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Welcome to the electronic Prior Authorization (ePA) information section! This section is focusses on the current prior authorization process and how it could be improved. It contains information about electronic prior authorization, the challenges it will solve in the current, largely manual process and some of the barriers to adoption.
In a fully electronic prior authorization (ePA) process, the preparation, submission, and adjudication of claims are made online. This is the way claims are processed for non-specialty drugs that do not require prior authorization.
Under an ePA claims process, prior authorization claims would be submitted and reviewed electronically by the ePA platform based on established algorithms.
Some, but not all, prior authorization claims would be approved for reimbursement without a manual review from payers. This is a goal for the future but not practical for the first generation ePA in Canada because the adjudication algorithms in place are complex and vary between payers.
A first generation electronic prior authorization process is available now and can be implemented as a first iteration of ePA in Canada. It replaces most steps in the current paper-based prior authorization process and can improve the logistics and timelines for prior authorization.
The adjudication of each claim would be based on the payer’s proprietary criteria and the reimbursement decision would be the result of a manual review by the payer. This first generation ePA solution will mean that all information related to the prior authorization claim resides online, including:
This is what a fully ePA submission and review process looks like:
* C&S represents the Claims and Submission platform used by prescribers, Patient Support Programs and Drug Access Navigators.
** Application Program Interface is a software intermediary that allows two applications to transfer information between them.
*** R&R is the payer’s Claims Receipt and Review platform.
The Simplify Prior Authorization initiative is an advocate for education about prior authorization (PA) and improvement in current prior authorization practices and processes. If your organization is interested in finding out more, getting involved, or in sponsorship of this important initiative, please contact us via the link below.
