Medicare Part D Plans Required to Support Electronic Prior Authorization

Regulations concerning the Medicare Prescription Drug Benefit program’s (Part D) e-prescribing requirement under the “Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act” or the “SUPPORT Act” will be put into practice.  These newly adopted standards for Part D e-prescribing will ensure secure electronic prior authorization (ePA) requests and response transmissions.

The SUPPORT Act authorizes the Centers for Medicare & Medicaid Services (CMS) to require ePA capability for processing prior authorization requests by Medicare Part D Plans for Part D-covered drugs prescribed to Part D-eligible individuals. Utilizing the NCPDP SCRIPT standard version 2017071, prescribers are required to supply clinical information, such as a patient’s diagnosis, before the prescription is sent to the pharmacy.  The goal is ultimately to ensure that patients receive their medications in a timely manner and that the process is not delayed by the traditional prior authorization procedure.  Prescribers, as part of this new standard, should be able to initiate and manage the process for Part D drug coverage approvals within their electronic prescribing systems.  Surescripts indicates that many top EHRs are already certified for ePA.[i]

A single ePA standard was mandated by CMS because, “In order to ensure that ePA permeates across the industry for Part D and that multiple Part D stakeholders can participate in it, we believe that one Part D ePA standard should be used rather than simply allowing any stakeholder to use his/her preferred standard.”[ii]  While these new regulations will certainly result in a major change in how prior authorizations are handled electronically, prescribers are still free to use existing non-electronic methods of managing PAs; Part D plans are similarly still required to accept any of these requests, such as those sent via facsimile.  CMS states that the NCPDP SCRIPT standard version 2017071 was chosen over other standards, such as X12 278 (Health Care Services Review Information transaction set), because its standardized fields were more relevant for medication use and other mandatory questions. Additionally, the X12 278 standard was determined to be more relevant to dental, professional, and institutional requests for review and response based on its current functionalities.

While the SUPPORT Act established a January 1, 2021 deadline for requiring the capability of ePA by Part D plans, considering the current public health emergency, CMS will begin enforcing this mandate January 1, 2022.

“We believe that the January 1, 2022 deadline affords sufficient time to ensure compliance with this rule. Although we understand the request for a 24-month implementation timeframe, we believe that the implementation date in this final rule appropriately balances the benefits of adoption of the standard and the time needed to ensure compliance. We also note that this is only a requirement for Part D plans—not providers—so we do not believe that the additional 12 months for providers to adopt updates needs to be accounted for in the implementation timeframe. As a result of our decision to delay requiring use of the standard until January 1, 2022, we do not anticipate using enforcement discretion.”[ii]

The potential impact is not known at this time, but it is likely that the effects of these standards will influence commercial and Medicaid markets in the future. An increasing number of payers, prescribers, and pharmacies may seek uniformity across lines of business and adopt more widespread ePA usage as a result.

[i] https://surescripts.com/enhance-prescribing/prior-authorization/

[ii] https://www.federalregister.gov/documents/2020/12/31/2020-28877/medicare-program-secure-electronic-prior-authorization-for-medicare-part-d

 

Posted: February 2021

 

 

Leave a Reply