The Authorization System’s Transaction Count feature adds more flexibility to existing tracking and override capabilities. You can use it to keep an eye on prescription metrics over time, limit the number of fills allowed, and manage overrides. When set on an authorization, the system will automatically increase counts at the end of claims processing and decrease counts if a claim is reversed.

This article covers:

• which contexts the transaction counts can be used,
• when to use ‘Up To’ vs ‘Over’ fields,
• where to find transaction counts,
• options for checking an authorization with a transaction counter, and
• a scenario for each selector field to illustrate how to use the feature in different situations.

Article Contents

Contexts

Transaction count selectors can be used in the Patient and Policy Contexts. For example, add an authorization with a transaction count selector to a patient’s profile to override refill too soon, duplicate therapy, or prior authorization rejections. Or create a policy with transaction counts defined in the authorization(s). Then, include this policy in a Patient authorization when needed.

🛈 Transaction counts increase based on the context of an authorization and the selectors specified. In rare instances, a counter could be used in Group or Global contexts. However, the Patient context will be used in most cases.

About Transaction Count Fields

Transaction counters are managed using two fields in the selection section of the authorization form called Tx Count ‘Up To’ and Tx Count ‘Over.’ Both fields can be used with pharmacy, drug, and doctor selectors.

🛈  The professional service code, reason for service code, and result of service code selectors CANNOT be used with transaction count selectors. All three service code fields will be disabled if either of the Tx Count fields are filled.

Field Functions

The function of each transaction count (Tx Count) field is described in the table below.

When to Use ‘Up To’ vs ‘Over’

Up To

The ‘Up To’ field is recommended for prior authorization, refill too soon, and duplicate therapy overrides.

• Allows up to and including a certain number of transactions or fills.
• Is represented in the system interface with the “<” symbol. For example, “Count < 1” means that up to one transaction or fill is allowed.

 Over

The ‘Over‘ field can be used in two situations:

1. When an authorization needs to cause a rejection, in which case an NCPDP rejection code must also be assigned.
2. Set on an authorization without an action or rejection code to track prescription metrics over time.

The ‘Over‘ field:

• Restricts transactions or fills beyond a certain number. 
• Is represented by the  “>” symbol. For example, “Count > 1” means that no more than one transaction or fill is allowed.

How to View Transaction Counts

Once you’ve created an authorization with a transaction counter, you can view the associated transaction counts in a table at the bottom of the authorization form. The table includes:

• the counter ID (which is just for internal use),
• the count value (the total number of transactions),
• the date and time the authorization was created, and
• the authorization chain (which corresponds to the authorization number).

Confirming Authorization Behavior    

A new field called Counter Behavior has been added to the Check screen on staging. From there, you can test the behavior of authorizations with transaction counters by selecting one of the following options:

• Increment matched counters: This simulates a processed claim by increasing the count with each check. 

• Decrement matched counters: This simulates a reversed claim by decreasing the count with each check. 

• Do nothing: This keeps the count the same following a check. 

Scenarios

The section has two scenarios:

• Scenario 1 describes two approaches to using the Tx Count ‘Up To’ field to authorize a one-time fill for a patient.

• Scenario 2 explains how the Tx Count ‘Over’ field can be used to approve more than one fill for a patient and send a rejection message if the limit is exceeded.

Scenario 1

The plan administrator has approved a one-time fill for Truvada for a patient.

Below are two ways the Tx Count ‘Up To’ selector field can be set on an authorization to handle the scenario above.

Approach A: Add a Patient Authorization

Add a Patient authorization with the approved number of fills specified in the Tx Count ‘Up To’ field, and a drug selector, such as the NDC or GPI, specified. 

The table below shows an example of a Patient authorization (# 20000-005) followed by the plan default it’s meant to override (# 80000-100). In order to override the plan default, the Patient authorization must have a matching action (i.e., Drug – Allow Drug) and a smaller authorization number (A/N).

Key: A/N = Authorization Number, DRUG = Allow Drug, N = No, Y = Yes

When the patient’s Truvada claim is submitted, the system will match on the Patient authorization before the plan default (# 88000-100) and process the claim. Once matched, the transaction counts will increase by one and the patient authorization will automatically be disabled. Then, the plan default will take priority again and future claims for Truvada will not be processed until approved. 

Approach B: Authorization with an Include Policy

Policies offer a proactive approach to plan design. They can be created in advance, are reusable, and can be included on an authorization when needed. An Include Policy can be used to approve the Truvada fill for the patient in our scenario.

An example of a policy called Fill Limits – Drug is shown in the table below.

Key: A/N = Authorization Number, DRUG = Allow Drug, N = No, Y = Yes

To approve the Truvada fill for the patient, the above policy can be included in a Patient authorization. In addition to including the policy, you’ll need to specify a drug selector, such as the NDC or GPI, in the Patient authorization to make it applicable to the claim being processed.

The next table shows an example of a Patient authorization (# 20000-700) with the Fill Limits-Drug policy included and 10-digit GPI specified in the Selection field.

Key: A/N = Authorization Number, DRUG = Allow Drug, N = No, Y = Yes

🛈 Authorizations with policies included (i.e., include authorizations) do not need an action if actions are already set in the policy!

When the Truvada claim is submitted, the system will match on the Patient authorization before the plan default (# 88000-100) and process the claim. Then, the transaction counts will increase by one and the authorization will disable automatically allowing the plan default to take priority again.

🛈 Authorizations with the ‘Up To‘ selector field do not need a rejection code because they are automatically disabled when the specified limit is reached. Once used, the plan default will take priority again and return a rejection message to the pharmacy when needed.  

Scenario 2

The plan administrator needs to approve three fills of a drug for a patient and send a rejection message to the pharmacy if the limit is exceeded.

This scenario is a good use case for the Tx Count ‘Over’ selector field.  There is an example of the Patient authorization in the next table.

Key: A/N = Authorization Number, MAXFILL = Maximum Fills Allowed, M = Met

A/N 25000-400 has a custom action – “Maximum Fills Allowed.” Contact your account manager to learn more about custom actions and their use!

With the above Patient authorization enabled, the system will track the number of transactions for Truvada and increment the count for each processed claim.  The authorization will remain enabled, even after all authorized fills are used. The 76 Plan limitations exceeded rejection code and a “Max 3 fills” message will be returned if the limit is exceeded.

🛈 Authorizations with an ‘Over‘ selector must have a rejection code set to cause a rejection.

Summary

The Transaction Count feature enhances the Authorization System’s tracking and override capabilities. You can manage transaction counts using ‘Up To’ or ‘Over’ selector fields. The field used will depend on your needs. This article covered two scenarios, but there are many more ways to use this feature. We can’t wait to see how you use it in your plan design! 

Contact Support

Our team is here to help!

For plan-specific or urgent needs, contact your account manager directly.

For general Authorization System questions, contact EHO360 Operations at ops@ehorx.com