As part of EZ Scripts Pharmacy, being what a workers’ compensation pharmacy should be, we will continue onto another series of breakdowns of topics related to workers’ compensation.
Workers’ compensation is difficult for all stakeholders, and our goal is simple, to demystify elements of a complex industry.
For our third installment, we will address the Prior Authorization Process.
This series will cover the following topics:
- What Is Prior Authorization in Workers’ Compensation? https://www.ezrxmeds.com/what-is-prior-authorization/
- When Is Prior Authorization Required? https://www.ezrxmeds.com/when-is-prior-authorization-required-in-workers-compensation/
- The Prior Authorization Process: Step by Step.
- Why Prior Authorization Requests Get Denied.
- What Happens After a Prior Authorization Is Denied?
- How Prior Authorization Affects Injured Workers.
- Best Practices for Providers and Claims Professionals.
- The Future of Prior Authorization in Workers’ Compensation.
The Prior Authorization Process: Step by Step
When you are injured at work, getting the medication you need can be an important part of your recovery. However, workers’ compensation insurance may require prior authorization before certain medications are approved.
Workers’ compensation medication prior authorization is the process used by a workers’ compensation insurance carrier, claims administrator, or other authorized entity to review a prescribed medication before it is approved for payment. The process may involve reviewing the medication, the work related injury, treatment history, and applicable workers’ compensation guidelines.
Understanding how workers’ compensation prior authorization works can make the process easier to navigate and help you know what to expect when a prescription requires additional approval.
What Is Workers’ Compensation Medication Prior Authorization?
Workers’ compensation medication prior authorization is a review process that may be required before a medication prescribed for a work related injury or illness can be covered by workers’ compensation.
Unlike a standard health insurance prescription claim, workers’ compensation prescriptions are connected to a workers’ compensation claim. The medication generally needs to be related to the accepted or compensable workplace injury and meet the applicable requirements for coverage.
Requirements can vary depending on the state, workers’ compensation program, insurance carrier, employer, claim, medication, and treatment guidelines.
A medication may require authorization because of its cost, type, dosage, duration of treatment, applicable treatment guidelines, or other claim specific requirements.
Step 1: Your Healthcare Provider Prescribes the Medication
The process begins when your healthcare provider determines that medication is appropriate for your work related injury or condition.
The prescription is then submitted to a pharmacy for processing under the workers’ compensation claim.
At this stage, the pharmacy may determine that prior authorization is required before the medication can be dispensed and billed to workers’ compensation.
Step 2: The Pharmacy Identifies the Prior Authorization Requirement
When the pharmacy processes the prescription, the workers’ compensation claim information is reviewed.
If the medication requires prior authorization, the pharmacy may receive a response indicating that additional approval is necessary.
This does not necessarily mean that the medication has been denied. It means that additional information or approval may be required before the workers’ compensation payer will authorize payment.
The pharmacy may communicate the authorization requirement to the healthcare provider or claims administrator so that the appropriate review can begin.
Step 3: The Healthcare Provider Submits Supporting Information
The healthcare provider may need to provide documentation supporting the medication request. The provider may also need to explain why a particular medication is necessary and how it relates to the workers’ compensation claim.
Complete and accurate information can help the reviewing entity make a decision without unnecessary requests for additional documentation.
Step 4: The Workers’ Compensation Payer Reviews the Request
Once the prior authorization request has been submitted, the workers’ compensation payer or designated reviewer evaluates the request according to the applicable rules and guidelines.
Workers’ compensation requirements can vary significantly from state to state. Some states have specific drug formularies, treatment guidelines, utilization review requirements, or other processes that determine whether a medication requires authorization.
Because of these differences, the exact prior authorization process depends on the workers’ compensation jurisdiction and the details of the claim.
Step 5: The Request Is Approved, Denied, or Requires Additional Information
After reviewing the request, the workers’ compensation payer may approve the medication, deny the request, or request additional information.
Approved
If the medication is approved, the authorization can allow the pharmacy to process the prescription under the workers’ compensation claim.
The pharmacy may then be able to dispense the medication without requiring the patient to pay the usual retail prescription cost, provided the medication is covered under the claim and all applicable requirements are met.
Additional Information Requested
Sometimes the reviewer needs additional information before making a decision.
The healthcare provider may need to submit medical records, treatment history, clinical documentation, or an explanation of why the requested medication is necessary.
Responding to requests for additional information promptly can help prevent unnecessary delays.
Denied
If the request is denied, the denial should provide information about the reason for the decision and any available next steps. We will go more into details about why prior authorizations get denied in our next installment of our blog series, so stay tuned!
Step 6: The Pharmacy Processes the Approved Prescription
Once the medication has received the required authorization, the pharmacy can attempt to process the prescription through the workers’ compensation claim. The pharmacy may need specific claim information to submit the prescription correctly.
If the pharmacy continues to receive an authorization or billing rejection after approval has been communicated, the pharmacy, provider, and claims administrator may need to work together to determine what information is missing or what issue is preventing the prescription from processing.
How Patients Can Help Avoid Delays
Although much of the prior authorization process is handled between healthcare providers, pharmacies, and workers’ compensation payers, patients can still take steps to stay informed.
Make sure your healthcare provider has the correct workers’ compensation claim information. Let your provider know if the pharmacy tells you that authorization is required. Ask whether the authorization request has been submitted and whether the payer has requested additional information.
If a prescription is delayed, contact your provider rather than assuming the medication has been permanently denied. A delay may simply mean that the authorization process is still underway.
Keeping track of communications from your healthcare provider, pharmacy, and workers’ compensation claims representative can also help you understand where the request stands.
The Role of the Pharmacy in Workers’ Compensation Prior Authorization
The pharmacy plays an important role in identifying prescription coverage issues. When a prescription is submitted, the pharmacy processes the claim using the workers’ compensation information available to it. If the claim returns a prior authorization requirement, the pharmacy can communicate the issue to the appropriate parties.
Working with a workers’ compensation pharmacy may help, as they usually navigate prior authorizations in workers’ compensation more than a standard pharmacy.
How EZ Scripts Pharmacy Can Help
Getting medication after a workplace injury should be as straightforward as possible. When prior authorization is required, however, communication between the pharmacy, healthcare provider, and workers’ compensation payer can become an important part of the process.
EZ Scripts Pharmacy understands that workers’ compensation prescriptions can involve additional requirements beyond a traditional prescription claim. Our goal is to help make the prescription process easier and provide a convenient pharmacy experience for patients receiving medications related to workplace injuries.
Call 443.290.6337 or visit to https://www.ezrxmeds.com/sign-up-today-clients-patients-referrals/ to enroll today.