Article Contents

About Override Policies

An override policy is a pre-defined set of authorizations that can override limitations on a plan. Just like traditional policies, override policies can be created in advance, saved for later use, and reused multiple times. Since they are built in advance rather than in real-time, they are testable and less prone to error than individual authorizations created on the fly.

Contexts

Override policies are created in the Policy context. Once built, an override policy can be used by including it on a Patient or Group authorization.

Scenario

A pharmacy submits a claim for Gleveec and it is not a covered drug on the plan’s formulary. The cost and day supply submitted also exceed plan limitations. The plan administrator wants to approve the drug, cost, and day supply submitted.

This scenario can be addressed in one of two ways:

1. create three separate authorizations to override individual actions; or
2. use an override policy to override multiple actions

Before we go over both approaches, take a look at the formulary policy in the table below, it contains the authorizations we will be overriding in our scenario.

Key: A/N = Authorization Number, D/S = Day Supply, N = No, ONFORM = On Formulary, Y = Yes

🛈 The grayed-out authorizations in the table are comment authorizations. Check out the article Organizing with Comment Authorizations to learn more. 

Override Individual Actions with Separate Authorizations

The claim in our scenario triggers three plan default rejections:

• Drug not on formulary (DRUG: N)
• Day supply over 30 (DAYSUP: N)
• Cost over $1000 (COST: N)

To override all three plan defaults, create a separate Patient authorization for each:

Key: A/N = Authorization Number, D/S / DAYSUP = Day Supply, N = No, ONFORM = On Formulary, Y = Yes

See how each Patient authorization maps to the plan default it overrides:

Once all three authorizations are added to the Patient’s profile, the claim for Gleevec can be processed. If the submitted cost or day supply exceeds the Patient authorization limits ($5,000 or 60 days), the plan default rejection applies.

Drawback: You’ll repeat this process every time this patient (or any patient) needs the same exception. For recurring scenarios, an override policy can be more efficient (see the next section for an example).

Override Multiple Actions with One Override Policy

Instead of three separate authorizations, use a pre-built override policy. The example below uses a policy called Management Override (MGMTORIDE).

Key: A/N = Authorization Number, D/S / DAYSUP = Day Supply, mgmt = management, N = No, ONFORM = On Formulary, Y = Yes

The override policy contains:

• Authorizations with actions matching the authorizatinos we need to override: DRUG, DAYSUP, and COST.  
• A drug authorization (50000-003) with no GPI specified, so it works for any medication.
• limits that are less strict than the plan defaults (cost up to $5,000 vs. $1,000; day supply up to 60 vs. 30)

Here we can see the relationship between the authorizations in the MGMTORIDE policy and the formulary policy:

To apply this policy, create one Patient authorization that includes MGMTORIDE and specifies the drug (GPI):

🛈 Note: We don’t need to set an action in the Patient authorization because the actions are already defined in the policy. 

Now, when the pharmacy submits the claim for Gleevec Patient authorization 10000-020 overrides all three plan defaults at once:

Now, the claim in our scenario will process! What’s more, the same policy can be used to approve future fills for any patient.

If a submitted claim:

• exceeds the allowable cost set in 50000-001, the system will match on 89999-997 and return a rejection message to the pharmacy;
• exceeds the day supply set in 50000-002, the system will match on 89999-998 and return a rejection message to the pharmacy;
• is for an unapproved drug, the system will match on 89999-998 and return a rejection message to the pharmacy.

Summary

Creating authorizations one by one to override individual actions is valid but can be time-consuming and error-prone. Pre-built override policies offer an alternative solution. Although they require planning, override policies improve long-term efficiency. Override policies for common scenarios can be created in advance and included in a single authorization, streamlining the override process. This approach also allows for review and testing before use, ensuring confidence in its effectiveness.