Prior Authorization : Submission Options

NCPDP Transactions

ForwardHealth accepts the following NCPDP Telecommunication Standard Version D.0 PA transactions: P2 reversal, P3 inquiry, and the P4 request. These transactions enable providers to reverse or inactivate a PA, inquire about PA status, or submit a PA request.

Providers should work closely with their software vendors or information technology staff and software user guides to ensure that electronic PAs are submitted accurately according to the ForwardHealth Payer Sheet: National Council for Prescription Drug Programs Version D.0.

The following are descriptions and/or requirements for each type of NCPDP PA transaction:

P2 Reversal

To reverse a PA (i.e., change the PA to an inactive status) using the P2 transaction, all of the following must be true:

• The provider is the original provider who submitted the PA.
• The PA is in one of the following statuses:
• Approved — The PA request was approved.
• Returned — Provider Review: The PA request was returned to the provider for correction or for additional information.
• Pending — Fiscal Agent Review: The PA request is being reviewed by the fiscal agent.
• Pending — State Review: The PA request is being reviewed by the state.
• Suspended — Provider Sending Information: The PA request was submitted via the ForwardHealth Portal and the provider indicated they will be sending additional supporting information on paper.
• None of the services on an approved PA have been used.

P3 Inquiry

Providers may inquire about PAs they have previously submitted and receive PA information from ForwardHealth by submitting a P3 inquiry transaction. ForwardHealth recommends indicating the PA number, if known, when submitting a P3 inquiry. If a PA number is not included on the P3 inquiry, the most recent matching PA number will be reported.

P4 Request

Providers may submit an initial PA request using the P4 request transaction; however, this will not result in a real-time approval. The P4 request transaction does not allow providers to submit the required clinical information needed to adjudicate the PA request.

After submitting a PA request via the P4 transaction, providers will receive a real-time response indicating whether the transaction is accepted or rejected. If the transaction is rejected, the response will indicate a reject reason(s), and providers can correct and submit a new PA request using the P4 transaction.

An accepted P4 transaction with a captured response status will include a PA number. The PA request will be placed in a status of "Pending — Fiscal Agent Review."

Uploading Additional Documentation

Once providers receive the PA number, they may upload additional documentation (e.g., the PA attachment, supporting clinical information) for the pending PA through the Portal.

After receiving the additional documentation, ForwardHealth will adjudicate the PA request and send the provider either a decision notice or a returned provider review letter.

Returned Provider Review Letter

Once the PA request is in a Pending — Fiscal Agent Review status, ForwardHealth will review the request and, if the additional documentation has not been submitted, will send providers a returned provider review letter indicating the information required to adjudicate the request. PA requests cannot be adjudicated until ForwardHealth receives the additional information.

After receiving a returned provider review letter, providers should submit the additional information through the Portal, fax, or mail if they have not already done so. Providers have 30 calendar days from the date on the returned provider review letter to submit the additional information or the PA request will become inactive. After a PA request has become inactive, providers can submit a new request using the P4 transaction.