Benefit Check (RxBC) = True/Checked
• The two settings below are optional, but recommended. These dictate the default assignee of the ePA Task Item when prescribing a medication that returns "PA Required". The User or User Group will see the ePA task in their CoverMyMeds ePA task list.
  • Company Setting: EPA Processor (optional) = User/User Group
  • User Setting: EPA Processor (optional) = User/User Group

Role

• The "My Tasks - CMM ePA" security screen will need to be enabled for the applicable roles. Write access will need to be granted.
  1. Setup > Roles > Search "CMM ePA"
  2. Set applicable access
  3. Save

ePA Process Step by Step

This section describes an expected workflow of the CoverMyMeds ePA process. Given the ePA process is a coordinated effort between the ePA Task assignee/prescriber, and Payer/PBM multiple variations to workflow or process can exist.

1. A user with appropriate settings enabled prescribes medication and the Benefit Check is run automatically at the time of print/send/queue. If the RxBC response is "PA Required" there will be an opportunity for the user to assign an ePA task to a user or user group. Utilizing the company and user settings for "EPA Processor", this value can default to a configured user/group.
   
   
   
2. Once, the "Print/Queue/Send as Prescribed" button is selected, the ePA task is created and is available to the assignee in the My Task List > CoverMyMeds ePA > My Assigned queue in the status of Initiated
   
3. The ePA processor will work their My Assigned list. The first status change will be from Initiated -> Follow Up this will mean there is a question set being presented that needs to be completed in order for the Payer/PBM to adjudicate the request.
   Complete the question set and submit the answers. This will change that status from Follow Up -> Submitted
   • Some cases may require attachments to be included with the ePA submission. In the header of the ePA task there is an icon that will pull up a screen allowing a user to attach either a SOAP Note, Order Result, or eDocument.
     
4. When the payer responds to the submission the task will either contain the adjudication and may be returned as Denied or Approved. The payer may also ask additional questions after the initial set, in this case, the ePA processor would work to submit the question set again. Otherwise, a user will complete the necessary steps to complete the PA such as calling the patient or communicating with the prescriber to determine an alternative treatment plan. In either case, the user will need to mark any "Pending" ePA as Complete in order to remove it from the My Assigned list and into the Completed category.