Improving Prior Authorization

Most stakeholders in the group benefits industry now recognize that improving the prior authorization claims process is necessary, and increasingly payers agree.

There are several reasons to support change in the prior authorization claims process:

An increasing number of specialty drugs are being introduced into the Canadian landscape
The use of prior authorization as a group drug benefits management tool is growing with the introduction of new prior authorization drugs, as are plan maximums, typically for smaller groups
Preparing and administering prior authorization claims has a high administrative and cost burden, not only for payers, but for physicians, patient support programs (PSPs), drug access navigators (DANs), and pharmaceutical manufacturers.

Technology is now available that provides an efficient electronic claims preparation and submission (ePA) solution for all prior authorization stakeholders, and it comes with several benefits:

Plan members, patients, physicians, patient support programs (PSPs) and drug access navigators (DANs) can securely complete and review claims information online, attach medical documentation, and add signatures.
Payers can receive and download prior authorization claims documentation electronically for their review.

There are other benefits to ePA, including:

Reduced timelines for submission, receipt, review, and response for prior authorization claims
Elimination of duplication and lost or missing claim forms, medical documentation, and correspondence
Reduced administration costs

The technology for a first generation agnostic electronic prior authorization solution (ePA) is available today.

Today’s ePA solution does not include claims criteria. It was developed with the ability for each payer to apply their own unique proprietary criteria for adjudicating prior authorization claims.

As a result these claims will be adjudicated manually in this first generation ePA solution. Second generation ePA will add algorithms based on each payers’ unique criteria, which will mean that there can be automation of some or most prior authorization claims based on each payers’ discretion.

For more information on this first generation ePA solution please contact info@simplifypriorauth.ca.

Insurer and Pharmacy Benefits Manager

Improving Prior Authorization​

Improving Prior Authorization