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The HITSP Pharmacy to Health Plan Authorization Request and Response Transaction is intended to provide a mechanism for a pharmacy to request approval from a health plan to authorize certain healthcare products and services, as required by the patients health plan contract. The health plan responds to the pharmacys request for the approval of products and/or services. The information exchanged includes, but is not limited to, approval status for coverage of the products and/or services that are included in the patients health plan benefits, and/or authorization limitations.
The Pharmacy Prior Authorization is done for evaluation of impact for (but not restricted to):
Alternative medications information is retrieved so the pharmacy and patient can discuss alternatives available (such as generic or lower tier products). The alternative choice may require a modification of the prescription
Patient liability and plan restrictions information is retrieved so the pharmacy can discuss with the patient their financial impact. The pharmacy and patient can discuss if that course of therapy is still to be done or decide if another therapy should be pursued
Whether clinical protocols/regiments/therapies have been followed
For HITSP purposes, the term Health Plan is used for prior pharmacy authorization which allows a Pharmacy Benefit Manager (PBM), payer, processor, health plan, or any entity to perform the approval process on behalf of the health plan. While each of these entities may perform other functions in the healthcare arena, specifically for processing pharmacy products and services, the prior pharmacy authorization functions as, and is grouped together, under one term Health Plan.
The HITSP Pharmacy to Health Plan Authorization Request and Response Transaction uses the National Council for Prescription Drug Programs (NCPDP) Telecommunication Standard Implementation Guide Prior Authorization Suite of Transactions. These transactions provide standards to accommodate the exchange of information between an information requester (pharmacy settings) and any information source such as a review entity, utilization management organization, health plan, an insurance company or a third-party administrator. The NCPDP Prior Authorization Suite of Transactions is request and response based, used in real-time or batch environments.
The HITSP/TP46 Medication Formulary and Benefits Information Transaction Package may also be used if the pharmacy would like to only check eligibility, or if the pharmacy would like to perform a predetermination of benefits.
2009 ANSI. This material may be copied without permission from ANSI only if and to the extent that the text is not altered in any fashion and ANSIs copyright is clearly noted.
This section provides a list of key reference documents and background material.
A list of key reference documents and background material is provided in the table below. These documents can be retrieved from www.hitsp.org.
Table 1-1 Reference Documents
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Reference Document |
Document Description |
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Lists and defines the acronyms used in this document |
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Provides definitions for relevant terms used by HITSP documents |
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TN900 is a reference document that provides the overall context for use of the HITSP Security and Privacy constructs |
This section describes the conformance criteria, which are objective statements of requirements that can be used to determine if a specific behavior, function, interface, or code set has been implemented correctly.
In order to claim conformance to this construct specification, an implementation must satisfy all the requirements and mandatory statements listed in this specification, the associated HITSP Interoperability Specification, its associated construct specifications, as well as conformance criteria from the selected base and composite standards. A conformant system must also implement all of the required interfaces within the scope, subset or implementation option that is selected from the associated Interoperability Specification.
Claims of conformance may only be made for the overall HITSP Interoperability Specification or Capability with which this construct is associated.
A HITSP Interoperability Specification must be implemented in its entirety for an implementation to claim conformance to the specification. HITSP may define the permissibility for interface scoping, subsetting or implementation options by which the specification may be implemented in a limited manner. Such scoping, subsetting and options may extend to associated constructs, such as this construct. This construct must implement all requirements within the selected scope, subset or options as defined in the associated Interoperability Specification to claim conformance.
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