Electronic Prior Authorization (ePA) Description

What is ePA

Electronic Prior Authorization (ePA) is a digital process that allows healthcare providers to submit medication prior authorization (PA) requests directly to a patient's insurance provider through integrated electronic health record (EHR) or prescribing systems. The goal is to streamline approval workflows for drugs that require payer review before dispensing.

Instead of relying on manual forms, faxes, or phone calls, ePA automates the prior authorization lifecycle, improving efficiency, reducing delays, and increasing transparency for providers, pharmacies, and patients.

Why is ePA Used

ePA is typically triggered when a prescribed medication requires special approval from the patient’s insurance provider before it will be covered. This can happen due to:

• High medication cost

• Specialty drug designation

• Step therapy or clinical guideline enforcement

• Dose/quantity restrictions

• Non-formulary status

ePA ensures that requests, questions, and approvals/denials are exchanged electronically via real-time integrations with ePA service platforms and payer systems.

ScriptSure uses multiple third party technologies to manage ePA. 

ePA Status Definitions and Rules in ScriptSure

Each status in the ePA process represents a step in the lifecycle of a prior authorization request. Below are the meanings and rules for each one:

PA Pending

The prescription includes a drug that requires PA. The PA message is queued and awaiting provider approval. If the provider approves the prescription and sends it to the pharmacy, the PA message is then automatically sent to ePA service. If the provider denies the prescription, the PA message is deleted and never sent.

PA Submitted

The PA request has been successfully submitted to ePA service. The system is now awaiting a response from the payer via CMM, which could be a determination or a question set for more information.

PA Question

ePA service has responded with a question set. The user must complete and submit answers before the question set expires. Failure to respond may cause the PA process to be closed or denied.

PA Question (Follow-Up)

ePA service issued a follow-up question set. This indicates that additional information or clarification is required by the payer. It may involve documents, updated responses, or diagnosis details.

PA Approved

The PA request was approved by the payer via ePA service. The prescription is automatically released from hold and sent to the pharmacy. The pharmacy can now fill the prescription as coverage is confirmed.

PA Denied

The request was denied by the payer. The prescription remains on hold until a user decides to keep it on hold, delete it, or release it without coverage. The denial includes reasoning, which can be reviewed by the provider.

PA Partially Denied

Only part of the PA was approved. Common reasons include quantity limits, duration of therapy restrictions, or covered strength/formulation differences. The prescription remains on hold until a user acts. Suggested actions:

1. Review the payer message.

2. Modify the prescription if acceptable.

3. Resubmit if possible.

PA Closed

ePA service has closed the PA case, typically due to expiration or inaction. The prescription remains on hold, unless the closure was with the “CC” (PA Not Required) code. In that case, it is automatically released to pharmacy.

PA Cancel Requested

A user has initiated cancellation of the PA process via ePA service. This can occur manually or automatically (e.g., prescription deletion). The request is pending payer acknowledgment.

PA Cancelled

ePA service confirms that the PA cancellation was approved. The process is terminated and removed from active review.

PA Cancel Declined

Payer rejected the cancellation request. Common causes include the PA already being finalized, the process too far along, or a mismatch in patient or drug information.

PA Error

A technical or data error occurred during the PA workflow. This can happen during submission, transmission, or at the payer response stage. Action may be required to correct and reattempt submission.

Summary Table

Best Practices

• Always answer question sets before expiration.

• Review payer messages closely for denial reasons.

• Use “PA Cancel Requested” if a prescription is no longer needed.

• Address PA Errors quickly to prevent disruption in therapy.