Prior authorization API

Overview

Under medical and prescription drug benefit plans, certain medications may need approval from your health insurance carrier before they’re covered - also known as a prior authorization (PA). Medications that require prior authorization will only be covered by your plan if your doctor requests and receives approval from your health insurance company.

We make this process simple and efficient using the Truepill API. We leverage our own internal workflows and use industry-standard CoverMyMeds for electronic prior authorization workflows.

Our prior authorization and specifically electronic prior authorization (ePA) workflows are based the NCPDP SCRIPT standard for ePA.

Prospective vs retrospective

There are two ways you can trigger a prior authorization request - they are commonly referred to as “prospectively” by a doctor or “retrospectively” after a claim rejection in the pharmacy. A majority of PAs today are still handled retrospectively at the pharmacy. We will cover the retrospective approach in more detail here and cover the prospective approach in more detail in our Telehealth API.

Using Copay request API vs Prior authorization API

We provide a streamlined approach to managing your PA process within your Copay Request or a more robust process with our Prior authorization API. It’s important to note that the end result is exactly the same - an approved or rejected PA request from the insurer.

Determining which pathway to use is largely dependent on the therapy class and/or medication being dispensed. If you know the medication being dispensed has a low or moderate prevalence of PAs, then you may choose to use the copay request since a bulk of your Copay Requests will be returned successfully without a PA rejection.

Alternatively, if you know the medication being dispensed requires PAs 100% of the time (most specialty products), then we recommend using our Prior Authorization which will provide finer controls to managing your PA process. Our Prior authorization API can also provide you a real-time prediction on whether a PA will be required based on the insurance and medication details provided.

Prior authorization request

Overview

In this section, we will cover the retrospective prior authorization process as a result of a PA- rejected insurance claim at the pharmacy.

Create a prior authorization request

A prior authorization can be created using our /prior_authorization API endpoint. Truepill will provide a receipt confirmation of the request, and multiple subsequent webhook events throughout the lifecycle of your PA.

Create prior authorization

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Success response

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Managing the prior authorization workflow

There are two types of PA requests: ePA, and a traditional PA. Both of them are managed in the Prior authorization API. Traditional PA requests are used with payers who have not yet adopted the new digital standard. The major difference between the two approaches is in the workflow as reflected in the different status updates you will receive.

Status updates are sent using a webhook event referencing your prior authorization request_id. You can reference the prior_auth_type field to determine which type of prior authorization workflow applies to your PA request.

Success webhook event

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Workflow status

There are different workflow statuses between the two types of PA request. The table below summarizes the status updates common between both approaches.

StatusDefinition
NewThe PA has been created, but not yet submitted to plan. Typically a PA in this status is awaiting action by the provider.
SubmittedThe PA has been submitted to the payer for approval
PendingThe payer is working to make a determination
ApprovedThe PA has been approved by the payer
DeclinedThe PA has been rejected by the payer
CancelledThe PA was successfully cancelled
AppealedThe PA was appealed and the payer is working to make a determination

Initiating a prior authorization from copay request

The prior authorization workflow is covered in full detail in the Prior Authorization Guide. If you need a more streamlined way to manage your PA process, you can do so from within your Copay Request.

Our approach to prior authorizations is to automatically initiate electronic PA requests at the point of claim rejection. If you intend to leverage our PA workflow, you can set the initiate_prior_authorization field to true on the Copay Request object.

Once a prior authorization is initiated by Truepill, we will notify you at various stages of the PA process through webhook events.

New prior authorization request webhook:

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Pending prior authorization request webhook:

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Approved prior authorization request webhook:

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Once a prior authorization request is approved, your webhook event for the Copay Request will look identical to a standard successful copay request. It and will be processed seconds after receiving a PA approval.

Success webhook event

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Using Prior authorization API vs Copay request API

We provide a streamlined approach to managing your PA process within your copay request - and a more robust process with our Prior authorization API. Note that the end result is exactly the same - an approved or rejected PA request from the insurer.

Determining which pathway to use depends on the therapy class and/or medication being dispensed. If you know the medication being dispensed has a low or moderate prevalence of PAs, then you may choose to use the copay request approach since a bulk of your copay requests will be returned successfully without a PA rejection.

Alternatively, if you know the medication being dispensed requires PAs 100% of the time (most specialty products), then we recommend using our Prior authorization API which provides finer controls to managing your PA process. Our Prior authorization API can also provide you a real-time prediction on whether a PA will be required based on the insurance and medication details provided.

Optimizing for time to fill

Time to fill is a duration that represents the number of days it takes to get medication out to the patient. For medications requiring a PA, the industry-average time to fill is 5-7 days.

We have aligned our entire pharmacy operation around this metric that is aligned with your success. On average our ability to turn around a PA-required prescription is nearly 24-48 hours faster than the industry average. We know this because we’ve hired some of the best and brightest leaders from the specialty pharmacy world.

Many of the largest specialty pharmacies in the country today will retry a PA claim every 24-48 hours as part of their daily PA queue management process. This has a significant impact on your patients. Let’s walk through how this impacts your patient journey:

Traditional specialty way

Monday 9:00am Traditional specialty pharmacy runs claim to check on PA status. PA pending.

Monday 9:01am Insurer approves PA, sends approval notification to pharmacy.

Wednesday: 48 hours later, specialty pharmacy runs claim. PA approved. Order then goes through the pharmacy fulfillment process.

The Truepill way

Monday 9:00am Truepill pharmacy runs claim to check on PA status. PA pending.

Monday 9:01am Insurer approves PA, sends approval notification to Truepill.

Monday 9:01:01am: Truepill notifies you of approved PA along with claim adjudication details.

Monday 9:01:02am: You send a FillRequest that kicks off the pharmacy fulfillment process.

Monday: Order shipped.

The net result is patients on average receiving their medications 24-48 hours sooner than the industry -average.

Prior authorization API Reference →

Electronic benefits investigation

Overview

A benefits investigation is the process of determining your patient's plan and coverage details for a specific medication. The details are determined by your patient's health plan which outlines the plan benefits and individual care plan.

In the Truepill ecosystem, an electronic benefits investigation is the process that enables youthe ability to determine benefit design, coverage requirements, and coding guidance. There are many variables associated with each patient’s benefits, and there may be differences by state and/or by site of care.

Multiple insurances

There may be cases where your patient has multiple health plans that provide benefit coverage, such as a commercial health plan and Medicaid.

Another common example is the use of primary insurance, combined with a manufacturer copay assistance program provided as secondary insurance. In the case of multiple health plans, it is important to establish during the Benefits Investigation which payer is primary, which is secondary, and which is tertiary. Please refer to our Insurance billing APIs to determine how to use multiple insurances for your patient.

Out of pocket expense

A patient's OOP costs may vary based on the specific benefit design and current state of their prescription benefit (i.e. deductible threshold cleared). Once your have insurance details for your patients, you can use our Copay request API endpoints to determine the exact OOP expense for your patient and given medication.

Medical vs. pharmacy benefit

It is important to understand a patient's plan design as it relates to their medication vs. pharmacy benefit. Typically, when working with Truepill you will be using your patient's prescription benefit which generally covers drugs that are self-administered orally, given by injection or inhaled.