RFI Browser

Back  RFI # 2256: Use of 278 for PA Effectuation

Formal vs. Informal Help Informal Formal

Submitter

Dale Zinkgraf

Description

I have a scenario where our company is doing clinical reviews for drugs covered under medical insurance plans. When we are done with the review we want to send an EDI msg to our client to actually setup the prior authorization(PA) in their system and send us back a confirmation that the PA has been setup. I was wondering if the 278 would be an appropriate standard for this situation. My concern is that your standard really starts with the PA request and the decision response and how we want to use it would be like starting in the middle of the process and adding the validation that the PA has been setup at the end of the process. If a company was setup to support 278 I am assuming that they are expecting to receive a PA Request and not a decision so would this work? Would you recommend still using 278 or a different standard or should we make a custom EDI layout for our purpose?

Submitter Assigned Keywords

278 usage prior authorization setup effectuation PA

Response

Please be advised that there are three different 278 implementations that support three different business use cases. The appropriate implementation for your business use case would be the Health Care Services Review Notification and Acknowledgment (278).

Recommendation

We recommend that once your company has completed the clinical review, using the 278 Notification/Acknowledgment to notify the client to setup their prior authorization (PA) in their system and send an Acknowledgment to confirm that the PA has been setup
Submission 11/28/2017
Status Date 2/22/2018
Status F - Final
Primary References
Document 004010X094
Section3-37