Article Contents

About Actions

Actions are administrator-defined categories the system uses to organize authorizations into sets. They classify authorizations, describe the managed parameter, and specify whether processing behaviors should be overridden (i.e., p-codes). Each action is comprised of a code and a value.

Action codes are abbreviated descriptions of the parameter associated with the authorization, such as COST (allow cost), ONFORM (on formulary), or DRUG (allow drug). Action values are tags that describe the intended behavior of the authorization; examples include yes, no, and ignore.

How the System Uses Actions

During claims processing, the Authorization System goes through authorizations with the same action code in ascending order. An authorization with a “Drug” action will be grouped with other authorizations with the “Drug” action, an authorization with a “Cost” action will be grouped with other authorizations with a “Cost” action, and so on. Selectors set in the authorizations are compared to claim facts. Once a match is identified between the authorization selectors and claim facts, the system either processes the claim or generates a rejection message for the pharmacy. The outcome depends on whether the matched authorization has a rejection tied to it or not.

The diagram below shows claim facts being checked against authorizations at runtime. In the diagram, a match is found on A/N 89999-996. The matched authorization has a rejection attached. So, the system returns a rejection message to the pharmacy.

Expanding the Action Set

The system comes loaded with a set of actions to help you get started quickly. These are based on parameters commonly used in plan design, such as drug, cost, and day supply allowances. And now, new actions can be added at any time!

Creating new actions allows you to:

• define categories for different types of authorizations.
• streamline authorization tracking and management.
• align action codes and values to the terminology used by your organization.

Currently, only EHO360 account managers can add new actions in the system, but this feature may be expanded to users in the future. In the meantime, let your account manager know your requirements, and they will collaborate with you to develop actions to meet your needs.

Scenario

Let’s look at a scenario that shows how to utilize a new action within an existing framework.

The plan designer needs to implement an administrative block on paroxetine at the Group level. It must take priority over the current formulary.

The contexts, authorization number (A/N) ranges, action codes, and action values for the existing authorizations on the plan (Plan A) are in the tables below.

The existing authorizations for Plan A are listed in the table below. 

🛈 Dashes are included in A/Ns to improve readability. Do not include dashes when entering A/Ns into the system interface or imported files.

Scenario Solution

We’ll address the scenario with an action called “Admin Blocks.” The action code is  ADMIN and the value is Block.

In the swimlane diagram below you can see the new action, ADMIN, together with the existing authorizations for Plan A. The authorizations are grouped by action code: DRUG (yellow), COST (green), DAYSUP (purple), and ADMIN (orange).

Next, we’ll create a policy called “Blocked Drugs.”

Every policy requires at least one authorization. Our policy will have two: a disabled comment authorization (A/N 64900-000) and an enabled authorization for paroxetine with the GPI selector (A/N 64900-005). Both are listed in the table below.

🛈 Discover how comment authorizations can help you stay organized. Read the article Organizing with Comment Authorizations here.

🛈 Did you know: You can leave the action field empty in your policy and set it in the “include authorization” instead. This way the same policy can be reused in various contexts and with different actions, without modification.

Now that the policy is created, we need to activate it by including it in an authorization.

The scenario states the block applies at the group level. So, we will include the policy in a Group authorization with the following:

• • An eight-digit A/N within the established range for Group authorizations. For our purposes, the number should be smaller than the approved drug authorization (A/N 55000-005) so it is checked first.
  • The Blocked Drugs policy included. 
  • The action code and value, ADMIN: Block, set.
  • No selectors; the GPI selector is already specified in the policy!
  • A relevant rejection code, such as 70 Product/Service Not Covered.

Here’s an updated list of authorizations for Plan A. The new Group authorization with the Blocked Drugs policy included is highlighted in orange.

 🛈 It is important to have a rejection authorization to counter approval authorizations, but it is possible to have a rejection authorization without an approval authorization!

Here are the same authorizations from the table above organized into swimlanes according to action. The new authorization is in the ADMIN column (orange). 

A block on paroxetine has been added at the Group level (A/N 54900-020). The system will apply the authorization to incoming claims as appropriate. A “70 Product Not Covered” message will be returned if a claim for paroxetine is submitted. Utilizing a policy for the block means more drugs can be added to the list if needed. Additionally, the same authorization (A/N 54900-020) can be applied to incoming claims for drugs on the list. There is no need to create multiple authorizations.

Claim Facts Checked Against Authorizations

The following diagram is an updated version of the graphic introduced earlier in this article. In this image, the system performs a check between claim facts and authorizations. A match is found on A/N 54900-020, and the system sends a rejection message to the pharmacy. The rejection message is specific to the reason for the rejection, ensuring easy interpretation by the pharmacy.

Conclusion

In this article, we discussed how developing your own actions can aid in authorization management. The scenario described  illustrates the utilization of a new action within an existing framework in combination with a policy. Consult with your account manager for help developing and integrating new actions into 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